Why Doctors Are Opting Out of Arkansas
The state’s abortion ban impedes recruitment and compounds physician workloads
By Caroline McCoy
A 2022 abortion rights rally in Little Rock, Arkansas; Photo by Ashley Clayborn
Over ten days in February, Shannon Barringer, a certified genetic counselor practicing in Little Rock, referred three patients to medical facilities outside of Arkansas. Each woman had chosen to terminate a nonviable pregnancy, a medical procedure that would present far less risk than carrying the fetus but is no longer legal in Arkansas. Barringer had spent hours coordinating care for her patients elsewhere, ultimately sending two to Chicago and one to Boston. “I think part of me is running on automatic, trying to get these people where they need to be,” Barringer said. “But I also feel very emotionally worn out.”
As a geneticist, Barringer joins a pregnant person’s healthcare team when a fetal abnormality is detected. She often delivers news of lethal fetal anomalies. Her role has long involved shepherding women and families through life-altering diagnoses. Since June of 2022—when the Supreme Court overturned Roe v. Wade, triggering an abortion ban in Arkansas—she has also been tasked with connecting her patients to care outside the state.
Choosing where to send a patient requires Barringer to consider a variety of factors, including cost, proximity to the patient’s friends or family, limitations of insurance, and whether the patient opts for induction of labor or an outpatient D&E (dilation and evacuation, in which the pregnancy tissue is removed). “It takes a lot more time, logistically, a lot more effort,” she said.
Barringer, who is nearing retirement after twenty-eight years in practice, has struggled with the emotional and physical toll imposed upon her and her patients by the state’s abortion ban. In almost three years since the trigger law went into effect, she has developed relationships with other geneticists and maternal fetal medicine doctors around the country, which has helped to streamline her referral process. And yet, she still grapples with the impact of transferring patients out of her care after presenting them with devastating diagnoses. “There’s a lot of burnout,” she said.
Whether or not her workload allows for additional time spent on out-of-state referrals, Barringer does it because she can’t fathom the alternative of burdening her patients with locating the care they need on their own. “There’s just no way that anybody could walk through this process by themselves, blind, alone, especially after receiving a diagnosis that we have to give.”
“In these children, they often have to be C-sections because their hips aren’t developed yet.”
Legislative efforts to ease restrictions in Arkansas’s abortion law have largely failed. Earlier this month, for example, a bill that would grant exceptions in cases of fetal anomaly, rape, or incest stalled in a House committee. Chad Taylor, an OBGYN practicing in Little Rock who has been a vocal opponent of the state’s ban, said that the failure of legislators to recognize the need for exceptions has been devastating. He spoke of cases in which pre-teen girls endured rapes resulting in pregnancies that they were forced to carry to term. “In these children, they often have to be C-sections because their hips aren’t developed yet.” Taylor also criticized the law’s impact on training in the state, referencing second-trimester uterine evacuations—D&E procedures—which are illegal in Arkansas. “If you don’t know how to evacuate a uterus, then you’re stuck doing an abdominal surgery. And that can be life-threatening.”
Joseph Fixler, who is one of only six maternal fetal medicine doctors practicing in Arkansas, agreed. “For OBGYN residency in general, one of the requirements is access to abortion training.” Because that training, which can save the life of the mother, is limited in Arkansas, he said, medical residents are traveling out of state to learn the relevant procedures. “There are a lot of downstream, unexpected, and unanticipated consequences when these laws are enacted, and they affect everything from the care that a person receives in the clinic all the way down to the ability to train physicians in these states.”
Such limitations in training—coupled with the punitive nature of Arkansas’s law, which subjects physicians to up to ten years in prison—have also hindered the state’s ability to recruit new doctors. Arkansas Business reported that UAMS, which offers the only OBGYN residency program in the state, saw a 32.6 percent decrease in applications after the total ban went into effect in 2022. “Where residents train is where they tend to stay, as far as practice is concerned,” said Fixler. The March of Dimes reports that almost half of Arkansas’s counties are maternity care deserts, areas without access to birthing facilities or maternity care providers. A decline in prospective physicians will almost certainly further decrease access to care.
Fixler’s career path offers a glimpse at how anti-choice legislation is impacting where physicians choose to practice. He grew up in Ohio and attended medical school at the University of Cincinnati. He relocated to Texas in 2020—a year before the state’s “Heartbeat Act” went into effect—to train in maternal fetal medicine, a specialty that covers high-risk pregnancies. “In Texas there is, in essence, a gag law on talking to patients about abortion,” he said. Because of that restriction, he felt a marginal sense of relief when he moved to Arkansas to practice two years ago. Like Barringer, Fixler sometimes refers women to providers out of state, which is not prohibited under Arkansas law. And yet, his workload also suffers under the extra burden of these referrals. “My job is busy, and when I have to do that, it takes time away from taking care of other patients.”
After five years spent training and practicing in anti-choice states, Fixler has decided to return to Ohio, where abortion is legally protected. He will begin his new appointment in the fall. He said that Arkansas’s abortion ban has been a significant factor in his decision to relocate. “The law in the state of Arkansas hampers our ability to allow people to make the best choices for them and their families in what are often impossible situations,” he said. “We’re just trying to do the best we can to take care of this person in front of us, and we’re not able to do that because of the laws that they write, and the ambiguity in those laws.”
“What is a medical emergency? Is it a ten percent chance of dying? Is it a ninety percent chance of dying?”
Like Fixler, Chad Taylor is among the many women’s health providers in the state who say that the law is both vague and punitive to the extent that physicians may be impeded from delivering optimal care. “The mother’s health is not covered—only mother’s life,” he said. “So, you could actually have a pregnancy that’s causing harm, but if it doesn’t threaten her life, then it’s not covered by the exception.”
Carrying a pregnancy to term is fourteen times more likely to kill a woman than having an abortion, according to the Mayo Clinic. In Arkansas, where maternal mortality rates are among the worst in the country, bad outcomes can be compounded by a lack of access to timely medical care when physicians are uncertain about how to determine if a woman’s life is at risk enough.
“Say you have a ten percent chance of surviving, but currently you’re okay. Do we have to wait till you’re not okay to intervene?” Taylor said. “Because we don’t know those things, doctors are scared. Doctors are terrified.” He argued that the threat of imprisonment imposed on physicians through Arkansas law creates an environment where doctors may hesitate amid the murky parameters of the life-of-the-mother exception. “In an emergency that might be a slow train wreck that you’re watching over a period of months . . . that’s where it gets more gray,” he said.
Fixler also believes that the legal bounds Arkansas physicians must practice within are unclear. “We can’t intervene until the mother develops a medical emergency,” he said. “That language is very ambiguous. What is a medical emergency? Is it a ten percent chance of dying? Is it a ninety percent chance of dying? Is it a ten percent chance of developing a condition which may cause somebody to die? Is it a ninety percent chance of developing that condition which may cause somebody to die?”
In March of this year, state legislators attempted to rectify this ambiguity by clarifying the legal exception to the law through an update to the language around what constitutes a risk to the life of the mother. Applying a standard of “reasonable medical judgement,” the updated law is intended to free physicians from fear of prosecution should they terminate a pregnancy they deem life-threatening. In practice, though, the new language does little to clarify the law, according to both Taylor and Fixler. “What is reasonable medical judgement?” Fixler said. “I could ask any physician and they would have a different opinion.”
Taylor said that he would never recommend treatment outside of the realm of reasonable medical judgment. “I wonder about the woman who has heart failure, and we might recommend termination,” he said. “There’s certainly treatment available that can—may even seem reasonable—preserve the life of a pregnant woman. That doesn’t really address at what cost in morbidity, and it doesn’t address the opposite—that there is also a reasonable medical judgment that termination is healthier for the mom and might also save her life.”
Photo by Brian Chilson/Arkansas Times, courtesy of Dr. Chad Taylor.
A report of zero abortions performed in 2023 is not just inaccurate but dangerous.
The most recently available data released by the Arkansas Department of Health indicates that zero abortions were performed in the state in 2023. That number is false, according to WeCount, an academic research group that has been tracking abortions nationwide since 2022. In fact, the group estimated that 2,250 abortions were obtained by Arkansas residents who traveled out of state or received abortion medications by mail—a slight increase from 2022. What the WeCount estimate does not consider—and what the Arkansas Department of Health fails to include in its 2023 report—are the abortions performed in the state of Arkansas under the life-of-the-mother exception to the law.
Taylor said that the failure to report medical interventions that meet the life-of-the-mother exception amounts to the politicization of crucial data. “Knowingly causing the death of the fetus is abortion,” he said. “If someone has sepsis and is pregnant and the baby’s alive, and you start an induction and the baby dies, it’s an abortion. If a woman has preeclampsia and has to be delivered at twenty-one weeks, you’re knowingly causing the death of the baby, and it’s an abortion.” Each of these scenarios meets the legal exception, but Taylor said that both instances are most likely to be recorded not as abortions but as fetal demises, skewing the data.
“These life-saving points for which there’s an exception—they do exist,” Taylor said. Omitting them from the state’s abortion data feeds misconceptions around the procedure and the critical role it plays in women’s health. Both Fixler and Taylor said that a report of zero abortions performed in 2023 is not just inaccurate but dangerous, because it implies an unrealistic impact of anti-choice policy that may fuel further restrictions that put women’s health at risk.
“A lot of these legislators . . . lack the empathy and the imagination to think about a situation like that.”
For Shannon Barringer, Joseph Fixler, and Chad Taylor, the gulf between the state’s law and the realities of their practice often feels demoralizing. How these physicians manage the distress they experience in their work varies. In 2024, both Barringer and Taylor participated in a citizen-led initiative to get abortion rights on the ballot. (That effort, and its failure, was recently detailed in an Arkansas Times series.) Taylor has continued to occupy a place on the frontlines of the abortion rights movements and recently testified against a bill that would mandate public schools to show students a fetal-development video created by an anti-choice organization. Barringer said that, while she pays close attention to new legislation, she has stepped away from policy battles for now. “I had to remove myself from it and get back to the where can I help the most. And where I can help the most is just day to day, when a patient needs this. That’s where my focus has to be.”
Though he has chosen to leave Arkansas for Ohio, Fixler said that clarifying the state’s abortion laws is essential for both physicians and their patients. Part of the problem, he said, appears to lie in a lack of understanding among legislators about the inextricable link between maternal and fetal health. For example, a woman who has been diagnosed with a partial molar pregnancy—a lethal fetal condition—has a 41.9 percent chance of developing preeclampsia, which is associated with an increased chance of cardiovascular disorders later in life. In the state of Arkansas, Fixler said, “we are essentially saying that this woman must carry that pregnancy either until the fetus dies or until she develops a medical condition that is thereby going to make her more likely of having long-term medical problems over the course of her life.” Arkansas’s life-of-the-mother exception fails to recognize such a scenario, in which the health of the fetus is directly linked to the health of the mother. “I think a lot of these legislators . . . lack the empathy and the imagination to think about a situation like that,” Fixler said. “So, we’re handcuffed in taking care of women.”
The physicians who participated in this story shared their perspectives as private citizens practicing medicine in an anti-choice state. Their views do not represent the views of their employers.