The 2019 Local Reproductive Freedom Index covers 50 cities. This includes the 40 cities from the 2017 edition, selected based on their population size or the size of their metropolitan area, and an additional 10 selected this year because of their size or their location in a previously unrepresented state. NIRH then identified 34 specific policies as “indicators” to evaluate each of the cities by, all of which fall within six broader categories that NIRH has determined are core to securing and advancing reproductive freedom at a city level. These indicators and the policies and principles of the Model City are based on NIRH’s expertise and values, those of partner organizations, and the work of allied social justice movements. They are a refinement of the initial 37 indicators in the 2017 Local Index, based upon lessons learned from NIRH’s experience conducting research and working with advocates.
See Changes in Categories and Indicators from 2017 for details on how the indicators changed in this edition of the report.
The Research Process
NIRH conducted the first round of research independently. This included a review of the websites of city and county governments, local and state departments of health, departments of education or school districts, and other relevant government agencies and commissions, as well as publicly available information from local community-based organizations and local media. Following this work, NIRH conducted phone and email interviews with partner organizations, other community-based organizations, departments of health, school districts, and city and county officials whenever possible in each of the cities. NIRH then shared its initial findings with local advocates and the heads of city or county departments of health for review. Finally, drafts of the City Scorecards were distributed to the mayor and heads of the city council and county government (if applicable) to verify data and identify any concerns. Final City Scorecards are based on the sum of this work.
Understanding the Score
The Policy Indicators
Each policy indicator is assigned a point value. Most indicators are one point. A small number count for two points, reflecting some combination of the following: the impact on abortion access and reproductive health, a degree of rarity among cities, investment required to pass and implement, and/or whether the policy is particularly effective in achieving its aim. For an explanation of each indicator and its assigned point value, see the Explaining the Indicators links.
A city’s score is determined using an equation that weighs the total number of points a city achieved divided by the total number of possible points. The score falls on a 10-point scale and corresponds to the five-point star rating, ranging from half a star to five stars, used in the final report.
Each city can receive one of the following designations for each indicator:
- Yes: A city or county has a policy related to the indicator in place
- No: A city or county does not have a policy related to the indicator in place
- Limited: A city has taken some steps towards achieving the indicator but has not acted to its fullest extent. Limited measures count toward a city’s overall score as half of the full point value.
- Preempted: State policy prevents a city from acting on policy described by an indicator, ora state policy fully addresses the entire area described by an indicator, making it unnecessary for the city to take further action. Preempted measures do not impact the city’s overall score.
- N/A: NIRH was unable to find sufficient information on a given measure to determine its status as of December 31, 2018. N/A measures do not impact the city’s overall score.
Policy Indicators Tracked in the Local Index
|Protecting Abortion Access Explaining the Indicators||Clinic safety ordinance||2|
|Regulations on anti-abortion pregnancy centers||2|
|Local protections for abortion clinics and providers||2|
|Public awareness about access to abortion care||1|
|Anti-discrimination ordinances for employees: reproductive health decisions||2|
|Anti-discrimination ordinances for housing: reproductive health decisions||2|
|Funding and Coverage for Reproductive Health Explaining the Indicators||Funding for abortion||2|
|Funding for STD/STI testing and prevention||1|
|Municipal insurance coverage of abortion||2|
|Funding to train providers in reproductive health care||2|
|Funding for contraception||1|
|Funding for community-based organizations to provide comprehensive sexuality education||1|
|Supporting Young People Explaining the Indicators||Support for pregnant and parenting youth||1|
|Funding for comprehensive sexuality education||1|
|Comprehensive sexuality education policy||1|
|Reproductive health care in school-based health centers (SBHCs)||2|
|Supporting Families Explaining the Indicators||Supportive breastfeeding policies||1|
|Paid family leave for municipal employees||1|
|Environmental protections for maternal and reproductive health||1|
|Anti-discrimination ordinances for employees: pregnancy and family status||1|
|Anti-discrimination ordinances for housing: pregnancy and family status||1|
|Building Healthy and Just Communities Explaining the Indicators||Positive public awareness campaigns on sexual and reproductive health||1|
|Menstrual equity initiative||1|
|“Shield” law for victim reporting||1|
|Paid sick leave||1|
|$15 minimum wage||1|
|Support for immigrants to access reproductive health care||1|
|Anti-discrimination ordinances for employees: gender identity||1|
|Anti-discrimination ordinances for housing: gender identity||1|
|Taking a Stand Explaining the Indicators||Opposition to deceptive practices of anti-abortion pregnancy centers||1|
|Support for abortion coverage, including the EACH Woman Act||1|
|Pro-choice stance on legislation or ballot initiatives||1|
|Support for anti-discrimination||1|
The Local Landscape
To create a more complete profile of each city, and to complement and contextualize the 34 policy indicators, NIRH also collected demographic and additional policy data related to reproductive freedom. This is reflected in the “Local Landscape” featured on each City Scorecard, but it does not contribute to a city’s overall score.
The data in the Local Landscape should be used as an additional tool for understanding the specific challenges and opportunities each city faces, as these data points and the Local Index policy indicators connect with each other in important ways. For example, the rate of pregnancy among young people cannot be understood in isolation from the city’s sexuality education policy, number of anti-abortion pregnancy centers, or the reproductive health care available in SBHCs.
Sources listed in the definition of each indicator below.
- Population, 2017: American Community Survey, unless a city is not tracked by ACS due to its population size. In that case, data is most often taken from the city itself.
- Median income: American Community Survey, unless a city is not tracked by ACS due to its population size. In that case, data is most often taken from the city itself.
- Annual costs (family of 4): According to the Economic Policy Institute Family Budget Calculator (https://www.epi.org/resources/budget/)
- Population breakdown by race: American Community Survey, unless a city is not tracked by ACS due to its population size. In that case, data is most often taken from the city itself.
- Number of abortion clinics: Sources include the Abortion Care Network, the National Abortion Federation, Planned Parenthood Federation of America, and independent research.
- Number of Title X clinics: Office of Population Affair’s Title X Family Planning Directory (https://www.hhs.gov/opa/sites/default/files/Title-X-Family-Planning-Directory-November2018.pdf)
- Number of SBHCs: This tracks all SBHCs, regardless of whether or not they offer reproductive health care; sources include the School-Based Health Alliance and independent research.
- Number of anti-abortion pregnancy centers: Sources include the ReproAction Fake Clinic Database (https://reproaction.org/fakeclinicdatabase/) and independent research.
- Maternal mortality rate: This term may be defined differently from city to city; data was found via independent research, most often from the local or state health department. This indicator does not break down the maternal mortality rate by race because the information is typically not available on the local level; however, it is important to recognize that significant racial disparities in the maternal mortality rate — with Black women dying at much higher rates than white women — exist in most places, which are masked by the overall rate.
- Teen pregnancy/teen birth rate: This data is tracked and provided by each city or county, and the rate is measured differently in many cities. Variables include whether the rate measures teen pregnancy or teen birth and the ages at which a city considers someone a “teen.” NIRH uses the language of “teen pregnancy” or “teen birth” in the Local Landscape to match the language used by cities and counties that track this data. However, because “teen pregnancy” has historically been viewed as a negative public health outcome, NIRH uses language such as “pregnant and parenting youth” or “young parents” throughout the rest of the report to avoid further stigmatizing young people who are sexually active and become pregnant. As pregnancy and parenting in adolescence can be the right choice for some young people, or the result of a system of inequities and/or a lack of resources and education, the information on teen pregnancy/birth rate included in this report should be read as one data point in the context of the nexus of applicable information.This term may be defined differently from city to city; sources include independent research; when available, this number most likely comes from the local health department.
- Number of Catholic hospitals: The number of Catholic hospitals out of all hospitals in the city; sources include MergerWatch and independent research.
- Rates of incarceration: This is the rate of people from the community who are incarcerated; sources include the Vera Institute of Justice and independent research.
- Infant mortality rate breakdown by race: This term may be defined differently from city to city; found via independent research, most often from the local or state health department.
The Challenges of Conducting Research on Local Governments
While some cities do not have county government, most of the cities in the Local Index are located within counties. In these places, city and county work are interconnected, and both levels of government are important to advancing reproductive freedom. In particular, counties typically play a significant role in public health. NIRH researchers first reviewed city policies that aligned with the indicators, and then filled in any gaps by reviewing county-level policies. The final score for each city includes policies in place on the county level so that the Local Index does not penalize cities for “not having” a policy described by a particular indicator in place when it is in fact addressed by the county and the city’s residents benefit from it. County-level policies and data are denoted by an accompanying asterisk on the Comprehensive and City Scorecards.
Similarly, some cities contain other entities that are part of local government but have different jurisdictions or geographic reach. The diverse types of government structures and jurisdictions — including city-county consolidated governments, mayor-council governments, council-manager governments, and commissions — make determining what information to include and how to analyze it complex tasks. For example, some cities have a city health department, others have a county health department, and still others have health departments at both levels. In a few cities, the state plays a role by administering a joint state-county health department. Many cities also contain multiple school districts and school boards, each of which has its own policy on sexuality education or reproductive health care within school-based health centers. Decisions about how to characterize a city in which multiple different policies are in place were made on a case-by-case basis. As a reader, it is important to note that the data and the indicators reflect the work of multiple bodies of government and may contain multiple jurisdictions. No one government body or agency can be credited, or blamed, for the overall city score.
Given this diversity in structure, it is no surprise that the quality of data available on a local level varies widely based on each city’s priorities, resources, and capacity. Information on the indicators in the Local Index is often difficult to access, varies widely from city to city, and can be challenging to interpret. Some cities publish health statistics and detailed budgets online, while others do not make such data available publicly. In some cases, the data is simply not available at all.
NIRH sought to mitigate each of these challenges by relying on its partnerships with state- and local-level organizations working on reproductive health, rights, and justice, as well as interviews with advocates, health departments, and local elected officials, but gaps or errors may still occur. NIRH is available to discuss decisions on particular indicators and explain the reasoning behind each; if necessary, corrections are welcome and will be incorporated into the report. All such inquiries and corrections should be sent to firstname.lastname@example.org.
The Impact of Race and Income
Race and income are essential parts of an individual’s and a community’s identity that impact how people experience life in a city. People of color and low-income people, in particular, often face greater barriers to accessing care and possess fewer resources to overcome those barriers. It is therefore important to consider the roles that race and income may play in mitigating or exacerbating the impact of a particular policy or lack thereof in a given city.
Because of the small population size of most cities, it is often difficult to disaggregate data by race and socioeconomic status, meaning that information such as the maternal mortality rates or a city’s median income level may mask significant disparities. NIRH encourages cities to make every effort possible to include race and income as metrics when collecting data and to publish those results whenever possible.
Even the most rigorous and thorough data collection, however, cannot fully illustrate the ways that race and income influence how individuals access services, or are unable to do so, due to factors such as segregation, immigration status, and size and diversity of communities of color. Advocates and public officials must look beyond the numbers, even when they are available, and speak directly with community members to fully understand how barriers and opportunities disparately impact people of color and low-income people.
Reproductive Justice for People Who Are Marginalized
Reproductive justice is a framework defined by SisterSong as “the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities.”* This framework, developed by Black women in the 1990s, is revolutionary because it places people who are the most oppressed at the center of its analysis and, therefore, at the center of the policy changes it demands. When the work of cities is viewed through a reproductive justice lens, it is clear that they must implement policies and programs to support people who are the most impacted by structural oppression. This includes those who are most marginalized in society and therefore extremely vulnerable to exploitation and injustice, including sex workers, people who are incarcerated, young people in foster care or juvenile detention, and pregnant people with substance use disorders. However, the policies needed to serve these communities do not easily lend themselves to a scorecard format because of the necessity of an in-depth analysis of their impact and implementation. Without training and rigorous, ongoing oversight of health care providers, law enforcement officials, and others who hold significantly more power than the vulnerable populations discussed here, it is difficult to evaluate whether policies are truly being carried out in the spirit they were intended.
To design and implement policies that effectively address the problematic ways that structural oppression impacts people most likely to feel the brunt of harmful policy, local officials must invest time and effort to first build trust with these communities. Once a relationship has been established, it is important to continue to work closely with the community and advocates who support them to develop policies that will truly meet their needs. Cities dedicated to reproductive justice can consider the below policies as a start. Each policy should include development of a comprehensive plan for implementation and ongoing evaluation.
- End policies that allow condoms to be used as evidence*: In most jurisdictions, possession of condoms can be used by law enforcement as a basis for an arrest, a charge, or prosecution of an individual for intent to engage in sex work. Such policies may lead sex workers to engage in unsafe sex, against their will, in order to avoid such a risk. By ending these policies, cities can support safer sex practices and reduce levels of harassment by police.
- Provide high-quality care to women, transgender men, and other people who are pregnant while incarcerated*: Cities have a responsibility to provide access to medical care, adequate nutrition, and appropriate clothing to all people who are incarcerated, but policies appropriate for the general population fail in particular when it comes to addressing the needs of pregnant and postpartum people. Local authorities that oversee jails and prisons in a city must design specific policies for women, transgender men, and all people who can become pregnant throughout their pregnancy, labor, and the postpartum period, and they must ban shackling at any point in pregnancy.* During pregnancy, all people must have access to all pregnancy-related health care, including abortion. After delivery, mothers should be able to stay with their newborn immediately after birth, and lactation accommodations such as pumps, breast milk storage, and a system for pickup must be in place.
- Offer comprehensive sexuality education and reproductive health care to young people in foster care or juvenile detention*: Cities should ensure that young people in foster care or juvenile detention receive comprehensive sexuality education, a commitment that requires oversight and investment from government officials given that they may often move from school to school in a single year. Cities should also provide funding and transportation for young people to access comprehensive reproductive health care, including abortion, and training for social workers and other frontline staff so they can support young people who need this care.
- Ensure that pregnant people with substance use disorders can safely access treatment*: In many states, a range of laws are used to prosecute pregnant people seeking treatment and support for substance use disorders. In addition to tearing apart families, these laws have a deleterious impact on maternal and infant health by discouraging people from seeking prenatal care or other assistance, for fear of arrest or child separation. Cities can offer funding to ensure that pregnant people with substance use disorders are able to receive comprehensive medical treatment at all stages of pregnancy while maintaining the stability of their family, and they can provide training to health care providers and social workers on how to best support pregnant people, instead of reporting them to law enforcement or child welfare agencies.
Changes in Categories and Indicators from 2017
|2017 Category||2019 Category|
|Protecting Abortion Clinic Access||Protecting Abortion Access|
|Funding and Coverage for Reproductive Health Care||Funding and Coverage for Reproductive Health Care|
|Supporting Young People||Supporting Young People|
|Supporting Families||Supporting Families|
|Advancing Inclusive Policies||Building Healthy and Just Communities|
|Taking a Stand||Taking a Stand|
|Local Landscape||Local Landscape|
|Indicators Removed in the 2019 Local Index||Indicators Added in the 2019 Local Index|
|No funding for crisis pregnancy centers||Local protections for abortion clinics and providers|
|Clinic escort programs supported by city||Anti-discrimination ordinances were divided into “employees” and “housing,” as opposed to “all employees” and “municipal employees”|
|Noise regulations||Environmental protections for maternal and reproductive health|
|Other protections for abortion clinics||Anti-discrimination based on family status|
|Protective zoning regulations||Menstrual equity initiative|
|Funding for family planning||“Shield” law for victim reporting|
|No gag rules on employees funded by the locality||Paid sick leave|
|Sexuality education policy||Support for undocumented people to access care was updated to include all immigrants|
|Abstinence-plus education||Advancing democracy|
|Abstinence-only education||Infant mortality, including breakdown by race when available|
|Reproductive health protections for nail salon employees||Population breakdown by race|
|Opposition to sex-selection abortion bans||Number of Catholic hospitals|
|Support for Women’s Health Protection Act||Rates of incarceration|