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.

Keywords

crisis pregnancy center rural maternal health shortage area access to maternal health care maternal morbidity

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 diabetes⁸ 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 women¹⁴ 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%)

Two 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.

Footnotes

Author Disclosure Statement

The authors have no disclosures or conflicts of interest to report.

Funding Information

Internal funding via PolicyLab at Children’s Hospital of Philadelphia Pilot Grant.

Appendix A. Interview Guide.

Abbreviations Used

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