OB-Gyns are abandoning 12 states that can't afford to lose them.

The only surprise is how fast the exodus started.

You spend 11 or more years becoming an OB-Gyn or a scarce obstetrical subspecialist like a maternal-fetal physician (perinatologist). Then the state where you live and practice not only changes the laws about how you can do your job, but refuses to tell you exactly how the laws have changed except to make sure you know breaking those laws could end your career and land you in prison.

Like Dr. Kylie Cooper in Idaho, you have a choice: stick it out, worrying daily about your Hippocratic Oath to do no harm, and hoping something changes, while constantly living in fear you might break an unclear law. Or close your hard-won medical practice and your livelihood, pull your spouse out of their job, pack up your family, leave your friends, reputation and career behind, and hope it all works out if you start a practice up again someplace else. A decade or more of your life, friends, and career blown.

[Not enought time for context? Skip to a summary article or the new JAMA study.]

That’s what OB-Gyns in these 12 states are facing: Alabama, Arkansas, Idaho, Indiana, Kentucky, Louisiana, Mississippi, Oklahoma, South Dakota, Tennessee, Texas, and West Virginia after the Dobbs decision in June 2022.

WAIT. I know we’re all exhausted about “Dobbs” and “abortion,” and that exhaustion can make any of us not personally affected click to move on to another story. But it’s a very different issue to live in a state where we or our daughters can’t get basic everyday Gyn care. That’s what this is about, and why we all need to think about it that way, because we’re decimating OB-Gyn care for decades in the increasing number of states fervently passing these laws without looking to the future of normal, everyday lives of women.

It takes years, sometimes decades, to collect enough data to discover side effects of medications or treatments. So not yet even three years after Dobbs, knowing almost 5% of OB-Gyns have already abandoned these states is even worse news than that they are indeed leaving. [Click for full JAMA report.]

Five percent may not sound like much, but consider how quickly those doctor had to work through denial and anger to get to acceptance—that the state they chose and may have lived in since birth was betraying them. And then make the hard decision to give up on their lives, homes, and friends there. Then search for another position, interview for it, and get hired, followed by the uproar around selling a home and often their medical practice, and moving. And it takes a while for their departure to make it into state records used after that for this data gathering and analysis.

Doing all that in just over than two years? That’s a devastating warning about those midway through the same timeline.

And the odds of finding a replacement for them are getting lower every day. The US already had had a shortage of OB-Gyns as Boomer physicians retired. In a thousand US counties—a third of US counties—there are now no OB units. They are officially “maternity care deserts,” with no obstetrical care at all. [map] Some of the most desolate of these deserts are in those 12 states, a key reason several also have some of the worst maternal death statistics in the nation.

Maternal death is what medicine calls a ‘never event’—evidence of serious, preventable medical errors that should never occur in healthcare. Highly egregious, ‘never events’ always signal significant failures in patient safety systems. Mississippi, Louisiana, and Alabama were already three of the most dangerous places to birth in the US. Expectant moms living there would be safer birthing in Libya or Iraq.

And now women in those states are losing not just doctors to deliver their babies safely, but providers for routine Gyn care taken for granted elsewhere. Pap smear and cancer screening. In-depth knowledge of the safest family planning methods for women with unique needs. Sophisticated menopause help for women during the most demanding period of time in their families and careers. That experienced, sensitive, first pelvic exam for a young girl. Emergency or routine Gyn surgery, completely unrelated to pregnancy.

The reason for the exodus? Restrictive, ambiguous abortion laws written by legislators long on morality and short on medical realities.

Restrictive is one thing; at least doctors know what they’re dealing with. What’s worse is not knowing what the restrictions actually are.

The Texas near-total abortion ban went into effect in 2 1/2 years ago, and allows not only criminal prosecution, but civil prosecution. Under Texas law, anyone can sue someone who performs, induces, or aids and abets an abortion, including those who pay for or reimburse the costs of an abortion after a fetal heartbeat is detected at around 5 to 6 weeks after the woman’s last period.

And there’s a $10,000 reward for reporting a possible abortion.

That means even a previously unknown and uninvolved father of a group of a tadpole-like cells the size of a pea can sue a doctor who provided care during a miscarriage “with the exception of documented medical emergencies” and get financially rewarded for doing so.¹ No risk to the reporter and a possible reward.

And just last year, the Texas Supreme Court formally refused to define what qualifies as those “documented medical emergency” exceptions, or what care—standard elsewhere—can be provided in Texas for the up to 1 in 5 pregnancies that results in miscarriage, when a woman can bleed out in hours or minutes, far more quickly than hospital administration and lawyers can be convened to decide if proposed care might break the law. And not only did Texas refuse to clarify the law, they stopped reporting standard maternal death and morbidity (severe illness) data that would show the impact of the law.²

For Texas legislators, it’s not their problem. For Texas hospitals, it’s a good excuse to get out of OB care altogether. For doctors, it’s career- , morale- and freedom-threatening.

For women like Josseli Barnica, it was also a death sentence.

And that’s why OB-Gyns are leaving these states, as was widely predicted after Dobbs in June 2022. Now, less than three years later, this new study verifies the prediction was right. And those doctors won’t be replaced. Fewer new medical school grads are applying for OB-Gyn residencies in those states, a major feeder for private practice in any state.

Recruit replacements in? I’ve done physician recruiting. In the existing shortage, it can take years to recruit new OB-Gyns in states where the laws are clear about how they can practice. OB-Gyns are dependent on obstetrics to build a practice; they aren’t moving to murky law states when there are plenty of opportunities elsewhere. We could see that train coming less than a year after Dobbs when OB-Gyn residents already indicated they were 8 times more likely to start a practice and settle in a non-restrictive state where their careers and lives could thrive.

Prediction is one thing, easily ignored by those with “tomorrow’s problem” thinking. Reality is another, and it happened far faster than we thought. There’s a song, “Mommas, don’t let your babies grow up to be cowboys.” The new version should be, “Mommas, don’t let your daughters live in these states.”

1. The threat of being sued—and the high cost of malpractice insurance—is constantly on the minds of OB-Gyn. The US is a litigious society, and OB-Gyns are the second-most sued specialty. A complication of pregnancy or birth can occur in seconds and when it does, there is a high potential for long-term injuries to mom or baby. Birth is also far more emotionally significant than most other medical events, leading to higher expectations, more emotional damage, and the potential to clarify blame if things go wrong—all of which is why OB-Gyns pay far more for required malpractice insurance than other specialists.

2. Texas has not just refused to clarify what is a crime (or not) in their near-total abortion ban, but is now also not collecting standard maternal death and morbidity (severe illness) data. [If you might not like the data, just don’t collect it, and definitely don’t report it—a trend we’re seeing more of.] But ProPublica did. The sepsis rate—a life-threatening, multi-organ infection—increased by more than 50% after the ban went into effect. ProPublica also identified increased deaths among pregnant women after the ban. Like the completely preventable death of Josseli Barnica, many of the deaths had nothing to do with abortions: they were simply one of the 20% of pregnant women who suffer a miscarriage—but whose Texas doctors are afraid to provide standard miscarriage care for fear of being accused of performing an abortion.