I write this article as a health care provider for more than30 years, an obstetrical nurse for 18 years prior to that, a woman and daughter, a mother, grandmother and great-grandmother.

I have spent my entire career in Iowa.

I loved working with expectant mothers who were in the process of giving birth and then enfolding their newborn into their family. I had the painful experiences of helping families adjust to the loss of their expected child prior to birth and shortly after birth. I have watched families receive inconceivably heart-breaking news that that pregnancy will not result in a healthy baby. I have cared for women whose pregnancies were going very wrong, and they needed lifesaving uterine evacuation (commonly a D&C) to save their lives. In my later career, I have provided family care, helping families with newborn care, children evolving through school agers, teenagers, young adults, adult women negotiating fertility, pregnancy, menopause and aging.

Over the course of my career, I have watched the availability of women’s health care and obstetrical care dwindle.

The reasons are many: aging populations, reductions in birth rates, migration of younger individuals to more populous cities, cost of education, low reimbursement rates for providing care to populations that are primarily Medicaid and Medicare based.

I moved to Newton, IA in 1993. At the time of my arrival, we had 7 family physicians who provided obstetrical care. Currently we have none, and our local hospital no longer provides delivery services, causing young families in our community to travel for obstetrical care and delivery. This isa significant stressor for families, requiring additional travel, time away from work, and for many, additional childcare costs.

One might think that having no one to provide OB care is nota huge issue to a community, but the effects are greater than that. When practices no longer provide obstetrical care, there is a natural attrition of individuals who are also well versed in other areas related to pregnancy care like general women’s health care, assistance with fertility control/menstrual issues/menopausal issues and aging woman care. It increases the pressure on larger OB/GYN practices which are already having difficulty keeping up with the demands of their communities.

Our state is also in crisis regarding providing care for gynecological cancers. Currently, in our locality, there is 1 gynecological oncologist in Des Moines, and 5 practicing physicians at the University ofIowa. These physicians provide care to women with cancers of the cervix, ovaries, uterus, vagina and vulva. Iowa women deserve better access to care.

What we, as a state need to work on is unrestricted training opportunities for OB/GYN providers and Family Practice providers who wish to provide obstetrical and gynecological care. We need better and faster regional consultation abilities, consistent outreach from larger institutions. Finding ways to facilitate providers offering services in rural areas to reduce travel requirements for pregnant women and women with other health related problems.Offering ongoing education and updates to providers who wish to remain up to date but have limited contact with women’s health care. Offering adequate educational reimbursement to those who choose to provide services in rural areas. Fixing the reimbursement disparities between private insurance andMedicaid/Medicare.

Currently, private insurance reimburses around $5,000 for comprehensive obstetrical care, the Medicaid reimbursement is $1364. Physicians are paid based on their revenue generation. Our state should not ask providers to take more than a 70% reduction in revenue to deliver Medicaid covered patients.

Iowa women deserve better. We deserve access to safe, timely, and compassionate care, no matter our zip code, income, or insurance provider. It’s time to stop treating rural healthcare like an afterthought and start making serious investments in the people and systems that sustain it.

As someone who has spent a lifetime caring for Iowans, I know this: if we want to keep our communities healthy, we must protect and prioritize reproductive care at every level.