Navigating Women’s Health: Iowa
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Summary
Reproductive and maternal health care in Iowa is complicated. Iowa fares better than the national average on a number of important metrics, including maternal mortality, sexually transmitted disease, and unintended pregnancy. However, these rates are rising. Since 2017, access to contraception and family planning services in Iowa has significantly declined. Here, we examine some key women’s health concerns in Iowa and offer policy recommendations for improving outcomes.
Family Planning Services, Reduced Access
Fewer Sites
In 2017, Iowa left the federal Medicaid family planning program, which meant rejecting $3 million in Title X funding. Instead, Iowa directed $3.4 million of state funds toward creating an internal family planning network that excluded any facilities that performed, referred to, or discussed abortion. The intention was to exclude all Planned Parenthood facilities, but this incidentally also excluded other facilities, including one of Iowa’s major hospital networks. The broad exclusion was amended to allow hospitals as long as they did not provide abortion services on site. Since the shift in funding, overall access to family planning services in Iowa has decreased. In 2018, Iowa had 43 Title X-funded sites. As of January 2024, there are 18 sites. Between 2018 and 2020, the number of users served at Title X family planning clinics declined by 50 percent. The most recent data shows that family planning clinics in Iowa are still only serving 70 percent of the patients they did in 2018. This means that, despite a slight improvement in resources since 2020, over 8,400 Iowans still cannot access clinics providing contraception and preventative health services.
Fewer Physicians
The decline in clinic access has not been met with a corresponding increase in doctor’s office visits. The number of physicians and OB-GYNs able to perform deliveries in Iowa is declining. Currently, there are 9.1 delivering physicians and 3.8 delivering OB-GYNs per 10,000 women of reproductive age in Iowa, noticeably worse than 10.5 and 4.1 in 2017, respectively. As of 2020, Iowa had only 231 practicing OB-GYNs. Seventy-one percent of counties have no practicing OB-GYNs, and 90 percent of all counties have fewer than three.
Impacted Contraceptive Care
After Iowa refused Title X funding, the share of patients not using any contraceptive rose from 9 percent to 15 percent. Patients who had not recently received contraceptive care increased from 32 percent to 62 percent. Use of the most effective methods of contraception decreased, as did patient satisfaction with their contraceptive method. What’s more, the share of patients using less effective methods rose.
Maternal Mortality
The maternal mortality rate in Iowa is increasing. The Iowa Department of Public Health Maternal Mortality Review Committee’s latest annual report shows that a huge majority of maternal deaths in Iowa are preventable. Of pregnancy-related deaths, the committee determined that 100 percent were preventable. Of pregnancy-associated but not related or undetermined relatedness, 81 percent were preventable. Many of these deaths were due to a failure of the health care system to catch or cure pregnancy-associated health concerns, including a failure of a provider to recognize a problem, failure to communicate the problem, failure to treat, and possible discrimination.
Sexual Health and Preventative Care
Iowa’s rate of sexually transmitted infections used to be well under the national rate, but is accelerating. In 2016, Iowa’s rate of chlamydia cases per 100,000 population was 414.6 compared to the national rate of 494.9. In 2021, Iowa’s rate was 489.0, much nearer to the national rate of 495.5. The chlamydia rate for Black Iowans in 2021 was 2,233.8, 4.5 times greater than the statewide rate.
Gonorrhea trends are similar. In 2016, Iowa’s rate was 83 per 100,000, compared to the national rate of 145.1. In 2020, Iowa surpassed the U.S. rate of 204.5 with a rate of 217 cases per 100,000 people. As with chlamydia, Black Iowans face disproportionately high rates of disease—they experience over 7 times the statewide rate.
Unintended Pregnancy Rates
Iowa’s unintended pregnancy rate is better than the national rate, but is still too high. In 2020, 31.4 percent of pregnancies in Iowa were unintended, compared to a national average of 39.6 percent. The teen birth rate in 2021 was 12.7 (births per 1000 females aged 15-19), under the national rate of 14.2. However much better Iowa than the national average, these rates are still too high, and can be improved.
Actionable Recommendations
LET PHARMACISTS PRESCRIBE CONTRACEPTION:
Given Iowa’s decline in access to family planning services, policymakers must consider better utilizing pharmacists. In about half of all states, pharmacists can now directly prescribe contraception to patients. In regions where primary care is especially hard to come by, pharmacists are often the most regular touchpoint patients have with a health care provider. The consultation for birth control is straightforward, and pharmacists are well equipped to provide it. Preliminary research on this model has shown it can reduce unintended pregnancy—and associated insurance costs—while increasing contraceptive use.
EXTEND THE SUPPLY:
Contraceptive patients report access barriers and prescription refill limits that cap how many refills a patient can pick up at one time. Iowa law allows for a 90-day supply of oral contraceptives at one time, but patients report an inability to get even that. Extended supply means fewer trips to the clinic, which is crucial in Iowa’s current landscape. At least 24 states and D.C. require insurers to cover an extended supply of contraceptives—usually 12 months—which can greatly improve both contraceptive uptake and continued use.
Conclusion
Reproductive health outcomes in Iowa have declined since the state left the federal Medicaid family planning program. Fewer patients receive reproductive health care, and women are using less effective contraceptive methods. The data also indicates that key women’s health metrics—including access to doctors, maternal mortality rate, and STI rates—are all deteriorating. Better support for reproductive health services in the state is needed. Improving funding for low-cost clinics, allowing pharmacists to prescribe contraception, instituting annual supply of contraceptives, and improving the family planning landscape for women is key to reversing the damage done.