Less than a year after the Trump administration finalized the domestic “gag rule,” data shows it has reduced the Title X family planning network’s capacity by nearly half and put contraceptive care for at least 1.6 million female patients at risk.

According to a Guttmacher Institute report released Wednesday, around one in four Title X service sites left the network in 2019 because of the administration’s rule, which prohibits Title X recipients from referring patients for abortion care and forces clinics to financially separate abortion services from Title X-funded activities.

Many providers gave up federal family planning funds so they could continue to provide comprehensive, unbiased information and referrals. An estimated 1,000 clinics no longer participate in the Title X program, reducing the program’s capacity to serve patients by at least 47 percent, according to Guttmacher.

“The one-quarter of clinic sites that lost Title X funding once provided care to almost half of all patients served by the program nationally—as the gag rule intentionally targeted clinics specializing in reproductive health care services, sites that also serve the highest volume of contraceptive patients,” according to Guttmacher’s policy analysis.

The report warned that these numbers likely represent an undercount: Caseload data from some clinics wasn’t available, and the analysis excludes all male patients as well as female patients receiving non-contraceptive care, such as STI testing.

“We have known from the start that the Title X gag rule is a horrendous policy, deliberately designed to undermine affordable birth control access. But now we have an estimate of the true damage being done—and it’s devastating,” Guttmacher Senior Policy Manager Ruth Dawson said in a statement.

Before the Trump administration’s restrictions, the federal family planning program served around 4 million people with low incomes each year. More than 110 public health organizations opposed the proposed family planning restriction in May 2018, panning the rule as “nothing less than an effort to eviscerate access to care and information for people with low incomes and underserved populations.”

Since its establishment in 1970, Title X has led to a sharp decline in the rate of unintended pregnancies. Unintended pregnancy among U.S. teens would have been 44 percent higher without Title X, according to a 2017 analysis. Title X funds are now being given to anti-choice clinics.

Planned Parenthood, which served 40 percent of the nation’s Title X patients, pulled out of the program in August 2019 as a result of the rule, as did other independent family planning providers.

The impact has been particularly high in some states. Guttmacher found that in 18 states, clinics that left the Title X network served at least half of the program’s caseload of female contraceptive patients. In six of those states—Hawaii, Maine, Oregon, Utah, Vermont, and Washington—the entire network of Title X clinics no longer receives funding. In 12 other states, the network’s capacity has been reduced by 50 to 99 percent.

Some states with Democratic-majority legislatures and governors have tried to replace clinics’ lost Title X funding. Such maneuvers, however, are widely seen as a stopgap measure.

The diminished capacity of the nation’s federal family planning program most directly affects people facing systemic barriers to care, including young people, people with low incomes, immigrants, people of color, and LGBTQ people. In 2016, Title X providers were the sole source of medical care for 60 percent of their contraceptive clients.

“These types of clinics are the first places marginalized communities go to take care of their bodies,” said Karla Gonzales Garcia, policy director for the Colorado Organization for Latina Opportunity and Reproductive Rights. “This is just another obstacle from the administration to create more barriers to access basic care. This is about power. This is about trying to dehumanize us.”

For the Latinx community, a reduction in Title X providers can mean losing a trusted source of medical care, Gonzalez Garcia said, and establishing a bond of trust with a new provider is not always easy. Lack of trust with a provider, and barriers like needing to travel longer distances, often means people go without care.

“Our community is running on fears right now because of all the attacks happening to us, and this is just another barrier to access health services,” Gonzales Garcia said. “If you go to another provider, are they going to have the culturally competent services our community needs in order to make healthy decisions for themselves?”

The gag’s rule’s final requirement forcing clinics to physically separate any abortion-related services from Title X-funded services goes into effect March 4. Once enforced, it could result in even more sites and grantees leaving the program. Title X funds are now being given to anti-choice clinics.

A similar rule has been in place for decades in Colorado. While health centers there attempted to comply by building physical barriers and establishing separate financial entities for abortion services, many were denied state funding and ended up closing. Planned Parenthood went from having about 30 health centers in the state to 18 centers by 2018.

“This is about public health at the end of the day—how we are going to take care of other people so we can take care of our communities,” Gonzales Garcia said. “If you want to take care of communities it isn’t just about access to abortion, but how do we take care of all reproductive health, so we can make decisions about ourselves, our bodies, and our communities.”