Any expectant mother should only be worrying about a prep bag and baby names before giving birth.

But, in Iowa, many pregnant women approaching their due dates must also factor an hour-long drive to the nearest hospital, the next nearest hospital if the first does not offer proper birthing resources, and even the potential implications of a simple headache, which cannot be monitored for blood pressure outside a hospital, into their birthing plan.

Over the past two decades, there have been more than 40 birthing-unit closures around Iowa, according to the American Medical Association. This has made it increasingly difficult for women in rural areas to access health care facilities for giving birth, ultimately causing maternal care deserts.

As of 2024, a March of Dimes report found that 35 percent of counties in the U.S. are considered maternal care deserts, meaning there is not a single birthing facility nor obstetric clinician in these counties. And a comparable 33.3 percent of counties in Iowa are defined as maternal care deserts.

These deserts are caused not only by hopital shortages but also by low birthing volumes and physician shortages, both of which are felt in Iowa.

Iowa Public Radio spoke to Steve Churchill, the CEO of the Iowa Medical Society, about the physician shortage and how to combat it. Churchill said patient care is becoming more prevalent than maternal care, as people are living longer, and many physicians are old enough to begin retirement. Meanwhile, young physicians entering the workforce prefer work schedules that better accommodate a work-life balance and avoid administrative burdens.

Even though access to maternal care in rural Iowa has been on a steady decline for years now, recent abortion restrictions have only exacerbated the issue.

On July 29, 2024, Iowa enacted a near-total abortion ban, following the overturning of Roe v. Wade in 2022, effectively ending federal protections for abortion access in the U.S. This ban bars all abortions after fetal cardiac activity is detected, which can be as early as six weeks – before most women even know they are pregnant.

The vague exceptions to this ban that include cases of rape, incest, and threat to the life of the mother, make it more stressful and difficult for physicians to decide whether to perform an abortion.

Increasing numbers of medical students studying family practice and obstetrics at the University of Iowa have since chosen to leave the university for residency programs in states with less restrictive abortion laws. According to a report from the Association of American Medical College Research Institute, the overall number of applicants to residency programs in states with abortion bans has decreased by 4.2 percent as compared to the previous application cycle.

Besides abortion bans, what makes maternal care more important than ever is the increasing difficulty of accessing contraception. While birth control is still protected by the federal government and President Donald Trump has not confirmed he is opposed to birth control, individual states can decide the extent to which it is accessible, and many of them are running with more conservative ideaologies.

A study from the Guttmacher Institute found that 10 percent of women in Iowa reported having troubles or delays in access to contraception between 2022 and 2023, as compared to 7 percent in 2021. The irony of all of this is that as the government spearheads legislation to reduce access to abortion care, which has trickled down to restrict birth control, it has made no efforts to support hospitals to keep birthing facilities open. In fact, a current U.S. House budget proposal seeking to cut spending on taxes and immigration would also require cuts to Medicare and Medicaid, both of which fund hospitals.

So, the government cannot seem to make up its mind. Does it want to facilitate more births, even though the national birth rate has continued to decline, or indirectly kill more women and children who do not have access to adequate maternal care?

But here’s the question our state needs to answer: How can Iowa effectively address the harmful impacts of recent legislation to decrease the number of maternal care deserts?

Missing the mark

Iowa legislation has certainly tried to address the impacts, but that doesn’t mean it has been effective.

On March 12, the Iowa House passed House File 516 requiring 80 percent of medical students admitted to be from Iowa or to have attended an Iowa college or university prior. The bill now awaits a decision in the Iowa Senate.

While this bill might help the UI attract in-state students, it will not have any effect on the more important disparity of maternal care deserts and makes no provisions for retaining in-state residencies. In fact, it could worsen the situation by preventing the possibility of out-of-state students visiting Iowa and deciding to stay.

That is not to discount the level of training that medical students at the UI receive, however. UI Health Care has committed to offering rigorous training for residents studying family practice and obstetrics. Through a federal grant and a partnership with the Iowa Department of Health and Human Services, UIHC has been able to provide educational programs including a fellowship, midwifery training, and a rural rotation.

The rural track for the OB-GYN program is offered to two residents each year and includes hands-on experience in smaller communities. According to the American Medical Association, “The hope is that these OB-GYNs will choose to practice in these smaller Iowa communities after finishing residency.”

But hope is not enough.

If the state of Iowa wants to grow its health care workforce, decision-makers need to acknowledge why people are leaving, which is not because of a lack of sufficient medical training at one of the highest-ranked medical schools in the country. The UI’s Department of Obstetrics and Gynecology could produce the best OB-GYNs of our generation, and they will still leave Iowa for a state more conducive to their practices.

On Feb. 18, Iowa Gov. Kim Reynolds introduced a bill that would consolidate and more than double funding for current state-funded student loan repayment programs; enhance payment to draw down federal dollars to create 150 new residency slots at Iowa’s 14 teaching hospitals; and unbundle Medicaid maternal rates to increase rates for health care providers who support mothers and babies.

The governor is quoted on her official state website saying, “The well-being of working families and rural communities depends on access to high quality health care. Iowa has a strong foundation to build on, but we need more medical professionals, including specialists, in every part of the state … That’s a game changer for rural communities and every part of the state.”

But is it?

Even if an OB-GYN resident in Iowa wants to practice in rural communities, there is a good chance there are no obstetric facilities in those communities to support them. The state must allocate funding to maintain clinics in rural counties before it funds more medical slots for residents in the UIHC, so those prospective residents will have the opportunity to practice in rural locations.

It doesn’t do expectant mothers living in rural areas much good to have more OB-GYNs working in urban hospitals when it still takes them nearly an hour to get there, a distance that can be fatal depending on labor and complications.

It also doesn’t do them any good to have more OB-GYNs who are too scared to perform their responsibilities for fear of losing their jobs.

Abortion bans have driven so many prospective residents elsewhere specifically because of their vague exceptions that leave medical practitioners throwing up their hands. The exact wording of Iowa’s exception law states a physician “certifies that the fetus has a fetal abnormality that in the physician’s reasonable medical judgment is incompatible with life.”

According to an Iowa Capital Dispatch article, health care representatives “have criticized the medical exceptions in the law, saying that it is often difficult for doctors to determine when an abortion is ‘necessary’ to save the life of the pregnant woman. In other states with more restrictive abortion bans, advocates argue doctors avoid performing needed procedures due to fear of losing their medical license or facing criminal penalties.”

Legislation in Iowa needs to be more specific when it comes to outlining what doctors can and cannot do when it comes to performing abortions. It needs to define which medical emergencies constitute the procedure so that women are not bleeding out on tables, in waiting rooms, or in parking lots while their doctors ponder the ethical question of life.

Maternal care deserts are an effect, and the only way to address them is by making reparations to their causes. Regardless of political or religious belief, we should all agree access to maternal and life-saving health care is a basic human right.

Let’s let mothers and fathers worry about putting cribs together instead of what might happen if they bring one less person home from the hospital.