As Abortion Laws Drive Obstetricians From Red States, Maternity Care Suffers

One by one, doctors who handle high-risk pregnancies are disappearing from Idaho — part of a wave of obstetricians fleeing restrictive abortion laws and a hostile state legislature. Dr. Caitlin Gustafson, a family doctor who also delivers babies in the tiny mountain town of McCall, is among those left behind, facing a lonely and uncertain future.

When caring for patients with pregnancy complications, Dr. Gustafson seeks counsel from maternal-fetal medicine specialists in Boise, the state capital two hours away. But two of the experts she relied on as backup have packed up their young families and moved away, one to Minnesota and the other to Colorado.

All told, more than a dozen labor and delivery doctors — including five of Idaho’s nine longtime maternal-fetal experts — will have either left or retired by the end of this year. Dr. Gustafson says the departures have made a bad situation worse, depriving both patients and doctors of moral support and medical advice.

“I wanted to work in a small family town and deliver babies,” she said. “I was living my dream — until all of this.”

Idaho’s obstetrics exodus is not happening in isolation. Across the country, in red states like Texas, Oklahoma and Tennessee, obstetricians — including highly skilled doctors who specialize in handling complex and risky pregnancies — are leaving their practices. Some newly minted doctors are avoiding states like Idaho.

The departures may result in new maternity care deserts, or areas that lack any maternity care, and they are placing strains on physicians like Dr. Gustafson who are left behind. The effects are particularly pronounced in rural areas, where many hospitals are shuttering obstetrics units for economic reasons. Restrictive abortion laws, experts say, are making that problem much worse.

“This isn’t an issue about abortion,” said Dr. Stella Dantas, the president-elect of the American College of Obstetricians and Gynecologists. “This is an issue about access to comprehensive obstetric and gynecologic care. When you restrict access to care that is based in science, that everybody should have access to — that has a ripple effect.”

Idaho doctors operate under a web of abortion laws, including a 2020 “trigger law” that went into effect after the Supreme Court eliminated the constitutional right to abortion by overturning Roe v. Wade last year. Together, they create one of the strictest abortion bans in the nation. Doctors who primarily provide abortion care are not the only medical professionals affected; the laws are also impinging on doctors whose primary work is to care for expectant mothers and babies, and who may be called upon to terminate a pregnancy for complications or other reasons.

Idaho bars abortion at any point in a pregnancy with just two exceptions: when it is necessary to save the life of the mother and in certain cases of rape or incest, though the victim must provide a police report. A temporary order issued by a federal judge also permits abortion in some circumstances when a woman’s health is at risk. Doctors convicted of violating the ban face two to five years in prison.

Dr. Gustafson, 51, has so far decided to stick it out in Idaho. She has been practicing in the state for 20 years, 17 of them in McCall, a stunning lakeside town of about 3,700 people.

She sees patients at the Payette Lakes Medical Clinic, a low-slung building that evokes the feeling of a mountain lodge, tucked into a grove of tall spruces and pines. It is affiliated with St. Luke’s Health System, the largest health system in the state.

On a recent morning, she was awakened at 5 a.m. by a call from a hospital nurse. A pregnant woman, two months shy of her due date, had a ruptured membrane. In common parlance, the patient’s water had broken, putting the mother and baby at risk for preterm delivery and other complications.

Dr. Gustafson threw on her light blue scrubs and her pink Crocs and rushed to the hospital to arrange for a helicopter to take the woman to Boise. She called the maternal-fetal specialty practice at St. Luke’s Boise Medical Center, the group she has worked with for years. She did not know the doctor who was to receive the patient. He had been in Idaho for only one week.

“Welcome to Idaho,” she told him.

In rural states, strong medical networks are critical to patients’ well-being. Doctors are not interchangeable widgets; they build up experience and a comfort level in working with one another and within their health care systems. Ordinarily, Dr. Gustafson might have found herself talking to Dr. Kylie Cooper or Dr. Lauren Miller on that day.

But Dr. Cooper left St. Luke’s in April for Minnesota. After “many agonizing months of discussion,” she said, she concluded that “the risk was too big for me and my family.”

Dr. Miller, who had founded the Idaho Coalition for Safe Reproductive Health Care, an advocacy group, moved to Colorado. It is one thing to pay for medical malpractice insurance, she said, but quite another to worry about criminal prosecution.

“I was always one of those people who had been super calm in emergencies,” Dr. Miller said. “But I was finding that I felt very anxious being on the labor unit, just not knowing if somebody else was going to second-guess my decision. That’s not how you want to go to work every day.”

The vacancies have been tough to fill. Dr. James Souza, the chief physician executive for St. Luke’s Health System, said the state’s laws had “had a profound chilling effect on recruitment and retention.” He is relying in part on temporary, roving doctors known as locums — short for the Latin phrase locum tenens, which means to stand in place of.

He likens labor and delivery care to a pyramid, supported by nurses, midwives and doctors, with maternal-fetal specialists at its apex. He worries the system will collapse.

“The loss of the top of a clinical pyramid means the pyramid falls apart,” Dr. Souza said.

Some smaller hospitals in Idaho have been unable to withstand the strain. Two closed their labor and delivery units this year; one of them, Bonner General Health, a 25-bed hospital in Sandpoint, in northern Idaho, cited the state’s “legal and political climate” and the departure of “highly respected, talented physicians” as factors that contributed to its decision.

Other states are also seeing obstetricians leave. In Oklahoma, where more than half of the state’s counties are considered maternity care deserts, three-quarters of obstetrician-gynecologists who responded to a recent survey said they were either planning to leave, considering leaving or would leave if they could, said Dr. Angela Hawkins, the chair of the Oklahoma section of the American College of Obstetricians and Gynecologists.

The previous chair, Dr. Kate Arnold, and her wife, also an obstetrician, moved to Washington, D.C., after the Supreme Court overturned Roe in Dobbs v. Jackson Women’s Health Organization. “Before the change in political climate, we had no plans on leaving,” Dr. Arnold said.

In Tennessee, where one-third of counties are considered maternity care deserts, Dr. Leilah Zahedi-Spung, a maternal-fetal specialist, decided to move to Colorado not long after the Dobbs ruling. She grew up in the South and felt guilty about leaving, she said.

Tennessee’s abortion ban, which was softened slightly this year, initially required an “affirmative defense,” meaning that doctors faced the burden of proving that an abortion they had performed was medically necessary — akin to the way a defendant in a homicide case might have to prove he or she acted in self-defense. Dr. Zahedi-Spung felt as if she had “quite the target on my back,” she said — so much so that she hired her own criminal defense lawyer.

“The majority of patients who came to me had highly wanted, highly desired pregnancies,” she said. “They had names, they had baby showers, they had nurseries. And I told them something awful about their pregnancy that made sure they were never going to take home that child — or that they would be sacrificing their lives to do that. I sent everybody out of state. I was unwilling to put myself at risk.”

Perhaps nowhere has the departure of obstetricians been as pronounced as in Idaho, where Dr. Gustafson has been helping to lead an organized — but only minimally successful — effort to change the state’s abortion laws, which have convinced her that state legislators do not care what doctors think. “Many of us feel like our opinion is being discounted,” she said.

Dr. Gustafson worked one day a month at a Planned Parenthood clinic in a Boise suburb until Idaho imposed its near-total abortion ban; she now has a similar arrangement with Planned Parenthood in Oregon, where some Idahoans travel for abortion care. She has been a plaintiff in several lawsuits challenging Idaho’s abortion policies. Earlier this year, she spoke at an abortion rights rally in front of the State Capitol.

In interviews, two Republican state lawmakers — Representatives Megan Blanksma, the House majority leader, and John Vander Woude, the chair of the House Health and Welfare Committee — said they were trying to address doctors’ concerns. Mr. Vander Woude acknowledged that Idaho’s trigger law, written before Roe fell, had affected everyday medical practice in a way that lawmakers had not anticipated.

“We never looked that close, and what exactly that bill said and how it was written and language that was in it,” he said. “We did that thinking Roe v. Wade was never going to get overturned. And then when it got overturned, we said, ‘OK, now we have to take a really close look at the definitions.’”

Mr. Vander Woude also dismissed doctors’ fears that they would be prosecuted, and he expressed doubt that obstetricians were really leaving the state. “I don’t see any doctor ever getting prosecuted,” he said, adding, “Show me the doctors that have left.”

During its 2023 session, the Legislature clarified that terminating an ectopic pregnancy or a molar pregnancy, a rare complication, would not be defined as abortion — a move that codified an Idaho Supreme Court ruling. Lawmakers also eliminated an affirmative defense provision.

But lawmakers refused to extend the tenure of the state’s Maternal Mortality Review Committee, an expert panel on which Dr. Gustafson served that investigated pregnancy-related deaths. The Idaho Freedom Foundation, a conservative group, testified against it and later called it an “unnecessary waste of tax dollars” — even though the annual cost, about $15,000, was picked up by the federal government.

That was a bridge too far for Dr. Amelia Huntsberger, the Idaho obstetrician who helped lead a push to create the panel in 2019. She recently moved to Oregon. “Idaho calls itself a quote ‘pro-life state,’ but the Idaho Legislature doesn’t care about the death of moms,” she said.

Most significantly, the Legislature rejected a top priority of Dr. Gustafson and others in her field: amending state law so that doctors would be able to perform abortions when the health — not just the life — of the mother is at risk. It was almost too much for Dr. Gustafson. She loves living in Idaho, she said. But when asked if she had thought about leaving, her answer was quick: “Every day.”

Audio produced by Adrienne Hurst.

02

UMass Memorial: Maternity ward’s Sept. 23 closure is final

LEOMINSTER — UMass Memorial Health made their decision to close the maternity ward final with the release of two documents on Monday.

The health care company released both a statement to caregivers and a larger report to the state Department of Public Health saying that they will provide transportation and funding for community engagement but will still be closing the Leominster Hospital maternity ward on Sept. 23.

The correspondence from UMass Memorial Health comes only hours after the Worcester legislative delegation joined with the legislative delegation in North Central Mass. to request a delay in the closure.

In the statement sent to all UMass Memorial Health caregivers on Sept. 11, UMass Memorial Health said they understand the decision was not an easy one but will still be going forward with the closure as planned.

“We want to acknowledge that the decision to close the unit has been a very difficult one — particularly for our caregivers and patients at HA-C and members of the North Central Massachusetts community,” read the statement from Dr. Eric Dickson, CEO of UMass Memorial Health, and Dr. Tiffany Moore Simas, Chair of Obstetrics and Gynecology, UMass Memorial Health. “We submitted our final correspondence to the Massachusetts Department of Public Health (DPH). Having fully complied with the regulatory process for the closure of essential services, it still is our intent to close the unit on September 23, 2023.”

In the statement to caregivers, UMass Memorial Health said they have a specific plan to provide 24/7/365 curb-to-curb transportation for patients needing non-emergency maternity services at alternative locations.

The statement also pointed out that UMass Memorial Health will put $600,000 toward supporting the most vulnerable in the North Central Mass. community with prenatal and postpartum care.

“This, along with the other plans we outline in our letter, will assure access for patients to appropriate care in HealthAlliance-Clinton Hospital’s service area,” read the statement to caregivers.

In recent days, the North Central Mass. legislative delegation and the Worcester legislative delegation have both called on UMass Memorial Health to delay the Sept. 23 closure date for the Leominster birth center.

“While the maternal mortality rate is increasing, particularly for women of color, the planned closure of the Leominster birthing center would run counter to our efforts as a state to address health disparities,” said state Sen. Robyn Kennedy, D- 1st Worcester.

North Central Mass. legislators also called on the UMass Memorial Health Board of Trustees to use their power to reverse the decision or delay the closure.

In the 29-page report to the DPH from their law firm Husch and Blackwell, UMass Memorial Health does mention that the Board of Trustees has voted on the closure.

“Our duty must be to the health and safety of our patients. It is with that duty in mind that we made this decision, and note that our Boards of Trustees, after  significant deliberation, have voted unanimously to support this decision,” stated the report from UMass Memorial Health to the state DPH. “We appreciate the ongoing dialogue with the [DPH] about our proposal as well as the  sincere concerns raised by the [DPH], city leaders, other elected officials, and community members throughout this process.”

The UMass Memorial statement to caregivers explained how it was their intention to go forward with the regulatory process to close the birthing unit with “civility, sensitivity and respect.”

“Out of respect for the DPH process, we have not been as public with our plans as we would have liked. As a result, unfortunately, some — not all — who oppose the closure have had loud voices and have grabbed headlines — often spreading misinformation that could harm patients,” read the statement. “Our duty must be to prioritize the health and safety of our patients. It is with that duty in mind that we will be closing our unit as this review process concludes.”

03

Maternity Deserts And Short Staffing Put American Births In Danger

There’s a two percent increase in counties that are maternity care deserts since our 2020 report. … [+] Ohio had the most women impacted by overall reductions in access to caregetty

Every day, more American women are realizing that their lives might be in danger during the birthing process. According to an August 2023 March of Dimes report, many of them live in a maternity desert – a county without a hospital or birth center offering obstetric care.

The report, entitled Where You Live Matters: Maternity Care Deserts and the Crisis of Access and Equity, lays out some of the stark realities facing women and babies in the United States. In 2020 for example, America experienced a nearly 14 percent increase in pregnancy-related deaths from the previous year and a nearly 31 percent increase from 2018.

The report also points to an increasing number of maternity deserts. As of August 2023, more than 5.6 million women live in counties with no or limited access to maternity care services. In 2022, the similar March of Dimes report found 2.2 million women of childbearing age live far away from hospitals and birth centers offering obstetric care.

Dr. Elizabeth Cherot, March of Dimes’ president and chief executive officer, said she has been discouraged not only by this complex reality but stakeholders’ unwillingness to find meaningful solutions.

“There is an awareness that we still have to, unfortunately, continue to drive that moms and their babies are the center of our family, and they are not doing well in this country,” Dr. Cherot. said. “That is a first-line conversation, and then start to get into everything else.”

With March of Dimes designating an alarming 36 percent of all U.S. counties as maternity care deserts, the lack of collective local, state and national action has been telling.

As March of Dimes’ first physician leader, Dr. Elizabeth Cherot is the President and Chief Executive … [+] Officer responsible for the development and implementation of a strategic vision to address the country’s maternal and infant health crisis, while increasing awareness and engagement in its work among key stakeholders.March of Dimes

Following the Dobbs decision, debate surrounding reproductive healthcare access has become heated. The collective unwillingness to address American birthing problems has been just as questionable and troubling. And, as hospitals continue to close since COVID-19, the situation has worsened for families.

In Wyoming, the Biglefthand family lives nearly two hours away from the closest birthing hospital. For Vania and Ray Biglefthand, long treks for doctor and prenatal visits have become part of an out-of-the-ordinary pregnancy.

Things became more stressful for Vania’s third pregnancy when a 29-week complication landed her on complete best rest for a little more than a month.

In the opening note of the March of Dimes’ 2022 report, Vania urges other families living in the maternity desert to keep fighting for their health and that of their babies.

“As a mom, being pregnant, you know your body, you know something is wrong. Speak up, no matter what. Speak up for yourself and your baby,” Vania said.

The Biglefthands’ story is one that Dr. Cherot has heard far too many times. She connected that to the financial cost of birthing in America.

“Many hospitals throughout this country are struggling with low birth volumes and staff recruitment and retention issues,” Cherot said. “All of this leads to a financial demonstration that says we aren’t going to value our moms.”

March of Dimes has laid out national, state and local-level solutions to alleviate American families’ birthing struggles, including expanding Medicaid for individuals who fall at or below the Federal Poverty level and expanding the Medicaid postpartum coverage period to 12 months. At the federal level, it’s currently 60 days after pregnancy.

The report also urges expanding maternity care telehealth services and enhancing perinatal regionalization to improve maternal and neonatal outcomes. Tannaz Rasouli, senior director of public policy at the Association of American Medical Colleges, cosigned this move.

“Maternity care deserts pose serious risks to pregnant people and, for their children, begin a cycle of unacceptable health disparities,” said Rasouli. “One key issue contributing to these deserts is health workforce shortages, which limit patients’ access to essential preventive, prenatal, and postpartum care.”

With non-Hispanic Black women dying at a three-times the rate of their non-Hispanic white counterparts, March of Dimes has been laser-forced on addressing the social determinants of health to reduce disparities.

Tonya Lewis Lee, a film director and producer, author and advocate for women and infant health, said this inequity exists for Black women inside and outside maternity deserts because of unconscious bias and long-lasting inequities in America’s healthcare system.

“It’s not necessarily the access to care; it’s the access to the type of care one is getting,” said Lewis Lee, producer of “Aftershock.”

Lewis Lee points out that either birthing people are getting too much care too soon due to the fear of bad outcomes, causing more Black and Brown mothers to be pushed into having C-sections too quickly, or families of color are not getting enough care early enough, and physicians dismiss their pain and concerns.

That’s why Dr. Cherot has championed the expansion of midwifery. As an organization, March of Dimes believes the presence of a midwife during the prenatal, birthing and postpartum period will increase positive patient outcomes and mortality.

Aftershock — Following the deaths of two young women due to childbirth complications, two bereaved … [+] families galvanize activists, birth-workers and physicians to reckon with one of the most pressing American crisis today: the US maternal health crisis. Executive Producer Tonya Lewis Lee, shown. (Photo by: Matt Sayles/Hulu)HULU

Lewis Lee, a March of Dimes trustee board member, echoed similar sentiments.

“The United States is the only industrialized nation that does not have midwifery care integrated into women’s health care, and we have the worst outcomes,” Lewis Lee said. “We’re asking doctors to do a job that they’re not trained to do.”

Regrettably, midwives’ utilization in the hospital and birth setting has fallen tremendously since the mid-20th century due to obstetric professionalization and the push for more hospital births,

“Physicians wanted those women in the hospital to give birth, and they successfully pulled people into the hospital,” said Karen Jefferson, a certified midwife and director of Practice and education at the American College of Nurse-Midwives. “And they decimated the vibrant culture of midwifery we had here that was primarily practiced by indigenous, immigrant, and black midwives.”

In the United States, certified nurse midwives (CNM), or registered nurses who undergo midwifery training and certification, are licensed to practice in all 50 states and the District of Columbia.

The other category is certified midwives (CN), or individuals who are not RNs but are trained in midwifery. They are licensed to practice in 10 states and the District. Both can provide primary care for women, including well-women exams, health education, disease prevention, family planning and common gynecological-associated health issues.

When allowed to practice at the top of the licensure, CNM and CN practitioners can provide independent physical and emotional support during birthing and reduce the rate of complications and surgical intervention.

Jefferson said healthcare professionals can also prescribe some medication and referrals to physicians and other providers.

“Midwives and physicians have complementary skills,” Jefferson said. “Physicians are superb at dealing with surgery and medical complications, medically complicated people, and midwives are specialists in physiologic birth and relationship-based care.”

Dr. Cherot agreed.

“Let’s be direct about it: we must diversify our workforce. And that means letting them [midwives] work at the top of their license,” Cherot said. “It is well documented that we won’t have enough OB/GYNs in this country, so we must expand our birthing workforces to more midwives and nurse practitioners and place them in the advanced practitioner bucket.”

Fountain Valley, CA – June 29:Midwife Angie Miller listens to the heart beat of MyLin Stokes … [+] Kennedys baby with her wife Lindsay and their child Lennox, 21 months, at their Fountain Valley home. Black women are turning to midwives to avoid racism, mortality rates and unnecessary C-sections in the hospitals. In Los Angeles County, mortality rates among Black mothers from perinatal complications are four times higher compared to White women. (Photo by Sarah Reingewirtz/MediaNews Group/Los Angeles Daily News via Getty Images)MediaNews Group via Getty Images

A recent Commonwealth Fund report found that a fully integrated midwife workforce could provide 80 percent of essential maternal care worldwide and “avert 41 percent of maternal deaths, 39 percent of neonatal death and 26 percent of stillbirths.”

Jefferson and Lewis Lee believe that this statistic should be the starting point for an expanded conversation about maternal care in the United States.

“If you increase the utilization of midwives, primarily by increasing the number of midwives of color, the outcomes will change,” Jefferson said. “Midwives in hospitals and involved in the birthing process can lead to fewer pre-births, fewer low birth weight, birth, higher breastfeeding rates, and higher patient satisfaction.”

“Midwifery care shows better outcomes than what we’re seeing right now, given the increase in maternal deaths,” said Lewis Lee. “Now, we must put policies in place so midwives get covered by insurance companies.”

Due to the lack of equitable insurance reimbursement, midwives are paid less for identical births performed by doctors, resulting in pay inequity and an unwillingness of hospitals to hire them. They are also only sometimes granted admitted privileges due to locally specific statutory restrictions.

Beyond expanding midwifery care, the March of Dimes report also advocates strengthening network requirements for the Affordable Care Act marketplace, investing in Perinatal Quality Collaboratives (PQC) birthing infrastructure and expanding equitable access to doula services.

Completing its first round of investments in September 2022, the March of Dimes is also working to be part of the solutions in the fight to end maternity deserts and the high number of maternal deaths through the March of Dimes Innovation Fund.

“The maternal health issue in the United States that can be solved,” Lewis Lee said. . “It takes a lot of education. It takes innovation. It takes people putting women and birthing people first and allowing them to have the kind of birth they need and deserve so that it’s safe and driven by their desire.”