After Missouri banned abortion, the state saw 25% drop in OB-GYN residency applicants

Medical students and residents increasingly come to Dr. Colleen McNicholas with the same concern: will their training in Missouri prepare them to competently care for pregnant patients?

McNicholas, who for years was among the few doctors performing elective abortions in Missouri, said that fear is reflected in a report released in May by the Association of American Medical Colleges. It found Missouri had more than a 25% drop in applicants for OB-GYN medical residencies since 2022, when abortion became illegal in the state.

“What does it mean to be an OB-GYN in a state that is telling you how to practice medicine?” asked McNicholas, chief medical officer for Planned Parenthood of the St. Louis Region and Southwest Missouri and Missouri chair of the American College of Obstetricians and Gynecologists.

All 14 states with abortion bans saw a decrease in OB-GYN residency applications, despite a slight overall increase in physicians applying for OB-GYN residency programs nationally, the study found. Missouri was second only to Arizona for the largest decrease in applicants.

The need for more robust and accessible maternal health care is particularly stark in Missouri, where lawmakers on both sides of the aisle have lamented the state’s woeful maternal and infant mortality rates — among the worst in the country — and lack of maternal health care providers in nearly half of its counties.

McNicholas said legal concerns aside, there are a couple things for doctors to consider when deciding where to do their residency, since historically, most physicians remain in the community where they do their training.

Physicians tend to start families later in life, which means they are inherently at higher risk of having pregnancy complications or needing to use assisted reproductive technology, she said. And OB-GYNs are increasing women, which means they need good maternal care if they choose to have a family.

“The need for more OB-GYNs is going to be at a crisis point here soon,” McNicholas said. “… You cannot even seriously consider how to fix that problem until you address the reality of what a workforce crisis looks like under an abortion ban.”

State Sen. Mary Elizabeth Coleman, an Arnold Republican and a board member for Missouri Stands with Women, a group formed to fight a campaign to legalize abortion in Missouri, doesn’t think the study’s conclusions are valid.

She instead pointed to other reasons she sees for declining OB-GYN residency numbers across the country, including a move by some universities to DEI-based admission and population declines, particularly in rural areas.

Coleman accused the medical association of fear-mongering, adding that if physicians choose not to apply to Missouri because of its abortion ban, then they are doctors she’d prefer to stay away.

“I wish they would focus on providing rural health care to Missourians,” she said. “Rather than a love affair with a violent procedure that ends a life.”

Alyssa Lally, a spokeswoman with the University of Missouri-Kansas City, said the school attributes fluctuations in OB-GYN residency applicants over the past several years in part to a change in how residents are now matched.

Over the past few years, the national organization that handles residency applications stopped sending all OB-GYN applicants to all medical schools with the program, and instead started sending the applications of residents only to the schools they showed interest in attending.

Despite this, she said UMKC continues to fill all its residency slots. A spokesperson for the University of Missouri-Columbia’s medical school said it also has no problem filling their four openings each year.

Lisa Cox, a spokeswoman with the Missouri Department of Health and Senior Services, said the state is working to improve physician retention through its Graduate Medical Education Grant Program, which supports extra residency positions.

“It is difficult to pinpoint a single cause (of the drop); however, our main takeaway is that Missouri needs more residency spots. Of course, this is an issue nationally,” Cox said in a statement. “ … Our residency spots, while already low, are routinely filled, and it remains a competitive field, which could deter applicants.”

‘states with bans are reaping what they sow’

Pamela Merritt, the executive director of Medical Students for Choice, said she has a hard time selling medical students on coming to states with abortion bans.

“I don’t know anybody who’s invested close to half a million dollars in their education who wants to walk into a residency program in a state where people with absolutely no background in medicine are drafting regulations that deny your ability to care for your patients,” she said.

The data reflects this due diligence by medical students to research where they want to start a life and start a practice, she said.

And while she said states should be doing all they can to attract top talent, bans often have the opposite effect.

“All of the states with bans are reaping what they sow,” Merritt said. “The tragedy is that the communities most harmed by this are rural communities and poor communities.”

She guesses public health outcomes will only worsen as a result.

Maternal mortality rates were 62% higher in states with abortion restrictions, according to a 2023 study published in the National Library of Medicine.

A study from the state’s Pregnancy-Associated Mortality Review board found that between 2018 and 2020, 210 Missouri women died while pregnant, during childbirth or within a year of birth. The majority were deemed preventable.

Missouri also scored a D- grade for preterm births in a 2023 March of Dimes report.

“Missouri already has indefensible maternal mortality rates,” Merritt said. “Missouri struggles to keep Black children who are born in the state alive for the first year after birth, and we have far too many young people who are living in poverty and are food insecure.

“We’re failing children and failing families and women and this ban not only puts the health of people in Missouri who can experience pregnancy at risk, but it now is putting the health of everybody in the state at risk when you become repulsive to doctors, that’s very dangerous.”

More than 41% of counties in Missouri are designated maternity care deserts, meaning there are no maternity care providers or birthing facilities. Missouri’s rate is higher than the national rate of 32%, according to a separate 2023 report from the March of Dimes. Across the state, 10% of women do not live within 30 minutes of a birthing hospital.

In the last decade, 19 hospitals across Missouri have closed, according to the Missouri Hospital Association.

The state’s board of healing arts, which licenses physicians, reports there are 1,041 licensed OB-GYNs working in Missouri. The March of Dimes estimates that in 2022, there were 1.1 million women of childbearing age, which means there is approximately one OB-GYN for about every 1,050 of childbearing age in the state.

Attempts to further limit training in abortion

During a House hearing earlier this year, state Rep. Emily Weber, a Democrat from Kansas City, said she’s heard about doctors first consulting attorneys before helping women in need of emergency abortions.

Under the state’s “trigger law,” health care providers who perform abortions not necessary to save the woman’s life can be charged with a class B felony, which means up to 15 years in prison. Their medical license can also be suspended or revoked as a result.

The only exception is in cases of medical emergencies when a pregnant person’s life is at risk or when “a delay will create a serious risk of substantial and irreversible physical impairment of a major bodily function.”

“We’re losing physicians and doctors,” Weber said. “They’re leaving the state of Missouri because they can’t perform their actual duties that they had extensive education on and got their degree in.”

House Minority Leader Crystal Quade pointed to some bills filed this year that didn’t pass, but that put Missouri on the national stage for “extremism,” likely to impact physicians’ decisions on whether or not to move to the state or out of it.

This included a bill from state Rep. Justin Sparks, a Republican from Wildwood, that would have prohibited public and private medical schools from providing any “abortion-specific training,” including through out-of-state partnerships; and a bill filed by state Sen. Mike Moon, a Republican from Ash Grove, proposed to charge those who perform or get an abortion with murder.

“It’s a perfect storm situation where we are continuing to lose access to care, particularly for maternal care,” said Quade, who is seeking the Democratic nomination for governor.

Quade has spoken with women who said they were sent home during a miscarriage because their life wasn’t yet in enough danger to get an abortion, and she’s spoken with providers who were unsure whether to stay in Missouri, weighing a moral dilemma between their duty to their patients and their fears of legal prosecution if they perform an abortion the state deems unnecessary.

She, too, fears this decrease in interest in Missouri as a place for providers not just to learn, but to establish roots, will only continue.

“What that means is not only potential shortages,” Quade said. “But also that we’re not getting the best of the best anymore.”

Sparks said his legislation wasn’t meant to target OB-GYNs, but rather was written based on conversations with Missouri physicians. He hoped to instead end “abortion fellowships” where doctors are sent across state lines to perform abortions.

Those conversations, he said, included doctors at Washington University in St. Louis who said their students went out of state in order to “become really good at abortions, and then come back to Missouri to perform them in the cases where they’re legal.”

Sparks said this argument doesn’t hold water for him, since universities already teach a standard of care for emergency abortions that he finds to be sufficient.

“To say that we just have to do abortions in order to maintain that level of care is disingenuous,” he said, adding that physicians going out of state for training contributes to “a generation of folks who won’t exist.”

He thinks it’s a stretch to correlate the decrease in OB-GYN applicants with abortion bans, but added that Missouri would not be an appealing state for physicians wanting to go into the “abortion industry.”