After she felt nauseated frying eggs for her kids, a 26-year-old named Alison took a pregnancy test. Then she drove straight to Pregnancy Decision Health Center, located in a strip mall near her home on the west side of Columbus, Ohio. The positive test didn't make sense to her, since she was on the Pill. Alison (who asked Cosmopolitan not to publish her last name) didn't yet know a course of antibiotics had interfered with her birth control. But did she know she wanted an abortion as soon as possible.
Alison had visited the Pregnancy Decision center multiple times during her first two pregnancies, when kindly staff had given her referrals to aid agencies and a basket of baby clothes. She hadn't received any indication the center was an anti-abortion organization, she says—the place looked like a regular medical office, staff performed ultrasounds, and no one made any mention of God.
This time when she arrived at Pregnancy Decision, Alison told a counselor that she and her then-boyfriend—working hard to get off welfare—couldn't afford another baby. "I was really scared," says Alison, who describes herself as very emotional person. "I assumed she'd say, 'This is why we're here.'" Instead, staff told her that the Bible forbids abortion.
In fact, Pregnancy Decision was co-founded by Peggy Hartshorn, who went on to become president of Heartbeat International, which describes itself as the world's largest anti-abortion pregnancy center organization. Heartbeat's network includes 1,800 affiliated nonprofit centers worldwide, including several Pregnancy Decision locations. Throughout the country, at least 3,000 crisis pregnancy centers offer free pregnancy tests and "options counseling." And increasingly these anti-abortion centers are being positioned as healthcare providers. It's a trend I witnessed during a year of interviews with dozens of pregnancy center workers, volunteers, physicians, and anti-abortion activists. Confronted with criticism that they are running deceptive fake clinics, pregnancy center directors have begun acquiring medical equipment and affiliating with doctors and nurses who share their ideological message.
Last year I attended Heartbeat International's annual conference in Charleston, South Carolina, where roughly 1,000 crisis pregnancy center staff and anti-abortion leaders gathered for training and networking. There, I heard movement leaders directly instruct pregnancy center workers to "compete with the abortion industry" by concealing their religiously motivated anti-contraception and anti-abortion mandates. Suggested tactics included operating multiple websites with different messaging, choosing pro-choice seeming names like "pregnancy options," removing religious paraphernalia from waiting rooms, and advertising free medical services and counseling.
Ohio, like other states, has increased funding for crisis pregnancy centers while moving to restrict funding for providers like Planned Parenthood that provide a full range of reproductive health care. In Ohio, as in many other states, the use of public funds for abortion has been restricted for decades, but this fall its legislature voted to defund Planned Parenthood's other services, including ob-gyn care, domestic violence counseling, HIV-AIDS programming, and more the nonprofit provides low-income women. Republican Governor John Kasich, a candidate for president, will most likely to sign the bill into law. Meanwhile, in its most recent budget, Ohio allotted crisis pregnancy centers $1 million for the next two years.
The day Alison came in for her appointment, knowing already that she wanted an abortion, Pregnancy Decision staff treated her very differently than when she'd arrived excited to be pregnant. A counselor, nurse, and ultrasound technician read Alison Bible passages, as she cried, and urged her to carry the pregnancy to term. She remembers the women saying, "Being a single mom is the toughest thing you can do, and you already did it. God won't give you anything you can't handle."
"It was almost like bullying," Alison says. "I felt set up. The name is Pregnancy Decision. I didn't know they were against abortion. It was intimidating. They tried to make me feel extremely wrong, like I was sinning."
For Alison, a churchgoer and self-described "God-fearing woman," that message was especially upsetting. But she stayed at Pregnancy Decision to get an ultrasound, which she assumed would indicate how advanced her pregnancy was.
It was an urgent question for her, as it is for many women. A woman's stage of pregnancy affects which kind of abortion is available. Alison knew she wanted to use the abortion pill, which usually can be taken up to about nine weeks; after that, doctors usually recommend surgical procedures.
At Pregnancy Decision, the sonogram technician said she couldn't find anything on the screen. The nurse said Alison might miscarry naturally. Alison hoped so. (At the Heartbeat conference I attended, I heard staff people say that presenting miscarriage rates could help persuade a woman she didn't need to "rush into" having an abortion.)
When her ultrasound wasn't conclusive, Pregnancy Decision staff did not refer her to a physician or another provider, Alison says. Instead, they scheduled her for a second appointment the following week. She says she didn't know anywhere else she could walk in, be given an immediate appointment, and get a free ultrasound.
Alison came back for two more appointments, until she says center staff told her the fetus was older than they had first anticipated. In the ultrasound image Pregnancy Decision gave her, two arrows point to the fetus, which is labeled "Baby." She says the Pregnancy Decision staff gave her a packet of pamphlets on fetal development at her stage of pregnancy, and leaflets with Bible verses. When she scheduled an appointment with an abortion clinic, staff told her she was too far along to take the abortion pill at home. She would need to have a surgical procedure, which must be done in a clinic and is usually more expensive. (Pregnancy Decision Health Centers director of operations, Julie Moore, said the organization would not to comment for this article.)
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As they push to discredit and defund Planned Parenthood, leading Republicans, including GOP Presidential candidates, have presented crisis pregnancy centers as worthy, even preferable, alternatives for public funding and support. Carly Fiorina— who gave the keynote address at the 40th anniversary gala for Americans United for Life, arguably the country's most powerful anti-abortion organization— has been especially vocal in maligning Planned Parenthood and was photographed in a South Carolina pregnancy center's ultrasound room. Jeb Bush, Ted Cruz, and Scott Walker, all took turns campaigning at the Carolina Pregnancy Center in Spartanburg, South Carolina. There and elsewhere, Bush has emphasized his "most pro-life" record by making the false claim that under his leadership, Florida was the only state to sponsor crisis pregnancy centers. (In reality, Pennsylvania began funding them in the early 1990s, under Bob Casey, an anti-abortion Democrat who opposed public funding for contraception.)
Marco Rubio—who has said repeatedly that he does not believe women should have abortions even when their lives are endangered—told Fox News that he wants Planned Parenthood's funding transferred to other healthcare centers "that don't do what Planned Parenthood does, but do provide women's healthcare, which is important." For decades, anti-choice leaders have been savvy about shape-shifting their movement. As Kimberly Kelly, associate professor of sociology at Mississippi State University, has documented, the very idea of promoting pregnancy centers originated as response to the criticism that pro-lifers care more about fetuses than pregnant women. In the 80's and 90's, anti-abortion legal strategists recommended legislators push for "abortion alternatives" programs alongside mandatory waiting periods and parental consent laws. "Going medical," as pregnancy center counselors say, is the latest way they are staying a step ahead of pro-choice critics.
Heartbeat International's "Pregnancy Help" database, now lists over 1,000 pregnancy centers that offer "medical services"—which means they can provide ultrasounds, according to Heartbeat's website—scattered across the country. Their spread has dovetailed with laws in 13 states that now require ultrasounds before abortions, regulations pushed by anti-abortion lobbyists and legislators. At the Heartbeat Conference I attended, speakers described how they wanted affiliated centers to be "abortion-minded" women's first option for services. Staff discussed how they consider ultrasound images an unparalleled tool for showing a woman that—as they see it—the fetus is a living person who deserves to be born. Research suggests the tactic doesn't dissuade women. About 98 percent of women who looked at ultrasound images proceeded with scheduled abortions, according to a study published in 2014 in the journal Obstetrics and Gynecology.
"Going medical" also allows centers to market themselves as a trusted source for health advice. Pregnancy centers routinely counsel women and distribute materials about the supposed health risks of abortion, including debunked claims that abortion increases the risk for domestic violence, despair, infertility, breast cancer, and more. Anti-abortion groups that provide materials to pregnancy centers cite fringe reports that abortion procedures themselves are risky. In reality, complications from abortions performed by qualified medical personnel are extremely rare, according to multiple studies, including a 2014 report published in Obstetrics and Gynecology. Another Obstetrics and Gynecology study, published in 2012 and based on Centers for Disease Control data, showed that a woman is 14 times more likely to die from childbirth than during a legal abortion.
Crisis pregnancy centers disproportionately interfere with young and low-income women's access to accurate information and care, says Joanne Rosen, associate director of the Clinic for Public Health Law and Policy at the Johns Hopkins Bloomberg School of Public Health. "In some states—for example, Texas and Mississippi—restrictions have dramatically reduced the number of abortion clinics and have severely impaired women's access to timely abortion procedures. Against this backdrop, the strategies employed by CPCs may constitute an even greater threat to a woman's ability to obtain an abortion."
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"We can look like a medical clinic because we are," explains Lori Szala, executive director of Pregnancy Resource Center, in the South Hills, a suburb of Pittsburgh. "We're not doing anything deceptive there at all."
Pregnancy Resource Center shares a brown brick medical complex with dentists and infectious disease specialists. On its sign facing the road, the pregnancy center advertises, "Free Pregnancy & STD testing." On its website, the center offers "Pre-Abortion Counseling and Education," with trained ultrasound technicians and nurses. Women in lab coats smile; Christian imagery is absent. Inside, a receptionist sits behind a window adjacent a waiting area with stuffed couches. A pine door is marked "Ultrasound Room."
Pregnancy Resource Center belongs to Care Net, an evangelical organization that prohibits its 1,160 affiliated centers from providing or referring for contraception or abortion. And deep-pocketed and politically connected anti-abortion organizations are working behind the scenes to make medical pregnancy centers like this one possible. Focus on the Family, an organization whose mission is "nurturing and defending the God-ordained institution of the family and promoting biblical truths worldwide," has funded 676 grants for ultrasound machines or sonography training in all 50 states. Americans United for Life, a legal organization that works with legislators to write abortion restrictions, has helped Heartbeat and Care Net to advance their political strategy. When I requested to visit Pregnancy Resource Center, Gavin Rhoades, a public relations representative affiliated with the anti-abortion organization Online for Life—funded by Texas billionaire Farris Wilks—arranged my visit and then flew from Texas to chaperon my conversation with Szala.
Szala referred to the center interchangeably as a "clinic" and "ministry," and said her goal was to "walk beside" women with unplanned pregnancies and show them compassion. She said, "Success for us would be that [a woman] chooses life, of course." She doesn't believe abortion is ever the best option and explained that her staff counsels women on abortion's "risks."
Before I arrived, a local physician, Colleen Krajewski, had told me that her patients sometimes tell her they've visited nearby pregnancy centers. "I can't know what the centers tell them, but I know patients come in believing myths," she said. In one especially stark case, a patient told Dr. Krajewski she'd had an ultrasound at Pregnancy Resource Center. Dr. Krajewski says the patient cried that she didn't want to become infertile or "hear the baby splash in a puddle of blood," and that she worried for her children—she believed there was a ten percent chance she'd die during an abortion. "Some patients are embarrassed to admit that they were at a pregnancy center—what they heard was just so shameful," Dr. Krajewski says.
"I don't think anybody here would quote a percentage, because we don't know that for sure, and wouldn't tell her that she's going to die," Szala said, when I told her about what Dr. Krajewksi had said about her patient. She stressed that her staff presents health risks simply as possibilities and that she defers medical questions to the nurse, whom I was told was not available to speak to me. "I'm not medical," Szala said.
Yet when we spoke Szala had been working with women at Pregnancy Resource Center for 14 years. The center's website notes she leads a team of full and part-time center and medical staff, and is also governed by a board of directors and an advisory board overseen by a local medical professional. Medical pregnancy centers often operate under the direction of unlicensed staff like Szala and the license of a physician who doesn't actually see clients at the center. Nurses and technicians usually report to that physician. Generally, pregnancy centers only offer "limited ultrasounds," meaning they can only confirm a pregnancy, not diagnose any problems.
Szala said that roughly half of Pregnancy Resource Center's clients "might come in considering abortion as their No. 1 option." She explained, "I think a lot of people are looking for free services, so even if somebody is calling around just looking for a place to go and … you offer something for free, [making an appointment] might be the first step that they take before they go to pay for a procedure."
I explained that I couldn't find indications that the center did not provide abortions on its website and asked Szala whether she'd ever considered putting Christian imagery on the site, to make the center's mission clear. "We are a Christian ministry," she said, but added about the imagery, "I don't know that we need to have that there." She explained that staff simply offers their Christian perspective as an option when a client brings up questions of faith. Later that day, Rhoades emailed me directions and I found the abortion disclaimer on one of the site's pages.
It is not uncommon for women who arrive at crisis pregnancy centers to believe they going to abortion providers, according to staff who spoke at the Heartbeat International conference I attended. And, says Dr. Krajewski, "some are angry because of the delay." She emphasizes how time-sensitive abortion is. In Pennsylvania, like many states, abortion is prohibited after viability—at about 24 weeks. In other states, abortion is restricted after 20 weeks. As states pass increasing restrictions on abortion providers, the number of clinics is dwindling in many states—which means longer waits for an appointment and longer drives to get there. The cost of an abortion tends to increase after the twelfth week of gestation. Not to mention that many women count their stage of pregnancy as a factor when they're weighing whether to have an abortion at all. If a "medical center" turns out to be a Christian ministry and a woman needs to wait weeks to secure another appointment at a full-service healthcare provider like Planned Parenthood she could pass the gestational limit for certain—or all legal— procedures.
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Alison called me right when she got home from her abortion. For several nights she'd had trouble sleeping. "I caught myself looking at the ultrasound pictures when my kids were asleep," she said. "I'm strong-willed, but I worried I was going to be a murderer, I was going to lose my relationship with God. Their words kept repeating in my head. I felt like I had to choose between my unborn child and my children." Shaken, she visited her pastor, who told her that no one who judges or shames speaks for God.
In November 2014, the very month Alison spent waiting for a conclusive ultrasound report from Pregnancy Decision, the Ohio House of Representatives passed a resolution commending pregnancy centers, saying the sites "provide comprehensive care" to meet women's "physical, psychological, emotional, financial, career, and spiritual needs," and recommending that the state and federal governments should better support crisis pregnancy centers. Similar resolutions have passed across the country, all based, seemingly word for word, on a model law drafted by Americans United for Life. Heartbeat International and Care Net sent the language to their affiliated centers, calling the resolution a "preemptive strike" against critics and including instructions on how to present it to local officials.
Meanwhile, since Kasich took office in 2011, he has signed a raft of anti-abortion laws, and the number of abortion clinics in the state has dropped from 16 to nine.
"I think it's BS. It's heartless," Alison says of Ohio's praise of pregnancy centers. "[Pregnancy centers] make everything about religion. They make everything about how you're killing your baby instead of making anything about the wishes of the mother. They say, 'You don't know God's will.' I know I don't."
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