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<\/p>\nOne by one, doctors who handle high-risk pregnancies are disappearing from Idaho \u2014 part of a wave of obstetricians fleeing restrictive abortion laws and a hostile state legislature. Dr. Caitlin Gustafson, a family doctor who also delivers babies in the tiny mountain town of McCall, is among those left behind, facing a lonely and uncertain future.<\/p>\n
When caring for patients with pregnancy complications, Dr. Gustafson seeks counsel from maternal-fetal medicine specialists in Boise, the state capital two hours away. But two of the experts she relied on as backup have packed up their young families and moved away, one to Minnesota and the other to Colorado.<\/p>\n
All told, more than a dozen labor and delivery doctors \u2014 including five of Idaho\u2019s nine longtime maternal-fetal experts \u2014 will have either left or retired by the end of this year. Dr. Gustafson says the departures have made a bad situation worse, depriving both patients and doctors of moral support and medical advice.<\/p>\n
\u201cI wanted to work in a small family town and deliver babies,\u201d she said. \u201cI was living my dream \u2014 until all of this.\u201d<\/p>\n
Idaho\u2019s obstetrics exodus is not happening in isolation. Across the country, in red states like Texas, Oklahoma and Tennessee, obstetricians \u2014 including highly skilled doctors who specialize in handling complex and risky pregnancies \u2014 are leaving their practices. Some newly minted doctors are avoiding states like Idaho.<\/p>\n
The departures may result in new maternity care deserts, or areas that lack any maternity care, and they are placing strains on physicians like Dr. Gustafson who are left behind. The effects are particularly pronounced in rural areas, where many hospitals are shuttering obstetrics units for economic reasons. Restrictive abortion laws, experts say, are making that problem much worse.<\/p>\n
\u201cThis isn\u2019t an issue about abortion,\u201d said Dr. Stella Dantas, the president-elect of the American College of Obstetricians and Gynecologists. \u201cThis is an issue about access to comprehensive obstetric and gynecologic care. When you restrict access to care that is based in science, that everybody should have access to \u2014 that has a ripple effect.\u201d<\/p>\n
Idaho doctors operate under a web of abortion laws, including a 2020 \u201ctrigger law\u201d that went into effect after the Supreme Court eliminated the constitutional right to abortion by overturning Roe v. Wade last year. Together, they create one of the strictest abortion bans in the nation. Doctors who primarily provide abortion care are not the only medical professionals affected; the laws are also impinging on doctors whose primary work is to care for expectant mothers and babies, and who may be called upon to terminate a pregnancy for complications or other reasons.<\/p>\n
Idaho bars abortion at any point in a pregnancy with just two exceptions: when it is necessary to save the life of the mother and in certain cases of rape or incest, though the victim must provide a police report. A temporary order issued by a federal judge also permits abortion in some circumstances when a woman\u2019s health is at risk. Doctors convicted of violating the ban face two to five years in prison.<\/p>\n
Dr. Gustafson, 51, has so far decided to stick it out in Idaho. She has been practicing in the state for 20 years, 17 of them in McCall, a stunning lakeside town of about 3,700 people.<\/p>\n
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She sees patients at the Payette Lakes Medical Clinic, a low-slung building that evokes the feeling of a mountain lodge, tucked into a grove of tall spruces and pines. It is affiliated with St. Luke\u2019s Health System, the largest health system in the state.<\/p>\n
On a recent morning, she was awakened at 5 a.m. by a call from a hospital nurse. A pregnant woman, two months shy of her due date, had a ruptured membrane. In common parlance, the patient\u2019s water had broken, putting the mother and baby at risk for preterm delivery and other complications.<\/p>\n
Dr. Gustafson threw on her light blue scrubs and her pink Crocs and rushed to the hospital to arrange for a helicopter to take the woman to Boise. She called the maternal-fetal specialty practice at St. Luke\u2019s Boise Medical Center, the group she has worked with for years. She did not know the doctor who was to receive the patient. He had been in Idaho for only one week.<\/p>\n
\u201cWelcome to Idaho,\u201d she told him.<\/p>\n
In rural states, strong medical networks are critical to patients\u2019 well-being. Doctors are not interchangeable widgets; they build up experience and a comfort level in working with one another and within their health care systems. Ordinarily, Dr. Gustafson might have found herself talking to Dr. Kylie Cooper or Dr. Lauren Miller on that day.<\/p>\n
But Dr. Cooper left St. Luke\u2019s in April for Minnesota. After \u201cmany agonizing months of discussion,\u201d she said, she concluded that \u201cthe risk was too big for me and my family.\u201d<\/p>\n
Dr. Miller, who had founded the Idaho Coalition for Safe Reproductive Health Care, an advocacy group, moved to Colorado. It is one thing to pay for medical malpractice insurance, she said, but quite another to worry about criminal prosecution.<\/p>\n
\u201cI was always one of those people who had been super calm in emergencies,\u201d Dr. Miller said. \u201cBut I was finding that I felt very anxious being on the labor unit, just not knowing if somebody else was going to second-guess my decision. That\u2019s not how you want to go to work every day.\u201d<\/p>\n
The vacancies have been tough to fill. Dr. James Souza, the chief physician executive for St. Luke\u2019s Health System, said the state\u2019s laws had \u201chad a profound chilling effect on recruitment and retention.\u201d He is relying in part on temporary, roving doctors known as locums \u2014 short for the Latin phrase locum tenens, which means to stand in place of.<\/p>\n
He likens labor and delivery care to a pyramid, supported by nurses, midwives and doctors, with maternal-fetal specialists at its apex. He worries the system will collapse.<\/p>\n
\u201cThe loss of the top of a clinical pyramid means the pyramid falls apart,\u201d Dr. Souza said.<\/p>\n
Some smaller hospitals in Idaho have been unable to withstand the strain. Two closed their labor and delivery units this year; one of them, Bonner General Health, a 25-bed hospital in Sandpoint, in northern Idaho, cited the state\u2019s \u201clegal and political climate\u201d and the departure of \u201chighly respected, talented physicians\u201d as factors that contributed to its decision.<\/p>\n
Other states are also seeing obstetricians leave. In Oklahoma, where more than half of the state\u2019s counties are considered maternity care deserts, three-quarters of obstetrician-gynecologists who responded to a recent survey said they were either planning to leave, considering leaving or would leave if they could, said Dr. Angela Hawkins, the chair of the Oklahoma section of the American College of Obstetricians and Gynecologists.<\/p>\n
The previous chair, Dr. Kate Arnold, and her wife, also an obstetrician, moved to Washington, D.C., after the Supreme Court overturned Roe in Dobbs v. Jackson Women\u2019s Health Organization. \u201cBefore the change in political climate, we had no plans on leaving,\u201d Dr. Arnold said.<\/p>\n
In Tennessee, where one-third of counties are considered maternity care deserts, Dr. Leilah Zahedi-Spung, a maternal-fetal specialist, decided to move to Colorado not long after the Dobbs ruling. She grew up in the South and felt guilty about leaving, she said.<\/p>\n
Tennessee\u2019s abortion ban, which was softened slightly this year, initially required an \u201caffirmative defense,\u201d meaning that doctors faced the burden of proving that an abortion they had performed was medically necessary \u2014 akin to the way a defendant in a homicide case might have to prove he or she acted in self-defense. Dr. Zahedi-Spung felt as if she had \u201cquite the target on my back,\u201d she said \u2014 so much so that she hired her own criminal defense lawyer.<\/p>\n
\u201cThe majority of patients who came to me had highly wanted, highly desired pregnancies,\u201d she said. \u201cThey had names, they had baby showers, they had nurseries. And I told them something awful about their pregnancy that made sure they were never going to take home that child \u2014 or that they would be sacrificing their lives to do that. I sent everybody out of state. I was unwilling to put myself at risk.\u201d<\/p>\n
Perhaps nowhere has the departure of obstetricians been as pronounced as in Idaho, where Dr. Gustafson has been helping to lead an organized \u2014 but only minimally successful \u2014 effort to change the state\u2019s abortion laws, which have convinced her that state legislators do not care what doctors think. \u201cMany of us feel like our opinion is being discounted,\u201d she said.<\/p>\n
Dr. Gustafson worked one day a month at a Planned Parenthood clinic in a Boise suburb until Idaho imposed its near-total abortion ban; she now has a similar arrangement with Planned Parenthood in Oregon, where some Idahoans travel for abortion care. She has been a plaintiff in several lawsuits challenging Idaho\u2019s abortion policies. Earlier this year, she spoke at an abortion rights rally in front of the State Capitol.<\/p>\n
In interviews, two Republican state lawmakers \u2014 Representatives Megan Blanksma, the House majority leader, and John Vander Woude, the chair of the House Health and Welfare Committee \u2014 said they were trying to address doctors\u2019 concerns. Mr. Vander Woude acknowledged that Idaho\u2019s trigger law, written before Roe fell, had affected everyday medical practice in a way that lawmakers had not anticipated.<\/p>\n
\u201cWe never looked that close, and what exactly that bill said and how it was written and language that was in it,\u201d he said. \u201cWe did that thinking Roe v. Wade was never going to get overturned. And then when it got overturned, we said, \u2018OK, now we have to take a really close look at the definitions.\u2019\u201d<\/p>\n
Mr. Vander Woude also dismissed doctors\u2019 fears that they would be prosecuted, and he expressed doubt that obstetricians were really leaving the state. \u201cI don\u2019t see any doctor ever getting prosecuted,\u201d he said, adding, \u201cShow me the doctors that have left.\u201d<\/p>\n
During its 2023 session, the Legislature clarified that terminating an ectopic pregnancy or a molar pregnancy, a rare complication, would not be defined as abortion \u2014 a move that codified an Idaho Supreme Court ruling. Lawmakers also eliminated an affirmative defense provision.<\/p>\n
But lawmakers refused to extend the tenure of the state\u2019s Maternal Mortality Review Committee, an expert panel on which Dr. Gustafson served that investigated pregnancy-related deaths. The Idaho Freedom Foundation, a conservative group, testified against it and later called it an \u201cunnecessary waste of tax dollars\u201d \u2014 even though the annual cost, about $15,000, was picked up by the federal government.<\/p>\n
That was a bridge too far for Dr. Amelia Huntsberger, the Idaho obstetrician who helped lead a push to create the panel in 2019. She recently moved to Oregon. \u201cIdaho calls itself a quote \u2018pro-life state,\u2019 but the Idaho Legislature doesn\u2019t care about the death of moms,\u201d she said.<\/p>\n
Most significantly, the Legislature rejected a top priority of Dr. Gustafson and others in her field: amending state law so that doctors would be able to perform abortions when the health \u2014 not just the life \u2014 of the mother is at risk. It was almost too much for Dr. Gustafson. She loves living in Idaho, she said. But when asked if she had thought about leaving, her answer was quick: \u201cEvery day.\u201d<\/p>\n