Ten years ago, during the George W. Bush presidency, the National Institute for Reproductive Health, fearing a clampdown on access to women’s health services, launched the Urban Initiative for Reproductive Health to support local policies and advocacy efforts working to counterbalance the Bush administration’s stance. It’s since funneled millions of dollars into local chapters of organizations like NARAL Pro-Choice America and Planned Parenthood, along with smaller local initiatives.
A decade later, after less than a year in the White House, Donald Trump has expanded the global gag rule, limiting the freedom of international NGOs to even speak about abortion; he’s made numerous attempts to roll back women’s health coverage and access by dismantling the Affordable Care Act; and, among other policies (and his general presence as a misogynistic force), he appointed the anti-choice Neil Gorsuch to the Supreme Court. NIRH president Andrea Miller says that while the actions of the Bush administration precipitated the launch of the Urban Institute, it “was admittedly not as hostile as the one we’re facing now.”
The Local Reproductive Freedom Index, published on October 18, is the NIRH’s response. It ranks the 40 most populous cities in America on the strength of their women’s health services to show that while the federal government may be hostile toward women’s health, it’s still possible for local policies and initiatives to create a framework to protect women.
The report uses a five-star system: None scored perfectly. But Los Angeles, New York City, and San Francisco rounded out the top three with 4.5 stars each. Jacksonville, Florida, with just one star, scored the lowest. Los Angeles scores well for making a concerted effort to extend health coverage and resources to immigrant populations, who are aren’t covered federally; New York is noteworthy for increasing quality abortion care training in city hospitals; San Francisco funds health clinic safety measures and advocates for pro-choice policies. Jacksonville, at the opposite end of the spectrum, was, until earlier this year, the largest city in the U.S. without human rights protections for LGBT residents in place, and provides no funding for abortion clinics or STI prevention campaigns.
Of course, Miller says, there are budgetary forces at work here: The top three cities are also among the wealthiest in the country. But culturally, the report notes, “they also have a long history of advancing social justice causes and have made a renewed commitment in recent years to . . . building a more equitable culture.”
The report assesses cities on 37 specific indicators, broadly grouped into six categories: protecting abortion clinic access, providing funding and coverage for reproductive healthcare, supporting young people’s access to reproductive healthcare, supporting families’ financial stability and health, advancing inclusive policies, and taking a stand on reproductive healthcare issues at play at the state, local, or federal level.
“The truth is that cities have a tremendous ability to act as a counterweight to the Trump administration, and the cities that have scored at the highest level give you a really good sense of that,” Miller says. “They absolutely can provide funding for family planning, for sex education that’s comprehensive, inclusive, and medically accurate. They can protect access to clinics.”
Because no cities are yet at a score perfect, the NIRH report lays out a blueprint for a “Model City” to “exemplify what a city could look like if it used the full extent of its policy and programmatic powers to support the freedom and ability of each person to control their reproductive and sexual lives, foster thriving families, and destigmatize abortion and contraception.” Among numerous other facets, the Model City has sufficient abortion clinics (supported by the local government and health system) to meet the needs of its population; its police department would protect people visiting the clinic from protesters. The city’s education department would require age-appropriate K through 12- and LGBT-inclusive sex education, and the city government would advocate the state and federal governments to support measures advancing access to reproductive healthcare.
The Reproductive Freedom Index focuses on the 40 most populous cities in the U.S. because, as Miller says, they house the majority of the population. But in more rural parts of the country, abortion clinics are closing at an alarming rate–6% between 2011 and 2014, according to a report from the Guttmacher Institue, and that number is unlikely to do anything but grow during the Trump administration. In Texas, for instance, 96% of the counties have no abortion provider, and up to 240,000 women in the state have consequently tried to self-induce. Comprehensive sex education is scant in those areas.
Taking large, well-resourced cities as a starting point, Miller says, allows NIRH to capture the widest variety of innovative policies and programs to express what’s possible in the reproductive health landscape. Around 20 years ago, Baltimore Public Schools, for instance, became one of the country’s first school systems to provide the long-lasting reversible implant at school-based health centers–a policy supported by the city health department. The Feminist Women’s Health Center in Atlanta, a nonprofit advocacy organization and abortion provider, combines activism and voter registration with services especially crucial in the larger red-state context.
The cities in the report are some of the strongest political levers in their states; if they are capable of building out a strong reproductive health framework, they could advocate more effectively at the state level to expand resources to underserviced areas. “It’s our hope that by creating this index and setting out these benchmarks and showing what the Model City could be that in the conversations about developing better health, there will be a recognition that reproductive health and access to the services can and should be a part of that conversation,” Miller says.