On a typical day Heather Bartos, M.D., sees about 30 patients; in an average month she delivers 20 to 25 babies. An ob-gyn practicing about 45 minutes outside Dallas and chief of obstetrics and gynecology at Texas Health Presbyterian Hospital in Denton, she also spends a day a week in surgery and another tackling administrative tasks. She works through lunch every day so she can attempt to get home at a reasonable hour to see her kids, but the fact that a woman can go into labor at any time makes her days and nights pretty unpredictable. Sometimes the pace is overwhelming. “I know I can’t keep it up forever,” says Dr. Bartos.

There’s another reason Dr. Bartos’ schedule is so hectic: She’s one of only a handful of obstetricians in Denton. A few years from now, when she’s in her early fifties (she’s 47), she plans to scale back her patient load and handle only five or six deliveries each month. She doesn’t know who, if anyone, will step in to take her place. “There’s a really high rate of burnout among ob-gyns,” she says, and there aren’t many young doctors clamoring to start their careers in areas like hers. The potential fallout? Denton could have a shortage of ob-gyns even greater than it already has.

A lack of ob-gyns is increasingly a national problem. Right now half—half—of all counties in the U.S. do not have a single obstetrician, says Hal Lawrence III, M.D., executive vice president and CEO of the Ameri­can College of Obstetricians and Gynecologists (ACOG). A recent ACOG report concluded that women in Arizona, Washington, Utah, and Idaho face the greatest risk of a severe ob-gyn shortage; Florida, Texas, North Carolina, and Nevada could soon be next, because the female population in those areas is growing without new ob-gyns flooding in. The problem could reach major cities too, according to Doximity, a network for physicians and clinicians. After polling its members and cross-­referencing those results with things like birth records and population data, Doximity found that cities including Las Vegas, Orlando, Los Angeles, Miami, Detroit, Memphis, Salt Lake City, and St. Louis, could soon be without enough ob-gyns.

Where the ob-gyns are

A few key factors are driving the decline: first, burnout. “About a third of providers stop obstetrics within the first 10 to 12 years of practicing,” says Dr. Lawrence. While some of them transition to only routine gynecological care, which tends to be less stressful and allows for more regular work hours, others turn to subspecialties like urogynecology or gynecological oncology that don’t entail delivering babies. “It’s a demanding field, and there’s a lot of nighttime work,” says Dr. Lawrence. “You have to really love what you do.” Even ob-gyns who stick it out retire earlier—at age 59 on average, according to Doximity—than primary care physicians, who tend to practice until their mid-sixties.

Right now half—half—of all counties in the U.S. do not have a single obstetrician.

Another reason: compensation. Sometimes the cash coming home isn’t enough to make up for the intense workload and erratic hours (especially true for providers who accept Medicaid, which generally reimburses doctors at rates much lower than private insurance companies). But the bigger money issue is insurance. Obstetricians face one of the highest rates of malpractice cases. As a result, malpractice insurance is often incredibly expensive. In some areas, says Dr. Bartos, “you could spend almost a third of your salary on insurance.”

Valerie Jones, M.D., an ob-gyn in the Maryland suburbs who retired early from clinical care, was warned about the insurance burden before starting her career. “I remember hearing that when you leave residency, you should expect to be sued at least twice in your career,” she says. But she was dismayed by how health care in the U.S. can sometimes emphasize productivity and cost-­effectiveness over quality of patient care. Disillusioned, she left the field last year when she was only 37, after a health scare of her own led her to reevaluate her priorities and motivated her to spend more time with her three children.