When Caslin Gilroy learned she was pregnant in May, she immediately contacted her doctor’s office to book prenatal care. She’d visited the same clinic for years – including for her first pregnancy in 2020 – and thought booking an appointment would be straightforward. But Gilroy was told her doctor had no availability until August, when she would be close to 12 weeks along.
Unable to get a pregnancy confirmation appointment, which ideally happens between eight and 10 weeks, Gilroy grew anxious, and even struggled to convince herself that the pregnancy was real.
“With my first pregnancy, I felt like I was a priority. I never had trouble getting an appointment,” she said.
These setbacks are widespread. One woman waited more than five weeks to connect with a specialist for a complication; another had yet to receive care at 20 weeks because of cancellations and insurance issues.
Delays can be traumatizing when something goes wrong. At an ultrasound last fall, Kelsey Stolfer of Pittsburgh learned that there was no longer a heartbeat and needed to undergo dilation and curettage – a surgical procedure to remove fetal tissue. The earliest slot available wasn’t for another full week.
“I just felt numb,” said Stolfer, describing the mental toll of waiting for the miscarriage procedure. “At that point, you’ve already spent a week and a half with a dead baby inside of you.”
Experts say these delays are just one symptom of a long-predicted nationwide OB-GYN shortage that has intensified in the wake of abortion restrictions, and it’s affecting women’s health across the country.
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In conservative states, care delays largely stem from the fallout of the Dobbs decision last summer when the supreme court revoked the constitutional right to abortion. Facing possible lawsuits for providing abortion care, OB-GYNs in Texas, Florida, Idaho and elsewhere are choosing to relocate to more liberal states, while medical students are opting for other fields entirely.
“Florida has become a place where it is unsustainable to be an OB-GYN,” said Stephanie Ros, a maternal fetal medicine specialist at the University of South Florida who, until recently, ran the school’s OB-GYN residency program.
For years, the program was among the nation’s top schools for abortion training, and was found on the prestigious Ryan list of the best family planning residency programs. But after the state banned most abortions after six weeks of pregnancy, the designation was revoked. Applicant numbers subsequently declined dramatically, as skilled candidates took their talents elsewhere.
In a national survey, 60% of medical students said they were unlikely to apply for residency in a restrictive state.
“States with stringent abortion laws won’t align with my goals as a future OB-GYN,” said Rohini Kousalya Siva, president of the American Medical Student Association. “If young doctors want to … get the skills they need, then they have to go to states where they can access [abortion] training.”
Verda J Hicks, president of the American College of Obstetricians and Gynecologists, described the trend as cause for concern about the “next generation of OB-GYNs”.
Notably, fewer residents means fewer doctors on the floor. To remedy that vacuum, USF hired locum doctors, who Ros described as “the substitute teachers of the doctor world”. Still, routine care appointments at USF are significantly pushed back. In August, the earliest a new patient could book a prenatal visit was November.
“We have people who … don’t get their first ultrasound until 30 weeks, because they just can’t get in,” she said.
Delays in prenatal care represent more than inconveniences. These scheduling issues can be dangerous. If a patient doesn’t receive first trimester care, they might miss windows for early genetic screening tests, or fail to safely treat diabetes or hypertension at a critical time in fetal development.
When chronic diseases are not managed as well, the overall risk of any pregnancy goes up, explained Erika Werner, chair of obstetrics and gynecology at Tufts medical center in Boston. “If you don’t have your first visit until 14 weeks, you don’t have the same access to prenatal testing. You may not have an early ultrasound that reveals a major structural problem,” she said.
Romeo Galang, an OB-GYN and medical officer in CDC’s division of reproductive health, echoed the importance of early treatment, noting that “quick and accurate treatment at the first sign of a serious pregnancy-related complication can save lives”.
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Even parts of the country without abortion bans are struggling to keep up with care needs. Christina Han, the director of maternal fetal medicine at UCLA in California, pointed to the influx of out-of-state patients seeking abortion care and how it stretches the workforce thin.
Han specializes in complex procedures like multifetal reduction – an operation that must be completed early in pregnancy. That time crunch means that if a patient travels to LA for urgent reproductive care, which Han says is happening with increased frequency, the hospital has to defer local patients’ scheduled operations, including terminations, that are not as time sensitive.
“We have to tell our patient who is struggling with a miscarriage … that we just can’t get them in. And that is an emotional, physical burden for these patients,” said Han.
Werner, who also chairs the Society for Maternal Fetal Medicine’s health policy and advocacy committee, explained that this displacement effect is especially pronounced in states that directly border those with restrictive policies, and are now receiving the lion’s share of out-of-state patients.
In Pennsylvania, which borders West Virginia, Stolfer remembers thinking about women in other states as she awaited care for her miscarriage. “It was one way that I was trying to make peace with how long it was taking,” she said.
Dobbs is not to blame for all of these stressors, however. A nationwide OB-GYN shortage has been on the horizon since well before the supreme court struck down Roe v Wade.
“It’s always existed,” said Ros in Florida, contending that workforce strains have been a topic of discussion since she was in medical school in the early 2000s.
Kousalya Siva describes the shortage as “a significant driving force” behind her choice of field.
For years, studies have predicted that population rise paired with an ageing workforce would lead to gaps in women’s healthcare. Ruth Crystal of Stanford University also points to the high risk for medical malpractice litigation and demands for long and irregular hours as factors that steer people away from the field.
“OB care is a 24-hour-a-day job,” she said. “Babies don’t come only between banking hours.”
As in other sectors of the economy, awareness of burnout (which OB-GYNs suffer in high numbers) and desire for greater work-life balance have prompted doctors to limit their working hours in ways they previously did not.
Taken together, this confluence of factors means physicians across the country have fewer hours to devote to patients for routine care.
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Constricted access hits some populations more than others.
Nationwide, 36% of counties are maternity care deserts, meaning they lack any obstetric care facilities or providers, explains Amanda Williams, clinical innovations adviser at Stanford University’s California Quality of Care Collaborative. The affected populations are also disproportionately people of color, people with lower incomes and people in rural areas – groups that already face care inequities.
In the US, Black women are experiencing soaring maternal mortality rates.
“All of these things compound for poor maternal health outcomes,” said Williams. “When patients give birth in these maternity deserts, they have higher rates of preterm births and maternal deaths.”
Resolving the crisis won’t be easy, said Crystal, underscoring the need for increased funding, especially in underserved regions, and student loan forgiveness, most notably for doctors who choose to practice in care deserts.
In Florida, Ros also points to government-mandated limits on the number of federally funded residency positions in each field, which have not been raised since 1996 despite population growth. “They need to undo these caps,” she said.
Werner believes the most critical fix is abolishing restrictive abortion laws and creating “parity across all states”.
“It’s only when it comes to OB-GYN care that what you can get in one state is different than what you can get in another,” she said. “That just forever means that we’re going to have unequal care in different states.”
