Reproductive Health Impact Study
What Policy Change Means for Women’s Health
The Reproductive Health Impact Study (RHIS) is a multiyear comprehensive research initiative that analyzes 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. For the study, the Guttmacher Institute is working with research and policy partners in each state.
The RHIS was 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 several relevant events—notably, the 2019 changes to the federal Title X regulations (the Trump-Pence administration’s “domestic gag rule”) and the COVID-19 pandemic.
The study uses original in-depth research and a wide range of secondary data sources to create a robust set of scientifically innovative, policy-relevant findings. The project’s objective is to illuminate the effects of policy change from a number of different angles:
- Family planning landscape: Identify how delivery networks are changing in composition and capacity as funding streams and programmatic guidance shift
- Clinics: Quantify changes to the number and types of safety-net health centers available to women, and to the number of women who visit these sites for contraceptive services
- Clinic staff: Describe the perspectives and experiences of clinic staff as they navigate the changing policy landscape while providing high-quality services to patients in their communities
- Patients: Describe the perspectives and experiences of family planning patients as they navigate access and barriers to access within a changing family planning service delivery system
- Reproductive health indicators: Monitor shifts in key reproductive health indicators and expenditures at the state level
These objectives will be achieved through the activities outlined below:
RHIS studies and resources
Cost-related barriers to sexual and reproductive health care: Results from a longitudinal qualitative study in Arizona
This study found that burdensome and unexpected costs from changes in family planning policies influenced whether, when and where Arizona residents sought care. The study, which was published in SSM-Qualitative Research in Health, recruited people assigned female at birth aged 15 and older who accessed sexual and reproductive health care in Arizona in 2019.
Measuring the Relationship Between the 2019 Title X Final Rule and Patients’ Sexual and Reproductive Health Care Access and Behavior in Iowa Using a Difference-in-Difference Approach
This study found that the Trump administration’s “domestic gag rule,” which prohibited Title X funds from being distributed to health care centers that provided any abortion-related care or referrals, negatively impacted publicly funded family planning patients’ access to, and use of, contraception. Drawing on data from 621 patients who sought publicly funded family planning care in Iowa between May 2018 and February 2019, these findings expand our understanding of the influence of the domestic gag rule.
Publicly Funded Clinics Providing Contraceptive Services in Four US States: The Disruptions of the ‘Domestic Gag Rule’ and COVID-19
This study found that family planning providers in the United States experienced changes, disruptions and challenges as a result of the Title X “domestic gag rule” and the COVID-19 pandemic. The analysis includes findings from two waves of surveys conducted with family planning clinic staff at 96 health care facilities in Arizona, Iowa, New Jersey and Wisconsin to capture changes in care between 2018 and 2021.
Effects of the COVID-19 pandemic on publicly supported clinics providing contraceptive services in four US states
This study found that about one-third of publicly supported clinics in Arizona, Iowa, New Jersey and Wisconsin reported reduced provision of contraceptive services for some period due to the COVID-19 pandemic, and another 5% of clinics reported temporarily stopping such services altogether. However, some clinics reported expanding access to some contraceptive services through telehealth.
Primary and reproductive healthcare access and use among reproductive aged women and female family planning patients in 3 states
This study examined the sociodemographic and health care–seeking profiles of individuals in Arizona, Iowa and Wisconsin and found that nearly 20% of respondents reported that they had trouble or experienced delays in obtaining their preferred method of birth control in the past year, primarily as a result of cost and insurance-related barriers. According to the study findings, cost is also a primary barrier to accessing health care services in general.
Where Do Reproductive-Aged Women Want to Get Contraception? Findings from Arizona, New Jersey and Wisconsin
This study finds that 73% of women aged 18–44 in three US states prefer multiple options for how and where to get contraception, including in-person from a health care provider, via telemedicine, via telehealth, at a pharmacy, and through innovative strategies such as drones or bike messengers. People who had not previously received contraceptive care that focused on their needs and preferences and those who mistrusted the health care system were more likely than others to prefer telehealth or innovative sources of care. Efforts to expand options for how people can obtain contraception should not prioritize one delivery source over others and should ensure that high-quality care is maintained across all options.
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.
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 and download the social media graphic (February 2022)
Title X grantee conference presentation
This five-minute presentation—including both slides and a recorded video—provides an overview of the RHIS. The presentation features a poster presenting some of the key ideas and preliminary findings discussed in the presentation. The conference was convened by the Office of Population Affairs, part of the U.S. Department of Health and Human Services.
Watch the presentation (July 2021)
State fact sheets
Choose a state:
State policy context and study timeline
- Wisconsin (Feb.): The Republican-controlled legislature enacted a law requiring the Wisconsin Department of Health Services to apply for Title X funds, starting with the state’s 2018 application for the funding cycle that began in 2019. The law requires the state to prioritize public entities and exclude agencies that provide abortions or are affiliated with organizations that provide them.
- Iowa (Apr.): The state discontinued its Medicaid family planning waiver and created its own family planning program that prohibits funding clinics that provide, give referrals for, or have any connection to abortion care. The number of people enrolled in the state-funded family planning program dropped by 75% in the first year of the program.
- Iowa (Nov.): The RHIS launched in Iowa after the state left the federally run Medicaid family planning program and started its own family planning network that prohibits patients from accessing care from providers with any connection to abortion.
- United States (Feb.): The Trump-Pence administration released a grant opportunity that detailed new requirements for providers who want to receive Title X funds. This announcement foreshadowed how the administration would undercut the reach of Title X and the quality of care it supports, both of which were eventually codified in the domestic gag rule.
- Arizona (Jan.): The RHIS launched in the state to understand the effects of policy changes on family planning service delivery in a demographically diverse state with large numbers of immigrant, undocumented and Indigenous residents.
- United States (Mar.): After nearly two years of laying the groundwork, the Trump-Pence administration finalized its domestic gag rule by overhauling the Title X program’s administrative regulations.
- Wisconsin (Mar.): The Department of Health Services won the state’s entire Title X grant. The Trump-Pence administration took this opportunity to shift Title X funding from Planned Parenthood of Wisconsin, which had long been Wisconsin's largest Title X grantee, to the state.
- United States (Mar.): The District of Columbia and 20 states, including New Jersey and Wisconsin, filed a federal lawsuit opposing the domestic gag rule.
- United States (Aug.): Planned Parenthood Federation of America announced that all Planned Parenthood affiliates were leaving the Title X network as a result of the domestic gag rule.
- New Jersey (Aug.): The RHIS launched in the state, which has a long-established family planning network and policies that are generally supportive of sexual and reproductive health.
- Wisconsin (Nov.): The RHIS launched in the state, following confirmation of significant shifts in Title X funding among state grantees.
- United States (Feb.): A Guttmacher analysis estimated that the domestic gag rule had the potential to reduce the Title X network’s capacity to serve female patients seeking contraceptives by at least 46%, potentially affecting 1.6 million patients annually.
- In New Jersey, Title X network capacity was reduced by 50–89%.
- In Arizona and Iowa, Title X network capacity was reduced by 25–49%.
- In Wisconsin, the Title X network was not affected by the gag rule, as this shift had already occurred because of the 2016 state law.
- United States (Mar.): As a result of the coronavirus pandemic, family planning providers across the country shifted to telehealth services and made other safety changes to continue providing services to their clients.
- United States (Apr.): Governors across the country issued executive orders to shut down businesses and activities during the pandemic. Nearly half of the states addressed reproductive health services in their stay-at-home orders or essential procedures orders; policies regarding sexual and reproductive health and rights ranged from supportive to harmful.
- In New Jersey, an executive order protected abortion and the full range of family planning services and procedures.
- In Wisconsin, an executive order protected obstetricians, gynecologists and midwives.
- In Iowa, an executive order limited in-clinic abortion.
- United States (Sept.): The Office of Population Affairs, part of the U.S. Department of Health and Human Services, released the Title X Family Planning Annual Report: 2019 National Summary, which provides the first national and state data on the impact of the domestic gag rule. The report shows that the capacity of the Title X program to serve patients fell by 21% between 2018 and 2019. This decline represents only a partial picture of the damage the program sustained under the gag rule because the rule was finalized in March 2019 and had a staggered rollout, and entities began exiting Title X in large numbers only in the summer of 2019.
- United States (Jan.): The Biden-Harris administration took its first step toward rescinding the Title X domestic gag rule. President Biden signed a presidential memorandum directing the Department of Health and Human Services to review the Title X regulations and consider whether to suspend, revise or rescind them.
- United States (Sept.): The Office of Population Affairs released the Title X Family Planning Annual Report: 2020 National Summary, which provides national and state data on the full impact of the domestic gag rule. The report shows that the capacity of the Title X program to serve patients continued to fall: Nationally, 61% fewer patients were served in 2020 than in 2018. This decline is attributed to clinics leaving the program because of the domestic gag rule and to the effects of the COVID-19 pandemic. An estimated 63% of the decrease in Title X patients served during this time is attributed to the domestic gag rule and 37% to the COVID-19 pandemic.
- United States (Nov.): 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 Title X regulations to focus on inclusion and health equity. Ohio and 11 other states have filed a lawsuit to block the Biden-Harris rule, which remains in effect while the case continues. Other lawsuits are expected.
- Arizona, Iowa, Wisconsin (Feb.): A Guttmacher analysis found that the COVID-19 pandemic disrupted access to birth control—57% of family planning patients in Arizona, 38% in Iowa and 30% in Wisconsin faced delays in, or barriers to, seeking birth control and related services. Patients who experienced financial hardship were particularly affected.
- United States (June): The US Supreme Court overturned Roe v. Wade, the landmark 1973 Supreme Court decision that affirmed the constitutional right to abortion.
- United States (July): A Guttmacher study found that restrictive federal and state policies—including the Title X domestic gag rule enacted by the Trump administration in 2019—negatively impacted publicly funded family planning providers’ clinic finances, ability to protect patient confidentiality, contraceptive counseling and service provision, and pregnancy options counseling.
Study states and partners
RHIS researchers and policy experts work in close collaboration with stakeholders in each study state.
We are grateful for the expertise shared by the following colleagues:
- Arizona Family Health Partnership
- Planned Parenthood of Arizona
- Planned Parenthood North Central States
- Family Planning Council of Iowa
- University of Wisconsin-Madison Collaborative for Reproductive Equity (UW CORE)
- New Jersey Family Planning League
- Other key stakeholders in each state
Key Guttmacher Institute project staff
- Nakeisha Blades
- Ava Braccia
- Ayana Douglas-Hall
- Joerg Dreweke
- Mollie Fairbanks
- Amy Friedrich-Karnik
- Christina Geddes
- Madeleine Haas
- Rubina Hussain
- Kathryn Kost
- Ellie Leong
- Ashley Little
- Managi Lord-Biggers
- Jennifer Mueller
- Lisa Remez
- Melissa Stillman
- Emma Stoskopf-Ehrlich
- Rebecca Wind
- Mia Zolna
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.