South Dakota has a women’s health care shortage. The abortion ban may worsen it, physicians say.

EDITOR’S NOTE: This is the third story in a three-part series about the impacts of South Dakota’s abortion ban. The first story examined the number of South Dakotans leaving the state for abortions, and the second story analyzed the state’s “life of the mother” exception.

Avery Olson has a choice to make.

She could practice women’s health care as an OB-GYN in her home state of South Dakota, where it is illegal to perform abortions and where the exception to perform one to protect the life of the mother is unclear to some physicians.

Or she could practice in a nearby state, one where abortions are legal and she can practice to her full ability while still staying close to her family.

She has two years left in her residency, but she’s already being recruited by South Dakota practices.

South Dakota is facing a shortage of OB-GYNs and is a leading state for maternity care deserts, which is a county without a hospital or birth center offering obstetric care. Olson wants to be part of the solution, but she hesitates. She worries the state’s abortion laws will serve to worsen the shortage, leaving future South Dakota OB-GYNs to bear heavier workloads while some rural women’s health care needs are neglected.

It’s a nationwide worry, as a patchwork of state laws in the aftermath of the U.S. Supreme Court decision overturning Roe v. Wade in 2022 could exacerbate an already looming national shortage.

“Where I’m training, there are maybe two out of the 28 residents who would consider working in a state that has restrictive laws in place for women’s health care,” said Olson, who is a resident physician at the University of Hawaii. “That’s because I’m from South Dakota and the other is from Texas. The rest of them wouldn’t even touch South Dakota.”

South Dakota’s OB-GYN shortage

Forty-six of South Dakota’s 66 counties do not have obstetric providers, according to the U.S. Health Resources and Services Administration.

OB-GYNs are trained in two specialties: pregnancy care from preconception to childbirth, and all women’s health issues. They handle Pap smears, mammograms, menopause and annual women’s health physicals; they also handle infertility and are the primary surgeons when cesarean sections are needed or when an abortion is performed.

While family physicians can provide many of the same services, they are not specialized in such surgical procedures.

Patients with high-risk pregnancies often see a specialist early. Some women may have pulmonary hypertension, cystic fibrosis or other conditions that pose high risks of death when pregnant. Some could develop cancer while pregnant, or fetal anomalies might be detected. Prior to South Dakota’s trigger ban, termination would have been among the options for those patients to consider.

In 2021, the Centers for Disease Control and Prevention documented increases in cesarean delivery, preterm birth rates and low birth weights across the country, all of which can increase other health risks and require specialized care. About a quarter of births in South Dakota are by cesarean delivery.

According to a 2021 report projecting the supply and demand for women’s health service providers across the county, South Dakota was short 10 OB-GYNs in 2018. Although the demand isn’t projected to increase by 2030, the report expects the supply of OB-GYNs to worsen — with only 78.6% of the demand being filled.

In a national survey of more than 2,000 medical students, residents, fellows and practicing physicians through social media, three-fourths of respondents said they would not apply to states with legal consequences for providing abortion care, and more than 80% would prefer to train or practice in states with preserved abortion access, according to a study published in February in the Journal of General Internal Medicine.

If medical residents bypass South Dakota for nearby states where abortion is legal, such as Colorado or Minnesota, that could lead to worse health outcomes for South Dakotans, said Morgan Schriever, a University of South Dakota medical school graduate and first-year resident at Southern Illinois University.

“Women’s health care is going to suffer,” Schriever said. “It’ll be harder to find an OB-GYN, there will be longer wait times to see a physician, and there will be ultimately more stress on providers because they’re taking more calls and more patients and more stress and more burdens on them. It’ll be a downward spiral.”

OB-GYNs travel out of state for residencies, less likely to return

South Dakota is one of five states that does not have an obstetrics residency, according to the American College of Obstetricians and Gynecologists.

The University of South Dakota ended its residency program in the late 1980s amid budget concerns and other complications the school faced at the time.

Since then, all USD medical students planning to become OB-GYNs must train in another state. That already makes it difficult to recruit OB-GYNs, Olson said, because residents are typically at an age where they’re planning future careers, marrying or starting families.

“It’s a time where a good portion of people stay in the state where they do their residencies,” Olson said.

When residents practice in states such as Hawaii or Illinois, where abortion law is not as restrictive as in South Dakota, it makes it a more difficult choice to return, Schriever said.

Originally from Sioux Falls, Schriever was intent on returning to South Dakota after her residency. But that’s changed. In Illinois, she regularly encounters patients requesting or requiring an abortion.

The frequency of those situations made her realize how integral the practice is to women’s health care, and highlighted the lengths to which women will go to receive an abortion — even spending over $1,000 and driving hours out-of-state for one.

“Coming to or planning on practicing in a state that has these bans means I can’t practice full-scope,” Schriever said.

OB-GYN residency programs are required to offer access to training in abortion, although students with moral or religious objections are permitted to opt out. This requirement has been enforced by the Accreditation Council for Graduate Medical Education since 1996, and programs unable to meet this standard jeopardize their accreditation status.

It’s already a problem for residents in states where abortion is banned, such as Tennessee. Several residents travel out of their residency state to another, like Oregon, to get the required experience.

“It’s just a skill as an OB-GYN you should have,” Schriever said. “No matter where you practice, you could have someone in the ER who needs that type of procedure and you’re the only one who can perform it. It should be a skill you should have even if you don’t perform it on a daily basis.”

If South Dakota continues to see a shortage of OB-GYNs it “won’t be fair to the patients,” Schriever added.

“These laws in these states make them less desirable locations for OB-GYNs to work,” she said. “Women’s health care will ultimately suffer, and the people who will pay the price are the patients in these states.”