Demonstrators hold signs outside the U.S. Supreme Court Kevin Lamarque/Reuters

Urban areas are battling state and federal authorities over reproductive rights, and some are doing better than others.  

If you’re looking for well-funded women’s health clinics and sexually transmitted disease prevention, don’t go to Jacksonville. The Florida city scored at the very bottom of a new report by the National Institute for Reproductive Health, which ranked America’s 40 most populous cities according to the breadth of their reproductive health, rights, and justice policies.

(NIRH/Madison McVeigh/CityLab)

Jacksonville’s one-star rating reflects the city’s lack of numerous reproductive health protections, such as funding for abortion clinics, STI prevention campaigns, and community-based sexual education programming. Still, NIRH president Andrea Miller sees signs of hope: In February, Jacksonville passed historic legislation that prohibits discrimination against gay and transgender people. It’s last city of its size to secure such protections.

“Jacksonville has taken this historic step of protecting LGBTQ people,” Miller says. “That is a remarkable move. Because they’ve proven that the kind of organizing and engagement between the community and elected officials can move us forward. That’s really what we hope people will take from this.”

No city received a perfect score of five stars—meaning no city has matched each of the 37 policies tracked by the NIRH, a New York-based advocacy organization that promotes reproductive freedom. But the report, which is called the Local Reproductive Freedom Index, provides a blueprint for what cities are doing well already, and how they can increase access to reproductive healthcare for their residents—and often for the residents of the rural communities around them, too.   

“Our urban centers are the linchpin for healthcare delivery for so many people,” Miller says. “Not just for their own residents, but for those who live tens if not hundreds of miles away.”

Indeed, in many rural counties in the Midwest, the average woman has to drive more than 180 miles to get an abortion. In comparison, women who live closer to large cities only have to drive about fifteen miles to reach a Planned Parenthood facility or another comparable clinic.

The reproductive rights ranking arrives as anxiety about reproductive health care is growing under the Trump administration. In January, the president appointed Supreme Court Justice Neil Gorsuch, who’s expected to be a foe of abortion rights, and reinstated the “global gag rule,” which halts U.S. funding to international NGOs that provide, or promote, abortion services. In July, the Trump administration cut the Teen Pregnancy Prevention Program two years short, in the middle of a five-year funding period that supported community-based approaches to ending teen pregnancy. And in October, the president announced a new rule that allows employers to opt out of birth control coverage in their health insurance plans.

Not surprisingly, it’s the progressive powerhouses of San Francisco, Los Angeles, and New York City that sit atop of the index, with 4.5 star ratings. These cities have adopted numerous protections for women and families, such as funding for abortion and sex-ed, support for anti-discrimination policies, and a $15 minimum wage (New York City plans to raise its minimum wage to $15 by 2019). On the whole, larger coastal cities with long histories of investment in social justice causes score the highest.

Rankings by NIRH. Map by Soren Walljasper.

The average score of all 40 cities was two stars, and even high-scoring cities have room to make improvements. San Francisco, for example, lacks protective zoning regulations around abortion clinics, and New York City has yet to fully defund so-called crisis pregnancy centers, which sometimes masquerade as full-service reproductive health clinics.

Some cities are working to protect access to controversial women’s health services, even as their GOP-led state legislatures seek to eliminate those protections. Columbus, Ohio, for example, passed the “Healthcare Workers and Patient Protection Ordinance” in 2016 to establish 15-foot buffer zones around clinics, within which certain behaviors are strictly penalized. Similarly, in 2015, Illinois’ Cook County ensured abortion coverage for low-income women in a local effort led by the NIRH, the Chicago Abortion Fund, and the Illinois ACLU. In both of these cases, such efforts have come after state or federal actions that threaten these protections.

The report offers creative solutions to pro-choice lawmakers in cities like St. Louis that might have to work harder against conservative state governments, or hometown cultures, to advance reproductive freedom. To get higher minimum wages and more paid family leave, for example, city officials can insist that tax incentives for companies are linked to living wage and comprehensive benefits requirements. Similarly, cities can ensure that health services for municipal employees include counseling on contraception and reproductive health options, including abortion.

“Every city has a budget. Every city makes decisions about how they use their budgetary power,” Miller says. “Municipal elected officials have a really important bully pulpit. Standing up not only sends a powerful message, but it’s also the beginning of change. That’s why we did this.”

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