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When Alison Dreith joined as executive director two years ago, she held no illusions about what lay ahead.

One of the most restrictive states for reproductive rights, Missouri at the time had only one abortion clinic (it now has three). “I knew the fight in the legislature would be defensive; nothing short of a miracle,” she said.

No time to wait for divine intervention, Dreith launched a campaign to win protection for women who faced employment and other discrimination as a result of their reproductive health choices—abortions, pregnancy, birth control. And borrowing a strategy from the LBGTQ movement, she took her argument not to the unsympathetic state Capitol but to the St. Louis City Hall. NARAL organizers visited thousands of homes in St. Louis as part of a full-on push that in February led the Board of Aldermen to pass an anti-discrimination ordinance.

“We need local officials to stand up for their residents.”

That hard-fought municipal win is the kind of tactic necessary these days to protect women’s access to reproductive care. A by the finds that cities increasingly are playing this crucial role as the federal government grows more hostile toward women’s rights overall and conservative state legislatures erect more barriers to care. And cities such as St. Louis and Austin, Texas—progressive cities tucked in conservative states—must work twice as hard, NIRH says, to implement programs that elevate women and families.

“Cities are leading this resistance, and women and local elected officials are at the forefront of that fight,” said Andrea Miller, president of NIRH. Municipalities have long been the center for advances and innovation, Miller said, and “now more than ever we need that. We need local officials to stand up for their residents and be a counterweight to the daily dose of damage coming from D.C. and from many state legislatures, as well.”

Between 2010 and 2016, states have enacted more than 330 measures to restrict abortion access, constituting about a third of all such restrictions since the 1973 U.S. Supreme Court ruling in Roe v. Wade made abortion legal, according to the .

Working with advocates and activists, local lawmakers are green-lighting policies that create buffers around abortion clinics to protect clients and staff. And they are pushing back against a proliferation of so-called “crisis pregnancy centers,” which critics characterize as anti-abortion fake clinics.

NIRH’s new Local Reproductive Freedom Index measures the reproductive health, rights, and justice polices in 40 cities, highlighting the kinds of successes advocates and local policymakers have had in helping improve the lives and health prospects of residents, while setting standards for progress. Evaluated against 37 possible indicators—things such as clinic safety, support for parenting youth, abortion and contraception funding and a $15 minimum wage—not even the bluest cities in the bluest states got a perfect score. 

Reproductive justice work at the city level offers opportunities for progress.

Naturally, those at the top, with 4.5 stars out of a possible 5, were resource-rich cities in more progressive states—places such as San Francisco, New York, and Los Angeles. Those on the bottom were mostly in conservative states and places where women are more likely to live in poverty.

Top-ranked , for example, became the first city in the country to force crisis pregnancy centers to tell the truth. Jacksonville, Florida, with one star, was at the bottom. Until this year, it held the dubious distinction of being the largest U.S. city without anti-discrimination protections for LGBTQ people. But after failed attempts in 2012 and 2016, the city council voted to enact an LGBTQ without the mayor’s signature.

The index demonstrates that reproductive justice work at the city level offers opportunities for progress; that is now not the case at the state level and especially the federal level.

A year ago when NARAL began its work in St. Louis, Missouri, Dreith expected Hillary Clinton would be the next president. As bad as things were for women in her state—which at the time had a Democratic governor and anti-choice Republicans controlling the Legislature—she never factored in Donald Trump. “We in November,” Dreith said. “Not only do we have a super predator as president, we now have a very, anti-choice governor with no previous political experience who is angling for a presidential run in the future.

“At every turn here in Missouri, women and families are under attack,” Dreith said.

Last year’s election swept Trump into office on a wave of divisive rhetoric, ushering in a conservative and at times brand of policymaking nationwide.

The numerous allegations of sexual assaults against him notwithstanding, Trump—as candidate and now as president—has made no secret of his contempt for reproductive rights. He once declared there should be for those who have abortions. He has supported defunding Planned Parenthood, calling it an abortion factory. He supported a ban on abortion after 20 weeks and last month reversed President Obama’s contraception-coverage guarantee.

While St. Louis earned just two stars, the average for NIRH’s index, the Midwestern city earned trailblazer status for its anti-discrimination work.

Dreith said her organization had been hearing—sometimes in whispered exchanges at rallies—from women who were fired or threatened with job loss after becoming pregnant or having an abortion. The problem was particularly common among those employed at Catholic institutions.

“There are always things we can do on the local level to reinforce our values.”

The ordinance that St. Louis includes a religious exemption so it does not extend protection to those workers, but it adds reproductive health decisions to the city’s anti-discrimination law. Dreith said Alderwoman Megan Green, who sponsored the measure, also added a provision to protect women facing housing discrimination.

Hailed by reproductive rights advocates nationwide, the measure immediately came under attack in Missouri. Republican Gov. Eric Greitens called a special session of the state legislature seeking to pre-empt it, saying he didn’t want St. Louis turned into an “abortion sanctuary city.” While he didn’t succeed in undoing what St. Louis had done, he did sign a measure that piled even more abortion restrictions onto the state. In May, several St. Louis Catholic groups sued the city over the new ordinance, despite the exemption they have.

Dreith is not deterred. NARAL, which now provides escorts for clients at some clinics, proposed a measure, now before the St. Louis Board of Aldermen, to create an 8-foot buffer around that city’s only abortion clinic. This week, the Columbia City Council unanimously passed an ordinance to add pregnancy protection to the city’s anti-discrimination laws. NARAL also wants to expand the anti-discrimination ordinance in Kansas City, another city that leans progressive.

“There are always things we can do on the local level to reinforce our values,” she said. “Local is where we live. We can at least create a pocket to move forward,” she said.

Political climates in municipalities everywhere have shifted since the federal Roe v. Wade decision four decades ago. Pamela Merritt, St. Louis-based co-director for the reproductive justice organization, , said she grew up in the St. Louis area and returned in her 30s to a radically more conservative city.

That political climate makes the work her organization is doing to draw attention to the deceptive practices of crisis pregnancy centers and  the alarmingly high rates among African-American women in the state that much harder. “The good news is that people are energized to organize and resist; there’s an appetite for that at a height I’ve not seen before,” Merritt said.

“Out there in the community I’m hearing from so many people: What can we do? I tell people, resistance is a stage; no one wants to live in a perpetual state of resistance. It sounds corny but people untied can do great things. We don’t want to rely on a regressive state legislature to wake up to reality.”

Rather than waiting for lawmakers, she’s been working with those who can directly effect change, health care professionals in hospitals who interact with these mothers. The work has involved urging doctors to look for signs of stress, training more doulas and urging more women to become doulas.

Elsewhere, progressive cities in some of the most hostile states for abortion rights are adapting similar strategies, NIRH’s Miller said. In Columbus, Ohio, citizens fought hard last year to pass a clinic-safety measure. Oklahoma City recently approved a resolution to protect its LGBTQ population from discrimination in housing.

“What we are hearing from advocates is how inspired they are by the prospect of being able to work and engage with local policy makers and elected officials…” Miller said. “These are people who live in their neighborhoods, in their communities; their kids might be in the same daycare.”