Assessing Crisis Pregnancy Centers’ Capacity for Supporting Perinatal Clients with Social Complexity in Rural Maternal Health Care Shortage Areas

Abstract

Background:

Pregnant people in rural communities experience constrained social services and economic supports, increased social complexities, and limited access to maternal health care. Within this environment, crisis pregnancy centers (CPCs) have proliferated to serve rural perinatal populations in the United States. CPCs provide wraparound services to pregnant and postpartum people and their families, but little is known about the services provided for pregnant people with social complexities that increase maternal morbidity risk. We examine CPC leaders’ perceived function in providing care to perinatal clients living in low-resource rural communities experiencing intimate partner violence (IPV), substance use, and mental health conditions.

Methods:

We interviewed 17 leaders of CPCs serving communities with health professional shortage areas in a state with a large rural population. We ask about their perceived role, assessment, and care for clients who may be experiencing substance use, mental health concerns or conditions, or IPV.

Results:

We find that CPC leaders in this sample did not describe the capacity to appropriately address some of the primary drivers of maternal morbidity. CPC leaders’ descriptions of delivery of medical, mental, and social care screenings, and that their policies and procedures are inconsistent with evidence-based medical care delivery, despite some CPC’s use of medical technology. CPC leaders describe a lack of standardized, validated health and social risk screening, reliance on relationship-based risk identification, non-systematic referral processes, unclear anticipatory guidance for medical conditions, and sometimes employ stigmatizing language.

Conclusions:

In this study, CPC efforts were found to be inconsistent and unsupported by current clinical care guidelines endorsed by medical professional societies.

Introduction

Birthing people in much of rural America experience pregnancy and the vulnerable first year after birth, or the “postpartum cliff,” in communities that have seen a decline in investment and access to health services. This contributes to higher rates of rural maternal and infant mortality.^1,2 As of 2022, 52.4% of rural hospitals lacked obstetric units. ³ The ongoing closure of obstetric units at rural hospitals contributes to lower rates of prenatal care utilization (even when prenatal care remains available), ⁴ late or no prenatal care, and higher preterm birth rates. This is amplified for those who are publicly insured, low-income, or people of color.^5,6 In the postpartum period, rural parents report worse health and are more likely than their urban counterparts to experience emergency department visits, hospitalizations, loss of health care coverage, and barriers to care. ⁷ Perinatal people in rural communities are more likely to experience (and less likely to have supportive resources for) the social factors contributing to maternal morbidity, like intimate partner violence (IPV), substance use, and mental health conditions.

IPV is more common during pregnancy than health issues like preeclampsia or gestational diabetes ⁸ and is a leading non-obstetric cause of maternal morbidity. ⁹ Rural residents, particularly Medicaid beneficiaries and uninsured populations, have a higher prevalence of perinatal IPV and are less likely to be screened for abuse compared with urban perinatal populations.^10,11 Despite higher rates, services in rural counties are less well-funded or comprehensive. ¹² There are additional barriers to IPV support unique to rural geographies, like increased stigma, perceived lack of confidentiality in reporting or seeking care, and increased social isolation amplified by lack of transportation. ¹³

Rates of maternal opioid use and neonatal abstinence syndrome are rising in rural areas, compared with urban areas, but treatment engagement lags due to substantial care gaps in rural communities.^14–16 Few treatment location options, lack of mother/child dyad support, fewer knowledgeable health care providers, long wait times, transportation barriers, lack of childcare, and stigma delay or prevent perinatal addiction treatment. ¹⁷ Rural-living perinatal women using substances often experience intersecting challenges related to food, housing, and transportation insecurity alongside increased stigma, social isolation, and lack of mental health supports. ¹⁸

Mental health conditions are an underlying cause of one in nine maternal deaths. ¹⁹ Perinatal people in rural communities are at higher risk for postpartum depression (PPD), ²⁰ and the risk of PPD is significantly higher for Black and Latina parents in rural communities. ²¹ Rural perinatal people are less likely to receive treatment, in part due to social isolation, stigma, lack of awareness of perinatal mood disorders, and shortages in mental health care.^22–24 In addition to shortages in mental health care providers overall, rural communities also have a shortage of providers with specialized training in the perinatal population, providers with uptake of innovative and current approaches, and less care coordination. ²⁵

Birthing people living in rural communities without comprehensive reproductive health care also experience higher poverty and a lack of health-promoting services and community-oriented primary care.^6,26 Despite the need for economic support during the transition from pregnancy to parenthood, rural postpartum people are more likely to report inability to pay medical bills from pregnancy, more likely to delay medical care due to cost, and significantly more likely to lose medical coverage after birth. ²⁷

Within this environment of constrained social services and economic supports, increased social complexities, and restricted access to maternal health care, crisis pregnancy centers (CPCs) serving perinatal people are expanding their efforts. ²⁸ CPCs, also known as pregnancy resource centers, are non-profit, faith-based organizations that provide support and resources for pregnant people and families. ²⁹ Clients at CPCs are often seeking pregnancy tests, ultrasounds, diapers, clothing, baby supplies, parenting resources and referrals, and emotional care.^30–33 CPCs often use a “learn to earn” model, where clients earn infant care items such as clothing, diapers, and safety items by attending parenting classes, counseling, Bible studies, and programming. ³³ In the past decade, many CPCs have broadened their focus from providing parent education and material goods to expanded medical services such as ultrasounds and testing for sexually transmitted infections. ³⁰ Though CPCs have local leadership and volunteers, they are often nationally networked. There are over 2,500 CPCs across the United States.^34,35 Clients often locate CPCs via internet searches for abortion services, pregnancy symptoms, or ultrasound services, or when looking for material aid and social safety net services during the perinatal period. ³⁶ Scholarship on CPCs has documented who utilizes them and what their experiences are,^{30,33,36–39} their geographic landscape in comparison to abortion facilities, ⁴⁰ and their legality and policy intersections.^41–43 Additional scholarship has documented how information about CPCs is accessed and what their online advertising strategies are.^44,45

CPCs are a part of the antiabortion and larger evangelical Christian movement and discourage clients from a full range of reproductive decision making, including access to contraception and evidence-based reproductive health information and care.^41,46,47 They promote traditional marriage and gender roles, and their faith-based beliefs extend to their views of mental and emotional health, relationships, and trauma.^25,48 CPCs often disproportionally target those who are young, low-income, and have less education.^43,49

Increasingly, CPCs have medicalized their image, positioning themselves as health care centers or pregnancy clinics to potential clients and as offering medical services in online advertising. ⁵⁰ Despite their medicalized appearance, CPCs are rarely staffed by licensed health professionals but rely on volunteer staff.^29,49 They often provide biased, limited, misleading, or inaccurate information on contraceptives, STIs, abortion, and fetal development and provide and promote unproven practices such as abortion recovery programs or abortion reversal services.^49,51–53,a The medical testing they provide has significant limitations. An estimated 71% of CPCs nationwide offer ultrasounds, but these are limited and non-diagnostic, increasingly restricted from identifying ectopic pregnancies (as is often advertised by CPCs), and often used to cultivate an emotional and social attachment to a fetus.^28,55

CPCs are not subject to regulatory oversight and medical standards of care because they are not technically health care providers. ³¹ CPCs legally maintain that they are non-profits that do not charge for services, with the protected right to free speech; thus, their organizations, staff, and volunteers are not required to adhere to health care regulations and licensure or commerce regulations.^31,56 This position translates to their internet presence; CPC websites often provide false or misleading information and engage in misleading or deceptive marketing practices.^57,58 Notably, CPCs use digital coercion strategies that specifically target rural populations; states with more restrictive abortion laws disproportionally empower CPC visibility in commercial internet search engines for rural populations. ⁵⁸ CPCs also use their websites, signage, and forms to promote their compliance with the Health Insurance Portability and Accountability Act (HIPAA) while collecting personal client information. Yet, because CPCs maintain that they are not health care providers, they are not governed by HIPAA, not obligated to enforce HIPAA protections, nor held accountable for privacy breaches of client information. ⁵⁹ They also are not held to American College of Obstetrics and Gynecologists (ACOG) recommendations for using validated, standardized screening for social risk factors, including for IPV (recommended at least five times in the perinatal period), substance use (recommended universally early in pregnancy), and perinatal mood disorders (recommended a minimum of three times during the perinatal period).

Numerous professional societies have warned of CPCs’ lack of unbiased or evidence-based information and care, including CPCs’ perspectives on relationships, trauma, and mental and emotional health. The ACOG, Society of Adolescent Health and Medicine, the North American Society for Pediatric and Adolescent Gynecology, the American Public Health Association, and the American Medical Association have all released public positions opposing CPCs.^29,60–62

There is significant variation at the state level for CPC regulations, licensure, accreditation, consumer protections, funding structures, and taxation. ^b CPCs have received and continue to receive funding from both federal and state governments. In the state where this research took place, the state legislature provided funding for over 30 years via contracts and direct funding to CPCs, including redirecting Temporary Assistance for Needy Families funding; this funding mechanism was canceled as data collection for this project began. ⁶⁴ Alongside the removal of this funding stream to CPCs, resources were reallocated to evidence-based comprehensive reproductive health care providers, and legislation (HB 1589) was introduced (but not passed) to prohibit CPCs from sharing medical data without explicit consent. ⁶⁵ The state does not currently have additional legislation to regulate CPCs. ³⁵

The state where this research was conducted has experienced ongoing rural obstetric unit closures and reduced access to perinatal health care, and a rise in maternal morbidity driven by social complexities such as substance use, mental health conditions, and IPV. ⁶⁶ There are 160 CPCs across the state, many serving rural communities. CPCs have increasingly marketed their ability to provide care to the perinatal population in medically underserved rural areas, often using language similar to the language used by reproductive justice organizations. ⁶⁷ Within this environment, we sought to understand how CPCs are networked with perinatal providers and social safety net organizations in rural communities and what services they provide to perinatal clients who are most at risk, including those experiencing substance use, IPV, mental health concerns, or other social indicators of maternal morbidity risk.

Methods

We interviewed leaders and directors of CPCs serving communities with health professional shortage areas in a state with a large rural population. The study was approved by the Children’s Hospital of Philadelphia Institutional Review Board.

Using data from the Crisis Pregnancy Center Map, ³⁵ we developed a list of CPCs within geographic target areas for our recruitment. As of 2024, 160 CPCs were operating in the state. We identified our geographic target areas, demonstrated in Table 1, by selecting counties within the state that contained either a rural or partially rural Health Professional Shortage Area (HPSA). We used the Health Resources and Services Administration (HRSA) designation of an HPSA—geographic regions that lack an adequate supply of health professionals to meet community needs; we removed HPSAs that were non-rural. Within the 34 counties that contained a rural or partially rural HPSA, there were 80 CPCs. We also identified 16 CPCs located specifically within the boundaries of a rural or partially rural HPSA. We targeted all 16 CPCs in the boundaries of a rural or partially rural HPSA and an additional 14 CPCs closest to the HPSA. Recruitment was conducted from January to May of 2024. Study team members contacted each center a total of three times, sharing a description of the project and requesting an interview with a director or leader.

Table 1.

Identifying Target Geographic Areas for Recruitment

Geographic target area for recruitment	Number (%)
County characteristics (n = 67)
Number of counties containing a rural or partially rural HPSAs	34 (51%)
HPSAs (n = 28)
Number of HPSAs in PA designated as rural	16 (57%)
Number of HPSAs in PA designated as partially rural	5 (18%)
CPCs in PA (n = 160)
Number of CPCs in a county with rural or partially rural HPSA	80 (50%)
Number of CPCs in a rural or partially rural HPSA	16 (3%)
Recruitment outcomes
Number of CPCs in a county with a rural or partially rural HPSA, including within the HPSA (i.e., target areas) contacted for an interview	30 (37.5%)
Number of CPCs in target areas who accepted interview	14 (17.5%)

CPCs, crisis pregnancy centers; HPSAs, Health Professional Shortage Areas; PA, Pennsylvania.

Study team members developed a two-part interview script, shared in Appendix A1. The first part covered the history of the CPC and the individual’s role, their perceptions of maternal health care in the community served by the CPC, and their perceptions of their role in the community. The second part focused on perinatal clients who may be experiencing substance use, mental health concerns or conditions, or IPV. Participants were asked how they screen for or assess these needs and support clients who may be experiencing them. Participants were asked how they feel their ability to support these clients is driven by the services available in their community. Interviews closed with how participants believed perinatal people could be better supported locally, and future directions they may take to accomplish this.

Phone interviews lasted from 60–90 minutes and were audio recorded and transcribed. The team took several steps to develop rapport with interviewees. ^c Interviewees received a $25 gift card for their time. Consent forms and a demographic survey were shared in advance of the interview, as well as a list of themes the interview would cover. The team debriefed following each interview, discussing what data were novel, what content reflected previous data collection, and how team members interpreted content.

Interview transcripts were entered into NVivo Release 1 for analysis. The team developed a codebook, shown in Appendix A2, using an inductive process where members reviewed transcripts for key themes and subthemes. ^d In consultation with maternal health experts, we developed an additional analytical layer of codes capturing content that did not appear to be evidence-based health care. We coded again across themes of maternal health care provision and provision of care for perinatal clients experiencing IPV, substance use, or a mental health condition.

All study team members have advanced training and professional experience as maternal and early childhood health researchers. The investigator has significant personal and professional experience living in and working with rural populations and those who identify as evangelical Christians. This religion is often the foundation for CPC efforts, and the investigator’s knowledge of the worldview and language of this population offered an additional layer of familiarity with the data. Throughout this study, we took steps to practice reflexivity and reflect on the ways our own biases may influence findings. ^e

Results

Study population

We interviewed a total of 17 directors or leaders of 14 CPCs from across the state. Most participants were women ¹⁴ who were employed full-time by the CPC. ¹¹ We document key demographic and center characteristics of our sample in Tables 2 and 3.

Table 2.

Demographics of Crisis Pregnancy Center Directors Who Were Interviewed

Demographic characteristics a	Number and percent
Gender
Female	14 (93.3%)
Male	1 (6.7%)
Age
18–30	1 (6.7%)
31–40	1 (6.7%)
41–50	4 (26.7%)
51–60	3 (20.0%)
61–70	4 (26.7%)
71–80	2 (13.3%)
Race
White	14 (93.3%)
Prefer not to answer	1 (6.7%)
Highest level of education
Vocational or trade school degree	2 (13.3%)
High school diploma or General Education Development (GED)	5 (33.3%)
2-year college degree	2 (13.3%)
4-year college degree	6 (40.0%)
Employment status at CPC
Employed part-time	4 (26.7%)
Employed full-time	11 (73.3%)

^aTwo participants who joined interviews but were not the executive director did not complete the demographic form and are not represented here.

Table 3.

Characteristics of Crisis Pregnancy Centers Whose Directors Were Interviewed

Number of locations operated by Crisis Pregnancy Center (CPC) organization interviewed
1	5 (35.7%)
2	3 (21.4%)
3	3 (21.4%)
4	1 (7.1%)
5	2 (14.3%)
Does the center offer free ultrasounds?
Yes	9 (64.3%)
No	5 (35.7%)
Loss in labor and delivery locally
County in which CPC is located has experienced a Labor and Delivery Unit (L&D) closure in the past 20 years	7 (50.0%)
No significant change in L&D services over the past 20 years (including never having L&D)	7 (50.0%)
Birthing hospital access
There is no birthing hospital in the county where the CPC is located	7 (50.0%)
There is a birthing hospital in the county where the CPC is located	7 (50.0%)

We document our findings in three parts. We describe how CPCs perceive perinatal clients experiencing higher risk factors for morbidity, CPCs’ screening and referral systems, and services provided.

Participant perceptions of social complexity within their perinatal clients

When asked about how frequently they saw clients with social complexities like substance use, IPV, and concerning mental health conditions, participants reflected a range of responses. Regarding clients with substance use, participants noted more alcohol, tobacco, and marijuana use than opiates among their clients. Many centers reported infrequently working with clients experiencing substance use, partially due to the perception of prevalent treatment options. For example, one participant describes how they have not had “a substance user just walk in my door for many, many years. Most of [them], they’re all in treatment at this point. They’re on suboxone or some other drug that’s deemed to be safe for pregnancy treatment.” Participants noted that when clients disclosed substance use, it was often because they were seeking information about the effects of substances or medication on the fetus. Unlike substance use, interviewees perceived IPV to be a significant issue in clients’ lives. Participants perceived clients to experience more emotional and verbal abuse than physical abuse. Physical abuse was more likely to be disclosed. Many participants felt that clients were unable to recognize emotional and verbal abuse as abuse, with one sharing, “I know that there’s a lot of mental abuse. And sometimes the client doesn’t even recognize it to be as such, but when we hear about what’s going on in their home, yeah.” Participants perceived the majority of their clients as having mental health conditions, including depression, anxiety, personality disorders, and post-traumatic stress disorder, with varying levels of official diagnosis. Participants did not have experience with clients in acute mental health crises. Similar to pregnant populations using substances, participants theorize that clients with acute or severe mental health needs were not seeking services at CPCs.

Participants perceived their clients hesitated to disclose substance use, IPV, and mental health conditions due to their fear of child welfare involvement and family separation. There was some variation in participants’ self-identification as mandated reporters. Some CPC directors discussed mandated reporting as related to sobriety, suspicion of physical violence, and child removal, while some did not see themselves as mandated reporters. Multiple participants identified their center as having educational programming approved by the state child welfare agency in support of caregivers seeking family reunification.

Participants’ descriptions of screening for social complexity

When describing their ability to support pregnant clients experiencing social complexities, CPCs often reported a lack of standardized screening and use of relationship-based identification. Though conventional health care providers would screen pregnant patients for mental health conditions, substance use, and IPV using validated screeners, interviewees reported a wide range of practices related to understanding the prevalence of social complexity among their clients. A few clients, demonstrated in Table 4, asked about social complexity on intake forms, but only two reported using established screening tools.

Table 4.

Crisis Pregnancy Center Leadership’s Description of How Their Organization Screens for Social Complexity

	Evidence-based screening tool (%)	Questions on intake form/verbal questions (%)	No questions, no screening (relationship-based identification) (%)	No response/Did not disclose (%)
Substance use	1 (7%)	8 (57%)	4 (29%)	1 (7%)
Mental health	1 (7%)	4 (29%)	8 (57%)	1 (7%)
IPV	0 (0%)	9 (64%)	4 (29%)	1 (7%)

IPV, intimate partner violence.

Description of supports and referrals provided to clients with social complexity

Participants reported few supports for social complexity (with the noted exception of IPV), non-systematic referral processes, and unclear anticipatory guidance for supporting perinatal clients. Participants primarily viewed their role in supporting clients with social complexity as being someone with whom clients could develop a trusted, stable relationship. When discussing referrals for social complexity, participants described reciprocal referral relationships with whom they both referred to and received clients from, including public benefit programs and public agencies like Women, Infants, and Children (WIC), Supplemental Nutritional Assistance Program, Early Intervention, and Head Start; child welfare agencies; and home visiting organizations. For example, one participant described, “WIC is also a huge partner because they [WIC] need that proof of pregnancy in order to get them [clients] started. They [WIC] can’t even do a pregnancy test, so they’ll send people our way to get the pregnancy test, and we go from there.”

In addition to relationships with non-profit service providers and religious organizations, some participants described relationships with local health care systems and the midwifery community, with one participant saying, “That’s one of the things I’ m most proud of. I worked real, real hard to secure relationships with the local OB GYNs…We have a liaison at most every office here that I can just call them directly and they will get them [clients] scheduled. I don’t have to call the scheduling line, sit on hold, wait for [an appointment]. If I needed somebody seen tomorrow because of something, we could likely get that to happen.” Participants often described challenges with connecting clients to services due to local service organizations that were overwhelmed and at capacity.

Most centers did not have in-house support for substance use besides classes that touched on the impact of substance use in pregnancy. Several participants emphasized their role in providing emotional support and wraparound services while encouraging clients to seek external care. One participant shared, “When someone is using, there’s usually so much more, right? Do they have place to live where they’re not surrounded by the drug? Do they have a place to live at all? In those situations, we wanna look at them holistically and not just be like, ‘Oh, you should call this rehab facility, or you should go to this methadone clinic.’” Other participants described a stricter stance toward substance use, saying they would not provide services to clients who were actively using. One participant described, “we’re not just plucking them off the street for a time only to go back. We’re not interested in bringing people into this program that have no intention of changing. You can’t be on drugs, you can’t be an alcoholic.” Participants described referring clients to a range of services, including local physicians, hospitals, treatment centers, substance use disorder organizations, and drug and alcohol counseling. One participant described their process, saying “we would obviously wanna get them connected with the local Drug and Alcohol to get them a rep through them and then, to encourage them to get them connected with their OB GYN office to prepare them through pregnancy or even after, especially after baby’s born, to not revisit that if they are a former, drug user alcohol [user].”

Interviewees reported more tangible involvement in supporting clients with IPV, describing helping clients develop safety plans, gathering necessary legal documents, using their facilities to make phone calls and plans, obtaining Protection From Abuse Orders, and supporting clients with material goods and housing. Some participants noted their internal access to a network of maternity homes, for which clients could access when leaving an abusive relationship, saying “pregnancy centers have access to a network of maternity homes. So, if a client truly was willing to, to go anywhere, we could find her a spot in a maternity home and we could get her there. We will get them on a plane to a maternity home, and someone will be there on the other end to take them in.” Participants spoke with more depth about referrals to support clients experiencing IPV than they did about substance use, with more knowledge of local service providers and law enforcement involvement. Interviewees described relationships with and referrals to local IPV organizations, including resource centers, safe houses, shelters, and hotlines. CPC directors described varying relationships with law enforcement in relation to IPV.

Participants viewed mental health conditions as common among their clients and emphasized relationship building and friendship as avenues for noticing signs of perinatal mood disorders or other concerning issues. Though one CPC had volunteers and staff with peer mental health coach certifications, most reiterated to clients and to us that they are not licensed clinical therapists. One participant said, “I’m totally happy to sit with someone and talk to her ‘cause she’s having a tough time. But I also wanna make sure that I’m helping her understand, ‘I’m not a therapist. I’m happy to listen to you, I’m happy to talk with you. I’m happy to even bounce like practical ideas around, but you might wanna talk to someone that has that next level certification’.” Some participants reported providing a suicide awareness hotline number and would encourage clients to seek emergency care if they were having acute mental health crises. Interviewees often referred clients to external resources, including medical and mental health professionals, physicians, hospitals, counselors, and local organizations. Some participants encouraged clients to have discussions with their obstetrician about the impact of medications on pregnancy. Several participants reported relying on referrals exclusively to faith-based organizations, including local pastors for counsel, Christian ministries, and Christian counseling associations. Some participants were hesitant to refer to non-faith-based mental health professionals. One participant describes their relationship with a local counseling service, saying, “My only problem lots [of] times with them, even though they have the ability to prescribe [medication] and everything, is that it’s not a Christian organization. Christian values are not anything that they are really all that interested in. They do have some Christian people on their staff, but the basic thing is a diagnosis of a mental illness or whatever and medication and I just sometimes feel like the medication is just too easy.”

Frequent stigmatizing language

Despite stated goals of relationship building to support clients with social complexity, many respondents employed dated or stigmatizing language around these topics. For example, one attributed the high prevalence of IPV to, “I think the falling away of the family. I think the fact that these women are having more and more sex outside of marriage and they’re not valuing themselves.” Another described mental health conditions as rooted in spiritual warfare and demonic practices, saying her client, “had some real mental problems … I believe that some of it is not all medical, but it is a spiritual warfare that goes on, and I think some are involved in demonic practices and those are kinds of things that the average psychologist [or] psychiatrist doesn’t really want to talk about that much.”

Discussion

This qualitative study of rural CPC leaders in a large state found high levels of variability in messaging and service delivery, alongside the consistent theme of inability to provide evidence-based, privacy-protected services for perinatal people with medical complexity. We found that CPC directors describe their service orientation to prioritize social interaction and support. Prior research has identified this relationship-based approach to service delivery, describing CPCs as leveraging affective care. ³⁰ This relationship-based service delivery contrasts with the often inadequate clinical care—driven by structural inequalities—experienced by marginalized patients. ³⁰ We hypothesize that, for people navigating the postpartum transition in a rural environment and without significant support, ²⁰ CPC’s relationship-based approach may serve a particular need for social support not provided by under-resourced rural health care and social welfare systems. Our findings also confirm previous scholarship demonstrating that the policy environment, including a lack of state investment in social programs and a fragmented health care system, supports engagement in CPC care delivery in resource-scarce environments.^36,41 For example, the need for pregnancy verification for WIC recipients was a frequent source of CPC care engagement in our study.

We note some limitations of this study. Data collection was reliant on secondary observations by CPC directors and their perceptions of their clients’ needs and desires. We did not collect direction client experiences nor did we triangulate statements of community need with health care or social service providers in the same communities. Similarly, although we recruited from locations with community-wide limited access to maternal health care, we relied on participants’ stated drive times for their clients to access health care and other social services. Additionally, we began data collection concurrent with the state government canceling a contract that provided significant funding to CPCs; CPC leadership may have felt additional external pressure to validate or enhance their descriptions of their services. Finally, the pediatric health care institution we sit within has a strong, positively associated regional presence in the state; participants may have been more highly motivated to present a medicalized version of their services to interviewers whom they viewed as being part of a nationally recognized health care system.

We find that CPCs report inconsistent delivery of medical, mental, and social care screenings, and that their policies and procedures are inconsistent with evidence-based medical care delivery, despite some CPC’s use of medical technology. CPCs in this sample did not describe the capacity to appropriately address the primary drivers of maternal morbidity. Inadequate and inconsistent screening for health-related social contexts, alongside few care pathways or appropriate referrals, may lead to an inaccurate identification of medical complexity and risk among their client population. This risk may be heightened for clients believing they are accessing comprehensive medical care that abides by HIPAA requirements. It is unclear if the client base with higher social complexity self-selects away from utilizing CPCs or if CPCs are not aware of the severity of social complexity among their clients. There also appears to be a wide range of beliefs, some stigmatizing, toward pregnant people with social complexity. Given our explicit focus on CPCs serving rural maternal health care shortage areas, we acknowledge that CPCs are operating in a landscape of institutional and resource scarcity, and some reported relationships with local health care systems. CPCs face the same shortcomings plaguing health care providers and social services in the community.^5,68–70

Though CPCs appear ill-equipped to respond to the needs of perinatal people in crisis, and some may undermine access to evidence-based care through practices such as only providing faith-based referrals, their presence in rural communities would be significantly less influential if they were situated within an environment of adequate access to high-quality care and support for pregnant people and families. Yet, the U.S. health care and safety net systems are failing pregnant people in rural communities. Prior ethnographic work by Hutchens concludes that CPCs “are not isolated aberrations in a well-functioning health care system but expected outcomes of critical absences in reproductive health care and severe economic inequality in the United States.” No place is this more glaring than for rural people who are recognized as “dangerously underserved” in pregnancy and the time following birth. ⁷¹ When the transition to parenthood intersects with unmet needs related to inadequate transportation, food insecurity, unaffordable and inaccessible childcare, social isolation and loneliness, lack of paid family leave, and financial instability,^72,73 we anticipate that CPC’s emphasis on relationship-building increases their influence on clients with fewer social supports.

On both fronts—providing accessible high-quality health care and ensuring adequate social and economic supports for new families—lack of funding and fragmentation in public systems have led organizations without evidence-based practices to have significant influence in communities with institutional and resource scarcity. As rural communities’ social safety net experiences increased stressors, the most vulnerable pregnant and parenting people will be left with the least evidence-based care, expanding inequities in those already poorly served.

Implications and Conclusions

While CPCs have been active for many decades, the ongoing drawback in rural perinatal health care and continued disinvestment in social and economic supports have created a substantial vacuum in care and services for rural pregnant people and caregivers. As CPCs expand their activities to fill this vacuum in rural areas, rural residents, particularly those with complex social needs, will have limited access to a full spectrum of evidence-based care. They may also face potentially stigmatizing care without privacy protections that, according to our findings, have limited standardization for recognizing and addressing their needs. CPCs stated ambitions to further medicalize or intertwine with activities that would traditionally fall within the health care delivery purview—shored up by patient dissatisfaction with a health care system that fails to provide person-centered care for pregnant people—may lead to adverse outcomes for patients with social complexity. Although some CPCs emphasize wraparound supports and distance themselves from their antiabortion roots, their services do not replace evidence-based, comprehensive, HIPAA-protected maternal and reproductive health care for people in rural communities.

Abbreviations Used

ACOG

American College of Obstetrics and Gynecologists

CPC

Crisis Pregnancy Center

HRSA

Health Resources and Services Administration

IPV

Intimate Partner Violence

PPD

Postpartum Depression

SNAP

Supplemental Nutritional Assistance Program

WIC

Women, Infants, and Children

Appendix A. Interview Guide.

Introduction

Thank you for taking the time to speak with me today. I’m part of a research team at the [institution] who focuses on improving the health of pregnant women, parents, and babies. We are especially interested in better understanding how to prevent some of the leading causes of maternal mortality and morbidity and poor birth outcomes in [state], like maternal deaths related to experiencing intimate partner violence, mental health crises, or substance use.

Some of our work, like this project, focuses on maternal and child health in rural areas of [state]. This project is about better understanding how pregnancy centers like yours provide care to people who are pregnant or recently postpartum and living in areas of [state] with limited or inadequate access to maternal health care and social services, particularly those who may be at higher risk for experiencing poor maternal health outcomes. I suspect you (/your organization) are often on the front lines of providing care to pregnant women who may experience some of these higher social risk factors. From our discussion today, I want to learn from you about how you (and your center) support or respond to women who may need more social support but may live in communities with less access to social services.

Our hope is that findings from this project will help identify best practices and identify and address potential gaps in service for pregnant women statewide, but particularly in areas with fewer maternal health services.

This conversation today has two parts. The first part focuses on [organization name] role in the community. The second part of the conversation focuses on providing care to pregnant women who may also be experiencing intimate partner violence, mental health crises, or substance use.

As a reminder, everything will be audio-recorded but everything you say will be kept private. When we type up the audio-recoded conversation, we will remove anything that could identify you as the person on the recording or your center. We will be combining your responses with other interviewees across the state to report out what we learn in aggregate.

You can skip any question that you prefer not to answer. Also, let me know if you don’t understand the question or would like me to better explain it. You can also stop the interview at any time.

Do you have any questions before we begin?

**Also, I may skip some questions based on how much time you are able to share today. Are you okay if we go a full hour, or do we need to be shorter?

Estimated time: one hour.

PART 1—COMMUNITY LANDSCAPE AND CPC ROLE IN MATERNAL HEALTH IN COMMUNITY

1. Tell me more about [CPC name].

• a.What is it like? What role does it play in your community?
• b.What is the history of the center? Why is it located here?
• c.What is the environment or atmosphere like?
• d.What is the physical space like?
• e.What services are provided?
• f.Where do you seek support and funding for your work?

2. Tell me more about the work you do at this center.

• a.What is your role? Do you consider yourself a part of this community?
• b.How long have you been involved in this center?
• c.What brought you to this work?
• d.What brings you joy from your work? What feels frustrating about your work?

3. I would like to ask more about the experiences of clients who visit your center. Who are your typical clients?

• a.What are their typical needs/reasons for visiting?
• b.Are clients usually at the beginning or end of pregnancy, postpartum, long-term or repeat clients, etc.

4. When you have a client visit with a pregnancy that she desires to carry to term (or a client who has recently given birth) can you share what services and care you’re able to offer them?

• a.
  What screenings would this client receive as standard care/practice?

  • i.
    IPV/DV
  • ii.
    Mental Health
  • iii.
    Substance use, opioid use
  • iv.
    Anything else?
• b.How might you (or do you) connect them to maternal health care or inquire about previous care? (e.g., OBs, delivery hospitals, ultrasound and prenatal testing, prenatal care/primary care/family physician, postpartum care, mental health care)
• c.Are there needs you feel you (your center/the community) are less able/prepared to address?

As I shared at the beginning of this interview, I want to talk more about access to maternal healthcare in your community. By maternal health care , I mean labor and delivery units at hospitals, health care locations that provide prenatal care (which may be primary care locations or OB/GYN locations). This may also include broader care like midwives and doulas, lactation consultants, or those working in maternal mental health care. As researchers, we have the numbers on what “access” looks like in different parts of the state, but perceptions of access are really important to us and that’s why we are asking these questions.

5. How would you describe the maternal health care available in the community where [CPC] is located?

• a.Where do women go for care?
• b.Do you think maternal health care feels accessible for your clients? For other pregnant moms in the community who may not be seeking care at your center?
• c.What would you say are the primary barriers (or opportunities) to accessing maternal health care?
• d.Do you think your clients, and women in the community more broadly, are generally happy with the maternal health care available locally? What do you hear clients saying about the maternal health care available to them?

6. How has maternal health care changed over time in this community where [CPC] is located?

• a.Has it changed? Why has it changed?
• b.What effect do you think these changes have had in your community?

Now that I know a little bit more about the maternal health care service landscape, I want to ask more about where you see [organization] fitting into this landscape.

7. How do you see your center positioned within the larger maternal health care landscape?

• a.What health care organizations do you see as key partners or relationships?
• b.Are there health care organizations or groups that are not key partners, but you are hoping may become partners in the future?

  Shifting these questions just slightly—I want to broaden the conversation to include social service agencies or other partners beyond health care (or health care adjacent). This may include state and local governments, other institutional partners, schools, small businesses, religious organizations, state or national affiliations or accreditations, etc.

8. Where do you see your center positioned within the larger social services landscape that supports maternal and child health?

• a.Who are your key partners in the social services landscape?
• b.Who do you hope may become a key partner?

PART 2—CLIENTS WITH SPECIAL NEEDS

As we shift into the second half of the interview, several of our next questions will ask about clients who may visit your center who you suspect may be experiencing substance use, mental health concerns , or intimate partner violence . I’ll ask similar questions about each of these issues separately, so we can really better understand each of them. In this conversation, I’ll be asking about clients who are pregnant AND clients who may be in the postpartum period.

Let’s talk first about clients who visit your center who you suspect may be experiencing substance use during their pregnancy or the postpartum period. By substance use, I mean tobacco, alcohol, illicit drugs, or the misuse of prescription drugs, particularly opioids. The reason we are so focused on this issue is that we know that the prevalence of opioid use during pregnancy has risen 333% since 2013. Around half of all maternal deaths in the state are related to drug-related overdoses in the immediate postpartum period.

9. How often do you see clients who you suspect may be in this group?

• a.What are their typical needs?

10. How might you assess if a client is using substances? Is there a screening process? Do you ask? What does the process look like?

11. If a client discloses substance use during pregnancy or in the postpartum period, can you share what your next steps would be?

• a.Which organizations or groups may you refer that person to?
• b.Do you provide support within your center for people who are in this group?—classes, support groups, educational activities, mental health related—“mom self care,” and so on.
• c.Is sobriety a prerequisite for providing any services (including learn to earn, etc.)
• d.Is there any type of client follow-up after an initial visit?

12. If you suspect someone is experiencing substance use during pregnancy or the postpartum period, can you share what your next steps would be?

13. How supported do you feel your staff are in addressing this issue?

• a.Do they have training in this area?
• b.How does stigma or beliefs about substance use during pregnancy arise?

14. How is (or isn’t) your course of action in these scenarios driven by the services that are available in your community?

I would like to ask very similar questions about clients who may visit you and have mental health concerns . By mental health concerns, we mean people who are experiencing depression, anxiety, mood dysregulation, or other psychiatric illness. Clients may or may not have a clinical diagnosis. We understand that clients may experience overlapping mental health concerns and substance use.

15. How often do you see clients who you suspect may be in this group?

• a.What are their typical needs?

16. How might you assess if a client is experiencing a mental health concern during pregnancy or the postpartum period? Is there a screening process? Do you ask? What does the process look like?

17. If a client discloses a mental health challenge during pregnancy or the postpartum period, can you share what your next steps would be?

• a.Which organizations or groups may you refer that person to?
• b.Do you provide any support within your center for people who are in this group? Is this support contingent on any actions on behalf of the client?
• c.Is there any type of client follow-up after an initial visit?

18. If you suspect someone is experiencing a mental health issue during pregnancy or postpartum, can you share what your next steps would be?

19. How might your course of action change if someone is experiencing an acute mental health crisis? I.e., suicidality, thoughts of physical harm to end pregnancy....

20. How supported do you feel your staff are in addressing this issue?

• a.Do they have training in this area?
• b.How may stigma or beliefs around mental health arise?

21. How is (or is) your course of action in these scenarios driven by the services that are available in your community?

Similarly, I want to ask about pregnant clients experiencing intimate partner violence (IPV), or domestic violence. By this, we mean clients experiencing physical injuries, psychological abuse, sexual assault, isolation, intimidation, or reproductive coercion perpetrated by a partner.

22. How often do you see clients who you suspect may be in this group?

23. How might you assess if a client is experiencing IPV during pregnancy or the postpartum period? Is there a screening process? Do you ask? What does the process look like?

24. If a client discloses IPV during pregnancy or postpartum, can you share what your next steps would be?

• a.Which organizations or groups may you refer that person to?
• b.Do you provide any support within your center for people who are in this group?
• c.Is there any type of client follow-up after an initial visit?

25. If you suspect someone is experiencing IPV during pregnancy or postpartum, can you share what your next steps would be?

26. How supported do you feel your staff are in addressing this issue?

• a.Do they have training in this area?
• b.How may stigma or beliefs about domestic violence during pregnancy arise?

27. How is (or is) your course of action in these scenarios driven by the services that are available in your community?

As we wrap up our conversation and have had a chance to talk through some of these issues, I’d like to end the interview with reflecting on the overarching themes around maternal health care in your community. I work in research, so I may see the broad trends or numbers in maternal health outcomes, but I’m not on the ground providing care in the way that you are. From your perspective and experience, and thinking about the services your center provides...

28. What is something you are most proud of to be providing to your community of clients?

29. What are the ways you would like to better meet the needs of your clients in the future, if you had more staff and funding capacity?

30. What do you believe would be the best way to improve maternal and infant health in your community?

• a.How do you see your organization taking steps in that direction?
• b.Who do you think should be involved? What actions should be taken? What policies are needed? Etc.

Appendix B.

Codebook

	Code	Definition or additional notes
About the CPC	Perceived role in the community	Captures language around organization’s perceived role
	Organizational history and change	Change in individual organization over time, organizational history, organizational growth, organizational shifts
	Mission and values	Language about organization’s mission and values, including pro-life conversation
	[SUBCODE] Maternal health mission	Mission and values conversation specific to pregnant and postpartum people (i.e., supporting moms, prenatal or postpartum care) excludes conversations on sexual health, STI testing, and so on. Is specific to pregnancy, birth, and postpartum
	Individual’s role and personal connection to mission	Interviewee’s role in the CPC, when they joined, the work they do, and so on, including the interviewee’s personal connections to the mission
	Funding	Captures discussion of funding sources (or lack thereof), including fundraising
	Staff training	Captures any discussion of personal or staff training, credentialing, continuing education, and so on, particularly around substance use, mental health, and IPV
	Future goals	Discussion of expansion, next steps, new ideas—can include concrete plans and ideas
	[SUBCODE] Pregnancy and birth support future goals	Discussion of expanding to doula services, birth center, childbirth education, additional ultrasound services, and so on, specific to birth
	[SUBCODE] Parenting support future goals	Discussion of parenting classes, social-emotional support for parents
	CPC local network	Key partners, places they refer to, organizations they collaborate with—including faith-based and non-faith-based organizations, that is, churches, home visiting networks, WIC, local government, L&D, doctors, and so on.
	Services offered	Captures broad language on services offered, with plan to subcode, including services not offered, including services not offered due to lack of capacity AND services not offered due to credentialling, that is, “not a mental health provider.”
	[SUBCODE] Material goods	Includes conversation on Learn to Earn, and other material goods offered
	[SUBCODE] Classes and education	Captures language where the participant discusses classes live or recorded, workbooks and worksheets, and other educational material.
	[SUBCODE] Therapeutic support and friendship	Separate from general classes but may be held in groups or individually. Does not need to be accredited or credentialed therapy. Includes language around relationship building, a “trusted ear,” “someone to listen,” “a friend they can call,” and so on.
	[SUBCODE] ‘Health care’	Discussion of what may qualify as health care, regardless of credentialling, including ultrasounds, pregnancy tests, pregnancy dating, and so on, or conversation about staff who are nurses, physicians, and so on. Includes discussion of pregnancy confirmation for public benefits.
	[SUBCODE] Enrollment in public benefits or supports	Discussion of assisting the client in signing up for state and federal benefits like WIC, Medicaid, and so on, as well as locally available services like housing or transportation.
	[SUBCODE] Duration of care or services	Captures language about how long a client can work with them, that is, “up to 3 years after the baby’s born”
About the community	Rurality	Discussion of rurality and/or isolation from larger population centers.
	Perceptions of community need and availability of general social services	Includes discussion of perceptions of generalized needs in community—that is, “our community has a drug problem,” or “we are a poor community,” “our community does not have a lot of good jobs.” Includes perceptions of the availability of more general social services related to poverty alleviation, food security, housing, child welfare, and so on.
	Perceived availability of evidence-based maternal health care	Availability of any type of evidence-based maternal health care, that is, labor and delivery units, prenatal care providers, doula or midwife services, and so on, including the change over time—that is, loss of care. Exclude description of availability of more general care, like mental health care or substance use care
	[SUBCODE] Evidence-based maternal health care change over time	Discussion of changes in EBMHC in the community—that is, hospital closure, L&D closure, prenatal care closure, hospital or L&D buyouts and mergers. Include language on perceived effect of these changes on the birthing community.
About clients	Clients experiencing substance use	Capture all conversations in this topic—broad coding with the intention to subcode
	[SUBCODE] Number or frequency of clients with substance use/perceived need	Discussion of how frequently CPCs are working with clients who are experiencing substance use. Including marijuana and nicotine
	[SUBCODE] Perceived needs of clients with SUD	Includes conversation of what participants believe their clients experiencing SUD need
	[SUBCODE] Screening, assessing, or documenting substance use	Including suspicion of substance use. Including conversation on not documenting or not screening. Include anything on intake forms, formal screenings, conversations, and so on. Including screening or assessing, capturing previous substance use.
	[SUBCODE] Support provided for substance use	Including referrals to other organizations in the community
	[SUBCODE] Perceived availability of substance use treatment care	Perceived availability of any type of SUD treatment, including faith-based providers, 12-step programs, AAA, and so on, even if they may be less evidence-based. Include conversations of wait lists, treatment capacity, and so on.
	Clients experiencing IPV	Capture all conversation in this topic—broad coding with intention to subcode
	[SUBCODE] Number or frequency of clients experiencing IPV	Discussion of how frequently CPCs are working with clients are experiencing IPV.
	[SUBCODE] Perceived needs of clients experiencing IPV	Includes conversation of what participants believe their clients experiencing IPV need
	[SUBCODE] Screening, assessing, or documenting IPV	Including suspicion of IPV. Including conversation on not documenting or not screening. Include anything on intake forms, formal screenings, conversations, and so on. Including screening or assessing, capturing previous IPV.
	[SUBCODE] Support provided for IPV	Including referrals to other organizations in the community, including CYS/child welfare, and law enforcement (with or without client knowledge)
	[SUBCODE] Perceived availability of IPV service providers	Availability of any type of IPV services, including faith-based providers. Include conversations of wait lists, treatment capacity, and so on.
	Clients experiencing mental health conditions	Includes conversation of what participants believe their clients experiencing mental health conditions need
	[SUBCODE] Number or frequency of clients experiencing MH	Discussion of how frequently CPCs are working with clients are experiencing mental health issues or conditions.
	[SUBCODE] Screening, assessing, or documenting MH	Including undiagnosed MH. Including conversation on not documenting or not screening. Include anything on intake forms, formal screenings, conversations, and so on. Including screening or assessing capturing previous MH, or documenting medication usage for MH.
	[SUBCODE] Perceived needs of clients with MH concerns	Includes conversation of what participants believe their clients experiencing mental health conditions need
	[SUBCODE] Support provided for MH	Including referrals to other organizations in the community
	per	Availability of any type of MH services, including faith-based providers. Include conversations of wait lists, treatment capacity, and so on.
	Barriers to accessing support	Barriers to accessing support for EBMHC, and/or services for IPV, MH, or SUD, including transportation, insurance coverage, language, and so on. Include language capturing perceptions of barriers—that is, “the client doesn’t want to work hard,” or “the client doesn’t have the motivation,” and so on. Specific to clients, not larger community.
	CPC and EBMCH alignment	Areas of genuine shared alignment or goals between EBMCH and CPC efforts—that is, continuity of care, provider relationships, importance of early prenatal care, prenatal vitamins, ensuring access to public benefits, having a birth plan, and so on.
	Not evidence-based (or problematic)	Actions (or opinions) that are not evidence-based. Include what appears to be purposeful opposition to an evidence-based and genuine intentions, that is “desire to do something to help” even in the face of shortage of capacity and ability.
	Intervention opportunity	Opportunity for inserting an evidence-based option or making changes or suggestions to improve care
	Doing well	What they appear to do well, or is a genuine service offered and/or needed by community. That is, relationship and community building, pregnancy and postpartum support, doula care, and so on.
	EBMCH gap-filling activities	Any stated actions they have undertaken in response to a hospital or L&D closure, or due to another community shortage in EBMCH, regardless of motivation

CPC, crisis pregnancy center; IPV, intimate partner violence; MH, metal health; STI, sexually transmitted infection; SUD, substance use disorder; WIC, Women, Infants, and Children.

31. Is there anything else related to maternal health that we have not talked about that you would like to share?

Cite this article as: Whittaker J, Nag D, Rosenquist R, Matone M (2026) Assessing crisis pregnancy centers’ capacity for supporting perinatal clients with social complexity in rural maternal health care shortage areas, Women’s Health Reports, 2026, 7, 26884844261435553, DOI: 10.1177/26884844261435553.