Do Crisis Pregnancy Centers in North Carolina provide women

with accurate and useful medical information?

The University of North Carolina at Greensboro
Sana Ansari
Alesha L Cooke
Jennifer Herget
Eliana Ribarsch
Casey Thomas

History and Background

In 1967, Robert Pearson opened the first Crisis Pregnancy Center (CPC) in the United
States in response to legalization of abortion in his home state of Hawaii. In an effort to support
the anti-abortion movement, Pearson later organized a national based organization to establish
several more CPCs around the country (Dupuy, 2009). CPCs are designed to appear as nonprofit
community centers or clinics. They promote themselves as low-cost or free clinics where women
can receive pregnancy testing, ultrasounds, counseling on pregnancy options, parenting classes,
temporary housing, and tangible items such as diapers (Belluck, 2013). Most of these centers are
not medically licensed facilities and as a result do not have medically trained professionals on
staff. Unlicensed staff members often perform services recommended for pregnant women by
the American Academy of Pediatrics and the American College of Obstetricians and
Gynecologists, such as prenatal care and gynecological exams (NPCNCF, 2011).
Many CPCs are operated by openly far-right Christian groups. Not all of the centers are
overtly religious, but the top three CPC networks in the U.S. are registered with the Internal
Revenue Service as faith-based organizations (Resnick, 2012). Since CPCs were started in
response to abortion legalization and are run primarily by far-right organizations, they have
strong anti-abortion views that influence the perspective of care and advice given by the
employees.
CPCs greatly outnumber healthcare providers capable of providing abortion services in
North Carolina, four to one (NARAL Pro Choice North Carolina Foundation, 2011). Currently
there are over 2200 Crisis pregnancy centers nationwide. These CPCs are eligible for federal
abstinence-only education grants because their primary mission is to promote abstinence (The
Womens Legal Defense and Education Fund, n.d.). North Carolina alone has over 122 CPCs.
Thirteen states currently directly finance crisis pregnancy centers, while 27 states in 2011 offered
Choose Life license plates that indirectly funded the CPCS (Belluck, 2013). In North Carolina,
there have been several failed attempts, and one successful attempt, to fund CPCs.
One of North Carolinas failed attempts was passing a bill to issue Choose Life license
plates beginning in March of 2011. These license plates would have donated a portion of the
specialty tag fee to CPCs. A federal appeals court ultimately ruled that North Carolinas attempt
to offer a Choose Life license plate without providing an abortion-rights alternative was
unconstitutional, and the plates never went into production (Jarvis, 2014).

Another failed attempt was the passing the N.C. Womans Right to Know Act in 2011,
which stated that a woman who is seeking an abortion must have an ultrasound 24 hours to 72
hours before it takes place (General Assembly of North Carolina, 2011). This would have placed
a burden on all women seeking abortions, especially on low-income women who do not have
insurance. In order to have an abortion, these women would need to seek out low-cost or free
ultrasounds. Under this law, the state would have been required to keep a list of free and low-cost
ultrasound providers to assist these women, many of which are CPCs. By directing low-income
women to CPCs, the state was supporting their operations. A federal judge struck down this law
in 2014, declaring it unconstitutional (Zucchino, 2014).
One of North Carolinas successful attempts to fund CPCs came in May 2013 when the
North Carolina senate redirected $250,000 from the Womens Health Services fund to the
Carolina Pregnancy Care Fellowship (Planned Parenthood Health Systems, Inc., 2013). This
organization funds CPCs throughout North Carolina. The Carolina Pregnancy Care Fellowship is
the North Carolina contact for Choose Life, Inc., a national anti-choice organization (Planned
Parenthood Health Systems, Inc., 2013).

Evaluation/ Effectiveness
These networks of CPCs are not wrong for taking a stance on their beliefs about abortion
and birth control. However, CPCs operate with a lack of transparency. Many of the centers
promote their services as an alternative to family planning centers, while their agenda is actually
anti-abortion (Resnick, 2012). From 2010 - 2011 NARAL Pro-Choice North Carolina
Foundation conducted an investigation of CPCs operating within the state of North Carolina. The
foundation investigated 66 of the 122 CPCs present in the state. Findings from their research
reveal the anti-abortion status of several of the centers, the dissemination of misleading and
inaccurate medical information, and the targeting of an at-risk demographic. More than half of
the CPCs (70%) expressed a dislike for abortion; however, only three of the centers disclosed an
anti-abortion status on their intake forms. The CPCs utilize deceptive practices through
advertising, as well as creating an atmosphere to mimic that of a real medical facility (NARAL
Pro Choice North Carolina Foundation, 2011). Sixty Seven percent of the centers examined
provided distorted information about the risks and consequences of abortion. The CPCs

specifically target college-aged women, African-American women, and Latinas. These

populations are identified as more likely to receive abortion services than others (2011).
CPCs are not held to any state standards and/or legislation that prevent fraudulent clinic
practices or ensure accuracy in medical advertising. A few cities around the nation have tried
regulating centers with ordinances requiring them to post signs stating that they do not provide
abortions or contraceptives, and disclosing whether medical professionals are on-site, but the
laws were blocked by courts after CPCs claimed they were free speech violations (Belluck
2014). As state funded facilities CPCs use millions in tax dollars to provide misleading
information women (SIECUS, 2006). In doing so the centers are hindering the ability of women
to make informed and responsible decisions. Access to accurate, non-misleading health
information is a right, protected by the government, under the Federal Trade Commission.

Landscape
Stakeholders:
Pregnant women seeking options counseling and inexpensive medical care
Pregnant women who are seeking options, counseling, or less expensive medical care
need accurate information regarding the options available to them at this vulnerable time in their
lives. They also need accurate medical information in order to ensure that they can make a
decision about whether or not to terminate their pregnancies. In a recent study of CPCs in North
Carolina, almost a quarter of women who called were informed that they did not need to make
any decisions early on, because of the high likelihood that they might miscarry (Bryant and Levi,
2012). This information was given without any insight into the gestational age of the callers
(Bryant and Levi, 2012). Additionally, in a separate study of CPCs conducted in North Carolina,
92% of the centers surveyed employed no medical personnel, but only 24% admitted this (Bryant
and Levi, 2012). Pregnant women who are seeking counseling and inexpensive medical care are
looking for accurate information that will allow them to make the most medically sound
decisions for themselves, regardless of how they intend to handle their pregnancy.
Women seeking birth control or family planning advice
Women who are seeking family planning advice need information that will assist them in
their family planning. Women were informed that condoms were not an effective form of

contraception by 92% of the CPCs surveyed in a North Carolina-based study (Bryant and Levi,
2012). Given that North Carolina has 122 CPCs, it is important for women seeking family
planning advice to be given accurate information. (NARAL Pro Choice North Carolina
Foundation, 2011)
Medical practitioners
Medical practitioners, who provide services to women seeking family planning advice,
pregnancy care, and neonatal care, have to combat misinformation spread by CPCs. This is not
limited to OB practitioners, but to any doctor who needs to inform their patients that the risks of
cancer and infertility are not increased by abortion. Given that 92% of CPCs do not have medical
staff on-site, but only 24% admit that their staff does not have medical expertise, patients may
not know that they are not receiving assistance from medical professionals (Bryant and Levi,
2012). This increases the amount of misinformation that licensed medical practitioners must
combat in order to keep North Carolinas women healthy.
Pregnant women who need medical proof-of-pregnancy verification for enrolling on
state insurance
Pregnant women who need medical proof-of-pregnancy verification for enrolling in state
insurance, and other women who need such verification for their private insurance programs,
need access to safe ultrasounds. Not having access to safe ultrasounds can put the pregnant
woman and her fetus at risk for merely fulfilling a requirement to enroll in state insurance. A
study determined that 35% of CPCs visited provide ultrasounds on site, but only 8% of all CPCs
had medically licensed staff (Bryant and Levi, 2012). Given that CPCs are not legally required to
have ultrasound technicians on-site, but that over a third of them perform ultrasounds, they are
posing a risk to the ability of pregnant women who need medical proof-of-pregnancy verification
to get insurance.
Crisis Pregnancy Centers
CPCs in North Carolina outnumber abortion providers 4 to 1 (NARAL Pro Choice North
Carolina Foundation, 2011). They provide medical services such as ultrasounds and STI testing,
as well as information about options that women have during pregnancy. Most CPCs intend to

prevent women from getting abortions by providing them with information regarding all of their
options. For example, the Pregnancy Resource Center in Charlotte states on their website that
Pregnancy Resource Center does not perform abortions or arrange adoptions...Before you visit
an abortion clinic in the Charlotte, NC area, we hope you'll visit us for information about your
choices, your health and for pregnancy verification. They are clear that they do not perform
abortions and are steering women away from abortion clinics. However, many CPCs do not
specify the nature of the services they offer women in their advertisements or when women call
them to make appointments.
A study by NARAL Pro Choice North Carolina determined that 48% of CPCs provide
inaccurate advice regarding birth control and 64% provide no accurate information on modern
contraceptive methods. Many CPCs suggested that women wait to make reproductive health
decisions until abortion is no longer an option, while 24% of CPCs even encouraged to wait and
see if they may miscarry before deciding whether or not to abort (NARAL Pro Choice North
Carolina Foundation, 2011). The tactics of CPCs in North Carolina prove that they are interested
in preventing women from getting abortions by providing misinformation.
Despite advertising medical services to potential clients, CPCs are not required to provide
visitors with a licensed physician on staff, health and safety standards for hygiene, employee
qualifications and supervision, and evaluated quality of care. They are also not required to keep a
patients identity confidential in order to avoid penalty of injunctions and fines (NARAL Pro
Choice North Carolina Foundation, 2011). CPCs are also not subject to inspection by the North
Carolina Department of Health and Human Services. While other entities that provide health care
are subject to these standards, CPCs are protected by the same laws that protect volunteers as
Good Samaritans (NARAL Pro Choice North Carolina Foundation, 2011).
The North Carolina State Legislature
Governor McCrory signed S.B. 402 on May 21, 2013. This bill grants $250,000 of the
budget to the Carolina Pregnancy Care Fellowship. This is a religious organization that provides
funding and support to CPCs in NC (Planned Parenthood, 2014).
Our majority Republican House and Senate have voted on limiting access to abortion by
passing HB730, restricting abortion coverage on health insurance. Their voting record is
indicative of being against any project that is seemingly pro-choice or might be associated with

abortion (Planned Parenthood, 2014). In the current political climate, measures that are seen as
promoting access to abortion are unlikely to pass.
The North Carolina Department of Health and Human Services (NCDHHS)
The North Carolina Department of Health and Human Services visits medical facilities
every three to five years to provide inspections. Currently, there are 10 full-time staff members
who perform this task. Adding 122 CPCs, along with other non-profit entities that provide
medical services and advice, to the list of sites they need to visit could negatively impact their
ability to perform the inspections they currently do given the limited amount of staff available
(Moffit, 2013).

Key Factors
Political Factor: Who supports the current operations of CPCs and how powerful are they?
CPCs have received $250,000 from our current legislature. Additionally, the previous
legislature supported other anti-abortion efforts such as the Womans Right to Know Act;
which requires patients to view an ultrasound image of their fetus, listen to a verbal description
of the fetus, and wait four hours before an abortion can be performed. Although funding CPCs
and supporting anti-abortion laws are not the same, CPCs and NCs anti-choice legislators are
working towards the same goal of preventing women from having abortions (NARAL Pro
Choice North Carolina Foundation, 2011).
Logistical Factor: Who would provide oversight of CPCs in North Carolina?
To have the North Carolina Department of Health and Human Services regulate CPCs
would cost the Department in manpower and funds. FTE hours would need to be devoted to
inspect the CPCs to ensure that they are operating under proper medical standards (Moffitt,
2013). Given that NCDHSS currently has ten full-time staff members who are available to
oversee the required evaluation of current medical sites, and that the current state administration
is anti-choice, it is possible that any regulation of CPCs may not be thorough. As it is, abortion
clinics are only inspected once every three to five years. Implementing a policy requiring
oversight of CPCs by NCDHHS would not guarantee the execution of that oversight.

Legal Factors: How do freedom of speech laws, non-profit status, and consumer protection
laws impact CPCs?
U.S. Circuit Judge Paul Niemeyer ruled that San Franciscos law requiring pregnancy
centers to tell women abortions were available to them at other locations is considered
compelling speech(Schoenberg, 2012). In New York, Judge William H. Pauley III ruled that
the City of New York could not require CPCs to disclose whether or not they had a licensed
medical provider on-site or provided emergency contraception and birth control. New Yorks
City Council cited consumer protection laws in attempt to regulate the CPCs. Judge Pauley,
however, ruled that the city defined commercial speech too broadly, because of the non-profit
status of CPCs. Judge Pauley also stated that the law was offensive to free-speech principles
labeling the measure compelled speech (Chen, 2011).
How does the Weldon Amendment, or, Abortion Non-Discrimination Act, affect what CPCs
can be mandated to disclose?
The Abortion Non-Discrimination Act, or Weldon Amendment, passed in 2004 in the
Departments of Labor, Health and Human Services and Education and Related Agencies
Appropriation Act 2005 spending bill. The Weldon Amendment prevents federal, state, and local
government discrimination against medical providers for not offering abortion services, abortion
referrals, coverage for abortions, or accurate information regarding abortion services. The
amendment codes any requirement that a health-care entity offer these services as discriminatory,
and would put any organization or government agency overseeing these agencies at risk of losing
federal funding if they made these services a requirement. This act is in direct conflict with Title
X, which prohibits medical institutions receiving federal funding via Title X from preventing
women from accessing abortion services. While CPCs do not receive federal funding as clinics,
they are in a grey area legally (Physicians for Reproductive Health, 2009). They are permitted to
offer medical services, such as ultrasounds (providing clients sign a waiver); however, they are
not technically medical entities, which is why they are not overseen by the Department of Health
and Human Services. The Weldon Amendment impacts medical organizations, which technically
CPCs are not. However, the law has been applied to CPCs in Pennsylvania, when pro-choice
advocates were unable to prevent Real Alternatives, which funds and supports CPCs, from
receiving a state-based dollar-for-dollar matching grant that is also used to fund Planned

Parenthood and other reproductive health clinics (Reproductive Rights Law Clinic at the
University of Pennsylvania Law School, 2007).

Options
Option 1: Maintain the Status Quo
The first option is to let the current trends continue without any obstruction. The best plans and
policies may not always solve -or may even worsen- how CPCs function. Assuming current
trends continue, CPCs will continue to provide misinformation without any oversight, be staffed
with untrained personnel, and may provide dishonest advertising and promotion.
Strengths: The status quo requires no additional costs from the legislature and CPCs.
Weaknesses: Since CPCs are not regulated by the state, there are no laws ensuring that CPCs
will not provide inaccurate medical information to their patients. CPCs will not be required to be
staffed with trained medical employees or supervisors.
Opportunities: CPCs can seek out new funding sources and partnerships. They are already
receiving state funding through SB 402 and they can seek out more supporters (Planned
Parenthood Health Systems, Inc., 2013).
Threats: Women who come to CPCs seeking help and resources will continue receiving
misleading and inaccurate information that may put their health at risk.
Option 2: Pass Bill to Prevent Fraudulent Clinic Practices
This would be modeled after Oregons SB 490 (2013), which requires the entity advertising and
providing specified health services to provide notices and disclosures about nature of services;
prohibits entity from disclosing health information about patron receiving services without
written consent of patron; [and] requires entity to provide health information to patron upon
request. This law would impose civil penalties for violations.
Strengths: This minimally intrusive bill would prevent CPCs from providing inaccurate medical
information to their clients. Several studies have documented CPCs across North Carolina giving

misleading medical information. Providing intentionally misleading medical information is

unethical and potentially very dangerous. Because of the potentially drastic consequences, this
may be the easiest way to convince lawmakers to regulate CPCs.
Weakness: A weakness of this option is that many of these facilities maneuver around existing
medical accuracy laws by having patients sign forms releasing the providers from their medical
obligations. An example of this is the Pregnancy Center in Greensboro, which does not have a
licensed ultrasound technician on staff yet is still able to provide ultrasounds by having clients
sign a form that gives consent to have an ultrasound done by an unlicensed technician. Another
weakness of this law is that the states executive branch may not be universally willing to enforce
it, either due to budget restrictions or opposition to the law.
Opportunities: The passage of this bill may set a precedent for how the legislature will handle
other organizations who may also provide inaccurate information to their clients. It also sets a
broad tone without curtailing CPCs services, but ensuring that clients are provided with honest
information. The bill does not take a political stance; it is merely enforcing a regulation that all
organizations should be held accounted to.
Threats: Conservative organizations and representatives of CPCs may dissent with this bill and
may pull funding and support from any representative who supports this bill.
Option 3: Pass Consumer Protection Law to Ensure Accuracy in Medical Advertising
Pass a consumer protection law to prevent any health center from misleading and misinforming
women who seek information about their reproductive options. It would require facilities that
provide medical services to disclose whether or not there is a licensed physician on staff. The law
would also require centers to disclose whether they provide referrals for emergency
contraception, birth control, abortions, or prenatal care. This law would impose civil penalties for
violations. This law would be similar to laws that Austin, Baltimore, and New York City passed
that require CPCs to post warnings about the limitations of their services. These regulations
generally require entrance or waiting room signs to inform clients if the CPCs offer referrals for
pregnancy and abortion services (Gilbert, 2013, p. 593-4).

Strengths: A benefit of this option is that clients would be able to make more informed decisions
about where they seek their reproductive care. CPCs strategically obfuscate their anti-abortion
and anti-birth control position. Many of the clients who seek them out for services are drawn in
by promises of free pregnancy tests, ultrasounds, and optional counseling. Because these are
services offered at legitimate medical facilities, most clients are unaware of the CPCs biases.
Weakness: A drawback of this option is that similar laws have had portions of their legislation
struck down, such as the requirement to disclose whether a center provides referrals. Groups in
favor of CPCs argue that this is a limit on their first amendment right to free speech (Lund,
2012). CPCs have fought against the regulations by arguing that the regulations violate free
speech freedoms. This argument has been upheld by the higher courts (Gilbert, 2013, p. 594).
Opportunities: Public discourse on CPCs will generate more publicity and may draw in more
supporters of the bill. Legislation from other states can serve as a basis for implementing a new
bill.
Threats: Public debate may lead to greater political divides on this issue. North Carolina is a
Republican majority state, and Republicans will be more likely to fight against this bill because
if they support it they may be painted as a liberal, may lose support from party members, and
may lose re-elections.
Option 4: Oversight of CPCs by The NC Department of Health and Human Services
(NCDHHS)
There has been discussion at the federal level to require federal oversight of CPCs (Daly, 2010).
This kind of legislation, however, has made little progress because it would incur massive
government costs and put federal legislatures in legal disputes against powerful CPC funders and
interest groups. Although legislation at the national level has stalled, it provides a context
through which legislatures could push for oversight at the state level. Such oversight would
ensure that CPCs and similar organizations that provide medical information across the state are
following similar and standard rules.

Strengths: Oversight by NCDHHS will bring state standards to CPCs. Organizations that have
state oversight must oblige to certain standards such as:

Requiring honest advertising and promotion that begins with disclosing the agencys
goals and objectives. For example, CPCs should disclose to patients that they are prolife advocates and want to provide services to help women maneuver their pregnancy

and options post-childbirth, such as adoption.

Ensuring that CPCs employ trained medical or counseling staff and make clear to

clients if they will be seen by untrained staff/volunteers.

Guaranteeing that advice and counsel being dispensed are medically sound and

accurate.
Requiring that CPCs keep client confidentiality as is required by legitimate medical and
counseling clinics.

Weaknesses: Similar legislation has not been tried in other states, so we are unsure of specific
responses that the organizations behind CPCs may use to argue against this. There are only 10
full time staff inspectors through NCDHHS and they are currently only able to inspect abortion
clinics every 3-5 years (Moffitt, 2013). NCDHHS may be strained to take on monitoring and
inspection of CPCS.
Opportunities: Because similar legislation has not been tried, CPCs do not have a pre-prepared
response. There is the potential for organizations bound to the NCDHHS regulation to
collaborate on services.
Threats: This option is vulnerable to the political whims of the appointees at the head of
NCDHHS and the state political landscape. At the national level, pro-choice advocates are
pushing for the law, but they face major opposition by pro-life supporters and the overall
political gridlock plaguing Congress (Daly, 2010).

Recommendation
Pass Consumer Protection Law to Ensure Accuracy in Medical Advertising

This is the best option because it will allow clients to make more informed decisions
about where they seek their reproductive care. Accurate advertising will prevent CPCs from
strategically obfuscating their anti-abortion and anti-birth control positions, and will prevent
clients from confusing CPCs with legitimate medical facilities.
This option is better than mandating medical accuracy because the non-profit status of
CPCs guarantees them exemption from oversight. They are covered under good Samaritan
laws that consider the work of the CPC employees and volunteers as free speech, which is
constitutionally protected.
This option is stronger than requiring oversight from NCDHHS because it is safeguarded
against the varying wills of the political appointees who head NCDHHS.
The weaknesses of this act are similar to weaknesses found in other options. Groups in
favor of CPCs have successfully argued that this infringes on their first amendment rights.
However, with the consumer protection act, CPCs are still allowed to practice their free speech
so long as they are accurately representing their services and credentials.

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