Posted with permission from STAT

ATLANTA - The bright pink signs popped up around the city last spring, advertising a new clinic offering abortion and birth control. "Doors open in Atlanta," the billboards proclaimed. "Because you matter."

A new abortion clinic in the region would be notable enough: Across the Bible Belt, the swath of spiritual states stretching from Texas to North Carolina, the number of abortion clinics has dropped nearly two-thirds over the past three decades, in part due to restrictive laws, constant protests, and sporadic violence.

But the activists behind the nonprofit Carafem didn't just want to quietly open their doors. Despite protests outside the clinic, the most recent a few weeks ago, they embrace an unapologetic brand of women's health care, and they launched it with an in-your-face advertising campaign - in a conservative state where 4 out of 5 adults identify as Christian.

"We want to be really out loud about what we do," said Melissa Grant, Carafem's vice president of health services, as she sat inside one of the clinic's exam rooms. Then she echoed the slogan on another of Carafem's provocative pink ads: "Abortion. Yeah, we do that."

In recent years, abortion rights activists have embraced a mantra of openness to erase the stigma of ending pregnancies, through initiatives such as "Shout Your Abortion," the Sea Change project, and the "1 in 3 campaign." Abortion providers like Whole Woman's Health, whose clinics are in five states including Texas, have plastered the words of famous feminists on the walls of exam rooms.

Even against that backdrop, Carafem stands out. One of its ads touts medication abortions, used in the first trimester, as "the 10-week-after pill" - and even has turned that slogan into a Twitter hashtag. Another ad depicts a text exchange in which one friend casually suggests abortion to another. All the ads grab attention with that eye-popping shade of Carafem pink.

Such promotions, combined with Carafem's vision for upscale, even chic, abortion clinics, have stirred outrage among anti-abortion advocates.

Brash ads stir a backlash

Carafem's promotion of abortion pills has "crossed the boundaries of honesty and decency," said Jody Duffy, the executive director of Post Abortion Treatment and Healing, which offers women - including some former Carafem patients - Christian counseling following abortions.

Elizabeth Greenwald, the leader of a local Georgia Right to Life chapter, said Carafem deceives women "by marketing a spa-like environment to hide the ugly truth that they're killing an innocent child." Mike Griffin, a pastor who lobbies for the Georgia Baptist Convention, said the fact that Carafem "creates a luxurious environment" in its clinic amounts to putting "a positive spin on a wicked act."

Abortion opponents are already fired up by the prospect of more action on the federal level, including the Republican proposal to strip federal funding from Planned Parenthood and President Trump's pledge to appoint pro-life justices to the Supreme Court. The backlash against Carafem could be sharp enough to stir more anti-abortion action at the state level, too, said Charles Bullock, a political science professor at the University of Georgia.

"This is the Bible Belt," Bullock said. "Some people out in the suburbs, and the further out you get, see Atlanta as evil as New York - like Sodom and Gomorrah inside the perimeter."

Despite the risks of a legislative crackdown, Carafem officials insist the only way forward is to talk about abortion in an "open and honest" manner that's no different from conversation about other kinds of health care. To mute that communication, Grant said, would give women the impression their care isn't as acceptable.

"People who don't agree with our message, our pink signs, are going to disagree regardless," Grant said. "What it can do is point out the difference in the way this service is talked about, in the way this division of health is handled. It can speak to the people who agree with us."

Developing a Southern strategy

Carafem launched its first clinic two years ago just outside Washington, D.C. The nonprofit sparked some controversy there, too.

When the clinic sought to promote its abortion services on public transportation this winter with the "10-week-after-pill" slogan, the D.C. Metro rejected the ad. So Carafem put the same ad on a billboard truck and had it driven around the city.

By then, the nonprofit had already expanded to its second clinic, in Atlanta. Originally, Carafem had no Southern strategy. But its executives soon realized a tenth of their D.C. patients had traveled more than 100 miles for an abortion - including from states as far away as Ohio and Texas.

"[W]omen are traveling further distances and incurring sizable expenses to access abortion care when they need it," Carafem President Chris Purdy wrote in a Huffington Post op-ed last year. "… because of state-specific, restrictive laws, they may have to stay in hotels, miss days of work, and pay for childcare while being forced to adhere to a 'mandatory waiting period.' There has to be a better way."

Purdy has long experience in the field: He's also the president and CEO of DKT International, a global nonprofit that promotes family planning and HIV prevention, in part through aggressive marketing of birth control in countries across Asia, Africa, and the Middle East.

As Carafem eyed expansion, Grant looked for cities with looser abortion regulations near states with restrictive laws.

Atlanta fit the bill. Nearby states such as South Carolina, Mississippi, and Alabama had been making it tougher for clinics to operate, though some of the laws enacted in those states remain hung up in courts.

Georgia has its own restrictions, including a law banning most abortion after 20 weeks gestation and a 24-hour waiting period for women seeking to terminate pregnancies. And the state, like many others across the nation, has had a history of abortion violence. In 1997, two bombs exploded at a clinic just outside Atlanta, in Sandy Springs, Ga., injuring several people.

But Grant saw potential.

Plush pink chairs and cups of tea

The Atlanta clinic is inside an aging office building on Peachtree Street, tucked between two Mexican restaurants. Located on the eighth floor - past a security guard, up an elevator, and past a locked entrance - Carafem's clinic has a chic aesthetic that includes pink plush chairs in exam rooms and framed photos of smiling millennials fit for a magazine spread. Clinic staffers offer patients tea and snacks.

"We want this to be the best health experience you've ever had," Grant said. "Not just the best women's experience you've ever had."

Doctors, on site three days a week, see patients in exam rooms that are as "de-medicalized as possible" to reduce anxiety, Grant said.

Carafem does screening for sexually transmitted diseases and sells a variety of birth control, advertised in the same cheeky style. One pink poster promises "5 star protection… for 5 star sex" and features peach and eggplant emojis. Ads on college campuses around Atlanta last fall used blushing and winking emojis to market birth control and abortion services to students experiencing "new sights... new sounds... new experiences."

But while most clients leave with some form of contraception, 90 percent of the roughly 1,000 patients Carafem has seen so far in Atlanta come in for abortions. For $550, there's "the Carafem procedure," a surgical abortion that usually lasts less than seven minutes and is available to women in their first 90 days of pregnancy. If a woman is fewer than 10 weeks pregnant, she can opt for a medication abortion, taking series of five pills for $475.

Before women leave the clinic, staffers encourage them to jot down notes about their care, either on #MyCarafemExperience cards that are shared on social media or in pamphlets passed on to future clients.

They say things like: "A safe environment without judgment," "I wish all doctor offices were like this one," and "You're angels."

A travesty - or a beacon?

The picketers outside on Peachtree Street hope those "angels" hear their prayers.

They pray for the unborn babies. They pray for the expectant mothers. They pray for the Carafem staffers to pack their bags.

"They're trying to de-stigmatize [abortion]," said state Senator Renee Unterman, a Republican, who chairs the health committee and has long been a staunch opponent of abortion. "I don't think they're being effective. You can't put lipstick on a pig."

Abortion rights advocates, however, see the pink billboards over Atlanta's interstates as a beacon for women seeking treatment without judgment. Diane Derzis, the owner of the only abortion clinic in Mississippi (known as the "Pink House" for its bold exterior paint), said Carafem's approach "takes away the shame" often associated with abortions by talking about them frankly and openly.

"This is putting abortion rights on the offensive," said Elizabeth Nash, senior states issues manager of the Guttmacher Institute, which researches issues surrounding reproductive health.

Carafem officials say the tactic works - and it's one they think will resonate throughout the South. Earlier this month, the nonprofit opened a third location in Augusta, Ga., about 10 miles from the South Carolina border. They hope the new clinic, like the first two, will make it easier for more pregnant women to say, "Abortion. Yeah, we do that."