The Problems with Crisis Pregnancy Centers: Reviewing the Literature and Identifying New Directions for Future Research

Background

Crisis Pregnancy Centers (CPCs) are nonprofit organizations that present themselves as healthcare clinics while providing counseling explicitly intended to discourage and limit access to abortion.^1,2 These facilities, sometimes referred to as “pregnancy resource centers” or “pregnancy support centers,” attract patients by offering free services such as onsite ultrasounds and STI testing; however, their primary purpose is to discourage abortion, often through manipulative and misleading tactics.³ Most CPCs have strong ties to evangelical Christian organizations and often further their goal of religious proselytism by promoting anti-abortion and anti-contraception propaganda not supported by medical evidence.⁴

CPCs often directly usurp state and federal dollars directed to reproductive health, which has helped encourage their proliferation. The first CPC in the United States opened in Hawaii in 1967, after the state legalized abortion. Today, the country has an estimated 2500–4000 operational CPCs, approximately triple the number of abortion clinics, which see over 1 million patients annually.⁵ CPCs are not a strictly American phenomenon, as evidenced by the presence of these centers in at least 84 countries; however, their evolution has played an important role in shaping the political landscape of abortion in the United States.⁶ In the early days of the so called pro-life movement, legal and legislative strategies aimed at restricting abortion were primarily focused on fetal rights.⁷ After Roe v. Wade was decided in 1973, CPCs played an important part in centering pregnant women within the pro-life movement and framing abortion as a byproduct of “an unjust system that did not value motherhood.”⁸ CPCs proliferated in the 1970s and 1980s as accessible spaces for primarily women volunteers to affirm their religious opposition to abortion, reinforce traditional gender expectations, and “save” other women from the harms of abortion. This ethos, which promotes strict, evangelical gender roles and positions abortion as a moral harm, remains central not only to the operation of CPCs but also to anti-choice activism more broadly.⁴

The majority of CPCs are supported by religious associations such as Care Net, Heartbeat International, Birthright International, or the National Institute of Family and Life Advocates.⁹ A recent study aimed at characterizing the geographic distribution of crisis pregnancy centers in the US determined that CPCs exist in every state, but are largely concentrated in the South and Midwest.¹⁰ Evidence suggests that CPCs have a negative individual and public health impact through dissemination of medically inaccurate information and delaying access to legitimate medical care.¹¹ Alongside increasing anti-abortion legislation, the proliferation of CPCs paired with the closure of abortion clinics perpetuates the ongoing harmful impact these centers have on the reproductive healthcare landscape. However, despite their growing influence, there is still limited research on patients’ understanding of and experiences with CPCs. In this review of the academic literature on CPCs, we explore both the impact of these centers on patient care and reproductive autonomy and suggest future directions for research.

Services Provided by CPCs

The operation of CPCs relies on over 40,000 volunteers, the majority of whom are laypersons; however, some medical professionals work in select clinics on either a paid or volunteer basis.^12,13 Staff in CPCs are primarily white and middle class.⁴ Comparatively, CPCs target their marketing towards and are attended most frequently by young people, people of color, and individuals of lower socioeconomic status.^14,15 This focus on disenfranchised communities highlights the exploitative practices of CPCs, especially when considering that these centers often offer free services in exchange for participation in abstinence seminars or Bible studies.¹⁶ While comprehensive reproductive health clinics have strict requirements regarding patient confidentiality, quality of medical care, and hygiene and safety practices, CPCs are not held to any regulatory standards and enjoy significantly less government oversight despite often being listed in state-sponsored pregnancy resource lists.¹⁰

Though the primary offering of CPCs is biased, medically inaccurate counseling, some also provide pregnancy tests, STI testing, and ultrasounds. Free ultrasonography is often a particularly strong and problematic enticement, especially since this service can otherwise be financially prohibitive and difficult to access.¹⁷ In offering ultrasounds, CPCs suggest they are legitimate medical facilities; however, the images are frequently non-diagnostic and often obtained by untrained, unlicensed staff.¹⁷ Moreover, the practice can be deliberately or inadvertently misleading or dangerous when clients receive inaccurate gestational age dating or if CPC staff miss a diagnosis such as ectopic pregnancy.¹⁸ Apart from these medicalized services, CPCs offer pregnant patients maternity clothes, diapers, parenting classes, information on adoption, social service referrals, and even housing, frequently in exchange for participation in religion-based seminars.¹⁶ These free services are often cited as the primary reason clients interact with CPCs, which suggests a lack of access to social services and resources via settings that provide high-quality, medically sound care to socioeconomically disadvantaged patients.¹¹ CPCs do not consistently provide transparent information about their services. One study analyzing the content of CPC websites found that 84% of sites stated that abortion information would be available at their respective centers while only 13% provided a disclaimer that the center was not a medical facility.¹⁹

Lack of Patient Awareness About CPCs and Risk of Deception

CPCs engage in deliberately misleading practices to convey legitimacy and credibility, which they are otherwise lacking. From their websites, which emphasize “all options” counseling to the white coats worn by layperson volunteers, CPCs are dangerously lacking in transparency.¹⁸ Notably, CPCs have developed strategies to trick abortion seeking patients into mistaking these centers for comprehensive clinics. These include naming themselves similarly to abortion clinics and using a method called “co-location” which refers to the purposeful opening of CPCs near reproductive health clinics. In several cases, CPCs are within a few blocks or even right across the street from legitimate abortion clinics.¹³ CPCs also concentrate their advertising efforts on groups of women that they feel to be the most “abortion-minded.”²⁰ This includes young women, women of color, and women of lower socioeconomic classes targeted with strategically placed billboards near high schools and colleges and advertising on public transportation and bus shelters.²⁰ Care Net has an “Urban Initiative” which focuses on bringing Black and Latina women to centers by advertising on the Black Entertainment Network (BET) and drawing comparisons between abortion and slavery.²⁰

Evidence is accumulating on how CPCs recruit clients and how those clients feel about the services. While CPCs are more prevalent than abortion clinics, only 60% of respondents among a national, representative sample of reproductive-aged women knew of their existence.^10,21 Many CPCs appear in internet searches for abortion, which adds to patient confusion regarding what types of services and counseling they will be provided if they present to one of these facilities.²² Websites of CPCs can be difficult to differentiate from those of abortion clinics, and lacking prior awareness of the existence of CPCs and low health literacy are risk factors for misidentification.²¹ While one study found that most women who sought care at a CPC “generally recognized the CPC was antiabortion, ideologically Christian, and not a medical establishment,” the potential for confusion and deception is high.²³ Furthermore, CPCs intentionally use scientific language while making false claims directly contradicted by research and medical guidelines, furthering intentional deception. This includes exaggerating the likelihood of miscarriage in early pregnancy to downplay the urgency in seeking abortion care, and emphasizing non-factual relationships between abortion and infertility, breast cancer and adverse mental health effects.^14,17,24

Other evidence both on prevalence of attendance and the client experience is mixed. Studies from Louisiana and Maryland report low prevalence of CPC attendance and that those who sought care at CPCs were looking for a supportive environment for their pregnancy or resources such as free ultrasound, clothes or diapers.^23,25 In contrast, a representative sample from Ohio reported a relatively high prevalence of CPC ever attendance, more frequent among those who were Black/non-Hispanic and low socioeconomic status.¹⁵ Thus, more research is needed both on how clients choose to attend a CPC and the effects of that care, particularly given concerns that biased counseling may undermine reproductive autonomy.²⁶

Funding and Regulation of CPCs versus Abortion Clinics

CPCs receive funding from a variety of mechanisms, including state and federal funding in addition to private donations. CPCs are written into state budgets of several states with a regulatory environment hostile to abortion.^27,28 The sale of “Choose Life” license plates supports CPCs or other explicitly anti-abortion organizations in 18 states, 10 of which specifically prohibit any of these funds from aiding organizations that provide abortion, abortion counseling or referrals.²⁹ Several states also fund CPCs through the Temporary Assistance for Needy Families (TANF) program, an annual block grant from the Federal government intended to assist state residents below the poverty line.^30–32 In this way, CPCs directly steal funding from the intended recipients of TANF, thus decreasing the financial and structural support available for low-income families.

Federal funding for anti-abortion organizations such as CPCs expanded in the early 2000s under the Bush administration via allotments from federal programs supporting abstinence only education and the administration’s Compassion Capital Fund, an initiative designed to support faith- and community-based organizations through capacity building grants.¹ More recently, changes to the Title X family planning program under the Trump administration allowed CPCs to receive funding from this entity for the first time, while limiting participation of organizations that provide induced abortion.³³ Federal grants to several large explicitly anti-abortion organizations, such as the California-based Obria Group, were approved in 2019. While Obria runs licensed clinics and brands itself as a comprehensive healthcare center, the group’s website contains stigmatizing language such as references to “post-abortion trauma symptoms” and promotes non-evidence-based medicine such as abortion reversal.³⁴

Funding awarded under Title X for family planning services has long been unavailable for abortion. Some healthcare organizations that provide abortion, such as Planned Parenthood, receive Title X funding for other services such as contraception and screening for breast cancer, cervical cancer, and sexually transmitted infections while other, non-Title X funding, is used for abortion. The 2019 changes to Title X, which many called the “domestic gag rule,” made existing regulations even more stringent and prohibited Title X providers from providing comprehensive options counseling for pregnancy or making referrals for abortion.³³ More critically, the ban on discussion of and referral for abortion meant clients could not rely on their providers to be an accurate and comprehensive information source. Though reversed as of November 2021, these changes to Title X led to departures of numerous grantees including Planned Parenthood, which previously served approximately 40% of patients relying on Title X for family planning services, and temporarily left six states with no Title X-funded services.³⁵ This demonstrates the concrete ways in which anti-abortion political sentiments may have a deleterious effect on overall reproductive health access.

Federal funding for abortion provision is also strictly limited. The Hyde Amendment, which has been included in annual Congressional spending bills since 1976, explicitly prohibits use of federal funds to cover abortion services.³⁶ At the patient level, the Hyde Amendment prohibits insurance coverage of abortion for individuals who obtain healthcare coverage through Medicaid, Medicare, the Indian Health Service, the Children’s Health Insurance Program (CHIP) or who are employed by the federal government, except in instances of rape, incest and life endangerment.³⁶ Although some states use their own Medicaid funds to cover abortion services or require abortion coverage by private health insurance plans, no form of public insurance can be used to cover abortion in 33 states, and nearly half of states further restrict federal marketplace or private plans from covering abortion.³⁷ Medicaid is the largest obstetric payor in the United States,³⁸ making abortion is an important and costly gap in coverage for a large population of reproductive-age individuals. These restrictions disproportionately impact low-income women and women of color, who are more likely to rely on public insurance.

There is also a marked disparity in regulation of abortion clinics and CPCs. In contrast to abortion clinics, which are regulated as licensed medical facilities, CPCs have varying levels of licensure and accreditation. In a landmark decision in 2018, the Supreme Court struck down a California law that required CPCs to post information about available abortion and contraceptive services and required unlicensed CPCs to disclose that they were not licensed medical clinics, claiming that the law violated CPCs' First Amendment rights to free speech.³⁹ This decision greatly limits the ability of states to regulate CPCs and safeguard public health.⁴⁰ Abortion providers, in contrast, are frequently mandated by state laws to provide scripted counseling that contains medically inaccurate information, including claims that abortion is associated with mental health risks, increased risk of breast cancer, and detriments to future fertility.⁴¹

Additional Harms Associated with CPCs

In addition to disinformation and deception regarding abortion, disinformation regarding hormonal contraception, condom use, sexually transmitted diseases and sexuality is widespread among CPCs.^14,16 Few CPCs provide education about contraception, and fewer still provide FDA-approved contraceptive methods.^14,16,17 Those that do provide information focus primarily on potential harms of contraception while downplaying the effectiveness of prescription methods.¹⁴ Unfortunately, CPCs do not limit the spread of harmful misinformation to their websites and clinics. Several CPCs have arrangements in their local communities to provide off-site “sexual education” programs, which primarily consist of abstinence-only messaging, gender essentialism, and anti-LBGTQ philosophies.⁴² Because they are not medical facilities, CPCs are not subject to the Health Insurance Portability and Accountability Act and many are collecting private client data, which could be used for a range of purposes, from evangelizing to informing anti-abortion lawsuits for bounty in Texas.¹⁷

In addition to the purposefully deceptive nature and explicit anti-abortion objectives of CPCs, engagement with CPCs may also lead to direct harms for both pregnant and non-pregnant women. Individuals seeking pregnancy confirmation at CPCs not only experience delays in accessing abortion care when desired,^23,43 but in the case of desired pregnancies, may also experience delayed entry into prenatal care or delayed recognition of pregnancy complications or medical conditions as a result of visiting a non-licensed clinic.^23,43 A recent survey study conducted with 607 CPCs in 9 states found that only 5% directly offered prenatal care, while only 40% provided referrals for prenatal care.¹⁷ The same study found that only 26% and 16% of CPCs have a registered nurse or physician on staff, respectively, which underscores that individuals attending CPCs are not receiving medical care, and potentially dangerous diagnoses such as ectopic pregnancy may be missed. Thus, rather than helping refer to early prenatal care, which is associated with improved maternal and neonatal outcomes, or providing tangible resources such as assisting individuals to obtain pregnancy Medicaid benefits as applicable, CPCs distract and divert pregnant women from the legitimate medical system to promote their own ideologic ends.^44,45

For patients who are considering pregnancy termination, CPCs not only misrepresent the health-risks of abortion but also may intentionally lie to their clients by reporting incorrect gestational ages of their pregnancies.⁴⁶ At best, this tactic forces an increase in second-trimester abortions, which are harder to obtain, more expensive, and less safe than abortions in the first trimester.⁴⁷ At worst, it prevents patients from accessing abortion altogether, a situation that will become more common as abortion becomes more difficult to access, thus robbing them of their reproductive autonomy.

Directions for Future Research

While scholarship on CPCs is beginning to increase, there are still several gaps in knowledge regarding the impact of these centers on reproductive justice and public health overall. With access to abortion likely to become much more limited throughout the US, diverse investigation of the harms of CPCs remaining the only alternative for people experiencing unplanned pregnancy is essential. General trends, such as delays in prenatal and abortion care, are evident; however, further quantification of these interruptions in care as well as elaboration on their effects is still ongoing and much needed. There is also limited information regarding how patient interactions with CPCs impact pregnancy-related decision-making and sexual health behaviors. Equally important to increasing investigation of the influence of CPCs is developing a deeper understanding of how misinformation about miscarriage, anti-LGBTQ+ bias, and new strategies to digitally recruit and store data about clients may cause harm.¹⁷ A research agenda with a broad focus also requires voices outside academics, such as the leadership of feminist activists working to decrease public funding of CPCs and increase oversight.⁴⁸ Research insights into what makes a website trustworthy or approachable should also be leveraged by legitimate reproductive health clinics.

Conclusion

CPCs are a unique and disconcerting hybrid of anti-choice activism, religious propagandism, and pseudo-medical practice. Their modes of operation are fundamentally unethical and undermine the respect to human life that they claim to protect. Currently, the government faces significant barriers to implementing regulation of CPCs. The overall protected status of CPCs exists in stark contrast to that of abortion clinics. As states across the country threaten to severely restrict, and in some cases eliminate, access to abortion, efforts to limit the influence of CPCs will become increasingly vital. Initiatives to promote transparency and protect people seeking unbiased medical care from deception by CPCs will require creative solutions. On a grassroots level, healthcare providers and pro-choice organizations need to remain knowledgeable about CPC operations within their communities and serve as reliable sources of information for patients. Structurally, in addition to pushing for greater oversight of these organizations, Americans should demand increased accountability from search engines and social media outlets regarding advertising of CPCs and the medical accuracy of their online content. There also needs to be widespread social and political support of public health policies that create legitimate, safe access to medical and financial resources that are currently offered under threat of coercion by CPCs. While reproductive rights advocates continue to demand responsible, appropriate action from local and national governing bodies, increasing patient awareness and education about these centers will hopefully protect anyone capable of pregnancy from erosion of their reproductive freedoms by CPCs.