South Dakota Lacks Any OB/GYN Residency Despite Highest State Fertility Rate and Over 50% Maternity Deserts

The STAT opinion correctly identifies Medicare graduate medical education funding as the structural bottleneck that concentrates OB/GYN residencies in urban academic centers. This allocation rule, unchanged since 1997, produces the observed outcome that physicians practice within 100 miles of training sites in roughly 70 percent of cases according to AAMC tracking data. Rural hospitals therefore cannot recruit sustainably when no local pipeline exists. South Dakota’s situation is not an outlier but the predictable endpoint of the same financing formula applied nationwide. CDC vital statistics show rural maternal mortality ratios 1.6 times urban rates between 2017 and 2022, with travel time greater than 60 minutes independently associated with increased severe morbidity in observational cohorts. The absence of training programs removes the only evidence-based intervention shown to increase long-term rural retention. Expanding positions without tying them to geographic need will not alter distribution patterns. Federal rulemaking that conditions new GME slots on documented shortage areas and requires rural training tracks would address the root misalignment. Pilot programs under the Rural Residency Planning and Development initiative have demonstrated 40 percent retention after five years when training occurs in underserved sites, offering a scalable template.