Dr. Emily Boevers is the only full-time OBGYN at a critical access hospital in a rural city in Iowa about 10 miles from the farm she grew up on.
She’s the only full-time OBGYN in the county, in a state that just banned most abortions.
Iowa enacted a law last week banning abortion once fetal cardiac activity can be detected, around six weeks into pregnancy, before many people even know they’re pregnant. The law includes exceptions for rape, incest and medical emergencies that threaten the life of the mother, and fetal abnormalities that are incompatible with life.
“What’s going to come to fruition at some point is that for a lot of us, we’re going to have a moment where we have to decide if we’re going to do the right thing for the patient that’s in front of us and risk our license, or if we want to step back and potentially let a patient – let a mother in our community – die from an obstetric complication, but preserve our license and our ability to continue to care for the other people in our rural communities,” Boevers said.
It’s a nightmare scenario that could become reality for doctors in Iowa. It’s also one that some doctors just aren’t willing to face.
Health care leaders are sounding the alarm that the constraints placed on them by the new abortion law could drive maternity care providers out of state and deter new ones from coming in, at a time when Iowa desperately needs them.
Iowa has the lowest per capita ratio of OBGYN providers to Medicare beneficiaries in the nation, according to a 2022 study published in the American Journal of Obstetrics and Gynecology.
More than 33% of counties in the state are considered maternity care deserts, where access to services is limited or absent, and 68,815 women live in a county without a single obstetric provider, according to a 2023 March of Dimes report.
The state is predominantly rural, with more than 10% of its population living below the poverty line, according to 2020 federal data. State figures show 40 of 61 rural Iowa counties had no OBGYN units in 2021, and about 82% of babies in the state were delivered in metropolitan communities, while around 27% were delivered in rural communities.
Boevers partners with two family medicine providers who can help cover calls and provide some obstetric care, but non-OBGYN providers don’t necessarily have the same training or surgical capabilities.
“It inevitably leads to kind of less safe care in those acute and emergent type situations,” she said.
Iowa’s infant mortality rate went up from 3.99 per 1,000 births in 2021 to 5.20 per 1,000 births in 2022, a roughly 30% increase, according to the US Centers for Disease Control and Prevention.
Boevers says that by the time a patient ends up in her office, they may have traveled hours to get there. Some Iowa providers told CNN they’ve had patients whose first care visit during a pregnancy is upon or right before their delivery.
When people put off care, it’s more likely that health issues can turn serious.
Doctors forced to make difficult decisions
The Iowa abortion ban makes exceptions for medical emergencies that threaten the life of the mother. But it’s unclear precisely what constitutes an emergency, experts say – and that’s a problem for providers, who risk facing up to $10,000 fines and losing their medical license if they break the law.
The Iowa Medical Board has crafted rules for doctors providing abortions under the law, but they do not outline medical emergency exceptions. CNN has reached out to the board for more information.
When seeking clarification on medical emergency exceptions, doctors are sometimes referred to hospital lawyers. In rural hospitals without robust staffing, Boevers says, that can mean trying to get in touch with a lawyer who lives in another state.
“It’s going to inevitably lead to delays in medically necessary care,” Boevers said. “It’s going to lead to people sitting and wringing their hands, wondering if they have a patient who’s sick enough to be able to offer an exception and waiting for non-medical professionals in administration or lawyer’s offices to decide whether or not patients – whether or not we can, you know, save a patient’s life.”
Iowa’s ban also makes exceptions for pregnancy as a result of incest or rape – so long as survivors can prove they reported the assault to the proper authorities before the deadline prescribed by the state. Rape survivors have 45 days from the day they were raped to report the assault to a law enforcement or health agency. People who get pregnant as a result of incest have 140 days to report the incident.
“It relies on the doctors adjudicating whether it’s rape or incest, which is something that even the police have a hard time adjudicating,” said Lyz Lenz, co-chair of the Iowa Abortion Access Fund’s board of directors.
Iowa Right to Life, an anti-abortion group, says doctors who take an “ethical” approach to abortion care decisions under the new law will be protected.
“We strongly believe physicians who take a moral and ethical approach to providing care and adhere to the language of the law in situations that apply to the life of the mother and baby, are protected. We believe lawmakers had this intent and wrote it into existing law,” Kristi Judkins, the organization’s executive director, told CNN in a statement.
Rather than take the risk, some doctors are choosing to uproot their lives and move to states with less restrictive abortion policies.
Boevers says that an OBGYN who practiced in an underserved rural community not far from hers recently moved to Minnesota. “She told me that part of the reason she left was she was just over the political interference,” she said.
“Physicians are very lucky that we are in demand. In basically every state, you could go and get a job,” she added. “What’s unfortunate for a place like Iowa is that it’s going to be harder and harder to convince these people to come here.”
Recent data shows this has also played out in other states with restrictive abortion policies.
Researchers with the Association of American Medical Colleges examined applications from the 2023-2024 residency cycle and found that states with abortion bans have seen a decrease in residency applications.
Of five obstetrics and gynecology students at University of Iowa Hospitals & Clinics in 2021, two went on to enter a practice in Iowa, according to an Iowa Health and Human Services report. And that was before the Supreme Court ended the national right to an abortion in 2022.
“It’s not just this amorphous fear that doctors are leaving,” Lenz said. “We cannot recruit doctors to come here.”
‘The chilling effect’
Fewer providers imperils access to other essential health care services, not just abortion, according to Ruth Richardson, CEO of Planned Parenthood North Central States.
“When you cut off one form of health care, it impacts access to health care across the board,” she said.
Richardson says their clinics offer maternity care, family planning and cancer screenings, among other services. As a safety net provider, Planned Parenthood is often one of the only options for people to access those essential services, she notes.
But it’s getting harder to recruit providers, she says, and they sometimes have to call in doctors from other states to help with the load.
“It’s the chilling effect. It’s the fear of being criminalized, the fear of losing a license that creates this sort of landscape of manufactured confusion,” she said. “It’s also having a huge chilling effect on future providers.”
Richardson says she’s heard from a number of providers and students who are flocking to medical schools and practices in states without abortion bans. The Emma Goldman Clinic, one of the only other abortion clinics left in the state, echoed this sentiment in a statement after the six-week ban went into effect.
“Right now, abortion care in Iowa looks bleak. Full spectrum reproductive health care may soon face additional challenges,” the statement said.
While health leaders are making an effort to recruit providers, for many the decision about where to practice is personal.
“Not very many people are like myself, practicing 10 miles from the farm that they grew up on, feeling committed and tied in a positive way to the community that they’re serving,” Boevers said. “They’re just going to go somewhere else – and I don’t blame them.”
Even Boevers, a mother to three daughters, has considered leaving.
“I think about my daughters. What would happen if one of them had a teen pregnancy, and decided they didn’t want to have a baby?” she asked. “Or what would happen if one of my daughters was raped – God forbid – and didn’t report it quickly enough? What’s going to happen if my daughters grow up in Iowa, and they decide to come back here and they have a life-threatening pregnancy complication?”
Richardson says Iowans need doctors like Boevers, or the Planned Parenthood staff, to stick around to provide care in a landscape flooded with uncertainty.