By Jenifer McKenna, Tara Murtha, Kim C. Clark, Christy L. Hall, Wendy Lee Basgall, Amy C. Poyer and Laura E. Dodge
In March 2020, as the COVID-19 pandemic rapidly spread across the United States, a singular question emerged: What are essential services?
The answer to this critical question shaped COVID-19 response efforts and the trajectory of the pandemic across the country. In healthcare, procedures and tests deemed “essential” remained available, while non-essential services were postponed. Though abortion-related services are essential, time-sensitive healthcare —as affirmed by the American College of Obstetricians and Gynecologists and other professional medical organizations at the dawn of the pandemic— anti-abortion lawmakers attempted to classify abortion healthcare as non-essential. While extensive research demonstrates that denying access to abortion results in significant medical and social harm, at least 12 states attempted to ban abortion to some degree during early months of the pandemic, forcing abortion providers in at least nine states to initiate litigation to stay open as recommended by public health experts.
Anti-abortion lawmakers and officials, meanwhile, largely ignored the status —and potential virus-spreading threat— of crisis pregnancy centers (CPCs). CPCs are anti-abortion organizations whose mission is to reach low-income people experiencing unplanned or “crisis” pregnancies to prevent them from accessing abortion and contraception. Public health literature recognizes CPCs as “unethical” organizations that pose a range of possible harms. While the anti-abortion movement increasingly markets CPCs as medical facilities, the vast majority do not provide medical services. Research shows most promote medical misinformation to discourage people from accessing abortion.
In this context, The Alliance: State Advocates for Women’s Rights & Gender Equality (“The Alliance”) conducted a study to determine whether CPCs remained open during early months of the COVID-19 pandemic, when non-essential services were generally ordered closed. This study was part of a broader Alliance investigation of CPC services in nine states: Alaska, California, Idaho, Minnesota, Montana, New Mexico, Oregon, Pennsylvania, and Washington.
The Alliance study found 59.2% of CPCs in eight states stayed open for in-person visits when non-essential services were ordered closed between April and early June 2020. Most provided pregnancy tests (87.4%) and counseling (87.7%), but the urine tests many CPCs provide are available over the counter, and most counseling appears to be provided by “peers,” not licensed professionals. Some open CPCs did not offer even these limited services; almost none offered well-person care (3.1%), prenatal care (1.7%), or contraception (0.6%). Only 49.0% of open CPC websites indicated a licensed professional was on staff, so it is unclear what essential healthcare the remaining 51.0% without a licensed professional could provide.
We excluded New Mexico findings because their shutdown was lifted early in our data collection; however, an informal survey also found nearly all New Mexico CPCs were open for in-person visits during the April shutdown.
In an era defined by urgent debate about what is an essential service, there was no apparent public discussion about CPCs. CPCs were not explicitly mentioned in any state guidelines regarding essential services, and decisions about staying open amid the rapidly spreading coronavirus appear to have been left to CPCs themselves. In this context, most CPCs stayed open while providing no apparent healthcare services, as the lobbying arm of the anti-abortion movement sought to close abortion clinics providing essential healthcare.
CPCs in the U.S. Increasingly Rely on Public Funds with Scant Oversight
As detailed by watchdog group Equity Forward, crisis pregnancy centers are generally not subject to policymaker oversight despite their escalating reliance on public funding in the U.S. Twenty years ago, three states funded CPCs. Today, 14 states directly fund CPCs, and CPCs in at least 27 states obtain state dollars through other means. Ten states divert money intended for children in poverty to CPCs through Temporary Assistance for Needy Families (TANF). Yet Equity Forward found CPC “contractors are subject to very little oversight or requirements to actually meet benchmarks or report on the use of (taxpayer) dollars.”
This lack of oversight is troubling for multiple reasons. While CPCs increasingly present as medical offices, most are not licensed medical providers and most offer no medical services. CPCs are largely staffed by lay volunteers. Yet some CPCs have received public money earmarked for public health services, including federal Title X Family Planning funds. And while CPCs can appear to be small, independent facilities, a significant percentage are “affiliates” of national and international anti-abortion organizations, for which the CPCs effectively function as neighborhood storefronts.
This lack of oversight is especially troubling because public funding has enabled CPC networks to expand while comprehensive, evidence-based reproductive healthcare has eroded under an onslaught of state abortion restrictions. Today, CPCs outnumber abortion providers in every state by an average of 3:1. In many states, especially states that directly fund CPCs, the disparity is exponentially higher: In Pennsylvania, CPCs outnumber abortion clinics by 9:1; in Minnesota, by 13:1. This shift in the landscape of reproductive healthcare in the U.S. disproportionately affects Black women and people of color—increasingly targeted by the CPC movement—who have less access to affordable contraception and are more likely to die from pregnancy-related causes because of deeply-entrenched structural racism and gender discrimination.
While CPCs purport to help vulnerable pregnant people, most did not close or shift to remote-only services in the early months of the pandemic, despite mandates that non-essential services close and warnings that pregnant people who contract COVID-19 face a higher risk of severe complications, including death. The lack of oversight of the CPC industry allowed CPCs providing non-essential services to stay open as the coronavirus rapidly spread and undermine efforts to protect the public health during a pandemic.
With COVID-19 variants circulating and the United States unlikely to reach herd immunity, future decisions around classifying essential services must be based on science and facts, and closure of non-essential services must be rigorous. That so many CPCs defied or evaded the attention of policymakers amid a public health crisis—despite being recipients of public funding—underscores the urgent need to clarify their status in general, implement accountability mechanisms, and analyze the nature and scope of services CPCs provide and their consequences for the public health.
Jenifer McKenna is program director for The Alliance: State Advocates for Women’s Rights & Gender Equality, a collaboration of state-based law and policy centers working at the intersection of reproductive rights, economic justice, LGBTQ+ equality, and gender-based violence. A centerpiece of The Alliance collaboration is advocacy to ensure equitable access to evidence-based reproductive healthcare and transparency and accountability in government-funded programs for pregnant people.
Tara Murtha is the director of strategic communications at Women’s Law Project (@WomensLawProj), a public interest legal organization devoted to advancing and defending the rights of women, girls and LGBTQ+ people in Pennsylvania and beyond.
Kim C. Clark is senior attorney at Legal Voice (@Legal_Voice), a progressive feminist organization using the power of the law to advance justice for all women and LGBTQ people in the Northwest.
Christy L. Hall is a senior staff attorney at Gender Justice (@GenderJustice), a nonprofit legal advocacy organization working to advance gender equity through the law.
Wendy Lee Basgall served as staff attorney at Southwest Women’s Law Center (@SWWomensLaw) until August 2021 and now works in the public sector. SWLC is a nonprofit legal advocacy organization harnessing the power of law, research, and creative collaborations to create greater opportunities for women and girls in New Mexico.
Amy C. Poyer served as senior staff attorney at California Women’s Law Center (@CWLC_la) until July 2021 and now works in the private sector. CWLC is a nonprofit legal advocacy organization working to create a more just and equitable society through transformative litigation, policy advocacy, and education.
Laura E. Dodge, ScD, MPH is a reproductive epidemiologist at Beth Israel Deaconess Medical Center and an assistant professor at Harvard Medical School and the Harvard T.H. Chan School of Public Health. Follow Laura on Twitter: @lauradodge