Restrictive policies disrupt individuals’ access to sexual and reproductive health care, which in turn affects people’s ability to afford and use their preferred contraceptive method, according to two new Guttmacher Institute studies. The two papers are part of Guttmacher’s Reproductive Health Impact Study. They describe the disruptions faced by patients who sought care at publicly funded family planning sites in Iowa in 2018, shortly after Iowa opted to leave the federal Medicaid family planning program and establish a state-run program that excluded clinics associated with abortion care from funding. One study focuses on the extent of disruptions to care and outcomes for patients, and the other focuses on the depth of disruptions and patients’ experiences navigating them.

After the new policy was implemented, the share of patients at publicly funded family planning centers in Iowa who had not recently received contraceptive care increased from 32% to 62% during the two-year study period. During this time, the share of patients not using any contraceptive method increased from 9% to 15%. 

While the studies predate the Supreme Court’s June 2022 decision to overturn Roe v. Wade, they illustrate how policy changes in Iowa that were driven by anti-abortion ideology led to serious disruptions in access to affordable contraceptive care. These important new findings come as birth control access in states that have restrictive abortion policies—including Iowa—is receiving increased public attention.

“State and federal policies that restrict access to contraceptive services have direct implications for the sexual and reproductive well-being of individuals who rely on publicly supported care,” says Megan Kavanaugh, principal research scientist at the Guttmacher Institute. “Much like high-profile federal and state policy attacks on abortion, attacks on contraceptive access are designed to undermine reproductive freedom and bodily autonomy. Rather than restricting contraceptive access, policymakers should improve people’s ability to access the care they want and need and more broadly ensure that the full spectrum of reproductive health care—including abortion—is available to all who want and need it.”

Key findings

Both studies seek to understand, from different perspectives, how the implementation of the 2017 Iowa Medicaid restrictions disrupted access to sexual and reproductive health care and subsequently impacted contraceptive outcomes. Taken together, the studies demonstrate a connection between the Iowa Medicaid policy changes, disruptions in access to care and individual patients’ ability to use their preferred contraceptive methods.

"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,” by Megan L. Kavanaugh, Mia Zolna, Emma Pliskin and Katrina MacFarlane, published in Population Research and Policy Review

• Patients who initially sought care at sites that were potentially impacted by Iowa’s decision to leave the federal Medicaid program reported higher levels of shifting to a different site or receiving no care, and of switching to using a free contraceptive method or no method, than those who sought care at sites not impacted by the policy change. 
• 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%. 
• The use of methods that are not free or require provider involvement (like birth control pills or IUDs) decreased over the study period, as did patient satisfaction with their contraceptive method. 

“Access to Preferred Contraceptive Strategies in Iowa: A Longitudinal Qualitative Study of Effects of Shifts in Policy and Healthcare Contexts,” by Lori Frohwirth, Megan L. Kavanaugh, Ayana Douglas-Hall, Katrina MacFarlane and Cynthia Beavin, published in Journal of Health Care for the Poor and Underserved

• During in-depth interviews, patients reported that they had experienced pervasive cost-, access- and quality-related barriers to contraceptive care and devoted a significant amount of effort to overcome these barriers. When patients were unable to overcome barriers to access their preferred contraceptive method, they switched to methods that were not ideal for them or used no method at all. 
• Although cost, access and quality barriers can affect people seeking contraceptive care in any context, respondents reported that the policies Iowa enacted reduced hours and provider availability at clinics, as well as reduced subsidies used to help offset the costs of care and methods. As a result, people described delaying or forgoing care, sometimes exposing themselves to unwanted pregnancy.
• Notably, while the barriers documented in this study were not all necessarily specific to, or directly caused by, the Medicaid policy changes, several cost-related barriers were directly attributed to them.

 
More information on publicly funded family planning services in the United States and related policies is available in Guttmacher’s fact sheet about paying for contraception. Additional information about the Reproductive Health Impact Study is available here.