A patchwork of state laws in the aftermath of a Supreme Court decision overturning the right to an abortion, combined with pandemic-related burnout and low reimbursement rates, could exacerbate an already looming national shortage of obstetrician-gynecologists, experts say.
Medical students say that given the Dobbs v. Jackson Women’s Health Organization decision overturning Roe v. Wade, they must consider a landscape of rapidly changing abortion legislation, with litigation often making it difficult to determine what is legal where.
Typically “physicians do not go to medical school and go into the practice of medicine because we enjoy interfacing with the legal profession,” said Katie McHugh, an Indiana-based obstetrician-gynecologist and board member with Physicians for Reproductive Health.
The OB-GYN shortage comes at a critical moment: In 2021, the Centers for Disease Control and Prevention documented gains in cesarean delivery, preterm birth rates and low birth weights, all of which can increase other health risks and require specialized care.
As the first class of post-Dobbs medical students prepares to be matched to OB-GYN residency programs on Friday, preliminary 2023 data from the American Association of Medical Colleges shows that the average number of applications per obstetrics and gynecology residency program fell from 663 in 2022 to 650 in 2023.
A CQ Roll Call analysis found that 84 obstetrics and gynecology residency programs of 299, or 28 percent, accredited by the Accreditation Council for Graduate Medical Education are based in states or territories enforcing pre-viability bans on abortion.
While regional applicant data is not available, in interviews some students expressed reluctance toward training in states with abortion bans that could affect their scope of medical training.
Isiah Romo, a fourth-year medical student at the University of Arizona College of Medicine who hopes to match in an obstetrics and gynecology program this year, said he applied to a number of programs but did not consider any in states where he would be unable to get abortion training.
He said while the ramifications of last summer’s Dobbs decision may make the field less attractive to some people, it solidified his interest. Still, he said, “it’s probably causing a lot of other people to not apply, which just creates even further gaps for the people who need the care.”
Maternity care deserts
The U.S. consistently ranks poorly in maternal care and outcomes compared with other developed nations. OB-GYNs warn that if the shortage isn’t addressed, the problem will only become worse.
More than 2.2 million women of childbearing age live in so-called maternity care deserts with no hospitals offering obstetric care, obstetric providers or birthing centers, according to the March of Dimes. An additional 4.7 million women of childbearing age live in counties with limited access to care.
Many are located in remote and rural parts of the country, with a particular concentration in the Midwest.
“Hospital closures, combined with the lack of access to outpatient and inpatient obstetrical care, results in the extremes of maternal and infant mortality that we see in my state,” said McHugh, in Indiana.
Half of all U.S. counties lack an OB-GYN, said Elizabeth Cherot, chief medical and health officer at March of Dimes. Practically, this means that pregnant women are faced with the choice to either travel long distances for care or skip an appointment. Pregnant people who do not receive prenatal care are three to four times more likely to have a pregnancy-related death, she said.
Babies in care deserts are also more likely to be born prematurely or underweight, according to the March of Dimes.
Key lawmakers have emphasized health workforce issues as something to focus on— but incentives like loan forgiveness or expanding the graduate medical education system are long-term strategies that require building up specialized skills, and the need is acute now.
“It’s something that’s worried me actually for years that it was on the horizon,” said Rep. Michael C. Burgess, R-Texas, a trained OB-GYN.
Burgess pointed to a 2018 maternity care law as an example of what Congress can do to alleviate OB-GYN shortages.
The law prompted the Health Resources and Services Administration to identify areas within health professional shortage areas that have a shortage of maternity care health professionals for purposes of assigning more OB-GYNs to these areas.
Senate Health, Education, Labor and Pensions Committee Chairman Bernie Sanders, I-Vt., and ranking member Bill Cassidy, R-La., asked stakeholders on March 2 to weigh in as they “intend to identify bipartisan solutions to remedy our nation’s health care workforce shortages and develop these ideas into legislation.”
HELP and House Energy and Commerce have jurisdiction over the National Health Service Corps, which expands the primary care workforce, including OB-GYNs and the Teaching Health Centers Graduate Medical Education Program, which trains medical residents, including OB-GYNs. Both programs are up for reauthorization this year.
During a Feb. 16 hearing, Cassidy called for both to be extended on time and to be fully paid for, and Sanders said he wanted to expand the teaching health center program and increase student loan debt forgiveness and scholarships through the National Health Service Corps program.
Burgess also highlighted the need to retain physicians already in the workforce, reduce paperwork related to prior authorization and increase reimbursement rates.
But workforce programs targeted at recruiting OB-GYNs also have the potential to face political backlash.
The American College of Obstetricians and Gynecologists, which represents more than 60,000 members, faced pushback during its annual conference in February after the American Association of Pro-Life OB-GYNs said it was denied access to the meeting because of its opposition to abortion rights.
“This is a blatant attack on the exploration of research and practice that academia is supposed to promote,” said House Labor-HHS-Education Appropriations Subcommittee Chairman Robert B. Aderholt, R-Ala., who is also the chair of the House Values Action Team.
Five House Republicans also issued a joint statement that they will “press for immediate changes to this unacceptable behavior — whether that means taking ACOG to task in meetings or refusing meetings until they change course.”
Medicaid as a problem and a solution
About half of maternal complications happen after the baby is born, according to the Commonwealth Fund, and physicians and experts alike say these issues can be alleviated with more postpartum care visits, which screen for everything from breastfeeding complications to hypertension, diabetes or postpartum depression.
Federal law mandates Medicaid postpartum coverage for moms and babies for 60 days after birth, but 29 states and the District of Columbia have expanded access to Medicaid for moms and babies for 12 months postpartum, and more states are working to do so.
The 2021 COVID-19 relief law gave states the option to extend Medicaid postpartum coverage. The option took effect in April 2022 and is available for five years. States that expanded Medicaid postpartum coverage before April 2022 did so through a Section 1115 waiver or via state funds.
New parents who have access to covered postpartum care are much more likely to seek it, even if that does mean going far out of their way or driving over an hour round trip for an appointment, Cherot said.
About 78 percent of OB-GYN practices accept Medicaid, according to a 2020 Kaiser Family Foundation survey, and Medicaid pays for more than 4 in 10 births nationwide. Yet the program reimburses physicians at a much lower rate than commercial payers. In many states, Medicaid pays providers less than half of what it costs to give birth.
The lack of payment can in turn lead to hospitals cutting their obstetrics staff or shutting down obstetrics units because they’re not bringing in enough revenue.
“What is just across the board hurting recruiting and retaining physicians right now is what’s happening to reimbursement rates in Medicare and Medicaid. It is just phenomenally detrimental,” said Burgess.