LOCAL REPRODUCTIVE FREEDOM INDEX 2023
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Learn more about each of the LRFI’s six policy categories, including what each indicator means and why it matters for reproductive freedom. We also offer a set of policy recommendations to help you build a Model City in your own backyard.

Protecting Abortion Access
Funding and Coverage for Reproductive Health Care
Supporting Young People
Supporting Families
Building Healthy and Just Communities
Proclaiming Local Values
The Research
For each city, we assessed the following policies for Protecting Abortion Access:

Clinic safety ordinance:
At least one local protection is in place, including but not limited to buffer zones, bubble zones, or enhanced penalties for crimes committed near a clinic. 

Addressing deceptive practices of anti-abortion pregnancy centers (AAPCs):
At least one local initiative is in place to protect against the deceptive practices of AAPCs, including but not limited to a public education campaign, signage ordinance, consumer protection, or restriction on municipal funding to AAPCs.

Local protections for abortion clinics and providers:
At least one policy is in place to protect abortion clinics and/or providers, including but not limited to a noise regulation for clinic protesters, parking regulation, residential picketing restriction, or zoning policy. 

Public awareness about access to abortion care:
The city has engaged in a public awareness campaign or initiative related to access to abortion care. 

Anti-discrimination employment ordinance for reproductive health decisions:
A policy prohibiting discrimination against workers based on their reproductive health decisions, including their decision to use contraception or choose an abortion, is in place citywide. 

Anti-discrimination housing ordinance for reproductive health decisions:
A policy prohibiting discrimination in housing based on tenants’ reproductive health decisions, including their decision to use contraception or choose an abortion, is in place citywide. 

THE ROADMAP
Actionable Steps for Protecting Abortion Access

To learn more about the policies listed below and additional ideas that may be relevant in your community, reach out to NIRH at partnerships@nirhealth.org. 

  • Address anti-abortion harassment by developing a policy tailored to local clinics’ needs and circumstances to allow safe access to clinics. 
  • Engage every relevant department in the city to implement and enforce policies and practices to prevent harassment, noise, and other disruptions at abortion clinics. 
  • Prevent harassment by enacting a policy to keep clinic staff personal information confidential under certain circumstances and/or prevent picketing at private residences. 
  • Pass and enforce regulations that address the deceptive practices of AAPCs. 
  • Understand zoning regulations for abortion clinics and the areas around them. Consider explicitly stating in zoning ordinances that abortion clinics are health care facilities. 
  • Launch a public awareness campaign to ensure residents know where and how to access safe and legal abortion care and educate residents on how to identify an AAPC. 
  • Create a directory of reproductive health care providers, including abortion clinics that consent to be included, and describe the services they provide. Include information on local abortion funds and other financial supports residents can access to help pay for their care. 
  • Officially recognize March 10 as Abortion Provider Appreciation Day to celebrate the important work of local abortion providers and clinics. 
  • Pass a reproductive health non-discrimination ordinance to prohibit workplace discrimination based on a person’s decisions about their reproductive health, including their choice to use contraception or have an abortion. 
  • Organize against hospital or health system mergers that would reduce access to abortion or contraception. Offer public education about the limits on services provided in religiously affiliated health care settings. 

The impact of the overturning of Roe v. Wade on cities.

As of December 31, 2022, 13 US states had banned abortion entirely and abortion was barely accessible in many others. In this report, the “Abortion Clinic” count reflects the number of abortion clinics actively providing abortion care as of December 31, 2022. To this end, for cities located in states that have restricted and/or banned abortion, the number of abortion clinics often had to be marked as “0” even if the clinic building was still standing. Despite the many harms caused by abortion bans, there is much that cities can do to protect and support abortion access, such as allocating funding to abortion care or providing public education on abortion access points.

IMPORTANT CONTEXT
Local efforts to deprioritize criminalization of abortion care

Since the leak of the Dobbs decision in early 2022, cities and counties across the country have passed resolutions or ordinances to deprioritize the prosecution of people who have had or assisted with an abortion or who have had unexpected, negative pregnancy outcomes such as stillbirth or miscarriage. These local efforts take away funding or limit access to resources that would be used in such investigations and prosecutions and/or demand that these types of prosecutions be given lowest priority by local law enforcement agencies. In this new landscape of abortion access, such creative and bold actions are important to protect people who need abortions and those who support them. The LRFI tracks these resolutions and ordinances within the “local protections for abortion providers” indicator. However, the impact of deprioritization work can be limited by several factors, including the governing body’s lack of authority over local law enforcement and the ability of other law enforcement actors at the county or state level to step in. There are other strategies that localities can pursue to achieve similar aims, and we encourage advocates or elected officials interested in pursuing such policies to reach out to NIRH for more information on their options. 

THE RESEARCH
For each city, we assessed the following policies for Funding and Coverage for Reproductive Health Care:

Funding for abortion:
Money is allocated to help patients who could not otherwise afford to pay for abortion care or practical support related to the logistics of accessing abortion care, such as lodging, transportation, or childcare. Alternatively, the city has established its own municipal insurance program for residents that covers abortion care.

Funding for STI/STD testing and prevention:
Money is allocated for at least one of the following initiatives, of any size or for any population: testing, prevention (to any extent), treatment, or expedited partner therapy.

Municipal insurance coverage of abortion:
Insurance coverage of abortion, and/or an explicit municipal policy requiring insurance coverage of abortion, is in place for all municipal employees.

Funding for contraception:
Money is allocated for contraception in any form, including condoms.

Funding to train providers in reproductive health care:
Money is allocated to train providers in at least one important aspect of reproductive health care, such as abortion care; long-acting reversible contraception (LARC) insertion or removal; person-centered counseling and care; or reproductive health care for LGBTQIA people, young people, or other specific populations.

Funding for community-based organizations to provide comprehensive sexuality education (CSE):
Money is allocated to at least one community-based organization to provide CSE.

THE ROADMAP
Actionable Steps for Funding and Coverage for Reproductive Health Care

To learn more about the policies listed below and additional ideas that may be relevant in your community, reach out to NIRH at partnerships@nirhealth.org.

  • Allocate municipal dollars to the city’s local abortion funds, practical support organizations, and/or local abortion providers to help people pay for costs associated with accessing abortion, including the procedure itself, travel, lodging, childcare, and other logistics.
  • Mandate that insurance benefits for municipal employees cover comprehensive reproductive health care, including abortion.
  • Require or incentivize companies that contract with the city to offer coverage of comprehensive reproductive health care, including abortion, to all their employees.
  • Offer trainings to reproductive health care providers and staff on how to provide care to populations with unique needs — including LGBTQIA-friendly care, teen-friendly care, and culturally responsive care — and how to provide person-centered care to all patients.
  • Offer trainings to reproductive health care providers on how to protect the safety of patients seeking abortion care, including those who have traveled from a state that has banned abortion and those who may have self-managed their abortion.
  • Allocate municipal dollars to provide support for people who are pregnant and parenting, including services like pregnancy tests and prenatal care and supplies like diapers, formula, and baby clothes. This funding meets an urgent need in the community and ensures that people do not have to rely on supplies or services from an AAPC.
  • Provide funding to ensure that immigrants, including those who are undocumented, can benefit from city-funded programs, and ensure protections are in place to guard their information so they can feel safe accessing these services.
  • Fund a residency training program in city or county hospitals that includes training in abortion and miscarriage management for medical residents in obstetrics, family medicine, and other relevant specialties.

Using the American Rescue Plan Act funding to support abortion care

The passage of the American Rescue Plan Act (ARPA) in March 2021 provided an unprecedented opportunity for governments to make meaningful and equitable investments in community-based programs and services that are aligned with reproductive justice values. Localities had great flexibility in how they used their ARPA funds. Unlike other federal funds, ARPA funds had no restrictions on abortion care or funding to support immigrant communities and were not subject to state preemption laws. Some cities, such as Columbus, OH, were able to successfully use ARPA dollars to support abortion access and immigrant communities.

THE RESEARCH
For each city, we assessed the following policies for Supporting Young People:

Support for pregnant and parenting youth:
At least one supportive, non-stigmatizing policy or program is in place to support pregnant and parenting youth, such as daycare in schools, lactation accommodations, a Pregnant and Parenting Youth Bill of Rights, or flexible absence policies.

Funding for comprehensive sexuality education (CSE):
Municipal funding is allocated for CSE in schools or the city has applied for and received state or federal grants to support CSE.

Comprehensive sexuality education (CSE):
A policy is in place requiring CSE that is evidence-informed, medically accurate, developmentally appropriate, and non-stigmatizing. To be categorized as CSE, a curriculum should include human development; healthy relationships; interpersonal behavior, including consent; and sexual health. CSE can include abstinence as an option but must discuss other forms of contraception.

Reproductive health care in school-based health centers (SBHCs):
SBHCs provide reproductive health care in some form, including dispensing of birth control or STI/STD testing and/or treatment. 

THE ROADMAP
Actionable Steps for Supporting Young People

To learn more about the policies listed below and additional ideas that may be relevant in your community, reach out to NIRH at partnerships@nirhealth.org.

  • Provide pregnant and parenting youth with the services and accommodations they need to continue and complete their education in a non-stigmatizing environment, including resources for lactation, childcare, and flexible absence policies.
  • Require schools to implement a K–12 CSE program that meets the National Sexuality Education Standards. CSE includes lessons about consent, healthy relationships, and bodily autonomy, in addition to lessons about sexual and reproductive health.
  • Allocate municipal dollars to teacher training and support, as well as monitoring and evaluation, to support the effective implementation of sexuality education programs.
  • Allocate funding to community-based organizations to develop culturally responsive sexuality education curricula that align with local community needs.
  • Pass policies and implement programming to ensure that all young people have consistent access to the same level of CSE, including those in juvenile detention and foster care settings.  
  • Fund SBHCs that offer reproductive health care services, including contraception services and counseling and STI/HIV screening. Train SBHC staff on providing LGBTQIA-friendly reproductive health care.  
  • Pass policies to ensure that young people in juvenile detention and foster care settings can access comprehensive reproductive health care at no cost and with support to overcome logistical barriers to access. Provide training in person-centered and teen-friendly care to staff and providers who work with young people in these settings to guard against coercion.  
  • If the city is in a state that requires parental notification or consent for young people to access abortion care, provide assistance to young people navigating the judicial bypass process. 

Protecting young people’s autonomy

Attacks on young people’s rights have intensified over the past few years. Young people should have the support and information they need to make the best decisions for their health, lives, and future opportunities, and they should be able to decide who to seek out for support and guidance. Local leaders must consider the needs of young people when passing policies and engage with young people and organizations that work with them to understand local needs and identify opportunities to protect and expand young people’s autonomy.

THE RESEARCH
For each city, we assessed the following policies for Supporting Families:

Supportive lactation policies:
The city has at least one policy or program in place to support lactation, such as workplace accommodations or education initiatives to destigmatize and facilitate chest feeding.

Paid family leave:
A paid family leave policy is in place for full-time municipal employees.

Environmental protections for reproductive health:
The city has one or more policies in place specifically linked to protections for prenatal or reproductive health, such as protections for nail salon workers or other workers exposed to toxic chemicals, protections for clean water, and regulation of skin lightening creams.

Anti-discrimination employment ordinances for pregnancy and family status:
A policy is in place that prohibits discrimination against employees based on pregnancy and family status.

Anti-discrimination housing ordinances for pregnancy and family status:
A policy is in place that prohibits discrimination in housing based on pregnancy and family status. 

Initiative to address pregnancy-related mortality:
The city has taken action to reduce pregnancy-related deaths, including but not limited to allocating funding or establishing policies and initiatives to support access to doula care and training, establishing collaborative practice agreement guidelines, passing a Pregnant Person’s Bill of Rights, offering universal basic income for people who are pregnant or parenting, supporting pregnant people who use drugs, and implementing environmental protections.

THE ROADMAP
Actionable Steps for Supporting Families

To learn more about the policies listed below and additional ideas that may be relevant in your community, reach out to NIRH at partnerships@nirhealth.org.

  • Create policies or programs to support lactation, such as workplace accommodations or education initiatives to destigmatize and facilitate chest feeding.  
  • Require a paid family leave policy for all municipal employees. 
  • Establish environmental protections specifically linked to prenatal or reproductive health, such as protections for nail salon workers or other workers exposed to toxic chemicals, programs to support clean water access, and regulation of skin lightening creams. 
  • Prohibit discrimination against employees based on pregnancy and family status. 
  • Allocate funding or establish policies and initiatives to support access to doula care, especially for the Black and indigenous communities most impacted by the pregnancy-related mortality crisis.
  • Allocate funding or establish a program to support doula training, especially in communities where doulas are underrepresented.
  • Establish a Pregnant Person’s Bill of Rights in the local hospital system to protect patient autonomy.
  • Provide training to local providers and hospital staff on how to support and not criminalize pregnant people who use drugs.

Webs of care operate differently within each of our communities. 

To effectively meet the reproductive needs of families, cities need to offer solutions that are inclusive of nontraditional familial structures, uplift youth agency, and ultimately work toward community care and sovereignty.  

IMPORTANT CONTEXT
Pregnancy-related mortality and link to abortion bans

For this year’s report, NIRH has added one new indicator: “Initiative to address pregnancy-related mortality.” The CDC defines pregnancy-related death as “a death while pregnant or within one year of the end of pregnancy from any cause related to or aggravated by the pregnancy.” NIRH intentionally uses the term “pregnancy-related mortality” to be inclusive of all people who give birth and to address pregnancy-related causes of death that may occur outside of a clinic or hospital setting. 

Structural racism and social determinants of health are key causes of the racial disparities in pregnancy-related mortality, and solutions to these disparities must also be structural. An important first step for local officials seeking to address pregnancy-related mortality is to connect with the communities most impacted by the crisis and the doulas and midwives who are from and work within these communities. Black Mamas Matter is an important national resource that local leaders can consult. 

As abortion bans and restrictions go into effect across the country, more and more people will be forced to carry pregnancies to term against their will, and pregnancy-related mortality rates are likely to rise. Abortion restrictions are one among many overlapping and institutional contributing causes of the pregnancy-related mortality crisis in America, and it is more important than ever to track pregnancy-related deaths and invest in sustainable, community-based solutions to address the crisis.   

THE RESEARCH
For each city, we assessed the following policies for Building Healthy and Just Communities:

Positive public awareness campaigns on sexual and reproductive health:
At least one public awareness campaign is in place that highlights an important local issue related to sexual and reproductive health. The campaign is not stigmatizing and is based on community needs.

Menstrual equity initiative:
At least one policy or program is in place that promotes menstrual equity, such as repealing the sales tax on menstrual hygiene products or providing free menstrual products in public buildings, including schools, shelters, and jails.

“Shield” law for survivors:
A policy is in place to ensure that people engaged in illegal activity can safely report a crime that they were a victim of or witness to without being charged themselves (e.g., a sex worker who is assaulted by a client can report that assault without fear of being arrested for engaging in sex work).

Paid sick leave:
A policy is in place requiring employers to provide paid sick leave.

$15 minimum wage:
A policy is in place requiring employers to provide a $15 or higher minimum hourly wage.

Support for immigrants’ access to reproductive health care:
At least one policy or program is in place to support immigrants’ access to reproductive health care, such as a sanctuary city policy, municipal ID program, or municipal health insurance program.

Anti-discrimination employment ordinance regarding gender identity:
A policy is in place prohibiting discrimination against employees based on gender identity.

Anti-discrimination housing ordinance regarding gender identity:
A policy is in place prohibiting discrimination in housing based on gender identity.

Advancing democracy:
At least one policy or program is in place to protect voting rights or advance democracy, such as protecting voting rights for people who are not citizens, lowering the voting age to under 18, establishing voting reminders or education programs, passing strong campaign finance reform policies, or establishing youth councils to engage minors in democracy.

THE ROADMAP
Actionable Steps for Building Healthy and Just Communities

To learn more about the policies listed below and additional ideas that may be relevant in your community, reach out to NIRH at partnerships@nirhealth.org.

  • Adopt a set of reproductive justice-informed values to guide the city’s public awareness campaigns regarding sexual and reproductive health. Reject stigmatizing messages around sexuality and individual behavior and offer accessible and culturally appropriate solutions instead.
  • Develop and fund a public awareness campaign to address important local issues related to sexual and reproductive health, such as contraceptive choice or STI/STD prevention. Use a sex-positive, inclusive, and nonjudgmental approach that provides information, connects residents to services, and/or changes the conversation on the issue at hand. 
  • Repeal the local sales tax on essential menstrual hygiene items, including pads and tampons.
  • Allocate municipal dollars to provide free menstrual hygiene products in public places that serve those in need, including jails, prisons, juvenile detention centers, government buildings, schools, and shelters. Ensure that a range of menstrual hygiene products are available under this program. 
  • Prohibit law enforcement from using the fact that someone is carrying condoms as a basis for an arrest, charge, or prosecution for intent to engage in sex work.
  • Establish and quickly implement a living wage for employees in the city, including tipped and contract employees and people under the age of 18.
  • Require all entities that contract with the city or county to provide their employees a living wage and comprehensive benefits.
  • Implement programs and policies to increase democratic engagement and protect the right to vote locally, including programs and policies related to campaign finance reform, ranked choice voting, access to voter registration, and transportation to the polls. Allow people who are not citizens and/or people under age 18 the right to vote in municipal elections.
  • Pass a gender identity anti-discrimination ordinance to ensure that landlords and employers are not able to discriminate against individuals based on their gender identity.
  • Pass an ordinance to ensure that anyone who is incarcerated has access to comprehensive reproductive health care, including abortion care, contraception, prenatal and postpartum care, doula support, and lactation accommodations. 
  • Ban shackling of people who are incarcerated while pregnant, in labor, or postpartum, and require that pregnant people’s specific nutritional needs are met while they are incarcerated. Engage in training and oversight to ensure these policies are instituted and followed.
  • Decriminalize sex work by removing criminal penalties for buying and selling sex (often termed “prostitution” in the law) to recognize the essential right of privacy for all while ensuring that sex workers do not face violence and abuse, including from law enforcement, and improve sex workers’ access to essential health services.
  • Reallocate municipal dollars from police departments to community services based on input from community members. Consider reallocating funds to alternative models of public safety and programs that address poverty and hunger and provide mental health care and drug treatment.

Connecting the fights for reproductive and trans justice

The reproductive justice and trans justice movements both advocate for the rights of individuals and families to make the decisions that are best for them about their bodies and to raise children free from state violence. Attacks on trans rights, including access to gender-affirming care, share the same roots as attacks on abortion access and reproductive justice and are often carried out by the same people and organizations. Local leaders and advocates should consider the interconnectedness of these fights and strive to make their policies and initiatives as inclusive of reproductive and trans justice as possible. 

THE RESEARCH
For each city, we assessed the following policies for Proclaiming Local Values:

Opposition to deceptive practices of AAPCs:
A resolution is passed stating opposition to AAPCs and/or opposition to funding for AAPCs. 

Pro-abortion stance on state or federal legislation or ballot initiatives:
A resolution is passed within the period of review (2021–2022) establishing a pro-abortion stance on state or federal legislation. The resolution can be positive, with the city endorsing legislation or calling for its passage, or negative, with the city opposing legislation.

Support for abortion coverage:
A resolution is passed in support of insurance coverage of abortion.

Support for anti-discrimination:
A resolution is passed within the period of review (2021–2022) supporting anti-discrimination on any of a range of issues, including race, ethnicity, religion, sexuality, gender identity, income, immigration status, disability status, or more, or a resolution is passed on related state or federal action. The resolution can be positive, with the city endorsing an action or calling for its passage, or negative, with the city opposing an action.

THE ROADMAP
Actionable Steps for Proclaiming Local Values

To learn more about the policies listed below and additional ideas that may be relevant in your community, reach out to NIRH at partnerships@nirhealth.org.

  • Pass a resolution or issue a proclamation declaring support for an expansive ballot initiative or legislation at the state or federal level that protects abortion access for all people, no matter their income, age, gestation, or ability to pay. 
  • Pass a resolution or issue a proclamation declaring opposition to an anti-abortion ballot initiative or legislation at the state or federal level, such as a ban on abortion based on a person’s reasons for choosing an abortion or a ban on insurance coverage of abortion. 
  • Pass a resolution or issue a proclamation opposing the deceptive practices of AAPCs and calling for an end to any state or federal funding they receive. 
  • Pass a resolution or issue a proclamation declaring the city a safe and welcoming place for all to receive reproductive health care, including abortion. 
  • Submit public comments to executive agencies in support of policies that will expand access to reproductive health care, including details on how such policies will help people in the city, and in opposition to initiatives that will restrict access to reproductive health care, including details on how such policies will harm people in the city.