On a muggy evening in mid-September, I drove from my home in Cincinnati to a rally 15 minutes west at a Planned Parenthood health center that was slated to close. Earlier that week, news broke that because of a reduction in funding, Planned Parenthood of Southwest Ohio would shut down two of its nine clinics in the state. In August the organization was forced to withdraw from the federal Title X family planning program after an unprecedented Trump administration rule prohibited those funds from going to facilities that provide abortions or refer patients to abortions elsewhere. Title X subsidizes birth control, breast and cervical cancer screenings, and other medical care for 4 million low-income patients. The soon-to-be-shuttered clinics, both of them in Cincinnati, served over 6,000 patients a year, with services including pregnancy testing and birth control. Neither location provided abortions. But staffers there acknowledged that abortion is a legal, legitimate form of health care that clients could pursue elsewhere. For that, these clinics and others like them across the country lost their access to federal funds.

I parked my car on a residential street called Prosperity Place and walked the few blocks to the health center, a squat, cream-colored building near a gas station. The center’s manager addressed a crowd of about 200 and listed the types of people who regularly came through the doors: LGBTQ patients who appreciated staffers using their preferred gender pronouns, a 17-year-old facing a positive HIV test, students from nearby Western Hills High School stopping in for free condoms. The testimony was moving, but the outlook was grim. A couple of days earlier, I asked Kersha Deibel, the CEO of Planned Parenthood of Southwest Ohio, where the people served by these clinics might turn after they’re closed. Those with transportation could go to other Planned Parenthood locations, Deibel said, but “they shouldn’t have to go anywhere else.”

In the national narrative about the places where abortion rights are under greatest threat, media attention has focused on the South, particularly on the abortion bans passed in Georgia and Alabama. But this year Ohio passed a ban after the sixth week of pregnancy, which was signed into law in April. (In July a federal judge blocked it.) A ban on abortion after 20 weeks has been in effect since 2017. This year’s Title X rule change was a blow, but something similar had already happened on the state level. In 2016 then–Republican Governor John Kasich signed a bill barring the state from funding health programs that cover sexually transmitted infection testing and treatment, cancer screenings, and infant mortality and sexual violence prevention if those programs are provided by clinics that also provide abortions. That law was tied up in court until March, when the Sixth Circuit Court of Appeals upheld it. In his eight years in office, Kasich enacted 21 restrictions on abortion. During his tenure, half the clinics providing abortions in Ohio closed. “It’s one thing after another after another after another,” said Jaime Miracle, the deputy director of NARAL Pro-Choice Ohio. “When all this stuff happens in the South, it’s ‘Bam! It’s happening.’ Here it’s been death by a thousand cuts.”

In 2014 one of Toledo’s two clinics closed. That year the number of abortions in Lucas County, which includes the city, declined. But Miracle said people crossed state lines to go to clinics in Detroit, which is closer to Toledo than Columbus or Cleveland. The flood of restrictions has also pushed more Ohioans past the 20-week mark, at which point they have to leave the state to terminate their pregnancies. A 24-hour waiting period for abortion that requires patients to visit clinics twice to have the procedure, parental consent laws, and the prevalence of crisis pregnancy centers (CPCs) can slow down the process, pushing women later into pregnancy before they can get the procedure.

Kersha Deibel is CEO of Planned Parenthood of Southwest Ohio. (Usa Today Network)

With Planned Parenthood clinics closing, more women in Ohio will find their way to CPCs, establishments that provide pregnancy tests, pressure women not to have abortions, and offer medically inaccurate information, such as telling women seeking abortions that they’re past the gestational limit. “For people who don’t necessarily have phone access, they go to whatever’s closest to them, and it’s probably a CPC,” said Stephanie Sherwood, the executive director of Women Have Options, the state’s abortion fund.

Sherwood said that at CPCs, people are often shamed for being honest about the services they want. One woman seeking an abortion was told that the procedure is dangerous. The woman’s reaction, according to Sherwood: “‘I can’t die, because I have kids to take care of.’ Then later [she] realized they were lying to her.”

The misinformation that people receive at CPCs can sow confusion and delay their access to abortion. “We will have people show us printed-out ultrasounds that definitely aren’t theirs,” Sherwood said.

CPCs are ubiquitous in the state. In 2013, Republican state legislators created the Ohio Parenting and Pregnancy Program, a funding mechanism that pours millions of dollars from the state’s Temporary Assistance for Needy Families block grant—which is intended for poverty alleviation—into these deceptive centers. (Programs that provide evidence-based information on abortion are ineligible for funds except in a medical emergency.) As of 2016, Ohio was one of seven states that funded CPCs using welfare dollars. The Trump administration recently awarded a Title X grant to a pregnancy center network. Responding to the news, Dr. Krishna Upadhya, a member of the Society for Adolescent Health and Medicine and a senior medical adviser at the Planned Parenthood Federation of America, wrote in a statement, “It is particularly harmful that the Trump administration is giving funding from the nation’s family planning program to CPCs that refuse to provide evidence-based sexual and reproductive health care, such as condoms and the full range of birth control methods, but instead offer misleading or inaccurate health information.”

Walking from my parked car to the September rally, I stopped to talk with the people I encountered. Teresa Brown, 36, sat on her porch as her two toddlers played nearby and her 6-week-old son slept inside. She told me she’d read on social media about the clinic closing and had mixed feelings about it, saying that she went there twice for tests when she needed proof of pregnancy to apply for Medicaid and that her sister got a referral there for an abortion, which she later regretted. “I wish I could talk to some of those girls before they go and get abortions,” said Brown, who was raised Catholic. “There’s so many families out there that want a child.”

The three children with her now are her youngest. She had five other children while in a violent relationship with someone who abused drugs, and those kids were now with adoptive families in Florida and Wisconsin, she said. Brown said she got pregnant three times despite being on the pill or Depo-Provera, and there’s a chance she’ll need a pregnancy test again. If so, now that the Planned Parenthood is closed, her nearest option will be Pregnancy Center West, a nearby CPC, which is where she goes to get car seats and other things for her kids. She watches videos, some of which are Christian, answers questions about them, and then gets Baby Bucks (what many CPCs call the cash substitutes they provide in exchange for participation in their programs), which she can use to buy what she needs. Brown said she is happy for the support but recognizes Pregnancy Center West’s limitations, namely that it doesn’t offer contraception. “I hope they put something there to help,” she said of the Planned Parenthood clinic, which has since been closed. “Because people need birth control.”

New Voices joined a coalition of reproductive rights groups and was the only black community-based group in the network. (New Voices for Reproductive Justice)

In Ohio, the Catholic Church is a political force. The Catholic Conference of Ohio has been active at abortion bill hearings in Columbus, the state capital, and has submitted written testimony in support of restrictive policies. In Dayton and Toledo, the church has mobilized to keep hospitals from signing transfer agreements that would allow clinics to move patients if they need to be admitted for emergency care. But many deeply religious Ohioans support abortion rights. Progressive faith leaders organized by the Ohio Religious Coalition for Reproductive Choice speak at the statehouse, conduct clinic blessings, and show up at rallies. The organization also works to meet people’s more immediate needs. It offers counseling to pregnant women considering their options and in December began working with congregations around the state to assemble care packages for people before, during, and after their abortions. “I don’t think there’s a way forward in Ohio without engaging faith communities when it comes to abortion,” said Elaina Ramsey, the organization’s executive director.

Growing up in Chillicothe, Ramsey was a conservative fundamentalist Christian. Her politics shifted after she was introduced to community organizing while working as a youth minister in the South Bronx in New York City. She lived on the East Coast for more than a decade before returning to Ohio two years ago to lead the coalition of progressive faith leaders.

Her work is just one example of the new approaches to organizing taking hold in the state. Like Ramsey, Cleveland-based reproductive justice advocate Jasmine Burnett recently moved back to the Midwest after years on the East Coast. The Indiana native lived in Brooklyn and then in Philadelphia, where she worked with the organization New Voices for Reproductive Justice. In 2015 she established the group’s office in Cleveland. At the time, she said, there weren’t many groups doing policy, advocacy, and organizing work using the reproductive justice framework, which emphasizes the relationship between the right not to have a child and the right to have a child and to parent in safe and healthy communities.

When Ohio Right to Life put up inflammatory, misleading billboards in Cleveland’s majority-black neighborhoods that summer, New Voices wrote an open letter calling for them to be taken down. It was unsuccessful, but the work attracted new allies. The group joined forces with NARAL Pro-Choice Ohio, Preterm (a local abortion clinic), and Planned Parenthood Advocates of Ohio to form a united front in the run-up to that fall’s gubernatorial election. With Kasich reelected and Republicans in control of the legislature, the groups put out a joint statement declaring, “[This] coalition will remain vigilant during the lame duck legislative session and will combine efforts for increased advocacy and awareness in the new legislative year.”

The new coalition had to learn how to work together. New Voices was the only black-led, black community-based organization in the network, Burnett said, and she wanted to highlight the existing power dynamics, introduce New Voices’ work as being rooted in human rights and racial justice, and establish lines of communication with the other reproductive rights organizations. She described this as “leading with the relationship over the work” and emphasized the importance of the organizers getting to know and trust one another.

The groups paid a lot of attention to understanding one another’s values and getting clear on the differences between reproductive health, reproductive rights, and reproductive justice. “It birthed a lot of really beautiful organizing and collaboration that didn’t come without its share of challenges,” Burnett said. “We talked about how we would address these challenges, [which] makes our relationships stronger to this day.”

Reproductive justice organizing is part of the effort opposing abortion restrictions, but the messaging is different from what you hear from groups more narrowly focused on the right not to have a child. A key focus for reproductive justice groups is the state’s mortality rate for infants born to black women, which is one of the worst in the country. Black babies in Ohio die before their first birthday at two to three times the rate of white babies.

“We don’t consider anything that’s along the reproductive health care spectrum in a silo,” said Jessica Roach, the CEO and cofounder of the Columbus-based reproductive justice organization Restoring Our Own Through Transformation (ROOTT), which provides perinatal-support doula services as a way to strengthen birthing families and improve black maternal and infant health outcomes. A nurse with a master’s degree in public health, Roach testified against the six-week abortion ban before the Ohio Senate Health Committee last spring. She said the efforts to restrict abortion make deaths among black infants more likely. “It’s not about it being an ‘abortion clinic,’” she explained. “It’s a health care facility that provides abortions. People go there for [sexually transmitted disease] treatment. They go there for pelvic exams. They find out that they’re pregnant, and they get their initial prenatal care there while they’re being referred to a practitioner.” But the state “keeps shutting down clinics because of one service that doesn’t morally feel good to them.”

In September, the pharmaceutical giant Merck announced that ROOTT would be one of the nine projects it will fund as part of its Safer Childbirth Cities Initiative. To some, it might not be immediately obvious how doula care for black families is part of the fight for abortion access, but to Roach, the connection is clear. “Our voices need to be dictating the care we wish to receive,” she said. “It is inappropriate for a white-male-dominated political system to tell any black woman or family what they’re going to do with their reproductive health care decisions.”

Burnett is no longer with New Voices Cleveland, but its work is still going strong. The organization encourages conversations around the ways bodily autonomy can be compromised and how to fight back. It is mobilizing its members around the issues of black maternal health, abortion access, and mass incarceration. In October it partnered with the American Civil Liberties Union of Ohio to host a discussion on Cuyahoga County’s bail system and the experiences of black girls in the juvenile justice system. Educational events like this are typically followed by a smaller gathering with a focus on healing, said New Voices community organizer Alana Garrett-Ferguson. It’s in these conversation-based groups that the real work happens, she continued. During one gathering, a participant who’d had an abortion was able to unpack the experience of being forced to wait for the procedure under the state’s mandatory 24-hour waiting period. In this more intimate format, other participants were able to show compassion and validate her experience. Organizers can explain how abortion doulas support a woman going through the procedure. In addition to its advocacy and public-facing events, the organization is committed to “giving black women and femmes a chance to be vulnerable,” Garrett-Ferguson said. “Educating the community is also listening to their concerns.”

Access to more health care may be the obvious goal for some in the abortion rights movement, but reproductive justice activists say that’s often not enough. Several times, Garrett-Ferguson made the point that “it’s not just about access but accountability.” Asked what she meant, she reiterated that abortion is another form of health care. Many of the people she works with distrust health care institutions for reasons both historical and rooted in their own experiences, so abortion clinics—like any doctor’s office—can feel alienating and discriminatory. Because of these nuances, Garrett-Ferguson has found that safe spaces, healing work, and opportunities to acknowledge stigma and traumatic experiences, including with abortion, have been just as important as rallies and lobbying. These types of engagement are sometimes linked. Once someone has worked through the stigma and shame alongside people she trusts, she’s more likely to want to testify about her experience in front of legislators.

Across the state, reproductive justice formations are fighting to preserve access to abortion on their terms. Last summer, New Voices Cleveland created the hashtag #ThisBlackBody to educate its members about the six-week ban. But these advocates are also focused on the slow work of supporting black families to have healthy pregnancies and births. Meanwhile, CPCs, flush with state dollars, are able to provide Ohioans with postpartum services in a way that abortion rights advocates—who are locked in a constant fight just to keep the clinics open—cannot. “I’m hoping that at some point, our movement can provide parenting resources, because our values are there. Organizations like ROOTT and New Voices are helping us focus on the right to parent in safe conditions when you want to,” said Sherwood of Women Have Options. Anti-choice activists and legislators are “going to continue to try to shut down clinics, and we’re going to continue to fight that. But we’ve got to make sure that we’re there” to meet people’s other reproductive needs.