When Anna Nusslock showed up at her local hospital 15 weeks pregnant and in severe pain earlier this year, she said, a doctor delivered devastating news: The twins she and her husband had so desperately wanted were not viable. Further, her own health was in danger, and she needed an emergency abortion to prevent hemorrhaging and infection.

Providence St. Joseph Hospital, in the small Northern California coastal city of Eureka, refused to provide the care she required because doctors could detect fetal “heart tones,” Nusslock said at a news conference Monday. California Attorney General Rob Bonta filed a lawsuit against the Catholic hospital detailing Nusslock’s dangerous experience and alleging the hospital violated multiple state laws when it discharged Nusslock — with an offer of a bucket and towels — to go elsewhere for what he described as standard medical care.

Bonta also filed a motion for a preliminary injunction in Humboldt County Superior Court, asking that it require Providence to treat anyone with an emergency medical condition. “The need for immediate relief is about to intensify,” the motion said. That’s because Mad River Community Hospital, where Nusslock ultimately got care 12 miles up the road, is slated to close its birth center this month.

Providence will be the only hospital within about 85 miles to offer labor and delivery, according to a KFF Health News analysis. When care is more than an hour away, academic researchers typically define the area as a hospital desert.

“It begs the question, what happens next time someone in Anna’s situation shows up at Providence? There will be no Mad River for them to go to,” Bonta said at a news conference. “With a dire lack of services, even here in California, and an influx of patients from states with abortion bans, we need hospitals to follow the law.”

The case illustrates how even in California, where the right to an abortion is enshrined in state law, there’s a glaring loophole. Catholic hospitals, which restrict reproductive health care because they follow the church’s “Ethical and Religious Directives,” are aggressively expanding nationally by acquiring secular hospitals. In swaths of the country, including parts of Northern California, they are the only choice. At the same time, maternity wards are closing rapidly, leaving more patients to contend with religious directives instead of accepted medical standards.

California’s lawsuit also comes amid uncertainty that emerged after the Supreme Court in 2022 overturned the constitutional right to an abortion: whether federal law requires hospitals to provide abortions as emergency medical care even in states that have banned the procedure. The high court punted on the question this summer. The Biden administration reaffirmed its policy that the Emergency Medical Treatment and Labor Act requires hospitals to stabilize or treat any patient who shows up at an emergency room. Texas is suing the administration over the policy.

The issue is also playing out in the presidential election. During the Oct. 1 vice presidential debate, Democratic Minnesota Gov. Tim Walz noted a Georgia woman who died because a hospital delayed care. Sen. JD Vance (R-Ohio) answered, in part, by asking Walz if he wanted to force Catholic hospitals to perform abortions against their religious beliefs, saying that “Kamala Harris has supported suing Catholic nuns.”

With federal protections in limbo, Bonta said California must rely on its state laws to protect patients. Specifically, Bonta, who is widely expected to run for governor, alleges that Providence violated a California law mandating that hospitals provide care “necessary to relieve or eliminate the emergency medical condition.”

Nusslock’s case isn’t an isolated incident, the lawsuit said. “One to two women per year receive abortion care at Mad River, after being refused care at Providence Hospital,” the lawsuit said. “These individuals, like Anna Nusslock, had all been discharged from Providence Hospital with instructions to go somewhere else.” Bonta said his office is investigating how widespread cases are in California, where Catholic hospitals represent 15 percent of hospital beds.

In an Oct. 1 letter to employees that was obtained by KFF Health News, Providence Northern California Service Area Chief Executive Garry Olney said the hospital is “heartbroken” about Nusslock’s experience, which “did not meet our high standards for safe, quality, compassionate care.” He added the hospital is revisiting its training, education, and escalation processes to ensure it doesn’t happen again.

Providence spokesperson Bryan Kawasaki said its 51 hospitals abide by applicable federal and state laws, including EMTALA. Kawasaki declined to comment specifically on Nusslock’s case.

More pregnant people are running into barriers to obtaining care as Catholic health systems have gained market power, a KFF Health News investigation found. Four of the 10 largest hospital chains by number of beds are Catholic, according to federal data from the Agency for Healthcare Research and Quality.

Many Americans don’t have a choice — ambulances may take patients to a Catholic-run health system without giving them a say. Non-Catholic hospitals could be out of their insurance networks or too far to reach in an emergency. In the U.S, nearly 800,000 people have only Catholic or Catholic-affiliated birth hospitals within an hour’s drive, including pockets of Northern California.

Pregnant people who must drive farther to a delivery facility are at higher risk of harm to themselves or their fetus, research shows.

“It’s really concerning, especially in a state like California, where people expect to have comprehensive access to care,” said Debra Stulberg, a family medicine physician at the University of Chicago. “The growth of Catholic hospitals, especially in this post-Dobbs era, continues to constrain the quality of care people get.”

The directives guiding care at Catholic-based health systems are issued by the U.S. Conference of Catholic Bishops. They state that abortions are “intrinsically evil” and “never permitted.”

The document does offer this guidance as an exception: Treatments that could cure “a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child.”

“The church, I would say, helps Catholic hospitals to apply some of our deepest beliefs and moral principles to very, very complex situations,” said John Brehany, executive vice president of The National Catholic Bioethics Center, an ethics authority for Catholic health institutions. “And one of those beliefs is that you can never directly intend to end the life of a developing human being.”

Brehany wouldn’t comment on Nusslock’s case but gave the example that if a woman needed cancer treatment, the church would allow her to proceed with the treatment even if it “results in the death of an unborn child.” He added that some situations are “more debatable” than others.

As Catholic-based systems have consolidated and acquired more medical facilities, their care denials have been compounded by other hospitals closing their labor and delivery wards at alarming rates across the country. In California, 56 hospitals have shuttered their maternity wards in the past 12 years, according to an investigation by CalMatters. Nationwide, at least 267 hospitals closed labor and delivery units between 2011 and 2021, representing about 5 percent of the country’s hospitals, according to Chartis, a health analytics and consulting firm.

With each closure, patients could lose options for abortion care, contraceptives, tubal ligations, and gender-affirming care, said Mona Shah, senior policy and strategy director with Community Catalyst, a national health equity organization.

Nusslock’s 12-mile trip for care at Mad River cost her, according to the lawsuit and her public statement. She had passed an “apple-sized blood clot” and was hemorrhaging in “blinding pain,” she said, by the time she reached the operating room. In the lawsuit, Nusslock said her doctor told her later that her test results showed she most likely had an infection.

It’s a trip Bonta described as “patient dumping” and one Nusslock should never have made.

Seven months later, Nusslock said, she has trouble sleeping, recalling how Providence sent her away.

“I’ll never forget looking at my doctor, tears streaming down my face, my heart shattered into a million pieces, and just pleading with her, ‘Don’t let me die,’” she said.

KFF Health News data editor Holly K. Hacker contributed to this article.

This article was produced by KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. KFF Health News is the publisher of California Healthline, an editorially independent service of the California Health Care Foundation.