Barriers to abortion access in rural areas of France are attracting increasing political and scientific attention. While official statistics have been used to document variations in utilization rates, travel distances, and abortion methods used, attesting to the existence and magnitude of territorial inequalities, the mechanisms by which these inequalities are produced remain under-researched and are often attributed solely to technical factors (the closure of maternity hospitals, a shortage of physicians, and the supposed poor profitability of abortion services). Based on an ethnographic study combining interviews with all the professionals involved in abortion care within a rural department of France and observation within hospital-based abortion clinics, this article demonstrates the active role played by physicians in the generation of so-called ‘medical deserts’. It explores the social trajectories of those physicians who refuse to carry out abortions, as well as the practices of others who do perform them but who contribute to these inequalities by limiting choice of method, requiring multiple consultations, and over-medicalizing abortion care pathways. This research invites us to view territorial inequalities in health through the prism of medical domination, highlighting how local constraints increase physicians’ power to control and restrict access to care.