[dropcap]O[/dropcap]n a sunny October afternoon, a young woman exits the Planned Parenthood office in Napa carrying a small white paper bag. She hasn’t taken more than five steps toward her car before she’s approached: “Hi, can I give you some information about free resources?”

It’s the Friday before Halloween of 2022, four months after the Supreme Court issued its landmark decision that overturned Roe v. Wade, leading to bans on most abortions in about 13 states (so far). It’s about a week before the midterms, when California voters will decide to enshrine the right to an abortion in the state constitution.

But today, here in Napa, the abortion conversation looks like this: A woman named Teresa Conemac sits on a stool steps away from the Planned Parenthood entrance, wearing scrubs and a badge that reads “client advocate,” praying and performing what she and her fellow volunteers with the Christian anti-abortion organization 40 Days for Life call “sidewalk counseling.” She talks to people approaching or exiting the clinic, and gives them pamphlets featuring widely debunked claims about the dangers of abortion and birth control.

a older white woman in orange scrubs talks to a Black woman in dark clothing outside a Planned Parenthood health clinic — Conemac talks to a person leaving a Planned Parenthood clinic in Napa. (Beth LaBerge/KQED)

Conemac also tells them about resources at, and distributes cards for, the facility next door: the Napa Women’s Center, opened by the Christian nonprofit Napa Valley Culture of Life in 2020. No medical professionals work at this facility, but a visitor can take a free pregnancy test, learn about adoption agencies and pick up pamphlets that inaccurately link abortion to breast cancer, infertility, depression and death.

The Napa Women’s Center is an anti-abortion center — sometimes known as a “crisis pregnancy center.” It’s one of approximately 3,000 such facilities across the country. Established by faith-based organizations, anti-abortion centers exist primarily to dissuade people from having abortions. They often attract clients by opening in close proximity to abortion care clinics and by advertising reproductive health services, despite the vast majority operating without medical licensing.

In Napa, it is no accident that an anti-abortion center operates right next to the city’s lone Planned Parenthood, in a state of uneasy tension, on one small city block. Connected by a 6-foot wooden fence, their facades are plain, and notably similar to the casual observer.

But behind those doors lie two vastly different worlds. For a pregnant person seeking health care, the choice of which one to enter comes with potentially life-changing consequences. None of the new state laws aimed at strengthening abortion rights can help a patient who’s standing on the sidewalk outside, deciding between the two, confused about what they’re seeing. And as long as California fails to regulate anti-abortion centers, advocates say, calling itself a sanctuary state won’t change a thing about that.

‘We don’t have a moment to lose’

Anti-abortion centers have existed in some form since the late 1960s, when Catholic activists first sought to counter the growing legalization of abortion in the United States. After the U.S. Supreme Court ruled that the right to an abortion was protected by the Constitution in its 1973 Roe v. Wade decision — which, had it been upheld, would have celebrated a 50th anniversary Jan. 22 — the so-called crisis pregnancy center movement expanded to include evangelical Christians. That expansion led to networks like Heartbeat International, which operates more than 2,000 centers worldwide.

Anti-abortion centers proliferated throughout the ’90s and aughts, in part thanks to federal grants for abstinence-only education under President George W. Bush; many received further federal funds due to changes made to Title X under the Trump administration. In 2019, for example, the California-based network of centers calling itself Obria Medical Clinics — which operates in Oakland, Redwood City, Union City and San José — was awarded $5.1 million over three years by the U.S. Department of Health and Human Services.

[aside label="Related Stories" postID="news_11934819,news_11931183"]But with the fall of Roe, abortion-rights advocates say these centers have assumed an even more powerful role in the landscape, becoming an increasingly valuable tool in the anti-abortion movement’s arsenal. At the same time, advocates charge, anti-abortion centers only intensify the inequities in abortion access along racial and socioeconomic lines.

These centers’ impact might be most dramatic in the 26 states that either recently banned or plan to heavily restrict abortions, where even seeking out abortion information could put a pregnant person on the wrong side of the law. But advocates say anti-abortion centers also play a surprisingly significant role in blue states like California, where they outnumber clinics that provide abortions by 20% — and where as many as 16,000 people are now expected to travel each year in search of abortion care (PDF).

“This is one of those issues where time is of the essence to the women who are involved, whose lives are at stake,” says former Los Angeles City Attorney Mike Feuer of the lack of regulation around anti-abortion centers. “And because of what’s happening nationally, we don’t have a moment to lose.”

In his last months as city attorney in 2022, Feuer successfully introduced a city ordinance that makes it punishable by up to $10,000 for a facility to “mislead women into believing they offer a full range of reproductive health services, including abortion or abortion referrals” when they do not.

“We may already be in a situation where women who are utterly desperate to exercise their full reproductive choices are coming to our city,” says Feuer. “And we need to ensure that when they do, no pregnancy center misleads them about their services and what their options are.”

[pullquote align="right" size="medium" citation="Christine Henneberg, Bay Area OB-GYN and author"]‘Working at medical facilities, we have so many regulations on everything we do. But then these places that are not medical facilities — that are disguising themselves as medical facilities — are totally unregulated? It makes no sense.’[/pullquote]Going unmentioned in LA’s new ordinance is how difficult it’s proven to regulate these facilities — Democratic lawmakers have been trying, and mostly failing, for years. Most recently, California’s 2015 Reproductive FACT Act required reproductive health care facilities to inform clients about the state’s programs that provide low-cost or free contraception and abortion, and forced unlicensed centers to post notices acknowledging that they were not licensed health care providers.

In 2018, after the law was challenged by an anti-abortion legal organization, the U.S. Supreme Court voted 5–4 to strike it down on the grounds that it violated the First Amendment.

For Christine Henneberg, a Bay Area OB-GYN and abortion provider — who says “a fair number” of her patients have interacted with an anti-abortion center by the time they land in her office — the continued lack of regulation is “absurd.”

“Working at medical facilities, we have so many regulations on everything we do,” says Henneberg. “But then these places that are not medical facilities — that are disguising themselves as medical facilities — are totally unregulated? It makes no sense.”

Absent meaningful regulation, some agencies have focused on education: In June of 2022, California Attorney General Rob Bonta issued a consumer alert about anti-abortion centers. And the state’s new hub for abortion resources, abortion.ca.gov, includes a section on how to spot the differences between such centers and legitimate clinics that offer abortion care.

But to Henneberg, it’s unfair to put the onus of research on the consumer.

“When you send a patient to get their tonsils removed, the language is of informed consent: You tell them the risks, benefits and alternatives that you can offer them. That is the physician’s responsibility in an ethical sense, and it’s the law,” she says. “You don’t assume, oh, well, they can find out for themselves … it boggles my mind that anyone would think it’s the responsibility of the consumer seeking a legal service to figure this out on their own.”

‘Patients get confused’

Lynda Metz knew immediately that the building she’d entered wasn’t a health clinic. But it was 1995, she was 17, and the center had been the first thing listed when she looked up “pregnancy test” in the Yellow Pages. Pregnant and terrified in a strict Southern Baptist community north of Little Rock, Arkansas, she was happy to take whatever free services were closest to home.

“There was nothing clinical about it,” recalls Metz, who went on to have two children by the age of 20. “I peed on the stick, and then a woman pulled me into a room and took out her Bible … and kind of held me hostage for two hours. She showed me pictures of little plastic babies with arms and legs and said, ‘This is what your baby looks like now.’ There was nothing about how to [take care of myself]. Their focus was just baby, baby, baby.”

a young teen girl with brown hair in a school photo at left, and in a portrait with her infant son on the right — On the left, Lynda Metz in a photo from her sophomore year of high school, the year before she became pregnant. On the right, Metz a month before her 18th birthday, with her son Matthew. (Courtesy Lynda Metz)

Nearly three decades later, search engines have taken the place of the Yellow Pages — with arguably more complicated results. Last August, responding to mounting public pressure, both Yelp and Google Maps announced that their apps would begin labeling so-called crisis pregnancy centers differently from health clinics that provide abortion care.

It would appear they’ve followed through, to a point: Up until July, a search for “abortion” on Google Maps returned nearly two dozen anti-abortion centers across the Bay Area’s nine counties, including one in San Francisco, one in Oakland and several in the South Bay. Six months later, that’s no longer the case. However, a search for “pregnancy center” or “women’s clinic” still returns most of these centers. And paid advertisements for anti-abortion centers still regularly appear in Google’s search results without any disclaimers.

Carly Thomsen, assistant professor of gender and sexuality at Middlebury College in Vermont, thinks the algorithm update was a small, overdue step in the right direction — but she doesn’t expect it to put much of a dent in anti-abortion centers’ business model.

“I can see how people would think crisis pregnancy centers are using technology to transform their approach, but I actually don’t think that’s true. I think technology has allowed them to make their same strategies more sophisticated and more wide-reaching,” says Thomsen, who recently co-authored a deeply researched opinion piece on these facilities for The New York Times. “And that strategy is to use scare tactics and deception to make claims about what they will offer you in terms of support, even though they’re never held accountable for any of these things.”

a mural that says "live life love" is seen on the side of a building labeled "alpha pregnancy center" — The Alpha Pregnancy Center, a faith-based anti-abortion center on Mission Street in the Excelsior neighborhood of San Francisco. After months of public pressure, Google Maps recently updated its algorithm so this center no longer appears when a user searches the word ‘abortion.’ (Beth LaBerge/KQED)

As a graduate student at UC Santa Barbara, Thomsen was part of a successful effort in 2010 to ban anti-abortion centers from advertising on campus. It’s still the only school, to her knowledge, with that restriction.

But perhaps the most insidious tactic, says Thomsen, remains simple geography: By design, religious groups open anti-abortion centers in close proximity to clinics that offer abortion care. In Thomsen’s research on these geographic relationships, she found that more than 99% of clinics that offer abortion care nationwide have an anti-abortion center located close by.

“Any place there’s an abortion clinic, there’s a crisis pregnancy center,” she says. “And that’s very intentional.”

In other words, say experts: these facilities count on vulnerable people making mistakes.

That dynamic is especially evident in places like Napa, where anti-abortion activists work blatantly to direct people away from Planned Parenthood and toward the Napa Women’s Center.

“Patients get confused,” says Gloria Martinez, senior director of operations for Planned Parenthood Northern California, of the situation at those two facilities. “Especially if it’s their first time with us or visiting that location, and there’s this person out there in scrubs and this person is telling them, ‘Oh, come over here instead.’”

While a so-called buffer zone is supposed to render the clinic’s entrance off-limits to protesters, Martinez says local law enforcement seems hesitant to enforce it due to fears “that the opposition will take action against them” with lawsuits that claim the buffer violates their First Amendment rights.

The presence of protesters is one major reason this Napa location of Planned Parenthood is scheduled to close in 2023 after more than 20 years. It will reopen in a new, larger facility elsewhere in Napa — staff are hesitant to say exactly where, lest anti-abortion activists begin planning protests there as well — in the hopes of a better patient experience.

As for the current patient experience, it’s difficult to quantify exactly how many people who intend to visit Planned Parenthood end up at the anti-abortion center next door. But there are indicators. During the twice-yearly campaigns by 40 Days for Life — in which anti-abortion protesters are present in larger numbers for, yes, 40 days — Martinez says the no-show rate for appointments at that Planned Parenthood doubles: It normally hovers at around 19%, but during campaigns, the number “skyrockets to 40, sometimes 50%.”

The hand of an older white woman holds a pamphlet describing inaccurate side effects of abortions — 40 Days for Life volunteer Teresa Conemac holds pamphlets she distributes outside Planned Parenthood in Napa. (Beth LaBerge/KQED)

“It’s just another barrier [for patients], when there are already so many barriers,” says Martinez. “So many of our patients are low-income, or maybe they’re facing a language barrier or a transportation barrier.

“And then this is another layer that they have to face: harassment. Harassment when seeking health care.”

Targeting communities of color

Even if a person mistakenly visits an anti-abortion center, then eventually finds their way to a clinic that offers abortion care, it’s difficult to overstate the trauma that such an experience can inflict, says Susy Chávez Herrera, communications director for California Latinas for Reproductive Justice in Los Angeles (CLRJ).

“It can be really intense, and it can really hurt a person’s well-being,” says Chávez Herrera. “Whether physically, by delaying a procedure that might be needed for medical reasons, or mentally, because of the toll it takes on folks who are seeking a medical service and met with this series of misinformation.”

That may be especially true considering the already vulnerable communities targeted by anti-abortion centers, according to advocates: immigrants, first-generation Americans, Black and Latinx people, young people and people from lower-income families living in rural areas.

pamphlets in English and Spanish on a shelf show a Black woman and a Latina woman who are pregnant. The pamphlet is titled "the first 9 months" — Pamphlets available at the Alpha Pregnancy Center in San Francisco. The APC, unlike the majority of anti-abortion centers, has a medical license. (Emma Silvers/KQED)

“We know they target the Latinx community,” says Chávez Herrera. “Just driving down the street here in LA, you see billboards from these groups, with this misinformation, in neighborhoods that we know have largely Latinx communities. And we know these anti-abortion clinics set up shop in our communities.”

A study by The Alliance, a consortium of law organizations and policy groups studying reproductive justice, found that some anti-abortion centers try to appeal to Black communities (PDF) — which already face disproportionate maternal mortality rates — by “blackwashing” their websites or pamphlets, prominently featuring images of Black women.

In the Latinx community, advocates say anti-abortion centers prey on fears undocumented immigrants might have about visiting a government-funded health clinic, wary that it could lead to deportation; others note that anti-abortion centers make a point of advertising on Spanish-language radio.

a screenshot of a spanish language website of a crisis pregnancy center called real options medical clinics, featuring a woman in scrubs talking to another woman, a patient — A screenshot from the website of Obria Medical Clinics, a network of anti-abortion centers that operates five facilities in the Bay Area, funded partially by federal grants it received under the Trump administration. Obria clinics also advertise that they accept Medi-Cal, which means their clinics receive reimbursements from the taxpayer-funded state program.

Care Net, one of the two biggest national networks of anti-abortion centers, has had a programming arm explicitly devoted to outreach in Black and Latinx communities since 2003, according to a study in the International Journal of Women’s Health. Initially dubbed the “Urban Initiative,” tactics include advertising on Black Entertainment Television (BET) and “drawing comparisons between abortion and slavery.”

“There’s no question that they target communities of color,” says Thomsen. “So we also need to be talking about crisis pregnancy centers as something that is impeding racial justice.”

a Black woman is seen on a website for the Alpha Pregnancy Center, a Christian anti-abortion center — A screenshot from the website of the Alpha Pregnancy Center, an anti-abortion center in San Francisco.

One small step in the right direction, according to abortion rights advocates, is Assembly Bill 2586, which was signed by Gov. Gavin Newsom in September as a means of addressing “the reproductive and sexual health inequities that Black, Indigenous and other communities of color face” by issuing grants to community-based organizations that focus on culturally relevant care.

[pullquote align="right" size="medium" citation="Carly Thomsen, assistant professor of gender and sexuality, Middlebury College"]‘There’s no question that they target communities of color. So we also need to be talking about crisis pregnancy centers as something that is impeding racial justice.’[/pullquote]The bill’s text included a pointed section about how the “dissemination of misinformation … particularly at the hands of organizations with a demonstrated interest in limiting choice that often misrepresent themselves as health centers, imposes a harmful barrier to reproductive health care access, especially for communities most impacted by a number of other obstacles to care.”

While abortion-rights advocates applaud the bill — CLRJ endorsed it enthusiastically — some also note that funding legitimate reproductive health organizations does little to directly curtail the impact that anti-abortion centers have in communities of color, the result of decades of groundwork by anti-abortion activists.

“What we’re talking about is an organized campaign of misinformation,” says Chávez Herrera. “And that has been around since well before the repeal [of Roe v. Wade], even in states that are trying to protect abortion rights.”

‘God works in mysterious ways’

On the street in Napa, as Conemac and a fellow volunteer perform their “sidewalk counseling” next to signs they’ve brought that read “EXPOSE PLANNED PARENTHOOD,” people drive by and honk every few minutes in response. In some cases the honk is followed by a middle finger, or a yelled epithet. They also receive thumbs-up signals, and in one case a shout of “God bless you!”

But inside the Napa Women’s Center, it’s quiet; the paint and furniture are all soothing beige and pastels. In a room often used to counsel pregnant people, Julie Murillo, executive director of the center, declines to estimate what percentage of the people entering the center are doing so mistakenly, thinking they will be able to access birth control or abortion care. It happens, she says casually, “all the time.”

a car with signs that read 'expose planned parenthood' outside a crisis pregnancy center — A car with signs for the organization 40 Days for Life sits outside the Napa Women’s Center, an anti-abortion center opened by faith-based nonprofit Napa Valley Culture of Life. (Beth LaBerge/KQED)

“I tell them that we’re not Planned Parenthood, we’re the Napa Women’s Center, and then I ask them if we can help them on what they need,” she says. She’s seated by a shelf full of English and Spanish brochures with titles like “Life Before Birth,” “What You Need to Know About Abortion Procedures” and one advertising information about “abortion pill reversal” — an experimental hormonal treatment not approved by the FDA, which the American College of Obstetricians and Gynecologists has said is potentially dangerous and not supported by science.

“We’re not here to lie to anybody,” says Murillo. “We are here to try and tell them the truth about what happens to their bodies, and to help them make good decisions for their life.”

Three printed-out signs advertising, among other things, 'abortion pill reversal' in a row of glass panels in a front door. — Signs on the door for the Napa Women’s Center advertise ‘abortion pill reversal’ at the facility in Napa on Nov. 4, 2022. (Beth LaBerge/KQED)

Like most anti-abortion centers, the Napa Women’s Center has no medical professionals on staff. But the organization is in the process of recruiting a nurse practitioner; then, the center plans to begin offering ultrasounds, which anti-abortion activists consider a powerful tool in dissuading a person from having an abortion.

The Alpha Pregnancy Center in San Francisco may be an example of what many anti-abortion centers would like to achieve. The facility — which is not located near an abortion care clinic, and which states clearly on its website that it does not offer abortions — was founded by a group of pastors in 1983. But the center completed a two-year process to obtain a medical license in 2015, and now has a full-time registered nurse overseeing its medical services, including ultrasounds.

For certified OB-GYNs like Henneberg, ultrasounds are also, notably, often the first indication that a patient has mistakenly been to an anti-abortion center before landing in a legitimate medical office.

“They’ll ask me questions like, ‘Do I have to look at the ultrasound?’ And I’ll say, ‘No, of course not.’ And they’ll say, ‘Oh, well, the other place made me look at the ultrasound, and I really don’t wanna see it,’” she says. In some cases, according to several reports, an anti-abortion center might perform an ultrasound, then show patients a falsified image of a fetus at a later stage of development to dissuade them from seeking an abortion.

“If you probe a little, often you’ll hear, ‘Yeah, I went to this place first and they told me not to get [an abortion]. And they’re obviously usually annoyed by that,” says Henneberg. “That’s not why they went there.”

a gray building with words that say 'free pregnancy tests' and 'Napa Women's Center, health and wellness matter' — The Napa Women’s Center, a facility opened by faith-based nonprofit Napa Valley Culture of Life, advertises free pregnancy tests. (Beth LaBerge/KQED)

Murillo remains adamant that Napa Women’s Center staff are not out to trick anyone. And she says that while the center and 40 Days for Life share the same beliefs about abortion — they are hoping to “help people choose life” — they are separate organizations. (Technically, the two nonprofits do have separate tax ID numbers. But in a video advertising the Napa Women’s Center, Napa Valley Culture of Life president Gerry Cruz details how the center grew directly out of 40 Days for Life’s 2009 campaign in front of Planned Parenthood. Volunteers and staff are on a first-name basis, many belong to the same church, and so on.)

In discussing the center’s offerings, Murillo is especially proud of the center’s “baby boutique”: In exchange for watching videos on relationships, fetal development and parenting, visitors can earn points, which can be exchanged for diapers or formula.

As for Murillo, she comes from a wine and hospitality background. “God works in mysterious ways,” she says, by way of explaining how she landed in this profession, which amounts to a combination of unlicensed social work and, ostensibly, distributing medical information. “You never know where you’re going to end up, and sometimes you just say yes.”

‘I felt tricked’

There are encouraging signs, say some abortion-rights advocates, that anti-abortion centers may finally be garnering attention. In June, a group of four Democratic congressmembers including Sen. Elizabeth Warren introduced the Stop Anti-Abortion Disinformation Act, which would have the Federal Trade Commission issue rules regarding deceptive advertising by anti-abortion centers. And the newly formed California Reproductive Rights Task Force lists “enforcing consumer protection laws against deceptive or unlawful conduct concerning reproductive healthcare” as one of its objectives.

But the anti-abortion movement may already be adjusting its strategies in response. Anti-abortion activists have explicitly stated that they view the Dobbs decision as a chance to expand their networks, including opening new centers. The National Institute of Family and Life Advocates has led an effort to help existing anti-abortion centers hire trained nurses and obtain medical licensing — potentially shielding them from lawsuits about false advertising. And some facilities have increasingly touted their so-called baby boutiques, branding themselves primarily as charities, though due to lack of oversight there’s very little data on how much they actually give away.

a white woman with short blond and gray hair in a pink suit speaks in front of the Capitol building — Sen. Elizabeth Warren (D-MA), seen here speaking about abortion rights at a press conference on June 15, 2022, is one of the members of Congress behind the Stop Anti-Abortion Disinformation Act, which would have the Federal Trade Commission issue rules regarding deceptive advertising by anti-abortion centers. (Joe Raedle/Getty Images)

In the meantime, according to the Alliance study, as of a 2021 count, anti-abortion centers outnumbered clinics that offer abortion care nationally by an average ratio of 3 to 1.

In California, roughly 170 anti-abortion centers continue to operate — and at least 10 have received state funding through Medi-Cal reimbursements, also according to the Alliance study, which noted that “[i]nvestment of public money in CPCs is escalating, especially in the states, with virtually no government oversight, accountability, or transparency.” An untold number of centers also received both federal and state funds during the pandemic through the Paycheck Protection Program.

In Napa, as daylight wanes, the 40 Days for Life volunteers pack up their things; Conemac likes to focus on the hours of 10 a.m. to 3 p.m., since that’s when she believes Planned Parenthood pharmacists give out RU-486, otherwise known as the abortion pill. (This location does not perform surgical abortions.) In her place, a group of teenage volunteers from the organization gathers with anti-abortion signs, and stands laughing and talking, flanking the space between the two centers.

a row of young teens holds anti-abortion signs on the sidewalk in between a Planned Parenthood and a crisis pregnancy center. From across the street, they seem to be diverse in terms of ethnicity, age., and gender. — Young volunteers for 40 Days for Life stand with anti-abortion signs on the sidewalk between Planned Parenthood and the Napa Women’s Center in Napa on Oct. 28, 2022. (Emma Silvers/KQED)

Some of them look to be around 17. That’s the age Lynda Metz was when she first set foot in an anti-abortion center, scared and confused. Some 27 years later, Metz — now a proudly pro-abortion-rights grandmother still living in a conservative area of Arkansas — can’t help but think about her experience. For one, that center is still in operation, and occasionally she has to drive by it. Or she’ll see a sign from a local business announcing they donate to that facility, and she makes a mental note not to shop there.

She also makes a point to talk to other young women in her community, and lets them know they have options. However, as Arkansas is now a state where abortion is “completely banned with very limited exceptions,” according to the Guttmacher Institute, those options are severely limited: A person seeking an abortion has to drive an average of more than 300 miles one-way to visit a clinic that offers them.

Mostly, when Metz thinks about her experience, it still feels fresh, and she still feels confused. She can place herself in that room, trapped with that woman and the Bible, realizing she was not going to receive any support or information about her health.

“I felt tricked,” she says. And nearly three decades later, she says, “I still just don’t understand. It’s not a necessary service. You are literally tricking people into thinking that this is a certified health clinic.

“I mean, how is this still legal?”

[ad fullwidth]

This story has been updated to reflect The Associated Press’ new guidance on language to describe anti-abortion centers.

[ad floatright]

anti-abortionanti-abortion

The Anti-Abortion Movement Next Door

Southern California Congressional Race Pits Anti-LGBTQ+ Trump Republican Against Gay Prosecutor

Supreme Court Sides with California Anti-Abortion Pregnancy Centers

Thousands of Anti-Abortion Activists Converge on S.F. for Walk for Life

Supreme Court Takes On Case About Free Speech and Abortion