Geography, Policy, and System Strain in U.S. Obstetric and Gynecologic Care

To examine how abortion policy environments and geographic context are associated with reproductive health outcomes, and to characterize implications for obstetrics and gynecology (OBGYN) care.

We conducted a cross-sectional analysis exploring associations between outcomes of health care quality and access ranked in the 2024 Commonwealth Fund State Scorecard to Guttmacher abortion policy categories (restrictive, middle-ground, and protective) and U.S. Census regions. Kruskal-Wallis rank-sum tests with Dunn post hoc comparisons and Spearman correlations assessed the relationship of these environmental factors with 32 outcomes.

Southern states had worse overall reproductive health rankings than other regions (p < 0.001). Restrictive abortion policy states had poorer outcomes across all domains of OBGYN care and access (p < 0.01). Higher rural population correlated with higher infant mortality (r = 0.31, p = 0.028), preterm birth (r = 0.36, p = 0.010), depression before/during pregnancy (r = 0.71, p < 0.001), and poor mental health (r = 0.44, p = 0.001).

Health disparities associated with restrictive abortion policies and geographic inequities signal regional variation in OBGYN workforce strain, reinforcing the need for systems-level, context-aware strategies to support retention and sustainability.