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

Objective: 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. Methods: 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. Results: 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). Conclusions: 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.