Introduction

Contraception is a tool to determine whether and when to become pregnant, contributing to people’s ability to realize their reproductive autonomy. Access to a diversity of contraceptive methods occurs at a range of health care sites across the United States, but this access continues to be differentially available to individuals based on income (Frost et al., 2021). The Title X federal family planning program was established in 1970 with an explicit goal of reducing inequities in access to contraception due to income level; program guidelines require the use of a sliding fee scale at sites receiving this funding, which reduces or eliminates cost barriers based on an individual’s ability to pay (United States: National Archives and Records Administration: Office of the Federal Register & United States: Department of Health and Human Services, 2019). Title X funds flow from the federal government to grantees in the states which, in turn, may provide clinical care themselves and/or allocate the funds to health care centers within their service areas. Entities receiving Title X funds comprise a diverse network of providers, including state health departments, federally qualified health centers, and reproductive health-focused centers such as Planned Parenthood affiliates. In 2018, about 3.9 million patients received family planning care through the Title X program; 40% of these patients were uninsured, a much larger percentage than among the broader US population (13%) (Fowler et al., 2019). The Title X program lays out fundamental principles for the provision of high-quality family planning care; at the same time, program regulations stipulate that no Title X funds may be used to cover abortion services (Office of Population Affairs, 2022b).

Despite this, and strong evidence of the broad benefits of the Title X program for people’s reproductive health and access to these services (Darney et al., 2022; Frost et al., 2019; M. L. Kavanaugh & Anderson, 2013), the “2019 Title X Final Rule” (also commonly referred to as the “Title X gag rule” or “domestic gag rule”) was issued in March 2019 and officially implemented in August of that year. The Rule prohibited federal Title X funds from being distributed to health care centers that provided any abortion-related care, including discussion of abortion as an option for pregnant patients and referral to a site that provides abortions, among other regulation changes (Hasstedt, 2019b). This resulted in large health care center affiliates and agencies that had previously been providers of both contraception (supported by Title X funds) and abortion (supported by non-Title X funds), such as Planned Parenthood affiliates, as well as some providers who did not specifically provide abortion care, to leave the Title X program all together, many doing so because complying with the Rule went against their ethical duty to patients (Planned Parenthood, 2019). Evidence indicates that these disruptions due to the Final Rule directly resulted in a drop of 945 health care centers from the network and an estimated 1.5 million fewer patients being served through the Title X program in 2020 as compared to 2018 (Dawson, 2020; Fowler et al., 2021; Frederiksen et al., 2020). Qualitative studies have highlighted how some individual providers and patients have experienced the aftermath of the Final Rule, including having to turn patients away because they could no longer offer sliding fees for lower income patients (providers) and encountering unexpected changes to costs of seeking contraceptive care (patients) (Frohwirth et al., 2022; Power to Decide, 2020; VandeVusse et al., 2022).

Beyond documenting changes in the numbers of Title X providers and patients being served within this system at the clinic level, understanding the extent of the impact of the Final Rule on patients’ reproductive lives and ability to realize reproductive autonomy at the individual level is essential. We draw on a unique panel dataset that followed family planning patients receiving care at publicly funded health care centers in Iowa during the time period before and after the implementation of the Final Rule to examine its association with patient outcomes. We examine patient-reported outcomes of access to care and contraceptive use, as these are each components of sexual and reproductive health and well-being (SRHW), the self-defined state in which individuals reach their own reproductive goals (CECA, 2021). Iowa provides a case study for understanding specific associations between the Final Rule and this particular patient population and their access to sexual and reproductive health (SRH) care and contraceptive use; findings for patients seeking publicly funded care in Iowa can provide insights into potential impacts of the Final Rule on patient outcomes in other similar states.

Methods

Data

Our analysis draws on panel data from patients recruited when seeking publicly funded family planning care in Iowa between May 2018 and February 2019; these data were collected as one component of the Reproductive Health Impact Study, a multiyear effort aimed at tracking the impact of policy changes related to the publicly funded family planning system in Iowa and three other states (Guttmacher, 2022). Briefly, facilities for patient recruitment into the study were identified based on three eligibility criteria: (1) receiving any federal and/or state public funds to support family planning care; (2) serving 100 + patients assigned female at birth in Iowa annually; and (3) being open as of February 1, 2018. Of 45 eligible facilities, 22 participated in the study; respondents from five of these sites were removed from the sample (N = 42) because their site of care at baseline served fewer than 100 patients annually based on a 2018 census of publicly funded family planning sites in Iowa conducted by the Guttmacher Institute (Unpublished tabulations from the Reproductive Health Impact Study 2018 Family Planning Clinic Census n.d.); this resource became available after baseline recruitment into the study was complete. Frontline staff at each facility offered participation in the study to all patients during intake and/or registration who were ages 15 and older and seeking family planning careFootnote 1 during the facility’s specific fielding period.Footnote 2

Participating patients self-administered the electronic questionnaire on a tablet; survey questions included items on access and barriers to sexual and reproductive health care, contraceptive use, and pregnancy attitudes, among other topics. Baseline surveys took approximately 25 min for patients to complete. Patients who participated in the study were offered the option of entering a facility-specific raffle for a $50 gift card. Across eligible participating facilities, the average response rate was 20%, resulting in a sample of 1388 respondents.

Individuals who elected to provide their contact information at baseline were contacted for online follow-up surveys occurring biannually, once every 6 months, for the 2 years following completion of their baseline survey. Those who participated in the follow-up surveys received incentives starting at $15 for the first follow-up survey, increasing by $5 for each subsequent survey. These follow-up surveys covered many similar topics to those covered in the baseline survey, including contraceptive use and satisfaction and access to sexual and reproductive health care. Links to the follow-up questionnaires were sent via email and/or SMS, depending on patient’s specific preference when indicating interest at baseline, and respondents took these surveys online via mobile phones, tablets, or computers. Follow-up surveys took about 10–15 min to complete.

All study protocols were approved by our organization’s Internal Review Board and by the Internal Review Board of our electronic data management partner, NORC at the University of Chicago. More details on these data collection activities have been published elsewhere (Kavanaugh et al., 2022).

Analysis

Our analytic sample comprised respondents who took the baseline survey and agreed to be recontacted for subsequent surveys, regardless of whether they responded to any further surveys.Footnote 3 Due to the difference-in-difference design being focused on examining differences in outcomes at the aggregate level, this unbalanced panel design maximizes sample size contributing data at the pre- and post-exposure time points.

Measures

We investigated associations between the 2019 Title X Final Rule and patients’ SRH outcomes of access to SRH care and contraceptive use, operationalized as seven different metrics. We examine multiple outcomes in our models that span both access to care and contraceptive method use because individuals’ need for SRH care, especially contraceptive care, may fluctuate over time, and it is likely that any one individual may not have a regular need for this care in a 6-month time frame. Thus, we focus on broad SRH care in addition to contraceptive care and we utilize multiple data points within each of the pre- and post-exposure time frames. Recognizing that access to care is really just the vehicle through which many people get their contraception, we also examined several different contraceptive access outcomes.

Our dependent variables representing access to care, which were assessed at each survey time point, include receipt of recent SRH care, receipt of recent contraceptive care, and quality of contraceptive care. We examine receipt of recent SRH care among the full analytic sample, as this group could have potentially experienced disruptions in access to broad SRH care, and we examine all other access to care and contraceptive use outcomes among a narrower sample of respondents who did not report trying to become pregnantFootnote 4 at any survey time point, as this group was hypothesized to potentially be more impacted by disruptions in access to, and use of, contraception. Receipt of recent SRH care included having received any of the following types of care in the prior 12 months (if asked at baseline) or prior 6 months (if asked in follow-up surveys): discussion or information about birth control or family planning, birth control method or prescription, pregnancy test, STI/HIV testing, or broader reproductive services including annual gynecological exams. Receipt of recent contraceptive care included having received any of the birth control-related services within the same list, but not any of the broader SRH ones. We conceptualize changes in the receipt of both SRH and contraceptive care as proxies for disruptions in access to these two types of health care.

Our final dependent variable representing access to care focuses on quality of care, using four items from the survey that together represent the validated person-centered contraceptive counseling (PCCC) scale (UCSF Person-Centered Reproductive Health Program, 2021). Respondents are asked to rate their most recent contraceptive care visit on four items: respecting the respondent as a person, letting the respondent say what mattered to them about their birth control, taking the respondent’s preferences about their birth control seriously, and giving the respondent enough information to make the best decision about their birth control. Following published guidance, we considered respondents who rated their providers as “excellent” on all four items to have received patient-centered contraceptive care (Dehlendorf et al., 2021; Dehlendorf & Silverstein, 2018). Respondents who rated their provider as less than excellent on one or more of the subscales were considered as not having received patient-centered contraceptive care.

Our dependent variables representing contraceptive method use include current use of any method, use of a provider-involved method, use of a method with a cost, and satisfaction with method use. On both the baseline survey and the follow-up surveys, respondents were asked if they had used any method of birth controlFootnote 5 in the past 3 months and, if so, what type of method(s) they had used. Overall method use was coded as a dichotomous variable, with respondents who reported using a method at any time in the past 3 months coded as “yes” and those with no recent use coded as “no.”

We examined method type among contraceptive users in two ways: use of a provider-involved method and use of a method with a cost. We considered use of any method that required contact with a health care provider for either initiation or ongoing maintenance during the study time frame as provider-involved, including oral contraceptive pills, the patch, the vaginal ring, and the shot. Respondents who reported having newly received a tubal ligation or IUD or implant during any of the survey waves were coded as using a provider-involved method for that wave only. In subsequent waves, they are coded as not using a provider-involved method. We considered use of a method with cost to include all of the same methods as the provider-involved group in addition to use of condoms or other barrier methods and emergency contraception. Respondents who reported using abstinence in the past 3 months, withdrawal, natural family planning methods, or a partner’s vasectomy were considered to be using a method with no cost. Those who reported initiation of a tubal ligation, IUD, or implant during the study time frame were considered to be using a method with cost starting at the first report of use of these methods and considered to be using a method without a cost through subsequent waves.

Our final dependent variable representing contraceptive method use focuses on method satisfaction among contraceptive users, based on responses to two separate items. In baseline surveys, respondents were asked to rate their satisfaction with their current method on a 5-point Likert scale from very satisfied to very dissatisfied. In follow-up surveys, respondents were asked if the current method they were using was the method that they wanted to be using. We combined these variables in the following manner: responses of “very satisfied” or “somewhat satisfied” with their method (baseline) and “yes” to using their preferred method (follow-up) were considered as satisfaction with a method at the corresponding survey wave, while responses of satisfaction lower than “somewhat” at baseline or a “no” on use of preferred method were considered as respondents not being satisfied with their method at the corresponding survey wave.

The main independent variables in this study are time and exposure. Specifically, time refers to the months before the Final Rule was first announced in March 2019 (pre-exposure) and the months after it was implemented in August 2019 (post-exposure).Footnote 6 We examine responses received between the months of April 2018 and February 2019 from the baseline and month 6 follow-up survey as pre-exposure data and responses received between the months of October 2019 to February 2021 from the month 12, 18, and 24 follow-up surveys as post-exposure data; this strategy allows us to both track changes in key outcomes over multiple time points and maximize sample size for the analysis. Of note, in 2017, 2 years prior to the change in the Title X regulations, Iowa legislators implemented a state-level Medicaid family planning program that removed funding eligibility from health care sites that provided abortion care or referrals and, as such, removed the ability of patients enrolled in this state family planning program to access subsidized SRH care at these sites. Given the decreased availability of publicly funded family planning care in Iowa following these changes, the implementation of the Final Rule may have further dampened access. The present study seeks to examine this additional decrease in access to SRH care in Iowa.

Prior to the Final Rule, Title X grantees in Iowa included the state health department and the Family Planning Council of Iowa (FPCI) (Office of Population Affairs, 2019). Following implementation of the Rule, one key subrecipient of FPCI, Planned Parenthood of the Heartland (now called Planned Parenthood of the North Central States), along with all other Planned Parenthood affiliates across the country and some individual health centers funded by one of the two Iowa grantees, left the Title X system. We define the exposure variable as whether a respondent received care at a Title X-funded health care center that subsequently left the Title X network after the Final Rule was implemented either at baseline (the site of study recruitment) or sometime in the 12 months prior based on baseline survey responses; that is, all respondents in the exposure group had, at baseline, recently received care from an impacted Title X site, regardless of whether the site they were recruited from at the baseline time point was an impacted Title X site.Footnote 7 Given the focus of the Final Rule specifically on health care sites within the Title X system, these sites were hypothesized to be the most likely locations where patients would experience potential impacts of the Rule. By contrast, the control group (exposure variable = 0) comprised respondents who had received care, at baseline and in the 12 months prior, at a health care center that either did not receive Title X funds for the delivery of family planning care or was a Title X-funded health care center that subsequently stayed in the Title X network following the 2019 Title X Final Rule.

We include several demographic variables in our analysis, some measured only at baseline (respondent age, respondent income as a percentage of the federal poverty line, race and ethnicity, educational attainment, nativity (within or outside of the USA)), while others were time-varying and measured at baseline and in follow-up surveys: sexual orientation, gender identity, relationship status, insurance status, and employment.

Analytic Strategy

First, among both the broader sample and among those who were not trying to become pregnant, we ran descriptive analyses of respondent demographics and key outcome variables pre- and post-implementation of the Final Rule. Next, we calculated differences in baseline demographic characteristics between our control and exposure groups using Pearson’s chi-squared tests for categorical variables and Welch’s t-test for age. We also used these tests to look at differences in post-exposure demographics between the control and exposure group. We also calculated differences in the seven key outcomes overall (three to represent access to care and four to represent contraceptive use) within both the control and exposure groups over the pre- and post-implementation period and between the control and exposure groups at each follow-up survey wave, as well as overall differences between the two groups at each pre- and post-implementation period, using Pearson’s chi-squared tests. For these tests, we considered differences between groups to be significant at the p < 0.05 level.

To examine the difference over time in these seven key variables, we ran logistic regression models with a time by exposure interaction term to calculate the difference-in-difference (DiD) estimator. We additionally account for unbalanced panel data and clustering at the facility level. We first ran simple versions of these models without the time by exposure interaction term to examine the bivariate relationship between respondents’ pre-exposure demographic characteristics and each key outcome variable. For each of the seven dependent variables, we entered all covariates that were significant at the p < 0.1 level in the simple model and any covariate with theoretical significance into a multivariable logistic regression model to produce adjusted DiD estimates. Covariates in the adjusted models include age, income, race and ethnicity, sexuality, education, relationship status, insurance status, and employment.Footnote 8 We present all results from our models as the difference in predicted probabilities between the exposure group and the control group over the time periods.

We ran the model examining the outcome of receipt of recent SRH care among the full analytic sample; all six other models focused more narrowly on contraceptive access and use included only respondents not trying to become pregnant. To maintain the integrity of our pre- and post-Final Rule implementation timeline, we only include responses in the post-exposure time from months after March 2020—6 months post-policy implementation period—for any analyses examining the three access to care outcomes, as these outcomes represent care received in the previous 6 months and we wanted to ensure that these metrics were not being assessed during the exact time frame of Rule implementation. In addition, we limit analyses examining the three contraceptive use outcomes related to grouped method use (provider-involved or carrying cost) and method satisfaction to respondents who reported current contraceptive use at the corresponding survey wave.

In order to isolate the potential impact of the COVID-19 pandemic on our study outcomes focused on contraceptive use, we conducted a sensitivity test in which we truncated the post-exposure time period in our DiD models at February 2020, the month prior to the public health emergency declaration of the COVID-19 pandemic in the United States. We cannot run this sensitivity test for our study outcomes focused on access to care, given that these items asked about care over the previous 6 months, potentially overlapping with the policy implementation period examined in this analysis (March–August 2019).

Lastly, as a post hoc test to check the parallel trend assumption—that differences observed between groups in a DiD model were not already occurring prior to exposure—we used the same difference-in-difference model with an interaction term for time and exposure to calculate differences for all seven outcomes between the exposure groups in the 10 months leading up to the Final Rule implementation period in March 2019. We examined differences between the outcomes between responses from the first 5 months (end of April 2018–September 2018) and the subsequent 5 months (October 2018–February 2019) until the start of the implementation period. This approach allows us to examine trends from a time point further away from the implementation period and one that was closer while utilizing all available data. All statistical analyses were conducted in Stata version 17.0.

Results

Sample Characteristics

We present a flow diagram of study participants and analytic sample, by control and exposure groups, in the pre- and post-exposure time periods in Fig. 1. We present baseline characteristics of respondents in Table 1. We also present characteristics of the analytic sample in the pre- and post-exposure time periods among the full sample and among the narrower sample of respondents not trying to become pregnant; among this latter group, we present further breakdowns of characteristics of the analytic sample at both the pre- and post-exposure time periods by control and exposure groups. We draw on data from 621 respondents who completed the baseline survey at one of 17 participating health care centers in Iowa and gave consent to be contacted for further surveys (Fig. 1). We use pooled responses from April 2018 to February 2019 for the pre-exposure period (N = 621) and we pooled responses from September 2019 to February 2021 for the post-exposure period (N = 385); analyses examining receipt of recent SRH care among all respondents draw on these responses. Analyses examining the six outcomes related to contraceptive access and use, which exclude 42 individuals from the full sample who reported trying to become pregnant at any survey time point, draw on a narrower sample of 579 respondents in the pre-exposure period and 351 in the post-exposure period. The exposure group—those who had received recent SRH care at a Title X health care center at baseline that subsequently left the network after the Final Rule—draws on 367 respondents in the full sample (not shown in table) and 344 in the narrower sample, while the control group—those who had received this care at a health care center not receiving Title X funds—draws on 254 respondents in the full sample (not shown in table) and 235 responses in the narrower sample.

Fig. 1
figure 1

Flow chart of study participants and analytic sample, by control and exposure groups, pre- and post-exposure. * “Recent care” refers to care received by the respondent either at baseline (the site of study recruitment) or sometime in the 12 months prior based on baseline survey responses. Site of any subsequent care received after baseline is not included in the determination of our exposure variable

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Table 1 Demographic characteristics of Iowa family planning patients ages 15 + at baseline and tabulations of these characteristics at time periods pre-exposure1 (responses from baseline and month 6 follow-up surveys prior to March 2019) and post-exposure (responses from month 12 follow-up, month 18 follow-up, and month 24 follow-up surveys after August 2019) to the Trump Title X Final Rule Implementation, 2018–2021
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Among all respondents at baseline, the majority had incomes < 200% of the federal poverty level (67%), identified as non-Hispanic white (69%), identified as straight (78%), had at least some college or Associates-level education (68%), were neither married nor cohabiting (63%), had either public or private health insurance coverage (85%), had been born in the United States (93%), were employed (59%), and identified as cisgender (99%). Respondents’ mean age was 26 years old.

Among respondents not trying to become pregnant at any point during the study period, there were no differences in demographic characteristics between those in the control group and those in the exposure group during the pre-exposure time period. Within the post-exposure time period, there was a higher proportion of individuals who had incomes < 100% of the federal poverty level among the exposure group (39%) compared to the control group (27%; p < 0.05).

Key Outcomes

We present changes in key outcomes of access to care and method use within the control group and within the exposure group in the pre-exposure and post-exposure periods and between exposure groups at each survey time point, and p values for significant differences, with each survey time point shown separately in Fig. 2. Additional data behind these changes, including Ns and the percent difference in each outcome over time, are included in Appendix 1. We present visual depictions of these changes and the differences in these changes in Fig. 2.

Fig. 2
figure 2

Changes in reproductive health outcomes between pre- and post-exposure to the 2019 Title X Final Rule among Iowa family planning patients, 2018–2021. Note that we consider August 2019 as the date of policy implementation for this analysis. However, given the initial issuance of the Final Rule in March 2019 and the likely differential time it took for operationalization of the Final Rule at the health center level, we represent this broader period of time in our figures. Sample represented in figure includes Iowa family planning patients ages 15 and older recruited between 2018 and 2019 and indicating that they did not intend to become pregnant at any time point during the study period. Point estimates presented at each time point represent the aggregated responses from the months that fall within each survey wave. Pre- and post- exposure difference (marked by open circle or triangle at month 24) refers to within exposure group differences over the pre- and post-exposure times. Control and exposure group difference (marked by filled in circle or triangle) refers to between group differences at each survey time point. Respondents from month 12 who responded before March 2020 were excluded from outcomes related to receipt of recent care because their recent care (6 months prior) could have occurred pre-exposure

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Respondents’ reports of receiving recent SRH care and receiving recent contraceptive care declined significantly over time within both the control and exposed groups but the decline was steeper within the exposed group than within the control group (p < 0.001).

Overall contraceptive use remained high and unchanged over the study among both the control and exposed groups. We found significant differences in the use of provider-involved methods between the control and exposure groups at multiple survey time points within the pre- and post-exposure periods, but we did not find significant changes in this outcome from the pre- to post-policy periods overall within either group. Respondents’ use of a method with cost significantly decreased over the survey period among the exposed group (p < 0.001) but remained unchanged among the control group. There was a significant decrease in reports of satisfaction with contraceptive method over the study period for the exposed group (p < 0.05), but no change in this outcome for the control group between the pre- and post-exposure time periods.

Difference-in-Difference Estimates

We present the estimated difference-in-difference of predicted probabilities for the adjusted relationship between the 2019 Title X Final Rule and our seven key outcomes in Fig. 3, with additional information on both the adjusted and unadjusted DiD models included in Appendix 2. After adjusting for respondents’ demographic characteristics, we found a significant association between the Final Rule and receipt of recent contraceptive care such that predicted probability estimates for receipt of recent contraceptive care among those in the exposure group—respondents who recently received care at Title X sites at baseline that subsequently left the Title X program—were 11 percentage points lower than these estimates among those in the control group—respondents who recently received care at non-Title X sites at baseline or Title X sites that remained in the program (p < 0.01).Footnote 9

Fig. 3
figure 3

Estimated difference-in-difference (predicted probabilities) of access to care and contraceptive method use outcomes between exposed and control groups pre- and post-exposure to the 2019 Title X Final Rule, among Iowa family planning patients, 2018–2021. Note that exposure is defined as having received care at a Title X site at baseline or up to 12 months prior that later exited the Title X program due to the 2019 Title X Final Rule implementation

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We did not find evidence of an association between the Final Rule and respondents’ receipt of recent broad SRH care or experiences of person-centered contraceptive care between the exposed and control groups over time. We also found no association between the Final Rule and current use, use of a provider-involved method, use of a method that carries cost among contraceptive users, or reports of method satisfaction among contraceptive users, between those in the exposed and control groups over time.

In our sensitivity analysis isolating the impact of the Final Rule from that of the COVID-19 pandemic (Fig. 4 and Appendix 3), we found a significant association between the Rule and three of the four contraceptive use outcomes: use of a provider-involved method, use of a method that carries cost, and satisfaction with method used. Specifically, prior to the onset of the pandemic and after adjusting for respondents’ demographic characteristics, among those in the exposure group, predicted probability estimates for use of a provider-involved method were 13 percentage points lower (p < 0.01), predicted probability estimates for use of a method that carries cost were 11 percentage points lower (p < 0.05), and predicted probability estimates for reporting satisfaction with one’s method were 18 percentage points lower (p < 0.001), all compared to those in the control group.

Fig. 4
figure 4

Estimated difference-in-difference (predicted probabilities) of contraceptive method use outcomes between exposed and control groups pre- and post-exposure to the 2019 Title X Final Rule, among Iowa family planning patients, prior to official COVID-19 shutdowns, 2018–February 2020. Note that exposure is defined as having received care at a Title X site at baseline or up to 12 months prior that later exited the Title X program due to the Title X Final Rule implementation. Post-exposure time period pools responses received during the months after the policy implementation (August 2019) and before the official recognition of the COVID-19 pandemic in the United States in March 2020

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In reviewing the results from our post hoc test, we observed one significant difference between the first 5 months and the last 5 months before the start of the implementation period such that respondents in the exposure group had predicted probability estimates of reporting satisfaction with their contraceptive method 8 percentage points higher than respondents in the control group over that time period (p < 0.1). However, we do not observe any significant differences within this pre-exposure time period for any other outcome, indicating that our main difference-in-difference models for the other outcomes do not violate the parallel trend assumption.

Discussion

Previous evidence has established the clear impacts of the 2019 Title X Final Rule on the capacity of the Title X health care system to deliver high-quality SRH care to patients: reduced numbers of health care centers receiving Title X funds and 1.5 million fewer patients being served within the system (Frederiksen et al., 2020). Our study expands understanding of the extent of the impacts of this Rule by highlighting the trickle-down effects of the Rule on patients themselves with regards to reduced access to contraceptive care, a critical component of SRHW. Our findings indicate that the Final Rule undermined the ability of the Title X system to fulfill its core mission of ensuring access to a broad range of family planning services for millions of low-income individuals (Office of Population Affairs, 2021), thus working against tenets of SRHW. Additionally, this evidence contributes to a growing body of literature documenting the harms to people’s reproductive freedom and autonomy perpetuated by policies aiming to restrict access to any aspect of SRH care (Malcolm et al., 2021).

Patients who had accessed SRH care at a Title-X funded health care center prior to the 2019 Title X Final Rule that subsequently left the network had lower levels of contraceptive care after the Rule was implemented than those who had initially accessed this care at a site that either stayed in the network or were never a part of it. This difference in contraceptive care may be indicative of insurmountable cost barriers faced by the exposed group, even as this group had high levels of health insurance coverage, as the reduced or no-cost access to care historically available through the Title X program had diminished following the implementation of the Rule. Given the Title X system being set up specifically to address and reduce cost barriers to contraceptive care, policy restrictions that prevent the realization of this goal most directly impact individuals with the fewest resources to surmount these barriers. Evidence from patients in Texas following the implementation of a 2011 state policy reducing access to subsidized family planning care demonstrate that this reduced access can lead to foregoing SRH care, aligning with our findings in Iowa (Hopkins et al., 2015). Additional evidence from Texas documents the pathway of reduced access to subsidized SRH care to reductions in contraceptive use and abortions to ultimate increases in birth rates among some population groups (Fischer et al., 2018; Stevenson et al., 2016). Building on this Texas-specific evidence, our findings help to demonstrate the path through which a policy aimed at restricting and stigmatizing abortion can lead to dampening effects on contraceptive access, highlighting the false bifurcation between these two essential and related aspects of comprehensive sexual and reproductive health and well-being.

Beyond associations between the Rule and contraceptive care, we found additional evidence that the Final Rule was associated with patients’ use of, and satisfaction with, contraceptive methods. Specifically, in our sensitivity test isolating the impacts of the Rule from the COVID-19 pandemic, we document additional associations between the Rule and patients’ contraceptive outcomes, including use of provider-involved methods, which are often the methods that are most preferred (Chakraborty et al., 2021). We interpret this finding as tentatively indicating that experiencing diminished access to the high-quality, more affordable, and more comprehensive SRH care historically associated with the Title X system may have resulted in patients shifting their contraceptive use to a method that they preferred less, running counter to the tenets of reproductive autonomy (Hasstedt, 2019a). These findings align with other studies demonstrating that cost is a key barrier to using preferred methods of contraception (Chakraborty et al., 2021; Kavanaugh et al., 2022). Although we were not able to isolate the impact of COVID-19 on all of our study outcomes and we draw on a limited number of data points in this sensitivity analysis, we interpret these results as a potential indication that the universality with which all patients experienced the COVID-19 pandemic may have dampened the ability of our models to fully detect the impact of the Rule on patients by equalizing differences in outcomes across the exposure and control groups.

The majority of studies tracking the impact of policy changes on contraceptive outcomes focus on overall use or use of specific types of contraceptive methods, like LARC methods, whereas our study includes the more patient-centered contraceptive use outcome of satisfaction with methods (Darney et al., 2020; Malcolm et al., 2021; Stevenson et al., 2016; Sumarsono et al., 2021). Incorporating more of these patient-centered outcomes into research documenting impacts of policy changes is an important shift towards capturing the full picture of changes that may be occurring. In addition, national evidence indicates that patient-centered contraceptive counseling can mitigate cost barriers to using preferred contraceptive methods (Kavanaugh et al., 2022), potentially via patient-provider discussions about anticipated cost barriers and proactive strategies for navigating them (Dehlendorf et al., 2014). Although we did not find a clear association between the Final Rule and Iowan patients’ experiences of patient-centered care, this link should be an important focus of future research to understand the broad impacts of the 2019 Title X Final Rule on patient-centered outcomes.

Although the Biden administration quickly moved to reverse the 2019 Title X Final Rule in January 2021, the new Title X regulations did not officially go into effect until November 2021, and the recent flat funding of the program in the spring of 2022 is inadequate to meet the full breadth of needs of potential patients (NFPRHA, 2021). The network remains in flux as providers work to bring their services back to the pre-Rule level with limited funding to do so; this work is exacerbated by the disruptions in service delivery incurred due to the COVID-19 pandemic. In Iowa, where there was about a 30% drop in Title X-funded health care centers and a corresponding almost 50% drop in patients served in Iowa Title X sites following the Final Rule, 23 distinct service sites were recipients of Title X funding in the spring 2022 grant cycle (Frederiksen & Gomez, 2021; Office of Population Affairs, 2022a). It remains to be seen whether the reductions in access and contraceptive use documented in our study will continue, stabilize, or be reversed with the changed regulations and updated network within Iowa. Future research should document the extent to which the 2019 Title X Final Rule impacts are mitigated in specific states and broadly across the national Title X program.

Our study has both strengths and limitations to note. A key strength is the use of panel data following individuals over 2 years from before and after the implementation of the policy under examination and the adoption of a DiD approach to tease out differences in key outcomes between those exposed to the policy and those not. At the same time, our findings represent patients accessing SRH care in Iowa, a state with a different context surrounding the delivery of SRH care and the legislative support for it than many other states. The fact that the Medicaid restrictions in IA seemed to already be dampening access to SRH care prior to this study focused on the 2019 Title X Final Rule points to our findings being conservative with regards to the size of the potential impact overall for patients needing SRH care in Iowa during these years. Patients in our study had higher levels of private health insurance coverage and lower levels of being uninsured than the national profile of publicly funded family planning patients in 2019 (Fowler et al., 2020); this coverage may have been a cushion that also lessened the financial impact of the 2019 Title X Final Rule on individuals’ outcomes, especially for those in the exposure group, given increases in private insurance among this group over the study period. A low response rate across participating sites in our study limits the extent to which we are able to generalize these findings to the full population of patients who receive family planning care at publicly funded sites in Iowa. Operationalization of the Final Rule may have occurred in a staggering manner across health care centers within the network between the time when the regulations were issued (March 2019), when providers were required to certify their “good faith” to comply with the regulations in August 2019, and how long it took for them to implement the changes at the health center level. We identified the August 2019 time point as the exposure to the Final Rule in our study based on the best available information from national entities working with these providers, but we acknowledge that this time point may not exactly represent the timing of when service delivery changes due to the Rule were implemented at each individual health center. Finally, while we account for as many covariates as we have available in our difference-in-difference models, there may still be unobserved characteristics of respondents that we cannot account for. Although we do not have strong evidence of violations of parallel trends in our pre-exposure period, a specific limitation for this analysis is the assumption of linearity of our pre-exposure time trends.

Policy Implications

Using Iowa as a case study to understand how the 2019 Title X Final Rule may have changed family planning patients’ sexual and reproductive health outcomes, we found evidence of a negative association between the Rule and patients’ access to health care and contraceptive use. These findings expand the evidence base of the impact of the Final Rule on the Title X health care system and its capacity to provide SRH care by highlighting the trickle-down effects of the Rule on patients themselves. Policies that restrict access to any aspect of sexual and reproductive health care, including contraception and abortion, are in direct conflict with people’s realization of reproductive autonomy. Policy makers, advocates, and public health professionals should continue to work to mitigate the ongoing harmful effects of policies like the Final Rule on the Title X system and on the patients it serves, even as the specific regulations of the 2019 Title X Final Rule have been rescinded. This is especially critical as direct threats to abortion access and other reproductive health care continue across the country.