In response to legislative attacks against family planning centers and the stacking of anti-choice judges in the federal court system, an organization that advocates for universal access to sexual and reproductive health care has given the United States a failing grade in its annual “The State of Reproductive Health and Rights: A 50-State Report Card.”

Population Institute released the report on February 19. It is the nonprofit’s eighth annual assessment, and it grades on affordability of reproductive health care services, teenage and unplanned pregnancy rates, and access to contraception and abortion care, reports Rewire.news. This is the first time that the United States has received a failing grade.

Per the report:

Reflecting the escalating toll inflicted by the Trump administration and its allies, the U.S. grade for 2019 was lowered to an “F” from the “D-” awarded in 2018. There were many federal setbacks in 2019, most notably, the finalization of a new set of rules for Title X, the 50-year old federal-state partnership that supports family planning clinics serving low-income households. Frequently referred to as the “domestic gag rule,” the new rules prohibit Title X family planning physicians and staff from counseling patients on abortion or referring them to abortion providers. In response to the new regulations, Planned Parenthood and other abortion providers dropped out of the program.

At the state level, there is a deep divide between the states that are promoting reproductive health and rights and those restricting access. This year, 21 states received a failing grade. Several of the states receiving failing grades have passed abortion restrictions that defy the Roe v. Wade guidelines in hopes of persuading the U.S. Supreme Court to overturn the landmark ruling.

Three main reasons were given for the failing national grade. They were: Title X funding restrictions; the appointment of Supreme Court Justices Brett Kavanaugh and Neil Gorsuch, who are both staunchly anti-choice, as well as the appointment of dozens of Trump-nominated judges to the lower courts; and the administration’s continued budget cuts to programs that teach comprehensive sexuality education, in favor of “abstinence only” curricula.

“Many people of color and low-income individuals are already struggling to access affordable reproductive health care,” Jennie Wetter, Population Institute’s director of public policy, said in a statement. “This report card is a call to action for all those who care about reproductive health and rights.”

Read the entire report here.