ATLANTA — As abortion clinics across the Southeast closed their doors this summer, one independent Atlanta clinic found itself expanding.
Independent abortion clinics — providers not affiliated with national organizations such as Planned Parenthood — operate at the very frontlines of the abortion battleground. “Indies,” as they’re called, make up only a quarter of all abortion clinics, but they provide more than half the abortions in the country. They are heavily reliant on abortion services for revenue, and over a third have shuttered since 2015 under the pressure of a record number of state regulations intended to restrict abortion. Twenty-six clinics closed down in the 100 days after Roe was struck down on June 24.
But this summer, Feminist Women’s Health Center was scaling up operations to meet a drastic surge in demand from states where abortion bans went into effect after the reversal of Roe v Wade, more than doubling the amount of patients they saw in July from the previous month. At the same time, staff were bracing for a potential existential blow themselves — a six-week abortion ban passed by state Republicans in 2019, previously blocked by a federal judge, was back in the courts. It would eventually be enacted in July, making abortion in Georgia close to illegal. The next month, the number of abortion patients who came to the clinic fell by half.
“We were contracting and swelling at the same time,” says Kwajelyn Jackson, the director of Feminist, as they’re known locally.
The chaos of the summer provides a snapshot into the extraordinary turbulence “indies” have been through in the past few years. Those that remain standing, like Feminist, are having to transform and expand the services they offer to survive as their primary source of revenue dries up. If they close down, even the abortions allowed within the bounds of current restrictions will be harder to access.
Feminist had seen Roe’s reversal coming and began prepping well over a year ago by launching a digital marketing campaign calling for people to come over to pick up some birth control.
“Sometimes people hear abortion [clinic] and birth control and they’re like, ‘Wait a second, what?’” says MK Anderson, development director at Feminist. “Believe it or not, we provide abortion care, but we [will] depend on wellness patients.” That means annual exams, screenings and contraceptives.
The health campaign served a dual purpose offering crucial reproductive healthcare services for the community at a time when abortion options were shrinking across the region, and opening up a new stream of revenue for the clinic.
Executing a pivot is rarely easy for a small outfit, but Feminist is trying to pull it off in an extremely unpredictable environment. When Roe was overturned in June, the clinic’s phone wouldn’t stop ringing. Pregnant people from other Southern states with tighter restrictions were looking for services in Georgia, where abortions were still allowed up to 20 weeks — the only state from Texas to South Carolina where this was an option.
Then an overlooked piece of legislation re-surfaced. The dormant regulations came into play, and a six-week abortion ban became effective overnight. With the count starting from conception, this gives women only about two weeks to get an abortion after a missed period. Clinic staff were forced to turn away patients who had traveled thousands of miles.
The past few months have been especially trying for the staff, who are trying to pull off a business transition while coping with increased workloads, shifting priorities, and an uncertain future.
Across the South and in rural areas, small health clinics are also stepping in to meet family planning needs. The difference, Jackson says, is “they don’t have anyone screaming at them with a bullhorn from their driveway.”
No time to process grief
Shaded by pine trees and tucked away on a residential street at the top of a hill, Feminist was founded in 1976 and has been a mainstay of the abortion access movement in the South for over four decades. Its discreet hillside perch is by design, thwarting persistent protesters at the edge of their driveway, keeping them far from the main entrance. But shouts, amplified by the bullhorns, still penetrate the building and seep into the examination rooms.
The clinic spends about $65,000 to $75,000 a year on security. But protesters still managed to enter the premises earlier this year.
Staff nerves were already frayed after years of fighting to stay open. Workers at independent clinics often choose the job because they are passionate about the work. Having to turn away desperate patients has left many feeling broken.
“I haven’t had a lot of time to process my own grief about what’s happening in this moment,” Jackson said. “But I am also not the person who has to look someone in the eye and tell them, ‘I’m sorry, we can’t see you today.’”
Feminist’s ultrasound technician of 25 years, Gloria Nesmith, has had to turn away dozens of patients since Georgia’s ban hit. At an October hearing on the state’s six-week ban case, she testified about the rollercoaster emotions folks go through as they wait to find out if they fall within the narrow window to get an abortion.
“I change out my tissue box more than I typically would ever, these days. We have more women who cry tears of complete relief, as well as from having to tell women they’re going to have to be referred to another state. Tears are normal but … I get different types of tears since the ban,” she said.
The clinic’s traffic dropped precipitously during the pandemic — from 5,000 patient visits to 3,000 — when many skipped annual check-ups and other routine care in 2020. Despite this, the clinic didn’t experience much of a drop in revenue from its services. That’s because patients were still coming for abortions; of those 3,000 patients, 85% came for abortion services.
Even if the clinic survives by offering new services, the six-week ban will deliver a major financial blow. Feminist charges between $518 to $1850 for abortions depending on type of abortion and gestation stage, compared to $100 for an annual gynecology exam. The clinic takes some insurance, but not Medicaid due to bans on federal funds paying for abortion, and offers sliding scale rates for low-income folks.
Feminist has benefited some from the surge in donations to the abortion rights movement in recent years. In 2020, it received almost $1.2 million in contributions, up from a little more than $1 million the year before. But the amount independent clinics like Feminist receive is a small fraction of overall philanthropy in this area. Of the $1.7 billion that flowed into reproductive health advocacy from 2015 to 2019, less than a quarter went directly to abortion access, as opposed to national political lobbying. Just 2% went toward funding abortion on the ground.
Instead, indies have been experiencing a rollback of support from national advocacy organizations since 2018, when the first tangible threat to Roe made its way through federal courts.
NARAL Pro-Choice America, the oldest abortion lobby group in the country, went from having local affiliates in 25 states to having offices in just three, looking to centralize its operations. Meanwhile, the National Abortion Federation, which spent $60 million to fund 100,000 abortions in 2020 and is the nation’s largest source of funds for women seeking abortions, has increased restrictions on funding for out-of-state patients, an important patient base for indie clinics.
Jackson knew the clinic would have to get creative to survive. When she became Feminist’s first Black director in 2018, she began plotting how to revamp the clinic’s mission.
The most dangerous place in America to be pregnant
For decades, those on the abortion frontlines in the South saw maternal and infant health outcomes worsen as the culture wars over abortion led to a broader rollback of abortion services in states dominated by Republicans. With hospitals closing down at unprecedented rates and prenatal resources shrinking, in tandem with conservative legislatures slashing health budgets, the South is the most dangerous place in the nation for pregnant people and babies: It’s home to the eight worst states for maternal mortality and the bottom four for infant mortality.
“The truth is, hospitals weren't offering the care, midwives were illegal, fertility treatment and access is not widely available. And now most people that are experiencing pregnancy are at a very high risk for being hurt,” says Erin Grant, deputy director of Abortion Care Network, a non-profit that provides financial support to independent clinics.
Jackson saw both an opportunity to make an impact, and a necessary business strategy. In addition to their existing pelvic exams and pregnancy testing, Feminist started to offer telemedicine, tubal ligation, trans hormone treatments, and in vitro fertilization (IVF).
The clinic is also trying to expand into prenatal services, with the goal of eventually becoming a birth center — on the face of it, an unusual journey for an abortion clinic, but a vital transformation that makes perfect sense to Jackson.
“We are really anxious to expand and to better serve trans women and intersex folks, really offer gender affirming care across the spectrum,” she says. “[That’s] something that's been demanded of us for a long time.”
The transition has allowed Feminist to stay afloat where many others have fallen. Jackson Women’s Health Organization — the organization whose case against Mississippi over its 15-week abortion ban was the vehicle used by the Supreme Court to overturn Roe — provided every abortion in the state for the past decade. The relentless demand the Mississippi clinic faced as the only abortion provider there meant they were not able to spare time and resources to execute a similar shift in strategy. When they shut down in July, it was a blow that reverberated for indies across the region.
“The only clinic in the poorest and blackest state in the country, of course they have focused their energy on trying to meet a need that feels unending. And when it’s ripped away from them, they don't have the investment to allow them to pivot in the ways that we perhaps have been able to,” says Jackson.
Feminist has no plans to close down, but survival is not a sure thing. For starters, it takes a dozen annual wellness exams to bring in the same revenue as one abortion. But the clinic has nearly paid off its mortgage, putting it on more stable financial footing. The organization is becoming a growing presence at the intersection of voting rights and reproductive justice in the South, hosting voter registration drives and legislative action days in the run up to the midterm elections. They are also one of the plaintiffs challenging Georgia’s six-week ban, with a ruling expected this month.
“It is critically important to me that this organization remain a beacon in the Southeast,” says Jackson. “What has happened in this country is going to take a long time to repair.”