Annie Galloway, a third-year medical student at the University of Iowa, plans to enter the field of obstetrics and gynecology after she finishes medical school. Despite having studied at Iowa for her entire collegiate career, Galloway said she would prefer to leave the Hawkeye State for residency training.

Galloway hopes to be matched with a residency program in a state without an abortion ban such as Iowa’s. She does not want her medical training to be limited by legislation.

Galloway said many OB-GYNs and family medicine physicians would be disinclined to practice in a state where they can be restricted from providing life-saving interventions, perpetuating Iowa’s lack of providers.

“Many people who train to be an OB-GYN want to practice at the top of their license, they want to be able to execute their training when appropriate,” Galloway said.

Galloway completed her undergraduate degree at Grinnell College and currently serves on the board of directors for the Emma Goldman Clinic, a reproductive health care facility that provides abortion care in Iowa City.

More medical residents are avoiding states with abortion bans, according to a May report from the Association of American Medical College, which revealed that for the second year in a row, students graduating from U.S. medical schools were less likely to apply for residency positions in states with abortion bans or restrictions.

Iowa enacted a near-total abortion ban on July 29, barring all abortions after fetal cardiac activity is detected, which can be as early as six weeks into a pregnancy. The law includes exceptions for the life of the mother, rape, and incest. The law was enacted after a lengthy court battle concluding with the Iowa Supreme Court, allowing the law to go into effect in July after they found no legal basis to block it from being enacted.

Since the U.S. Supreme Court in 2022 overturned the landmark precedent set in Roe v. Wade, which guaranteed federal protections for abortion access, more than a dozen states have restricted abortion access. And with those new laws came reactions from new doctors: The Association of American Medical College Research Institute found the average state saw a 10.1 percent decline in U.S. doctor of medicine senior applicants.

The report showed overall the number of applicants to residencies in states with abortion bans decreased from the previous cycle by 4.2 percent, compared with a 0.6 percent decrease in states where abortion remained legal.

Across the country, obstetricians in red states — including Texas, Oklahoma, and Tennessee — are leaving their practices, and new doctors are avoiding such states due to restrictive abortion laws.

The departures can result in new and worsened maternity care deserts — areas that lack maternity care — and place strain on physicians who remain. Maternity health care is the health care provided to women, their partners, families, and children before, during, and after pregnancy.

With Iowa’s maternal health care deficit worsening, experts worry the abortion ban will exacerbate the state’s already dwindling OB-GYN numbers.

Iowa has among the fewest number of OB-GYNs per capita in the nation. According to a report from March of Dimes, a nonprofit organization that works to improve the health of mothers and babies, one-third of the state’s 99 counties are considered maternity care deserts, meaning they have no OB-GYNs or birthing facilities.

With medical students like Galloway opting to pursue careers in states without abortion bans, experts worry Iowans’ access to maternity care will only worsen and OB-GYN education and training will decline.

OB-GYN education and retention numbers decrease

Maternal health care experts say Iowa’s abortion ban will have long-term impacts on education in the state, potentially reducing the number of providers and OB-GYNs.

Francesca Turner, an OB-GYN in Des Moines and co-founder of Iowans for Health Liberty, said the ban will have a chilling effect on OB-GYNs in Iowa. Turner said she and other OB-GYNs will need to stop and question if they are in compliance with the ban.

For those who are the only OB-GYN in their county, if they were to lose their license, every woman in their county loses their provider, Turner said.

The March of Dimes report showed that 90 percent of Iowa’s counties have fewer than three OB-GYNs.

Doctors and providers risk facing up to $10,000 in fines or losing their medical licenses if they break Iowa’s law. The legislation allows women to receive abortion care until there is a “detectable fetal heartbeat,” a term highly disputed among medical groups.

The law includes exceptions for rape and incest, as long as the rape survivors tell police or a health provider within 45 days and incest survivors within 140 days. Another exception is made for when the life of the mother is at risk, but Turner said the language is vague and difficult to interpret.

She said the gray area created by the new law will make her job more stressful and discourage others from entering the field, harming OB-GYN education in the state. Turner is also the American College of Obstetricians and Gynecologists’ legislative chairperson for Iowa.

Turner said the abortion ban threatens education and the accreditation of the UI Health Care OB-GYN residency program because, to meet national accreditation guidelines, a program has to provide full spectrum training, which includes abortion care.

To receive education on abortion care, residents would have to travel out of state, Turner said, which takes significant planning and could be a financial burden for recently graduated medical students.

According to a statement provided to The Daily Iowan by Josh Lehman, senior communications director for the Iowa Board of Regents, the university will maintain its accreditation and provide education to students and trainees. UI Health Care officials declined the DI’s request for an interview and directed the DI to the Board of Regents.

RELATED: Iowa abortion providers navigate near-total abortion ban

The Accreditation Council on Graduate Medical Education currently requires obstetrics and gynecology programs in the United States to include training or access to training in the provision of pregnancy termination, Lehman wrote in the email.

“Like medical schools in states with similar restrictions, the university will adapt to maintain its accreditation and provide the education needed for its students and trainees,” Lehman wrote.

Galloway said medical students are not all able to live out of state or commute to receive training, and they factor in how easily it is to be trained in a state when deciding which residency program they want to match with.

“People are going to want to train where they can learn the full scope of practice of that specialty,” Galloway said. “I think that when states have bans like this, it’s more difficult to get that training, and so I do think that people are going to apply to programs where they know they can get a full scope of training.”

Iowa’s maternal health care deficit worsening

At least 41 Iowa hospitals have closed their labor and delivery services since 2000, according to a 2022 Iowa Department of Public Health report. By 2020, only 46 of Iowa’s 99 counties had at least one hospital providing obstetric services — plummeting from 77 counties in years prior.

The Newton Clinic will halt labor and delivery care later this year, leaving Jasper County — with a population of about 32,000 people — without an OB-GYN.

The hospital in Newton, Iowa,  announced on Aug. 30 that it will no longer continue its hiring process for physicians dedicated to obstetrics for labor and delivery clinics, and as a result, maternal care partner MercyOne Newton Medical Center will pause labor and delivery services indefinitely after Oct. 15.

A March of Dimes report revealed nearly 69,000 Iowan women live in a county without a single obstetric provider.

The decision comes after a decade of significant recruitment struggles, Newton Clinic Administrator Mark Thayer said.

Thayer said 28 years ago, when he was originally hiring doctors, almost all of the applicants wanted to practice obstetrics at the clinic.

“Over the last 10 years, that paradigm has changed, and it’s just a reflection of the reality of how doctors are getting trained nowadays and what their expectations are,” Thayer said.

The clinic has only ever had one OB-GYN, and the last one left in March 2023, Thayer said. For a time, Thayer was receiving quality candidates every three to four months, but that became nonexistent in the last year, and he has not received an application from a serious candidate in the past 12 months.

“That market has just dried up,” Thayer said. “I think it’s just a combination of [the fact that] they are not getting the training and residency or they don’t have a particular interest in obstetrics.”

The American College of Obstetricians and Gynecologists projects a potential shortfall of up to 22,000 OB-GYN doctors by 2050. Additionally, federal officials projected in a 2021 report from the Department of Health and Human Services that roughly 3,000 fewer OB-GYNs will be practicing in the country by 2030.

The number of medical students applying to OB-GYN residency programs declined by 5.2 percent overall in 2023, according to the American Medical Association. States with abortion bans are experiencing an even steeper decline — a 19 percent drop in Texas and a 21 percent drop in both Alabama and Tennessee.

Regarding Iowa’s recent six-week abortion ban, Thayer said it has nothing to do with the OB-GYN recruitment struggles his clinic faces.

“In my 28 years, I’ve never had a doctor ask me to do an elective abortion, not one, so this new legislation has nothing to do with the situation we’ve been dealing with the last 10 years,” Thayer said. “There’s some people that I’ve seen that are trying to use this as a political witch hunt against Governor Reynolds, and the people that were in support of that, and I couldn’t be in any more disagreement. Those people, in my opinion, are uneducated on the topic.”

Nichole Nidey, a UI assistant professor who studies maternal and child health issues, said instead of focusing on whether legislation is conservative or liberal, both parties should identify how to put systems into place that will recruit OB-GYNs to Iowa.

Nidey said it’s difficult to predict how OB-GYN closures such as that at the Newton Clinic will impact Iowans, but prior research shows that restricted access to health care is strongly associated with poor outcomes.

“The state really needs to pay attention to how closures are affecting health outcomes for families, because we’re not quite sure what that means for Iowans yet,” Nidey said.

Nidey said there is some interest from researchers at the university and elsewhere to study how Iowans will be affected.

Iowa House Democrats and Republicans place abortion and the state’s OB-GYN shortage as a priority for the upcoming legislative session. In past legislation, some Iowa Republicans have tried to define life as beginning at fertilization, known as life-at-conception bills, and enact a total abortion ban, both of which have been unsuccessful.

UI Health Care targets initiatives to close the gap

UI Health Care is pursuing several initiatives to fix the state’s growing loss of obstetric services, including expanding its obstetrical care capability, according to the department. UI Health Care has over 50 locations across Iowa and several locations for OB-GYN services with offices in Iowa City, Cedar Rapids, Coralville, and Davenport.

In fiscal 2023, eight percent of Iowa’s deliveries occurred at UI Health Care, which is a 24 percent increase from fiscal 2019.

The labor and delivery unit at UI Health Care was designed to handle about 1,600 births per year since the early 2000s. Nearly 3,000 babies were delivered at the labor and delivery unit last year. Officials anticipate that number will grow by another thousand in the next few years.

With the support of a five-year $10 million grant from the federal Health Resources and Services Administration, UI Health Care specialists are aiming to fulfill Iowa’s obstetric needs by bolstering the obstetric skills of hospitals and providers.

Through the use of a mobile simulation program, the department is teaching obstetric skills to ER teams and providers and traveling to rural hospitals to teach the American Academy of Family Physicians’ Advanced Life Support in Obstetrics course.

Hoping to practice medicine on the West Coast and avoid educational limitations caused by abortion bans such as Iowa’s, Galloway, the UI medical student, said she is grateful for the training she has received in the state but does not want to limit her future training.

“Looking at Iowa as a whole state and as a politically red state, it’s discouraging,” Galloway said. “I feel bad that the state will potentially continue to suffer because fewer people may want to practice here.”