Reproductive Health Impact Study: Iowa

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The Reproductive Health Impact Study (RHIS) is a multiyear comprehensive research initiative analyzing the effects of federal and state policy changes on publicly funded family planning care in the United States. The study, which focuses on Arizona, Iowa, New Jersey and Wisconsin, documents the impact of these policies over the period 2017−2022 on family planning service delivery and on patients who rely on this care. Iowa was selected as a focus state in 2017 after leaving the federally run Medicaid family planning program and starting its own network that prohibits patients from accessing care at providers with any connection to abortion. For the Iowa study, the Guttmacher Institute is working with the Family Planning Council of Iowa, Planned Parenthood North Central States, and other in-state research and policy partners.

The RHIS was initially conceived in the aftermath of the 2016 election, in anticipation of federal and state efforts to change funding streams and service delivery for publicly funded family planning. As the study progressed, the RHIS team adapted ongoing study activities to document the impact of several events—notably, the 2019 changes to the federal Title X regulations (the Trump-Pence administration’s “domestic gag rule”) and the COVID-19 pandemic.

In early 2021, the Biden-Harris administration took the first step toward rescinding the domestic gag rule by signing a presidential memorandum directing the U.S. Department of Health and Human Services to review the rule and other restrictive Title X regulations and consider whether to suspend, revise or rescind them. In November 2021, the Biden-Harris administration’s Title X rule went into effect, restoring the crucial reproductive health care program to its previous state. The Biden-Harris rule revokes the 2019 Trump-Pence rule and updates regulations to focus on inclusion and health equity.

Ohio and 11 other states filed a lawsuit to block the Biden-Harris rule, which remains in effect while the case continues. Iowa did not join either side of the lawsuit. In 2022, a federal court ruled in favor of the administration; the decision has been appealed. If the current rule is blocked, providers who left the Title X program as a result of the Trump-Pence gag rule might do so again.

Some of the key reproductive outcomes for Iowa residents that are being tracked in the study appear below. Documenting changes to these outcomes over the study period helps identify the effects of changes related to publicly funded family planning care in the state.

RHIS studies and resources

Disruptions and Opportunities in Sexual and Reproductive Health Care: How COVID-19 Impacted Service Provision in Three US States

This study describes the shifts family planning providers in Arizona, Iowa and Wisconsin made to continue providing sexual and reproductive health care during the COVID-19 pandemic. Clinics implemented COVID-19 safety protocols, shifted service delivery methods and staffing to meet patient needs, and expanded telehealth services. These innovations could increase access to sexual and reproductive health care for many patients, but standards must be established to ensure that the focus remains on patients’ needs and preferences.

Read the study and news release (November 2022)

A Prospective Cohort Study of Changes in Access to Contraceptive Care and Use Two Years After Iowa Medicaid Coverage Restrictions at Abortion-Providing Facilities Went into Effect

This study, examines the impact of Iowa’s 2017 decision to leave the federal Medicaid family planning program on publicly funded family planning patients. This policy change led to serious disruptions in access to affordable contraceptive care. Overall, the share of patients who had not recently received contraceptive care increased from 32% to 62% during the two-year study period, and the share of patients not using any contraceptive method increased from 9% to 15%.
Read the study and news release (September 2022)

Access to Preferred Contraceptive Strategies in Iowa: A Longitudinal Qualitative Study of Effects of Shifts in Policy and Healthcare Contexts

This study examines publicly funded family planning patients’ experiences navigating disruptions to contraceptive care following Iowa’s 2017 decision to leave the federal Medicaid family planning program. Patients experienced pervasive cost-, access- and quality-related barriers to contraceptive care and devoted significant effort to overcome these barriers. When they could not do so, they switched to contraceptive methods that were not ideal for them or used no method at all.
Read the study and news release (September 2022)

The impact of policy changes from the perspective of providers of family planning care in the US: results from a qualitative study

This study, conducted in late 2020, examines the impact of restrictive state and federal policies on publicly funded family planning providers at 55 clinics in Arizona, Iowa and Wisconsin. It finds that restrictive policies—including the Title X domestic gag rule enacted by the Trump administration in 2019—negatively impacted clinic finances, providers’ ability to protect patient confidentiality, contraceptive counseling and service provision, and options counseling for pregnant patients.
Read the study and news release (July 2022)

Financial instability and delays in access to sexual and reproductive health care due to COVID-19
This study—conducted in three RHIS states between May 2020 and May 2021—examines access to contraception and other sexual and reproductive health care among almost 1,500 patients at more than 50 publicly funded clinics in Arizona, Iowa and Wisconsin. It finds that the COVID-19 pandemic has prevented or delayed as many as half of family planning patients from getting birth control or related sexual and reproductive health care—and that those who experienced financial hardship were particularly affected.
Read the study, read the news release and download the social media graphic (February 2022)

The policy landscape in Iowa

Iowa’s state policymakers are largely hostile to reproductive rights, although some support contraceptive access to prevent abortions. In 2018, Gov. Kim Reynolds (R) signed a bill to ban abortion at or after six weeks’ gestation, but a district court blocked the law as unconstitutional before it went into effect. In 2019, Gov. Reynolds championed an ultimately unsuccessful bill that would have allowed pharmacists to dispense birth control and offer 12-month supplies. In the 2020 election, Republicans retained their control of the governor’s office, Senate and House.

In 2017—two years before the Trump-Pence administration finalized the domestic gag rule—Iowa left the federal Medicaid family planning program. In making that decision, the state decided to forgo $3 million in federal funding and released itself from that program’s federal standards. Also in 2017, the Iowa legislature designated $3.4 million to create its own state family planning network; the express intent was to exclude any clinic that provides abortion, makes referrals for abortion care or has any other connection to abortion. This prohibition purposefully excluded Planned Parenthood from the program and had the unintentional consequence of excluding other health care facilities, including one of the state’s major hospital networks. In 2018, lawmakers amended the legislation to allow hospitals or clinics that do not provide abortion services on site to be part of the state network.

Funding for family planning in the state remains complex. Along with all other Planned Parenthood affiliates across the country, Iowa’s affiliate, Planned Parenthood North Central States, left the Title X network in August 2019 as a result of the domestic gag rule. The affiliate still receives reimbursement for some care, such as cancer screenings, through the larger federal Medicaid program. However, Iowa’s 2019 budget prohibited federal funding that is funneled through its Department of Public Health and Human Services (including Title X; the Personal Responsibility Education Program, a sex education program; and the Community Adolescent Pregnancy Prevention program) from going to entities that have anything to do with abortion—including providing abortion services and making abortion referrals.

In 2020, a district court overturned these restrictions for the other programs, but not for Title X. The case was appealed, and in 2021, the Iowa Supreme Court upheld the restrictions. Federal funds that do not flow through the state, such as Title X funds that go directly to a grantee, are not restricted in this way.

The Family Planning Council of Iowa currently serves as the state’s Title X grantee.

Abortion is explicitly excluded from sexual and reproductive health care services that are part of the Title X program. Nevertheless, access to abortion is an important component of sexual and reproductive health and well-being, and restrictive abortion laws may affect people’s ability to access contraceptive services, as well as family planning providers’ capacity to provide contraceptive and other sexual and reproductive health care. In June 2022, days before the US Supreme Court overturned Roe v. Wade, the Iowa Supreme Court ruled that the state constitution does not protect abortion rights, opening the door for a renewed push to ban abortion.

In the 2022 midterm elections, Gov. Reynolds won reelection, and the state legislature remained in Republican control. It is likely that there will be continued hostility toward Title X because both the governor and a majority of state legislators oppose reproductive rights and funding for sexual and reproductive health services.

Publicly funded family planning in Iowa

In 2018, 69 sites provided publicly supported contraceptive services in Iowa. Of these, 43 sites received Title X funding and served nearly 30,000 contraceptive patients. Three percent of these patients were served at health department clinics, 44% at Planned Parenthood clinics, 28% at federally qualified health centers, 15% at hospital-affiliated sites and 10% at other sites.

In August 2019, six Planned Parenthood clinics in Iowa that received Title X funding left the Title X program because of the domestic gag rule.

Exclusion of these clinics from Title X resulted in a decline in the program’s capacity. Between 2018 and 2020, the number of female contraceptive patients served by the Title X program in Iowa, as reported in the 2020 Family Planning Annual Report, fell by nearly 50%.1,2,3 This decline is attributed to clinics leaving the program because of the domestic gag rule and to the effects of the COVID-19 pandemic. Nationally, 63% of the decrease in Title X patients served during this time is attributed to the rule and 37% to the pandemic.

COVID-19 and reproductive health in Iowa

The COVID-19 pandemic has led to significant interruptions in patients’ ability to access family planning—particularly for those who rely on publicly funded clinics. Guttmacher researchers found that at the beginning of the pandemic in spring 2020, 33% of U.S. women faced delays or had been unable to get contraceptive or other care because of the pandemic. This decreased to 19% in a second Guttmacher study conducted in summer 2021. RHIS data on the impact of the COVID-19 pandemic on individuals’ ability to access contraceptive methods and sexual and reproductive care in Iowa demonstrate the ongoing challenges of the pandemic at the state level—especially for people who have experienced financial instability as a result of COVID-19.


This study was funded in part through a generous grant from the William and Flora Hewlett Foundation. The views expressed are those of the authors and do not necessarily reflect the positions and policies of the donor.