Assessing the impact of federal restrictions to the Title X program on reproductive health service provision between 2018 and 2022 in the United States.

Objectives: In 2019, the Trump administration introduced rule changes, colloquially known as the "Domestic Gag Rule," to the federal Title X program. As a result, many grantees withdrew from the program. This study aims to assess the impact of the rule change on service provision within the Title X program, both while the rule was in place and in the period following its reversal.

Study Design: We obtained disaggregated Family Planning Annual Report data for all states from 2018 to 2022. Using a previously created variable determining the proportion of each state's Title X capacity loss from the 2019 rule (0%, 1-24%, 25-50%, 50-89%, 90-99%, 100%), we conducted mixed effects linear regression exploring outcomes of interest (number of total clients served; number of female/male contraceptive methods provided; contraceptive method mix; sexually transmitted infection [STI] services provided) prerule change (2018), during the rule change (2019-2021), and postrule change (2022).

Results: During the rule change period, the average total number of services Title X provided decreased by 16% nationwide from the prerule change period. However, states with higher levels of reduced capacity saw significant additional losses in reproductive health service provision. The total number of clients, the number of female/male contraceptive methods, and the number of STI services provided did not improve in the postrule change period. In addition, the number of moderately effective methods provided decreased significantly during the rule change period and continued to decline postrule change.

Conclusions: Title X services were significantly impacted by the rule change, and subsequent recovery is slow.

Implications: During the 2019-2021 Title X rule change, there was a nationwide decrease in reproductive health services provided (contraceptive services, STI testing) through Title X. States with higher capacity loss had a more significant decline. Postrule change, service levels did not return to prerule change levels, indicating a slow recovery.