Charity Scott, JD and professor of law at the Georgia State Catherine C. Henson School of Law, stood at the front of our medical school lecture hall with her arms stretched wide. “The welfare of a pregnant mother?” she said as she dipped one arm down, burdened by an invisible weight. “Or the welfare of an unborn child?” She hovered at a point of balance before tipping all the way to the other side. “Who takes precedence? Who has more weight on the scale?”
The room sat in silence.
Reproductive health has been a lively debate in the United States for decades. The two weights on Professor Scott’s scales — the challenging balance of simultaneously caring for an unborn child and a mother — have led to health policy encroaching into medical practice in a way that is completely unique from any other field. A recent Supreme Court case involving access to women’s reproductive healthcare shed light on a lesser-known part of this debate: Crisis Pregnancy Centers.
A Crisis Pregnancy Center (CPC), or pregnancy resource center, is a non-profit organization that provides counseling services to pregnant women. Most CPCs are structured like outpatient clinics where women make appointments to see a counselor or advocate. The clinics’ key draw is inexpensive or free pregnancy tests, and they also exist as a resource for prenatal counseling. CPCs are often most prevalent in areas with limited access to obstetric healthcare and are seen as a cheaper or more accessible source for information on pregnancy management.
During their meetings with CPC counselors, women discuss their social and economic statuses. The centers are largely funded by state governments or private organizations. Investigations into individual CPCs have found that some offer false or misleading information about the health risks and availability of abortion casting the operations of these centers into controversy.
To understand CPCs, one first has to understand the landscape of reproductive health in the United States. For years, America has struggled with maternal and infant health outcomes, despite high per capita expenditures. Rural hospitals are responding to financial pressures by closing their obstetrics wards, forcing women to travel for hours to access prenatal or peripartum care. Ninety percent of all U.S. counties lacked an abortion clinic in 2014. Of the clinics that remained, eighty-four percent reported at least one form of anti-abortion harassment ranging from picketing patient entrances to bomb threats. It can be challenging — financially, logistically, and emotionally — to access family planning as an American woman.
Now, in this climate, two broad changes are happening simultaneously. Financial burdens are straining obstetrics and primary care offices in rural areas, and legislative regulations are shutting down abortion clinics across the country. Studies have shown that excessive barriers to abortion access can lead to negative impacts on maternal mental health and considerations of self-induced abortion which presents its own health risks to both mother and child. As lawmakers and advocates continue to debate access to various elements of maternal healthcare, CPCs are quietly booming: there are currently twice many CPCs as abortion clinics available in the U.S.
The impact of CPCs has also been disproportionately targeted to vulnerable populations. CPCs are often located in neighborhoods without healthcare providers and offer free pregnancy tests to populations with low rates of insurance and high rates of poverty, according to the National Women’s Law Center. Many other groups, like Care Net, have also developed urban initiatives to reach pregnant women of color on the grounds that black and Hispanic women have higher rates of abortion. Unfortunately, its work often disregards the disparities in contraception access among these same populations.
As the public came to know more about CPCs, so did the government. The Federal Supreme Court became involved in the operation of CPCs after the state of California sought to regulate what pregnancy centers were allowed to say — and omit saying — to expecting mothers. The FACT Act, passed in 2015, mandated that CPCs read a script detailing all of the state-sponsored family planning services available to each woman. In addition, centers that were not medically licensed would be required to display documentation making their statuses clear. The hope was to limit the claims of fraudulence and omission that had made CPCs so controversial.
Crisis pregnancy centers challenged the FACT Act on the basis of free speech and religion. Opponents of the bill also argued that it would force CPC employees to express views and information contrary to their own beliefs. The lawmakers who passed the bill cited a concern that Californian women may remain unaware of public programs available to them should they seek their prenatal care from a CPC. Precedence for the bill came from the oft-cited Reproductive Privacy Act which guarantees a fundamental right of privacy with respect to reproductive decisions.
The Supreme Court heard arguments against the FACT Act on June 26, 2018 and made a five-four decision that the proposed bill violates the First Amendment by specifically targeting pro-life speakers. The ruling overturned a unanimous decision from the U.S. Court of Appeals in San Francisco to uphold the Act.
California is not the only state to write legislation for the operation of CPCs. Many states are working to pass bills to either restrict or guarantee a CPC’s freedom to counsel patients without limitations. The Federal Supreme Court’s ruling for CPCs will likely forge the way for similar legislation in Missouri, New York, Louisiana and other states to come.
There are an incredible number of inequities in medicine: socioeconomic status, access to resources and insurance status. Many of these are deep-rooted and immovable forces built into the history and politics of our country, which make up the landscape we must navigate as physicians to provide the best possible care to our patients.
Other issues, such as CPCs and the information we give our most vulnerable patients about their access to care, are ones that healthcare providers and legislators should be able to understand and improve. The debates on reproductive health will continue, and it is our duty as future health care providers to be strong allies on the sides of both patients — mother and child — in that fight.
Image credit: “This is on the desk of one of my friends” (CC BY-NC-ND 2.0) by sarahinvegas