Planned Parenthood is by far the largest recipient of family planning funds under the $287 million Title X program, which offers services to about 4 million low-income women and girls. Planned Parenthood is at risk of losing that funding because of a recent rule change that requires abortions be delivered in separate places than family-planning services and bars directive counseling that mentions abortion.

Now, antiabortion organizations are attempting to fill that void by expanding clinics that focus on abstinence and natural family planning as methods of birth control. Operated by the California-based Obria Group, new health centers appear to be modeled after faith-based crisis pregnancy centers, designed to persuade women to continue their pregnancies, but with a twist: Obria’s clinics encourage young clients to use online apps, developed with funding from religious conservatives, to “move them away from sexual risks as their only option in life, to an option of self-control.”

Chief executive Kathleen Bravo is pitching Obria as a “pro-life” alternative to Planned Parenthood. Bravo, in an email response to questions, said many women “want the opportunity to visit a professional, comprehensive health care facility — not an abortion clinic — for their health care needs.”

“Obria gives women that choice,” she said.

Some Obria centers participating in Title X also offer “abortion pill reversal,” which involves administering large doses of the hormone progesterone to patients who have taken the first dose of the two-pill medication abortion regimen, according to the group’s site. The procedure, which the American Congress of Obstetricians and Gynecologists says is not supported by scientific research, is not reimbursable under Title X.

Political analysts have called the Obria grant a game-changer for the antiabortion movement that may lead to similar clinics being eligible for more types of federal grants, reimbursement from Medicaid and participation in private insurance plans.

The Department of Health and Human Services granted $1.7 million to Obria in fiscal year 2019, with the possibility to be renewed for two more years for a total of $5.1 million — part of a larger effort by religious conservatives in the Trump administration to transform women’s health-care services to promote alternatives to abortion and hormonal birth control, such as birth control pills, and to promote marriage between a man and woman.

Historically, Title X grants have been used to fund clinics that provide a broad range of family planning options, including condoms, birth control pills and intrauterine devices (IUDs). Although taxpayer funds could not be used for abortion services, the clinics have provided referrals and counseling about continuing a pregnancy as well as terminating one. Crisis pregnancy centers — which have been criticized by mainstream medical groups as deceptive because of their opposition to birth control and abortion — did not apply for funds or were rejected by past administrations.

When the award to Obria was announced in March, women’s rights groups expressed concern. Obria’s application was initiated at a time when Health and Human Services official Valerie Huber, a prominent abstinence advocate, was in charge of steering the family planning funds, and it was approved by Diane Foley, who previously served as president and chief executive of crisis pregnancy centers in Colorado. Foley took over from Huber as deputy assistant secretary in the Office of Population Affairs in May 2018.

Few details were available, and Obria officials declined to elaborate to media organizations, but documents obtained by the Campaign for Accountability under the Freedom of Information Act and shared with The Washington Post detail Obria’s vision for the health centers.

Inside the Obria clinics

The first set of 21 Title X Obria-branded centers, which will include brick-and-mortar operations as well as telemedicine and mobile clinics, are scattered across Los Angeles, Orange, San Diego and Santa Clara counties and serve about 36,000 girls and women over the three years of the grant. They offer reproductive health screenings for sexually transmitted diseases/infections, HIV and cancer, as well as pregnancy testing, ultrasounds and prenatal education and care.

Obria clinics will not offer hormonal birth control or sterilization but will operate in conjunction with more traditional health clinics that do provide such options. Those partners include Share Our Selves (SOS), which provides primary and specialty care in Orange County, and Hurtt Family clinics, which focus on the uninsured and homeless in Southern California. Officials for SOS and Hurtt declined to comment. The setup allows Obria to fulfill a federal checklist of services through referrals to other clinics listed as part of its project.

Alice Huling, an attorney with the Campaign for Accountability, said allowing Obria to participate in the federal family planning program in this manner is misleading to patients.

“This means women will be going to a clinic to talk about options and not know that they are at a place driven by a very narrow ideological view on birth control and reproductive health,” Huling said.

A review of Obria’s website shows that it promotes services such as “pregnancy decision consultations,”without disclosing its opposition to abortion. The section of the site offering information about abortion mentions the procedure’s side effects and risks, without ever noting that it is a safe and common procedure.

HHS officials said women who are seeking family planning services can access profiles of each center through the program’s online clinic locator tool. “It will be clear what services are offered at each site,” a spokesperson said.

Obria is made up of 50 clinics, only about half of which are participating in Title X, and its goal is to have more than 200 sites by 2022. It recently rebranded as “the fresh new face of comprehensive care.”

Despite not offering forms of hormonal birth control approved by the Food and Drug Administration, Obria’s health-care providers would take part in birth control “discussions” and “emphasize the value of abstinence,” according to Obria’s Title X application to HHS.

“Contraceptive education and counseling, especially for adolescents, will emphasize that avoiding sex is the only 100-percent effective method to prevent pregnancy and STDs,” the company wrote.

The controversial app that is part of Obria’s approach

“Fertility awareness” is another key part of Obria’s approach. The company wrote that patients would have the option of using a program/app called FEMM to monitor their hormonal cycles to either decrease the risk of pregnancy or achieve it.

FEMM, which the nonprofit says has been downloaded more than 400,000 times in 161 countries, provides a data-driven approach to help women track their period, ovulation, body temperature, medications and other physical or emotional symptoms to find patterns to help avoid or achieve pregnancy. It has been promoted internationally by the Catholic Church’s diplomatic arm and, according to government tax filings, was funded by a charity, the Chiaroscuro Foundation, backed by Sean Fieler, a New York hedge fund manager who opposes abortion.

FEMM’s chief executive Anna Halpine said in an emailed statement the company “is committed to informed choice for all women.”

“A growing number of women, in both developed and developing nations, prefer to be the primary agents of their health care choices and actions,” she wrote. “They choose to know and understand how their body works before making their own reproductive health decisions.”

Although many health professionals agree that educating women about their hormonal cycles is a worthy objective, the Centers for Disease Control and Prevention has said this approach, similar to what’s known as the “rhythm method,” is not as effective as other forms of birth control, having a failure rate of 24 percent. It also does not protect against sexually transmitted infections. Another controversial aspect of the app has been its tips and advice, such as its emphasis on the side effects of hormonal birth control.

A changing landscape for Title X

Throughout its Title X application, Obria emphasizes the importance of a “couple” — as opposed to the needs and desires of the woman as an individual — and “the benefits of commitment and marriage.”

It describes how the clinics would encourage patients to develop a “reproductive life plan” that takes into account “partner relationship and communication, long-term family planning in regard to number of children desired and spacing of children.”

Obria also plans to use another popular program funded by religious conservatives to counsel adolescents about “sexual risk avoidance,” according to its application. Known as Relationship Education and Leadership Essentials (REAL), it was written by abstinence advocate Joneen Mackenzie, a registered nurse and former Air Force lieutenant in Denver.

Obria described in its Title X application how the REAL curriculum, combined with a telehealth app, could provide real-time coaching for teens: “Obria can have a nurse or health educator right there with them, in any location, and move them away from sexual risks as their only option in life, to an option of self-control.”

The Title X program is in a time of major transition. In February, the Trump administration took aim at Planned Parenthood — which serves about 41 percent of the program’s clients nationwide — when it barred groups that provide abortions or abortion referrals from federal funding. The most controversial of the provisions — called a “gag rule” by critics — prohibits providers from providing “directive” counseling for abortions. Conservative groups, such as the Susan B. Anthony List and the Family Research Council, celebrated the decision. A number of state governors, medical groups and Planned Parenthood took to the courts and sued in cases that are still pending.

HHS officials announced on July 15 that they would start immediately withholding funds from clinics that do not comply with several provisions. A two-page guidance released late Saturday extended that deadline to Sept. 18. Clinics have until March 4 to ensure operations related to abortion are physically separate from non-abortion services.

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