Changes to the Title X family planning programs have brought onboard a new kind of reproductive health clinic. What does that mean for patients?

Signs for COPE Pregnancy Center in Montgomery, Alabama. (Photo: Robin Marty/Flickr)

When I wanted birth control in those lean years during and after college, I knew what to do. I looked up the nearest Planned Parenthood, which was just a bus ride away. There, I would see a doctor, or sometimes a nurse practitioner, who would give me a quick exam, then send me home with a year's worth of pills, packed into a brown paper bag. I didn't even have to go to a pharmacy. The appointment and pills were both priced on a sliding scale, based on my income. I don't remember how I first learned about Planned Parenthood—a sign of its brand recognition.

A decade later, for some folks in my position, the landscape looks different. Historically, Planned Parenthood has been a major recipient of federal money for family planning. In its latest round of funding, however, the Department of Health and Human Services declined to give grants to Planned Parenthood affiliates in several states. Instead, the government funded more general health clinics, as well as one headline-grabbing institution: Obria Group, a faith-based network of clinics that's philosophically opposed to contraception and abortion, according to an email from the group's chief executive officer, Kathleen Eaton Bravo, obtained by the pro-choice Campaign for Accountability. (A spokesperson for Obria Group said no one was available for an interview and wouldn't answer specific questions I sent in an email.)

Clinics like Obria's have never before qualified for grants under Title X of the Public Health Service Act, which offers taxpayer money to help poor Americans afford family planning services. Under changes the Trump administration made to Title X, however, they now qualify. It remains to be seen who these clinics will serve—if they'll take on patients who used to go to Planned Parenthood or similar facilities, or if they'll find new visitors altogether. Either way, research suggests these patients' experiences will be quite different than if they'd gone to a more traditional Title X-funded clinic.

There are a couple of ways to look at what it's like to go to a pro-life reproductive health clinic. First, how effective are the family planning methods these clinics champion? There's solid research about this. Second, will clients like them? Title X-funded, anti-contraception, anti-abortion clinics are a new phenomenon, so it's hard to say for sure. There have been a few—but not many—studies of their predecessors, which are sometimes called pregnancy resource centers, or crisis pregnancy centers.

These centers' primary mission is to convince women with unwanted pregnancies not to get an abortion. Historically, they didn't provide much in the way of medical care: typically just pregnancy tests and maybe ultrasounds, plus free baby supplies and conservative parenting classes (which might emphasize the importance of being married to an opposite-sex partner, for example). Some centers have made the news for giving clients inaccurate information about the risks of abortion, or pretending to provide abortions, to lure people in. Now, however, some are trying to provide more medical services, in a bid to earn government funding and become pro-life alternatives to Planned Parenthood, as Obria Group's website describes and Politico reported last year.

So how can a clinic that opposes contraception provide family planning services? Obria plans to encourage abstinence until marriage, especially with its teen clients, and to promote an app that helps users track when they're fertile, the Washington Post reports, based on documents obtained through the Freedom of Information Act. A statement that Obria's spokesperson sent me lists "sexual risk avoidance education"—a newer name for abstinence-based education—among the services it provides, but not fertility tracking, nor any other method of family planning.

Abstinence education for adolescents has been shown, over and over again, not to work. Teens who undergo it are no less likely to have sex, have no fewer sexual partners on average, and are no more likely to delay having sex, than teens who didn't take classes on abstinence. On the other hand, teens who get comprehensive sex ed are less likely to become pregnant and less likely to acquire HIV and other sexually transmitted infections, as one systematic review found.

Meanwhile, fertility tracking works to prevent pregnancy for more than 95 percent of people who do it perfectly, according to the American College of Obstetricians and Gynecologists. Many users, however, aren't perfect. Under typical conditions, 12 to 24 out of every 100 people who use fertility tracking will get pregnant when they don't want to.

Other methods of contraception that Obria clinics seemingly shun have better success rates, under typical conditions. Hormonal birth control pills, patches, and rings fail 9 percent of the time, while IUDs and sterilization procedures fail less than 1 percent of the time. Hormonal methods become more than 99 percent effective when they're used perfectly.

It's unclear what Obria's stance is on condoms, which are about 82 percent effective at preventing pregnancy, under typical conditions, and 98 percent effective when used perfectly. They're also the only birth control method that also prevents the spread of sexually transmitted infections.

To fulfill requirements from the government for its Title X money, Obria will partner with clinics that offer hormonal contraception and sterilization, according to plans the Washington Post obtained. Researchers fear, however, that the extra step may discourage some patients from going through with getting birth control.

"Being told that now you have to go to another place, make another appointment, take time off work, figure out child care, figure out transportation—all of those things will contribute to at least some people not completing that pathway," says Katrina Kimport, a sociologist at the University of California–San Francisco's Advancing New Standards in Reproductive Health program, who has surveyed prenatal and abortion patients at pregnancy resource centers.*

"I think they're certainly going to cause more unwanted pregnancies than if an actual comprehensive clinic were available," says Kimberly Kelly, a sociologist at Mississippi State University who embedded for two years in a pregnancy resource center in the South, to observe its practices.

In addition, clinics like Obria don't refer for abortion. Indeed, the Trump administration's latest changes to Title X forbid any grantee from doing so. Kelly argues that this may lead to some clients getting abortions later than they would otherwise, or even being delayed so much that they aren't able to get an abortion at all, either because local laws forbid it, or because there's no nearby clinic that performs later abortions. "Imagine if you don't know Obria doesn't perform abortions or even refer for them. You save up money for the procedure. Oh, you don't refer for that? You have to start all over again," she says.

As for how clients will like going to an anti-abortion reproductive health clinic, it may depend on what they're going for, and what their pre-existing beliefs are.

It's not hard to find uncomfortable or even horrific stories about crisis pregnancy centers. They appear in magazines; in studies of centers by Kimport and Kelly; in lawsuits, dating to the 1990s, detailing how staff at centers pressured clients into giving their babies up for adoption. One woman Kimport interviewed described the lengths to which staff at a Texas pregnancy resource center went to prevent her from leaving the premises, after she'd asked for an abortion: "The female ultrasound tech and then the fatherhood coach are both standing at the door physically blocking our exit, and they're just nailing us with: 'God wants you to keep this baby. It's a baby, not a fetus!'"

The experience, the interviewee said, "kind of haunts me." She went on to have an abortion a few days later.

At the very least, numerous studies and investigations have documented centers giving their clients inaccurate information suggesting abortions are more dangerous than they really are. Obria clinics offer medication abortion reversal, which is scientifically unproven.

Still, many of Kimport's interviewees, who planned to keep their pregnancies, liked the crisis pregnancy centers they visited. "They felt clean and friendly, and people were nice to them, and for some of them, that was in contrast with their experience receiving health care [elsewhere]," Kimport says. Most clients quickly realized the nature of the centers, too, after talking with staff. "Once the lady explained a little bit, I realized then, like, OK, maybe this is not a clinic," one of Kimport's interviewees said. "It's them persuading [patients] to not have an abortion."

Many of Kimport's interviewees were poor. They appreciated that the centers gave them free pregnancy tests, which some used to apply to government aid programs for low-income expectant mothers. They got free prenatal vitamins from the centers and the promise of pricey necessities, like a car seat or crib, for free, if they kept coming back. "That was very appreciated," Kimport says. Some had staff offer to pray with them, which they liked.

Kimport found three women who had gone into a crisis pregnancy center considering abortion, but were convinced to choose parenting instead. Two felt conflicted to begin with, while one was told, after an ultrasound, that she was 18 weeks and two days along. Her family already didn't support abortion, and the counseling had made her feel "pretty bad" about wanting one, she said. Nonetheless: "A big part of me felt like I was going to get the abortion if I was able to," she said. Her local clinic would only perform abortions on pregnancies up to 18 weeks' gestation, however. She decided to keep the pregnancy. All three women said they ultimately were happy they continued their pregnancies, and would recommend a pregnancy resource center to a friend.

Critically, Kimport only surveyed women who were pregnant at the time they went to visit a pregnancy resource center. Why would you go to one otherwise? There's little direct evidence of what happens if what used to be a pregnancy center begins seeing patients who want contraception or testing or treatment for sexually transmitted infections—the services that form the bulk of Planned Parenthood's work. Kelly and Kimport had different guesses.

Kelly is prepared for disaster. "I think it's going to mess up a lot of people's lives," she says.

Kimport thinks horror stories from patients are less likely. After all, most of her interviewees quickly understood the nature of the centers they visited and liked the staff. Other interviewees had an experience that might have ranged from uncomfortable to emotionally traumatic, but eventually got the abortions they wanted, anyway.

Instead, Kimport thinks the consequences could be more subtle. Title X clinics and crisis pregnancy centers serve poor Americans and, disproportionately, Hispanic and black Americans. Middle-class and wealthy white Americans never expect to go someplace like this, to speak to staffers like the ones Kimport's inteviewees met with, when they are pregnant or want birth control.

"Why is this a different standard of care that is being offered to low-income women, disproportionately women of color? Why isn't this everyone?" Kimport says. What if every American imagined that this is what reproductive care looked like for them? What would they support then?

*Update—August 9th, 2019: This post has been updated with the correct institution where Katrina Kimport works.