Two Planned Parenthood clinics in Ohio will close their doors today as dozens of other reproductive health centers struggle to remain open after the organization rejected millions of dollars from a federal family planning program that banned abortion referrals.

The closures in Cincinnati are just the beginning of what abortion rights advocates say will be an uphill battle as groups figure out how to make up the federal Title X funding.

About 4 million patients are served nationwide under Title X, which distributes $260 million a year to provide reproductive health care for poor women.

So far, 16 recipients, including several Planned Parenthood partners, have withdrawn from Title X in protest of a new policy that blocks them from referring patients to abortion providers. Of those 16, at least seven groups were the sole recipients of Title X money in their state.

Many of the clinics do not perform abortions, but provide birth control, sexually transmitted infection testing and treatment and cancer screenings covered by the program.

"The Trump administration has put us in a terrible, terrible situation," said Clare Coleman, president and CEO of the National Family Planning and Reproductive Health Association. “I keep trying to underscore that the effect on patients and their lives and their health could be devastating."

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Anti-abortion groups, however, praise the new policy. David O’Steen, executive director of National Right to Life, said it enforces the fact that Title X was not designed to promote abortion as a method of family planning.

O'Steen said he believes Planned Parenthood's decision to reject funding and close clinics is "purely political."

"No one is taking the money away from them," O'Steen said. "They are taking it away from themselves."

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The new policy comes amid sweeping measures by Republican lawmakers to restrict access to abortion. Many states have passed abortion bans this year with hopes that legal challenges will escalate to the Supreme Court and overturn Roe v. Wade.

Earlier this week, the Guttmacher Institute released a study showing the number of abortions in the nation has dropped to its lowest level since the procedure became legal in 1973. The study cited a decrease in pregnancies due to increased access to contraceptives.

Some states, including New York and Washington, have pledged to replace Title X funding for organizations that opted out of the federal program.

Elsewhere, the loss is likely to result in more clinic closures, staffing cuts, shorter hours, fewer services, and more out of pocket costs to patients.

“I am begging people to try to find a way to stay open,” Coleman said.

The two closing Cincinnati Planned Parenthood clinics in Springdale and Western Hills served more than 6,000 patients a year, many of whom were women of color.

Kersha Deibel, president of the Planned Parenthood Southwest Ohio Region, said the loss in Title X money combined with state lawmakers' funding cuts for STI testing forced Planned Parenthood to close the two centers. Neither clinic provided abortion services.

Patients now will have to find transportation to other family planning centers or go without care, Deibel said.

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The loss is especially tough for the community because Cincinnati has the highest rates of chlamydia and gonorrhea in the state, according to Planned Parenthood.

“This is the culmination of many harmful attacks,” Deibel said. “We are teetering on a public health crisis.”

Coleman said her group is still fighting in the U.S. Ninth Circuit Court of Appeals to block the Title X rule while attorneys challenge its merits in court. The appeals court denied a motion in July allowing the federal government to enforce the policy.

Funding options

Many clinics that remain open are racing to find ways to fund their services.

The Planned Parenthood Association of Utah, the state's only Title X grantee since 1983, received $2 million a year from the federal government. Now, some 39,000 Title X patients risk losing their care, said Karrie Galloway, president of the association.

Galloway said there are no immediate plans to close any clinics. She is considering alternative funding sources such as tapping private donors for more money or charging patients a $10 co-pay for every visit.

“We want to make sure that we can provide the most affordable reproductive healthcare to serve the people of Utah," Galloway said. “But the reality is, it costs money. The clients will have to share in the cost."

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Coleman said co-pays could be challenging for many patients. Nationally, 65% of Title X patients earn less than $12,140 a year.

In New York, Public Health Solutions canceled plans to close two of its clinics earlier this month after lawmakers pledged to make up the Title X funding. The state remains supportive of abortion rights. Gov. Andrew Cuomo signed legislation this year that safeguards Roe v. Wade and permits late-term abortions when a woman's health is at risk.

Lisa David, president and CEO of Public Health Solutions, said the state's $3.8 million pledge will allow the organization and five other family planning groups to continue normal operations through March.

After that, the state will reconsider the allotment for its next budget cycle.

But some reproductive health advocates worry that state governments will not be able to maintain the funding provided by Title X for nearly 50 years.

"It's definitely a concern that we are one of many priorities when the state has to figure out what to do with its budget," David said. "It's definitely not guaranteed."

A 'trusted relationship'

Despite the challenges, family planning centers remain firm in their opposition to the new Title X policy, which many refer to as a "gag rule." They say staying true to their values as healthcare providers meant forgoing the funding.

David said the policy would have prevented Public Health Solutions from giving complete information to its patients.

“We serve tons of adolescents and young people and the core of the success of family planning is trust that’s built between the providers and the patients,” David said. “And we weren’t willing to erode that kind of trusted relationship.”

Galloway called it "unethical" for the federal government to regulate what information doctors can share with patients.

“I don’t tell them that just because they are in need of a federal subsidy they only get part of their information,” she said. “This rule is preying on the most vulnerable people and that’s what I find so appalling.”

Georgia Right To Life Executive Director Zemmie Fleck however, said abortion should not be part of the conversation when physicians discuss options with patients.

"When you're resourcing out for abortion as your method of health care then that’s an issue," Fleck said. "That kind of reveals what their target is."

This article originally appeared on USA TODAY: Trump Title X abortion policy forces Ohio Planned Parenthoods to close