Free, but at what cost? How US crisis pregnancy centres provide services

Abstract

In the USA, the most popular form of anti-abortion activism, crisis pregnancy centres (CPCs), provide a variety of services to prevent abortions. Moving beyond debate about misinformation and the ethics of CPCs, this study considers the services they provide and given their popularity among state legislatures, their connection to the state. Using interviews with ten CPC staff in Ohio (a state providing support to CPCs) and supplemental data from both state and CPC organisations, we find three relevant themes. First, CPC services reflect ideas about personal responsibility and Christianity held by the CPC staff. Second, we show that CPCs have assumed a variety of state duties (e.g. pregnancy testing and parenting classes), appealing to lawmakers in conservative states eager to transfer responsibility for disadvantaged residents to other entities. Finally, we consider the future direction of CPCs, highlighting tension between organisational goals (focusing on abortion prevention) and the on-the-ground experience of CPC staff (where non-pregnant clients need material aid). Drawing theoretical connections between CPC staff and social service workers sheds light on whose responsibility it is to address poverty in a post-welfare era.

Keywords:

• Abortion
• bureaucracy
• crisis pregnancy centres
• state
• welfare

Introduction

In the USA and beyond, crisis pregnancy centres (CPCs) are non-profit organisations that provide counselling, financial assistance, material resources related to pregnancy and infants (e.g. maternity and baby clothes), or adoption referrals to women experiencing ‘crisis’ (unintended) pregnancies (FRC (Family Research Council) 2010). These organisations are part of a broader social movement that discourages pregnant people from choosing abortion and encourages parenting or adoption (Hussey 2020). The CPC movement has grown with thousands of locations in the USA and a presence in over 70 countries (Heartbeat International 2022; Swartzendruber and Lambert 2020). Research shows that CPCs more commonly provide material aid (e.g. nappies and baby clothes) than counselling on pregnancy options, as most pregnant CPC clients have already decided to parent (eKYROS, Inc. 2022; Kelly 2014). Research has begun to illuminate how staff at CPCs think about their work. Hussey (2020) reports that Christianity is a strong motivator to join the CPC movement, and that staff describe themselves in terms of ministry and service provision over activism or political affiliation.

Emerging work illuminates a highly ambivalent relationship between the CPC movement and politics. Though members of the CPC movement consider their work distinct from political activity and say that the majority of the funds come from individual donations (Hussey 2020), there is a deep and growing relationship with the state. Thirteen US states, including Ohio, provide funding for CPCs. Ohio lawmakers increased funding to CPCs by millions of dollars through the TANF (Temporary Aid for Needy Families) initiative and Title X (a grant programme for low-income patients to receive family planning and reproductive health services) support (Wormer 2021; Zeltner 2019). Anti-abortion politicians consider CPCs an alternative to abortion care, and because of this state-level sources of funding to CPCs are increasing in Ohio and other states (Covert and Israel 2016). Given this situation understanding the services CPCs provide is essential.

We conducted in-depth interviews with ten CPC staff members, supplemented by data from local and national CPC websites, as well as podcasts, videos, and promotional materials from centres. We found three main services are provided: pregnancy verification, material aid, and counselling and education (e.g. parenting classes and counselling on abstinence outside of marriage). These services fill service gaps, while reflecting conservative and Christian ideals and advancing anti-abortion agendas. We also suggest that CPC staff may experience tension between social service provision and ‘foetus-focused’ activity.

Background

CPCs emerged in the USA during the 1970s. Originally considered fringe, the mainstream anti-abortion movement has embraced CPCs (Haugeberg 2017; Munson 2009). CPCs initially drew on tactics of the anti-abortion movement (e.g. showing photos of foetal parts), but by the 1990s, their approach began to include services for pregnant people (Hussey 2020; Kelly 2014). Today, CPCs constitute the most popular form of grass-roots anti-abortion activism (Munson 2009).

Scholars have criticised CPCs for providing misinformation. For example, some CPCs have been set up near abortion clinics with the intention to divert potential abortion clients to delay care, which risks people’s health (Cartwright, Tumlinson, and Upadhyay 2021). CPCs do not have to disclose their lack of medical facility licencing in line with Anon a 2018 US Supreme Court ruling (National Institute of Family and Life Advocates v. Becerra 2018). CPCs may also provide medically-inaccurate information, including alleging false links between abortion and risk of breast cancer, mental health issues, and infertility, as well as overestimating the risk of miscarriage among individuals with a recognised pregnancy, to dissuade clients from seeking an abortion immediately (Tsevat, Miracle, and Gallo 2016). CPC websites include false or misleading statements regarding the amount of time available to have an abortion and inaccurate consequences of having an abortion (Swartzendruber et al. 2018).

An emerging body of research considers CPC services and clients’ reasons for visiting. CPCs promote free pregnancy testing as their core service (Hutchens 2021; Swartzendruber and Lambert 2020). Yet research suggests that many, if not most, clients attend CPCs for material aid (Kimport 2020). Despite the widespread critique that CPCs intentionally mislead people into thinking they provide abortions (Borrero, Frietsche, and Dehlendorf 2019), few clients visit CPCs seeking abortion services. When people desiring an abortion visit a CPC, their visit rarely influences their decision-making (Kimport, Kriz, and Roberts 2018). CPC service data provides evidence of their difficulty in meeting their mission of changing minds about abortion: ∼41% of clients in 2021 already planned to continue their pregnancy, while only 5% changed their views against abortion, and 12% did not change their views (the remainder were not pregnant) (eKYROS, Inc. 2022). This reveals a contradiction for CPCs as organisations: their most popular service (promotion of material aid) may not attract those seeking an abortion (Kelly 2014).

Recent work has begun to examine CPC staff and their motivations to be part of the CPC movement. Hussey (2020) has found that political motivations are not a sufficient way to think about people who work at CPCs. She reports that most staff or volunteers would not consider themselves activists, and many actively distance themselves from political activity. Rather, they see CPC work as a ministry to which they are spiritually called to prevent individuals from seeking abortions and to bring them into Christianity (Hussey 2020; Hutchens 2021). A major component of this work is dealing with poverty, and CPCs try to provide practical resources to help ease these burdens. Hussey (2020) finds that CPC staff tend to prioritise ‘social and spiritual [needs], rather than material [needs].’ Results from this work further suggest that CPC staff may not be as conservative on social welfare issues as other members of the anti-abortion movement (Hussey 2020).

Though members of the CPC movement may describe their motivations as more spiritual than political (Hussey 2020), CPCs have become increasingly intertwined with the state through their clients’ needs, politicians' interest in CPCs, and the commensurate funding following this interest. CPCs report that funding is largely the result of individual donations and fundraising (Hussey 2020). At the same time, thirteen US states provide funding streams for CPCs thought TANF and Title X. In 1996, the Ohio legislature implemented welfare reform with the introduction of TANF, which had time limits and work requirements (Hallett 2009). In the wake of declining cash assistance, CPCs stepped into the social safety net by attracting new clients who needed aid (Hussey 2020). More recently, Ohio lawmakers have directed TANF and Title X funds toward a grant programme for CPCs to ‘increase community awareness’ of relevant services for parents with infants, specifically promoting ‘childbirth, parenting, and alternatives to abortion’ (Ohio Legislature 2013; ODAS [Ohio Department of Administrative Services] 2019). Solidifying connections between CPCs and the state via such funding mechanisms raises questions about how each organisations’ goals align and how workers negotiate not only the tension between helping people experiencing poverty while promoting individual solutions to poverty, but also how these tensions are shaped by an anti-abortion agenda.

Material and methods

Overview

This study has its origins in a larger research project exploring crisis pregnancy centres, including staff perceptions of their work and client experiences in the centre. We conducted in-depth, semi-structured qualitative interviews with ten staff members at eight CPCs in Ohio between April-August 2019. Before the interview began, we asked the ten staff members to complete a short demographic questionnaire. When necessary for a more complete understanding, we consulted local and national organisation’s websites, podcasts and videos produced by leading CPC organisations, and promotional materials collected during the CPC visits, online materials from CPC websites and the national organisations. We consulted both local and national organisational materials to fill in any gaps in our understanding about what services individual CPCs provide, but also how responses from staff fit in with the broader movement. All the centres we visited were affiliated with national organisations Care Net or Heartbeat International, and these affiliations allowed staff to access abundant materials, such as videos on parenting and educational handouts on pregnancy and parenting. The Ohio State University institutional review board approved the study.

Sample and recruitment

By visiting several CPCs in Ohio to inquire about interviewing staff and volunteers, we learned that CPCs often have several paid positions. Executive directors manage the organisation, represent the organisation to the community, and report to a board of directors (who are either former CPC staff or wealthy community members). Development directors fundraise for the organisation. Client services managers train client advocates, who are volunteers working directly with clients. CPCs that provide ultrasound scans also have an ultrasound technician (often a local nurse) and a medical director, a physician who reviews the results of the scans off-site.

We next identified CPCs in Cincinnati, Cleveland and Columbus, and within 100 miles of Columbus (Swartzendruber and Lambert 2020). We approached 24 centres to interview an available staff member or volunteer. All interviews took place with paid staff rather than volunteers. Ten staff members at eight locations agreed to participate: seven executive directors, one ultrasound technician, one client services manager, and one social media manager. Respondents worked at rural (n = 6) and urban CPCs (n = 4). They were 27-71 years of age, and uniformly identified as Christian: three Protestants, four evangelical Christians, and three Catholics. Nine identified as white and one identified as white and Black. Annual household incomes were <$45,000 (n = 4), $45,000-$74,999 (n = 3), and >$75,000 (n = 3). Most (n = 6) had a bachelor’s degree or higher with the remainder having an associate degree or some college education.

The first author interviewed respondents in person at their CPC and toured the facility. Interviews lasted ∼60 (range: 45–90) minutes. Immediately afterwards, the interviewer wrote field notes (e.g. reflections on the respondent, interactions and thoughts on interview themes).

We used an open-ended interview guide (available upon request to the corresponding author) to allow for probing. The guide included questions about the services provided (e.g. ‘What happens after a client arrives at your centre? What is the usual process that they go through?’), the mission of the CPC (e.g. ‘How would you describe the purpose of this centre? What is the place of the centre in the community?’), and perceived community needs (e.g. ‘In your view, why do women seek services at CPCs?’). The interviewer encouraged respondents to lead the discussion to allow the factors they considered most salient to emerge. Respondents were asked the same basic questions to allow for comparison; however, they could dictate the depth and breadth to which they discussed a topic.

After transcribing the interviews, we coded the transcriptions using a flexible approach (Deterding and Waters 2021). We began by indexing the transcripts. Index codes (based on thematic sections of the interview guide) represent large chunks of text, which reduce the data into retrievable pieces and allow subsequent rounds of reading to be more focused and analytic coding to be more reliable. In this study, we read data from the most relevant index code called ‘CPC services’ and applied specific analytic codes. We coded for references to each service type, such as pregnancy counselling and ultrasound scanning, and created codes based on descriptions of services. We organised these codes into themes (ideology, connection to the state, and future directions). After applying analytic codes, the first author checked the codes’ validity by querying the intersection of the response category and the analytic codes.

Our initial analysis of interview data revealed several gaps in understanding about how certain CPC services work, as well as how these services fitted within the larger goals of the CPC movement. We took fieldnotes on agreement or contradiction with our interview codes. We coded these data looking for information to fill in gaps from the interview transcripts. Reported names are pseudonyms and no identifying information is provided.

Results

We first introduce those services that reflected CPC staff beliefs about poverty, such asindividual responsibility, and the need to address this through the provision of material aid. Second, we show that CPCs have become a direct arm of the state via the provision of parenting classes and pregnancy testing. Finally, we address the services that CPCs may emphasise in the future (e.g. ultrasound) and posit how those services will continue to intersect with more secular forms of provision.

Reflecting values shared by the state

Eight respondents reported that their centre provided free material aid for parents of infants in exchange for taking classes on parenting, abstinence or Bible study. These necessary and expensive items, such as baby and infant push chairs, nappies, and wet wipes, cannot be purchased via the Supplemental Nutrition Assistance Program (SNAP), and thus may be financial burdens. While CPC clients may receive an occasional gift, they are otherwise expected to earn material aid. Karli, a staff member at a rural CPC, described ‘Baby Bucks’:

[The clients] could do self helps [worksheets designed to help overcome personal problems], read brochures, and answer a few questions. If they, like, went to a community breastfeeding class or something like that, they could get Baby Bucks. It's basically just like play money and then they can purchase anything they need: cribs, strollers, car seats, diapers, formula, clothes, really anything. Instead of just handing it over, we want to instil better values and that they earned it.

Baby Bucks come from Earn While You Learn (EWYL), a programme developed by the Christian organisation Heritage House. EWYL covers a wide range of topics including parenting, family values,¹ sexual activity and intimate partner abuse. Karli explained the reasoning behind the programme.

Our society now, it's like ‘gimmie gimmie gimme’…In our society today, and especially in this community, no one wants to work. Everyone just wants to live off the government…They think they're entitled to everything, and we want to teach them a work ethic. You have to do something. We want you to learn and better yourself and then we will give you what you need. I mean, it's still free in a sense, but at least they're doing something for it and they're learning and they're bettering themselves.

Karli’s community had many stable jobs until a major employer pulled out of the area leaving thousands of people unemployed and, subsequently, seeking public assistance. Karli noted that while lack of employment opportunities is a local problem, the bigger issue facing clients was what staff referred to as an ‘entitlement mindset’ (that clients believed they were owed financial support without doing the work to achieve it) and poor decision-making. Heritage House curricular materials echoed this view, stating that ‘Giving things away free only enables our clients and fosters the entitlement mentality… The lessons they learn are crucial to the emotional and physical well-being of their babies and break cycles of poor parenting, neglect and abuse’ (Heritage House n.d.). Karli and other CPC staff expressed the belief that community members could lift themselves out of poverty by making the right choices and that their educational programming provided not only appropriate content, but also modelled the appropriate work ethic for clients.

Kimberly, the executive director of a rural CPC, also directly referenced a ‘handout mentality,’ using Karli’s same refrain of ‘Gimmie gimmie gimmie!’ Kimberly tied clients’ expectations of assistance without work to family background. She distinguished between those ‘easy’ clients who ‘come from a background where they had a good family home… They just need the extra help,’ and

… the more challenging clients who require more classes, because [they] come from a background, you know, their family life was not [a two-parent household]. They came from like a generational poverty situation, or an addiction situation or whatnot situation. Those take longer to pour into, because of the mentality. You're trying to educate and stuff like that. The mentality takes longer to change, that mentality of, ‘Gimmie gimmie gimmie!’ Handout after handout. We're not a handout program. We make them work for it…Sometimes that's a long process. Sometimes that may be when we're on a second or third child before [the client] gets there.

Kimberly sought to correct those whose background failed to emphasise personal responsibility for life outcomes. She and others attributed their understanding of the importance of family background to Bridges Out of Poverty, a popular educational workshop aimed at social service workers that promotes the ‘otherness’ of people experiencing poverty (Payne, DeVol, and Smith 2006). Bridges Out of Poverty borrows heavily from a culture of poverty approach, emphasising how the values of people experiencing poverty are fundamentally different to those of the middle class and relies on explanations of individual deficiencies while largely ignoring the structural reasons behind poverty (Lewis 1961).

At their core, staff see crisis pregnancy work as a spiritual mission to attract clients to Christianity, which ends up intertwining with their social service work. For example, Patricia, the executive director of a rural CPC, described allowing clients to do Bible study for Baby Bucks. She said,

We're a faith-based organisation. Number one is this… We let them choose the things that they want do. We've seen lives change because of that, as well. But here's the thing. They can go anywhere in town, anywhere in the county, and get free stuff. But the first thing they can get here is…. I'm concerned about them emotionally, physically, but I'm also concerned about them spiritually, okay?

Also linking conservative, Christian values and CPCs was the assumption that clients are engaged in problematic sexual behaviour, warranting their need for CPC services. Donna, the executive director of a rural CPC, described the CPC role as

… being a part of helping [clients] make healthy decisions and also helping with sexual health in general… Teaching them that there is a better way to take care of yourself, especially if you have a kid and you haven't even thought about getting married yet. [We want them to] start thinking about just making better decisions and be responsible in sexual choices as well.

Besides reinforcing their poverty, clients’ bad decision-making was seen as causing unintended pregnancy from improper (extramarital) sexual activity. Another way in which poor people place themselves in harm’s way is from not knowing any better. To rectify this, CPCs offer non-evidence based ‘Sexual Integrity’ classes to promote abstinence outside of marriage. These classes advance Christian values, with abstinence being a major component of Christianity and anti-abortion activism, and also conservative political values such as delayed gratification. This is in direct contrast to the non-judgemental environment often recommended for abortion counselling (Walker and Needle 2007).

Representing an arm of the state

As in most states, a network of formal agencies provides Ohio’s social services. These agencies often work together and with other organisations. Our results suggest that Ohio CPCs have become embedded within the state network of social services in three ways: through pregnancy verification, through court reunification activities, and through informal casework through networking. In the first two cases, CPCs formally carry out the tasks of the state.

To enrol in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Emergency Medicaid due to pregnancy, or other subsidised insurance programmes in Ohio requires pregnancy verification from a state-approved institution. All CPCs in our sample provided urine pregnancy tests free of charge, and six provided ultrasound services. While CPCs cannot legally diagnose pregnancy in Ohio (Ohio Administrative Code 2020), state organisations accept CPC tests as official pregnancy verification, as Linda, an executive director of a rural CPC, explained:

If a client comes in and thinks that she's pregnant, we perform a urine pregnancy test…. We are not diagnosing [pregnancy]. We are just saying this is what the test result was… But [this is] enough for [clients] to go to Job and Family Services and get signed up for Medicaid. They will accept our pregnancy [verification].

Through pregnancy verification, CPCs act as extensions of the state providing evidence about which residents are eligible for state services. Yet Linda’s response illustrates an incongruity in the state’s definition of pregnancy and diagnosis, whereby the state grants power to verify pregnancy to an organisation that legally cannot diagnose a pregnancy.

Representatives of the state such as health workers, social workers, lawyers and judges may refer clients to CPCs for parenting classes. All CPCs provided educational materials and six CPCs worked directly with the court system to provide parenting classes for the purposes of possible child reunification following loss of custody to the state. We found this to be a common practice in rural areas, where clients may have few choices for free court-approved parenting classes. CPC classes are administered in a one-on-one format, and interactions with CPC staff members during coursework have major implications for client reunification with their children. As the client services manager at a rural CPC, Jessica supervises client advocates who work with clients seeking reunification. She said,

With the reunification clients, we are very careful to do lots of details. Stuff like, are they late? [Do they have] a bad attitude? Because the case workers want to see that…We have clients that we don’t write letters for because they are really just here to get diapers.

Jessica’s quote illustrates the power of CPC staff in reunification cases. Based on their assessment, clients may fail to gain custody of their children for attending for the ‘wrong reasons,’ including violations of CPC staff’s ideology, such as seeking material aid for free. If they deem the client to be entitled and reflecting the wrong values, CPC staff may withhold the needed letter upon completion of classes.

CPCs engage with other agencies and non-profits who distribute state aid or services. In a policy context that relies heavily on securing grants, developing strong relationships with other actors via networking helped these CPCs to become trusted partners. To increase the relevance of her organisation in her city, Mary, the executive director of an urban CPC, began to network with local health organisations, particularly an infant mortality prevention group. She said,

I get out there and get [centre]'s name out there… I have to admit, [previous executive director] wasn't real good about getting out in the community and with the other larger centres coming in, we kind of got buried. And so, my mission in the last couple of years is to get my name, get [CPC]'s name back out there. We have a lot of social workers who will bring the girls in. We are on the list for all the hospitals… We do get referrals from a lot of different places…. plus going to this [infant mortality] coalition. [The county] started a new website… We're on there, and I love it. Under health services, we come up number one.

Reducing infant mortality is a primary state goal (CDC [Centers for Disease Control and Prevention] 2020; ODH (Ohio Department of Health) 2019), and through her interest in this area, Mary was able to increase her organisation’s visibility and promote the legitimacy of her CPC as a public health organisation.

Furthermore, because CPCs refer clients to state organisations (e.g. Medicaid), these organisations may in turn refer clients to CPCs. For example, Mary had developed a relationship with a local drug treatment facility whereby she referred clients for drug treatment and counselling at the facility, which in turn referred pregnant clients to the CPC. This extended the CPC’s legitimacy as a social service and healthcare organisation.

While CPC leadership aligned themselves with state social service providers, tensions within CPCs related to their mission emerged. Although CPCs express an anti-handout sentiment, they simultaneously promoted the use of social services (e.g. Medicaid and WIC). Executive director Kimberly talked about the danger of handouts, but at the same time, positioned her CPC to facilitate use of social services:

We do an intake form to see what situation brought them here today. We go into reviewing that intake, sitting down and talking with the client when she first comes in, showing her all the services that we have and what we can provide for her based on what she's told us. [We ask ourselves] ‘Ok, so where can we plug her in the community to get her the help that she needs? Besides what we're providing for her, like, does she need housing? Does she need a job? What kind of skills does she need?’ … We go from there and build the relationship, going through the program.

Kimberly helps clients access social services, which may contrast with some of her personal beliefs. Kimberly expressed the belief that many clients can access more benefits than her own family can. Through her paid position at the CPC and her husband’s job, her family earned just enough to not qualify for state social services. As most CPC staff are middle-class, white women from an evangelical or Catholic background, they tend to value not just an ‘espousal of economic libertarianism, but its advocacy of extensive statutory control over private morality, and proclivity for political authoritarianism and social control’ (Midgley 1990, 95). Advocacy for social welfare services may seem at odds with CPC staff ideology. However, it may be that the Christian beliefs of staff members and the importance of their spiritual mission may override the importance of their beliefs about welfare (Hussey 2020).

Future directions (foetal rights)

While CPCs endorse the state’s ideology and, in some capacities, act on its behalf, staff identified tensions between their stated mission (as imparted by the national organisations) and the realities of their clients.

By providing educational and training materials, national CPC organisations control messaging coming from CPCs (Care Net n.d.; Shaughnessy n.d.). The national organisations have debated the merits of providing material aid to non-pregnant people (Kelly 2014). In Anon (2018), a 2018 video titled ‘Why You Should Be Pro Abundant Life’ on the Care Net web page, CEO Roland Warren says, ‘When we see a woman facing an unplanned pregnancy, it’s that she needs to become a disciple of Jesus Christ… You can’t make disciples without material support. Moreover, you can’t make disciples without being involved in the political.’ Warren recognises that material aid is an important way to access a vulnerable population such as low-income pregnant people. Furthermore, a key way of accessing the funding needed to provide material aid is to become involved in the political system. While crisis pregnancy advocates recognise that material aid is popular and a way to gain legitimacy and connection with the state, this agenda has moved CPCs farther away from their goals: preventing abortion and bringing clients to Christ. In interview, Sarah, the executive director of an urban CPC, said,

In years past, we were absolutely, hands down seeing majority life-minded clients, which was not good because that is not our mission. In this past year, we got the ultrasound machine, and we also partnered with a marketing firm, which has helped us create Google ads that speak to the abortion-minded client, and actually get her in.

Here, Sarah clarifies that the mission is not to serve individuals who have already chosen to continue their pregnancy or who are not pregnant. Their mission must focus instead on clients who might choose abortion. Mike, another urban CPC executive director, echoed Sarah’s comments, saying, ‘2014 is when we really got focused, and said we have to help those that are facing unplanned pregnancies that are really abortion-minded and abortion-vulnerable. How can we help them to make a wise decision?’ To re-centre their work on individuals who might choose abortion, ultrasound technology has become a major component of their services. Sarah said,

Leveraging ultrasound is huge… Ultrasounds elsewhere are very, very expensive. At a Planned Parenthood they're easily $100-plus. … Ultrasound is a way for us to get them in our doors. More than that, it's not just a ploy. Like, ‘Come in!’ It truly is where we are going to get the most accurate information on their pregnancy that we believe they deserve…. Planned Parenthood, every ultrasound they make, they make money… We just want you to know what a nine-week child in your womb consists of. The rhetoric is that it is a blob of tissue, or that it's an unrecognisable mass. That's not true. … That’s really why ultrasounds became so crucial in these types of centres, because it's completing the fullness of truth that we want to offer them.

CPC staff’s interest in using ultrasound services to attract ‘abortion-minded’ people to their centres appears to fill a healthcare gap for low-income people, with significant consequences. For example, Hutchens (2021) reports that people who attend CPCs are frustrated by their experiences in the healthcare system, which they find to be impersonal and bureaucratic. CPCs recognise these frustrations and have positioned themselves as part of healthcare.

Courses such as Earn While You Learn also reveal tensions in the abortion-based mission of CPCs. For example, according to Heritage House, the purpose of Earn While You Learn is to connect with ‘abortion minded’ clients: ‘When counsellors are working to convince clients that the baby is alive, the fears of the future also need to be addressed. EWYL gives answers to those fears’ (Heritage House 2017). Heritage House messaging suggests that offering parenting classes should help convince clients seeking abortion to instead choose childbirth by providing them with skills and promoting the idea that people choose abortion because of fears about their ability to parent successfully. Furthermore, they hope that clients who have changed their minds will become recruiters and refer other people considering abortion to the centre. Yet, in part due to poverty and lack of cash assistance, most pregnant clients visiting CPCs and taking parenting courses at CPCs are individuals intending to continue their pregnancy (eKYROS, Inc. 2022). Thus, CPC staff do not meet their goal of changing people’s attitudes regarding abortion but rather are investing in promoting ideas about individual responsibility for poverty, which moves them away from their core mission and perhaps closer to the goals of the state.

Discussion

In this study, we found that CPC staff in Ohio provide pregnancy verification, parenting classes and material aid. In a context where politicians seek to promote anti-abortion initiatives, CPCs are well positioned to take advantage. Findings also reveal organisational tension stemming from concern that providing material aid may dilute the ability of CPCs to successfully target people who are considering abortion to dissuade them from going through with the procedure.

Previous studies have shown that CPC staff are motivated to work as part of a Christian spiritual mission and are less inclined to see their mission as political (Hussey 2020). Our results are in line with Hussey’s finding that there is ambivalence among staff at CPCs towards the ‘welfare state,’ with conflicting feelings between the need for aid to individuals and doubts about its effectiveness. We extend this work by illustrating that beliefs about the success of the welfare system extend into CPC interventions, particularly, material aid and the Earn While You Learn program. Staff report believing that pregnant people need aid to prevent abortion, but that clients have a ‘handout mentality,’ whereby they will try to secure more than they deserve. Conservative and Christian beliefs come together in the assumption that the low-income clients of CPCs have engaged in problematic behaviours, including sex outside of marriage and limited budgeting, that lead them to repeatedly need help.

Although CPC staff may see their mission as more spiritual than material, most are deeply engaged with the material needs of people in poverty (Hussey 2020). Clients want and need services (Kimport 2020), and CPCs have been well positioned to take over these activities. For example, TANF has long promoted marriage (Heath 2012), a core goal of CPCs, as a solution to poverty even though marriage is an unlikely path to financial success for poor women (Edin and Kefalas 2011). As social systems become increasingly overburdened due to reduced funding for social programmes, CPCs have found a niche for maintaining importance at the state level. Through their involvement with agencies such as Medicaid and the court system, CPCs become extensions of the state. By accepting pregnancy verifications or parenting classes from CPCs, the state extends legitimacy by treating CPCs like clinical facilities. Furthermore, the state does not need to accept pregnancy verification from CPCs because free pregnancy verification is provided at state-sponsored health clinics. Urine pregnancy tests used at home are indistinguishable from those at CPCs or medical facilities (FDA (Food and Drug Administration) 2019) and have dropped considerably in price. While passing this expense on to other entities may have once made economic sense, this is no longer the case. CPCs’ role in helping clients access governmental and non-governmental aid is a boon to a state led by conservatives such as Ohio, which is interested in reducing the number of state employees and transferring responsibility for Ohio residents living in poverty to non-government entities.

Our findings highlight areas of tension within CPCs as organisations. An important debate has emerged in the literature about what services CPCs will provide going forward, specifically, whether they will continue providing material aid in exchange for coursework, or whether they will reduce their material aid services in favour of focusing on ultrasounds (Kimport 2020). Kelly (2014) suggests that movement towards foetal rights as an exclusive practice is the result of a disconnect between the mission of the larger organisation, which is to intervene in unintended pregnancies that may result in abortion, and the daily realities faced by the ‘on the ground’ staff, who mostly serve individuals seeking material help rather than pregnancy options, counselling or abortion services. However, we found several CPC staff reported that pregnancy testing via ultrasound should be central to their mission and have taken steps to ensure this. Recent research on the other hand has downplayed the importance of pregnancy verification as few people in a study in the state of Louisiana sought these services (Kimport, Kriz, and Roberts 2018). Our findings are in line with Hutchens (2021) who found that in the case of ultrasound scans, CPCs fill an important gap in healthcare for marginalised and underinsured people. The current healthcare system lacks well-rounded reproductive healthcare and, in a system rife with economic inequality, CPCs can step in and exploit the desire to access these services.

Limitations

A primary limitation of this study derives from the fact that we were only able to interview CPC staff, not volunteers. Thus, the opinions expressed by staff, especially the executive directors, may reflect organisational ideology instead of day-to-day realities. However, for a study of organisational ideology, a focus on staff may be a boon. Furthermore, past work has excluded Catholic CPCs, due to their different cultural history than those operated by evangelical Christians. However, we did not find differences between evangelical and Catholic CPCs in terms of their service provision or relationship to the state; thus we do not differentiate between them in the present study. We did not however interview the most prominent CPCs in Ohio. This is important to note, as those CPCs may be the best positioned for state funding given their dedicated development directors who focus on fundraising and are often experienced in securing state funding. Further, the more prominent CPCs are also less well known for their religious activism. It could be that these institutions do less religious activism to be able to successfully procure state funding or, alternatively, they might more actively seek state funding as they lack financial support from religious donors to draw upon. Finally, our study focused on Ohio and findings from it may not be generalisable to other locations. While insights may be relevant to other states, some geographic areas may have different needs in the community or different connections between CPCs and the state. For example, Californian law restricts CPC activities, and thus this state likely has a different relationship with CPCs. Finally, given their orientation as conservative Christian organisations, CPCs are ill prepared to serve all types of people who may need abortion care (e.g. people in the LGBT community). Future research should consider the ways that these organisations engage with racial and gender minorities, for example, as they are also target populations for CPC services.

Conclusion

In summary, this study contributes to an expanding literature on the experiences of CPC staff. As such, it fills an important gap in a literature, which often focuses on the impact of organisations, but not the individuals who run these organisations and how the ideology of staff intersects with their CPC work. Our work also draws meaningful connections between anti-abortion and poverty work, an underexplored topic. Specifically, it shows how historical changes in social welfare have created service vacuums that CPCs can fill given their current commitments and shared ideology.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Disclosure statement

The authors have no conflicts to disclose.

Additional information

Funding

This study was funded by a grant from a philanthropic foundation that makes grants anonymously.

Notes

1 ‘Family values’ here refers to moral and ethical principles, especially those that pertain to family structure, function, roles and beliefs. The term is often associated with 1980s conservatives, especially those in the political-religious realm (e.g. Jerry Falwell, James Dobson). Family values in this context refers to the ideal of a two-parent household, with a father as breadwinner and mother as caretaker.