Sunday, February 18, 2024

A new way to let AI chatbots converse all day without crashing


Researchers developed a simple yet effective solution for a puzzling problem that can worsen the performance of large language models such as ChatGPT



Reports and Proceedings

MASSACHUSETTS INSTITUTE OF TECHNOLOGY




When a human-AI conversation involves many rounds of continuous dialogue, the powerful large language machine-learning models that drive chatbots like ChatGPT sometimes start to collapse, causing the bots’ performance to rapidly deteriorate.

A team of researchers from MIT and elsewhere has pinpointed a surprising cause of this problem and developed a simple solution that enables a chatbot to maintain a nonstop conversation without crashing or slowing down.

Their method involves a tweak to the key-value cache (which is like a conversation memory) at the core of many large language models. In some methods, when this cache needs to hold more information than it has capacity for, the first pieces of data are bumped out. This can cause the model to fail. 

By ensuring that these first few data points remain in memory, the researchers’ method allows a chatbot to keep chatting no matter how long the conversation goes.

The method, called StreamingLLM, enables a model to remain efficient even when a conversation stretches on for more than 4 million words. When compared to another method that avoids crashing by constantly recomputing part of the past conversations, StreamingLLM performed more than 22 times faster.

This could allow a chatbot to conduct long conversations throughout the workday without needing to be continually rebooted, enabling efficient AI assistants for tasks like copywriting, editing, or generating code.

“Now, with this method, we can persistently deploy these large language models. By making a chatbot that we can always chat with, and that can always respond to us based on our recent conversations, we could use these chatbots in some new applications,” says Guangxuan Xiao, an electrical engineering and computer science (EECS) graduate student and lead author of a paper on StreamingLLM.

Xiao’s co-authors include his advisor, Song Han, an associate professor in EECS, a member of the MIT-IBM Watson AI Lab, and a distinguished scientist of NVIDIA; as well as Yuandong Tian, a research scientist at Meta AI; Beidi Chen, an assistant professor at Carnegie Mellon University; and senior author Mike Lewis, a research scientist at Meta AI. The work will be presented at the International Conference on Learning Representations.

A puzzling phenomenon

Large language models encode data, like words in a user query, into representations called tokens. Many models employ what is known as an attention mechanism that uses these tokens to generate new text.

Typically, an AI chatbot writes new text based on text it has just seen, so it stores recent tokens in memory, called a KV Cache, to use later. The attention mechanism builds a grid that includes all tokens in the cache, an “attention map” that maps out how strongly each token, or word, relates to each other token. 

Understanding these relationships is one feature that enables large language models to generate human-like text.

But when the cache gets very large, the attention map can become even more massive, which slows down computation. 

Also, if encoding content requires more tokens than the cache can hold, the model’s performance drops. For instance, one popular model can store 4,096 tokens, yet there are about 10,000 tokens in an academic paper. 

To get around these problems, researchers employ a “sliding cache” that bumps out the oldest tokens to add new tokens. However, the model’s performance often plummets as soon as that first token is evicted, rapidly reducing the quality of newly generated words.

In this new paper, researchers realized that if they keep the first token in the sliding cache, the model will maintain its performance even when the cache size is exceeded. 

But this didn’t make any sense. The first word in a novel likely has nothing to do with the last word, so why would the first word be so important for the model to generate the newest word? 

In their new paper, the researchers also uncovered the cause of this phenomenon.

Attention sinks

Some models use a Softmax operation in their attention mechanism, which assigns a score to each token that represents how much it relates to each other token. The Softmax operation requires all attention scores to sum up to 1. Since most tokens aren’t strongly related, their attention scores are very low. The model dumps any remaining attention score in the first token.

The researchers call this first token an “attention sink.”

“We need an attention sink, and the model decides to use the first token as the attention sink because it is globally visible — every other token can see it. We found that we must always keep the attention sink in the cache to maintain the model dynamics,” Han says.  

In building StreamingLLM, the researchers discovered that having four attention sink tokens at the beginning of the sliding cache leads to optimal performance. 

They also found that the positional encoding of each token must stay the same, even as new tokens are added and others are bumped out. If token 5 is bumped out, token 6 must stay encoded as 6, even though it is now the fifth token in the cache. 

By combining these two ideas, they enabled StreamingLLM to maintain a continuous conversation while outperforming a popular method that uses recomputation.

For instance, when the cache has 256 tokens, the recomputation method takes 63 milliseconds to decode a new token, while StreamingLLM takes 31 milliseconds. However, if the cache size grows to 4,096 tokens, recomputation requires 1,411 milliseconds for a new token, while StreamingLLM needs just 65 milliseconds.

The researchers also explored the use of attention sinks during model training by prepending several placeholder tokens in all training samples. 

They found that training with attention sinks allowed a model to maintain performance with only one attention sink in its cache, rather than the four that are usually required to stabilize a pretrained model’s performance.  

But while StreamingLLM enables a model to conduct a continuous conversation, the model cannot remember words that aren’t stored in the cache. In the future, the researchers plan to target this limitation by investigating methods to retrieve tokens that have been evicted or enable the model to memorize previous conversations.

StreamingLLM has been incorporated into NVIDIA's large language model optimization library, TensorRT-LLM.

This work is funded, in part, by the MIT-IBM Watson AI Lab, the MIT Science Hub, and the U.S. National Science Foundation.
 

###

Written by Adam Zewe, MIT News

Paper: “Efficient streaming language models with attention sinks”

https://arxiv.org/pdf/2309.17453.pdf

Op-Ed: 
The bullet everyone saw coming is due this year — Commercial property is in deep trouble


By Paul Wallis
DIGITAL JOURNAL
February 16, 2024


A business centre in the heart of London. Image. — © Tim Sandle.

It’s interesting that markets that keep sticking to obsolete not to say fraudulent business models keep tanking, isn’t it? The commercial property market and its dung cart of bad loans is about to hit the fan, and it could be worse than 2008 for banks and lenders.

These commercial property bad loans are worth trillions. Some are better than others, but “better than godawful” isn’t exactly an investment opportunity.

Yep, it’s “Go back to your deeply indebted unflippable office and keep the myth alive” time. The building may be gone before you get there, at this rate.

At a time when people can’t even afford to rent a home, this will be just one more bit of necrotic fecal icing on the cake. As though the global economy wasn’t in a bad enough state, particularly in the West, without this.

Commercial property was a shining light. Now nobody will touch it. Prices have been caving in since 2022. Lenders stock prices have been crashing, too. Exposure to this black hole is dangerous.

Valuations for these overstated chicken coops are also likely to be worthless. The valuations are always on the upside. In the big commercial property booms, nobody did a lot of due diligence. They just made money for themselves.

The New York Community Bancorp is a good example of what happens when the waters and the liquidity get choppy. This bank is a “regional” bank. It’s not huge. It’s not even a bad player. It’s in a market that’s this dangerous. It’s a player in a famously tough regional market. This type of lending is core business for banks of this type.

So, when the market pulls the rug out from under valuations, and the bank makes losses, the stock price gets hammered. Extrapolate this to every other bank on Earth, and you see the problem.

Lenders are now directly in the firing line.

This means that they have to cover their tails. That will make borrowing more expensive. Never mind official interest rates, rates can go up on their own as demand for credit increases.

There’s another issue here. If these bad loans aggregate and become massive losses across the banking and credit sectors, it’s Armageddon.

Excuse the expression:

“They’re too big to bail. “

Nobody has a few lazy trillion to bail them out. The US can’t do 3 to 4 trillion dollars. Europe can’t, although their debt is slightly more manageable. Local economies with heavy property investment like the UK, and Australia will be floundering.

How did it all happen, you ask, slyly hiding under that nice oxalis with your 18 children and 200 or so dependents?

Waaal…

You remember when deregulation was the big deal for rich hypocritical criminal drunks who believed in Reaganomics and Thatcherism? They didn’t actually believe in them but saw opportunities. Making bad loans and fiscal irresponsibility became a lot easier with no compliance. Let’s just say corruption became a lot more profitable.

Credit makes the world go round, but it can also stop it going round in cases like this. The hit to the credit market will be bad enough in real money, let alone pretend money.

How to fix it, you enquire from your bunker in the Mojave Desert?

Quarantine the loans.

Dispose of the borrowers and some of the lenders in some scenic landfill.

Anyone working with credit must be required to have at least one verifiable IQ point.

Regulate the hell out of these fools.

Who’s paying for it, you ask in your fashionable graffiti-ornamented crypt? You are, as usual. This will spill over into consumer credit soon enough.

Op-Ed: Should Europe have nuclear weapons? The case for abolishing politics

By Paul Wallis
February 15, 2024



I’ve always wanted to fit this into an article: There are 8 billion people on this planet who would like a chance sometime to get on with their lives. This mystic vision would be greatly assisted by shutting down the never-ending series of political catastrophes.

What causes human misery? The total failure to respond rationally to any situation. Who’s supposed to get it right? Politicians. Have they got anything right in the last 40 years?

No further witnesses.

There are also the compulsory wars, crime, profiteering, and insane cultural obscenities to be considered. Clearly the best people to manage these issues must be living in someone’s pocket.

A case in point for this elegant audit of the obvious is the debate whether Europe should have nuclear weapons. France and the UK have some, but Europe as a whole doesn’t. Germany has now raised the issue following comments from that roguish and also presumably compulsory sage Donald Trump.

Thanks to politics, a new trigger in humanity’s instant demise may well be added to the mix. It took one rant for America’s Least Interesting to start this debate. Only in a political system where you have to take sides would this utter drivel be taken seriously.

You could argue by scratching on your cave wall that any useless prehistoric idiot could have made the same statements. True. Said idiot, however, wouldn’t get the publicity that a political hernia like Trump gets.

Politics is the science of amplifying stupidity. However idiotic, when it becomes political it has to be taken seriously. Europe is quite rightly wondering what the funicular it’s supposed to do if facing Russia alone. The subject didn’t even exist previously.

…But, you declaim, hopefully for proper remuneration:

“Doth not the vainglorious vaunted vacuum of far too many noises have a right to speak? Shall we not be blessed with his fabled wisdom?”

Uh… No. there is no statutory or other legal obligation to listen to drivel.

Even Americans, who are sometimes slightly verbose, are running out of names for Trump. Interestingly, it was the NATO commentary that prompted this sudden descent into honesty. The NYT link is quite eloquent, and as usual with Americans who can read or write, much too polite.

Back to the political issue:

How many morons do we actually need to destroy the world?

Why are we paying actual money to listen to this idiocy?

Is the political system’s total and utter failure to address any of the world’s actual issues indicative of some sort of systemic problem?

How many lapdogs does it take to change a light globe? None. Lapdogs don’t change light globes or anything else if they can help it.

I have a much better gooder sorta snufflier plan.

Now that we’ve found an all-round reliable moron, we simply put it in a terrarium and use it for entertainment. Ditch the rest of them, and rake in money on the subscriptions to the only show in town.

We’d save billions and maybe even see out the decade without the wars.


Disclaimer
The opinions expressed in this Op-Ed are those of the author. They do not purport to reflect the opinions or views of the Digital Journal or its members.

WRITTEN BYPaul Wallis
Editor-at-Large based in Sydney, Australi




France, Germany block EU deal on scaled-back app worker law


By AFP
February 16, 2024

The rules for app workers in the gig economy, first proposed in 2021, have been a source of controversy - Copyright AFP/File Tolga Akmen

France and Germany on Friday refused to back a watered-down agreement on controversial EU rules covering app workers in the gig economy, European diplomats said.

The European Union’s objective was to bring in bloc-wide rules that supporters hoped would improve conditions for app workers in the gig economy by reclassifying some as employed.

But the latest text scaled back those efforts, by scrapping any formal list of criteria and letting states decide how to classify workers.

For any approval, there needed to be a qualified majority of 15 out of 27 EU nations, representing at least 65 percent of the bloc’s population.

During a meeting of member states’ ambassadors in Brussels, the EU’s two most populous countries, France and Germany, blocked the text with the support of Estonia and Greece, the diplomats told AFP.

They said they could not support the text, therefore denying the qualified majority, the diplomats added.

“Unfortunately, the necessary qualified majority voting wasn’t found,” Belgium, which holds the rotating EU presidency, said on social media.

“We’ll now consider the next steps,” it added.

EU diplomats said the presidency would not give up. “Why would they? There are 23 countries supporting this deal,” one said.

Others were sceptical, arguing that this would not be possible and the issue would be kicked into the long grass until after June elections across Europe.

The draft rules have been a source of controversy since the European Commission first proposed the text in 2021.

Member states and the European Parliament struck a first agreement on the draft text in December 2023 but days later, a France-led blockade stopped the deal in its tracks.


The Powerful Constraints on Medical Care in Catholic Hospitals Across America

© Kaiser Health News
2024/02/17

Nurse midwife Beverly Maldonado recalls a pregnant woman arriving at Ascension Saint Agnes Hospital in Maryland after her water broke. It was weeks before the baby would have any chance of survival, and the patient’s wishes were clear, she recalled: “Why am I staying pregnant then? What’s the point?” the patient pleaded.

But the doctors couldn’t intervene, she said. The fetus still had a heartbeat and it was a Catholic hospital, subject to the “Ethical and Religious Directives for Catholic Health Care Services” that prohibit or limit procedures like abortion that the church deems “immoral” or “intrinsically evil,” according to its interpretation of the Bible.

“I remember asking the doctors. And they were like, ‘Well, the baby still has a heartbeat. We can’t do anything,’” said Maldonado, now working as a nurse midwife in California, who asked them: “What do you mean we can’t do anything? This baby’s not going to survive.”

The woman was hospitalized for days before going into labor, Maldonado said, and the baby died.

Ascension declined to comment for this article.

The Catholic Church’s directives are often at odds with accepted medical standards, especially in areas of reproductive health, according to physicians and other medical practitioners.

The American College of Obstetricians and Gynecologists’ clinical guidelines for managing pre-labor rupture of membranes, in which a patient’s water breaks before labor begins, state that women should be offered options, including ending the pregnancy.

Maldonado felt her patient made her wishes clear.

“Under the ideal medical practice, that patient should be helped to obtain an appropriate method of terminating the pregnancy,” said Christian Pettker, a professor of obstetrics, gynecology, and reproductive sciences at the Yale School of Medicine, who helped author the guidelines.

He said, “It would be perfectly medically appropriate to do a termination of pregnancy before the cessation of cardiac activity, to avoid the health risks to the pregnant person.”

“Patients are being turned away from necessary care,” said Jennifer Chin, an OB-GYN at UW Medicine in Seattle, because of the “emphasis on these ethical and religious directives.”

They can be a powerful constraint on the care that patients receive at Catholic hospitals, whether emergency treatment when a woman’s health is at risk, or access to birth control and abortions.

More and more women are running into barriers to obtaining care as Catholic health systems have aggressively acquired secular hospitals in much of the country. Four of the 10 largest U.S. hospital chains by number of beds are Catholic, according to federal data from the Agency for Healthcare Research and Quality. There are just over 600 Catholic general hospitals nationally and roughly 100 more managed by Catholic chains that place some religious limits on care, a KFF Health News investigation reveals.

Maldonado’s experience in Maryland came just months before the Supreme Court’s ruling in 2022 to overturn Roe v. Wade, a decision that compounded the impact of Catholic health care restrictions. In its wake, roughly a third of states have banned or severely limited access to abortion, creating a one-two punch for women seeking to prevent pregnancy or to end one. Ironically, some states where Catholic hospitals dominate — such as Washington, Oregon, and Colorado — are now considered medical havens for women in nearby states that have banned abortion.

KFF Health News analyzed state-level birth data to discover that more than half a million babies are born each year in the U.S. in Catholic-run hospitals, including those owned by CommonSpirit Health, Ascension, Trinity Health, and Providence St. Joseph Health. That’s 16% of all hospital births each year, with rates in 10 states exceeding 30%. In Washington, half of all babies are born at such hospitals, the highest share in the country.

“We had many instances where people would have to get in their car to drive to us while they were bleeding, or patients who had had their water bags broken for up to five days or even up to a week,” said Chin, who has treated patients turned away by Catholic hospitals.

Physicians who turned away patients like that “were going against evidence-based care and going against what they had been taught in medical school and residency,” she said, “but felt that they had to provide a certain type of care — or lack of care — just because of the strength of the ethical and religious directives.”

Following religious mandates can be dangerous, Chin and other clinicians said.

When a patient has chosen to end a pregnancy after the amniotic sac — or water — has broken, Pettker said, “any delay that might be added to a procedure that is inevitably going to happen places that person at risk of serious, life-threatening complications,” including sepsis and organ infection.

Reporters analyzed American Hospital Association data as of August and used Catholic Health Association directories, news reports, government documents, and hospital websites and other materials to determine which hospitals are Catholic or part of Catholic systems, and gathered birth data from state health departments and hospital associations. They interviewed patients, medical providers, academic experts, advocacy organizations, and attorneys, and reviewed hundreds of pages of court and government records and guidance from Catholic health institutions and authorities to understand how the directives affect patient care.

Nationally, nearly 800,000 people have only Catholic or Catholic-affiliated birth hospitals within an hour’s drive, according to KFF Health News’ analysis. For example, that’s true of 1 in 10 North Dakotans. In South Dakota, it’s 1 in 20. When care is more than an hour away, academic researchers often define the area as a hospital desert. Pregnant women who must drive farther to a delivery facility are at higher risk of harm to themselves or their fetus, research shows.

Many Americans don’t have a choice — non-Catholic hospitals are too far to reach in an emergency or aren’t in their insurance networks. Ambulances may take patients to a Catholic facility without giving them a say. Women often don’t know that hospitals are affiliated with the Catholic Church or that they restrict reproductive care, academic research suggests.

And, in most of the country, state laws shield at least some hospitals from lawsuits for not performing procedures they object to on religious grounds, leaving little recourse for patients who were harmed because care was withheld. Thirty-five states prevent patients from suing hospitals for not providing abortions, including 25 states where abortion remains broadly legal. About half of those laws don’t include exceptions for emergencies, ectopic pregnancies, or miscarriages. Sixteen states prohibit lawsuits against hospitals for refusing to perform sterilization procedures.

“It’s hard for the ordinary citizen to understand, ‘Well, what difference does it make if my hospital is bought by this other big health system, as long as it stays open? That’s all I care about,’” said Erin Fuse Brown, who is the director of the Center for Law, Health & Society at Georgia State University and an expert in health care consolidation. Catholic directives also ban medical aid in dying for terminally ill patients.

People “may not realize that they’re losing access to important services, like reproductive health end-of-life care,” she said.

‘Our Faith-Based Health Care Ministry’

After the Supreme Court ended the constitutional right to abortion in June 2022, Michigan resident Kalaina Sullivan wanted surgery to permanently prevent pregnancy.

Michigan voters in November that year enshrined the right to abortion under the state constitution, but the state’s concentration of Catholic hospitals means people like Sullivan sometimes still struggle to obtain reproductive health care.

Because her doctor worked for the Catholic chain Trinity Health, the nation’s fourth-largest hospital system, she had the surgery with a different doctor at North Ottawa Community Health System, an independent hospital near the shores of Lake Michigan.

Less than two months later, that, too, became a Catholic hospital, newly acquired by Trinity.

To mark the transition, Cory Mitchell, who at the time was the mission leader of Trinity Health Muskegon, stood before his new colleagues and offered a blessing.

“The work of your hands is what makes our faith-based health care ministry possible,” he said, according to a video of the ceremony Trinity Health provided to KFF Health News. “May these hands continue to bring compassion, compassion and healing, to all those they touch.”

Trinity Health declined to answer detailed questions about its merger with North Ottawa Community Health System and the ethical and religious directives. “Our commitment to high-quality, compassionate care means informing our patients of all appropriate care options, and trusting and supporting our physicians to make difficult and medically necessary decisions in the best interest of their patients’ health and safety,” spokesperson Jennifer Amundson said in an emailed statement. “High-quality, safe care is critical for the women in our communities and in cases where a non-critical service is not available at our facility, the physician will transfer care as appropriate.”

Leaders in Catholic-based health systems have hammered home the importance of the church’s directives, which are issued by the U.S. Conference of Catholic Bishops, all men, and were first drafted in 1948. The essential view on abortion is as it was in 1948. The last revision, in 2018, added several directives addressing Catholic health institution acquisitions or mergers with non-Catholic ones, including that “whatever comes under control of the Catholic institution — whether by acquisition, governance, or management — must be operated in full accord with the moral teaching of the Catholic Church.”

“While many of the faithful in the local church may not be aware of these requirements for Catholic health care, the local bishop certainly is,” wrote Sister Doris Gottemoeller, a former board member of the Bon Secours Mercy Health system, in a 2023 Catholic Health Association journal article. “In fact, the bishop should be briefed on a regular basis about the hospital’s activities and strategies.”

Now, for care at a non-Catholic hospital, Sullivan would need to travel nearly 30 miles.

“I don’t see why there’s any reason for me to have to follow the rules of their religion and have that be a part of what’s going on with my body,” she said.

Risks Come With Religion

Nathaniel Hibner, senior director of ethics at the Catholic Health Association, said the ethical and religious directives allow clinicians to provide medically necessary treatments in emergencies. In a pregnancy crisis when a person’s life is at risk, “I do not believe that the ERDs should restrict the physician in acting in the way that they see medically indicated.”

“Catholic health care is committed to the health of all women and mothers who enter into our facilities,” Hibner said.

The directives permit care to cure “a proportionately serious pathological condition of a pregnant woman” even if it would “result in the death of the unborn child.” Hibner demurred when asked who defines what that means and when such care is provided, saying, “for the most part, the physician and the patients are the ones that are having a conversation and dialogue with what is supposed to be medically appropriate.”

It is common for practitioners at any hospital to consult an ethics board about difficult cases — such as whether a teenager with cancer can decline treatment. At Catholic hospitals, providers must ask a board for permission to perform procedures restricted by the religious directives, clinicians and researchers say. For example, could an abortion be performed if a pregnancy threatened the mother’s life?

How and when an ethics consultation occurs depends on the hospital, Hibner said. “That ethics consultation can be initiated by anyone involved in the direct care of that situation — the patient, the surrogate of that patient, the physician, the nurse, the social worker all have the ability to request a consultation,” he said. When asked whether a consultation with an ethics board can occur without a request, he said “sometimes it could.”

How strictly directives are followed can depend on the hospital and the views of the local bishop.

“If the hospital has made a difficult decision about a critical pregnancy or an end-of-life care situation, the bishop should be the first to know about it,” Gottemoeller wrote.

In an interview, Gottemoeller said that even when pregnancy termination decisions are made on sound ethical grounds, not informing the bishop puts him in a bad position and hurts the church. “If there’s a possibility of it being misunderstood, or misinterpreted, or criticized,” Gottemoeller said, the bishop should understand what happened and why “before the newspapers call him and ask him for an opinion.”

“And if he has to say, ‘Well, I think you made a mistake,’ well, all right,” she said. “But don’t let him be blindsided. I mean, we’re one church and the bishop has pastoral concern over everything in his diocese.”

Katherine Parker Bryden, a nurse midwife in Iowa who works for MercyOne, said she regularly tells pregnant patients that the hospital cannot perform tubal sterilization surgery, to prevent future pregnancies, or refer patients to other hospitals that do. MercyOne is one of the largest health systems in Iowa. Nearly half of general hospitals in the state are Catholic or Catholic-affiliated — the highest share among all states.

The National Catholic Bioethics Center, an ethics authority for Catholic health institutions, has said that referrals for care that go against church teaching would be “immoral.”

“As providers, you’re put in this kind of moral dilemma,” Parker Bryden said. “Am I serving my patients or am I serving the archbishop and the pope?”

In response to questions, MercyOne spokesperson Eve Lederhouse said in an email that its providers “offer care and services that are consistent with the guidelines of a Catholic health system.”

Maria Rodriguez, an OB-GYN professor at Oregon Health & Science University, said that as a resident in the early 2000s at a Catholic hospital she was able to secure permission — what she calls a “pope note” — to sterilize some patients with conditions such as gestational diabetes.

Annie Iriye, a retired OB-GYN in Washington state, said that more than a decade ago she sought permission to administer medication to hasten labor for a patient experiencing a second-trimester miscarriage at a Catholic hospital. She said she was told no because the fetus had a heartbeat. The patient took 10 hours to deliver — time that would have been cut by half, Iriye said, had she been able to follow her own medical training and expertise. During that time, she said, the patient developed an infection.

Iriye and Chin were part of an effort by reproductive rights groups and medical organizations that pushed for a state law to protect physicians if they act against Catholic hospital restrictions. The bill, which Washington enacted in 2021, was opposed by the Washington State Hospital Association, whose membership includes multiple large Catholic health systems.

State lawmakers in Oregon in 2021 enacted legislation that beefed up powers to reject health care mergers if they would reduce access to the types of care constrained by Catholic directives. The hospital lobby has sued to block the statute. Washington state lawmakers introduced similar legislation last year, which the hospital association opposes.

Hibner said Catholic hospitals are committed to instituting systemic changes that improve maternal and child health, including access to primary, prenatal, and postpartum care. “Those are the things that I think rural communities really need support and advocacy for,” he said.

Maldonado, the nurse midwife, still thinks of her patient who was forced to stay pregnant with a baby who could not survive. “To feel like she was going to have to fight to have an abortion of a baby that she wanted?” Maldonado said. “It was just horrible.”

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

Click to open the methodology

Methodology

By Hannah Recht

KFF Health News identified areas of the country where patients have only Catholic hospital options nearby. The “Ethical and Religious Directives for Catholic Health Care Services” — which are issued by the U.S. Conference of Catholic Bishops, all men — dictate how patients receive reproductive care at Catholic health facilities. In our analysis, we focused on hospitals where babies are born.

We constructed a national database of hospital locations, identified which ones are Catholic or Catholic-affiliated, found how many babies are born at each, and calculated how many people live near those hospitals.

Hospital Universe

We identified hospitals in the 50 states and the District of Columbia using the American Hospital Association database from August 2023. We removed hospitals that had closed or were listed more than once, added hospitals that were not included, and corrected inaccurate or out-of-date information about ownership, primary service type, and location. We excluded federal hospitals, such as military and Indian Health Service facilities, because they are not open to everyone.

Catholic Affiliation

To identify Catholic hospitals, we used the Catholic Health Association’s member directory. We also counted as Catholic a handful of hospitals that are not part of this voluntary membership group but explicitly follow the Ethical and Religious Directives, according to their mission statements, websites, or promotional materials.

We also tracked Catholic-affiliated hospitals: those that are owned or managed by a Catholic health system, such as CommonSpirit Health or Trinity Health, and are influenced by the religious directives but do not necessarily adhere to them in full. To identify Catholic-affiliated hospitals, we consulted health system and hospital websites, government documents, and news reports.

We combined both Catholic and Catholic-affiliated hospitals for analysis, in line with previous research about the influence of Catholic directives on health care.

Births

To determine the share of births that occur at Catholic or Catholic-affiliated hospitals, we gathered the latest annual number of births by hospital from state health departments. Where recent data was not publicly available, we submitted records requests for the most recent complete year available.

The resulting data covered births in 2022 for nine states and D.C., births in 2021 for 23 states, births in 2020 for nine states, and births in 2019 for one state. We used data from the 2021 American Hospital Association survey, the latest available at the time of analysis, for the eight remaining states that did not provide birth data in response to our requests. A small number of hospitals have recently opened or closed labor and delivery units. The vast majority of the rest record about the same number of births each year. This means that the results would not be substantially different if data from 2023 were available.

We used this data to calculate the number of babies born in Catholic and Catholic-affiliated hospitals, as well as non-Catholic hospitals by state and nationally.

We used hospitals’ Catholic status as of August 2023 in this analysis. In 10 cases where the hospital had already closed, we used Catholic status at the time of the closure.

Because our analysis focuses on hospital care, we excluded births that occurred in non-hospital settings, such as homes and stand-alone birth centers, as well as federal hospitals.

Several states suppressed data from hospitals with fewer than 10 births due to privacy restrictions. Because those numbers were so low, this suppression had a negligible effect on state-level totals.

Drive-Time Analysis

We obtained hospitals’ geographic coordinates based on addresses in the AHA dataset using HERE’s geocoder. For addresses that could not be automatically geocoded with a high degree of certainty, we verified coordinates manually using hospital websites and Google Maps.

We calculated the areas within 30, 60, and 90 minutes of travel time from each birth hospital that was open in August 2023 using tools from HERE. We included only hospitals that had 10 or more births as a proxy for hospitals that have labor and delivery units, or where births regularly occur.

The analysis focused on the areas with hospitals within an hour’s drive. Researchers often define hospital deserts as places where one would have to drive an hour or more for hospital care. (For example: “Disparities in Access to Trauma Care in the United States: A Population-Based Analysis,” “Injury-Based Geographic Access to Trauma Centers,” “Trends in the Geospatial Distribution of Inpatient Adult Surgical Services Across the United States,” “Access to Trauma Centers in the United States.”)

We combined the drive-time areas to see which areas of the United States have only Catholic or Catholic-affiliated birth hospitals nearby, both Catholic and non-Catholic, non-Catholic only, or none. We then joined these areas to the 2021 census block group shapefile from IPUMS NHGIS and removed water bodies using the U.S. Geological Survey’s National Hydrography Dataset to calculate the percentage of each census block group that falls within each hospital access category. We calculated the number of people in each area using the 2021 “American Community Survey” block group population totals. For example, if half of a block group’s land area had access to only Catholic or Catholic-affiliated hospitals, then half of the population was counted in that category.