SIOUX CITY, Iowa (AP) — The first patient to receive services through Siouxland Community Health Center's Title X family planning program needed an expired birth control implant removed.

As the appointment progressed, health care providers discovered a potential sign of cancer.

"She came in, we removed (the implant) and we found a relatively substantial lump in her breast," Brandi Steck, the health center's HIV and Title X program manager, said. "She said she noticed the lump about two months ago and just didn't know where to go."

Before seeking medical care at the health center, the woman unsuccessfully tried calling the former Sioux City Planned Parenthood of the Heartland clinic for an appointment. The clinic closed its doors in June after the Republican-controlled Iowa legislature blocked Planned Parenthood of the Heartland and other health care providers that perform abortions from receiving family planning services funding and established its own state-funded program.

While much of the debate is centered on abortion, the closures of the Planned Parenthood of the Heartland clinics in Sioux City, Burlington, Keokuk and Bettendorf come at a time when sexually transmitted diseases are surging in the state.

Siouxland Community Health Center is expected to help fill some of the gap in services left in the wake of the Sioux City clinic's closure, but the health center won't be providing abortions, the Sioux City Journal reported.

The health center is a sub-recipient of Title X funding from the Family Planning Council of Iowa. Title X is a federal grant program that provides low-income Americans with family planning and preventative health care services, including cervical cancer screening, contraception, infertility counseling and STD testing.

Iowa's new $3 million Family Planning Program (FPP) replaces the Iowa Family Planning Network (IFPN), or the Medicaid waiver for family planning. Providers who offer abortion services can't participate in the FPP.

The FPP helps cover the cost of birth control, pelvic exams and sexually transmitted disease testing and treatment for men and women ages 12-54 with household incomes at or below 300 percent of the federal poverty level, as well as women who have a pregnancy end while they're receiving Medicaid.

Besides Planned Parenthood of the Heartland, UnityPoint Health and the University of Iowa Hospitals and Clinics were also ineligible to participate in the FPP because, in rare cases, some of their providers perform abortions.

Iowa Department of Human Services data shows a significant drop in family planning program enrollment five months after the state switched from the IFPN to the FPP.

According to the data, which was obtained by the Journal through a Freedom of Information Act request, the FPP had 6,542 enrolled members in December 2017, just 46 percent of the enrollees the IFPN had in December 2016. Family planning program enrollment has been declining since at least December 2013, according to the data.

"The FPP and IFPN are programs with limited benefits and declining enrollment due to increased health care coverage through the Affordable Care Act, as FPP and IFPN do not meet the definition of required 'minimal essential coverage,'" Matt Highland, public information officer for the Iowa Department of Human Services, said of the decline.

As efforts to "defund" Planned Parenthood ramp up, Iowa's abortion rate is down.

According to the Guttmacher Institute, a research and policy organization committed to advancing sexual and reproductive health, Iowa's abortion rate declined by 23 percent between 2011 and 2014, from 9.7 to 7.5 abortions per 1,000 women of reproductive age. Some 4,380 abortions were provided in the state in 2014.

In fiscal year 2016, Sioux City's Planned Parenthood of the Heartland clinic, which stopped offering surgical abortions in 2014, served 2,305 patients through 4,747 visits. Siouxland women seeking abortion services will have to travel to Sioux Falls or Omaha.

As for patients seeking other family planning services, Steck said she is unsure exactly how many the health center will end up absorbing. Its Title X funding covers patients living in Woodbury, Cherokee, Plymouth and Ida counties.

"We don't really know how big that gap is," she said. "We didn't know exactly what to expect with our first week and it was more patients than I thought we would see."

Steck said most former Planned Parenthood of the Heartland patients are finding out about Siouxland Community Health Center's expanded family planning services by word of mouth.

The Iowa Department of Human Services has a database on its website that Iowans can use to find a provider, but it seems to be fraught with errors. Some of the hospitals and clinics listed say their health care providers don't belong in the database.

"We were not aware that these providers were listed as a Family Planning Program provider, nor do we have control of this website. These providers do not provide family planning services," a statement from Mercy Medical Center — Sioux City read. Mercy's parent company is Trinity Health, a national Catholic health system. The Catholic church opposes artificial contraception.

Even though UnityPoint Health providers can't participate in the FPP, Northwest Iowa Hospital Corporation, which UnityPoint Health-St. Luke's does business as, appeared twice in the results of a search conducted March 12, along with St. Luke's emergency room physicians. Northwest Iowa Hospital Corporation has since been removed from the list of providers.

"Due to recent changes in the law, UnityPoint Health facilities and providers, including UnityPoint Clinic, are not in the approved network for the Family Planning Program," said Suzie Fischer, a spokeswoman for St. Luke's. "DHS is in charge of the Family Planning Program provider database, so we can't speak to the discrepancy in what DHS has stated in terms of who is able to provide FPP services versus what is listed on their site."

Highland said the provider list was updated in early March and that the department continues to accept providers who meet the FPP's requirements.

According to Iowa Department of Public Health preliminary data, there were 3,600 cases of sexually transmitted disease in Iowa in 2017, a 145 percent increase since 2013, and a one-year increase of more than 38 percent. While there were 99 fewer cases of chlamydia detected in Woodbury County in 2017 than in 2016, gonorrhea cases rose from 131 to 172.

Tyler Brock, Siouxland District Health Department deputy director, said he has seen an uptick in patients seeking STD testing and treatment at the health department since Sioux City's Planned Parenthood of the Heartland clinic closed its doors. Siouxland District Health Department recently expanded its free STD testing services and trained additional staff members to perform female exams.

"We don't know for sure whether that's the cause of our increase, as our numbers can vary significantly from year to year," Brock said. "But it's reasonable to assume that Planned Parenthood closing has led to an increase in the amount of individuals coming to Siouxland District Health Department."

On Siouxland Community Health Center's second day of offering Title X family planning services, Steck said a patient was diagnosed with syphilis. She said this highly contagious STD is the "great imitator," because it mimics so many other diseases. If patients aren't tested for syphilis, Steck said they won't know whether they have it and won't be treated for it.

"It has multiple stages where it can lie dormant, and it's highly infectious. That right there is a public health issue," she said.

Although Steck hasn't heard of any Siouxland patients driving significant distances to Planned Parenthood clinics because they feel uncomfortable receiving services elsewhere, she assumes some will.

Steck, who worked for Planned Parenthood in Illinois for about 15 years, said Siouxland Community Health Center's Title X family planning program providers, Staci Sterud, Jamie Wright and Dena Neiman — who are all advanced registered nurse practitioners, have extensive knowledge in reproductive and sexual health. She said health center staff have put in many hours preparing to deliver the best possible care.

"It's all confidential and nonjudgmental," she said. "The providers are very passionate about this care and are easy to talk to. It's a safe environment."

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Information from: Sioux City Journal, http://www.siouxcityjournal.com