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Barriers aren’t limited to birthdays
HARD TO DELIVER
Southeast Iowa Union offers audio versions of articles using Instaread. Some words may be mispronounced.
“Hard to Deliver” is a three-part series about maternal health care barriers in Southeast Iowa, as told by the mothers and families who’ve had to navigate them. This article is the final installment.
WASHINGTON — Once labor begins, the clock is ticking for expecting parents to get to an appropriately equipped obstetric professional, and every passing minute can make a world of difference for pain management and long-lasting health outcomes.
While that makes Southeast Iowa’s lack of birthing hospitals an especially urgent issue when it comes up, it’s not the only gap in the region or state’s maternal health care system. Southeast Iowans have few options when it comes to perinatal providers, and many sacrifice other aspects of their health or put careers on pause just to make appointments before and after giving birth.
The problem seems to be worsening. Iowa faces a dire shortage of OB-GYNs, and it’s losing access to obstetric care at one of the fastest rates in the country according to Medicine Iowa, a seasonal publication released by the University of Iowa. With fewer physicians and longer commutes to reach them, young families in the Hawkeye State must spend disproportionate cash, time, and paid leave to get the care they need.
Prenatal appointments demand time, money
For Southeast Iowans who opt against in-home midwives, faraway appointments throughout pregnancy become a fact of life. Visits to providers usually happen every other week early in the term, before eventually progressing to weekly, then twice a week.
The costs add up fast.
Mallory, a mother in Fairfield who agreed to be identified by only her first name to protect her medical privacy, said she drove to Iowa City for all of her prenatal appointments in 2024, an over 60-mile trip taking about an hour and 10 minutes each way.
While she had closer options — including the Ottumwa Regional Health Center, or midwives available through WCHC — she said she preferred a specific provider she knew in Iowa City, and the abundance of specialists available there in case of emergency. She also knew UIHC tended to score better on quality of care metrics compared to rural hospitals like Ottumwa’s.
The result was a multi-hour round trip for every prenatal visit. While that was manageable for her first child, Mallory said it was much harder for her second, as she balanced the appointments with day care arrangements and long work hours, ahead of a delivery in December of last year.
“It was easy when I had my toddler, because I was a first-time mom and didn’t have to coordinate anything,” she said. “But as a second-time mom … It was exhausting. You’re going to be exhausted no matter what, so you kind of just deal with it.”
More than an inconvenience, the financial and physical burden is an outright barrier to care for some Iowans. A report from nonprofit March of Dimes in 2024 said 11.3% of women in Iowa started prenatal care at five months of pregnancy or later, or made less than half of the appropriate number of prenatal visits to their doctors.
When families can afford the travel and time commitments, their distance from obstetric care still adds major logistical challenges.
Maddie Widmer spent much of her pregnancy fighting to balance her professional and personal life.
The self-employed financial adviser from Washington needed to stay in the loop with clients during her pregnancy in 2020, when the early waves of the COVID-19 pandemic threw much of the money management world into disarray.
Widmer found herself taking calls and answering emails from a hospital bed, between — and sometimes during — her prenatal appointments, after showing early signs of preeclampsia around the 30th week of her term. The blood pressure condition required several lengthy checkups each week for the rest of her pregnancy.
“It’s not conducive, it’s unprofessional when you’re trying to run your own business,” she said of her improvised work environment at the Iowa City location then known as Mercy Hospital. “I have a really fantastic client base, so everybody understood … but I was constantly being interrupted with people having to come in to draw my blood, check the blood pressure.”
The situation went from untenable to exigent during her 37th week. Widmer found herself struggling to stay awake through a midafternoon appointment, before providers clocked her resting blood pressure at an alarming 160 over 111.
Doctors said they needed to induce labor immediately or risk catastrophic shock.
With delivery not planned for another three weeks, Widmer had none of her personal support on-hand: her husband was sitting in a dentist’s chair in Washington, running low on paid time off and asked to skip his partner’s routine appointments anyway as a social distancing measure. Her parents were also miles away in her hometown with no reason to expect a call, much less for their daughter to deliver three weeks early. Widmer herself had left a gallon of milk in the back of her car, expecting to head home after a quick, routine appointment.
Alone at the hospital, she had to make the immediate decisions about her care by herself, a tall order under the stress of unexpectedly induced labor.
“Nobody was around me, and I had to make arrangements immediately. The stress of not being somewhat close to my support people was terrifying, especially for a first-time mother,” Widmer said. “To not have somebody with a clear head there with me, (it) was really, really stressful.”
Iowa faces an OB-GYN shortage
Stories like Widmer’s are increasingly common as rural Iowa hospitals slowly lose their obstetricians and gynecologists. And those that keep such services often struggle to fill open positions, as the state faces a severe shortage of OB-GYNs.
The issue doesn’t just impact patients - It’s taken a toll on providers themselves, some of whom say they can spend around 100 hours a week on call and in appointments.
Dr. Emily Boevers has worked as an OB-GYN at Waverly Health Center since finishing her residency in 2022. But shortly after she started, both of her expected partners in the unit parted ways with the hospital. That made her the only OB-GYN in the building, fresh out of residency.
The hospital has since recruited a few family medicine doctors with obstetric training to help relieve some of her low-risk caseload. But she learned late last week that one of those physicians plans to depart soon as well.
“I don’t know that I can do it that much longer,” she said. “The last two summers, since I’ve been in practice here, we’ve had something come up where somebody was out, or somebody had left ... my kids are getting older, I want to spend time with them, I want to be around for them and take them to the pool and stuff, and I don’t know that I can do that again. I’m just burnt out, and I’m only three years out.”
Experts who spoke with The Union said a number of factors were likely driving providers away from the state, citing things like poor Medicaid reimbursement rates, a lack of private practices or entry-level positions, an unfavorable legal environment and a general lack of curb appeal for a state much of the nation considers flyover country.
Some, like Dr. Jonna Quinn, have left the state altogether. A first-generation college student and Iowa native, she returned from a residency in Ohio to work as an OB-GYN at MercyOne in Mason City in 2013.
But she said short staffing there, combined with restrictive policies at the Catholic hospital and state laws limiting her medical discretion in abortion cases all left her disheartened as the years went by. In March of 2024, her family packed their bags, sold her husband’s small business, and moved to Duluth, Minnesota, where she practices today.
While Quinn considered switching to a non-religious hospital in Iowa, she said the rest of the state just couldn’t compete with job opportunities at better-staffed, more flexible employers elsewhere.
“I was losing joy for my profession, and I was losing faith in people believing in women’s rights and women’s choices, and had to leave to continue my career. I just couldn’t do it anymore,” Quinn said. “I moved, and it was glorious. I love my job again, women are trusted, and there’s no judgment ... and I’m fully staffed here.”
Quinn said Iowa’s abortion reform in 2023 was one of the last straws driving her exit, and many other obstetric professionals cite the policy as an accelerant of the state’s provider shortage.
Iowa code now bans abortions after the first six weeks of most pregnancies, when some Christians believe an embryo becomes a person. The law grants exemptions in cases of rape or incest, or when a physician deems the pregnancy “incompatible with life.” It does not, however, make exceptions for elective abortions, even if patients don’t learn they’re pregnant until after six weeks.
Despite legal measures to protect patients’ lives and avoid criminalizing miscarriages, Quinn said the policy was a major red flag to many prospective doctors as they decided where to put down roots.
“Abortion is one tiny piece of the overall dynamic of how a state feels about women, and how they feel about how they’re going to support women,” she said. “It’s like a thermometer, or a litmus test of how a state feels about women’s rights in general. If you don’t trust women to make choices on their reproductive care, do you trust women to do anything?”
The issue was also top of mind for Meg Moreland, an Iowa City native who left the state for the Twin Cities in 2018, where she studied and became an obstetric nurse. Now working with IVF patients in Seattle, she said she had several reasons to leave her home state, but that chief among them was growing sentiment against abortions at the time.
Moreland said she was worried Iowa would pass ideological laws needlessly restricting abortion for people who needed it, withholding a sometimes critical element of obstetric care.
“I wanted to be in a state that would provide safe policies and public support for (abortions) so that’s why I chose to go to Minnesota,” she said. “I mean, it’s nice to give back to your community, but you have to have a community that’s willing to receive that help.”
In contrast, Dr. Ryan Beardsley, an OB-GYN at MercyOne in Waterloo, said he agreed on-face with the state’s abortion policy. But he worries the law will exacerbate Iowa’s dearth of providers, due to common misconceptions about its scope.
“I actually don’t mind the fetal heartbeat bill, but the reality is that it will keep some OB-GYNs out,” he said in an email. “Many OBs worry that they will be penalized for treating ectopic pregnancies, performing suction D&Cs or (providing) medications after miscarriages ... The law excludes all those things from being illegal, but even OBs don’t realize that because of how skewed the reporting has been on this topic.”
Despite doctors’ and patients’ anecdotes, precise data on Iowa’s OB-GYN shortage is somewhat inconsistent. Experts and studies do seem to agree on one overarching truth: the state is nowhere close to keeping up with demand.
Several news sources including the Daily Iowan, the Business Record and the University of Iowa’s Medicine Iowa magazine in recent years have repeated a claim that Iowa has the fewest OB-GYNs per capita of any state or territory, all citing the American College of Obstetricians and Gynecologists, but a spokesperson from ACOG told The Union the organization doesn’t track such workforce supply data.
The spokesperson did direct the paper to the U.S. Health Resources and Services Administration. The federal agency reported in 2022 that Iowa had just 6.84 OB-GYNs per 100,000 people, the second-worst ratio of any American state or territory, after Guam, which had 5.91. Minnesota, for comparison, boasted 12.1, ranking it 24th.
HRSA has not published OB-GYN data for 2023, or any data for 2024, but did place Iowa at the same second-to-last rank every year back to 2019, the oldest publicly available dataset on the agency’s website.
The American medical Association also gave the Hawkeye State low marks in 2015, at spot No. 51 on a list of OB-GYN to patient ratios in every state and the District of Columbia. Its findings were endorsed by a 2020 physician workforce study commissioned by the Iowa Legislature. Another report from the U.S. Department of Health and Human Services in 2021 said Iowa had 360 OB-GYNs in 2018, juggling about 500 providers’ worth of demand for their services. At 72%, the finding would also put Iowa’s adequacy below any other state’s, with projections to sink even lower (68.1%) by 2030.
More recently, the United Health Foundation reported Iowa had 37.7 obstetricians, gynecologists and midwives per 100,000 females age 15 and older, based on data collected in September of 2023. The number is slightly more optimistic than others, and would rank Iowa 45th in the nation, outperforming Alabama, Arkansas, Oklahoma, Nevada and Mississippi.
The Union was unable to find any other reliable state-level OB-GYN workforce data published since the passage of Iowa’s six-week abortion ban in July of 2023.
Unit closures, burnout, create ‘vicious cycle’
Regardless of the reasons behind it, obstetric providers say the shortage in their field has accelerated the closure of rural labor and delivery units as smaller hospitals struggle to find staff.
The trend channels rural patients to predominantly urban hospitals, where already overclocked physicians and nurses must absorb ever-higher caseloads, increasing turnover and dissuading potential newcomers who can find less demanding entry-level work in other states.
The result is a feedback loop: shortages cause burnout, burnout increases turnover, and turnover worsens shortages.
“Sometimes you’re up all night, and not getting any sleep every (few) nights really catches up with you,” said Dr. Beardsley, who sometimes picks up shifts at MercyOne’s hospitals in Mason City and Davenport due staff shortages there. “The ones who are here are more likely to end up getting burnt out faster ... it’s kind of a compounding problem, the shortage is more likely to cause more shortages.”
Dr. Karla Solheim, Iowa Chair of the American College of Obstetricians and Gynecologists, has closely monitored the disappearance of obstetric units in the state since 2017. Like Beardsley, she called the issue a “vicious cycle.”
On top of burnout, she said there was a political element to that cycle, as OB-GYNs simply don’t have time to call lawmakers, attend hearings, or otherwise fight for reforms that might make the state more appealing to professionals in their field.
Low Medicaid reimbursements, unfavorable malpractice laws and limited physician discretion, for instance, can drive prospective OB-GYNs away from Iowa, according to Solheim. That worsens caseloads for existing providers, who in turn have even less time for policy advocacy in another cycle that perpetuates itself.
“I feel like we don’t have time to advocate for ourselves and actually talk with the decision-makers,” she said. “Because our patients need us so much, we haven’t had time to be at the table where these decisions are made.”
Some worry the damage is irreversible: Iowa’s shortage of obstetric professionals already deters newcomers, while less severe shortages in other states make for a highly competitive national job market.
Conventional wisdom suggests that maintaining a workforce in the obstetric field is infinitely easier than luring providers back to the state. But for some, like Dr. Quinn, that ship has already sailed.
“You will never get me back into a two-person practice that’s supposed to be eight. I’m not going to sign up for that again,” she said. “I’m super happy up here, and now my kids are in school and thriving. I mean, my office is overlooking Lake Superior, it couldn’t be more beautiful. You should’ve prevented me from leaving in the first place, to find out there are nicer places to live than Iowa.”
Comments: Kalen.McCain@southeastiowaunion.com
