Advancing Abortion Justice An Ethnography of Gender-Based Violence and Contentious Politics at Clinics

Advancing Abortion Justice: An Ethnography of Gender-Based Violence and Contentious

Politics at Clinics

Introduction

An Ethnography of Entrenched Contention

Abortion clinics are contested political spaces that provide essential health care. Few

places experience this duality of contention and care that I’ve had the privilege of observing first-

hand. When Roe was reversed, I headed to the South Bend clinic to document what we thought

would be the last weekend of care before an abortion ban. I arrived to the clinic on a cloudy day

in late July. The air is sticky with humidity and my hair is trying to escape its bun. The parking

lot was nearly empty except for a few older model sedans driven by clinic staff. I watched the

women who work at the clinic set up their areas for check-in, pregnancy testing, ultrasound,

counseling, payments, and pharmacy. Every surface became a place to fill out paperwork to meet

the state’s demand for documentation. Today’s books are filled with 40 patients, double the

normal schedule. The clinic tried to accommodate as many requests as they could from Ohio

where a six-week ban is being enforced. Overtime is expected, no one packed lunch. The patient

advocates at Whole Women’s Health South Bend talk in soft tones through matching rainbow

face masks. They affirm that everyone will be seen - we will stay till everyone is cared for and

find the money to cover outstanding balances. By 9 am the waiting room is full and people sit

under blankets sipping hot cocoa as a rain storm cools the air. The purple walls covered in quotes

from movement leaders feel even more purple with the lavender oil in the air.

Indie pop fills the room as the gentle shuffling of paperwork is interrupted by the clinic phones.

For a moment, you would think you were in any doctor’s office, but the security camera showed

the small crowd outside that has made it their mission to shut us down. Abortion was legal this

day but we did not know for how much longer. Uncertainty is a feeling you learn to live with

when you work in abortion spaces.

Abortion clinics are special places. Communities need clinics to be complete and we

must preserve all options of reproductive health care to achieve gender equity. In South Bend,

Whole Woman’s Health has acted to operationalize the values of the reproductive justice

movement by improving access to abortion care. The clinic is also a symbol of resistance by

existing in spite of political and social hostility. Clinics reproduce legitimacy by unapologetically

existing with the expressed purpose of providing abortion care. I approach the dynamics of

abortion contention by focusing on clinics as the site of politicization, violence, feminist

advocacy, and health care. Abortion care defies the interlocking political system of “imperialist

white-supremacist capitalist patriarchy” by offering essential reproductive freedoms (hooks,

2010). A single clinic experiences a diverse array of challenges and opportunities within this

political system. The story of abortion care and provision in South Bend provides an example of

these dynamics to understand how anti-abortion violence can be addressed through community

effort and policy change.

I propose that anti-abortion violence is a form of gender-based violence mechanized by

contentious politics observed in “entrenched contention.” Gender-based violence is harm that is

directed at someone because of their perceived or actual gender. Numerous forms of genderbased

violence are experienced worldwide, such as sexual assault, intimate partner violence, workplace

discrimination, and unequal democratic representation (Hill, 2021; Rico, 1997). Gender-based

harms are reinforced by sociopolitical structures that reproduce inequities to inhibit women’s

empowerment (Sinha et al., 2017). Abortion clinics are a targeted site of antiabortion violence

because of the gendered care they provide (Doan, 2009; Joffe, 2010; Rankin, 2022). Anti-

abortion violence is gender-based violence, as these harms restrict access to essential healthcare

through intimidation and prohibition. Contentious politics are public actions by

groups making political claims. Social movements are often the vehicle for sustained collective

action against powerful opponents to coordinate response amid changing political feasibility and

opportunity (Tarrow & Tilly, 2009; Sidney G. Tarrow, 2011). Formative studies of contentious

politics include case studies on Black insurgency during the Civil Rights Movement, political

action by people experiencing poverty, and the evolution of collective action in France

(McAdam, 2010; Piven & Cloward, 2012; Tilly, 1986). Anti-abortion violence is characterized

by continuous conflict between movements and the state. These conflicts rule the provision of

abortion care.

Entrenched contention refers to social movement activity spatially fixed at a particular

location. The study site, Whole Woman’s Health of South Bend, features a variety of spatial

characteristics; these include proximity to supportive and hostile communities, a built

environment regulated by local authorities, and resources constraints. Social movement activity

is South Bend is homegrown and community members mobilize to express their political, social,

and moral stance on abortion. The stand-alone clinic occupies property with a private parking lot

and security fencing (Images 1 and 2). This location was selected to shield patients and staff from

protestor harassment. Clinic efforts to create an ideal built environment were quickly jeopardized

when the anti-abortion movement purchased the residential home next door. Governments have a

responsibility to protect resident safety and well-being. Movement conflict at the clinic produces

encounters with local authorities that must navigate personal bias and political pressures. The

abortion clinic is subjected to targeted state-regulations and protestor harassment that causes

financial and workforce challenges. These challenges are further exacerbated by geography, as

Indiana is simultaneously politically hostile and overlooked. Until recently, South Bend lacked

national attention to galvanize necessary outside support to ensure local access to abortion.

Locations of entrenched contention have rooted circumstances such that actions are often

repetitive or routinized. Repetitive interactions and prolonged conflict in contested spaces behave

like classic “repertories” - amenable to a “repertoire of contention” approach first put forward by

Charles Tilly. For example, trespassing is a violent anti-abortion repertoire on the rise nationwide

that has caused multiple challenges in South Bend to protect patients and staff on clinic property.

Fencing around the clinic is costly to extend and maintain, which allows protestors entry to the

property and proximity to patient rooms. Repetitive trespassing by protestors in South Bend

eventually caused local authorities to redirect their ire onto clinic volunteers as the problem. As

protestors who violate private property boundaries never face consequences, nonresponse to

violence directed at the clinic by law enforcement in South Bend is routinized. The spatial factors

in South Bend that produce opportunities for violence further ensconce protestors at the clinic.

Contentious abortion politics is characterized by long periods of routinization and bursts

of innovation. The lack of Congressional action to codify Roe or pass fetal personhood

demonstrates repertoire routinization to entrench abortion politics in a powerful institution

unlikely to generate change. Clinics have experienced periods of protest routinization. Instances

of protestor disruption from picketing remained relatively stable from 2000 to 2009 compared to

the surrounding decades (NAF, 2022). Protestors and clinic safety volunteers in South Bend

developed a tactical familiarity within a couple years of opening. Deviations from expected

repertoires are notable as discontent with routinization and can breed innovation to spark change.

The advancement of medical technologies to improve abortion access through medication was a

positive disruption to uproot where abortion can occur. The anti-abortion movement disrupts

routinization through abortion bans and extreme violence. Innovation requires resources and

resourcefulness to shift entrenchment toward more favorable circumstances for movement goals.

The dynamics of abortion contention are entrenched at the clinic-level as the site of

antiabortion efforts to end abortion. Entrenched abortion contention has significantly impacted

abortion provision and availability. The number of abortion facilities has declined for the last 20

years, with a 22% loss in the Midwest from 2011 to 2014 during a sharp rise in state-level clinic

regulation (Jones & Jerman, 2014). This period of clinic closure was followed by a rise in clinic

violence. Incidents of clinic disruption from picketing, hate mail, and digital harassment more

than doubled between 2014 and 2015 (NAF, 2022). Violence and disruption at clinics have

continued to rise in recent years as sites of care become more concentrated from clinic loss. NAF

reported 3,092 instances of violence at abortion clinics from 2020 to 2021 nearly totaling the

sum of yearly incident counts from 2000 to 2009. The anti-abortion movement does not engage

in sustained violent protest directed at the government to murder politicians, bomb statehouses,

or harass legislative aides. The anti-abortion movement concentrates efforts to disrupt abortion at

the site of care.

In this study, abortion clinic facilities are the site of contestation; however, this theoretical

category could be applied to continuous collective actions against authorities at other locations

such as police stations, Capitol buildings, or the homes of Supreme Court Justices. The main

difference between abortion clinics and elite-occupied spaces is that anti-abortion protest is often

directed at non-state actors, including providers, volunteers, and patients. This trend toward

contention, directed at individuals rather than the state, is becoming entrenched in policy through

a new generation of anti-abortion legislation. At this moment, when negatively polarized parties

and their affiliates dominate American political competition, the entrenched contention approach

promises to advance social movement organization scholarship.

The Problem Setting: Anti-Abortion Violence at Clinics

The prevalence and magnitude of anti-abortion violence are well-documented. Previous

literature on anti-abortion violence has shown how harm negatively impacts personal experiences

of care, service delivery, and population-level indicators such as the abortion rate (Doan, 2009;

Foster et al., 2013; Jacobson & Royer, 2011; Joffe, 2010; Shah, 2020). Scholarship and personal

narratives on anti-abortion violence often examine the conflict between those seeking vital care

and the violent opposition meeting them before the clinic doors (Bader, 2015; Cohen & Connon,

2015; Cohen & Joffe, 2020; Foster, 2020; Shah, 2020). One in four women in the United States

will have an abortion in their lifetime (Jones & Jerman, 2019). Pregnant people, abortion

providers, and advocates experience harm from a society that does not value the full spectrum of

reproductive care and agency.

Abortion clinics are a primary site of directed hostility towards reproductive freedom

from movement activity, government regulation, and negative depictions that reinforce clinics as

volatile and illicit places (Grimes et al., 1991; Kimport et al., 2012; Russo et al., 2012). Since

Roe, anti-abortion operatives have committed 11 murders, 42 bombings, 196 arsons, 491

assaults, and thousands of incidents of reported violence and disruption at clinics (NAF, 2022).

Nearly all clinics (88%) report on-site protestor activity, and 62% of clinics experience daily or

weekly protests (Smeal, 2018). At the field site in South Bend, Indiana, the threat of violence

requires expert vigilance, and the reality of everyday harassment causes operational disruptions

and patient distress that does not characterize other healthcare settings.

State regulation and limitation of abortion has shaped the landscape of care. The number

of policies enacted by states to restrict abortion has vastly outnumbered the laws to protect access

to care in the last twenty years (Nash, 2019). Abortion bans and restrictions are a result of

effective collaboration between conservative-controlled state governments and the anti-abortion

movement (Doan & Schwarz, 2020; Herd & Moynihan, 2019; Reingold et al., 2021). Prior to

Dobbs, hostile states have rendered abortion “unchoosable” by implementing regulations that

leverage structural barriers such as increased costs, time, and travel (Kimport, 2021). Many of

these states moved to ban abortion following the reversal of Roe. Abortion provision is

determined by contested political geographies that reinforce or resist gendered power

relationships (Calkin, 2019). Advocates and clinics must employ multiple strategies to mitigate

and circumvent state violence from anti-abortion laws. Abortion provision is supported by a

patchwork of nonprofits that assist patients in overcoming barriers to abortion care at the

remaining clinics nationwide (Hernandez, 2021; Jones et al., 2013). Patients, providers, and

volunteers are resilient to anti-abortion violence, but this harm is costly and damaging in a

multitude of ways.

Political hostility towards abortion rights has created a scarcity of abortion care. The

number of clinics providing abortion has dropped steadily nationwide over the last 20 years, with

a significant loss of reproductive health care services in places politically hostile to abortion

(Fischer et al., 2018; Gerdts et al., 2016; Jones & Jerman, 2019). Federal funding is a powerful

governance tool to put political values into action. Federal restrictions on family planning

funding have excluded abortion under most circumstances since the 1978 Hyde Amendment. As

such, most abortion services are provided by standalone outpatient clinics (Jones & Jerman,

2019). Under the Trump administration, Title X grantees were prohibited from performing or

providing information about abortion in the same facility as approved family planning services.

Providers like Planned Parenthood, who withdrew from Title X, were placed in a financially

precarious position until the “domestic gag rule” was reversed under Biden.

The Supreme Court handed state governments total control of abortion policy by

reversing Roe and created a national crisis of clinic loss. The Dobbs decision is expected to close

202 clinics, 26% of facilities nationwide, with a near total loss in the South and Midwest

(Schroeder et al.). Clinic closures from post-Dobbs abortion bans will widen existing abortion

deserts and are expected to increase the median distance from a clinic from about 40 miles to 114

miles (Cartwright et al., 2018; Kelly et al., 2022).

At the time of writing, the future of abortion is uncertain and Indiana is experiencing a

period of legal limbo. The Indiana General Assembly passed a near total abortion ban in

midsummer during a special legislative session. The ban bill, SB1, was filed 32 days after the

Dobbs decision and enacted on August 5, 2022. Indiana was the first state without a pre-Roe

“trigger law” to ban abortion. Lawsuits brought by abortion providers, legal advocates, and

religious groups to challenge the ban have provided injunctive relief to continue abortions while

the cases proceed. If the clinic closes, the nearest same-day abortion provider to South Bend,

Indiana will be in Chicago, a 200-mile round trip. Residents in South Bend has been without an

abortion provider before but advocates were able to restore access. A state-wide abortion ban

leaves few options for abortion seekers, advocates, and providers. Indiana is poised to setback

gender equity and deny reproductive freedom to generations of Hoosiers.

Study Site: South Bend, Indiana

South Bend, Indiana, is named for the changing direction of the St. Joseph river. The

water flows down from Lake Michigan to bisect the city on its way east. I would follow the path

of the river daily, making my way from the neighborhood subdivisions in Mishawaka to

downtown South Bend. The border between Indiana and Michigan is barely noticeable unless

you need to buy liquor on a Sunday. The area adopted the term “Michiana,” which is convenient

for intergovernmental relationships but tends to get stuck in your mouth like most forced

perspectives.

South Bend is a mid-size rust belt city home to around 100,000 people. A generation of

suburbanization and deindustrialization has taken a toll on the city. A local landscape analysis of

the City reveals racial divides in economic security and reproductive health (Table 2: South Bend

Local Landscape). The median income of South Bend residents is $46,000, while annual costs

for a family of four total $82,500. An analysis by Prosperity Now found the average household

income for Black residents was half that of white residents in South Bend (Asante-Muhammad,

2017). The South Bend-Mishawaka census district has four anti-abortion crisis pregnancy

centers, one Title X clinic, and one abortion clinic. Neither of the two area hospitals provides

abortion training for physicians and the Catholic hospital where my parents once worked is

explicitly anti-abortion. Indiana has one of the worse maternal mortality rates in the country with

pregnancy-associated death occurring in 89.5 out of 100,000 births. In comparison, the

pregnancy-associated mortality ratio in nearby Illinois from 2008 to 2017 ranged from 38 to 58.

The pregnancy-associated and pregnancy-related mortality rate for Black women in Indiana is

significantly higher than outcomes for white and Hispanic women. The leading cause of death

for infants in St. Joseph County is complications from prematurity. Death rates for Black infants

in the first year in South Bend are 4.8 higher than national rates. The City of South Bend spends

$439 per resident on policing and the county budgets $447 per resident for health and emergency

services each year. South Bend surrounds the University of Notre Dame and the city struggles to

establish an independent identity from the wealthy Catholic institution world-renowned for its

football program. South Bend residents are quick to reject labels that reduce their home to

college town or dying rust belt city.

I moved to the county in October 2013 and stayed until my doctoral program started in

August 2019. South Bend was on the verge of transformation before I arrived, and my time there

was marked by many notable events and people that caught national attention. South Bend felt

like the center of the political universe between Vice President Pence, Secretary Buttigieg, and

Justice Barrett. I begin the story of abortion care in South Bend further back when they were

Governor Pence, Mayor Pete, and Professor Barrett, and our community was trying to change

abortion care for the better, one clinic at a time.

Indiana’s state motto is the Crossroads of America, and local advocates joke that South

Bend is sort of the crossroads of abortion (Nemes, 2022). Politically active progressives often

call the city a blue dot in a sea of red since our local government leans Democrat compared to the

conservative supermajority at the statehouse three hours away in Indianapolis. Democrat does

not mean pro-choice in South Bend. Senator Joe Donnelly, who served the district for twelve

years in Congress and is now ambassador to the Holy See, joined Manchin and Casey to vote in

favor of banning abortion at 20 weeks. I had been in his office days before with a group of

physicians urging him to reconsider. Donnelly is an alumnus of the university that is synonymous

with the city. Few people knew where South Bend was before Buttigieg ran for President, but

everyone knew Notre Dame. The conservative Catholic university cultivates a certain kind of

Catholic presence in the community. The clinic manager who grew up in the area describes it

beyond “traditional Catholic” and more of a “very conservative kind of restrictive

Catholic.” Notre Dame has expected ties to the anti-abortion movement in Michiana; the

university President, Father Jenkins, serves on the board at the local crisis pregnancy center.

Proabortion advocates also have strong connections to the school as former students, staff,

faculty, or faculty spouses. The scale and scope of Notre Dame’s influence in the area puts

almost everyone in one to two degrees of separation from the university, which now also applies

to the Supreme Court.

South Bend’s first and longest-running abortion provider opened in 1978, about a mile

south of the Norte Dame campus. The Women’s Pavilion of South Bend was one of many

freestanding, independently-owned abortion clinics that were established soon after Roe.iii

Abortion occurs primarily (96%) in clinics, and independent providers care for three of every

five patients (ACN, 2022).iv Following Roe, this free-standing, independent model of care

appealed to feminists looking to practice women-centered care and enterprising physicians able

to open practices where abortion was newly legal (Schoen, 2013). The Pavilion was owned by

the latter. Opening and operating abortion clinics have never been easy, especially in small-town

America. Local authorities compound state and federal obstacles that raise costs and limit where

clinics can open (Schoen, 2013). The first site of the Pavilion on 425 N. St. Louis St was opposed

by the nearby Catholic hospital, which felt the proximity would cause “irreparable damages” by

associating the hospital with the clinic (Gray, 2016). The hospital would flee downtown South

Bend in 2009 for a new facility in the suburbs that places their emergency services out of range

for gun-shot-related trauma care. The local chain of crisis pregnancy centers, Woman’s Care

Center, opened its flagship location a block away from the clinic in 1984.

The Pavilion would move in 1988 to its second and final location at 2010 Ironwood Circle.

Women’s Care Center would open another location in Ironwood Circle, and Right to Life

Michiana would rent the building next door for their headquarters. Protestors would line the

chain link fence protecting the Pavilion parking lot to harass patients and staff (Image 3). The

Apostolate of Divine Mercy in Service of Life, Marriage, and the Family bought the building

behind the Pavilion and erected a little white chapel (Image 4). Opponents also constructed a

fake bus stop outside the clinic, and trained anti-abortion operatives would pretend to wait for

buses that would never arrive (Image 3). Patients tricked by the bus scheme would find

themselves talking to a stranger increasingly concerned with their pregnancy and offering

alternatives to abortion. The Pavilion was surrounded by hate.

The Pavilion staying an owner-operated facility for nearly 40 years, is also an anomaly

among provider trends. From 1996 to 2000, small abortion providers, like the Pavilion,

consolidated into larger operations, with specialized stand-alone facilities becoming the industry

standard (Henshaw & Finer, 2003). Following this consolidation trend, three of the four clinics in

Northern Indiana were owned by the same doctor who looped from Chicago to Gary, South

Bend, Fort Wayne, and back. The nearest Planned Parenthood to South Bend that provides

abortions is 70 miles east in Merrillville, IN. Provision downstate has more options. Three clinics

serve the population-dense Indianapolis area, and two more clinics cover the flagship campus of

the Indiana University (IU) system in Bloomington and Purdue University in Lafayette. Planned

Parenthood operates four of the seven abortion facilities in Indiana and has never provided

abortion care in the Michiana area. Indiana has two independent clinics in Indianapolis; Clinic

for Women and Women’s Med were founded around the same time as the Pavilion and are still

in operation.

South Bend’s next provider was already lined up by the time the Pavilion stopped seeing

patients in late 2015. Whole Woman’s Health (WWH), known for Whole Woman's Health v.

Hellerstedt (2016), was going to open its next clinic in South Bend after being approached by a

group of pro-abortion advocates. The local pro-abortion movement wanted WWH to bring their

model of patient-centered feminist health care to the Michiana community. Whole Woman’s

Health of South Bend started seeing patients in summer 2019 after a long road to opening that

required the WWH to sue the state to issue a license on top of purchasing and renovating a

building (Russell-Kraft, 2019). The new South Bend clinic attracted the same opposition as the

Pavilion but benefited from a new movement organization formed to support its efforts.

Pro Choice South Bend (PCSB) was founded by a collective of advocates that included

former clinic workers, patients, and escorts. I joined PCSB shortly after the group had a name

and led the organization from Trump’s election in 2016 to the clinic opening in 2019. I stayed

involved with PCSB and WWH as an advisor and consultant. In the summers of 2021 and 2022,

I conducted preliminary and dissertation fieldwork, as well as provided support for volunteer

programming and community response to the General Assembly's special session to ban

abortion. I approach this work as an embedded insider with community knowledge seeking

action.

A Case Study Approach

This case study monograph tells the story of abortion provision in a contentious

community accompanied by indicators that measure the scale and scope of violence. This

firsthand ethnography on the opening of Whole Woman’s Health South Bend illustrates a causal

process through the practice of political ethnography and autoethnography. The case study

features a week of participant-observation fieldwork during clinical services in July 2022. My

observations and participation at the clinic occurred days before the state assembly convened to

ban abortion. Additional data collection draws from my personal experience, interviews with

pro-abortion participants, and archived materials. The investigation took a “from-within”

ethnographic approach to generate knowledge as research immersed in a social process (Schatz,

2013; Smith et al., 2021). Descriptive data from multiple sources describe, contextualize, and

analyze anti-abortion trends nationwide and provide local indicators to the field site. Combined,

these methods allow for a quantitative overview of the problem and qualitative grounding of how

problems operate in a “real-world” context. This multi-methods strategy traces the complex

process and systems producing and responding to anti-abortion violence.

Yin (2011) supposes that all case studies come from the desire to derive an up-close

understanding of a single phenomenon set in a real-world context. I come to this work with an

intimate understanding of anti-abortion violence and responses. Living as a woman in the United

States is to be confronted with issues of [in]fertility confounded by politics. My experiences have

pushed me beyond the personal as I took a leadership role in the local pro-abortion movement.

During my time in this role, I have witnessed the closure of a long-established clinic and worked

to open and secure its replacement in a community hostile to abortion. The process of clinic loss

and recovery in South Bend has intrinsically shaped my understanding of abortion care and

prepared me for the in-depth examination ahead. Gerring (2004) explains that a case study is “an

intensive study of a single unit with an aim to generalize across a larger set of units.” Lessons

learned from abortion violence, provision, and policy in South Bend provide insight for

communities across the United States.

Beyond my personal connection, Whole Woman's Health South Bend's opening provides

a case for theory testing by observing the causal relationship between social movements'

organizational and political factors on gender-based violence. Bennet and George (2005) assert

that well-developed theories are ripe for testing. The maturity and relative stability of contentious

politics scholarship provide an opportunity to identify if and how variations in gender-based

violence at abortion clinics can be attributed to social movement organizational and opportunity

factors. Empirical limitations to theory testing include reliance on linear relationships, complex

causal interactions with many variables, pushing a theory beyond its scope (George & Bennett,

2005). Although the proposed causal process is laid out in a linear progression to simplify the

model, the reality of anti-abortion violence and response is convoluted and dynamic. This system

is unpredictable and best tested within the context of a specific case.

To avoid rejecting or narrowing the scope conditions for theory testing, I defend South

Bend as a most likely case for theory testing through process tracing. Bennet and George (2005)

use the work of Wendt (1999) to place process-tracing as a method for a constructivist approach

to describe the causal mechanism through case study and historical scholarship. Wendt (1992)

argues that patterns of behavior are produced in and through situated activity. The study of

contextualized process is a causal determinate for outcomes, as outcomes have no meaning

outside their history and collective meaning (Sterling-Folker, 1997). As a participant in this

process, my observations are a source for analysis. An example of translating participant

observations into process tracing is captured in Figure 1 which shows various movement and

state responses to the Pavilion closing. Further analysis in the resource, repertories, and abortion

ban chapters extending the process tracing timeline to January 2023.

Ethnography is a sustained and researcher-involved method of study that provides

detailed knowledge of a multidimensional social environment (Charmaz, 2014). Ethnography is

an appropriate methodological match to the theoretical framework because it can capture the

complex and interconnected milieu required of my theoretical approaches and causal chain.

Autoethnography is a feminist method of theorizing that extends beyond biography to turn

“personal stories into political realities” by analyzing power, relationships, and complex systems

(Ettorre, 2016). Autoethnography is also a queer political method that examines whiteness,

capitalism, and heteronormativity and summons empathic and affective responses (Adams &

Holman Jones, 2008, 2011). Political ethnography is a method that immerses the researcher in

their subject and positions them within the social process to generate knowledge (Schatz, 2013).

This “from within” approach allows for the investigation of political processes to understand and

test political theory (Schatz, 2013). This method fits study design as it will be based on the

understanding that people are experts of their own lives, and empowerment is possible when

people learn how solutions and challenges from one another (Fields et al., 2008; Freire & Ramos,

1972). Fu and Simmons (2021) demonstrate that ethnography can answer “how,” “why,” and

“what” happened questions essential to understanding social mobilization and contentious

politics. Ethnography captures the messiness of movements that can be lost in other methods to

analyze internal dynamics and meso-level processes between groups, opponents, the state, and

authorities. Fu and Simmons (2021) also emphasize that people determine contention and

ethnography centers on the lived experiences of people. As I am both a participant and observer

in this work, O’Byrne (2007) provided a pragmatic approach to mixing autoethnography and

political ethnography as methods of critical analysis that shaped this research toward a more

transparent evaluation process. I proceeded with an open mind as both an observer and

participant. Details on data collection and analysis are included in the Technical Appendix.

Researcher Positionality

This ethnography weaves together theory, methods, data collection, positionality, and

research ethics. As a participant in the processes I am studying, my role in these events is

fundamental to understanding and has shaped outcomes. I hold a deep personal connection to the

research site and worked through ethical and positionality considerations using Smith et al.

(2021) as a guide for a dissertation in practice. As my work has a social justice focus, I

incorporated feminist participatory methodology into the research plan. This method moves my

dissertation into a space between participant observation and participatory action research. As a

member of this group, my participant capacity is more prominent than my ability to observe. My

position as a doctoral student limits my ability to design fully, collaborate, and co-discover with

the people under study. This position will be a challenging role for me to navigate. I am taking

inspiration from Dodson and Schmalzbauer (2005), who use an interpretive research stage to

include community participants in the analysis phase to co-construct meaning. I had regular

check-ins with those closest to the work to understand where my interpretations met and

challenged their expectations. I am also creating accessible products from this dissertation to

inform advocates and policymakers to derive multiple uses from this work outside of the

academic pursuit.

I expect that my work will be critiqued by scholars who believe research is most

legitimate and trustworthy when inquiry is separated from the researcher's bias and free from

influence from the researcher's background, perspectives, identity, or social position. This

epistemic approach attempts to reduce threats to validity by stamping out researcher influence

and assumes knowledge can be reduced to one true perspective (Guba & Lincoln, 1994). I am

not interested in inquiry that pursues apolitical replication to verify results; I am interested in

disrupting the cycle of violence and using reflexive knowledge to help others challenge the status

quo with better outcomes (Charmaz, 2014). Feminist standpoint epistemology privileges the

situated knowledge that I bring to this research from personal experience and positionality. I

focus on my positionality as a PhD student as this is my most privileged social location relative

to the primary grouping of interviewees who are also educated white women with the ability to

work in a contentious space.

Standpoint theory rejects the linkage between objectivity and neutrality as this

perspective upholds “androcentric, Eurocentric, and bourgeois assumptions” that have dominated

the culture of science (Harding, 1995). The process of social change in pursuit of justice

demands we take a stance. Standpoint ethnography is overtly political and seeks to explain the

lives of oppressed groups and what they need (Gurung, 2020; Harding, 2009). Linda Tuhiwai

Smith (2021) cautions that research must go beyond offering explanations that are intuitively

known by those who experience them. Hill-Collins(2019) summarizes this research tendency as

inquires concerned with explaining social order while ignoring social problems. This research

analyzes the ruling relations and structural challenges involved with abortion justice, as well as

offering lessons for advocates to advance movement goals.

Choosing a side does not exclude researchers from including multiple voices. The

practice of comparing alternative viewpoints for comprehensive knowledge production is central

to feminist standpoint theory (Gurung, 2020). This practice is accounted for in my oral history

collection to supplement my autoethnographic grounding. Standpoint theory demands a

researcher starts at people’s lives, interrogates power relationships in knowledge building, and

offers a plurality of different positioned voices.

The dissertation starts with my experiences as an organizer because activism was my

entry into addressing the problematic aspects of abortion policy. Several of the movement

scholars evoked in this piece, including Angela Davis, Loretta Ross, and Marshall Ganz,

continue to pair their academic credentials with the title of organizer proudly. Alexandra Piñeros

Shields, a Heller doctoral alumni and community organizer, developed the Midwife for Power

model using a successful police accountability campaign as her case study. Scholarship,

especially ethnography, is improved by understanding the everyday processes of resilience and

resistance as a participant with access to the problem setting and insider knowledge of the social

relations ruling the space (Smith, 1987; Smith, 1990). Following this tradition, I do not build

boundaries between activism and academics as these pursuits come from the same place with the

same goals. I intentionally recruited participants for this research who work in the South Bend

community as clinic staff, abortion advocates, and movement leaders to share their experiences

with reproductive coercion and gender injustice. This dissertation is a form of epistemic

resistance, as defined by Hill-Collins (2019), that joins the collective effort towards reproductive

freedom.

Chapter 1

Theories of Power and Violence

Theories of gender-based violence and contentious politics provide conceptual

frameworks to understand the mechanisms of and responses to harm from anti-abortion violence.

Clinics operate in irreducibly complex structures that call for a combination of deeply normative

and social scientific sensibilities. To understand conflict at clinics, we must interrogate the

imbalance of power that allows violence to rule. Gender-based violence is an analytical approach

that prioritizes and privileges the perspectives of the most impacted in investigations of

frameworks of power, politics, and struggle. The contentious politics "school" lends a greater

emphasis on social science methodology to address substantive problems in a real-world context.

Contentious politics provides gender-based violence scholars with tools for the empirical study

of specific mechanisms to then generalize about the causes and consequences of gendered harm

in any local context. For movement scholars, gender-based violence can offer a normative social

and gender justice perspective that motivates the study of interlocking forms of injustice to help

people rectify oppression with social change. Contentious politics explains the mechanisms of

harm, while gender-based violence conceptualizes and motivates the study of harm and guides

the consideration of possible responses to that harm.

Gender-Based Violence

Anti-abortion violence is varied, and its effects are multidimensional and intersectional.

Gender-based violence provides a framework for understanding the complexities of anti-abortion

violence and reclaiming power through policies to promote gender equity. The U.N. defines

gender-based violence as physical, sexual, psychological, economic, or social harm and suffering

occurring in private and public life, directed against a person because of their gender or

disproportionately affecting a particular gender ("Declaration on the Elimination of Violence

against Women," 1993). Gender-based violence is a human rights issue by virtue of the

limitations it places on the right to equality, security, liberty, and freedoms guaranteed by the

Declaration of Human Rights (Rico, 1997). Violence directed at abortion providers and patients

is gender-based because it decreases the capacity to perform and access disproportionately

gender-related services. In these ways, anti-abortion violence acts as reproductive coercion.

Limiting reproductive freedom projects that the only acceptable role for a pregnant person is

parenting, or for people deemed inappropriate parents, placing a child for adoption. Framing

violence as the denial of freedom prioritizes equality-based anti-violence outcomes that center

survivors (Park, 2015). The conceptualization of anti-abortion violence as gender-based violence

centers on knowledge collection and policy action on providers and patients.

Gender-based violence provides a multidimensional approach to account for varied

harms, behaviors, and responses. The U.N. categories of harm map onto the experiences of

abortion seekers, havers, and providers. The Turnaway study found abortion patients and

providers report experiences of physical, sexual, psychological, economic, or social harm at

various stages of the care process (Foster, 2020). Between 6-22% of women having abortions

reported recent intimate partner violence, and some women give concern for violence as their

reason to terminate their pregnancy (S. Roberts et al., 2014). Due to state restrictions on

insurance, most patients experience cost burdens and barriers to care (Roberts et al., 2014). The

majority of clinic staff (83%) report the need to habitually comfort patients upset by protestors

(Foster et al., 2013). Gender-based harms are rarely isolated, and people often experience

multiple compounding forms of violence from various sources. For example, patients at the

South Bend clinic: contend with confrontation from protestors (physical) who may be their

neighbors (social); state-mandated processes that delay care, spread misinformation, extract

personal information, and may require medically unnecessary vaginal procedures (psychological,

sexual, and administrative); and employ a variety of strategies to afford care (economic). As our

understanding of gender-based violence develops, these categories can evolve to expand our

conceptualization of harm.

Gender-based violence provides inclusive framing for anti-abortion violence to account

for all people who experience pregnancy. Gestational-related reproductive health, including

abortion, pregnancy, contraception, and birth, is experienced by women and gender minorities,

including transmen, nonbinary, gender fluid, and genderqueer people (Janiak et al., 2021;

Moseson et al., 2020). This framing respects that the variety of gendered positions is unfixed,

with the potential to change over a lifetime or be subjective to social, sexual, or kinship

circumstances (Doan, 2019). The inclusive language such as “people with the capacity for

pregnancy” accounts for these lifetime changes as “women” excludes abortion experiences of

those too young to be considered women. Pregnancy alone does not denote someone has reached

the age of majority, otherwise there would not be any standing for parental consent laws. Gender-

based violence and discrimination are punishments for gender nonconformity and acts to

maintain gender norms (Lombardi et al., 2002). Prescriptive gender roles limit expressions and

practices of sexuality, fertility, and parenting to reinforce patriarchy through shame, stigma, and

coercion (Ellison, 2003). By placing anti-abortion violence in the structure of gender-based

violence, measurable indicators and policy remedies include violence against all pregnant people

seeking abortion care.

Structural and State Violence

Galtung (1969) expanded our understanding of violence to account for systematic

sources, such as “caste systems or race societies, " protected by those who benefit from

continued exploitation and exclusion. The social, political, and economic power structures that

normalize and perpetuate structural violence include patriarchy, slavery, poverty, and

discrimination based on race, gender, and sexuality (Rylko-Bauer & Farmer, 2016). Government

actions can reinforce structural violence. Soon after Roe, the Hyde Amendment was passed and

prohibited federal funding of abortion, which divested the right to legal abortion for women of

color and their “impoverished white sisters” (Davis, 2011). Sterilization has remained free and

on-demand, compelling women in diminished economic circumstances to “relinquish their right

to reproduction” (Davis, 2011).v Reproductive freedom is dependent on circumstances that are

dictated by power structures beyond our personal control.

Structural violence affects everyone and is experienced differently by different groups of

people. When analyzed through a human rights framework, the power imbalance of structural

intergender and intragender inequality are the root cause of gender-based violence (UNHRC,

2010). Intergender (between genders) and intragender (within genders) inequality can be

understood as a hierarchy of hostility. Intergender structural abortion violence is conceived in the

over-regulation of women's reproductive health compared to men's reproductive health and the

exclusion of reproductive healthcare needs for sexual minorities. Intragender gender abortion

inequality examines how relational power differences in social position (Hill-Collins, 2019) and

the process of social positioning (Hall, 2017) contributes to abortion outcomes and experiences

of violence.vi bell hooks (2000) was speaking about intragender violence when she said that “as

long as women using class or race power to dominate other women, feminist sisterhood cannot

be fully realized.” Structural violence shapes gendered interactions and power dynamics.

In recent years, political science has expanded the analytical approach to violence beyond

actors and motivations to account for structural violence intrinsic to our social systems and

institutions (Dilts et al., 2012). Political organizing and collective action are resistance strategies

to state violence embedded in systems of racism, patriarchy, and capitalism (Davis, 2011; James,

1996; Piven & Cloward, 2012). In his examination of police violence against Black people,

Butler (2022) argues that state actors are often the perpetrators of violence rather than acting with

an obligation to alleviate harm. Butler (2022) suggests that eliminating racial and economic

inequalities is the most effective way to resist violence from anti-Blackness and white

supremacy. Structural violence requires structural solutions.

Intersectional Considerations

The structures of discrimination and imbalance that cause gender-based violence are

interactive, and an intersectional analytical approach is necessary to understand the scale and

scope of harm (Manjoo, 2011). Intersectionality provides a framework to identify connections

and counteract inequalities that result from structural oppression (Hill-Collins, 2019). An

intersectional framework for gender-based violence at abortion clinics considers the root causes

of marginalization and oppression as central to the problem (Henne, 2013; Ross, 2017). In

developing a methodology for studying gender-based violence, indicators must reflect varied

lived experiences and interrogate the patterns of oppression central to these political struggles.

Intersectionality is also a critical legal framework to interrogate, theorize, and contest the

relationship between law and social power that is applied across fields, including Black

feminism, critical race theory, and community activism (Cho et al., 2013). Legal restrictions and

regulations demonstrate the need for intersectional perspectives on anti-abortion violence.

Abortion is legal and prevalent in the United States; however, legislative regulations severely

restrict access, and these structural barriers shift the burden of care onto patients and providers

(Cohen & Joffe, 2020; Kimport, 2021). Due to onerous regulations, clinics survive by reducing

their capacity below patient needs. Facilities reduce how often they provide abortions, limit

payment options, restrict the types of care available, and turn away people with pregnancies

exceeding conception timing determined in the statehouse rather than the exam room (Witwer et

al., 2020). In South Bend, abortion is provided once a week, and services are limited to

medication-only care. A medication abortion protocol is approved by the FDA for use up to 10

weeks’ gestation. Abortion restrictions compound structural inequalities and are felt most by

people experiencing low incomes, people of color, young people, and those who identify as

LGBTQ (Foster et al., 2018; Nash & Naide, 2021). The unnecessarily complicated process of

abortion care is harmful and layered upon existing systems of oppression.

The movement for reproductive freedom has long recognized the need to address

structural violence and racial injustice in health policy. The decisions and actions of white

women and women of color are bounded differently, and reproductive health policy magnifies

these differences at personal and structural levels, from the legacy of reproductive

commodification under slavery to welfare exclusions and forced sterilizations (Roberts, 1999).

Reproductive Justice Theory is a paradigm shift that provides an intersectional framework for

analyzing scholarship and action with the goals of reproductive rights and freedom to understand

this bounding (Ross, 2017). The exclusion of Black women in reproductive health movements

gave birth to the concept of reproductive justice (Luna, 2020). Reproductive justice was coined

by twelve Black women in 1994 at a conference to analyze healthcare reform policies proposed

by the Clinton administration. The women in attendance “believed that the proposals, while

tiptoeing around abortion rights, inadequately addressed the range of intersectional reproductive

health concerns in the African American community” (Ross et al., 2017). A new movement was

born to center on the needs of Black women and others who experience marginalization to

address shortcomings in reproductive rhetoric and policy that primarily served the interest of

income-secure heterosexual white women. Reproductive Justice theory and praxis provide the

intersectional framework and social movement tools to advance reproductive freedom.

Intersectionality and Reproductive Justice theory are intertwined branches of Black

feminist thought that reinforce a vision of gender justice and guide my study of anti-abortion

violence. Ross (2017) presents a Reproductive Justice framework that uses intersectionality as a

process to understand and dismantle structural violence and interlocking oppressions among

groups and communities. Hill-Collins (2019) organized intersectionality as a critical social

theory into core constructs that appear independently or in combination throughout the

intersectional scholarship. I propose that the core constructs of intersectionality identified by

Hill-Collins (2019) correspond to Reproductive Justice concepts found in Ross (2017). Table 3

unites constructs and concepts to provide an intersectional approach for policy scholarship that

advances abortion justice.

Table 3: Combining Intersectionality and Reproductive Justice Theory

Intersectionality Core Constructs Reproductive Justice Concept

Relationality Rejects an individual rights approach in favor of a human

rights framework

Power Attentive to the connections, concentration, means, and

directionality of power

Social Inequality Accountable to disrupting and correcting the multiple

causes of social, political, and global inequalities rather

than replicating or shifting harm

Social Context Rooted in historical, political, and intellectual realities that

produced current social conditions to shape just futures

Complexity Understands that our reproductive lives are not isolated

from other social determinates or problems; intersectional

constructs are intertwined, and inquiry requires multiple

lenses

Social Justice Centers an ethical commitment to equity and puts theory

into practice to amplify truth and build power

Contentious Abortion Politics

Abortion is not inherently political. Anti-abortion organizations have politicized abortion

over time by constructing controversy and contention. The variation in structure, behavior, and

impact of anti-abortion organizations, pro-abortion organizations, and the state can be broadly

studied through the concept of contentious politics. When people mobilize collectively to assert

claims that affect other people, they contend for power or act with contention (McAdam et al.,

1996). Contentious politics are public interactions between claimants, objectors, and

governments that bring together the social processes of collective action, politics, and conflict

over claims (McAdam et al., 2001; Tilly & Tarrow, 2015). Contentious abortion politics includes

interactions between social movement organizations to end abortion or advance reproductive

freedom and various state authorities. On a national level, contention between social movement

groups and the government has matured since Roe, with well-established national organizations

operating in routinized conflict (Munson, 2018). Shifting the analysis of abortion contention

from the national social and political stage to abortion clinics as sites of conflict allows for a

nuanced study of actors on their home terrain.

The politicization of abortion places conflicts at clinics within the study of contentious

politics. McAdam, Tarrow, and Tilly (1996) employ the background concept of "contentious

politics" to include the subfields of social movements, revolutions, and collective action

connected empirically and theoretically to one another across histories and institutions. Based on

contemporary structural approaches, social movement organizational and opportunity factors

empirically evaluate macro-level social structures to analyze contentious abortion politics. These

indicators are drawn from social movement literature from political science, sociology, conflict,

and mobilization studies. While this scholarship has developed with relative stability, scholars

engage with these concepts in slightly different and overlapping ways to inform the development

of my suppositions. Organizational and opportunity indicators can empirically evaluate the

processes between anti-abortion movements that produce violence and pro-abortion movement

responses.vii

Organizational and Opportunity Indicators

Organizational indicators of social movement organizations for anti-abortion violence

include resource mobilization and repertoires of contention. McCarthy and Zald (1977) define

resource mobilization as the variety of resources available, and internal organizational structures

and employed histories of movements demonstrate the importance of stable and regular resource

flow for organizational growth and competitive advantage. McCarthy and Zald (1977) theorized

that longevity, and a history of accomplishments, are essential assets that advantage established

social movement organizations. Conceptually, the older a social movement organization, the

more power they have. Since Roe, the modern anti-abortion movement has invested untold

resources in radicalizing its followers to launch direct action against the constitutionally

protected right to abortion (Michael, 2013; Munson, 2018). The anti-abortion investment in

political power has paid off: as of writing, 13 states have banned abortion.

While resource tensions can explain some of this dynamic, the ways in which resources

are deployed require equal consideration. Repertoires of contention are the tools, collective

actions, innovations, and options available to political actors and social movement organizations

(Sidney G Tarrow, 2011; Tilly, 2003). Repertoires are a limited resource. As Tilly (1999)

explains, movements experience a routineness of performance when conflicting parties fall into

patterns or cycles of action that repeat over time unless disrupted by a shift in opportunity.

Eventually, movement organizations and state authorities learn to predict and respond to each

other. Compared to other movements that direct collective action against state authority,

antiabortion organizations use unconventional tactics of political harassment to target

nongovernmental actors, primarily clinics (Doan, 2009). Clinics must plan for violence by

adopting safety policies and volunteers to escort patients past protestors (Jacobson & Royer,

2011).

The pro-abortion movement mobilizes in response to these threats, and clinical care has

emerged as an essential element of response. Early clinics were not necessarily

movementoriented, and while pro-choice physicians engage in “high-risk activism” by providing

abortion care, they did not always self-identify as activists (Goldstein, 1984; Joffe et al., 2004).

The strategic decision to open a new clinic in an abortion desert with hostile policies is a newer

phenomenon. Whole Woman’s Health agreeing to open a clinic in South Bend, Indiana, is a

disruptive and novel movement tactic – especially when paired with a lawsuit to challenge state

regulations. Abortion bans and regulations are a repertoires of the anti-abortion movement that

pair the collective power of opposition to abortion among interest groups, movement

organizations, and the state. Alignment with the Conservative Party to assert the state has a

preference for birthing outcomes has been a tactic of the anti-abortion movement since the 1960s

that lead to controlling statehouses and the courts (Roberts, 1999; Ziegler, 2020, 2022).

Established pro-life groups lobbied state governments to pass exacting standards that put clinics

out of business to achieve their goals without the risk of legal liability or criminal consequences

from street-level clinic violence and disruption (Ziegler, 2022). Movement groups must assess

the political opportunity for disruption and how to respond to disruptions to the status quo from

the opposition.

Opportunity indicators evaluate the political context outside of social movement

organizations. In his political process model, McAdam (2010) theorized that social movements

emerge based on a confluence of factors that all follow from broad structural and socioeconomic

processes: 1) organizational strength, 2) cognitive liberation, and 3) expanding political

opportunities. The political process model contextualizes organizational resources and capacity

as a strategic inventory to understand collective movement choices and outcomes (Meyer &

Staggenborg, 2007). Factors of political opportunity can be analyzed in several ways that account

for movement resources and the complicated process of policymaking through collective action.

Ganz (2000) reflected on his time with the United Farm Workers to understand how

resourcefulness compensated for organizational deficiencies and newness to generate a more

effective strategy. I expect to find parallels between the strategic capacity theorized by Ganz’s

experiences and my own to explain how under-resourced groups are able to achieve big goals

like forming a union or opening an abortion clinic. The contentious politics literature also

provides ways to quantify support and opposition to policymaking. In evaluating the causes and

pace of women’s collective action, Soule et al. (1999) measured political opportunity by the level

of institutional access and presence of elite allies, using Congressional hearings and roll call

votes. This measurement strategy accounts for the actions of multiple parties and participants to

evaluate political opportunity and collective action success.

Disagreement over what counts as a political opportunity and the state-centeredness of

this theory present conceptual challenges that require additional viewpoints. For example, much

of the literature on political opportunity emphasizes the legislative and executive branches, while

the judicial branch has a significant role in contentious abortion politics. Political opportunity

also focuses on elected officials, while abortion policy is, until recently, largely enforced through

administrative actors.

Political opportunity structure also privileges state-oriented processes, which limit

sources of authority and power to access and act upon opportunity. Rather than a conflict

between the masses and the government, contentious abortion politics involves many state and

non-state actors operating in cooperation and conflict with one another. This system broadly

involves pro-abortion movements, anti-abortion movements, and government authorities. The

state-centeredness of political opportunity structure is limited to understanding the violence

between movement groups that occurs in my phases through crisis pregnancy centers and daily

harassment. Bracey (2016) argues that political process theory is compromised by an emphasis

on state structures as the only source of opportunity as these spaces perpetuate and replicate

racial inequality. As Andre Lorde said, the master’s tools will never dismantle the master’s house.

Policy advancement for abortion justice must seek political opportunity within and outside of

state structures of power.

Multi-Institutional Approaches

The continuous politics affecting reproductive freedom requires a model of measuring

organizational and opportunity factors that expands beyond the binary of state and insurgency.

Armstrong and Bernstein (2008) developed a multi-institutional politics approach to examine

variations in power across state and nonstate institutions. Movements must judge opportunity

across various institutional settings, adding complexity to their processes, responses, and

decisions. A multi-institutional politics framework contextualizes institutional and cultural power

to understand how activists must often challenge and leverage multiple, often interrelated

institutions rather than enter into one conflict with the state. Organizational choices that seem

irrational on their own may be illuminated when accounting for a complex political environment.

Multi-institutional approaches are essential to understanding movement strategy within a

political and organizational context. Armstrong and Bernstein (2008) use Gamson’s (1989) study

of ACT UP to explain how activists targeted both the visible target of government agencies to act

and fight the abstract cultural repulsion to AIDS. As anti-abortion politics are expressed in law,

media, and clinic violence, abortion advocates employ complex and diverse strategies. Legal

action, abortion funds, storytelling, and clinic defense programs are measurable resistance

strategies and tactics that respond to varying levels of opportunity across institutions.

A single abortion clinic can be examined in a multi-institutional approach by considering

the context and strategies specific to that location. For example, Family Planning Associates in

Chicago operates in one of the few places in the Midwest friendly to abortion and, prior to

Dobbs, experienced relatively contained protest activity. Without the urgent need for clinic

defense from protestors or legal defense from anti-rights state policy, reproductive freedom work

in Chicago is focused on maintaining a robust abortion fund to assist people traveling to Illinois

for care and expanding the right to abortion under state law. Daniel and De Leon (2020) use the

Chicago Abortion Fund as an example of “intersectional mobilization” and focus their

examination on internal transformation through leadership succession. This is different than

South Bend, where external threats have more impact on mobilization. The absence of direct and

state violence in Chicago creates an oasis of abortion care in the Midwest and provides

conditions for an introspective case study for movement activity.

Chapter 2

Toward an Innovative Theory of Cause and Effect

I propose a causal process to explain the replicated cycle of anti-abortion violence

observed in entrenched contention. This causal process acts to both advance the theoretical

conversation between gender-based violence and contentious politics and explains cycles of

violence and response within the case study phases. I conceptualize anti-abortion violence as a

form of gender-based violence mechanized by the organizational power of anti-abortion social

movement organizations and state actors. I propose a four-step causal process from anti-abortion

violence to pro-abortion advancement to trace the variability of actors, actions, outcomes, and

responses (Figure 2). The causal process between anti-abortion violence and reproductive

freedom includes state and non-state actors operating in an interlocking political system of

“imperialist white-supremacist capitalist patriarchy” (hooks, 2010). These processes operate in

systems of intersectionality and multi-institutional politics and can be observed through the

frameworks of gender-based violence and contentious politics.

A causal chain provides a useful heuristic function to simplify a complicated problem for

a preliminary study that links social actors, actions, theory, mechanisms, and structures (Gross,

2018; Swedberg, 2014). Tilly (1999) employed causal chains to understand the effectiveness of

social movements by working upstream and downstream to observe if hypothesized instances

occurred and identify competing explanations. The chain begins with the organized power of

anti-abortion social movement organizations and state actors. The causal chain places anti-rights

actors in the primary position because harm and response flow from their actions. Continuing

along the causal chain, gender-based violence leads to direct and indirect harm that disrupts and

alters the behavior of individuals seeking care and organizations providing access to abortion.

These outcomes of anti-abortion violence cause pro-abortion response as social movement

organizations to rethink strategies, tactics, and goals. In these ways, anti-abortion violence

affects how the pro-abortion movement 1) employs methods of self-defense and deflection on

the ground, 2) develops favorable national, state, and local policies, and 3) capacity for

organizational growth and effectiveness.

Figure 2: Simplified Causal Chain

Organized Power Direct and Pro-Abortion

of Anti-Abortion Gender-Based Indirect Harm to SMO Responses

SMOs and State Violence Individuals and and

Actors Providers Advancement

The causal chain is the most simplistic understanding of the process to present

information in an advancing linear progression. In reality, the chain is more of a cycle that is

replicated over and over with multiple interconnected institutions causing and responding to

violence. The entrenched nature of the causal cycle is demonstrated by its repetition over time. In

the case of South Bend, the opening of the Whole Woman’s Health clinic was a pro-abortion

response to the closure of the Women’s Pavilion that caused a renewed mobilization of

antiabortion organizations to deploy protestors to the new clinic. This process is not always linear

or complete. Advocates in South Bend could at times disrupt escalating harm caused by

protestors through nonengagement tactics. The impact of violence depends on who has more

power to cause or alleviate harm—the proposed causal cycle centers clinics as the site of

violence, care delivery, and advocacy.

Case Example: Whole Woman’s Health of South Bend

The story of Whole Woman’s Health of South Bend provides an example of how the

causal chain functions in a real-work context. This chain of events begins with an end with the

closure of South Bend’s long-standing abortion provider. The Women’s Pavilion was opened in

1978 by Dr. Ulrich “George” Klopfer and was South Bend’s only free-standing physician-owned

facility. Almost everyone involved with Pro Choice South Bend that had an abortion went to the

Pavilion. As with hundreds of clinics in the last decade, state regulation was a critical factor in

the Pavilion closing. The number of clinics providing abortion has dropped steadily nationwide

over the previous 20 years, with a significant loss of reproductive healthcare services in places

politically hostile to abortion (Fischer et al., 2018; Gerdts et al., 2016; Jones & Jerman, 2019).

Over the last ten year, 30% of independent clinics have closed (ACN, 2022). The Pavilion, and

two sister locations, held on for almost 40 years before being forced to close.viii

The Organized Power of Anti-Abortion Movement

The anti-abortion movement has harnessed the power of government regulations and

restrictions toward their goal of abortion abolition. The alliance between the anti-abortion

movement and conservatives has successfully garnered control of key political venues to

supplant abortion rights. While conservatives waited for the opportunity to overturn Roe, state

legislators passed an increasing volume and variety of abortion regulations that imposed demand

and supply-side restrictions (Joffe, 2018). This influx of health laws meant that states took an

ever-growing role in the surveillance of abortion and compliance of clinics to code.

Anti-abortion groups used this new bureaucracy to target clinics in new ways. Indiana

Right to Life filed over 1,200 consumer complaints with the state's attorney general, claiming to

have found 1,494 errors or omissions in Klopfer’s paperwork filed with the Indiana State

Department of Health between July 2011 and June 2013 (Crockett, 2014). Klopfer disputed the

claims and accused the anti-abortion group of falsifying his documents in their complaints. It’s

unclear how many of these complaints were from abortions provided in South Bend as Klopfer

also owned clinics in Fort Wayne and Gary, Indiana and these documents were not made public.

By the time the Pavilion closed, anti-abortion groups claimed over 2,000 recordkeeping

complaints had been filed with the state against Klopfer’s clinics (Gray, 2016). The state never

investigated how anti-abortion advocates could make claims against care they did not receive

using patient paperwork they should not be able to access.

Abortion care in Northern Indiana had been in a precarious position with Klopfer as the

main provider. Between 2013 and 2016 all three independent clinics in the area had closed,

which left one Planned Parenthood facility in Merrillville, IN. The Fort Wayne clinic was forced

to stop services in December 2013 after Klopfer could not meet the state’s admitting privileges

requirement (Rankin, 2022). A year later, Lake County prosecutors filed charges against the

doctor for allegedly failing to file paperwork with the state within three days of performing an

abortion for a 13-year-old girl. St. Joseph Superior Court also brough criminal charges for the

same circumstances on June 27, 2014. The Indiana State Department of Health (IDSH) became

involved by January 28, 2015 and filed two licensing actions against the Women’s Pavilion for

failure to maintain proper records, unqualified medical personnel, and not providing mandated

state information to patients. Facing investigations by multiple agencies, Klopfer decided to stop

practicing and told staff in Gary and South Bend that clinics services were on an indefinite

hiatus. This created an avalanche of confusion. Clinic staff did not know if they had jobs.

Residents needed to find the next nearest provider after relying on Klopfer’s clinics for almost

two generations.

The mounting legal actions from multiple agencies makes it difficult to pin down the

timeline and cause of the Pavilion’s closure. I triangulated news reports, state records, and

participant interviews to supplement recollections. ISDH termination reports list November 6,

2015 as the date the Pavilion closed (Reynolds & Kayser, 2016). This date is when abortions care

ceased and reports stopped being filed. Klopfer had entered into a settlement with the ISDH in

November 2015 to not seek a renewal of the Pavilion’s license for ninety days in return for a

dismissal of the action against him. Pavilion did not officially close until March, 18 2016 (Gray,

2016). Pro Choice South Bend organized a candle light vigil to mark the end of the era. We were

not sad to see Klopfer go, but mourned the loss of an essential service close to home. The

Medical Licensing Board of Indiana taking action against Klopfer’s license was a major

contributing factor to the Pavilion closing. Klopfer defended an administrative complaint against

the medical license from January 11, 2016 to November 22, 2016, when his license was

suspended indefinitely. By this point, the Pavilion had sat empty for eight months and advocates

were searching for a lease to open a new clinic with new provider.

Gender-Based Violence

The closure of the Women’s Pavilion is an example of gender-based violence by the state.

Klopfer was unfit to practice and his retirement was the best outcome for the community.

However, the state’s actions left South Bend without an alternative abortion provider. Consider

how the state would respond to a different kind of provider offering inadequate healthcare. The

Madison Center in South Bend closed in 2011 after whistleblowers altered authorities to a $11

million Medicaid scam committed by the behavioral health provider to remove low-income

“problem students” from classrooms and enroll them the Center’s day programs that did not

provide appropriate diagnostics or treatments (U.S. ex Rel. McCoy v. Madison Center, 2011).

Madison Center assets were held in receivership until a local hospital pledged less than 200 days

later to resume these inpatient behavioral health services that are significantly subsidized by

government funding. In contrast, South Bend abortion advocates had to reach out to a provider in

Texas when the Pavilion closed and the state made every effort to stop a new clinic from

opening. A gender equity approach to closing the Pavilion for Klopfer’s professional

incompetence would have been the state making every effort to support and subsidize a new

local abortion provider.

Anti-abortion laws are a form of state structural violence to reinforce gender inequality.

These laws prevented other clinics from entering the South Bend market to compete with the

Pavilion. TRAP laws focused the Pavilion’s energies towards compliance with

medicallyunnecessary regulations rather than quality patient care. State violence is much debated

and conceptualized. Miliband (1969) starts his analysis of the state in a capitalist society by

reminding us that we all “live in the shadow of the state” – an omnipresent power structure. The

state is a powerful source of repression with an armory of control through bureaucratic and

militarized means (James, 1996). Political theory on state violence often centers on the discourse

around legitimacy and justification, as questioned by scholars such as Weber (1948) and Arendt

(1970). However debatable the validity or reasoning, the effects of state violence are harmful,

measurable, and mutable. State violence comes in many forms and is embedded in bureaucracy

(Arendt, 1970). The organized power of the anti-abortion movement elected agents of their

mission and used the force of the state to regulate clinics out of business.

Anti-abortion laws that target and regulate providers use administrative and bureaucratic

power to cause gendered harm. Policy implementation determines how people interact with the

government as administrators seek to shift onerous labor to other administrators or the public

(Burden et al., 2012). Beyond red tape, variation in policy implementation can cause barriers to

services that systematically cause administrative burdens and increase inequities (Moynihan &

Herd, 2010). Herd and Moynihan (2019) include anti-abortion regulation as a form of

administrative burden in the form of learning, psychological, and compliance costs. These laws

constrict the supply of abortion through costly regulating clinics and attempt to restrict by

dictating who is eligible for care and under what circumstances. These burdens were weaponized

to close the Women’s Pavilion and observed during my fieldwork to shape the process of

abortion provision to state standards decided by anti-abortion policymakers.

It is essential in recounting these events to acknowledge that Klopfer committed

genderbased violence against his patients that was uncovered in life and death. Klopfer’s legacy

shaped abortion provision in our community, movement activity, and state response. The Medical

Licensing Board of Indiana suspended Klopfer’s license in part for a number paperwork

violations and mandatory counseling violations designed to target providers and make their job

more challenging. These included failing to meet the strict timing requirements and omitting

information on forms such as father’s name. Paperwork alone did not end Klopfer’s medical

career. The Board (OAG, 2020) found that Klopfer violated his duty of care “due to professional

incompetence as he continued to engage in a pattern of conduct which demonstrated an inability

to exercise reasonable care.” State evidence showed that Dr. Klopfer had inadequately trained

staff and insufficient protocols for sedation medication (OAG, 2020). The medical board was

also disturbed that Klopfer would upcharge pain medication for adults (Kelly, 2016). Klopfer

performed suction curettage abortions for which pain is a common side effect and pain

management is a critical aspect of patient care (Meckstroth & Mishra, 2009). Disentangling

Klopfer’s violations between state administrative burden and patient harm is unnecessary in

understanding his damage and incompetence. A quality abortion provider would have followed

state protocols to protect their practice from closure. Staff at Whole Woman’s Health take care to

ensure their operations are audit-proof while their legal team focuses on overturning medically

unnecessary state restrictions.

Klopfer is an example of a “rogue provider.” Joffe (2010) introduced the concept of

rogue providers and clinics to describe facilities with “inadequate medical standards and often

egregious ethical practices.” The anti-abortion movement allows rogue providers to flourish by

creating conditions that make it difficult for reputable clinics to survive or become established. A

reputable clinic would have ceased patient care before functioning under unsafe or illegal

conditions. Operating a reputable abortion clinic under hostile conditions is challenging, as

lawmakers determine nearly every aspect of care. Compliance with both standards of medical

practice and intentionally burdensome state regulations requires vast resources, a well-trained

staff, and the capacity to respond rapidly to comply or fight changes. Reputable clinics meet this

challenge or close; rogue providers fail and harm patients.

Rogue clinics and providers often serve marginalized people with no other options for

abortion care (Joffe, 2010). Klopfer did not open a clinic closer to his home in Chicago where his

practice would be subject to Illinois state and societal standards. Indiana’s focus on trying to

regulate abortions out of business created a scarcity of care that Klopfer used to his advantage.

Joffe offers several reasons why patients may visit rogue providers. Kermit rogue Gosnell’s

clinic in Philadelphia, Women’s Medical Society, offered lower prices, fewer protestors, and a

willingness to exceed state limitations on gestational limits (Joffe, 2013). People who had

abortions by Klopfer often start by expressing how grateful they for the Pavilion to have been

available close to home when they needed it. For these local patients, proximity to abortion care

was prioritized over quality of practice.

Advocates in South Bend continue to question if Klopfer committed violations beyond

the scope of the state’s investigations and how much Klopfer’s actions contribute to ongoing

abortion stigma in the community. State evidence against Klopfer relied on medical records

maintained by his clinics and no patients provided testimony within the public record. No one

harmed by Klopfer had made their grievances public since his license was revoked and his

clinics were closed. Abortion patients are in a marginalized position that prevents them from

seeking justice. The compounding stigma from protestors, circumstances of provision, and social

values, beliefs, and norms disempowers people from asking questions about their procedure and

talking to others about their experience (Norris et al., 2011). The psychological effects of

abortion stigma can last for years (Biggs et al., 2020). Studies on abortion stigma show find that

health care providers reinforce these feelings when displaying a lack of empathy and sensitive

toward patients (Sorhaindo & Lavelanet, 2022). A local advocate involved at the Pavilion recalls

that Klopfer had “the worst bedside manners.” Another advocate recalled how Klopfer called her

“Grandma” during her appointment. She was a 30 year old mother of two young children at the

time. These breaches of patient comfort do not meet the standard of medical malpractice but do

illustrate how patients harmed by Klopfer may be reluctant to come forward due to abortion

stigma reinforced in his practice. As the only provider in the area, Klopfer’s practice was the

normative experience of care, and combined with people’s low expectations of abortion care it is

possible that harmed people do not feel violated or are not empowered to report incidents. Power

dynamics in the patient-provider relationship contribute to a silencing of patients experiencing

psychiatric and sexual abuse (DuBois et al., 2019; Subotsky et al., 2010). Former abortion

patients of Klopfer may be experiencing similar silencing. The state did not pursue further

investigation into possible patient violations once Klopfer’s clinics were closed. South Bend may

never know the full scale and scope of Klopfer’s harm, but advocates can reflect on the

circumstances that contributed to his actions.

The Pavilion operated under constant threat from state and movement violence which

influenced Klopfer’s practice. Klopfer had a strong will as an owner that helped the Pavilion

survive nearly 40 years in a hostile community and contributed to his clinic management style.

One advocate familiar with Klopfer said that he was “just was going to do what he wanted to do,

regardless of whether or not it was good or right or compliant.” As clinic owner, Klopfer

maintained a staff of underpaid young women without advanced medical training. Pavilion staff

who questioned Klopfer or attempted to change protocols were not employed long. A former

clinic escort with advanced medical training recalled how neglected the practice became over the

years. Klopfer’s inability to dispose of old food, update equipment, or maintain a coherent filing

system would soon become less of a quirk and more proof of his neglected practice. Abortion

advocates were left with few options to intervene in the decaying practice beyond encouraging

Klopfer to retire, but without a transition plan the only provider in town would close. It’s

probable that his professional marginalization in the community contributed to his management

practices but Klopfer is not alive to clarify and horrific discoveries following his death do not

motivate local advocates to defend his practice.

Klopfer died in September 2019 and his family made a horrific finding. Authorities were

alerted to the discovery of 2,411 medically preserved fetal remains and thousands of medical

records at Klopfer’s home in Illinois (Mack, 2020; OAG, 2020). The fetal remains were kept in

Klopfer’s garage and the truck of a car. Investigation later revealed that the remains were most

likely from one of his medical practices in Indiana from 2000-2003 and Indiana Attorney

General Curtis Hill claimed jurisdiction over the matter. Authorities were unable to verify

identifying information to link the fetal remains to a practice or patient record (OAG, 2020).

People who received care from Klopfer during those four years will never know if the fetal

remains were from their abortions. The State of Indiana interred the fetal remains at Southlawn

Cemetery in South Bend at a public funeral presided over by Hill on February 12, 2020 (Mettler,

2020). Right to Life Michiana organized a second memorial two weeks later that Hill also

attended (Lewis, 2020). Women who received abortions at the Pavilion spoke at the second

memorial, the news did not record their testimony and local abortion advocates did not attend the

service. The state did not offer any pathway for patients to seek damages or amends. There are

two simultaneous truths here. Klopfer is responsible for the harm he caused our community. The

state is responsible for the circumstances lead to Klopfer being the only abortion provider in

South Bend and consequences from his clinic’s closure.

Manifestations of Harm

Advocates in South Bend were gravely concerned about the forthcoming burdens to

abortion seekers following the Pavilion closing. The first press release Pro Choice South Bend

wrote following the announcement of the clinic closure highlighted this inevitability. The local

paper ran our statement that “many people in need of an abortion don’t have money or time to

spare; to receive the health care they rightfully deserve, they now have to travel long distances

for two to four hours for multiple appointments, which increases the chance of preventable health

risks and imposes financial burdens” (Gray, 2016). Abortion laws that close clinics cause gender-

based violence through economic harm. The average cost of an abortion procedure, or

medication, within the first 12 weeks was $500 before the pandemic (Upadhyay, Ahlbach, et al.,

2022). Thirty-five percent of all U.S. adults would have trouble coming up with $400 for an

emergency, and due to systematic racism, asset poverty is much more common among Black and

Latinx households (Brevoort et al., 2021). We know that women are more likely than men to live

in poverty, and poverty rates are even higher for women of color (Fins, 2020). Abortion is an

unexpected expense that becomes more cost-prohibitive when adding up expenses from travel,

childcare, and wages lost while navigating barriers to access care (Cohen & Joffe, 2020; Jones et

al., 2013). In a previous paper, I calculated that without a local provider, South Bend residents

would spend an additional $690 beyond the clinic fees to afford an abortion at the nearest in-state

clinic (Morgan, 2018). Financial and logistical barriers to care mean that not everyone who

wanted an abortion before Dobbs could obtain one. People who are denied abortions are more

likely to experience economic insecurity, adverse health outcomes, and stay in contact with a

violent partner (Foster, 2020). Abortion denial increases household poverty, debt, bankruptcies,

and eviction (Miller et al., 2020). Denying people full control over their own reproductive lives

excludes them from the protective effects of abortion, and for women of color, continues the long

history of sexual coercion and control to subjugate health and wealth.

Pro-Abortion Responses

The pro-abortion response to reduce reproductive harm in South Bend was to find a new

provider. This process started well before the state became involved with Klopfer and

demonstrates the consequences of the historical opposition to abortion care in South Bend. The

Pavilion was the only abortion provider in South Bend from 1978 to 2019 when WWHA opened.

Opposition to abortion could concentrate efforts on putting one doctor out of business, and

patients only had one choice in provider. Klopfer lived in Chicago and for many years made a

loop across Northern Indiana every week to his three facilities. Abortion is not normalized and

integrated into mainstream medicine (Joffe, 2014). Medical institutions in South Bend actively

opposed the Pavilion or passively ignored the ongoing threats against the clinic. After decades of

isolation, Klopfer was not interested in community-building or changing the way he practiced

medicine towards a feminist model of care. These circumstances created a perfect storm to

isolate the Pavilion from positive accountability until the clinic became staffed by Women and

Gender Studies majors from IU South Bend. Staff began questioning practices that did not

respect a patient’s emotional, social, or financial needs. Pro-abortion community interest in the

clinic became intensified in March 2015 when the St. Joseph County Council tried to pass an

ordinance that would have required clinics to report the name of backup physicians.ix The

convergence of clinic defense in local politics and concerned staff, along with mounting pressure

from the anti-abortion forces, gave advocates hope that Klopfer might be interested in retiring

and selling the practice.

A group of advocates emerged to approach several organizations to consider restoring

compassionate patient-centered abortion care to South Bend. This group was steered by women

involved in reproductive health and rights advocacy for decades in their roles as family

physicians, university professors, nonprofit professionals, and public servants. They were joined

by the clinic staff and volunteers, who were mostly in their early to mid-20s. This

crossgenerational collective had no public presence but was well-connected and had a wealth of

experience. Scaling up services at the Mishawaka Planned Parenthood was their first choice to

relieve the Pavilion since this health center was well-established, but the local affiliate quickly

dismissed the idea. Advocates reached out to Midwest Access Project (MAP), an organization

that trains medical students and professionals on comprehensive reproductive health topics. MAP

engaged their network to raise the possibility of a provider interested in buying the Pavilion. The

CEO of Whole Woman’s Health (WWH), Amy Hagstrom Miller, came to South Bend in

February 2016 to meet with advocates about a new location for her company. While Klopfer

decided to abandon the business rather than sell, WWH brought their commitment and model of

feminist healthcare to our community. Whole Woman’s Health of South Bend started seeing

patients in the summer of 2019 and has provided over 1,000 abortions since opening. Proabortion

advocates secured an intervention to anti-abortion violence that improved abortion patient

outcomes geographically, medically, and psychologically.

The nature of entrenched contention means that this is a never-ending story. The proposed

clinic was a target of anti-abortion opposition immediately. The state continued to introduce

increasingly specific abortion restrictions after the Pavilion closed to support their denial of a

clinic license for WWH South Bend. But the South Bend pro-abortion movement was stronger

with WWH. The change in providers ultimately embedded an organization in South Bend with

the courage and tenacity to advance reproductive health, rights, and justice through advocacy

strategies that partner with the community and challenge anti-abortion laws. The process of

losing the Pavilion also launched Pro Choice South Bend and activated a new wave of advocates

like me. We could respond in new ways and stand prepared to protect local abortion access after

Dobbs.

The story of abortion provision in South Bend from Roe to Dobbs illustrates the

macrolevel causal cycle, focusing on clinic loss and rebirth. Further sections on resources and

repertoires demonstrate how this causal process can be applied at the micro level to understand

power, violence, harm, and response between anti-abortion protestors and patients, providers,

and volunteers. The organized power of the anti-abortion movement has constricted the ability of

clinics to provide care. Pro-abortion advocates are limited in their ability to alleviate antiabortion

harm and have to exercise strategic capacity to optimize resources and resourcefulness. New

clinics offer a venue of opportunity for protestors to employ repertoires of contention. The

escalation of anti-abortion violence is bounded by time and tactical response. The entrenched

contention of anti-abortion opposition in South Bend is observed in the deployment of these

resources and repertoires.

Chapter 3

Resources

Decline of Clinic Availability

The Dobbs decision is the progression of anti-abortion political action that began after

Roe. Government regulation and abortion restrictions have been putting clinics out of business

since the Casey decision established state interest in regulating and restricting abortion. This shift

to “health-justified” regulations in the law and political framing has denied access to care by

closing clinics (Greenhouse, 2016; Roberti, 2021). The number of clinics providing abortion has

dropped steadily nationwide over the last 20 years, with significant loss of reproductive health

care services in places politically hostile to abortion (Fischer et al., 2018; Gerdts et al., 2016;

Jones & Jerman, 2019). Nearly half the abortion clinics in Texas closed after the introduction of

House Bill 2 in 2013 that mandated doctors have admitting privileges in a nearby hospital to

practice abortion care and that clinics meet the standards of ambulatory surgical centers (Gerdts

et al., 2016). While these provider regulations were found unconstitutional in Whole Woman's

Health v. Hellerstedt (2016), much of the loss and provider exit is permanent. Tracking by the

Texas Policy Evaluation Project shows that of the 46 facilities providing care in 2013, only 18

clinics survived until 2015 (Grossman & Baum, 2015). Abortion bans following the Dobbs

decision have closed clinics in 13 states and providers have been forced to close, pause, or

relocate. This process of state regulation, legal advocacy, and constitutional challenge through

the courts is unstainable, and only the strongest providers are currently weathering this storm.

The Cost of New Clinics

Abortion clinics are a high-cost, high-reward strategy to improve abortion access and

advance abortion justice. Resources emerged as a frequent topic of interviews with South Bend

advocates. This was expected as resource mobilization is a core topic in contentious politics

literature and a key issue for social movement capacity for organizational and political

advancement (Ganz, 2000; McCarthy & Zald, 1977). Abortion scholarship has demonstrated the

burdensome effects of restrictive laws that increase the cost of care and close clinics (Foster,

2020; Fuentes & Jerman, 2019; Joffe, 2010). Interviews with local advocates confirmed previous

literatures and brought new insights to the role of anti-abortion violence in the deficit,

acquisition, and distribution of resources. Organizations need money, which takes effort to raise

and put into action. Mentions of resources appeared 203 times in qualitative coding. Every

participant talked about resources, most without direct prompting from me. These occurrences

ranged from organizational insights to personal accounts to cover a variety of themes that often

overlapped with repertoires. Those who had experienced or expected harassment and injury from

anti-abortion protestors shared about the cost of violence and strategies to mitigate exposure.

Participants in roles supporting the clinic talked about raising money for the operations, patient

services, and practical support for abortion. We also discussed the limitations of clinics to be self-

sustaining and the challenges of fundraising for care in the Midwest. Abortion clinics are a site of

entrenched contention that provide essential community services. When residents invest in

abortion clinics, they become part of community. In a post-Dobbs America with increasing

threats to rights, the future of clinics in will require a combination of resources and

resourcefulness.

The costs to open a clinic are prohibitive. In South Bend, the clinic required a nonprofit

business structure to offset expenses with grants and giving. Following Whole Woman's Health

v. Hellerstedt (2016), Amy Hagstrom Miller had the momentum to expand her business beyond

Texas to other places hostile to abortion. Whole Woman’s Health Alliance (WHHA) was formed

as a 501(c)3 nonprofit and a separate legal entity from Whole Woman’s Health (WWH) LLC. The

Alliance reopened the clinic in Austin that had been closed due to onerous state requirements

under H.B. 2 that were overturned in the Supreme Court case. New and acquired clinics were also

brought under the nonprofit in Maryland, Virginia, Illinois, and Minnesota. Fundraising off a

Supreme Court win is short lived and clinic start-up is expensive. WWHA needed to expand

fundraising to support the new enterprises. These donors often do not live where their money

goes. Staff shared with me that people were more willing to donate to support initiatives in the

South than the Midwest. The South was seen as under attack and in need of urgent support – it

was “sexy” to donate to Texas. This perception was in conflict with how

WWHA saw their Midwest efforts. As one staff member engaged in fundraising said, the “South

Bend clinic really exemplified the mission of WWHA, here was a place where access had gone

away” and the community asked us to restore care. However, the South Bend community was

unable and unwilling to financially contribute at a level that would sustain the clinic.

WWHA and community advocates were responsive to the unanticipated actual cost of

starting the South Bend clinic. The initial $50,000 in grant funding for the South Bend clinic was

secured by community advocates. This seed money and additional funding was raised from

foundations and donors that have remained confidential (Russell-Kraft, 2019). We expected to

have the clinic operational in six months. This seed money was quickly depleted as costs accrued

along the extended timeline. The original plan to rent a space evolved into purchasing a building

through the generosity of a west coast donor close with Hagstrom Miller. The building was a

former chiropractic office that provided many advantages for conversion but still needed major

work to comply with Indiana health codes. The main hallway for patient rooms needed to be

moved a couple of inches to make way for a hospital gurney, even though the clinic was only

applying to dispense medication. The first contractor quit mid-renovation due to anti-abortion

harassment, which delayed progress and ran up costs when the next contractor found his subpar

work. After the remodel and hiring a doctor in August of 2017, the clinic sat empty for 18

months during a legal battle with Indiana’s state health department over the facility license.

During this time, the clinic had to lay off all their South Bend staff members and relied on PCSB

to check in on the building. Having met all the requirements of licensing despite the state

refusing to issue, the clinic received injunctive relief to open in May 2019 and was finally

granted a license in 2022.

The Cost of Anti-Abortion Violence

Clinics, patients, and advocates pay a high price for sustained anti-abortion harassment

and political violence. Anti-abortion groups use violence and disruption to close clinics, raise the

cost of care, and cause providers to quit (Cohen & Connon, 2015; Doan, 2009; Nelson, 2000).

Arson and bombings caused $8.5 million in damages to clinics during the 1990s (Nelson, 2000).

Since 2010, there have been 22 incidents of arson, 1 bombing, and 9 attempted arsons or

bombings at abortion clinics (NAF, 2022). Wellspring Health Access was preparing to open this

summer in a 280 mile abortion dessert between Jackson and Casper, Wyoming when a masked

women set fire to the building. With no leads, the Denver field division of ATF is still offering a

$5,000 reward for information. Julie Burkhart, the founder and president of Wellspring Health

Access, has felt the devasting effects of anti-abortion violence. Burkhart is a veteran of

antiabortion violence. Her mentor Dr. George was murdered in 2009 by Scott Roeder for

providing abortions. The Wellspring clinic has faced supply chain delays rebuilding and has

made plans to open with a mobile unit to start seeing patients while construction continues

(Kudelska, 2022).

Anti-abortion violence directed at gendered health services had caused immeasurable physical,

psychological, and societal expenses. Yet clinics have no relief or grant options through the

government to rebuild after violence or install security measures.

Abortion clinic security is extensive and expensive. The South Bend clinic pays for 24/7

on-call security, surveillance systems, fencing, private parking, higher business insurance

premiums, and defensive landscaping upkeep in a harsh climate. Clinic workers have to be

experts in security, a set of skills that rarely translate to other healthcare jobs. Everyone coming

into the clinic has to be verified by smart lock that transmits audio and video for staff to confirm

identity before entry is granted. Staff are always problem solving to account for new threats and

behaviors. A new door had to be installed early on to block noise from amplified sermons on the

front lawn. The exterior of the building is monitored by a series of cameras that must be

maintained, adjusted, reviewed, and archived. The clinic manager has overseen the installation of

fencing and a parking lot expansion to improve safety that were paid for by a grant secured by

the national office. A pro-bono lawyer specializing in digital gender harassment was consulted

when antis started pointing cameras at the parking lot. Staff spend time managing clinic

volunteer programs that provide exterior patient safety and monitor conflicts with protestors and

police.

This labor does not account for the psychological and emotional cost of working in a

violent space (Cohen & Connon, 2015; Doan, 2009). My interviews included four former

reproductive health, rights, and justice employees who were candid about the mental toil of their

jobs. These participants had different reasons for leaving their positions supporting reproductive

care in South Bend but shared feelings of distress from their experiences. One physician had her

car vandalized by an anti while parked during her shift at the clinic. The doctor had to find her

own lawyer to seek compensation in small claims court and the anti-abortion organization hired

an attorney paid for by the Thomas Moore Society, who countered sued for $75,000. Another

physician who provided state-mandated information shared her anger with state interference with

a process that “for eons, for generations, for hundreds of years women were [safely] handling on

their own.” This physician went on to share how it would be dangerous for them to provide

abortions in South Bend and recounted instances of doctors who had been killed. The threat of

violence from supporting the clinic extended to their family saying, “I can imagine that there

would be people on my front lawn banging on the door making my life more difficult, making

my family's life more difficult.” The two advocacy staff that I interviewed left their roles due to

burnout following organizational challenges during COVID and escalated expectations on their

roles as resources become constrained. One recounted the false sense of urgency they

experienced as an organizer and volunteer manager that took them away from work that was

building community solidarity and power. Another shared the stress of waiting for the Dobbs

decision. Both have stepped away from reproductive health jobs and are either on a career break

or employed in public health.

Anti-abortion violence has caused employees to leave reproductive health jobs and clinics

mitigate risk to keep staff safe. Much like the physicians documented in Cohen and Connon

(2015), doctors traveling to work in South Bend are provided rental cars so they do not park their

personal vehicles at the clinic. Anti-abortion operatives in South Bend stand at the entrance to the

parking lot with clip boards writing down the license plates of any visitors. The physician

attending to patients during my field work is based in Indianapolis. The clinic pays for her rental

car from home and a three-night stay in a local hotel. The doctor arrived into the clinic later in

the day after all the staff to blend in with the incoming patients. She would change out of her

street clothes and into scrubs in the clinic bathroom. The doctor shared with me that most

protestors think she’s a patient since she’s an unfamiliar Black face to them. She quipped that as

a Black women, it’s the first time her race offered her a layer of protection. The white protestors

view her through a prism of racism and discrimination that allows her to come and go from the

clinic without being perceived as the physician on-duty. The all-white clinic staff stayed until the

doctor had wrapped her work and was ready to leave as an assumed patient. Not once did I hear

any concerns about overtime for safely protocols. These costs are expected and normal for

clinics.

The Cost of Targeted Regulation

Contentious abortion politics further constrain how clinics can manage costs. Indiana

requires that all abortion is provided by a physician regardless of method; a doctor must hand

patients their first set of abortion pills. Hiring and scheduling doctors has been an on-going issue

for the clinic. The previous abortion clinic in South Bend was physician-owned and operated on

a weekly schedule as the owner traveled from his home in Chicago. Violence and harassment has

reduced the number of available doctors trained and able to provide abortion care (Cohen &

Connon, 2015; Shah, 2020). Health-system owned clinics, like Whole Woman’s Health,

coordinate with travel physicians. The staff breakroom has a calendar that has the last name of

the doctor scheduled and this board is known to change frequently. Traveling abortion doctors

often visit multiple sites or are employed full-time at a different healthcare facility, which can

create challenges with scheduling and employer restrictions. The South Bend clinic has been

forced to reschedule patients and pause care because a snow storm hundreds of miles away

grounded the incoming doctor. COVID caused even more costly scheduling issues as healthcare

providers fell ill. The South Bend clinic staff were some of the first people I knew to get the first

vaccine. The physicians interviewed for this project shared that many local health systems in

Northern Indiana either explicitly bar doctors from practicing abortion care or threatened

employment termination if found to be in association with abortion providers. Local stigma

means that supporting an abortion clinic could be considered cause for termination that could

extend to one’s family. Only one physician employed by the clinic since opening has lived

locally and she had waited until her husband retired from teaching at Notre Dame to get involved

with reproductive healthcare.

Government regulations that restrict abortion care to physicians prevents clinics from

lowering cost (Herd & Moynihan, 2019). My observations and conversations centered on two

aspects of administrative burden related to optimizing patient flow and hiring strategies.

Abortions in Indiana are a two-day process due an 18-hour mandatory waiting period between

when patients receive state-mandated information and their abortion. The clinic schedules

everyone as early as possible on day one to start the clock. Patients start their visit like most

doctor’s offices with a clip board of paperwork. The difference is the volume of required

information exceeds the needs of the clinic to provide care and these personal details are reported

to the state.

Abortion patients in South Bend must complete 17 pages of forms. Indiana requires

abortion providers to report private patient information, which the state complies into annual

Termination of Pregnancy Reports. This includes demographic and geographic information on

marital status, education, race, ethnicity, home city/county. The state requires patients waiting for

the abortion appointment to provide detailed information regarding previous pregnancies,

including the number of births, miscarriages, and abortions. There are six questions on menstrual

history and the state requires clinics to report the date of last period as part of the calculation of

gestational age. Patients must certify they have received alternatives to abortion information that

lists the anti-abortion group Real Alternatives as the first resource. A fetal ultrasound and heart

tone certification form requires patients mark if they wish to view imagining and hear any

audible fetal activity. Patients can decline to view and hear the ultrasound but clinics are required

to carry equipment that can provide these features.x Indiana requires that patients determine the

“final disposition of the aborted fetus” for all abortions. Patients are required to certify if they

choose to have the clinic arrange for disposal or if they will arrange a method and location on

their own. For medication abortion, the form asks if the patient is “planning to return the aborted

fetus to the abortion clinic.” Pregnancy websites are fond of equating fetal size with fruit and a

strawberry is used for 10 weeks’ gestation. I watched staff help patients fill out this form who

were confused and distressed that they might need to collect and return their pads to the clinic.

Patients with abortion complications are subjected to more paperwork including screening

questions for 25 types of psychological or emotional conditions. Patients have no rights to refuse

this invasive reporting and clinics can be shut down for paperwork violations. I watched as staff

checked and double check files to make sure everything was in order.

The South Bend clinic uses paper, and patients and staff must transfer state-mandated

information into the vital records database. Physicians are then required to also enter the system

to verify and certify the information is accurate. This database is primarily used to maintain and

issue birth and death certificates. Staff showed me how the vital records system was not designed

with their needs in mind. The state requires staff to report on a number of clinical factors not

provided by the patient, including gestational age as confirmed by ultrasound. Clinic staff must

report if multiple gestations are present. The state has a field on the record that reads “multiple

fetuses detected” and the drop down counter starts at one instead of zero. Staff were entering

“other” which promoted a curt message from Vital Records asking for an explanation. After

explaining that the clinic interpreted “1 multiple” to mean twins, the state advised that entering

“1” on a multiple question meant only one fetus present. Staff shared that this kind of close

administrative review was common and often much less innocuous.

Abortions on minors have additional mandated reporting and paperwork. Prior to my

visit, the staff had wrapped a surprise paperwork audit by two state health department employees

that was suspiciously timed with AG Rokita’s public feud with Dr. Bernard. Clinic staff are

required to enter a termination report for a minor and have the doctor verify within three days of

care. Missing this short window of timing for reporting abortions for minors is what prompted

state investigations into the Women’s Pavilion that lead to the closure of the clinic after the

doctor-owner lost his licenses. Abortion providers are also required to report any abortions for

minors to the Department of Children’s Services (DCS). The clinic manager was required to

provide her first and last name to the DCS call agent to make the report. The agent sounded

uncomfortable and uncertain as they collected information. The agent used “Dad” to refer to the

father of the minor and the minor’s partner which caused a few moments of confusion. The clinic

manager was asked if they suspected any abuse in the home. WWH has a protocol to screen all

patients for violence and coercion during the abortion counseling process and none was detected

in this case. The clinic manager made sure to get the name of the agent and a DCS case number

to ensure record of the report. These examples demonstrate the unease between state agencies

and abortion clinics that creates administrative inefficiencies for all parties and worsens the

patient experience.

Abortions can be safely and effectively provided by mid-tier practitioners or advance

practice providers (Renner et al., 2013; Weitz et al., 2013). Prior to Dobbs, 22 states had

expanded the scope of care for nurse‐midwives, nurse practitioners and physician assistants to

provide abortions. These states include expected coastal communities but also places like

Montana and Alaska, where rural needs have expanded the scope of care for non-physicians.

Conversations with the clinic manager confirmed that removing the physician requirement would

reduce the labor cost of the clinic and open up the hiring pool to other medical professionals.

Anti-abortion laws further limit who can provide care by requiring clinics hire doctors with

formal agreements at local hospitals to admit and treat patients. Indiana requires that abortion

providers have admitting privileges in the county (or contiguous county) or have an agreement

with a local doctor with these privileges. Admitting privilege laws are built on the myth that

abortion is dangerous and patients require this level of care in case of complications (Cohen &

Joffe, 2020; Joffe, 2010). Keeping a doctor on payroll who does not provide patient care, except

in a hypothetical emergency, is an added expense for clinics. For local physicians, maintaining

agreements with an abortion provider in hostile communities is a risk. When anti-abortion

operatives publicly released the name of the local physician who provided the admitting

agreement, she was threatened with the termination of her employment even though she never

performed abortion services at the clinic. The clinic was closed while a new local physician was

contracted and an agreement was secured.

Abortion clinics have few ways to increase revenue. Planned Parenthood is the largest

system for reproductive health. According to CRS reporting, affiliates reported a total annual

revenue of $1.29 billion in 2015. Reimbursement from Medicaid and grants from Title X were

the largest category of revenue (43%).xi None of these funds could be used towards abortion care

and were inaccessible to PPFA during the Trump administration. The domestic gag order

prevented federal funding of reproductive health centers associated with abortion. The Biden

administration did not end the Title X gag until October 2021. The South Bend clinic has never

had the capacity to provide reproductive health services like contraception and sexual health

screenings that are eligible for Title X funding. WWHA staff have shared many times with

advocates, and the South Bend Mayor, that the costs are too high and returns are too low to scale

up. The clinic was poised to provide vacuum aspiration and considering services that were

eligible for Title X funding when the Roe was overturned. Investing in a clinic when the state

government intends to ban abortion is not a wise business decision for a health system struggling

to survive.

Anti-abortion organizations have capitalized on the perception that clinics are profitable;

nothing could be further from the truth in South Bend (Kimport et al., 2012). The staff I

interviewed shared that the South Bend clinic relies on donations, grants, and profits from other

WWHA health centers in friendlier places. The clinic cannot self-sustain on service fees alone,

and many patients cannot self-pay without assistance. Indiana has Medicaid, state exchange, and

private insurance coverage restrictions that prevent patients from submitting claims for abortion

care. Patients must pay out-of-pocket for abortions in Indiana, and costs are high due to state

mandates requiring a waiting period, gestational age verification by ultrasound, and extensive

counseling. The clinic charges $200 for the first consultation visit, which covers all state

requirements, and $650 for the abortion pills - $850 total. Patients can waive an additional $50

fee if they decline a rhesus (Rh) factor test for an uncommon condition that may require an

additional injection to prevent excessive bleeding. South Bend service fees are higher than the

national average for first-trimester abortion care and other Whole Woman’s Health system

clinics. Upadhyay, Ahlbach, et al. (2022) found that the median charges for medication abortion

in the Midwest was $550 in 2020. Patients in South Bend pay more because the state requires

staff to provide two in-clinic visits to meet regulations. Bloomington, MN, has a similar

population to South Bend, and Whole Woman’s Health charges $700 for an in-clinic medication

abortion at this site. This fee is also lower for their clinics in Virginia, New Mexico, and

Maryland ($550-600). Abortion medication by mail is even less, costing $400, but Indiana’s

telehealth laws ban this option. Anti-abortion laws increase the cost of care, creating a

geographically variable fee schedule for clinics in the same company.

Clinic staff prioritize care over payment. When patients are unable to piece together

money for the $850 fee the manager would proceed with the appointment and plan to reconcile

later through in-house and external funds.xii During my visit in July, NAF had increased their

funding pledge from $200 to $450 to account for extra barriers due to travel bans. Chicago and

Indiana abortion funds could pledge between $100-200 per person. Still, these strategies fall

short. Clinic volunteers told me stories about patients crying in the parking lot because they were

unable to afford the cost of care. Sometimes volunteers or patient families donated the difference

without the clinic staff knowing. Patients and volunteers can have difficulty understanding how

abortion fees cannot generate profitability. And at times, this is also difficult for staff who feel

underpaid for their labor. Anti-abortion hostility has clinics operating in constant survival mode.

Anti-Abortion Resources

Pro-abortion in South Bend have observed the seemingly unending capacity of

antiabortion organizations. Two organizations in South Bend demonstrated the resource capacity

of the local anti-abortion movement. I will first discuss crisis pregnancy centers through an

examination of Women’s Care Centers. Next, I will provide an analysis of the main protest group

occupying the property next door to the clinic, Right to Life Michiana. The capacity of these

organizations contextualizes their ability to cause harm and how outmatched pro-abortion

advocates are to respond to violence through strategies that require material resources.

While the United States had 800 abortion clinics before Dobbs, there were more than

2,500 crisis pregnancy centers (CPCs) (Cartwright et al., 2021). These unregulated fake clinics

are not medical facilities but manufacture this pretense by opening next door to real clinics and

mimicking clinic branding while hiding their religious affiliations (Cohen & Joffe, 2020; Queen,

2020). The goal of a CPC is to stop people from having an abortion by convincing pregnant

people to parent or relinquish their child for adoption (Cartwright et al., 2021). Policy

interventions to protect patients from the harm of misinformation by CPCs have been met with

First Amendment challenges. The Supreme Court held in National Institute of Family and Life

Advocates (NIFLA) v. Becerra (2018) that California could not require crisis pregnancy centers

to disclose their services and do not offer.

CPCs position themselves as providing alternatives to abortion. States hostile to abortion

turn to CPCs to alleviate criticism by claiming these programs support people experiencing

unplanned pregnancy better than abortion. Nonprofits organizations and social movements have

a long history of addressing social problems with the pretense of improving the health equity of

marginalized populations (Douglas, 1987; Gould, 2009; Nelson, 2011; Young, 2000). Public trust

in the effectiveness of nonprofits since the Reagan administration has created a mutual

dependency between governments and nonprofits to provide social services (Lipsky & Smith,

1989). Unlike abortion clinics, CPCs receive direct funding from the government. Changes to the

Title X family planning programs under Trump allowed CPCs to receive federal funding, and

over 30 states provided opportunities for CPCs to receive funding (Cartwright et al., 2021).

In 2021, thirteen states directly funded CPCs, and several statehouses introduced bills to

increase or start alternatives to abortion programs in anticipation of Roe reversing. The Indiana

General Assembly met in a special session in the weeks following Dobbs to ban abortion and

allocate $2 million in TANF funding to an alternative to abortion group. State funding for

antiabortion programs falls into two broad categories that allocate direct funding for CPCs and

Alternatives to Abortion (A2A) programs. A2A funding is often passed through an intermediary

organization that holds the professional contract with the state and doles out grants to CPCs or

other anti-abortion organizations. The lack of fiscal oversight on these no-bid contracts makes

auditing challenging for state governments, watchdog groups, and abortion advocates (Moore,

2019; Wormer, 2021). Michigan stopped funding A2A programs in 2019 after Governor

Whitmer vetoed the allocation in the state budget. A Michigan Department of Health and Human

Services spokesperson responded to the veto by saying “the program has been of questionable

benefit to families, and it’s been difficult for us to get data on the program to gauge its

effectiveness (Coleman, 2019).” Accusations of fraud have not stopped other states from fueling

A2A programs. An Equity Forward investigation found that the median funding amount for A2A

in state budgets over the last three years was $2,247,500, with Iowa allocating the least

($500,000) and Texas allocating the most ($100,022,732).

Income from state contracts and private donations have allowed CPCs to amass wealth

that they can put into action. Less than five months after the site of the clinic was made public,

the local chain of CPCs, Women’s Care Center (WCC) paid $130,000 for the residential home

next door. The home was not on the market and had been assessed at $74,900 for county taxes.

At the time of purchase, WCC had eleven locations in Indiana, seven of which in the Michiana

area. This CPC has a history of opening offices next to reproductive health providers in Indiana.

In 2016, a Women’s Care Center moved into a property next door to the Bloomington Planned

Parenthood. This property was purchased for WCC by anti-abortion foundation for $1,050,000.

In Michigan City, a Planned Parenthood clinic and a Women’s Care Center are a little more than

a half-mile apart. This trend continues in Indianapolis, Merrillville, and Fort Wayne. The WCC

location next to the Women’s Pavilion can be seen from the street better than the clinic. A WCC

in Mishawaka is located 2.8 miles from a Planned Parenthood clinic that has never provided

abortion care. The distance between the existing Women’s Care Centers and the new property is

at most a 10 minute car ride or 30 minute bus ride.

Whole Woman’s staff were especially alarmed at the South Bend rezoning plans because

their clinic in Peoria, Illinois shared a property line with a WCC.xiii Whole Woman’s Health staff

told city officials that patients in Peoria would frequently confuse WCC with the clinic because

the facilities look and sound similar. Staff recounted how patients would sometimes miss their

appointments because workers at WCC would check them in like they’d arrived at the right

place. WCC workers would keep patients waiting or begin their anti-abortion counseling process

until patients realized what was wrong or clinic staff could reach them to ask what was causing

their delay. The clinic would always manage to see the late patients and shared how this

deception caused an emotional toll. Patients felt foolish and some had endured anti-abortion lies

meant to change their minds through fear. Clinic staff also reported that WCC let protestors use

their parking lot and facilities. This observation contradicted WCC claims that they did not

support direct action against clinics and merely provided a passive alternative to abortion. We did

not want WCC employing these tactics in South Bend.

The Women’s Care Center could afford to lose the rezoning campaign. The CPC opened

across the street from the clinic on the site of a cat boarding facility that was going out of

business and capitalized on the moment to secure a buyer. The CPC could afford to demolish the

old building and invest $506,300 on a $62k land parcel to construct a 3,453 square foot facility

that had zero cars in the parking lot during my four days at the clinic. In contrast, the South Bend

clinic is an actual medical facility where the combined building and land are assessed at

$148,700.

South Bend is also home to an anti-abortion group that has mobilized under a tax

exemption since 1985. The WCC made numerous claims during the rezoning process that they

would be better neighbors than our alternatives. WCC leaders were threatening that the only

other group interested in the property was Right to Life Michiana. WCC said in meetings with

policymakers that Right to Life Michiana would be a larger threat to public safety due to their

history of protest.xiv Speaking on behalf of WCC to the local paper St. Joseph County Auditor

Mike Hamann softened their language to say “the reason the care center wanted to go next to the

abortion provider was so that they could block another group that has a more confrontational way

of doing things; these are good people. We just don’t agree with their tactics (Parrott, 2018).”

Yet, WCC brokered a property transfer to Right to Life Michiana rather than holding on to the

house and waiting for the political opportunity to petition the zoning variance again. As

discussed, Right to Life Michiana has sustained anti-abortion harassment toward the clinic from

the property. The anti-abortion organization claims to have a tenet living full-time in the property

but neighbors rarely see anyone at the house besides protestors. Right to Life Michiana can

afford to keep the house as a base for harassment, in addition to their headquarters next to the

Women’s Pavilion.

Right to Life Michiana is vastly more resourced that the pro-abortion movement in

Indiana. Since 2010, Right to Life Michiana has increased its operating budget nearly 7 times

over from $60k to $423k.xv This annual budget increase is accounted for in the expansion of their

program revenue that began to appear on tax returns in 2018.xvi Outreach, education, advocacy,

and prayer programs have made up 58% of their operating revenue in the last four years. Right to

Life Michiana expanded beyond clinic protest to indoctrinate and normalize their extremist

viewpoint across community spaces from churches to the County Fairs and nonpublic

classrooms.xvii

Tracing the income and wealth of anti-abortion organizations is intentionally difficult.

Right to Life Michiana tax filings categorize them as an organization that receives a substantial

funding from a government unit but grant details are not provided to trace where the funds

originate. I could not trace Right to Life Michiana funding through the state, county, city

budgets. I suspect grants could be subcontracted through alternatives to abortion funding. The

same A2A funding that channels anti-poverty dollars into anti-abortion initiatives also flows to

organizations like Right to Life Michiana that offer faith-based sexual and reproductive health

education. Indiana contracts with Real Alternatives for A2A programming. This organization

promotes dangerously inaccurate information about abortion and misappropriated state funding

to advance their national political agenda (Wormer, 2021). I did locate Right to Life Michiana on

a list of Indiana State Employee Combined Campaigns for automatic payroll deduction

charity.xviii I also found regular and on-going grants distributions to Right to Life Michiana on tax

returns from the Community Foundation of St. Joseph County and University of Notre Dame. At

the time of the rezoning campaign, the Community Foundation was fundraising for the Women’s

Care Centers and the President of Notre Dame, Father John Jenkins, was on the WCC

Board. Money and power link these organizations despite their professed differences in methods.

Resources Mobilization and Conflict at New Clinics

New clinics create opportunities for both sides of the conflict. The anti-abortion

movement is well funded to pay the costs of collective action and sustained political pressure

(Doan, 2009; Ziegler, 2022). Abortion providers that open in hostile places fulfill a mission to

expand abortion provision where it is most needed can also change the political landscape. In the

last decade, Whole Woman’s health acquired clinics in Virginia and Minnesota where

conversative statehouses were determined to enact abortion restrictions already in place in

Indiana and Texas (Guttmacher, 2013). Protestors at these established clinics behaved differently

than what we experienced in South Bend. The Virginia clinic did not have regular side-walk

protestors for the first several years of operations. Much like in South Bend, the previous clinic

owner was the frequent target of administrative harassment as anti-abortion groups used the

Health Department to investigate possible violations to state TRAP laws and regulations

regarding the care of minors. Rather than address daily harassment, the Virginia clinic could

focus on relationships in state government to help pass pro-abortion laws and repeal state

interference in care. In contrast, the conflict between protestors and escorts at the Minnesota

clinic was unchanged when Whole Woman’s bought the clinic. NARAL Minnesota (now Pro

Choice Minnesota) coordinates clinic escorts for several facilities in the state. The resource of

having a consistent escort group that does not require clinic management meant an ownership

change was not a disrupting event.xix

Resource mobilization theory would predict that violence and disruption at clinics would

escalate over time as movement conflict matures and both sides continue to secure new and

maximize existing assets. A former clinic-system director that I interviewed estimates that new

clinics takes about “two years for clinics to get their feet under them to really start being able to

get rolling.” In future conversations with staff and volunteers, we identified a few key

organizational maturity factors at the South Bend clinic impacted by resources related to staffing,

revenue, and community investment.

The South Bend clinic is staffed by local employees and overturn was high at the start as

most new hires had never worked at an abortion provider before this job. Workforce challenges

from the COVID pandemic experienced by all health providers to retain staff also impacted

abortion clinics (Joffe & Schroeder, 2021). The South Bend clinic manager proudly told me in

spring 2022 that her current team was the most effective, efficient, and empathic group to work

the clinic. She crushed her team was being disbanded in preparation for the abortion ban, even if

this change allowed a few staff members to maintain employment in other roles within the

company. A strong team is productive and can provide optimal operations to reach full patient

capacity. During my visit, I watched a well-coordinated crew carefully process double their

normal patient load without compromising quality of care. Staffing significantly impacts the

number of patients that can be seen which impacts clinic revenue. The staff adjust when

scheduling patients for a new doctor by delaying the arrival of the first patient and allowing more

time between appointments. This means the clinic see less patients as the new physician learns

their process flow and office environment. Consistent staffing is essential to reduce cost and

maximize productivity.

The South Bend clinic has been a community project and this both offset costs and

cemented our commitment to the facility. The competent contractor and real estate agent were

both connected to the clinic by my sister-in-law who has deep roots in the community. I helped

unpack shipments from Texas hand-me-down equipment that had been in storage. PCSB

consulted on which movement quotes adorn the walls, a feature at all WWHA clinics.xx Karen

and April are longtime PCSB board members who have taken on many volunteer roles

supporting the clinic from patient escorting to clinic landscaping. Karen began driving her push

lawnmower out to the property soon after purchase to keep the grass to city code. Green thumb

volunteers, like April, maintain the flower beds and have donated trees and shrubs to block “our

noisy neighbors.” I’ve seen clinic volunteers remove weeds and pick up trash between patients.

PCSB paused fundraising after Dobbs to direct money to the clinic. Everyone pitches in where

we can to show our support.

A clinic is most valuable to a community when providing abortion and communities

mobilize to protect and foster what is valuable. This may seem obvious but the delay in opening

created challenges to mobilize local support. Plans to open the clinic were kept on a strict “need

to know” basis as we did not want to anti-abortion groups informed until a license was secured.

This meant keeping the community in the dark. It is incredibility difficult to fundraise or

mobilize support for a clinic that no one is supposed know about. Some allies felt betrayed they

were not in the know when the news was leaked and began criticizing our approach. We used the

clinic as a resource to make amends by inviting people to tour the facility and secured a grant to

host reproductive health, rights, and justice events with local leaders. The goal was to shift

stigma by opening up the space to demystify abortion and position Whole Woman’s Health as a

local healthcare provider. This tactic helped us build solidarity that was essential when needing

to mobilize for the rezoning campaign. Additionally, the rezoning issue gave people a reason to

turn out and speak up for abortion in South Bend. Although the court case to secure a license was

more essential for clinic operations, there were no opportunities for collective action that

generated visible support. The legacy of the rezoning campaign is that it forced Mayor Pete

Buttigieg to take a stance and become a valuable voice to reach moderates in the abortion

discourse. Clinic operations build community relationships. Since opening, community members

have become patients, employees, and volunteers. Patients often become volunteers, donors, and

vocal supporters.

Advocates in South Bend are increasingly concerned that the clinic will not have the

resources to stay open now that Roe has been overturned. The national landscape of abortion care

continues to shift as pro-abortion legal advocates litigate to overturn abortion bans in state courts.

In the absence of a national abortion policy, many clinics are unable to weather the legal

uncertainty of lengthy court cases. An October report found in the 100 days after Dobbs that 26

of the 66 clinics in places where abortion is no longer legal had closed while the rest were still

providing care (Kirstein et al., 2022).xxi Independent clinics in banned states have been forced to

choose between costly options: stay and stop providing abortions or relocate operations. West

Alabama Women’s Center responded to the trigger ban by expanding legal reproductive health

services, including gender-affirming care. Red River Women’s Clinic in Fargo, North Dakota,

relocated across state lines to Minnesota. Jackson Women's Health Organization sold its iconic

“Pink House” and was greeted by anti-abortion protestors at the site of their proposed location in

New Mexico. Whole Woman’s Health also announced a move to New Mexico after permanently

closing all of its Texas locations. Clinics with a primary mission to provide abortion, like Whole

Woman’s Health, will relocate rather than remain in places where such care is banned.

Pro-abortion advocates in Indiana have been watching the exodus of clinics from the

south with growing concern as two lawsuits hold off the state-wide abortion ban. The South

Bend clinic will close if Indiana state courts allow the ban to go into effect. Since Dobbs, the

clinic has been operating on a skeleton staff. The clinic manager and the only full-time

patientservice employee transferred to administrative roles in the health system’s nonprofit.

Whole

Woman’s Health has promised to provide care to the South Bend community for as long as they

are able. It’s uncertain if their ability to remain in business will be limited first by mounting legal

or organizational challenges as the ban drives them closer to closure. In a Post-Dobbs America,

contention becomes more entrenched and more costly to provide.

Chapter 4

Repertoires

Repertoires are public displays of political action and organizing that range from public

demonstrations to violence and disruption. Tarrow (2011) qualifies that “a key feature of social

movements is their capacity to employ a wide array of performances and combine them in

contentious campaigns.” In practice, movement players develop a limited set of actions that are

learned and often repeated (Tilly, 2008). PCSB experimented with repertoires as a new

movement player developing our strategic identity. We hosted a candle light vigil to mark the

closure of the clinic, wrote letters to the editor encouraging support for abortion, met with and

protested politicians, and organized the South Bend Women’s March after Trump’s election.

These early years were focused on mobilizing community support for abortion justice through

these political performances such as grassroots organizing, coalition building, and public rallies.

The South Bend clinic opening in 2019 provided anti-abortion movements with a new

venue for their claim making and repertoires. Meyer and Staggenborg (1996) propose that

movements choose arenas that provide strategic advantage and that once a movement enters a

venue, opposition must follow. Sustained political harassment, extreme violence, and terrorism

are repertoires of the anti-abortion movement that are institutionally supported by organizations

that train, deploy, and defend operatives (Doan, 2009; Jacobson & Royer, 2011; Russo et al.,

2012). These possibilities threatened clinic safety and PCSB responded.

Anti-abortion protest following the opening of WWHA South Bend shifted PCSB’s

limited capacity from formal political venues to clinic defense. Right to Life Michiana had

strategic advantages that PCSB lacks. Right to Life occupy the home next door to the clinic, can

draw upon monied institutional resources, and a readily mobilized population indoctrinated to

their mission. Other anti-abortion groups soon joined in to concentrate actions at the clinic.

Protesting a clinic accomplishes multiples goals including creating a visible anti-abortion

presence in the community to demonstrate the strength of opposition, declare immortality

happens on clinic grounds, and attempt to deter patients from having abortions. Protesting also

generates fear as anti-abortion disruption has escalated into lethal actions in other communities.

In South Bend, anti-abortion protests evolved concurrently to the development of clinic safety

programs run by volunteers. Over time repertories shifted to respond to embedded conflict.

Increased altercations between escorts and protestors caused a renewed commitment to radical

nonengagement for clinic volunteers and the addition of legal monitors. The clinic added fencing

to secure the property after escalated trespassing incidents by protestors were dismissed by local

law enforcement. This cycle of violence and response demonstrates entrenched contention at the

South Bend clinic.

History of Violence at Abortion Clinics

Clinics are documented sites of conflict between vital care and violent opposition that

harms patients, providers, volunteers, and communities (Bader, 2015; Cohen & Connon, 2015;

Cohen & Joffe, 2020; Foster, 2020; Shah, 2020). The spectacle of anti-abortion protesting is

ubiquitous around clinics in the United States, and demonstrates the organized power of the

movement to sustain harassment nationwide. Incidences of picketing, trespassing, and

obstruction at clinics have risen steadily since 2010 with a spike during the Trump administration

(NAF, 2022). These disruptive demonstrations can quickly become destructive and deadly. Since

Roe, anti-abortion operatives have committed 11 murders, 42 bombings, 196 arsons, 491

assaults, and thousands of incidents of reported violence and disruption at clinics, and thousands

of incidents of criminal activities directed at abortion providers (NAF, 2022). During the

systematic reversal of gender-based rights during 2016, the first year of the Trump-Pence

administration, violence and disruption directed at clinics doubled, and the Justice Department

refused to prosecute antiabortion movement offenders (Joffe, 2017; NAF, 2018; Rothe & Collins,

2019).xxii Clinic surveys quantify the escalation and pervasiveness of these movement-

manufactured conflicts. In 2018, Feminist Majority Foundation (FMF) found that 88 percent of

clinics experience a form of onsite anti-abortion protesting, with almost one in four clinics

reporting daily activity (Smeal, 2018). About half of all clinics reported targeted threats against

staff, severe violence, and harassment (Smeal, 2018). These threats are real and taken very

seriously. Last summer, I joined a staff training where we assessed what around us could be used

to defend ourselves in case the clinic was breached.

Protest varies by region and facility making it a place-based process. Clinics in the South

and Midwest report higher frequency and aggressiveness of protesting than those in less

politically conservative regions; higher-volume clinics report more violence and disruption than

low-volume facilities like hospitals (Cohen & Joffe, 2020). Safety measures are baked into

nearly every aspect of clinic operations (Kimport et al., 2012). As such, violence from

antiabortion protestors, demonstrators, and operatives was always top of mind when preparing

for the new clinic. Local advocates who had experienced violence at the Pavilion knew the new

clinic would be a target. Clinic security informed the selection of a location with our own

parking lot, privacy landscaping, and friendly neighbors. Countering protestors through clinic

safety programs became the focus of Pro Choice South Bend once patients started arriving for

services.

One of the main goals of clinic safety is to ensure patients are shielded as much as possible from

violence and are not deterred from receiving care. Staff and volunteers at the South Bend clinic

provide this emotional care work as an expected part of their roles. While less than half of

Turnaway Study patients reported seeing or hearing protestors, the vast majority of staff (83%)

reported the need to habitually comfort patients upset by protestors (Foster, 2020; Foster et al.,

2013). To account for the gap between clinic and patient reporting of protest activity, Sociologist

Carole Joffe points to the effectiveness of clinic escorts who shield patients from protestors

(Cohen & Joffe, 2020). The presence or intensity of protestor activity does not affect the patients'

emotional response to their abortion one week after the procedure (Foster et al., 2013).

Furthermore, anti-abortion harassment activities do not reduce the demand for abortion or cause

a patient to change the location of their procedure (Medoff, 2003). Protestors are an injurious

part of abortion experiences but rarely deter patient determination.

Observed Violence at a New Abortion Clinic

Abortion clinics are a site of entrenched contention from their conception. Whole

Woman’s Health of South Bend had protestors the day the address was leaked to the press by an

unknown source. Crowds of anti-abortion protestors began gathering at the proposed new

location of Jackson Women’s Health Organization in Las Cruces, New Mexico days after their

move was announced in July (Totiyapungprasert & Rossi, 2022). New clinics provide

antiabortion groups the opportunity to engage in direct action in a place where conflict is not yet

routinized. Tilly et al. (2003) assert that collective actors have a limited set of activities and

responses that they draw on routinely. McAdam and Tarrow (2010) further argue that movements

innovate in response to changing threats and opportunities. This scholarship often focuses on the

dynamics of contention between the state and claim-making movement groups (Tilly, 1984).

Meyer and Staggenborg (1996) proposed that conflict between movements and counter

movements where the state is not always involved was becoming more common on a number of

social issues, including abortion. In South Bend, I observed anti-abortion and proabortion

movements engaged in entrenched contention against one another and the state, with clinics as a

primary site of conflict.

I asked volunteers who have the most field time and incidence response experience to

share the moments that stand out as memorable. These experiences demonstrate the escalation,

variety, and scale of harm. This selection of anti-abortion protest-related is analyzed through

gender-based violence lens. I categorize violence by routinized harassment, escalating tactics,

mobilizing children, weaponized womanhood, CPCs, and extreme violence in digital spaces.

This section is followed by a segment on how pro-abortion advocates in South Bend responded

to violence within our strategic capacity.

Routinized Harassment

Whole Woman’s Health South Bend is a site of repeated violations of harassment and

disruption by protestors. Anti-abortion groups began vying for space and attention once

intentions to open a new clinic in South Bend were made public. Local media reported the clinic

had filed a license to open with the State Department of Health. This application process is not

public and advocates suspect someone at the health department purposely leaked the news to an

anti-abortion group or the press. The day the news broke members of Right to Life Michiana

trespassed on clinic property to hold a mock ribbon cutting. They live streamed the incident on

Facebook before PCSB or WWH could assemble a response to the press. The small group of

white women gathered in the clinic parking lot and vowed to stop the clinic from opening.

Advocates in South Bend were confused by this message and upset law enforcement refused to

act on the recorded trespassing. The police were not interested in taking action against a group of

white women who did not cause any damage and had left the scene. A few days later a small

group of dedicated protestors started day camping outside the empty clinic with graphic signage

and rosaries. Protestors quickly learned which days clinical care occurred and concentrated

efforts at times when patient harassment was possible.

Several groups and opportunists harass the South Bend clinic. Protestors from Right to

Life Michiana occupy their property next door to the clinic. This local anti-abortion group

maintains a weekly protestor presence and have at least two to three people on shift when the

clinic sees patients. As discussed in the Resources chapter, they are the most resourced and

established local anti-abortion group. Prior to Dobbs, Right to Life Michiana could afford a

fulltime salaried executive director, summer interns, and numerous facility updates that threatens

clinic safety. Right to Life Michiana has removed portions of the shared fence to access the clinic

driveway, installed cameras pointed at the clinic, and erected a gazebo on the property line for

their protestors to shield themselves from harsh weather. Abutting the clinic property allows

Right to Michiana the opportunity to gain direct access to patients while remaining on their

property.

Clinic protestors, on a typical day, gather on the front yard and along the back fence

where they have the best access to patients and their companions. Protestors often mistake me for

a patient during my field work, which has allowed me to experience the tactics they use to

persuade people to choose life. The protestors mobilize as people drive into the clinic parking lot

to clamor for the attention of patients. This tactic has Midwest origins. Rankin (2022) traces

“sidewalk counseling” back to anti-abortion protest activities in 1985, before Chicago-area

clinics had escorts and security. Agents attempt communication with the goal of persuading

people not to have abortions. They told me to “meet my baby” and that they will “adopt my

baby.” The longer I spend outside, the more personal the comments become to get my attention.

Once protestors yelled “your baby loves pizza” while I carried Dominos into the clinic for staff

lunch. Protestor comments are much more painful and precise for patients and their companions.

Escorts tell me that white women protestors will yell “Black babies matter” at Black patients.

These protestors are seen driving cars with MAGA bumper stickers.xxiii Protestors demonstrate a

patriarchal worldview when homing in on men accompanying patients and preaching about

fatherhood. Escorts report that direct harassment by protestors has caused a number of domestic

violence incidents by raising tension between partners. COVID protocols that prevented

companions from staying with patients exacerbated this situation as rule required men to wait

outside for hours. Escorts and clinic staff began offering ideas for places people traveling from

out of town could wait offsite.

Regular protestors in South Bend are generally community residents. This local

familiarity means sometimes protestors know patients and can shout at them by name. Two

abortion advocates I interviewed were graduate students at Notre Dame at the time of their

abortion prior to the WWHA clinic opening. One chose to travel to Chicago for her abortion to

avoid engaging with anyone. The other concealed her face and parked far away from the Pavilion

to avoid her car being recognized in the parking lot. The fear of encountering protestors can be

countered with the comfort of knowing your clinic escort. April is active in the community and

loves being able to offer patients a familiar friendly face when they arrive at the clinic. Patients,

providers, escorts, and protestors in South Bend are all connected in many ways from work,

school, church, and shared grocery stores. South Bend is a small town without the space to keep

people completely divided by politics.

Over time, escorts learned to predict protestor behavior. Many of these groups are

attention seeking and actively recruiting new members. Escorts could easily infiltrate open

Facebook pages to gather intel on happenings. This opposition research allowed escorts to plan

increased volunteer presence to counter special events or happenings. The relative predictably of

local protestors made large gatherings of unfamiliar outsiders even more intimidating.

Escalating Tactics

South Bend is a town of about 100,000 people and most of the spaces in the city can be

easily overwhelmed by crowds. Managing the flow of staff, patients, and volunteers is a

coordinated effort that has been helped by staggered scheduling and an expanding parking lot.

But we have no control of protestor turnout. The clinic is on a busy four-lane streets and has no

sidewalk (Images 1 and 2). The mixed use node surrounding the clinic includes the Right to Life

Michiana house on the right and a combination Arby’s-gas station to the left. A wooded acreage

prevents protesting from the back of the clinic. Right to Life Michiana denied other anti-abortion

groups access to their property. The Arby’s manager has shooed protestors off our shared fence

and will call to have their cars towed from the restaurant’s parking lot. This concentrates all

protest not on the Right to Life Michiana property but rather on the 15-foot easement in front of

the clinic, which would have a sidewalk if South Bend had the infrastructure. Anti-abortion

protestors do not respect clinic property lines and the public right-of-way became a flash point

for conflict. We had to consult the deed and city planners to assess property lines that extended

beyond the fencing. Karen pounded wooden stakes in a line and strung flagging to mark the

property lines until fencing was installed three years later (Image 5).

Right to Life Michiana relied on escalated spectacle, celebrity, and fear to expand their

repertoires of clinic violence. A man showed up one day cosplaying Jesus on the cross and

protestors lined up to take selfies. Another man spent an afternoon patrolling the Right to Life

property as women with clipboards recorded patient activity (Images 6 and 7). Right to Life

Michiana welcomed prominent anti-abortion opportunists and politicians often visit the

protestors. Abby Johnson, self-described as a “Planned Parenthood director turned pro-life

advocate” became a regular. Abby was often promoting her books, film, or podcast. Former

Indiana Attorney Curtis Hill, best known for his sexual misconduct in office, was a frequent

guest speaker for Right to Life press conferences and vigils for “aborted babies.” Rep. Jackie

Walorski never held a town hall during her tenure but did spend a few afternoons shaking hands

with protestors on the clinic lawn thanking them for their service. Secret Service followed up

with one of our volunteers after one of Walorski’s visits with protestors. The volunteer had pulled

into the clinic driveway a little too close and fast for the Congresswoman’s comfort.

The anti-abortion groups have escalated their approach to security over the years. Indiana

is a constitutional carry state with no regulation on permitting or concealment of handguns in

public. Escorts often report protestors with handguns and have no recourse to address this

convergence of First and Second Amendment rights on clinic safety. Following the Alito leak,

armed men in guard uniforms began joining the women and college students at the Right to Life

property. Escorts were uncertain who Right to Life Michiana perceived as a threat. Some escorts

speculated the armed protestors were protecting against threats from other anti-abortion groups

as they had observed conflict between locals and out of towners. The other popular theory

amongst volunteers was that the guards were meant to intimidate people at the clinic. The guards

introduced a new psychological harm as the threat of physical violence from the Right to Life

was more visible and overt.

Disruption and violence from mass mobilization and audio amplification were common

themes of physical safety threats shared by escorts. The “Church of” anti-abortion events

exemplified both hazards. The clinic is harassed by outside groups that travel to multiple clinic

sites across the country. The clinic became a stop on the “40 Days of Life” tour during lent and a

site for the “Church of [name of clinic]” events. The monthly “Church of Whole Woman’s

Health” events drew hundreds of unmasked protestors to our small site during the peak of

COVID. Pastor Ken Peters started the “Church of” events to harass the Spokane Planned

Parenthood. Peters gained support for these events from the Stop the Steal movement. Brent

Buckley of Northern Indiana Abolitionists and Pastor Jason Gingerich of Maple Grove Church

brought the “Church of” protest tactic to South Bend.xxiv Pastor Gingerich mobilized his

congregation to make a monthly two-hour round trip from Topeka, Indiana to protest the South

Bend clinic (Church at the Gates of Hell, 2021). Out of town protestors do not have to account

for neighborhood etiquette the same way as local groups. Right to Life Michiana has to maintain

a positive relationship with the community as property owners and they tend to avoid large

gatherings or loud noises. The “Church of” can terrorize the neighborhood and leave without

consequences.

The “Church” format mimicked a tent revival popularized by evangelists known for their

vociferous gospel. The monthly events featured amplified sound systems for participants to

preach and sing for hours outside the clinic. Patients, staff, and escorts could hear every word.

Escorts told me the choir of children affected them the most. Lentjes et al. (2020) classifies

antiabortion speech as gendered sonic violence that “that subjects women to nonconsensual

listening in its intrusion of the abortion clinic’s private, feminized space.” Sonic violence

occurred in both the invasion of sound space and the content of the speech. Participants would

testify about the damnation of providers, volunteers, and patients. These speeches were often

feature prophecies about God violently applying justice by harming people who aid in abortion.

Escorts recorded hours of “Church” sermons hoping they could convince law enforcement that

the sermons were evidence of hate speech, intent to commit extreme violence - or at very least, in

violation of city sound ordinances. Law enforcement declined to take action and claimed noise

was difficult to regulate under the ordinance. The Health Department also declined to enforce

any public safety guidelines on outdoor gathering during COVID.

We were left to organize our own response to the “Church of” events. Following legal

advice from Spokane advocates, WWHA sent a cease and desist letter to stop Buckley and

Gingerich from using the business name under copyright law. Maple Grove Church responded by

changing the advertising from “Church of Whole Woman’s Health” to “Lordship of Christ at the

Whole Women's Health abortion clinic in South Bend.” This tactic scrubbed mentions of the

“Church of” events from online searches. People seeking care should have access to quality

information about options and not return results mobilizing clinic violence. Most abortion clinics

are designed or retrofitted to withstand sonic violence. Whole Woman’s Health installed sound

proofing during the South Bend remodel and staff play up-beat music to dampen the effects of

sonic violence inside the clinic. Volunteers spend their entire shift outside with protestors and

developed personal ways of processing sonic violence. One early technique employed by South

Bend escorts, and described in Shah (2020), was to play competing music from car stereos.

Disney songs became a favorite since videos featuring unauthorized music by the mouse are

often removed for copyright reasons on large platforms like YouTube and Facebook. However,

we moved away from this strategy when the protestors brought louder equipment and no one

benefited from the escalating din. Escorts had to find nonengagement tactics to cope with sonic

violence. April has a doctorate in English and is able to locate the absurdity in the repetition of

amplified political rhetoric outside the clinic. She recalls a street preacher mixing up scripture

because he was repeating himself over and over. He shouted at her that “because of the clinic

there would be a coming day of gnashing and weeping of teeth.” The humor of the moment that

stays with her, which limits the intended effect of the harm.

Mobilizing Children

Movement agents’ deployment of children in anti-abortion protest deeply disturbs

proabortion advocates in South Bend. Toddlers stand alongside their parents as cars speed by at

60 miles an hour, thin poster-board is their only shield from the street. Parents lift a small blonde

boy in a striped shirt over the back fence to hold a sign that says “babies are MURDERED here.”

Parents shouting at the clinic through megaphones ignore a playgroup by the Arby’s dumpster.

One is missing a shoe. Children are scaling poles to be visible over the fencing because someone

believes that their tiny bodies somehow convey the message “you are making the wrong choice.”

As if seeing a child will change someone’s mind as they walk into the clinic any more so than

graphic fetal images or aggressive cultural and political rhetoric. The police tell the children not

to scale the poles and they look confused at the officer contradicting their parents. A young girl

running across the lawn smacks into an escort’s umbrella and the child’s mother screams into the

face of the escort. These children grow into easily mobilized young adults that intern with Right

to Life in the summer and take school sponsored bus trips to D.C. for the annual March for Life.

They become the group of college students wearing Notre Dame face masks apathetically

protesting the clinic and gossiping about dorm life while earning community service hours. April

assumes that for these students anti-abortion protest is an easy and social way to fulfill a

university requirement. We witness indoctrination and moments of childhood lost to afternoons

of violence.

The use of children as anti-abortion protest “props” seems to carry the message that

people choosing, supporting, or providing abortion are anti-children. But over half of all people

who have abortions are parents considering the needs of their current children when planning

their families (Foster, 2020; Jones & Jerman, 2019). Many of the staff and volunteers at WWHA

South Bend are parents and grandparents. Abortion provision can even be a family affair. April’s

oldest child was on the clinic defense team at the Pavilion and used to play their accordion to

drown out the protestors. A patient advocate at clinic is the mother of the former patient advocate

at the Pavilion. The escort slack messaging group created a raucous celebration when Karen

became a grandmother last year. The Pro Choice South Bend “About Us” page lists the three

core tenets of the reproductive justice movement that include the ability to decide if and when to

have children and the freedom to raise those children in safe communities (Ross, 2017). We

provide information on the full spectrum of reproductive, pregnancy, and parenting options

available in our community. PCSB has mobilized for child welfare in our community including

action on childhood lead poisoning, racist school discipline policies, increases to SNAP benefits,

maternal health, and diaper drives. PCSB and Whole Woman’s have worked in partnership with

All-Options Pregnancy Resource Center in Bloomington, IN on community and legal advocacy.

All-Options is the only “non-antiabortion” pregnancy resource center in the United States and

provides “open-hearted support across all your pregnancy and parenting turning points (Kimport

et al., 2016).” No one at PCSB would ever consider bringing children to the clinic for a day of

political violence.

The anti-abortion movement promotes a myopic view of motherhood through online

tactics. Like many nonprofits, Right to Life Michiana pivoted to overcome the challenges of

social distancing during the pandemic. The smaller group of protestors started filming the

driveway and recording descriptions of cars and patients on clipboards. These unwelcome

observers were almost always white women. Opposition research revealed that the camera hosted

a livestream prayer service. Right to Life Michiana used Facebook to gather people to protest

digitally during COVID and fundraise from their privacy violations. Right to Life Michiana

would post tributes to “aborted babies” on their Facebook page at least once a month that always

included a donation request. These tributes never accurately reflected the termination reporting

provided to the state, which provided us with some relief about the perceived information sharing

between the organization and state health department. What they were doing was so much worse.

Right to Life Michiana was surveilling people visiting the clinic to count the number of

terminations on their own and construct a fictional narrative. To our ongoing horror, these false

stories were racialized. For example, if protestors saw a Latina presenting woman leave the

clinic, they would include a tribute line for “Isabella” or “José.” We consulted a law firm that

specializes in online gender violence to compel the Meta corporation into action, but they refused

to remove the content.

Weaponized Womanhood

South Bend anti-abortion organizations weaponize femininity to promote their message.

The week the clinic opened, a group of anti-abortion protestors covered the front lawn with

longstem red roses to symbolize mourning and motherhood. We gathered the flowers and took

them home to enjoy. Gift bags became another street-level anti-abortion protest strategy of

femininity of Right to Life Michiana. WWHA patients leave the clinic with an aftercare package

put together by volunteers to relieve common side effects of the abortion medication. Soon after

we began distributing aftercare packages, Right to Life Michiana protestors countered with

unsolicited gift bags. Protestors that had been approaching exiting cars to paper patients with

propaganda were now they holding up party bags when knocking on windows. The bags

included all their printed materials along with dollar store toiletries and candy.

The cooptation of gift bags by anti-abortion protestors combines Judith Butler’s concept

of gender performativity with Tilly’s contentious performances. Butler argues that gender is a

learned behavior that is demonstrated through performances of femininity and masculinity

(Butler, 2002). Tilly proposes that contentious performances have causal and symbolic logics that

evolve as organizations and actors learn (Tilly, 2008). The anti-abortion gift bags are a feminine

gesture to counter-protest the care packages provided by the clinic. Anti-abortion protestors

engage in a stylized repetition of the gender conventions associated with Hoosier hospitality to

make political claims against reproductive freedom.

Anti-abortion operatives use the gift bag as a gentle entry point to their extremist

mission. Ministries use similar tactics to build relationships with sex workers and people

experiencing homelessness, which implies anti-abortion organizations view people seeking

termination care in the same moral and social risk categories. In these ways, the gift bags imply

anti-abortion organizations are recusing abortion patients. Being offered unknown items in bags

from strangers outside a clinic is creepy; this practice became more frightening during COVID as

many protestors were unmasked. Escorts responded by letting patients know they might be

approached and did not need to engage with the protestors: “the weird lady with the bag is not

with us but go ahead and take the free lotion if you want it.”

Right to Life Michiana adopted the branding of feminism to promote their mission

through HerMichiana.org. PCSB was first made aware of HerMichiana because they were

inescapable on Facebook. Our area was heavily targeted with ads introducing “a website created

by women, for women.” We were suspicious but hopeful to welcome a new resource for

reproductive health, and perhaps even retire our efforts maintaining a list. The resource pages for

HerMichiana are extensive and for the most part mimic social service listings provided by other

organizations like the LGBTQ Center or PCSB. These resources diverge at reproductive health

services. HerMichiana only lists CPC resources for “unplanned pregnancy,” includes maternity

home listings for “housing,” and does not include Planned Parenthood locations under “STD

testing.” The “For Him” section provides options for “dads experiencing grief after an abortion.”

Priests for Life, an anti-abortion organization who legally challenge the contraception coverage

mandate, founded this model of male-centric post abortion support. The mixture of secular and

faith-based service providers on HerMichiana is not uncommon for South Bend but the website

lacked key resources for abortion, queer health, and intimate partner violence. The website was

created for some women by a certain type of woman.

The anti-abortion movement aggressively promotes their message through a variety of

marketing tactics to frame their mission as pro-woman. Across Northern Indiana, pro-life yard

signs, license plates, and bumper stickers are as common place as Notre Dame football

merchandize. You cannot drive through South Bend without seeing several large pro-life

billboards. I used to park downtown under a Right to Life billboard featuring a smiling white

couple possessively flanking a pregnant Black women to promote adoption (Image 8). The Right

to Life billboards in suburbs featured chunky white girls with blue eyes and head bows. When

Whole Woman’s Health was planning to open in South Bend, their communications team

planned a billboard campaign to increase awareness of their new services. After numerous

rejections, the clinic could only secure an ad-buy for a single digital billboard on State Road 23

across from the Notre Dame football parking. This single public display and accompanying

digital and radio ads, was cause for the local paper to churn out an article questioning why the

clinic was advertising before they had secured a license to practice (Booker, 2018). The

landscape of places like South Bend is dominated by visual protest to reinforce anti-abortion

attitudes as embedded into the fabric of the community.

Family-centered anti-abortion imagery acts to make a reproductive agenda focused on

social control palatable and aspirational. Social movements gain public attention by giving voice

to grievances such as frames employed by the labor movement to express concerns for working

conditions (Snow et al., 2004). Snow et al. (2004) argue that abortion movement frames reflect

and reinforce cultural norms and ideological commitments. Pictures of happy families represent a

shift from the graphic images of aborted fetuses used by protestors, CPCs, and anti-abortion

political candidates in the 1980s and 1990s (Doan, 2009; Haugeberg, 2017; Levi, 1996). The

anti-abortion movement in South Bend largely projects an idealized narrative of birth and

parenting that fits narratives of white motherhood. This framing can be traced to the early days of

the anti-abortion movement. Luker (1984) found that motherhood was the primary identity of

first generation pro-life activists who feared that social reforms seeking gender equality in the

1970s would end the protections they garnered from marriage. Mansbridge (2015) argued that

this generation of activists mobilized these fears to stop the passage of the Equal Right

Amendment. The visual rhetoric of healthy white babies and parents contributes to the erasure of

other types families. The critique here is not to suggest more inclusive anti-abortion messaging

but rather to understand how these images continue to project a society aligned with this

movement’s goals. Luna (2017) finds that prolife and prochoice movements must demonstrate

competency in histories of sexism and racism to be perceived as authentic messengers in Black

communities. Johnson and Williams (2015) analyzed anti-abortion advertising campaigns that

target communities of color to conclude that these heteronormative depictions of Black families

promote the public control of private bodies rather than a pro-health agenda necessary for

reproductive justice. South Bend activists join many in our movement who simply call these

billboards racist and patriarchal.

CPCs as a Repertoire

Crisis pregnancy centers are an anti-abortion space that has been branded as for women

by women. CPCs emerged from grassroots anti-abortion activism as a “women-centered

approach” in the late 1960s, while men in the movement focused on fetal rights (Haugeberg,

2017). This framing of unplanned pregnancy as a “crisis” in need of social intervention also has a

long history. Solinger (2013) speaks to the sexual crisis a daughter’s unplanned pregnancy causes

in a household that could not afford to keep family business private. Such families sought help

from agencies for unwed mothers to facilitate circumstances to maintain or repair social

standing. As Solinger (2013) explains, the “cure” for unmarried white women before Roe was to

keep a pregnancy secret. Maternity homes offered a way to keep a pregnancy hidden and

coordinate the private adoption of white babies. Black mothers were more likely to rely on

family, or kinship care, to support unplanned pregnancy and the vast majority of maternity

homes only served white women (Solinger, 2013). An estimated 1.5 million children were

relinquished to adoption from 1945 to 1973 (Fessler, 2013). But, this record keeping often

prioritized privacy, which confounds accurate counts. As the social context of pregnancy shifted

and access to contraceptives improved, so did circumstances of adoption. Adoption is rare

compared to other pregnancy options with about 1 in every 3,000 American women of

reproductive age relinquishing an infant each year (Jones & Jerman, 2019; Sisson, 2022a).

Sisson (2022b) found that birth mothers who use adoption agencies now are older and more

racially diverse than prior generations. These mothers often chose adoption due to economic

insecurities. Today, the crisis of pregnancy has shifted from unwed mothers having illegitimate

children to preventing abortion and promising resources to pregnant people.

Whereas maternity homes were used to conceal pregnancy to avoid stigma, their modern

version in the form of crisis pregnancy centers are embedded into communities to proudly and

loudly preach their mission. The Women’s Care Center is known for their bright pink “pregnant,

we can help?” billboards throughout town that offer testing, ultrasounds, and counseling. On the

Uncertain Hour podcast, Clark (2016) investigated the story of one South Bend women seeking

abortion care who turned to the promise of these CPC signs she’d seen every day. The podcast

plays a clip from the WCC website of a soft feminine voice smoothly lying about providing

information on abortion referral. CPCs only refer people to alternatives to abortion. Their

concept offers the veneer of women-centered care without considering the full needs of a person

or their agency to determine the best care for themselves when provided access to all options.

Crisis pregnancy centers position their services as providing alternatives to abortion but

these organizations promote harm. Struggling parents need an alternative to CPCs. Pregnancy is

expensive, and the relative accessibility of free services is a main reason people use CPC services

(Kimport, 2020). Downstate from South Bend, All-Options runs the only secular pregnancy

resource center in the U.S. out of a cozy building in Bloomington. All-Options is a national

advocacy and service provider living up to its name by supporting people through all pregnancy,

parenting, abortion, and adoption options. The Bloomington pregnancy resource center (PRC) is

a judgment-free space that houses a diaper program and an abortion fund. Kimport et al. (2016)

found that the All-Options PRC clients sought parenting resources, not pregnancy services.

Nearly all the 273 PRC clients in the study were interested in free diapers (87%), while only 2%

of clients discussed abortion during pregnancy counseling services (Kimport et al., 2016).

Judgment-free counseling for abortion is essential to help people make informed decisions.

Abortion seekers at CPCs interviewed by Warren et al. (2022) were concerned the CPC staff

would judge them but had no other affordable options to confirm their pregnancy. Crisis

pregnancy centers fill a need that is not being met by the government but do not provide services

that meet the needs of all people who use their service.

Extreme Violence in Digital Spaces

Social media has become an increasingly important tool of modern social movements to

mobilize across decentralized networks (Tufekci, 2017). Pro Choice South Bend relied on

Facebook to recruit members and engage supporters. The Facebook page was the pillar of our

communications strategy to send action alerts, share events, and promote pro-abortion

messaging. People were more likely to direct message PCSB through Facebook than use the

email listed on our website. We answered requests for information about abortion services and

connected people with resources. Facebook allowed us to connect with the community, reporters,

allies, and fellow advocates. The page added a layer of legitimacy to our organization and record

of our work. Facebook started making changes that curtailed our use of the platform after the

Cambridge Analytica scandal uncovered a scheme that harvested personal data from the site for

political campaigns. Every post that mentioned “abortion” or “pro-choice” was flagged for

political speech and removed. Facebook required that we register a personal home address with

the company to maintain a “political page.” In 2021, anti-abortion operatives mass reported the

Facebook page claiming bogus community violations. Meta removed the page and denied our

appeal. We lost touch with thousands of followers in the span of one week. PCSB retreated to our

less popular Instagram and Twitter pages only to face more censorship follow the Dobbs

decision. Pro Choice South Bend was one of many accounts to have posts about abortion pills

removed by Meta which claimed we were violating community standards against selling drugs

(Seitz, 2022). Meta took no action against Right to Life Michiana after South Bend advocates

filed complaints that their page featured images of patients filmed without consent. Meta policies

prevent abortion justice groups like PCSB from using their platforms while creating an

environment where harm and hate can thrive.

Online gender-based violence has proliferated due to a lack of cyber regulation and rise

of alt-right digital communities populated by extremist men (Chan, 2021). Digital spaces for

individual pro-abortion advocates in South Bend became dangerous as the compounding political

circumstances during summer 2020 inflamed connections between white supremacy, patriarchy,

and anti-abortion violence. Reproductive justice is an intersectional praxis for advocacy and

PCSB lived this by engaging in political action across other social justice issues. This put some

of our team members at risk for digital violence in social media spaces. That summer two of our

volunteers were “doxed” by a far-right “sock-puppet” account on Facebook. The user had a

network of friends all involved in the boogaloo movement, a loosely organized anti-government

extremists group. The person behind the Facebook account encouraged people to rape and kill

our volunteers in posts that included photos of them and home addresses. We reported threats to

the FBI through our contacts at the clinic but the Facebook account contained no identifying

information that could prompt legal action. Facebook removed the posts that contained death

threats and encouraged sexual violence but did not ban the user or other accounts that we found

connected to the user. We had to investigate ourselves. Our internet sleuths uncovered the user’s

real name, Adam Fox. Fox was estranged from his family for anger issues, behind on child

support, and lived in the basement of a business. We took steps to block accounts associated with

Fox and his friends on all accounts. PCSB provided an enhanced digital security training and

protocol for all volunteers. We thought this was the end of the story. In October 2020, the FBI

announced the arrest of Fox and 12 other men suspected of a plot to kidnap Gretchen Whitmer,

the Governor of Michigan. Their group, the Wolverine Watchmen, wanted to overthrow the

government. Fox was sentenced to 16 years in prison for the kidnapping conspiracy.

Violence directed at abortion advocates and providers has long been connected to other

extremist and terrorist movements. Anti-government extremists like Fox are committing violent

acts against clinics. Mark Thomas Reno burned down Planned Parenthood’s newly renovated

clinic in Knoxville, TN on December 31, 2021. Almost a year prior, Reno had participated in the

January 6 insurrection. He fired a shotgun into the doors of the same clinic on January 22, 2021 -

the anniversary of Roe v. Wade. Reno was free until his arrest on July 18 when he opened fire

into a federal office building. Compounding hate is deadly.

Anti-abortion assassins have murdered eleven individuals involved in abortion in various

ways since Roe (NAF, 2022). These zealots targeted clinics and killed physicians, clinic staff, an

escort, a security guard, and a police officer. Abortion clinics have also been the site of 26

attempted murders (NAF, 2022). These incidences of deadly violence took place between 1993

and 2015. Clinics across the country were targeted including facilities in Florida, Kansas,

Massachusetts, New York, Colorado, and Alabama.

Hate was not isolated to abortion for many of these murders. In January 1998, Eric

Rudolph murdered a security guard and maimed a nurse at New Woman All Women Health Care

Center in Birmingham, AL with bomb filled with nails. He then fled the state. Rudolph is better

known for his bombing of the 1996 Summer Olympics in Atlanta. Rudolph maintains that his

motivation for the Olympic bombing was a protest of legal abortion and called violence against

providers "a moral duty." However, U.S. Attorney David Nahmias argued that Rudolph's

contention is broader. Nahmias told reporters that Rudolph expressed hatred of "the federal

government, law enforcement, African-Americans, Jews, Hollywood” but expressed no opinion

on abortion to investigators (Dewan, 2005). In 2005, Rudolph avoided murder charges for the

Birmingham by pleading guilty to bombings at three abortion clinics, a gay bar, and the

Olympics. Rudolph filed a hand-written appeal to overturn his life sentence for the clinic

bombing in spring 2022. Rudolph’s appeal to severe the cases and revisit prison terms is based

on the United States v. Davis (2019) ruling that found enhanced penalties for using a firearm

during a “crime of violence,” under Title 18 U.S.C. §924 were unconstitutionally vague. He is

arguing that arson is not a “crime of violence.”

Violence is a repertoire bounded what society dictates is allowed or prohibited (Sidney G.

Tarrow, 2011; Tilly et al., 2003). Nonviolence is observed until violence is deemed acceptable

and this demarcation is eroding nationwide. NAF reported significant increases in anti-abortion

violence with rising incidents of stalking, bomb threats, invasions, and assault in 2021 (NAF,

2022). Abortion clinics have long been a site of extreme movement violence and new venues for

political unrest are emerging to create a concerning pattern of acceptability. The eruption of

violence at the Capitol on January 6, 2021 following Trump’s rally that led to the insurrection

pushed beyond the boundaries of the polity into previous forbidden actions. Anti-abortion

extremists claim their actions save children and this framing has emerged to justify a range of

new violence. Armed protestors have targeted Drag Queen events in Oregon, Texas, New York

City, and South Bend. School boards across the country have received death threats over

pandemic protocols and inclusive curriculum. I moved my final class meeting to Zoom after

Tufts University received a week of bomb threats targeting the Medford campus and nearby

Planned Parenthood. Advocates in South Bend are increasingly wary that the national attention

our city has received over the last few years has placed a target on our town. If movement actions

are bound by what is perceived as acceptable to the community, then communities must refuse to

tolerate and support anti-abortion violence as acceptable harm.

Local Responses to Clinic Violence

Newness was both a challenge and an opportunity for clinic volunteer programs in South

Bend. Whole Woman’s Health does not manage volunteers and PCSB quickly converted our

main purpose from political organizing to volunteer escorting to meet the emerging safety needs

of the clinic. Developing a volunteer clinic safety program from scratch allowed us to tailor a

program to our environment but caused a deficit of institutional history that required a learning

curve. Movement organizations have a standard set of repertoires and these contentious

performances are “‘learned and historically grounded” (Tilly, 2008).xxv PCSB was less than five

years old when the clinic opened. The movement organization next door to the clinic, Right to

Life Michiana, began their organizational history 45 years ago. The local crisis pregnancy center

chain across the street was founded in 1984. Ganz (2000) introduced the concept of strategic

capacity to explain how organizations can overcome resource and repertoire challenges

associated with newness. His case study reflected on how strategic choices made by a new

insurgent labor organization (UFW) succeeded where an established national union (AFL-CIO)

had not. Primary to success was the UFW reliance on local knowledge of conditions compared

with the professional repertoires employed by the AFL-CIO. While Ganz was comparing

organizations with broadly similar goals, I’m applying this concept to the conflict between PCSB

and anti-abortion movement groups. Strategic capacity helps explain why PCSB was able to rely

on local knowledge to develop site specific repertoires that optimized our limited capacity as an

entirely volunteer-run organization that has never raised enough money to file taxes.

Pro Choice South Bend started with half a dozen former clinic workers and escorts sitting

around a kitchen table after learning the Pavilion would close. They soon realized their effort

needed to be bigger than themselves started by hosting open meetings at the Unitarian Church to

strategize. I attended one of the early meetings after seeing a Facebook post and was recruited to

the leadership circle after disclosing my nonprofit management experience. As we grew, we

added people to help us address our fulfil our mission, broaden our collective skills, and diversity

our perspectives. I had the least amount of experience in South Bend, most of my comrades were

lifelong locals. We joke that South Bend is the “Stars Hollow of Indiana” because everyone

knows everyone and not much changes.xxvi These connections to place provided us vendors that

were willing to work with a pro-abortion group when most would not. Karen’s friends own a

local print shop and stepped up to produce our table banner when the Fastsigns franchise refused.

I focused on building solidarity between PCSB and other movement groups to strengthen

our collective capacity. These relationships became essential as we mobilized community support

for an abortion clinic. We hosted pro-abortions public events at Indiana University, tabled at

South Bend Pride, and participated in an annual advocacy event at the local mosque that

encouraged progressive political action. Allies with the local chapter of Black Lives Matter could

have conversations in community spaces that our group of mostly white women could not. We

consulted with a local immigration nonprofit on how we could reduce access barriers for

undocumented abortion seekers. April and I relied on our collective rapport with local politicians

to navigate the rezoning campaign. Nearly every policymaker in that decision was personally

connected to us or an ally in some way.xxvii Our social capital was essential in campaigning

against the rezoning and building the volunteer programs. We recruited South Bend volunteers

for All-Options to provide logistical support for people traveling to Chicago for care while we

waited for the clinic to open. A former co-worker of mine from the City stepped up to coordinate

a legal monitoring program to complement escort efforts.

Clinic volunteers in South Bend developed repertoires for safety by drawing on local

knowledge in solidarity with national networks of support. Established organizations can rely on

histories of previous interactions to act, respond, and innovate. Many escorts from the previous

clinic joined the new program. Clinic defense tactics were adapted from their histories and best

practices shared through private networks with other escort groups. I received funding through

Brandeis during the summer of 2020 to develop a volunteer handbook to document and

standardize our practices. While South Bend clinic staff were largely recruited from the

community and new to abortion work, Whole Woman’s has a deep bench of experience. We

relied on the wisdom of Sharon Lau, Whole Woman’s Midwest Director of Community

Partnerships and former security expert with the National Abortion Federation (NAF). NAF

provides technical assistance for the South Bend clinic. NAF has over 350 members nationwide

including independent clinics, Planned Parenthood affiliates, women's health Centers, physician

offices, and hospitals. NAF member facilities are equipped with up-to-date security-related

repertoires and a professional network to grow tactical knowledge. In 2021, we arranged separate

NAF trainings for clinic staff and volunteers that I attended. The staff intensive strengthened

security protocols and safety practices that I saw followed a year later. For volunteers, this

training shifted how escorts responded to threats and provided tools for assessment.

Conflict between escorts, anti-abortion protestors, and police were escalating at the clinic

around this time. Anti-abortion protestors are trained to antagonize escorts. Protestors in South

Bend adopted the term “deathscorts” to refer to our volunteers. This insult frames escorts as

culpable in what they consider to be the murder of babies. Protestors also learned what actions

generated the biggest responses from escorts and kept them engaged in conflict. Trespassing and

traffic obstruction became the tactics of choice. The clinic only had fencing along the sides and

backyard. In places without fencing, escorts took up positions to defend the permitter of the

property and keep protestors from gaining close access. Protestors and escorts would be in direct

proximity on these unseen property boundaries that tipped animosity into physical contact.

Protestors would inch their way across the lawn towards the clinic or stand in the middle of the

driveway to block cars. Escorts would use their bodies to block protestors from advancing which

was increasingly dangerous.

New tactics were required to prioritize escort safety. No matter how upsetting the

experience, volunteers at Whole Woman’s Health clinics cannot add to clinic violence and

disruption by responding to protestor agitation. The practice of strict, or radical nonengagement

is standard escorting tactic that prohibits all interactions with protestors (Rankin, 2022).

Nonengagement is emotionally taxing and requires a high-level of individual patience and

confidence, along with group reinforcement. One volunteer had to be suspended, and eventually

terminated, after his screaming match with a protestor was put on the internet. We now limit the

number of hours escorts can volunteer to avoid burnout and blow-ups. We also no longer position

escorts where anti-abortion protestors gather and prohibit body blocking. Escorts now stay in the

back parking lot to greet patients and spend downtime quietly chatting with each other. Two

escorts were talking about field organizing with the Democrats in the upcoming election when I

visited this summer. These changes have helped us relieve physical risks and have shown

psychological benefits. Shifting the focus from protestors and clinic defense to patients and clinic

safety decreased the number of emergency meetings called by the escort team to assess threats.

Nonengagement has also been applied to digital spaces and threat assessments can determine if

opposition research is worth the emotional harm generated by entering into those spaces. We can

balance the need to know with how that knowledge affects us.

The reliance on escorts for clinic safety is partly due to the inaction and limitations of law

enforcement. The South Bend clinic has struggled to convince local law enforcement that

protesting is a problem. Indiana does not have any buffer or bubble laws to limit where protestors

can gather. Responding officers rarely enforce trespassing and sound violations at the clinic. We

have been told by local police and politicians that protesting is just part of operating a clinic and

people have a right to assemble. South Bend police claim they cannot distinguish between

escorts and anti-abortion protestors as both sides call 911 to resolve disputes. Protestors once

called the police for property damage at the same time escorts called to report trespassing. Karen

had turned on the sprinklers to water the landscaping on clinic property and the water ruined a

protestor’s sign. The responding office yelled at everyone for wasting his time. Several attempts

were made by Whole Woman’s to develop a good working relationship with local law

enforcement, including engaging a friendly and knowledgeable FBI agent to intercede on our

behalf. While police leadership was relatively receptive and empathic, street-level response did

not improve. Volunteers and staff were further dismayed when they realized one of the officers

that patrolled the area was married to a regular protestor and would bring her snacks when he’d

visit in his cruiser. Our direct connection to local law enforcement ended once I left the Mayor’s

Office and the new city administration is not receptive to clinic needs. We needed a new tactic.

Sharon suggested we bring on legal monitors to supplement the escort program.

Legal monitors observe and document protestor and police conflict at the clinic. Our

documentation efforts prior to the legal monitors program were suboptimal. Escorts had been

tasked with reporting daily violence and disruption reports for the clinic manager to file monthly

with NAF. We learned that counting protestors and inputting data was not a joyful task for any of

our escorts. The escorts were invested in opposition research and generating evidence of

harassment that at times conflicted with their main purpose. We soon were accumulating hours of

protest footage from cell phones and security cameras that was not legally actionable. This

practice ended and recording were destroyed after I observed we had nonconsensual recording of

patients. We needed escorts to focus on patients and not protestors. Legal monitors provide a

creditable source of evidence that may be relevant in criminal investigations. The legal monitor

volunteer role is modeled after a similar program created by the National Lawyers Guild to

observe protest for the purpose of defending against police interference and documenting

unconstitutional restrictions on political expression. South Bend advocates partnered with the

Feminist Majority Foundation to provide training for legal monitors and recruited community

members to fill these new volunteer roles. Both the escorts and monitors have a central point

person who trains, schedules, and manages other volunteers in these roles. The monitor and

escort coordinators work together with clinic staff to share information and problem solve

threats.

The introduction of legal monitors had an immediate calming effect on anti-abortion

protestor behavior. Our escorts wear bright colored vest for patients to spot them easily and have

big rainbow umbrellas to shield from anti-abortion harassment. South Bend legal monitors wear

a small arm-band and carry a clip board. The first day of legal monitoring shook up the space in

our favor. We can best describe this as a “Hawthorne effect” as protestors changed their behavior

in response to being observed by an unknown but legitimate looking new entity. Initially, some

of the anti-abortion protestors assumed the legal monitors were there to support their actions.

This idea was quickly disabused early on when legal monitors confirmed to the police that a

protestor refused to leave the property after the clinic called to report a trespassing violation.

While the novel effect of legal monitors dissipated, their presence has continued to ease the

conflict outside the clinic. Police interactions with legal monitors are generally less contentious

than with escorts. Monitors are trained in a similar legal language to law enforcement which

emphasizes speaking plainly to the facts of the situation. The division of labor has allowed us to

organize volunteers into roles that best fit their preferences and strengths to maximize our

capacity.

Protest escalation and decline at the South Bend clinic could be attributed to many

sources. Whole Woman’s Health has stayed in the national spotlight following Hellerstedt and

may be targeted by anti-abortion groups for their political action. In the early 2020s, South Bend

was also home to two relatively unknown figures that landed high-level federal jobs. The clinic

was newly opened during Mayor Buttigieg’s presidential campaign which brought a small army

of press to the city. This attention on the small city was renewed during Justice Coney Barrett’s

appointment to the Supreme Court. Abortion was a central topic of interest surrounding the

candidacies of Buttigieg and Barrett. Protest could have also been directed at the South Bend

clinic because the site created a new opportunity for people to oppose abortion close to home –

just as the clinic created space for supporters. Along this reasoning, it’s probable that protest at

the South Bend clinics is motivated by “not-in-my-backyard” (NIMBY) factors (Joffe, 2003).

PCSB attempted to counter this position by framing abortion as a social good and that a

community is not complete without a clinic.

While we generally observed a reduction everyday harassment over time, it is impossible

to isolate the cause of decline. Clinic escorts provide insights that fit with a routineness of

performance theory proposed by Tilly (2008). Overtime, escorts and protestors learned to

anticipant opposition behaviors and actions which routinized conflict. Volunteers also attribute a

reduction in direct physical conflict with protestors to de-escalation techniques reinforced by the

NAF training. Escorts found that when they pulled back to focus on patients and stop policing

the property that the regular protestors became less aggressive. It is also possible that the

protestors feel their political goals have been achieved, which has slowed the need for escalation

and mass mobilization. Anti-abortion protest at the clinic reduced significantly following the

Dobbs decision and volunteers report those left are familiar faces who rarely cause any new or

notable disruptions.

Chapter 5

Abortion Bans

The Day of Dobbs

If I type “s” into my browser, “scotusblog.com” will autofill. Like many abortion

advocates this summer, I spent mid-mornings on Supreme decision days monitoring the news

and analysis site known for being the first to report on cases. There is violence in refreshing a

website to see if you have fewer rights than yesterday. Protestor presence at the clinic had been

intensifying in the weeks leading up to Dobbs, and volunteers were wary about anti-abortion

movement response following the ruling. What violence would the Dobbs decision unleash? If

abortion stayed legal, we were increasingly concerned that anti-abortion protestors would react

like Trump supporters after the 2020 election and storm clinics. If Roe were overturned, Indiana

would have the political and legal means to ban abortion. The decision would cause

antidemocratic political violence toward the clinic either way. We had speculated that the news

would drop near the end of the Court session. Justices often staged a quick exit from D.C. when

deciding contentious and controversial cases. Those impacted by their decision were left to deal

with the aftermath.

On June 24, 2022, the Court delivered its decision in Dobbs v. Jackson Women's Health

Organization that held “the Constitution does not confer a right to abortion; Roe and Casey are

overruled; and the authority to regulate abortion is returned to the people and their elected

representatives.” Politico had reported a leaked draft of the opinion by Justice Alito on May 2,

and the 53 days between the leak and the Supreme Court’s decision had steeled many seasoned

advocates for this eventually. Still, this betrayal of reproductive rights came as a shock to many

in the South Bend pro-choice majority and they would turn to PCSB for answers and action.

My phone rang immediately after the news that the Court had invalidated fifty years of

precedent. Karen, the Acting Director of PCSB, and I had a conversation neither of us wanted to

have about our next steps. As the only reproductive justice organization in the area, people

expected PCSB to respond publicly. We also had a responsibility to our team of volunteers to set

the tone in this new reality. Indiana did not have a trigger ban and our primary message during

this time was that abortion was legal and available in our community. We knew a pathway to ban

abortion was readily available to state lawmakers. Karen moved to coordinate with the clinic,

comfort our volunteers, rally supporters on social media, and talk to the press. I crafted rapid

response pieces to be published through my university affiliations that explained the dangers of

abortion bans and provided talking points to local advocates. As we ended our strategy session, I

told Karen, “we’ve been here before, and we know what to do.” South Bend abortion advocates

are resilient because we restored clinical abortion care in our community. Following Dobbs,

South Bend is threatened with another clinic being closed by government interference, but we

were not alone this time. The people, and their elected representatives, were mobilizing to protect

abortion access everywhere and resist the harm from abortion bans.

Abortion Bans are Dangerous and Violent

Abortion bans are a form of state violence directed at those who need and provide care.

Gender-based violence is often characterized by the state’s failure act to provide equal protection

in the law. Weissman (2000) documents this failure in inadequate legal structures, policing

response, and protections for people experiencing domestic violence. Laws like the Violence

Against Women Act are state remedies to protect the well-being of survivors from structural and

system failures (Weissman, 2000). Similarly, protections in states like Illinois and Massachusetts

to guarantee the right to abortion and offer state support to access care act to address structural

and system inequities. Anti-abortion laws are a form of gender-based violence by the state which

contradicts the purpose of government. Policy that denies access to abortion algins state power

with anti-abortion movement strategies of violence and intimidation to restrict care by force. The

United Nations contends that the state is obligated to eliminate discrimination and ensure the

right to health, which includes access to abortion (OHCHR, 2020). Abortion violence committed

by the state reinforces structural gender inequality and must be held to stricter scrutiny than over

forms of anti-abortion violence because of these obligations. Abortion bans demonstrate state

interest in potential citizens rather than a duty to end discrimination against pregnant people.

The Supreme Court decision in Dobbs triggered abortion bans in states that are home to

40 million women. Denial of care from state-level bans and extreme gestational limits is an

immediate and accelerating crisis nationwide. Abortion provision in the United States is a

fragmented system fraught with challenges for patients trying to exercise their fragile rights

(Cohen & Joffe, 2020). Not everyone who wanted to have an abortion before Dobbs could obtain

care, and we know the harms from being denied an abortion are vast and compounding (Foster,

2020). The loss of abortion care will exacerbate and intensify inequities for people with the

capacity for pregnancy. As of January 2023, 13 states have near-total abortion bans in effect. The

gap between people who want an abortion and those who obtain an abortion will only continue to

widen as access is lost and availability is concentrated by political geography. The harm to come

will be swift to those experiencing pregnancy in a country where your address and bank account

determine your access to the full spectrum of reproductive care. The harm from Dobbs will also

be steady as the anti-abortion movement continues to peel away rights and define whose

personhood matters. Advocates will be clawing back reproductive rights in the pursuit of justice

and freedom across many venues to respond to the multitude of threats ahead. How we respond

to this crisis of care will shape the next 50 years of reproductive health policy in the United

States.

Forced clinic closures due to state-level abortion bans that went into effect following

Dobbs were a rapid form of violence to eliminate health access. In the first 100 days after Dobbs,

state restrictions forced sixty-six clinics in fifteen states to stop providing abortion care (Kirstein

et al., 2022). The Indian ban threatens six clinics. Thirty-two clinics in states bordering Indiana

will close if state courts fail to overturn bans across the Midwest (Image 9). State governments

had laid the legal groundwork in anticipation of the Court reversing Roe by passing “trigger

bans.” Many clinics in trigger states were forced to pause services immediately following the

Dobbs decision and staff the heart-wrenching job of breaking the news to patients in the waiting

room (Taladrid, 2022). Whole Woman’s Health closed all four clinics in Texas twelve days after

Dobbs after losing a final effort to appeal to the State Supreme Court. Clinics in five states,

including Indiana, are able to provide abortions as litigation for near-total bans proceeds in state

courts (Table 1). Operating in this legal limbo creates confusion for patients and staffing

challenges for the South Bend clinic. People are more likely to know Indiana banned abortion

and less likely to understand the clinic can provide care under a court injunction. Clinic staff are

working a job that might be eliminated at any moment.

Abortion bans harm abortion seekers. The six-week Texas abortion ban (SB8), enacted

without injunctive relief since September 2021, provides insights into changes in abortion

provision from Dobbs in places where abortion is banned or limited now. The Texas Policy

Evaluation Project has documented the efforts of abortion providers to expedite care that meets

state timing restrictions, wayfaring patients to out-of-state facilities, and connecting people with

funding to overcome increased out-of-pocket expenses. This complex, timely, and resourceheavy

work to connect Texans to abortion care is now more difficult as the nearest border states

providing care at that moment were Kansas and New Mexico, which have state-level restrictions

and limitations. People who were denied an abortion because of SB8 started having children in

the months following the ban (Kitchener, 2022). The loss of abortion clinics places enormous

strain on the remaining places where care is legal. Abortion appointment requests at clinics in

South Bend and Pittsburg surged during the Ohio ban during the 2022 summer which put strain

on scheduling patients and staff (Capital-Star, 2022; Kim, 2022). The Turnaway study found that

women who are able to obtain a wanted abortion experience better wealth, health, and stability

than those denied care (Foster, 2020). Clinic closures deny access to abortion care which harms

pregnant people and creates gender inequality.

Abortion bans are a form of gender-based violence that disproportionately impacts young

parents experiencing income insecurity. One in four women will have an abortion in their

lifetime (Jones & Jerman, 2019). The majority of people obtaining abortions are in their 20s and

experience low-income (Jones & Jerman, 2019). Nearly half of all abortion patients in 2014 had

a household income at or below the poverty line, up from 27 percent in 2000 (Boonstra, 2016).

Only a quarter of abortion patients have incomes above 199% of the federal poverty le(Jones &

Jerman, 2017). The federal poverty threshold in 2023 is $14,580. Due to insurance restrictions

and limitations, abortion care is an out-of-pocket expense. Most people who have abortions

already have a child who needs to be cared for during their appointments (Jones & Jerman,

2019). People in banned states may need to travel 500 miles or more to reach an abortion

provider.xxviii State-mandated waiting periods add days to the time someone needs to complete

abortion care. Affording the cost of care, travel, and time to obtain an abortion will be a barrier

for more people than we will ever know for certain. Health experts have shown that restricting

access to abortion increases maternal mortality, another crisis where systematic inequalities

across race, age, and class determine health outcomes (Adesomo, 2022; Grossman et al., 2022).

We know who will bear the burden of social and economic inequalities due to abortion bans.

When analyzing the gender-based violence of abortion bans, we must also consider the

needs of people whose bodies are controlled by the government. The U.S. legal system has long

controlled women’s bodies through the allowance of gender-based violence and prohibitions

against full participation in society. Harms from gender inequality are compounded with racism,

ableism, heteronormativity, cis-genderism, and other mechanisms of structural oppression that

get reified in policy. Women of color have endured a long history of coercive government

policies that deny bodily autonomy (If/When/How, 2016; Roberts, 2015; Roberts, 1999). While

the promise of Roe was never actualized for everyone, the loss of national abortion protections

places women of color at risk for disproportionate harm (Taylor, 2022). U.S. immigration policy

is a means of racially and ethnically restrictive population control through forced sterilization,

family separation, and denial of reproductive healthcare (Doriss, 2007; Ghandakly & Fabi,

2021; Stern, 2005). In 36 states, minors must receive parental consent for abortion or obtain an

order from a judge. Judicial bypass to allow minors access to abortion without parental

involvement is likely to end now as the conservative moment seeks to restrict reproductive

decision-making to the family unit. Trans men, nonbinary, gender fluid, and genderqueer people

have abortions. Places hostile to abortion are also hostile to LGBTQ politics (Price &

Brettschneider, 2017). Authorities police disabled people’s bodies to control reproduction, which

denies sexual freedom and safety (Powell, 2022). Reproductive justice demands and requires full

freedom to control our bodies, gender, sexuality, and reproduction (Ross, 2017). Abortion

restrictions, from restrictions to outright bans, deny this necessary freedom.

A Brief History of State Reproductive Violence in Indiana

Indiana has a tradition of being the first state to implement novel and cruel restrictions to

reproductive health. Indiana was the first state to pass a compulsory sterilization law in 1907 for

“socially inadequate persons,” including the “feebleminded,” criminals, and “promiscuous”

women (Ross & Solinger, 2017). Harry C. Sharp, a physician employed by the Indiana State

Reformatory, lobbied for mass sterilization as a “remedy for race degeneration” and pioneered

new methods for vasectomy on 456 inmates under his care (Roberts, 1999). The Indiana

Historical Bureau estimates that 2,500 people in state custody were forcibly sterilized under the

Act. This estimate of abuse does not account for undocumented sterilizations or those performed

outside of state custody. People living in poverty, and on the margins of society, with suspected

intellectual disabilities were evaluated for sterilization by bigoted state doctors earning $3 a

patient (Stern, 2007). The practice of state-mandated sterilization was overturned by Williams v.

Smith (1921) after the Indiana Supreme Court ruled the practice was a cruel and unusual in

violation of the Fourteenth Amendment. The Indiana Sterilization Act was not repealed until

1974 when all state sterilization laws were repealed. While vasectomies should be covered by

health plans as a family planning method, reproductive justice advocates in Indiana have

expressed concerns that the state continues to target people with this service. One Black women

at a meeting I attended in Indianapolis shared her distress at the eugenics movement never

ending Indiana. Her husband had recently received an unwelcomed postcard from the state

advertising free sterilization mixed in with the junk mail. She expressed that she was motivated

to support reproductive rights to ensure the state was not erasing the possibility of Black futures

and the right to decide whether to parent or not. Indiana has a legacy of reproductive coercion

and control that has no place in modern life.

Indiana has been on the vanguard of anti-abortion laws since the proliferation of

statelevel restrictions began in the early 2000s. Anti-abortion laws are designed to erode the legal

foundation of abortion rights and capitalize on the political opportunity of the conservative courts

(Oeding, 2020)xxix. Indiana has followed state-level trends in anti-abortion laws that adopt

movement framing to justify restrictions as pro-woman or in defense of fetal personhood.

Roberti (2021) calls this anti-abortion frame a “love them both” approach. Laws for gestational

limits, informed consent, and waiting periods were justified through myths and misinformation

that falsely assert people have difficulty deciding if abortion is the right choice for them (Arora

& Salazar, 2014; Tobin, 2008). Indiana joined the surge of Targeted Regulation of Abortion

Providers (TRAP) laws that attempted to shift the framing of state focus from controlling

pregnancy to a legitimate state interest in clinic operations. Abortion has been on the Indiana

legislative agenda every session since PCSB was founded in 2015, and abortion rights groups

have sued over these laws every year. Indiana has fiercely defended harmful laws requiring fetal

burial, prohibiting telemedicine, and banning the termination of a pregnancy based on sex, race,

and genetic abnormality. Following the Dobbs decision, Attorney General Rokita petitioned the

Supreme Court to dismiss or reverse cases that relied upon arguments stemming from the U.S.

Constitution. In addition to the above-mentioned laws, Rokita has requested a judicial review of

injunctions on a dilatation and evacuation ban and a notification requirement that alerts parents

when minors receive approval for abortion through judicial bypass. Advocates in Indiana

describe how the aggressive focus on anti-abortion policies is in contradiction to a state that

claims to believe in limited public intervention in private life as “government so small it fits in

your uterus.”

Anti-abortion laws have deadly and devasting consequences for Hoosiers. Indiana was

home to 17-year-old Rebecca Suzanne “Becky” Bell, the first person known to die of an illegal

abortion after the Bellotti v. Baird (1979) ruling that states could require minors to obtain

parental consent before care. Pregnancy Justice (2021) has verified 1,700 women have been

arrested for pregnancy outcomes since Roe. South Bend county prosecutors used the state’s

feticide law to convict Purvi Patel under the accusation that she self-induced abortion. Patel was

sentenced to 20 years and spent three years in jail before her appeal was granted. Patel was not

the first Asian woman in Indiana to be convinced of feticide. In 2011, Bei Bei Shuai was detained

for 435 days and charged with first-degree murder after a suicide attempt during her pregnancy.

Michelle Goodwin served as an expert witness in Shuai’s defense before writing her book on the

criminalization of motherhood. Goodwin (2018) writes in Policing the Womb that

“legislators, prosecutors, and doctors claim their interventions are about saving babies and

preventing disabilities; yet, pregnant women caught in the criminal grips and gaze of the state are

almost exclusively poor and of color, like Bei Bei Shuai, Paula Hale, Regina McKnight, Purvi

Patel, and many others.” Anti-abortion laws and feticide laws operate in the same way to restrict

and punish pregnant people.

The Patel and Shuai cases demonstrate how, in Crenshaw’s (1990) words, “the

experiences of women of color are frequently the product of intersecting patterns of racism and

sexism.” The politicization of abortion operates much like the politicization of domestic violence

described by Crenshaw (1990) to obfuscate and isolate the political interest and experiences of

women of color. As the advocates of domestic violence in Crenshaw’s (1990) work worried that

statistics showing violence occurring in minority communities could be interpreted as this issue

is a minority problem, the selective prosecution of women of color for feticide reinforces

stereotypes that justify discrimination. Roberts (1999) explains that stereotypes of Black

motherhood perpetuate the idea that “unregulated Black reproduction” is dangerous and that U.S.

social policy surveils and restricts reproductive freedom in communities of color to this purpose.

In these ways, laws that punish pregnant people act to reinforce gender and racial subordination.

Abortion bans punish pregnant people by restricting access to care and these bans have increased

requests for self-managed abortion provided by telemedicine (Aiken et al., 2022b). Ken Cotter,

the St. Joseph County prosecutor who oversaw Patel’s sentencing, was reelected to office in May

2022. Cotter has avoided advocate demands not to use the power of his office to criminalize

pregnancy. Thirty-eight states have similar feticide laws to Indiana, and advocates were primed

to defend against any possible prosecution of pregnant people in the proposed abortion ban.

The Political Opportunity of Dobbs

The Dobbs decision provided a new gateway to political violence for anti-abortion

lawmakers. Abortion became briefly illegal in Indiana when Senate Bill 1 (SB1) went into effect

on September 15, 2022. The law requires the Indiana Health Department to terminate the

licensure of all abortion clinics and restrict care to hospitals. SB1 prohibits abortion except as a

lifesaving intervention for the pregnant person, in cases of lethal fetal anomaly, or when

pregnancy is a result of rape or incest. Indiana currently threatens doctors with felony charges

that have a penalty of 12 years in jail for performing an abortion outside of legal requirements.

SB1 would further require the state medical board to revoke the licensure of any doctor found in

violation of the law. While the Indiana Republicans in the General Assembly touted the bill as a

victory to protect life, anti-abortion groups across the state called the bill “weak and troubling”

for not achieving a total ban with stricter enforcement and punishment measures. These

movement demands are cruel and out of touch with the people of Indiana. Opinion polling during

the SB1 debate showed that the majority of Hoosier oppose criminal action being taken against

pregnant people, physicians, or people who support those obtaining abortion care (Patterson,

2022). The supermajority of Republican lawmakers running Indiana had the opportunity to

become the first state to ban abortion following Dobbs. The Indiana ban was in effect for one

week before a court injunction allowed abortions to resume.

Indiana is a case study for political action to ban abortion following Dobbs in a state

without a trigger law. Given the stakes, all eyes were on Indiana, and political analysts expected

an abortion ban to be brought in a special session of the legislature. I was monitoring the

proceedings from Boston and in constant communication with advocates on the ground and our

allies at the statehouse. Special sessions are uncommon, and none of us were confident about an

expected timeline or if this legislative process would provide opportunities for action similar to a

regular session. The special session was legally required to start on July 6 per the Governor's

declaration and was limited to 40 days (August 14). We were uncertain how long the process

would take, given the rarity of special sessions in the state. Since instituted in 1851, Indiana has

called 35 special sessions, and, the stated purpose of nine of the eleven called since Roe were to

complete the budget.

Special sessions are traditionally used to take care of unfinished business that has already

gone through public debate. These are matters that are essential to keep the government

operating smoothly. Special sessions are not a place for equitable policymaking to ensure the

public interest is accounted for and consequences are carefully considered. A speedy session

required a policy that had been prefabricated for these exact circumstances by those without an

interest in a compromise for political contention. We knew the Indiana-based lawyer for the

National Right to Life Committee (NRLC), Jim Bopp, had been circulating model state

legislation that “recommends prohibiting abortion except to prevent the death of the pregnant

woman” (Bopp, 2022). We all assumed the Indiana GOP would be moving forward with the

NRLC language without much editing to speed through the process and deliver on promises

made to their supporters. The clinic planned one last weekend of operations on July 15 and 16

because you cannot schedule people for a timely procedure if you cannot guarantee they will

receive care.

Indiana lawmakers did not act in good faith when calling the special session. Indiana has

part-time legislators, which is common among states (80%). The Indiana General Assembly

starts business in mid-January and adjourns after 30 nonconsecutive working days (by March 15)

on even years and 61 nonconsecutive working days (April 30) during odd years. Only the

Governor has the authority to call a special session for business outside the legislative calendar.

Indiana lawmakers needed the support of the Governor to call them into session to ban abortion.

Governor Holcomb managed to conceal expectations poorly that Roe would be overturned by

issuing an order for a special session two days before the Dobbs decision. Rather than admit the

special session would be about abortion, Holcomb asked the General Assembly to address

inflation by returning $1 billion in state taxes – about $225 per Hoosier. The state Constitution

allows lawmakers to consider their own agenda once called into session, and economic relief was

not their top priority. None of the tax relief bills proposed in the 2022 regular session were

enacted which indicates that the General Assembly had concluded a robust legislative process on

fiscal policy. The revenue refund bill that was passed in the special session included several

provisions for reproductive and sexual health. The theme of the special session was reproductive

health, even if Holcomb’s office tried to avoid accountability for launching the process.

The state did not have an urgent mandate to ban abortion due to external factors that

might shift national policy before the legislature could meet. The 116th Congress had already

failed to pass abortion protections to prevent trigger bans after Dobbs. The pressure to rush an

abortion ban was generated by internal state factors to capitalize on new political opportunities

and fulfill promises made to the anti-abortion movement. As long as partnerships with

antiabortion movement groups can offer state legislators power, these policymakers will continue

to pass laws that ban and restrict care regardless of the quality or quantity of studies and stories

produced showing that abortion is essential (Castle, 2011; Reingold et al., 2021; Roberti, 2021).

The Indiana General Assembly may have felt pressure to take action on abortion before the

November elections. All Indiana House Members and half of the Senate were facing reelection.

The state-wide abortion ban did not change party composition in the midterm elections. Indiana

Republicans lost one seat in the State House and gained a seat in the State Senate to maintain a

strong supermajority.

The expedited timeline of the Indiana abortion ban demonstrates how states will commit

anti-democratic violence to end abortion (Table 5: Indiana abortion ban timeline). State

lawmakers chose to hold a special session for the abortion ban rather than put the issue through

the regular legislative process, referendum, or amendment process. The Indiana General

Assembly colluded with the Governor to pass the abortion ban under the least democratic

process available to subvert mass mobilization and civic engagement. This process demonstrates

how Republican lawmakers in Indiana had planned for the opportunity of Dobbs and recognized

the need to suppress public participation to pass the ban.

The pace at which the ban progressed left many feeling that democracy had been denied.

The legislative process started in earnest on July 25, when Senator Glick (R-13) introduced SB1,

an Act to amend the Indiana Code concerning health.xxx Movement organizations mobilized

supporters and sustained protests during the special session. Hundreds assembled to testify during

the first public hearing on the bill in the Senate Committee on Rules and Legislative Procedure.

Of the three dozen who were able to testify at the first reading, not a single person was in favor of

SB1 (Chapman, 2020). Advocacy framing fell into familiar patterns, with antiabortion speakers

demanding a total ban on the basis of morality while those speaking in favor of the status quo

covered the spectrum of reproductive health, rights, and justice reasoning. Proabortion chatter on

and offline emphasized the number of people who had traveled to Indianapolis to testify and were

denied the right to speak as the proceedings quickly reached capacity.

Actions from General Assembly members indicated early nonpartisan disapproval of

SB1. Policymakers introduced 148 amendments, held 55 roll call votes, and provided 13

supplemental documents for SB1. Many of the amendments were from Democratic

representatives to provide clarity to the bill or promote the party agenda.xxxi Indiana Democrats

received national support for their efforts. The White House deployed Vice President Harris to

meet with minority leadership and galvanize national attention. While national figures in the

Republican party did not publicly visit Indiana, Mike Pence lives in an enclave outside the

statehouse and would have an immeasurable private influence on the ban due to his deep

relationships from his time in Indiana politics. Someone as wealthy as Pence can afford to

provide themselves and their family with full spectrum reproductive care free from state

interference. Abortion bans are most harmful to low-income people and those most impacted by

the law should be centered in policymaking.

Republican lawmakers continued to be divided on the SB1 headed into the final vote.

Senator Mike Bohacek (R-8) voted for the bill to advance to the House and changed his position

after raising concerns that the laws would not allow enough time for rape and incest victims to

access care. Bohacek shared in his testimony against SB1 that his intellectually disabled daughter

could be pregnant beyond eight weeks without anyone knowing. Senator Gary Byrne (R-47)

voted for the bill three times after arguing for a total ban and supporting the failed amendment to

eliminate rape and incest exceptions. Every Senate Democrat voted against SB1 in every vote; in

the final reading, eight Republicans joined them. Bohacek joined the nays.

Widespread disappointment and concerns over the consequences of the bill did not stop

the ban from being passed at a rapid pace. In total, the legislative process for SB1 lasted ten

business days – a week in each chamber. A flurry of activity went on late into the night on

August 5 when the bill passed the House, was concurred in the Senate, and then immediately

signed by the Governor. When asked to respond to critiques of SB1 during the early process,

Senator Glick responded, “am I happy with the bill? Not exactly, nor was I happy when it was

drafted; we’ll bring it to the floor so we can discuss it in detail, and if it’s the will of the body to

kill the bill on the floor — then so be it” (Padilla, 2022). Glick made this comment knowing full

well the chances the bill would be defeated through a vote were slim. The balance of power at

the state house has grown steadily in Republican favor since 1992. Democrats hold 26 fewer

seats in the House and 11 fewer in the Senate than 30 years ago (Putman, 2022). However, the

effort by the minority party to kill the bill was celebrated by advocates who could be heard

chanting outside of closed chambers during floor debate. Democratic lawmakers at every stage

of the legislative process urged their colleagues to drop the bill. They pleaded with the majority

party to move the issue to the regular session when everyone could be heard. Rep. Maureen

Bauer (D-South Bend) made a passionate speech before the final House vote. Rep. Bauer

testified, “you may not have thought women would show up…But people in the state of Indiana

are getting involved in politics as if their lives and futures depended on it. I have seen rallies in

my community of South Bend and Mishawaka places, like Elkhart, Goshen, Osceola,

LaPorte…people are demanding their voices be heard by this legislature…to remain free from

government overreach.” Bauer gave voice to advocates who were unable to participate in the

legislative process.

Reproductive rights supporters in South Bend had limited options for direct action on this

accelerated timeline. Whereas South Bend advocates could employ resourcefulness to respond to

movement violence in novel ways, factors of movement structure and political access limited

how PCSB could respond to SB1. Bernstein (1997) outlines moments of celebration and

suppression experienced by queer rights movements to demonstrate similarly that weak

organization structure and limited access to polity determined movement success. South Bend

advocates do not live close enough to the state house to engage in sustained activities or develop

close relationships with state policymakers. PCSB had also shifted as an organization to focus on

clinic volunteer programs after Whole Woman’s Health opened. We were less involved with state

politics by 2022 and struggling to support the clinic. Planned Parenthood had placed a field

organizer in South Bend starting in 2018 but the role was eliminated during the COVID

pandemic. Local advocates had no substantive connections to state or national groups and these

groups were also understaffed and overwhelmed. The threat of Dobbs laid bare capacity issues

that kept our focus on anti-abortion violence in our community. As volunteers, PCSB advocates

felt their energies were best spent supporting the clinic and abortion seekers. Years of efforts to

stop anti-abortion laws had not generated any success and further demoralized efforts against the

ban. Additionally, social movements have a limited array of repertoires of contention to make

claims against the government that are often repeated (Tilly & Tarrow, 2015). PCSB drew from

the usual repertoires of civic engagement to encourage supporters to send in written testimony,

continue to call their representatives, and if they could make the 300-mile round trip, attend the

protests at the capital organized by the ACLU of Indiana and Planned Parenthood. I relied on my

personal network from my time working in local government to connect with one receptive

representative and gain some insight into statehouse happenings. Our local knowledge and

commitment to abortion care was sidelined from the legislative process because we were not

embedded in the polity.

The Problem with Exceptions

The debate for SB1 centered not on whether the state should ban abortion but rather if a

total ban was politically possible. As the days stretched on without the ban bill being introduced,

we started to hear about discontent at the capitol. A small but vocal minority of GOP lawmakers

were seeking a total abortion ban. Bopp’s model legislation from NRLC banned all abortion

except to “prevent the death of the pregnant woman” or when rape and incest were reported as a

crime. Abortion in Indiana has been banned after 20 weeks gestation since 2011, except if

physicians decide abortion is the only intervention able to save the pregnant person. In debating

the inclusion of exceptions, Indiana lawmakers were challenging legal precedent and social

acceptability that pre-dated Roe.

This analysis of exceptions recognizes the need for exceptions when the only other

political option is a total ban while acknowledging exceptions have problematic aspects and

analyzing their negative consequences. Abortion advocate Laurie Bertram Roberts sums up the

reality of exceptions as “just a way for Republicans to say, ‘Now, now, don’t worry, we’re doing

this ban, but when you need your “good abortion,” access will be there for you,’ but it’s all

bullshit. It won’t be there for you” (Messerly, 2022).xxxii A good abortion is not a moral judgment;

a good abortion is accessible quality healthcare without interference.

Health Exceptions

The Indiana abortion ban provides two health exceptions that allow physicians to

terminate pregnancies when the continuation of the pregnancy results in serious medical risk for

the pregnant person and as a treatment for fatal fetal anomaly. A primary outcome of the debate

to remove exceptions was that advocates were put in the position to defend their inclusion, in

addition to demanding lawmakers vote against the ban. Advocates on both sides were most vocal

about exceptions for the health of the pregnant person and for pregnancy-related rape or incest.

Neither side engaged in substantial discourse on fetal health exceptions.

The inclusion of exceptions to abortion prohibitions can be traced to the late 1950s when

the American Law Institute (ALI) began proposing legislation in states that criminalized abortion

to permit termination in circumstances of severe fetal abnormality, rape or incest, and threats to

women’s health (Ziegler, 2020). While Roe should have ended the exception compromise by

removing state-level restrictions prior to viability, advocates were forced to hold the line at

exceptions as the prolife movement eroded abortion rights (Goodwin & Ziegler, 2021). A health

exception has been included in every version of the Hyde Amendment, a budget rider that has

restricted federal funding of abortion care since 1977 (CRS, 2022b). Public opinion consistently

shows favor for lifesaving exceptions (Saad, 2018). But lawmakers and the courts have flipped

on the issue. In Stenberg v. Carhart (2000), the Court ruled that total bans on certain methods

used later in pregnancy were unconstitutional without exceptions for the life of the mother.

Seven years later the Court reversed course in Gonzales v. Carhart (2007) and no longer required

bans to include health exceptions. According to Donley and Lens (2021) “Carhart entrenched

into law the idea that women need protection from abortion procedures.” This shift in the Court’s

approach to life exemptions reflects a session when Justice Ginsburg was the sole woman on the

bench. Justice O’Connor left the Court between Carhart I and Carhart II and was replaced by

Justice Alito. While SB1 passed with exceptions, nearly identical to the early ALI proposals, anti-

abortion lawmakers in Indiana vowed to introduce a total ban in the 2023 session. If a total ban

were to pass in Indiana, abortion rights advocates might have a stronger case for litigation on a

Section 1 argument as the Indiana Constitution provides for the right to life, safety, and

wellbeing. Dying because of an abortion ban is a denial of life by the state.

Lifesaving exceptions for the health of the pregnant person may seem like a common

sense policy but in reality, these policies create a new set of challenges. These exceptions require

that physicians decide if abortion is the only intervention able to save the pregnant person. There

is no standard practice among medical professionals to determine what “lifesaving” means, and

each hospital system has its own standard of practice (Harris, 2022). Medical professionals are

put in a harmful position to decide how close to death people need to be to qualify for a

lifesaving abortion. Physicians practicing under abortion bans must weigh legal limitations

before acting and providing medical care. Doctors, especially abortion providers, are profoundly

motivated to act in the best interest of their patients within the narrow confines of the law

(Freedman, 2010; Joffe, 1996, 2010). The early ALI statute reforms were championed by

physicians to improve health by reducing abortion-related fatalities and providing a pathway for

psychiatric justification of care at a time when state-level criminalization limited options. Ziegler

(2020) points to a study that found nearly half of all abortions performed in major hospitals in the

1960s were considered psychiatrically indicated. On its face, it’s unclear whether the Indiana

abortion ban would consider abortion for mental health a lifesaving intervention. Yet, people who

have abortions often consider the experience lifesaving for a multitude of reasons beyond

medical. Since the Texas abortion ban in September 2021, a Nexis Uni search returned 63

instances of the phrase “abortion saved my life” in U.S. news sources that speak to the

alleviation of physical, sexual, psychological, and economic harm. Similar examples can be

found in the hundreds of entries on shoutyourabortion.com or other abortion storytelling

platforms. Abortion bans exclude the many reasons abortion is lifesaving.

Healthcare Advocacy.

Health experts are generally in favor of lifesaving exceptions and were forced to defend

this position as the abortion ban progressed at the statehouse. One of our first local indicators of

political support for a total ban was criticism in response to our local health department’s

position on exceptions. The St. Joseph County Department of Health (2022) received public

criticism after releasing a response to growing questions about the Board’s position on the

proposed state-wide abortion ban.xxxiii Indiana is ranked 3rd worst in the nation for maternal

mortality and pregnancy-related deaths for Black women are three times higher than for white

women. The Health Department stated that “women, their partners, and families, and medical

professionals must maintain the authority to make the judgment surrounding the need for the

termination of a pregnancy with exceptional circumstances to protect the lives of women and

prevent an increase in maternal morbidity and mortality." Although this statement was framed

conservatively by the Board to recommend exceptions to the abortion ban within clinical

settings, a former board member and anti-abortion leader refuted the authority of the Board to

hold this position. Local media attention entertained this manufactured controversy by running

the story and publishing an interview promoting the anti-abortion position (Peterson, 2022).xxxiv

As examined more in the repertoires chapter, discourse on abortion access is decentered time and

again from real harm by restrictions to political debates that exclude people with the capacity for

pregnancy – or experts in reproductive health.

Medical associations in Indiana had a variety of responses to SB1 that left many

advocates wanting. Dr. Daniel Elliott, Indiana chapter President of the American College of

Emergency Physicians, testified on the first day of SB1 hearings. Despite questioning from both

sides, he failed to take a stance on the bill beyond saying his organization supported the current

language that protects physicians from criminal charges when providing emergency care to save

the life of a “mother” (Hearing on SB1, 2022). Motherhood is not a medical condition; this is a

social category that has expectations, exclusions, and implications. LGBTQ advocates are

concerned pregnant men could be excluded from this narrow legal language that could also

restrict surrogates from this right. The protection of physicians from prosecution when

intervening to save the life of the pregnant person was also a concern for the Indiana Hospital

Association and Indiana University Health. A physician shared with me that internal struggles to

craft a position on the abortion ban are ongoing at the Indiana Academy of Family Physicians.

Responding to the void of organizational leadership, individual medical professionals

spoke out against SB1 at significant professional and personal risks. Dr. Caitlin Bernard became

the face of Hoosier physicians against the abortion ban. She sounded the alarm nationwide when

she publicly shared her experience providing an abortion to a 10-year-old rape victim from Ohio.

The child had to be transported to Indianapolis for care as the Ohio abortion ban was in effect at

the time. South Bend clinic workers have fond memories of Dr. Bernard, who was one of their

first doctors on rotation. Dr. Bernard was forced to cease traveling for work after a kidnapping

attempt on her young daughter by anti-abortion operatives. Right to Life Michiana has since

removed Dr. Bernard from the website after multiple news outlets reported on their “Local

Abortion Threat” page. Following her outspoken advocacy against SB1, Dr. Bernard was

targeted by the state. Dr. Bernard is now embroiled in a number of legal disputes with Indiana

Attorney General Todd Rokita, who intends to revoke her medical license. Rokita opened an

investigation into Bernard following the news coverage claiming she did not fulfill her duty as a

mandated reporter, which was found immediately found false. The Indiana Department of

Children’s Services and Department of Public Health confirmed Dr. Bernard submitted the

required reports within the three-day statute. Dr. Bernard also reported the case to Ohio

authorities, where the child resides. Rokita continues to use the power of office to harass Dr.

Bernard for performing a legal abortion on a child rape victim that, as President Biden remarked,

“maybe saved her life.” Dr. Bernard’s experience demonstrates the complexity of care not

captured in the law, as abortion can straddle many exceptions yet still be legally challenged.

Fetal Health Exceptions.

Abortion exceptions for fetal health must affirm disability rights and justice. Strategies

for abortion rights have not always aligned with reproductive justice, and these failures to

include the human rights of all persons have echoing damage (Ross & Solinger, 2017). Not all

early justifications for the ALI exceptions were health-promoting, and the anti-abortion

movement has ceased arguments that perpetuated harm against disabled people (Powell, 2022;

Ziegler, 2017). A horrific example can be found in a 1967 Administrative Law Review by

Indiana Law Professor Robert Force that argues exceptions for fetal abnormalities are necessary

because “many infants are forced to suffer throughout their blighted lives, a burden to

themselves, their families, and to society.” Ziegler (2017, 2020) provides historical context to

this dehumanizing viewpoint. She proposes that abortion for fetal health reflects the fears of

expecting parents as congenital disabilities from medical malpractice and environmental hazards

were on the rise just as technology to diagnose in utero became more effective. The abortion

rights movement stepped away from advocating for disability-selective abortion following Roe,

but anti-abortion groups continued to connect abortion with eugenics to mobilize support and

gain political momentum (Ziegler, 2017). Advocates in South Bend witnessed this framing of

abortion as disability-selective eugenics during a rezoning hearing to allow a Crisis Pregnancy

Center to move next to the clinic. A Council Member changed his vote from recognizing the

proximity of a CPC and abortion clinic would be a public safety concern to advocating for the

services provided by the CPC to prevent abortion. The Member justified his vote in favor of the

CPC by sharing how a doctor had recommended his wife terminate their last child after fetal

abnormalities were detected. Advocates had not prepared for this possibility but should have

given local groups had used this framing before to justify abortion denial and reproductive

coercion.

Legislators in Indiana passed a ban on abortion for genetic abnormalities in 2015 as

disability-based bans were considered nationwide. Disability-rights scholar Robyn Powell (2022)

argues that such laws have a “false pretense” as they do not address real disability-related needs

such as access to health care, including abortion, freedom from sexual violence, or

discrimination in pregnancy and parenting. Furthermore, Whelan and Goodwin (2022) argue that

“opponents of abortion focus on hypothetical disabled fetuses at the expense of those who

actually bear the brunt of anti-abortion laws: pregnant persons with disabilities.” Rhetoric

without reconciliation or rights will continue to cause conflict between disability and abortion

rights discourse. Fetal health exceptions were not considered until the second week of SB1 when

Representative Davisson (R-73) brought amendment 25 to the House floor to define health

exceptions for lethal fetal anomaly and medical risk to the pregnant person.

Sexual Violence Exceptions

Exceptions for pregnancy resulting from rape or incest became a critical issue of debate

during SB1. An amendment brought by Senator Mike Young (R- Indianapolis) to remove

exceptions for rape and incest failed after two hours of debate with a vote of 18-28. On the

Senate floor, Young framed the amendment as “exceptions equal death” and argued that SB1 was

too lenient. A repeated talking point among Indiana conservatives was that SB1 left a loophole

for women to lie about the circumstances of conception. The myth that “women lie about being

raped” has a long history that is perpetuated by our legal system and media (Edwards et al.,

2011). Research continues to prove that false or unfounded rape accusations are rare (Belknap,

2010). Abortion bans are already an extremist position and taking an even further position to

remove bans moves the needle of compromise. Advocates needed to defend that no one would lie

about rape to have an abortion, and strategize how to reduce secondary victimization and trauma

for a law that would close every abortion clinic in Indiana.

Senator Young’s concern that women will lie about rape to access abortion exceptions is

easily disproven using government accountability reporting. Public insurance information

provides insight into how many abortions are reported to the state as a result of sexual crimes.

Medicaid programs are required to cover abortions when pregnancy is the result of rape or incest,

but this funding is rarely spent. Abortion exceptions for sexual violence are practically

impossible to receive in states hostile to care. Dennis and Blanchard (2013) found that providers

in states that restrict abortion were more likely to experience claim denials than in states with

fewer regulations. According to a GAO investigation, Indiana has a record of not exercising the

rights of Hoosiers to access abortion funding exceptions for Hyde exceptions. On average,

Indiana only covered 2.6 abortions a year through federal Medicaid funding between 2013 and

2017 (Yocom, 2019). Senator Young’s amendment to remove exceptions was more rhetoric than

a quantifiable public problem, but abortion abolitionist frameworks leave no room for

evidencebased policy analysis. Senator Young’s position is that any abortion exception is murder.

The reproductive justice position is also absolutist but relies on an equity lens rather than a

punitive outcome. Forcing survivors to carry a pregnancy to term is impossibly cruel. No one

should have to prove to the state they deserve an abortion because everyone deserves access to

all pregnancy options.

SB1 uses the criminal code to define abortion exceptions for rape and incest. This

language limits how exceptions are exercised by victims and survivors by narrowing defining

violence to specific criminal acts. Sexual violence and coercion circumstances rarely meet the

criteria of criminal definitions. Indiana has four legal circumstances of rape: 1) compelled by

force or threat of force, 2) the other person is unaware of sexual intercourse, and 3) the other

person is mentally disabled or deficient. The fourth circumstance is an attempt to address issues

surrounding a loophole in the law for marital rape. The criminal code was updated in 2022 to

expand the definition of rape to include the "disregarded the other person's attempts to physically,

verbally, or by other visible conduct refuse the person's acts” (Public Law 92). This definition of

rape continues to place the burden on victims rather than define violence as the lack of consent.

Pregnancy resulting from rape is more likely to occur in intimate relationships (Basile et al.,

2018). These instances of partner violence may not be perceived as adhering to the strict criminal

circumstances for abortion eligibility. For example, someone experiencing partner violence may

not indicate a lack of consent through physical, verbal, or visible means because they fear how

their partner may respond to sexual refusal.

SB1 lacks clarity in many aspects, and this is most highlighted in the void of sensitivity

and thoughtfulness the law provides to those who became pregnant from sexual violence. SB1

makes provisions that people who became pregnant as a result of rape and incest may seek an

abortion up to 10 weeks post-fertilization. This time limit applies to all instances, even those

involving child abuse or a person with a cognitive disability that meets the category 3 standard.

The law does not specify what actions pregnant people need to take to exercise their right to

abortion under sexual violence exceptions. The first draft of SB1 required pregnant people to

provide their physician with an affidavit attesting to rape or incest that carried penalties of

perjury if proven false. This requirement would have encouraged investigations into self-reported

rape-related abortion care and further victimized rape survivors. The final law removed the

criminalization aspects but still requires physicians to certify in writing the abortion was

performed under the rape or incest exception.xxxv

The Indiana abortion ban offers no assistance for sexual assault victims. In collaboration

with colleagues at Heller, I developed materials for PCSB to advocate for changes to SB1

modeled after existing victims' support services. These recommendations included processes for

victims to avoid out-of-pocket expenses through insurance claims, Crime Victim’s

Compensation Fund or Services, or Training, Officers, Prosecutors (STOP) grants through the

VAWA. While these recommendations were not prioritized during the SB1 development,

material support will become a more pressing issue if the ban goes into effect. Republican

lawmakers did consider how the state budget could prioritize birthing outcomes under the

abortion ban. SB2(ss) created the Hoosier Families First fund that appropriated $45 million from

the state general fund to support a variety of family planning services for adults. Abortion

advocates were alarmed by a provision in SB2 to increase funding for crisis pregnancy centers

that already receive millions in state funding diverted from the Temporary Assistance for Needy

Families program (Polcyn et al., 2020). Hoosier Families First fund will “provide funding to

providers of maternal support services and services to help pregnant women and their families

bring their pregnancy to term.” Organizations affiliated with abortion clinics are excluded from

receiving funding from the Hoosier Families First fund. At the time of writing, the Hoosier

Families First has not released a budget or request for funding proposals.

Barriers to Accessing and Providing Abortion Ban Exceptions

Finding a physician will be the primary and most significant barrier for people trying to

exercise legal exceptions to the abortion ban. SB1 is very clear on who can and cannot provide

abortion care. Indiana has long required that physicians are the only medical professionals

allowed to perform abortions or dispense abortion medication that must be provided in person.

SB1 revokes all clinic licenses and restricts abortion care to acute care hospitals or ambulatory

outpatient surgical centers (ASC) owned by hospitals. xxxvi Since the state began reporting on the

location of facilities in 2014, state-issued termination reports name seven hospitals that have

provided abortion care in Indiana. All of these facilities are located in southern Indiana, with six

located in Marion county (Indianapolis) and one in Warrick county (boarding Kentucky).

Hospitals are not prepared or able to expand abortion services to care for the entire state. The six

Indiana hospitals that provided abortion care in 2021 accounted for 133 abortions, 1.5% of total

terminations state-wide (Chawla, 2022). The ban is designed to severely limit the circumstances

people are eligible for abortion and who can supply care. Hospitals will be solely responsible for

in-state legal abortion provisions. With the exception of Indiana University (IU), I have not

found any instance of hospitals announcing plans to ensure abortion access for the limited

circumstances allowed under the ban. IU School of Medicine requires residents to complete

abortion training as part of their gynecological education. IU is currently demonstrating its

commitment to care by sending doctors to Illinois to learn since they are unable to teach

effectively under the ban (Doran, 2022). Echoing concerns that the abortion ban will have a

chilling effect on labor made by large employers such as Eli Lily, medical program directors at

IU are concerned the ban will deter their ability to retain and recruit physicians.

Termination reports from the Indiana State Health Department (ISDH) show that

hospitals have taken on a growing role in Indiana abortion care in recent years due to

antiabortion policy. In 2014, only 33 abortions, 0.4% of all terminations, occurred in a hospital or

surgery center. The number of hospital-provided abortions in Indiana remained under 0.6% until

2019 (Chart: Terminations reported in Indiana by hospital facilities, 2014-2021). According to

the most recent report from the ISHD, hospitals provided 1.6% of terminations in Indiana in

2021. While this may seem like an insignificant change, hospitals only provide about 3% of

abortions nationwide (Jones et al., 2022). An increase of 100 abortions provided by hospitals

from 2014 to 2021 may reflect policy changes as growth increases following the 2019 passage of

HEA 1211, the “Abortion Matters” law that banned dilation and evacuation (D&E) procedures

except as a lifesaving measure. D&E is the most common method for second-trimester

procedures in the United States, and forty years of medical research have shown that D&E

procedures are safe and effective (Grossman et al., 2008; Kapp & Lohr, 2020). The U.S. District

Court for the Southern District of Indiana blocked the D&E ban from going into effect after the

ACLU on behalf of Dr. Bernard successfully argued the law would place an undue burden on

abortion patients.xxxvii AG Rokita successfully petitioned the Court to overturn this injunction in

July 2022 and enact the ban on D&E procedures except when the continuation of the pregnancy

would present a serious health risk.

Abortion later in pregnancy primarily occurs in hospitals. The ISDH began reporting in

2019 that all terminations beyond 14 weeks’ gestation occurred in acute care hospitals (Chawla,

2022). PCSB tracking indicates that no stand-alone clinic in Indiana has been providing abortion

care beyond the first trimester since at least 2015. Abortions increase in medical complexity and

cost as pregnancy progresses. For these reasons, abortion clinics are also not equipped to

determine, provide, or legally defend if a person is in a condition critical enough to receive a

lifesaving procedure under abortion bans. South Bend residents are familiar with traveling long

distances to reach reproductive health care. Advocates in South Bend have traveled to

Indianapolis for high-risk births and Chicago for fertility treatments. Restricting abortion care to

hospitals adds to this burden by placing long distances between people and essential

reproductive health care.

In an effort to further restrict abortion access, lawmakers in Indiana may target public

hospitals in the next legislative session. The facilities responsible for the majority of abortions in

hospitals are part of public, not-for-profit systems; four are owned by Indiana University. xxxviii

Universities are increasing targets of anti-rights agendas with a proliferation of legislation to

restrict freedom of information and access to education on a number of “culture-war” issues,

including voting, identity, and abortion. This fall, the University of Idaho made national news

after issuing confusing guidance for employees on how to comply with state laws regulating

abortion and contraception. The university told employees that they risked losing their jobs or

criminal charges for promoting, advertising, or giving abortions while on the clock. The guidance

was based on Idaho’s No Public Funds for Abortion Act (2021), which prohibits state funds from

being used to promote or perform abortions. Idaho had passed a trigger law several years prior

that banned abortion across the state in August following Dobbs. This law created a

“gag rule” on public employees. The law specifically states that no public school tuition fees can

be used to pay for abortions or counsel in favor of them. In response, the Department of

Education will be issuing new guidance and resources to universities emphasizing they’re

obligated under federal law to “protect their students from discrimination on the basis of

pregnancy, including pregnancy termination.”

Indiana lawmakers could pass a similar law to Idaho that prevents the state university

system from providing abortion care, teaching provision, or discussing reproductive health

options with the 90,065 students enrolled on its campuses. IU hospitals performed 47% of all

acute care hospital terminations in the state during 2021 and accounted for four out of six

hospital providers (Chawla, 2022). Indiana lawmakers attempted to pass House Bill 1336 in 2013

to ban abortions at IU Hospital teaching facilities. This bill never left committee but its sponsor,

Jeffrey Thompson (R-28), is still in office. IU Medical is one of the few places in the state that

provides care to trans youth. Given the connections between abortion and genderaffirming care,

it’s likely Indiana lawmakers would combine these issues into a single policy to restrict gendered

care at public universities.

Indiana Abortion Ban Litigation and Injunctions

In the absence of Roe, legal arguments must rely on state constitutions and laws. The

Indiana abortion ban was in effect for a week before a judge granted a preliminary injunction. A

group of Indiana abortion providers, an all-options pregnancy resource center, and the ACLU had

filed a lawsuit against SB1 in the time between the bill signing and law enactment. The case

Planned Parenthood Northwest v. Members of the Medical Licensing Board of Indiana was filed

in state trial court on August 31, 2022. Plaintiffs in this lawsuit argue that the abortion ban

violates the Indiana Constitution under the right to privacy and equal privileges protections.

Specifically, the plaintiffs' reasoned that restrictions on hospitals’ ability to offer abortions

violated the Equal Privileges and Immunities Clause of the state’s constitution, denying clinics

the right to practice, and amounting to business discrimination. Indiana circuit court Judge Kelsey

Hanlon decided the plaintiffs’ arguments, in this case, merited a pause on the ban and allowed

abortions to resume.

The Indiana Supreme Court heard opening arguments in the constitutionality on January

19, 2023. This hearing was streamed online and I watched it live. The State, represented by

Solicitor General Thomas Fisher, argued this case merits a limitation of judicial powers in favor

of the legislative will. Fisher further contends that abortion clinics do not have standing to claim

direct injury from the abortion ban. The Justices were interested in probing the state authority to

implement a total ban, to which Fisher admitted exceptions for the life of the mother were most

likely protected by the state constitution. Kenneth Falk represented the Indiana ACLU. Falk

defended the third party standing of clinics to make claims on behalf of patients, in addition to

the injury the abortion ban would cause their businesses. The Justice’s questions for Falk

centered around the scope of their decision. If the Indiana Supreme Court ruled that the state

constitution provided the right to abortion to overturn the ban, would this right also overturn all

other state-level abortion laws? Falk advocated that the Court reverse the ban and restore the

status quo before SB1 was passed (Table 4: Indiana Abortion Regulations before September 15,

2022). Falk ended his arguments by reiterating how abortion bans harm women. Fisher’s rebuttal

centered on the Roe era as an anomaly in Indiana’s legal history and the abortion ban restores the

law to the Founder’s intent. The Court has yet to set a date to rule on the appeal. This case does

present a procedural issue for the Court. The Justices asked both sides if they should rule on the

entire case or restrict the appeal to the injunction status. Advocates are hoping a lengthy court

process will extend the injunctions for the possibility of federal progress to restore national

rights. Every day the injunction is in place is a day that abortions can occur in Indiana.

A second lawsuit against SB1 was filed on September 8, 2022 by the ACLU on behalf of

Hoosier Jews for Choice. The plaintiffs in the case Anonymous Plaintiffs 1-5 v. Individual

Members of the Medical Licensing Board of Indiana argue that abortion is protected under the

Indiana Religious Freedom Restoration Act (RFRA). To justify abortion rights under RFRA, the

ACLU contends that “Indiana’s RFRA law protects religious freedom for all Hoosiers, not just

those who practice Christianity.” Marion County Superior Court Judge Heather Welch agreed

“substantially burdens the religious exercise of the plaintiffs” and granted another injunction

against the ban on December 3, 2022. No further action has occurred on this case at the time of

writing.

Advocates in South Bend relish the irony that the religious freedom law in Indiana is

being used to justify abortion rights after staging protests against the law. RFRA is widely

viewed by South Bend advocates as an anti-LGBTQ law in response to national marriage

equality. Johnson Hammersmith (2016) argues that Indiana’s RFRA was passed with intent to

discriminate on individuals based on sexual orientation due to its scope, timing, and lack of state

protections. Twenty-one states passed RFRA laws following the ruling in City of Boerne v. Flores

(1997) that stated the religious freedom act signed by Clinton in 1993 only applied to the federal

government. Indiana’s law goes beyond the national law by allowing businesses to use RFRA as

a defense against the private lawsuit (Johnson Hammersmith, 2016). Indiana was one of two

states to pass an RFRA law during the 2015 session when 16 states proposed bills between the

overturning of the Defense of Marriage Act (DOMA) in United States v. Windsor

(2013) and the guarantee of marriage rights in Obergefell v. Hodges (2015). Civil rights law in

Indiana does protect against the discrimination of people based on their sexuality or gender

identity. Several Indiana cities had ordinances declaring LGBTQ protected class provisions when

RFRA was enacted. LGBTQ community members and allies in South Bend, including Mayor

Pete, were concerned the new law would preempt the local human rights ordinance.

The abortion lawsuit is the first real test of RFRA after contention from both sides has

attempted to clarify the law. Indiana did not repeal RFRA despite widespread criticism, protest,

and boycotts. The following year Pence faced backlash from conservative groups when the

legislator clarified that the law could not be used as justification for discrimination. Religious

conservative groups, led by again by Jim Bopp, filed a lawsuit claiming the RFRA violated their

freedom of speech and religion because the law should protect their right to discriminate. The

appellate court in Indiana Family Institute Inc., et al. v. City of Carmel, et al. (2020) affirmed

there was no evidence that these groups had suffered penalties for their actions and have

remained “free, without interference, to express their religious views on marriage and human

sexuality as they always have.” In other words, conservative groups could not prove local human

rights ordinances had caused injury that RFRA may have protected. Indiana is now in a position

to defend against individuals claiming harm by the abortion ban based on rights granted by

RFRA.

Chapter 6

Policy to Advance Abortion Justice

Contentious politics shape abortion care in the United States, and strategies are needed to

increase access and support pro-abortion movements. Cohen et al. (2022) propose it is time to

“put the antiabortion movement into a defensive posture.” Reproductive rights should be

preserved furiously, and access must be expanded with the same vigor. Now is the time for a

broad and bold policy agenda that claws back our rights and builds for just reproductive futures.

Reproductive justice will require actions at all levels. The following recommendations are

organized by local, state, and federal policy actions and priorities. The full force of the state

apparatus must bolster the change-making power of communities. As such, these

recommendations reflect the needs and demands of advocates on the front lines of care and the

reproductive justice movement. Policy approaches to reproductive freedom are varied because

threats to abortion care are many and multiplying. Political opportunity and accountability must

be harnessed across venues to reverse the erosion of abortion access and reduce anti-abortion

violence.

Federal

Presidency

A national strategy to advance reproductive justice in a post-Roe era must contend with

the lack of federal constitutional protections and mounting state-level restrictions. Executive and

legislative responses to the overnight elimination of fifty years of national policy will take time

and creativity to formulate and implement within the limits of federal authority. Executive orders

are tactics employed by Presidents to fast-track policy change during their tenure. A month after

the Dobbs decision, the Biden-Harris administration signed an executive order empowering

Health and Human Services (HHS) to protect reproductive health care services. The order

focused on emergency and pharmaceutical care, including ensuring abortion care as a lifesaving

intervention under the Emergency Medical Treatment and Labor Act (EMTALA). The

administration vowed to use regulatory power and budget resources through the Affordable Care

Act, Title X, FDA, and the Centers for Medicare and Medicaid to protect and expand access to

contraceptives and medication abortion. HHS was instructed to ensure access to accurate

information on family planning services, secure private patient information, and establish an

interagency task force to coordinate additional policymaking. The task force included the

Attorney General’s office to address issues arising from out-of-state patient care. The order did

not address state limitations, declare a public health emergency, or allow abortion on federal

land.

The White House has prioritized access to medication abortion as state regulations close

clinics nationwide. The FDA Mifepristone and Misoprostol regimen authorizes use within the

first 70 days (10 weeks) of pregnancy. People take one dosage of Mifepristone to block

hormones necessary for fetal viability and follow 24-48 hours later with a dosage of Misoprostol

to induce uterine contractions. The use of medication abortion has grown to account for half of

all abortions in the United States (Nash, 2022). Medication abortion is safe, and telemedicine

does not increase risk (Grossman & Grindlay, 2017; Kapp & Lohr, 2020). Home-based abortion

care eliminates the need for in-clinic visits, which alleviates harm from protestors and logistical

barriers like travel and childcare (Kerestes et al., 2021). Direct-to-patient telehealth abortion

expanded during the pandemic to reduce exposure to COVID-19 (Upadhyay et al., 2020). Clinics

will always be needed for surgical procedures and patients residing in the 18 states that restrict

abortion telehealth (Upadhyay et al., 2020). Anti-abortion collective action concentrated at

clinics as the primary site of care with public access. Telehealth threatens the anti-abortion

movement because it affords privacy and broadens the possibilities of where abortion can happen

away from public protest and unwelcome witnesses.

Proactive measures at the FDA under the Biden-Harris administration are expanding

medication abortion options. Until recently, clinics were the only site of prescription drug

dispensation for medication abortion. The Food and Drug Administration permanently lifted the

in-person requirement on abortion pills allowing patients to receive medication by mail or

through certified pharmacies. Patients must still sign an acknowledgment that they have been

informed about the medication, and only specially certified providers can prescribe abortion

medication. In early 2023, the FDA introduced a certification process for retail pharmacies to

dispense abortion pills where legally allowed. Nineteen states require abortion medication to be

distributed in-person by a provider, including Indiana (LawAtlas, 2023). Attorneys General in

states requiring in-person medication distribution have threatened to sue pharmacies that seek

certification to fill these prescriptions directly to customers. Telehealth abortion care is available

in 25 states and D.C. This incremental deregulation will alleviate stress on clinics absorbing

patients from banned states. Whole Woman’s Health scaled up its telehealth capacity to provide

pills to people who can access a mailbox in Illinois, Maryland, Minnesota, New Mexico, and

Virginia. Virtual care increases options for abortion seekers and allows WWH clinics to prioritize

in-person appointments for people traveling from out-of-state or further along in their pregnancy.

The FDA could move to further expand abortion medication access by allowing use within the

first 12 weeks of pregnancy as authorized by the World Health Organization.

Courts

The Dobbs decision demonstrated the power of the Supreme Court to unmake decades of

abortion policy in one day. While concerns over the right to marriage equality and contraception

were questioned in the Dobbs decision, abortion medication has emerged as the most pressing

matter before the courts. Cohen et al. (2023) argue that returning the matter of abortion to the

state will generate a new phase in the courts by prompting “interjurisdictional abortion wars.”

Challenges over the use of abortion medication demonstrate the complexity of abortion policy

without a national standard as conflicting cases seek to accomplish opposite results in different

judicial venues.

The anti-abortion movement is seeking to reverse the FDA approval of mifepristone to

discontinue use nationwide. Health and Human Services is currently defending a lawsuit in Texas

brought by Alliance Defending Freedom, an anti-abortion Christian legal group. The plaintiffs in

Alliance for Hippocratic Medicine vs. U.S. Food and Drug Administration (2023) argue that

FDA “chose politics over science” when approving the use of mifepristone under the Clinton

administration. An audit of the FDA approval process commissioned by Congress to respond to

criticisms similar to this lawsuit found that the agency acted in accordance with their mandate to

evaluate the safety and efficacy of mifepristone (GAO, 2008). It has been twentythree years since

the FDA approved mifepristone for abortion use and fifteen years since the GAO audit found no

issue with the approval process. Numerous scientific studies have since supported the continued

clinical and at-home use of mifepristone to end early pregnancies (Grossman & Verma, 2022;

Henderson et al., 2005). The anti-abortion plaintiffs further argue that the FDA lacks the

regulatory authority to approve abortion medication because “pregnancy is not an illness.”

Separating reproductive health from other health care is an on-going tactic of the anti-abortion

movement. These arguments especially also concerning in light of growing trends in

conservative movements to delegitimize science and medicine.

The Trump appointed judge in this case has the power to remove mifepristone from the

market and force the FDA to start a new approval process that could last years. The notoriously

conservative Fifth Circuit would preside over any appeals further indicating that this case was

intentionally filed in the Amarillo Division to seek a progression of judges favorable to the

plaintiffs cause. Indiana joined 21 other states on an amicus brief filed by State Attorneys

General seeking to end the FDA approval of mifepristone. At time of writing, a decision on this

case could be made as early as February 24, 2023. Abortion advocates are preparing for all

outcomes including advising people how to use misoprostol alone on their own to end

pregnancies when clinics are restricted to in-clinic abortion care using aspiration methods.

Misoprostol is the most common method worldwide for self-managed care as the medication can

be obtained for its primary use in treating stomach ulcers (WHO, 2022a). Misoprostol is more

effective when combined with mifepristone and abortion using misoprostol alone is not approved

by the FDA (Raymond et al., 2019). Forcing pregnant people to obtain abortion outside the

healthcare system through less effective means is not a scientific approach to health policy.

Recent cases filed by a pharmaceutical company and a physician are seeking to reverse

restrictions on abortion medication. GenBioPro is one of two companies in the U.S.

manufacturing mifepristone. They argue that West Virginia’s abortion ban interferes with their

ability to sell a federally approved medication. Dr. Amy Bryant, an OB-GYN at UNC Chapel

Hill, filed a federal lawsuit in North Carolina to end restrictions on abortion medications that

interfere with her practice. Dr. Bryant’s case challenges state laws that go beyond the FDA

restrictions for abortion medication including restrictions for in-person physician distribution of

medication at certified facilities, unnecessary ultrasounds, a 72-hour waiting period, and

statemandated information. The multidimensional legal advocacy essential to restoring

reproductive rights is limited by the current composition of the Supreme Court.

Overturning Roe renewed interest in modernizing the Supreme Court. All of these

abortion medication cases were filed in District Court under the federal judicial system. The

Constitution is vague about the judicial branch of government in comparison to the other two

branches of federal government. The nonpartisan nature of the Court to self-regulate is largely

supported by favorable public perception of the institution. There are no Constitutional standards

for the number of Supreme Court Justices and the size of the Court has been adjusted seven times

by Congress. The Judiciary Act of 2021 (H.R. 2584) would have expanded the court from 9 to 13

seats in response to Trump appointees tilting the conservative sway of the Court.

Expansion is a risk as a few elections could generate even more political imbalance. Epps and

Sitaraman (2019) propose that the Court could counter ideological effects by institutionalizing

partisanship with ten Justices equally allocated to the two dominant political parties. Term-limits

have also been recommended for Justices, however, Epps and Sitaraman (2019) are concerned

mandatory retirement could lead to more politicization as Justices could seek a second career in

Congress or the White House. The possibility of “President Brett Kavanaugh” would produce a

chilling effect on judicial term-limit support for many feminist activists. Trust in the Court and

job approval is at a historical low follow the Dobbs decision (Jones, 2022). The window of

action for Court reform is wide open and the continued contention around abortion makes these

actions urgent to ensure reproductive rights.

Congress

Congress has not been a productive venue for federal abortion legislation. The national

legislative body remains at a decades-long stalemate as neither national bans nor protections

have passed to challenge or codify Roe. Ainsworth and Hall (2010) suggest that Congress has

taken an incremental legislative approach to abortion in response to the public’s nuanced,

ambivalent, or conflicted beliefs. Under this model of strategic incrementalism, Congress is less

likely to be persuaded by movements advocating for wide-sweeping change when the masses

appear content with the status quo under Roe (Ainsworth & Hall, 2010). Incrementalism allowed

the anti-abortion movement to erode Roe through laws that limited access as they built power

through the Republican party to reach the conditions that facilitated the Dobbs decision (Ziegler,

2018, 2022). The stronghold of Congressional incrementalism is demonstrated in the failure to

codify Roe. The Freedom of Choice Act would have established the right to terminate before

viability, or as a lifesaving measure, failed in 1989, 1993, 2004, and 2007. Although Obama had

sponsored the 2007 version of the Freedom of Choice Act, he opted for an “abortion neutral”

health care agenda (Ziegler, 2020). Access to abortion was not protected or expanded by the

Affordable Care Act, allowing states to prohibit private insurance from offering coverage.

Congress had a slim Democratic majority after the 2020 elections, and the party had campaigned

on codifying Roe. The 117th Congress revived the Women’s Health Protection Act (WHPA) to

preempt state laws to guarantee the right to obtain and provide abortion care free from medically

unnecessary restrictions. Versions of the WHPA have been introduced every session since 2013

and died in committee each time. The WHPA passed the House in September 2021 and again in

July 2022 but failed to receive the 60 votes needed to overcome the filibuster in the Senate. A

WHPA bill was reintroduced in the 118th Congress, but this version has little chance of passing

with the new Republican majority.

Congress has taken action to protect abortion clinics and providers from anti-abortion

violence. Federal policymakers responded to escalating and deadly violence against abortion

clinics by passing the 1994 Freedom of Access to Clinic Entrances (FACE) Act. The FACE Act

prohibits intentional property damage and the use of “force or threat of force or…physical

obstruction” to “injure, intimidate or interfere with” someone entering a health care facility (18

U.S. Code § 248). The FACE Act also protects against interference with access to religious

worship places; however, the Justice Department has never found cause to file actions under this

section. During the height of FACE Act prosecution between 1994 and 2000, the Civil Rights

Division convicted 56 individuals in 37 criminal cases and brought 17 civil actions against more

than 100 defendants (Springborn, 2003). However, enforcement of the FACE Act depends on the

Justice Department's appetite to act. Only one FACE Act case was brought during the Trump

Administration. The case United States v. Thomas et al. (2017) charged eleven operatives with

Operation Save America blocking EMW Women’s Surgical Center's entrance and refusing the

Louisville Metro Police Department's order to leave the property (Tulbert, 2017). The reduction

in FACE Act prosecution by the Department of Justice is in contradiction to the rise in violence

towards clinics and law enforcement investigations. The FBI (2020) reported a 40% increase in

FACE Act investigations from August 2019 to January 2020. The FBI linked this finding to the

rise in trespassing, obstruction, and threats of harm reported by clinics through the National

Abortion Federation (NAF, 2020). Pro-abortion advocates in Congress must be mindful of

attempts to erode the power of the FACE Act to protect anti-abortion protestors from prosecution

and continue to pressure the Department of Justice to enforce the Act.

In a post-Roe era, Congress will be testing the scope of its power to enact abortion

legislation. Congressional authority to preempt state laws is limited, and critical social problems

test the bounds of federalism. Issues of abortion, immigration, marriage equality, gun reform, and

covid restrictions all create conflict between state and federal interests. Under the U.S. system of

dual sovereignty, issues related to health, family, and the welfare of citizens are generally

delegated to the state unless subject to the Supremacy Clause (CRS, 2022a). This foundational

principle of the U.S. government establishes that state constitutions and laws are subordinate to

federal authority granted by the Constitution. Arguments that state bans violate the Supremacy

Clause have been used by abortion pill manufacturers, providers, and the Department of Justice.

Dobbs established that the Constitution does not provide the right to abortion, and a national law

would most likely be contested as a violation of state sovereignty. Political and legal avenues for

Congress to codify abortion rights are unlikely unless the reversal of Roe can galvanize support

for a Constitutional Amendment that could succeed where the ERA failed. MacKinnon and

Crenshaw (2019) proposed an Equality Amendment that would incorporate intersectional

frameworks to eliminate gender inequality in the law.

While Congress may not be a readily available venue for restoring national rights,

legislative action to increase access can be pursued. Congress has the Constitutional authority to

enact legislation to address abortion affordability and care across state lines (CRS, 2022a).

Congress has the power to alleviate the burden of abortion costs for millions. The

Spending Clause allows Congress to restrict or distribute federal funds for abortion (CRS,

2022a). The 1977 Hyde Amendment is the main barrier to affordable care by restricting federal

funding of abortion. Ending Hyde would provide abortion coverage for 13.9 million

Medicaideligible women of reproductive age – two out of every ten women in the U.S.

(Salganicoff et al., 2021). Medicaid expansion has helped narrow racial health disparities,

particularly for infant and maternal health among Black and Hispanic women (Guth et al., 2020).

Currently, 16 states provide Medicaid for abortion, and 34% of patients fund care from these

state budgets (KFF, 2019; Roberts et al., 2014). Private insurance offers little financial relief due

to abortion exclusions; 34 states either ban or do not offer abortion services on health insurance

exchanges (KFF, 2019; Roberts et al., 2014). Indiana bans all insurance coverage for abortion.

Eliminating public and private insurance exclusions would drastically reduce economic barriers

for people to afford abortions.

The Equal Access to Abortion Coverage (EACH) Act is a legislative measure to provide

equal access to abortion coverage. The law would require federal insurance to cover abortion and

prohibit federal restrictions on private insurance coverage for abortion care. The Act would apply

to Medicaid, TRICARE, and people eligible for Indian Health or Veterans Services. The EACH

Act extends abortion coverage to federal employees, military service members, and their

dependents. Federal health insurance programs for low-income residents of Washington, D.C.,

people incarcerated in federal prisons and detention centers, and Peace Corps volunteers would

also be expanded to cover abortion. The Biden-Harris administration supports the passage of the

EACH Act and the elimination of the Hyde Amendment (Axelrod, 2021). The Black

Reproductive Justice Policy Agenda further recommends the removal of all cost-sharing for

abortion services and the passage of the Abortion is Health Care Everywhere Act. This Act would

end the Helms Amendment that limits foreign assistance for abortion and fully incorporate

abortion care into reproductive care provided through international aid programs.

The EACH Act unlocks to federal funding to improve health equity domestically and aboard.

The infrastructure of care required to provide logistical, financial, and emotional support

to those traveling to clinics is now reliant on abortion by mail and interstate travel. The

Commerce Clause grants Congress the ability to regulate economic and social activities across

states (CRS, 2022a). The Courts recognized that Congress had the authority to enact abortion

laws under the Commerce Clause, including the Freedom of Access to Clinic Entrances Act of

1994 and the Partial-Birth Abortion Ban Act of 2003. Today, the priority for interstate abortion

care is either getting pills to people or getting people to clinics. The Justice Department clarified

that the Comstock Act does not prohibit the act of mailing abortion medication to places where

abortion is banned (Schroeder, 2022). Congress can secure the current administrative guidelines

of the FDA, Post Office, and Justice Department to protect access to abortion by mail. However,

these rules would not provide legal immunity to those sending or receiving medication with the

intent to violate state law or stop state prosecutors.

Prior to Dobbs, anti-abortion state legislators were concocting ways to avoid

Constitutional oversight and federal authority. Now, Republican state legislators are working on

ways to restrict interstate abortion travel. The President of the National Association of Christian

Lawmakers told Kitchener and Barrett (2022) in the Washington Post, “Many of us have

supported legislation to stop human trafficking. So why is there a pass on people trafficking

women in order to make money off of aborting their babies?” The Justice Department has

warned that abortion travel is protected under the right to interstate commerce. However, judicial

relief could be challenging if these laws are modeled after civil litigation mechanisms like SB8

in Texas. The six-week ban passed in Texas under SB8 in 2021 incentivized private citizens to

sue those who aid others in obtaining an abortion. Nearly everyone involved in the abortion, but

the pregnant person, could be held liable for violating the ban, including clinic staff, rideshare

drivers, insurance companies, or the friend that offers to babysit during the appointment.

Providing advice or information could theoretically be considered libel under SB8. This scheme

removed the enforcement of the abortion ban from state jurisdiction, which prevented advocates

from suing the state to seek injunctive relief. Idaho and Oklahoma soon passed similar laws. As

lawsuits progress on the Constitutionality of these “bounty laws,” Congressional representatives

are taking symbolic creative action. Lizzie Fletcher (TX-07) and Tom Malinowski (NJ-07)

introduced the Stopping Abortion Bounties Act to impose a 100% federal tax on any awards

granted under SB8 or similar legislation.

The extension of anti-abortion lawmaking into civil court is not new. Indiana passed SEA

404 in 2017, allowing parents to seek civil damages against anyone who aided minors in

obtaining an abortion. Oklahoma passed SB1728, the Unborn Person Wrongful Death Act, in

2020, which allowed the “parents or grandparents of unborn children” to sue physicians to

recover damages for emotional or psychological harm following an abortion. These laws have a

chilling effect as personal risk may be too great for people to extend support or care. Justice

Kavanaugh supposes in his concurring opinion in Dobbs that pregnant people have the

constitutional right to interstate travel. However, this suggestion is not law, and no such

provisions were mentioned for those who aid others or provide care.

The future of national abortion policy must account for the novel approaches to harm

enacted by anti-abortion state legislators. The pro-abortion movement must harness the full

potential of Congressional power to push back against the violence of abortion bans. Additional

research and legislative analysis should be conducted to protect the variety of commerce-related

activities surrounding abortion care, such as banking, patient privacy, employer-sponsored travel

aid, and access to information.

State

The legality and provision of abortion are now left to the individual states. Near-total

abortion bans are being enforced in thirteen states. Among states with bans, Alabama, Louisiana,

Tennessee, and West Virginia have constitutional amendments that explicitly state abortion is not

a protected right. These amendments create an extra layer of political challenge to restore access

in the absence of national policy. We know from the era of Roe that access to care in states where

abortion is legal is often a challenge. State regulations create and exacerbate barriers to care that

drain the resources of patients by requiring multiple trips to a clinic, waiting periods, and

extended travel caused by reduced clinic availability (Ely & Murshid, 2021). Pro-abortion

movement resources have long focused on political advocacy to alleviate harm from state

interference (Andaya & Mishtal, 2017). The Dobbs decision has intensified a focus on state-level

policy, politics, and process. Abortion is now decided in fifty-two separate arenas across the

country, each requiring its own approach.

While a national policy of fetal personhood remains the goal of the anti-abortion political

agenda, the movement has an aggressive plan for state-level policy post-Roe. At its most

restrictive, this strategy includes increased ban enforcement to prevent interstate travel, and

punishment for those supporting abortion seekers. Abortion advocates remain attentive to

legislation that funds reproductive coercion and separates families. Anti-abortion lawmakers

continue to pass bills that claim maternal assistance but actually funnel money into religious

groups and CPCs. Mississippi authorized a $3.5 million tax credit for businesses and people that

donate to CPCs in the state. TANF and other welfare programs are essential poverty safety-net

programs that keep families together. Reproductive justice scholar Dorothy Roberts predicts that

an increase in adoption following abortion bans will be due to forced child removal on

conditions of poverty and racism and not the idealized circumstances of voluntary infant

surrender after birth. Justice Alito partially justified the Dobbs decision to maintain the

“domestic supply of infants” for adoptive families. Children are not a commodity. Alito’s

argument relies on the logic and legal framework of chattel slavery to supersede the interest of a

third party over the bond between mother and child (Roberts, 1999). Furthermore, Alito’s

argument conveniently ignores the trauma and ethical considerations of adoption for birthing

parents, relinquished children, and adoptive families (Phelan, 2022). Poverty alleviation dollars

must flow directly to needy families rather than be redirected into programs encouraging and

facilitating family separation.

Banning abortion has allowed conservative state legislators to shift the business of

government to new targets. Republican lawmakers in Indiana are waiting on the courts to decide

the legality of the ban before continuing to legislate on abortion in the 2023 session. The Indiana

General Assembly is prioritizing an anti-trans rights agenda to ban gender affirming care for

youth and restricting birth certificates to binary options for male or female sex. Gender-based

violence includes violence against trans and non-binary people. The ACLU (2023) is tracking

299 anti-LGBTQ bills filed across U.S. state-houses with a geographic concentration of harm

overlapping with anti-abortion politics. Indiana lawmakers proposed 17 anti-LGBTQ bills in

2023 to target healthcare, education, public accommodations, and identification. Gender equity

requires full bodily autonomy in all reproductive, sexual, and gender aspects of life.

Pro-Active State Abortion Policy

Strategies for proactive state abortion rights have been gaining momentum. As of

February 2023, 17 states have laws to protect abortion always, maybe, or sometimes. Colorado,

New Jersey, Oregon, Vermont, and D.C. have codified the right to abortion without state

interference throughout pregnancy. Massachusetts is one of twelve states that permits abortion

before viability or as a lifesaving intervention; and one of eleven states to protect abortion

providers, patients, or both from out-of-state abortion bans. The backlash from Dobbs has been

reflected at polls. Abortion won everywhere it was on the ballot in 2022. Voters in California,

Vermont, and Michigan voted to protect the right to abortion in their Constitution. Kentucky

rejected an amendment to enshrine the state abortion ban. Kansas failed to amend its constitution

to overturn Hodes & Nauser v. Schmidt (2019), which established that the Kansas Bill of Rights

provides a right to abortion. A failed ballot measure in Montana would have imposed criminal

penalties on healthcare providers who did not exhaust all medical options for infants with no

chance of survival. This law would have severely interfered with the patient-physician

relationship, patient privacy, and parental rights at a heartbreaking time. Advocates are

challenged with sustaining this favorable referendum on abortion rights across red and blue

states. Civil rights require a long march, but the longer access is lost, the higher the risk of

abortion bans becoming the new normal.

As the anti-abortion movement chipped away at rights, pro-abortion advocates have

focused on passing state-level abortion protections through comprehensive bills that repeal

archaic restrictions and align state law with health equity standards of care. The variety of

approaches reflects the individual political opportunities of each state to pass what is possible.

Illinois enacted the Reproductive Health Act in 2019, declaring abortion a “fundamental right”

free of government interference and discrimination in reproductive health care decisions. This

statutory protection mirrors full-spectrum language from the reproductive justice movement to

grant the right to autonomous decisions about pregnancy, abortion, and birth. The Act also

included a provision to preempt fetal personhood, declaring that “a fertilized egg, embryo, or

fetus does not have independent rights under the laws of this State.”xxxix Virginia relieved state

burdens on clinics after the passage of the 2020 Reproductive Health Protection Act that repealed

certain TRAP laws, state-mandated waiting periods, and informational counseling for patients.

Virginia and Illinois also expanded the scope of practice for advanced practice clinicians to

provide abortion and insurance coverage. Minnesota took steps to protect the right to

reproductive determination and privacy following Dobbs by passing the PRO Act in late January

2023. While the Act has little effect on current clinic operations, state Democrats prioritized

reproductive freedom after seizing control of both chambers this session.

While Democratic partisan control has sometimes provided an opportunity for pro-active

abortion policy, states with divided governments have forged ahead. The ROE Act in

Massachusetts was passed in its entirety by legislative veto override in 2020. The Act codified

the state right to abortion, removed barriers to self-determination by lowering the age of consent

to services without parental involvement, and in certain circumstances, decriminalized expanded

access to those seeking care later in pregnancy. Republican Governor Baker vetoed sections of

the bill related to youth access that lowered the age of abortion consent from 18 to 16 years old

and abortion exceptions after 24 weeks. These circumstances are among the most stigmatized

healthcare experiences. Mandates that require parental consent for young pregnant people to

receive abortion care can place teens in harmful situations. About one-third of pregnant teens

want to keep their abortion private from their parents and voice concern that they will be forced

to continue an unwanted pregnancy, expelled from home, or experience violence (Foster, 2020).

Baker justified his veto by saying he supported the current judicial bypass system for youth

access which requires minors to seek relief from parental consent from the court.

Restrictions on abortion later in pregnancy create confusion and barriers at a difficult

time. Kimport (2022) spoke with those who had experienced abortions later in pregnancy to

identify two pathways that lead to these circumstances of care. Patients may receive new

information about changes to fetal health or learn about pregnancy after 24 weeks of gestation.

Many people experience barriers to care that prevent abortion earlier in pregnancy, such as cost,

travel, and time. Abortion restrictions cannot account for these personal, complex, and nuanced

experiences. Updates to state law to expand access through the Roe Act did not protect a

pregnant woman in Boston this May who received devastating news from her doctor that

radically altered her parenting experience. Kate Dineen shared her story with the Boston Globe

in hopes that others would understand the limits of the law (Leung, 2022). At 33 weeks pregnant,

Dineen learned her baby had suffered a massive stroke and had little chance of surviving after

delivery. Her care team at Massachusetts General Hospital refused to provide abortion care under

the ambiguity of the state viability law. Dineen traveled to Maryland and paid $10,000 out-

ofpocket to terminate her pregnancy. Dineen’s story highlights how government interference in

reproductive healthcare causes harm.

Decriminalizing Pregnancy

Hostility towards abortion care is operationalized in the criminalization of care. The first

political campaign to criminalize abortion came from physicians at the American Medical

Association (AMA) in the 1850s. The AMA declared a fetus a living being and moved to

professionalize reproductive healthcare by driving midwives out of business with restrictions on

who could provide care (Möhr, 1978). Under this pressure, state legislators began to criminalize

abortion and establish exceptions when a doctor deemed a mother's life at risk (Stetson, 2001).

Abortion was illegal in 30 states in 1973 when Roe was decided. Pregnancy is a site of state

surveillance that reflects the overcriminalization of women of color and marginalized people.

Bridges (2011) witnessed how state Medicaid requirements dehumanize pregnant people by

requiring them to divulge personal information and supply their bodies to a small army of

professionals, from healthcare workers to financial officers, social workers, educators, and

counselors to access benefits. Goodwin (2018) furthers the problematic by arguing that the

hospital is an agent of the state that “takes control of a pregnant woman’s body in order to protect

the fetus.” No state requires medical professionals to report patients to authorities for suspected

abortion or intent to terminate. Manns-James et al. (2023) call for a harm-reduction approach to

caregiving that safeguards patient rights to privacy. Purvi Patel and Bei Bei Shuai were both

reported to Indiana authorities by the hospitals charged with their care following adverse

outcomes later in pregnancy.

State governments can reduce violence against pregnant people by decriminalizing

reproductive health and shielding providers from anti-abortion targeting. Interrupting

Criminalization, and the Center for Advancing Innovative Policy, provide recommendations to

promote reproductive autonomy through the deregulation of harmful healthcare restrictions and

decriminalization of pregnancy (Ritchie & Flores, 2019). These include avoiding laws that use

gestational age or viability as legal categories for when care can occur. Dineen’s story

demonstrates how the trimester framework in Roe and the viability standard in Casey could not

account for all circumstances and modern medical technologies to monitor pregnancy. Shield

laws to limit the liability of patients and providers have become more urgently important as

interstate travel becomes a growing necessity to access care at all stages of pregnancy. Fifteen

states have shield laws of varying coverage to provide protection related to assisting

investigations, compelling participation in proceedings, the disclosure of medical records, and

provider sanctions (LawAtlas, 2023). Shield laws passed after Dobbs in California and

Massachusetts apply to out-of-state courts, and these states join ten others in prohibiting the

extradition of providers (LawAtlas, 2023). Unfortunately, like may legal responses since Dobbs,

shield laws are untested. Risk is known, but protections are unclear. Protecting providers and

abortion helpers from interstate civil liability and criminal prosecution is an essential legal shield

as anti-abortion lawmakers seek to extend the reach of abortion bans beyond borders.

States can ban abortion but governments cannot stop abortion. Self-managed or

selfadministered abortion care refers to abortion care outside of a formal healthcare setting. Since

the early 2000s, when the FDA approved the oral medication mifepristone for abortion,

selfmanaged abortion has primarily referred to self-sourcing pills.xl For too many, ending

pregnancy through a self-induced abortion before Roe was all too often traumatic, dangerous,

and deadly (Grossman & Verma, 2022; Ross & Solinger, 2017). The coat hanger has been an

enduring symbol of the reproductive rights movement, representing the desperation of self-

attempts at termination (Joffe, 1991). Upadhyay, Cartwright, et al. (2022) found the most

common methods of self-managed abortion in the United States were herbs, supplements, or

vitamins (52%), followed by contraceptives (19%), abortion medication (18%), and physical

trauma (18%). Of these methods, abortion medication has the greatest chance of success and

lowest health risks. The World Health Organization (WHO) provides guidance for the self-

assessment of pregnancy and instructions to self-administer abortion care in the first 12 weeks of

pregnancy using mifepristone and misoprostol medications (WHO, 2022b). Ralph et al. (2022)

found that people seeking abortion care early in pregnancy can accurately self-assess eligibility

for medication without needing an ultrasound.

Self-managed abortion is safe and effective and improves global health equity in places

hostile to abortion by relying on social resources rather than formal medical systems (Erdman et

al., 2018; Harris & Grossman, 2020; Moseson et al., 2020). The WHO considers access to

abortion essential to good health and well-being and gender equality (WHO, 2022a). The reasons

for choosing self-induced abortion are structural and personal. A person who does not want to be

pregnant may experience one or more social, financial, privacy, or immigration reason for

selfmanaged abortion care (Rosing & Archbald, 2000). Abortion seekers who choose self-

managed care may prefer home-based methods to avoid medical systems and government

interference (Grossman et al., 2010; WHO, 2022b). People who have experienced sexual

violence, minors, people of color, immigrants, disabled people, those who identify as LGBTQ,

and others without sexual agency may harbor valid distrust in the professional medical system

that makes selfadministered care a more appealing option for personal safety and well-being

(Diaz-Tello et al., 2017). The right to self-managed abortion is rooted in self-determination.

Self-managed care has increased as a method for those facing insurmountable barriers to

clinic care. Aid Access is a online-only provider that mails medication for self-managed abortion

up to 10 weeks gestation to people in all fifty states at a maximum cost of $150. The organization

provides an asynchronous clinician-supported model of care that patients access online (Godfrey

et al., 2021). Patient requests from states where abortion is banned are routed to European

doctors who ship medication from India. Data from Aid Access shows increased requests during

times of heightened abortion restrictions, including the COVID-19 pandemic lock-downs, and

following the passage of the Texas abortion ban and Dobbs decision (Aiken et al., 2020; Aiken et

al., 2022a, 2022b). The rise in Aid Access provision and formal telehealth reinforces the need for

state-level policy that allows people to source abortion medication via the internet and mail. As

of November 2022, telehealth is restricted in eight states where abortion is legal and five states

where bans are temporarily blocked (KFF, 2023). Advocates should prioritize repealing state-

level telehealth restrictions to open up the possibilities for care from the relaxed FDA regulations

on abortion pills.

The main difference between self-managed care and formal telehealth is risk.

Selfadministered abortion happens without the direct supervision of a licensed healthcare

provider. Self-managed care is often paired with telehealth support with a physician, doula, or

trained helper to plan for at-home treatment. This support often includes preparation for potential

health complications and legal risks. Medication abortion is 13 times safer than childbirth, but

even rare risks require preparation (Harris & Grossman, 2020). People taking abortion

medication in and out of clinical settings are advised to seek emergency care if they experience

heavy blood loss, high fever, or long-lasting severe pain. Patients using telehealth or clinic

services at WWH can call a helpline to talk through complications and identify a friendly urgent

care facility if needed. Those who self-managed care in places where abortion is illegal may feel

forced to choose between receiving emergency services and avoiding criminal charges. The

American College of Obstetricians and Gynecologists has called for the decriminalization of

self-managed care, as prosecution may deter women in need from seeking medical care. They

further argue that requiring clinicians to report suspicious symptoms to law enforcement violates

the integrity of the patient-physical relationship (ACOG, 2017). People experiencing

complications from selfmanaged abortion do not need to disclose that they sought to end their

pregnancy. Spontaneous abortion, or miscarriage, is common and estimated to occur in 30% of

pregnancies (Weigel et al., 2019). Induced abortion from the oral ingestion of abortion pills is

clinically indistinguishable from miscarriage, and no test exists to detect mifepristone or

misoprostol (WHW, 2019).

Nevertheless, lying to health professionals during a medical emergency to avoid criminal charges

for yourself or others is not an equitable solution.

Five states have self-induced abortion bans, and thirty-eight states allow homicide

charges to be brought against the unlawful death of a fetus (If/When/How, 2020; Rowan, 2015).

Few fetal homicide laws provide explicit exceptions for the pregnant person. Black women and

low-income women have overwhelmingly been the target of arrest and forced medical

interventions under pregnancy criminalization laws (Goodwin, 2018; Paltrow & Flavin, 2013).

Laws and policies that increase surveillance of pregnant people are hazardous to health as people

may forgo care when medical and criminal systems are entwined. The rampant and persistent

racial and economic disparities and inequalities in maternal and infant health from racism and

discrimination in the U.S. medical care system place pregnant people at further risk of suspicion.

If every miscarriage were investigated as a suspected abortion, few would seek care.

States have primary jurisdiction in the criminalization and decriminalization of pregnancy

outcomes. The power to enforce and enact criminal laws is almost exclusively the power of the

states. Although women have rarely been convinced of self-induced abortion, anti-abortion state

legislators have tried strengthening criminal codes to enforce (Rowan, 2015). Utah attempted to

outlaw self-managed abortion in 2009. The Utah legislature passed the Criminal Homicide and

Abortion Amendments (HB12) after a teenager paid a man to assault her to induce a miscarriage.

Utah Governor Gary Herbert vetoed HB12 but signed the state trigger law to ban abortion ten

years later. States that have banned abortion may soon move to criminalize self-managed care

further. The Louisiana House Criminal Justice Committee advanced a bill to charge abortion as a

homicide during the 2022 session. States have moved to decriminalize self-managed abortion in

recent years. Nevada, New York, and Washington D.C. moved to repeal criminal codes that

punished pregnant people for adverse outcomes of self-managed care. Pro-active state

policymakers should move to legalize over-the-counter abortion medication as researchers

explore pathways toward this drug application process. Care is incompatible with

criminalization.

Local

Abortion Friendly Cities

Imagine an abortion-friendly city where the local government supports the reproductive

freedom of all residents. This vision is the Model City built by the National Institute for

Reproductive Health (NIRH). The NIRH Local Reproductive Freedom Index evaluates localities

on 34 policy indicators developed in partnerships with partner organizations and refined their

research process with local advocates (NIRH, 2021). The Index assesses six areas of municipal

action and values to build healthy and just communities, protect abortion access, fund

reproductive health, and support families and young people. A local landscape providing context

on population demographics, along with economic and health variables, accompanies each city

profile. NIRH has created 50 city profiles across the United States, focusing on state capitals or

most populated municipalities. For example, New York has entries for New York City and

Buffalo, while Indiana only includes the state capitol of Indianapolis. NIRH also provides a

selfassessment tool for local advocates to conduct their own research.

The self-scoring evaluation for South Bend, Indiana, yielded 1.5 out of 5 stars for

reproductive freedom (Table 6: South Bend Reproductive Freedom Scorecard). NIRH rated

Indianapolis, IN, at 1.5 stars. These two Indiana cities share many evaluation metrics owning to

preemption on the state level for health, labor, housing, and human rights policy. Lending to the

geographic nature of reproductive freedom in the United States, even counties within the same

state experience variation. Indianapolis does not meet any of the criteria for protecting abortion

access, while the clinic escort program provided by Pro Choice South Bend provides limited

local safeguards.

A city that models reproductive freedom invests in public health. The Indianapolis score

for reproductive freedom is improved by county-level funding for educational, preventative, and

screening programs for sexual and reproductive health that are absent in South Bend. Public

health in Indiana is under the jurisdiction of local county departments. State-level budget cuts

under Pence in 2013 reduced services and closed sexual health clinics across Indiana public

health departments. Marion County continues to offer on-site testing services and HIV selftesting

by mail. St. Joseph County includes sexual health in its health improvement plans but has not

taken funding or other action to restore services. All 50 cities in the NIRH Index provide funding

for STI/STD testing and prevention, which indicates that the absence of public health investment

in reproductive health services for mid-size cities, like South Bend warrants additional

consideration.

Cities can ease economic harm from state and federal abortion restrictions by allocating

city funds to local nonprofits with the expertise to support patients (NIRH, 2019). In response to

the abortion ban, Mayor Hamilton of Bloomington, Indiana allocated $100,000 in emergency

grants to organizations helping people reach care. Municipal funding for abortion support is

under threat from preemption. The Indiana state government uses this tactic to restrict political

subdivisions from implementing policy to deny local minimum wage adjustments and increased

protections for renters. Indiana House Bill 1593 was introduced in the 2023 session and would

prohibit public funds for any costs associated with abortion. This preemption would further state

violence against abortion seekers.

Public sector gaps and failures are often addressed by nonprofits. Abortion funds assist

almost 30% of patients through financial and logistical assistance (Roberts et al., 2014). The

Hoosier Abortion Fund is housed in the All-Options Pregnancy Resource Center in

Bloomington. Nearly every local patient had a portion of their bill sponsored by the Hoosier or

Chicago Abortion Fund during the weekend of care that I witnessed in South Bend. There are

over 100 abortion funds across the country providing substantial support to women of color and

people without insurance or financial security despite fundraising shortages (Hernandez, 2021;

Jones et al., 2013). Radical shifts in philanthropic investment directed at abortion funds would

transform the promise of Roe into a reality faster and further than changing political will

(Hernandez, 2021). Taking care of patients through direct funding, practical support, and

insurance coverage allows the pro-abortion movement to focus on advancing rights and

protecting clinics.

The NIRH Local Index is a comprehensive for rating tool for many key categories for

reproductive freedom related to health, wealth, and safety, and I propose adding measures for

information. My interviews with advocates stressed the importance of local media as a

community asset. (Oliver & Maney, 2000) argue that the interplay between local media,

movements, and politics affects public policy and political process in a city. The press is a source

of information on reproductive health and politics. In the later part of the nineteenth century,

newspapers ran discreet advertisements for clinics that provided relief from menstrual

irregularities (Luker, 1984). The local media outlets in South Bend have provided free

advertising for Whole Woman’s Health for better and worse. Tricia was the communications

director for PCSB while they worked at a local news station. They witnessed how stories are

pitched and constructed. Tricia shared during their interview that abortion news received

increased community engagement through clicks, likes, and shares that boosted revenue for the

outlet. Reporters were pressured to cover anything and everything having to do with abortion for

the 24-hour cycle. The station rarely invested in long-form pieces that could have provided

nuance and sensitivity to abortion-related issues in the community. Abortion advocates in South

Bend, including myself, experienced harassment by reporters eager to meet deadlines and push

story angles. South Bend advocates often express disappointment with how local news stories

portray abortion access as a political debate rather than an issue effecting real people in our

community. An internal report provided to PCSB by watch group Media Matters showed a

pattern of bias towards anti-abortion reporting in South Bend that peaked during the closure of

the Pavilion. Local advocates and communications staff at Whole Woman’s Health have invested

in educating reporters and editors on how to cover abortion for local audiences.

Quality local journalism is under threat as newspapers vanish and conglomerates

consolidate once independent operations (Abernathy, 2020). The South Bend Tribune was

founded in 1872 and owned by a local family until its purchase by media giant Gannett in 2019.

Under Gannett’s leadership the Tribune reduced staff and installed paywalls for articles.xli This

research would not have been possible without access to local media as clinic news rarely

ascends to national coverage unless extreme or tragic. The loss of local institutions with

journalist standards and ethics has given rise in South Bend to media outlets that promote

violence. A local conservative digital outlet has targeted clinic escorts by published their full

names and photos. This website has also published the addresses of board members from the

LGBTQ Center along with inflammatory framing of their work as harmful to children. An

abortion-friendly city has access to quality information through a free and local press.

Local Approaches to Clinic Safety

An abortion-friendly city protects clinics from anti-abortion violence, harassment, and

disruption. In South Bend, we learned that the answer to anti-abortion protesting is not equally

aggressive pro-abortion protesting. Patients cannot tell the difference between intentions when

actions are the same. Pro Choice South Bend developed patient-centered repertoires to reduce

harm and chaos at clinics under the guidance of the National Abortion Federation and Whole

Woman’s Health. Our shift in strategy to deescalate escort-protestor interactions was working

before Dobbs, and perhaps more time would have routinized contention. However, this was the

work of community advocates, clinic staff, and national support organizations, not local

governments. Many clinic escorts and legal monitors in South Bend lament that their existence is

a policy failure. Reproductive freedom demands better solutions than relying on clinic volunteers

to mitigate anti-abortion harm by placing themselves between patients and protest.

Contested spaces are challenging to control as freedom of speech is weighted against the

right to privacy and property. Fifteen states and cities have enacted bubble or buffer zones around

clinics and patients to create a space free from uninvited activity (Cohen & Connon, 2015;

Costello, 2021). The FACE Act allows a pathway to prosecution following violent acts, while

protective zones offer relief from harassment and disruption. An advantage of protective zones is

creating space between patients and unwelcome solicitors that are not in violation of the FACE

Act. Most protective zones include provisions against approaching people without their consent

to engage in counseling, education, oral protest, or distribution of materials. A buffer zone in

South Bend would protect patients from interactions with protestors approaching their cars to

hand them unwanted gift bags full of propaganda. These zones are essential for clinics like EMW

in Kentucky that occupy a commercial retail strip space without private parking.

Patients entering EMV rely on a Louisville ordinance to clear a 10-foot wide path across the

sidewalk for patients to enter their building. Protestors line the walkway maintained by clinic

escorts from the street to the clinic door.

The Louisville buffer zone is currently barred from enforcement by the Sixth Circuit

Court as the court hears a lawsuit brought by Sisters for Life and Kentucky Right to Life. The

plaintiffs argue that the zone violates the First Amendment rights of protestors. Free speech

arguments have been successful in repealing state-level abortion clinic protections. Court rulings

in Hill v. Colorado (2000) and McCullen v. Coakley (2014) struck down protective zones in

Colorado and Massachusetts. Conservative lawmakers in New Hampshire have repeatedly

attempted to repeal state buffer zone and were most recently halted by Governor's veto. These

lawsuits and legislative attempts demonstrate the reach and power of the anti-abortion movement

to challenge any and all attempts to curtail their actions. The Louisville Metro Council passed the

protective zone ordinance in May 2021, and the lawsuit was filed less than a month later.

A Post-Dobbs era requires a renewed focus between national and local collaboration to

enforce, investigate, and prosecute offenders. Interagency cooperation was crucial for

implementing the FACE Act. Today’s efforts must combine the knowledge gained from decades

of anti-abortion security knowledge with reforms focused on the future of policing. Additionally,

localities that may not have experienced intense or persistent anti-abortion protesting may soon

be targeted as abortion care is concentrated due to bans. Law enforcement must be prepared for

new and escalating threats to clinics. State and local police forces must implement and evaluate

protocols for officers responding to anti-abortion crimes in collaboration with oversight entities

such as Safety Boards and Citizen Review Boards. Officers must be trained to respond to clinic

calls to deescalate dangerous situations impartially to reduce violence against patients and

providers. Responding officers must understand how to balance the protections of the FACE Act

and other state and local laws with the protections of the First Amendment. The Women’s Law

Project is developing guidelines for state and local police departments after defending a

Pittsburgh buffer zone in Bruni v. City of Pittsburgh (2019). The NIRH provided strategic

guidance for the Louisville buffer zone and offers grants to abortion-forward organizations to

advance proactive policy initiatives. Clinic safety requires better coordination with local law

enforcement and innovative policy solutions for clinic defense that do not rely upon the criminal

legal system.

A critical analysis of the role of the police as effective agents of clinic safety is necessary

as law enforcement selectively protects and endangers. Local police maintain clinic protection

zones, and reliance on law enforcement can erode zone effectiveness. Policing is not the same as

safety, and protective zones can operate in contradiction to anti-violence priorities for

communities of color and gender minorities (Park, 2015; Ross, 2017). Police interventions have

not effectively reduced protestor trespassing in South Bend, as responding officers are reluctant

or unwilling to enforce existing laws. In places with protective zones, clinic staff feels better

about going to work to avoid directly interacting with harassment (Cohen & Connon, 2015).

However, police report frustration at responding to calls at clinics, and frequent interactions

between police and protestors soon become costly for cities (Cohen & Connon, 2015; Doan,

2009). Calling the police for gender-based violence is a risk. Researchers have found that police

attitudes and bias negatively influence victim outcomes of calls related to gendered crimes,

including rape, anti-abortion terrorism, domestic violence, and human trafficking (Bowdler,

2020; Cohen & Connon, 2015; Logan et al., 2006; Musto, 2016). The prejudicial viewpoint that

providers should expect anti-abortion crime as a part of their job was on display in Michigan last

August when an officer responding to a clinic blockade was captured on video sympathizing with

trespassers and offering to advise them on how to avoid arrest next time (Cohen & Connon,

2015; Lawlor, 2020). Policies that rely on law enforcement must be reviewed and reimagined to

account for police bias and brutality experienced by the very people who have abortions –

women, people of color, LGBTQ people, and other marginalized people (Logan et al., 2006;

Ross, 2017; Schlosser, 2013). Clinics must be places of tranquility and safety for all pregnant

people and clinic staff, not just those privileged to be protected by police.

Policing alternatives to protect clinics requires prioritization of those most impacted and

the full toolbox of local governance possibilities. For cities to address gender-based violence at

abortion clinics to fulfill their mandate of public welfare, they must listen to and honor the voices

of those most impacted and the recipients of unwanted aggression and attention: patients, staff,

and volunteers. Cities blessed with a clinic should hold regular meetings with the clinic manager

to share and strategize how to protect access to essential health services. These meetings should

include surrounding businesses and neighbors to understand the impact of protestor activity on

their welfare, peace, and safety.

Anti-abortion violence is directed at clinics and radiates community harm. In addition to

laws prohibiting how close anti-abortion operatives can be to a clinic, local ordinances can install

security measures to protect patient and provider safety. Municipal planning entities must work

with clinics to allow for variances in code, such as protected vehicular access, privacy fences,

and defensive landscaping to block the view of protest activity. Alterman et al. (2021)

recommend that cities ban sound amplification technology and install quiet zones around

healthcare facilities to prohibit sonic violence from anti-abortion protestors. Planning and police

departments should work together to define and restrict public easements to limited use and

enforce trespassing laws to reduce situations of officer discretion when responding to calls at

clinics,. Clinic safety for all means prioritizing and protecting the rights of patients to access

health care without disruption and violence.

A Bold Vision for Abortion Justice Policy

Policy solutions to reduce gender-based violence must address the demands of the

reproductive justice movement. The focus on gendered liberation through reproductive freedom

has been dominated by a white rights-based agenda that achieved abortion legalization through

Roe but did little to intervene in the lengthy history of abuse that shaped the reproductive lives of

women of color (Roberts, 1999; Ross, 2017). A reliance on Roe instilled a myopic focus of

liberation of the individual and not the communal or social construction of the individual as part

of interdependent relationships at the intersection of racism and sexism. Universal policies for

health care, basic income, education, child care, and anti-discrimination protections are necessary

for just reproductive futures. The fragile and fragmented system of abortion care in the United

States is built on a legal foundation that a coordinated anti-rights agenda will continue to erode.

To advance abortion justice, we must understand the multiple manifestations of antiabortion

violence and respond collectively to ensure everyone has access to all care options.

Conclusion

I am concluding this project during a time of widespread legal limbo and uncertainty

about the future of abortion in the United States. Entrenched contention is characterized by

continuous conflict, and this research has no natural stopping point. I offer instead an outline for

my future research agenda to document post-Dobbs harm and expand the universe of cases for

entrenched contention.

The erosion of this vital care infrastructure, and escalating anti-abortion violence from

government and movement operatives, have placed tremendous burdens on abortion patients,

providers, and advocates (Gerdts et al., 2016; Grossman & Baum, 2015; Joffe, 2018). Before the

pandemic, an estimated one in four women in the United States would have had an abortion in

their lifetime (Jones & Jerman, 2019). New estimates to capture access barriers following Dobbs

show a decrease of 6% in total abortions performed by clinicians and a 33% rise in virtual care

from April to August 2022 (Norris & Upadhyay, 2022). We are in a critical moment for gender

equity in the absence of national abortion rights following the reversal of Roe, which requires

continued action and attention.

I have been putting my work into action throughout the research process by staying

involved with Pro Choice South Bend. During my time at Heller, I co-authored a volunteer

handbook for the clinic escorts and assisted coordinating clinic safety training. I advised local

movement responses to the abortion ban bill. I maintained the PCSB website to provide timely

updates on the legal status of abortion, available options for care, and opportunities to get

involved with the movement. I authored a policy brief on local solutions for clinic safety using

an intersectional framework as a member of the Gender-Based Violence working group at

Brandeis. I plan to present this work in South Bend following the dissertation defense to share

these important lessons with the community that made this work possible.

This research examines how the oppressive atmosphere of anti-abortion violence causes

clinic closures, limits pro-abortion interventions, and drains movement capacity. I have collected

more data and stories than could be told here. I prioritized the reoccurring theoretical themes

central to my interviews conducted between May and August 2022. The Alito leak, the Dobbs

decision, and the Indiana abortion ban greatly influenced these conversations. As such, the

dissertation focuses on classic organizational-level opportunities and limitations of movement

resources, repertories, and administrative burdens (Ganz, 2000; Herd & Moynihan, 2019;

McCarthy & Zald, 1977; Tilly & Tarrow, 2015). Additional analysis of existing data would

explore spatial factors around public and private spaces that have been an ongoing public policy

debate within “women’s issues” and how crisis pregnancy centers represent an alternative space

between public and private interest. I can conduct follow-up interviews to understand changes in

a post-Roe America thanks to generous permissions from most participants.

My future research will explore individual, community, and governance resistance

strategies in post-Dobbs America in two crucial ways. First, I intend to continue at the current

research site to understand the impact of Indiana’s abortion ban, changes to the care

infrastructure, local movement response, and legal advocacy. Suppose the devastating possibility

that the Indiana abortion ban is found constitutional by the state courts. In that case, I will

examine renewed local strategies to connect people with care, such as logistical support to reach

clinics, telehealth, and self-managed abortions. I will also track how policymakers in Indiana

respond to the abortion ban and their attempts to exclude exceptions or reverse course toward

abortion justice. Advocates in Indiana hope the Indiana Supreme Court upholds the right to

abortion. If this victory becomes a reality, I will examine if and how Indiana clinics survived the

ban. I expect that the prolonged legal process may cause some clinics to close and further erode

access to care.

Secondly, I am interested in studying the migration of clinics following state bans to

places that protect abortion rights. Advances in abortion medication mean people have access to

more options than they did 50 years ago. However, in-clinic care will always be needed as an

option for those further along in pregnancy, living in places where self-managed care is a crime,

and as a preferred method of termination for some. Whole Woman’s Health closed all its clinics

in Texas after exhausting all legal options and announced its intention to shift southern

operations westward. Similar strategies are underway for other clinics in banned states, such as

Red River Women’s Clinic in Fargo, North Dakota, moving a mile away and across the state

border to Moorhead, Minnesota. I intend to expand the scope of my work to include additional

sites for comparative analysis. Whole Woman’s Health clinics operate in different political

environments that constrict abortion provision. There are established clinics in Minnesota and

Virginia and planned clinics in New Mexico and Illinois. I aim to develop this work into my first

book project to share timely lessons on political polarization and the rise of anti-rights policies.

As I continue my career, I am interested in expanding the universe of cases observed in

entrenched contention. In the dissertation, I observe how abortion clinics, as locations of

entrenched contention, experience routinization over time. Discontent with routinized conflict,

the anti-abortion movement continues to innovate toward abolition, heightening pro-abortion

response to escalating government restrictions, violence, disruption, stigma, public divestment,

and legal uncertainty. Entrenched contention can explain growing social movement conflict and

anti-rights policy proliferation at targeted locations, such as polling places, primary schools, and

drag shows. As with abortion clinics, I expect these locations to have racial and gendered aspects

that make them targets of conflict. My goal is to grow this theory to explain why certain issues

develop in specific venues and how movements can navigate opportunity streams to advance

equity in these bounded conditions. Understanding entrenched contention unlocks insights into

political processes that produce gender-based violence to address harms with action at all levels.

Advancing Abortion Justice An Ethnography of Gender-Based Violence and Contentious Politics at Clinics

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