Abortion debate draws attention to severe shortage of OB-GYNs in SC's rural areas

COLUMBIA — For many women in rural South Carolina, pregnancies come with the additional complication of having no doctor nearby who specializes in prenatal care. 

In 14 of South Carolina's 46 counties there are no OB-GYN doctors, not even with a part-time practice.

Five other counties each have just one OB-GYN doctor, according to a December report by the state Office for Healthcare Workforce. 

It's a problem no matter what the GOP-controlled Legislature decides on abortion in the current debate landscape.

Opponents of a proposal to ban nearly all abortions contend women's existing difficulties of just getting appointments will be compounded if thousands more pregnancies go forward. And if more women travel to where there are OB-GYN practices, quality prenatal care will become harder to come by in the cities too, opponents warn. In 2021, 6,279 abortions were performed in the state.

OB-GYN doctors who support abortion access told senators Aug. 17 they're already struggling to comply with the state's "fetal heartbeat" law, which bans abortions as early as six weeks. Confusion over what qualifies as exempted life-saving measures could cause doctors to leave or not come to South Carolina at all, further exacerbating the shortage, they said.

Midway through the hearing, the state Supreme Court issued an order temporarily blocking the law, though its suspension is not expected to derail legislators from proceeding. 

"Who will deliver all of these babies y’all are forcing women to have?" Rep. Pat Henegan, D-Bennettsville, asked Aug. 16 before the House Judiciary Committee advanced a measure that allows abortions only to save the mother's life or prevent lifelong health problems.

Some Republicans have publicly pledged support for improving access to prenatal care as part of the abortion debate, though solutions remain elusive. And whether they can get a majority of their colleagues to agree to anything on that front remains to be seen. 

"If women are going to have children, or we're going to force them to have children, inherent in that is an obligation to ensure they have emotional and financial support and making sure the baby has good medical attention," said Sen. Tom Davis, R-Beaufort, adding he's working on amendments for next month's Senate debate.

Before voting "yes" Aug. 16 to advance the abortion ban in her chamber, Rep. Sylleste Davis said she did so with an expectation.

"I don't believe our efforts stop here. There's plenty more we need to do," said the Moncks Corner Republican, adding that includes an "emphasis on prenatal care."

Her home county of Berkeley, with a single full-time and six part-time OB-GYNs, is an example of how concentrated access has gotten.

A Healthcare Workforce map of OB-GYN practices shows doctors clustered in and around South Carolina's major cities — primarily Charleston, Greenville and Columbia, in that order — leaving giant swaths of even prosperous counties without a doctor who specializes in pregnancy care.

Less than 8 percent of the state's 604 licensed OB-GYNs practice outside of cities, according to the report. 

"It's a very striking map," said Dr. Brannon Traxler, public health director for the state Department of Health and Environmental Control. "There's definitely a shortage, particularly in the rural areas."

That shortage helps explain why the infant mortality rate is 35 percent higher in South Carolina's rural counties, where nine of every 1,000 infants die before their first birthday. 

"Women have to travel further. That will put them at higher risk," Traxler said. "They'll be less likely to even go to their prenatal appointment if they have long distances." 

Traxler stresses that OB-GYNs aren't the only providers of prenatal care. Others, including some family medical doctors, can perform routine care and deliveries to help fill in rural gaps for non-high-risk, uncomplicated pregnancies, she said.  

But there's a growing scarcity of them too. 

In the last decade not only did the number of licensed OB-GYNs plummet by 43 percent in rural South Carolina counties, there were also giant drops in family medical doctors, pediatricians, registered nurses and nurse midwives, according to Healthcare Workforce data released last month. 

And, as OB-GYNs know all too well, women can't count on routine pregnancies.   

Access to specialty care is important during that short period that can impact the mother and child for a lifetime, said Dr. Manasi Patwardhan, director of Summerville Medical Center's new OB-GYN residency program. 

"Even for what's supposed to begin as a straightforward pregnancy can turn into a high-risk one because complications can evolve," she said. Pregnant women need "someone to identify that issue and create a management plan and do any sort of intervention that's needed."

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Before voting Aug. 16 against an abortion ban, Rep. Spencer Wetmore recounted her own experience of how "pregnancy can be extremely dangerous, even in the best of circumstances." 

While pregnant with her youngest daughter, who's now 7, her placenta separated from the wall of her uterus, a serious complication called a placental abruption.

"I was standing on my front porch, hemorrhaging blood and begging 911 to get in touch with my husband at work," the 39-year-old Folly Beach Democrat told her colleagues.

"I am so thankful I got the treatment I needed in and out of the hospital over the next several months, including an emergency C-section, to bring Lola Kate into this world," she said. "But because of this history I cannot risk another pregnancy and the excruciating decision of what would happen without such excellent medical care."

Why so few? 

There's no single reason for South Carolina's dearth of rural doctors providing prenatal care.

The multi-faceted problem involves a consolidation of health care systems, not enough deliveries in rural areas to make OB-GYN practices financially viable and skyrocketing malpractice insurance rates, which has resulted in increasingly fewer of the family practitioners left in rural counties offering any obstetric care, said Dr. Graham Adams, CEO of the state Office of Rural Health for more than 20 years.

Even rural hospitals aren't doing deliveries anymore because they lack specialists trained in high-risk pregnancies, and solo OB-GYN practices that require the doctor to be on call 24/7 are generally unsustainable, he said.

Add to that the usual difficulties of recruiting young people of any profession to live and work in rural counties.

South Carolina has an incentive program for rural health care providers that offers up to $25,000 annually for four years to doctors who practice in rural or underserved areas, which include prisons. Amounts vary depending on what they do and where they work. Of the 101 providers funded last fiscal year, seven were OB-GYNs working in Beaufort, Clarendon, Dillon, Georgetown, Lancaster and Laurens counties, said Kristin Cochran, director of recruitment for the state's Area Health Education Consortium.  

A $250,000 boost from the Legislature in 2019, which bumped the program's annual funding in the state budget to almost $1 million, has allowed the program to cover every qualified applicant since, she said.  

But that's clearly not closing the gap. 

"Doctors who get out of medical school are young, married and enjoy the Columbias, Greenvilles and Charlestons," said Dr. Robert Ridgeway of Manning, OB-GYN chief at the hospital there when it was Clarendon Memorial. "From a family standpoint, I can't blame them." 

Practicing in rural areas has its advantages, but doctors who realize that and want that lifestyle — like him — usually grew up in rural areas, he said.    

"I'm homegrown," said Ridgeway, a Democrat in the state House from 2013 through 2020. "You get to know your patients a lot better. You know where they work, their family. You go to church with a bunch of them and know ahead of time whether they'll be able to afford the medicine you're prescribing." 

He called delivering babies the "best time of my life," noting he's watched infants he delivered become adults and delivered their children too. He still works part-time, but he stopped delivering babies about eight years ago, partly because commuting to Columbia made it difficult to be on call.

"We need to do something to get more doctors in the rural areas," he said, though he's not sure what. 

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A partial solution? 

Another piece of the problem is a national shortage in training options, with just over 1,500 spots for would-be OB-GYNs to train and nearly 2,200 medical school graduates yearly applying, said Heather Woolwine, spokeswoman for the Medical University of South Carolina. 

More residency slots to train doctors for wherever they practice, along with additional, targeted incentives for rural areas could help increase access, she said. 

Until July 1, there were three OB-GYN residency programs in South Carolina: One at MUSC and two with Prisma's hospitals in Greenville and Columbia.  

Newly adding to that is Summerville Medical Center, which last month launched an OB-GYN residency program with three doctors-in-training. The plan is to add three spots annually until the hospital has a total of 12, Patwardhan said. 

Nearly a thousand medical students from across the country applied for the initial spots, so the need is far greater. But the program needs to grow slowly, as it takes a lot of work, she said.

Launching a residency program costs a lot of money, but it also takes buy-in from a whole team of specialists willing to work alongside and train the next generation for all the varied situations they will encounter, Patwardhan said.

While based in Columbia and Greenville, Prisma's OB-GYN residents get experience in more rural settings, with the Midlands program including rotations at its Sumter hospital and Upstate residents spending time at hospitals in Easley and Greer.    

Prisma recently expanded its OB-GYN residency program in the Midlands and hopes to expand its Upstate program soon, said Prisma spokeswoman Sandy Dees. 

The number of people applying for the slots continues to increase, with 900 OB-GYN applicants in the last round, she said.

Graduates unable to get a coveted OB-GYN residency slot often pursue another medical field, representing missed opportunities to increase access.  

"Either they go to a specialty that’s not their first choice or they wait another year to reapply," Patwardhan said. But "they may or may not get it again because competition will only increase every year. It gets tough if you don’t get selected in your first attempt."

South Carolina's not alone in experiencing an OB-GYN shortage. Nationwide, there will be about 5,200 fewer OB-GYNs than needed by 2030, as their numbers decrease by 7 percent while demand increases by 4 percent, according to the National Center for Health Workforce Analysis.

In the past, South Carolina's kept about half of the doctors who go to medical school in the state. And more than 40 percent of specialists who complete their residencies in South Carolina stay here to practice, according to the state Area Health Education Consortium. 

It's too early to tell whether the "fetal heartbeat" law in place for six weeks before the court suspended it, or whatever legislators do in the coming weeks with abortion, will impact applications to come to South Carolina's OB-GYN training programs, Woolwine and Patwardhan said.

Ridgeway wishes his former colleagues would hold off and not pass anything else on abortions until there's time to figure out the practical ramifications of the fetal heartbeat law, unless it's to clear up confusion. Regardless, he sees the shortage of doctors in rural areas as a separate issue that needs attention.

As a rural legislator, Senate Majority Leader Shane Massey said he agrees there needs to be a focus on attracting doctors to rural South Carolina. 

"If there are ways we can encourage doctors to practice in rural areas, you definitely have my attention," said the Edgefield Republican, noting his wife's OB-GYN and his children's pediatrician are in Augusta. "There's not going to be one silver bullet to fix it, but it's clearly an issue we need to address."