KANSAS CITY, Mo. — Jessica Babler, a nursing student at Research College of Nursing in Kansas City, Missouri, is tired of being vilified for wanting to provide abortions, which she views as health care, to her patients.
Babler hopes to be an OB-GYN nurse and practice in Kansas, but she said the Kansas Legislature’s continued efforts to limit abortion — even after Kansans overwhelmingly rejected a constitutional amendment which would have restricted or banned abortion in 2022 — have caused her to reconsider where she wants to practice.
For Babler, a state’s laws on abortion, which will decide what kind of care she is allowed to provide, is a central factor when choosing where to practice. Missouri’s near-total abortion ban made Babler want to practice in states where abortion laws are more lenient despite attending school in Missouri.
Though she said Kansas is still a viable option because abortion is accessible, further attacks on abortion health care could curb her enthusiasm for working in Kansas.
“Living in Kansas is like having your hands tied as an educator and as a provider,” Babler said. “We have lots of stress, and many times we don’t feel supported by the government. Practicing in a state that’s continually trying to limit abortion access could directly violate my oath to do no harm — how would I know what’s best for my patient if I don’t have access to all the options?”
Babler’s concerns as a student pursuing OB-GYN careers are growing more common. In the midst of a nationwide shortage of OB-GYN providers, residencies declined by 5.2% from 2022 to 2023, with significantly less students applying for residency in states which limit or ban abortions after the overturning of Roe v. Wade last year.
In addition, only half of OB-GYN residency programs offer routine abortion training, and 70% of students said their abortion training was inadequate during their third-year rotation, according to a 2022 study by the American College of Obstetricians and Gynecologists.
The nationwide shortage of OB-GYNs has left millions of women living in counties with limited access to maternity care. In Kansas, the consequences of the OB-GYN shortage are severe, especially in rural counties.
Just 32 out of 89 rural counties in the state provide maternity care — but by 2030, that will likely decrease to 24 as maternity care centers continue to close, forcing mothers in 65 counties to drive to an adjacent county or further to receive care, according to a 2020 study by Rural and Remote Health, an academic research organization which studies rural heath care access.
While Kansas law permits abortion up to 22 weeks and a 2019 Kansas Supreme Court ruling set a high legal bar for additional restrictions, a number of anti-abortion bills were passed during the recent legislative session, which adjourned in late April, with many measures directly targeting providers.
One measure criminalizes providers if they fail to provide care to infants “born alive” after an abortion, while another requires providers to inform patients that the effects of mifepristone, a common type of medication abortion, is reversible, though the method is unproven. Both bills became law after the Legislature overrode Democratic Gov. Laura Kelly’s vetoes.
Another piece of legislation aims to address the statewide shortage of OB-GYNs by providing loan assistance to medical students entering residency training programs in OB-GYN, but prohibits students from creating or working at a clinic that provides abortions. If students violate this provision, they must pay back the entire loan with 15% annual interest. Kelly signed the measure into law last week.
Lawmakers also considered a bill which would have prevented OB-GYNs who perform abortions from purchasing professional liability insurance from state’s health care stabilization fund — which every physician who has an active license must pay into. The legislation passed in the Senate 26-12 but was not voted on in the House.
Dr. Elizabeth Wickstom, an OB-GYN practicing in Overland Park, said many doctors in the field do not want to train or practice in Kansas because of the decisions of the Legislature. Anti-abortion laws, she said, will cause medical students to continue avoiding entering the field and cause an exodus of providers already practicing in the state.
Wickstom pointed to a recent study by the Idaho Coalition for Safe Reproductive Care, which found that 75 out of 117 OB-GYNs surveyed said they may or were already considering practicing in another state. Out of the 75 considering leaving the state, 73 said it was because of Idaho’s restrictive abortion laws.
“These measures are just a backdoor way for them to edge out anyone who is providing abortion and make it impossible to provide abortion,” she said.
But Rep. John Eplee, an Atchison Republican and a family physician, argued Kansas is a good location for attracting OB-GYNs because abortion will remain legal for the foreseeable future and because of its proximity to other states with stricter laws.
“I don’t think Kansas will be in an unfavorable position when it comes to maintaining, recruiting and keeping OBGYNs in our state,” he said. “We will be in a very favorable position because the states around us, particularly in the southeast, have restricted abortion access and abortion capacity much more.”
Hurdles for Kansas OB-Gyns
To explain the statewide shortage, many OB-GYNs point to an increased stigmatization of their work, increased levels of burnout and “hoops and hurdles” put in place by the Legislature for patients seeking abortions and providers performing them.
Dr. Iman Alsaden, an OB-GYN and the chief medical officer at Planned Parenthood Great Plains, said anti-abortion legislation often acts as a deterrent to students pursuing a career in the field by stigmatizing reproductive health care, thereby marginalizing providers and their patients.
“We deal with quite a bit of extra stuff compared to other health care providers,” she said. “When you marginalize and stigmatize communities in medicine and their providers you are essentially saying this type of medicine is lesser than.”
In addition to a number of additional “regulatory hoops” providers and their patients must jump through — including a 24-hour consent form, which includes information about alternatives to abortion, complications of the procedure and state-mandated information not reflective of the clinic’s medical opinion, and a mandatory ultrasound the day of the abortion — OB-GYNs are experiencing increased rates of burnout since the COVID-19 pandemic, putting stress onto practicing and training OB-GYNs.
Wickstom said Missouri’s near-total abortion ban has caused patients seeking abortions to flood into Kansas, increasing the rate of burnout amongst Kansas OB-GYNs who provide abortions and causing long delays for some patients seeking treatment — sometimes waitlisting patients past the 22-week limit, where they can no longer legally have an abortion.
She said these additional barriers have caused many OB-GYNs to leave the state or stop practicing because “it’s not worth it to them anymore.”
“Anytime you are practicing medicine that is stigmatized, there is a tremendous emotional burden,” Wickstom said. “OB-GYNs are already stretched thin and burned out. But top that off with the stigmatization of normal health care any OB-GYN should be providing, and it’s absolutely true that providers will be driven out.”
“If I go to my office every single day being afraid that the next thing will happen is I will lose my medical license, never practice medicine again and go to federal prison, it’s hard to go to work in the morning,” she said.
But Dr. Jonathon Scafford, an anti-abortion OB-GYN in Wichita, offered other explanations for the shortage, such as historically higher rates of burnout, worse work-life balance, and that their jobs — whether they perform abortions or not — are emotionally taxing.
Scaffold said that while states that have tighter restrictions on abortion may attract fewer applicants interested in performing abortion procedures,which would shift the distribution of physicians, he said abortion is not medically necessary.
“I don’t, in general, see abortion as legitimate health care,” he said. “From my perspective, I don’t see it as intrinsically problematic to have fewer physicians training in a procedure that is not conducive to delivering what I would consider appropriate health care.”
Danielle Underwood, a spokesperson for Kansans for Life, the state’s leading anti-abortion lobbying group, said the vast majority of OB-GYNs do not provide abortions.
“While a wide variety of factors affect a person’s career choices, it’s clear that laws that protect vulnerable patients align perfectly with the doctor’s Hippocratic oath to care and heal,” she said.
Lack of access to maternity care in Kansas
The large amount of maternity deserts especially in rural areas of the state are largely due to workforce shortages, financial difficulties and widespread hospital closures in rural areas, said Carrie Cochlan-McClain, the chief policy officer at the Kansas Rural Health Association.
After the Supreme Court overturned Roe v. Wade last year, Cochran-McClain is anticipating an increase in births. With a severe shortage of maternity care providers in rural areas of the state, she said the need for more health care providers is great.
“We know we already have shortages of OB providers and facilities to take care of women,” she said. “And we are very concerned about the growth in the number of individuals who will need care but won’t have access to it.”
David Jordan, the president of the Hutchinson-based United Methodist Health Ministry Fund, said the shortage of OB-GYNs will create worse health outcomes for mothers and their children while seeking prenatal, labor and delivery services and postpartum care — especially when they are forced to drive long distances.
He emphasized that hospitals must be financially viable so they can keep maternity wards open, and that the expansion of Medicaid in Kansas will be essential in attracting and keeping the state’s OB-GYN providers in rural areas where the need is greatest.
“OB-GYN and labor and delivery services are a critical part of ensuring healthy moms, healthy babies and a healthy start to life for both mom and baby,” he said. “We have to make sure there are no additional barriers to entering that workforce.”
Eplee, a family physician, said family physicians have fulfilled the role of OB-GYNs when delivering babies in rural areas. To combat the shortage, he said it will be increasingly important to give support to family physicians and OB-GYns, with an increased focus on recruiting them to rural areas.
Despite the growing shortage of OB-GYNs and the barriers erected for providers, Alsaden said working in the field is not only necessary but rewarding.
“If you want to provide this care, it will be harder,” Alsaden said. “But it will be worth it. Providers who have the knowledge and confidence to provide this care to patients even in this harmful political environment are some of the greatest providers and patient activists we have.”
