Dr. Emily Boevers stands as the sole full-time OBGYN at a critical access hospital in a rural Iowa city, about 10 miles from her childhood farm.
She is the only full-time OBGYN in the county, in a state that recently enacted a restrictive abortion law.
Iowa’s new law, effective last week, bans most abortions once fetal cardiac activity is detected, around six weeks into pregnancy. This often occurs before many even realise they are pregnant. The law permits exceptions for rape, incest, medical emergencies that endanger the mother’s life, and fatal fetal anomalies.
“We’re going to face a moment where we must choose between doing the right thing for a patient and risking our license, or stepping back and potentially letting a mother die to preserve our ability to care for others,” Boevers stated.
This scenario poses a harsh reality for Iowa’s doctors, with some unwilling to endure it.
Healthcare leaders warn that the new abortion law could drive maternity care providers out of the state and deter new ones from coming in, exacerbating Iowa’s critical need for them.
A 2022 study in the American Journal of Obstetrics and Gynecology found Iowa has the lowest per capita ratio of OBGYN providers to Medicare beneficiaries nationwide.
Over 33% of Iowa counties are maternity care deserts, lacking access to services, according to a 2023 March of Dimes report. Additionally, 68,815 women live in counties without a single obstetric provider.
The state, primarily rural, has over 10% of its population living below the poverty line, according to 2020 federal data. In 2021, 40 of Iowa’s 61 rural counties had no OBGYN units, with 82% of babies born in metropolitan areas compared to 27% in rural communities.
Boevers collaborates with two family medicine providers, but they lack the same training and surgical skills as OBGYNs.
“This leads to less safe care in acute and emergent situations,” she said.
Iowa’s infant mortality rate increased from 3.99 per 1,000 births in 2021 to 5.20 per 1,000 in 2022, a roughly 30% rise, according to the US Centers for Disease Control and Prevention.
Patients arriving at Boevers’ office often travel hours. Some providers report patients receiving their first prenatal care visit only upon or just before delivery.
Delaying care increases the risk of serious health issues.
The Iowa abortion ban allows exceptions for life-threatening medical emergencies, but experts say the definition of an emergency is unclear, posing a problem for providers who risk $10,000 fines and losing their licenses if they violate the law.
The Iowa Medical Board has rules for doctors performing abortions under the law, but they do not specify medical emergency exceptions. Attempts to reach the board for clarification have been made.
Doctors seeking clarity on medical emergency exceptions are sometimes directed to hospital lawyers. In rural hospitals with limited staff, Boevers notes this can mean contacting a lawyer in another state.
“This will inevitably delay medically necessary care,” Boevers said. “It leads to people wondering if a patient is sick enough for an exception while waiting for non-medical professionals to decide if we can save a patient’s life.”
The Iowa ban also has exceptions for pregnancies from incest or rape, provided survivors report the assault to authorities within the state’s prescribed deadlines. Rape survivors have 45 days to report the assault, while those pregnant from incest have 140 days.
“It requires doctors to determine if it’s rape or incest, which even the police struggle with,” said Lyz Lenz, co-chair of the Iowa Abortion Access Fund’s board of directors.
Iowa Right to Life, an anti-abortion group, believes doctors who follow an “ethical” approach under the new law will be protected.
“We believe physicians adhering to the law’s language in situations involving the mother’s and baby’s life are protected,” said Kristi Judkins, the organisation’s executive director.
Some doctors, rather than take the risk, are moving to states with less restrictive abortion policies.
Boevers mentioned an OBGYN from a nearby rural community who recently relocated to Minnesota, partly due to political interference.
“Physicians can find jobs in almost any state,” she said. “It’s unfortunate for Iowa, as it will be harder to attract people here.”
Recent data indicates this trend in other states with restrictive abortion policies.
The Association of American Medical Colleges found states with abortion bans saw a decrease in residency applications for the 2023-2024 cycle.
In 2021, only two of five obstetrics and gynecology students at University of Iowa Hospitals & Clinics stayed to practice in Iowa, according to an Iowa Health and Human Services report. This was before the Supreme Court ended the national right to an abortion in 2022.
“We cannot recruit doctors to come here,” Lenz said.
Fewer providers threaten access to essential services beyond abortion, according to Ruth Richardson, CEO of Planned Parenthood North Central States.
“Cutting off one form of healthcare impacts access to healthcare across the board,” she said.
Richardson noted their clinics offer maternity care, family planning, and cancer screenings. As a safety net provider, Planned Parenthood often remains one of the few options for these services.
However, recruiting providers is becoming more challenging, sometimes requiring doctors from other states.
“The fear of being criminalised and losing a license creates confusion,” she said. “It’s also affecting future providers.”
Richardson has heard from many providers and students moving to states without abortion bans. The Emma Goldman Clinic, one of Iowa’s remaining abortion clinics, echoed this sentiment after the six-week ban took effect.
“Abortion care in Iowa looks bleak,” the statement read.
While efforts to recruit providers continue, the decision of where to practice is often personal.
“Few people are like me, practising 10 miles from their childhood farm, feeling a positive commitment to their community,” Boevers said. “They’ll go elsewhere – and I don’t blame them.”
Even Boevers, a mother of three daughters, has considered leaving.
“I think about my daughters. What if one had a teen pregnancy and didn’t want the baby? Or if one was raped and didn’t report it quickly enough? What if they had a life-threatening pregnancy complication?” she asked.
Richardson emphasised the need for doctors like Boevers and Planned Parenthood staff to stay and provide care amidst the uncertainty.