As a Texas city debates an abortion travel ban, maternal care is scarce in nearby rural counties

The town of Cactus on Jan. 29, 2020. Cactus is in the upper part of the Texas Panhandle, about 50 miles north of Amarillo. (Credit: Miguel Gutierrez Jr./The Texas Tribune)

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AMARILLO — Texas’ urban cities can offer women a luxe birthing suite, equipped with high-tech monitoring for mom and the baby, spacious rooms and a full team to handle any emergency.

That isn’t the case in the Panhandle, where just eight hospitals are scattered in the 26,000 square mile region. Instead of high-tech monitoring, women are hooked up to the most basic medical equipment in a cramped and outdated room. There is no emergency team in the face of risks or complications, except in Amarillo.

“Your small town hospitals may have the staff and some stirrups to handle a delivery,” said Lisa Dillard, director of Maternal Child Health for March of Dimes in Lubbock. “And just like a paramedic on the roadside, they will do the delivery.”

This medical desert lies in the backyard of Amarillo, where the long battle over abortion access has found a new front. Anti-abortion activists, led by Mark Lee Dickson, director of East Texas Right to Life, has pressured the city to approve an ordinance outlawing the use of city roads and highways for an abortion outside of Texas. Amarillo was chosen due to its proximity to states that offer abortion services.

On Tuesday, the conservative City Council rejected the ordinance — delivering a major loss for the so-called sanctuary city movement. Now, a group of residents who successfully petitioned the council to consider the proposal must decide whether to ask voters in November to override the council’s decision. They are likely to do so.

The largest city near the top of the state — population 201,000 — serves as a medical hub for the rest of the 26 counties in the northern Panhandle, essentially an oasis in a maternal care desert. Women’s health advocates say the neverending fight over abortion access is ignoring the more pressing matters of expanding health care access to more than 122,000 girls and women between the ages of 10-54 in the Panhandle. Those women lack access to quality OB-GYNs, maternal health support, and insurance providers.

The picture is grim. At best, women can have their babies delivered safely in one of eight rural hospitals scattered in the vast region. At worst, a person with a high-risk pregnancy or an emergency is traveling to one of Amarillo’s two hospitals, regardless of how far it is from home.

These advocates argue that the health care profession is already stressed due to bad policies, workforce shortages and tight budgets.

“The infrastructure is not in place for women to access the health care they need,” said Lindsay London, co-founder of the Amarillo Reproductive Freedom Alliance. “It all comes down to the bootstrap mentality of, ‘Figure it out.’”

Texas women face countless challenges to their reproductive health. And in a state with the highest numbers of maternal deaths in the nation, women in rural areas fare worse. Maternal access is stretched thin in the Texas Panhandle — only eight hospitals, including those in Amarillo, have labor and delivery services for the upper 26 counties. And, it’s a national issue. The Commonwealth Fund’s research shows nearly 7 million women in the U.S. live in counties without hospitals or birth centers.

Lindsay London listens as Amarillo Reproductive Freedom Alliance members discuss strategy during a meeting in Amarillo on April 28. (Credit: Annie Rice for The Texas Tribune)

If Amarillo voters ultimately decide to approve the abortion travel ban, women health care advocates worry about the city’s ability to be a medical hub for a region that desperately needs it.

What a maternal health care desert looks like

Spread out over 85% of the state’s geography are 3.1 million Texans who live in small communities few and far between. The rural landscape offers an idyllic lifestyle for some, including vibrant sunsets, tranquil nights, and wide open spaces full of fresh air.

The peace and quiet comes at a price though, and part of it is losing critical resources, including labor and delivery services.

Health care deserts don’t happen overnight in rural Texas. In most cases, the decline is caused by a single factor — an EMS service runs out of funding, a clinic loses providers, a hospital locks its doors for the last time.

According to the Texas Organization of Rural and Community Hospitals, 28 rural Texas hospitals have closed since 2010, the most in the nation. This leaves underserved communities vulnerable, as any need for medical care could turn into a long drive.

And even in these dire circumstances, pregnant women and new moms are more vulnerable during a significant time in their life. Only 64 of the remaining 158 rural hospitals in Texas still provide obstetrical and delivery services.

“Labor and delivery services are one of the first to go when hospitals need to tighten belts,” said Erika Ramirez, senior director of the Texas Hospital Association’s policy team.

Hospitals can face financial loss when a patient uses Medicaid to give birth. The federal program covers nearly half of all births in Texas, but hospital officials say the Medicaid payout rate is low. This can lead to financial loss for hospitals trying to be paid for services, along with trouble retaining physicians and recruiting new ones.

Ramirez said for years, maternal care in Texas has been limited for women seeking care before, during and after pregnancy. The hurdles are reflected by the state’s maternal mortality numbers.

According to a March of Dimes report card for Texas, an average of 28 women die from causes related to pregnancy or postpartum per 100,000 births in the state, compared to 23.5 deaths on average in the U.S. Women in rural areas have a 9% higher chance of maternal mortality than those in urban areas.

The same report gave Texas a D- and found that nearly 47% of counties are a maternity care desert. The Texas Maternal Mortality and Morbidity Review Committee also recommends increasing access as the top recommendation to prevent maternal death and illness.

Dillard with March of Dimes said west of Interstate 35 in Texas, which encompasses the Panhandle, South Plains, Permian Basin and Far West Texas, has disproportionately more counties than the rest of the state. The area also has two times more maternity care deserts than east of I-35.

“You have more dispersed communities, so they have to go even further to access care,” Dillard said.

As a result, Amarillo, Lubbock, Odessa, Abilene, San Angelo and El Paso have all become medical hubs for smaller cities that surround them, near and far.

If women can find a physician within driving distance, insurance can be another hurdle. According to the U.S. Census Bureau, nearly 17% of Texans are uninsured, and has the highest number of uninsured residents for years. This is why, Ramirez said, the Texas Hospital Association advocated for state legislation that allows women to stay on Medicaid for 12 months postpartum. Pregnant women also qualify for Medicaid.

As beneficial as it is, Christine Garner, a maternal and child health researcher in Amarillo, said signing up for Medicaid in a timely fashion is challenging in rural communities. Any delay can cost women from getting care early in their pregnancies, another factor that plays a role in maternal mortality. In Texas, 21% of people received care starting in the second trimester.

First, the mom-to-be would have to obtain insurance or Medicaid, which a Medicaid navigator could help with.

“There aren’t that many Medicaid navigators,” explained Garner, a researcher with Texas Tech University Health Sciences Center. “Not every small town has one. There aren’t even that many in Amarillo, a city of 200,000 people.”

Once someone is insured or on Medicaid, they often have to get on a doctor’s waitlist. Then there’s a question of transportation if their provider is far — in Panhandle counties without a hospital, the closest medical center with delivery services can range from 26 to 72 miles away. Garner said every delay can result in more complications.

“By the time somebody goes to their first appointment, oftentimes that’s past the first trimester,” Garner said. “Every day can result in more complications and worse health.”

Even if a mom in the Panhandle has a hospital with delivery services in her county, complications or high-risk factors could still send her to Amarillo’s major hospitals. Garner said Amarillo gets an “overwhelming majority” of high-risk pregnancies — emergency or not — for the Panhandle, parts of New Mexico and Oklahoma. In some cases, women are airlifted because the drive is too long.

“This is what's required for people who live far away from their providers,” Garner said.

Garner said a lot of work is being done to close the gaps for pregnant women and mothers in the region. This includes raising awareness in communities about potential concerns to look out for, using mobile units, and remotely monitoring vitals and check-ins through telehealth — virtual health care is better than none, she says.

“I think that can help communities understand the importance for their own health, as well as the health of their families and babies,” Garner said.

Certain medical issues can’t be treated remotely, however, and may lead to medically necessary abortions. There is confusion over state law which has some doctors hesitant to call for them. Recently, the Texas Supreme Court ruled against 20 women who sued the state in an attempt to seek more clarity about the new abortion laws and how they apply to complicated pregnancies. The law does allow abortions to save the life of the mother, although dozens of doctors said they are still uncertain when abortion becomes medically necessary.

That confusion has reached Amarillo.

Dr. Frederick Poage, an ER physician, warned the city council that women’s lives can be endangered when abortion services are inaccessible. He said he delivered non-viable fetuses and carried dead, full-term babies to first-time mothers. Now, he’s taking courses to learn how to treat patients with botched at-home abortions. It’s his main concern with the ordinance.

Poage believes the law is meant to lack proper guidance, particularly because it’s unclear about what constitutes a medical emergency.

“It’s not with the understanding of providing quality care for my patient,” Poage said. “It’s intentionally vague, anything I do can get me thrown in jail.”

Poage said everyone deserves access to comprehensive reproductive health care, which includes safe and legal abortions.

“It’s crucial that we, as health care professionals, prioritize evidence-based, compassionate care for all patients,” Poage said. “This is not a matter of medical practice, but a commitment to respecting individual autonomy and promoting the well-being of those in our care.”

Why Amarillo is the new battleground 

Amarillo has found itself at the center of the fight over what little access remains to an abortion for a Texan.

In November 2022, months after the U.S. Supreme Court overturned Roe v. Wade, an organization of anti-abortion doctors filed a lawsuit in Amarillo, challenging the Food and Drug Administration's approval of an abortion-inducing drug. U.S. District Judge Matthew Kacsmaryk, the sole federal judge presiding in Amarillo, sided with the anti-abortion group last year, suspending the approval for mifepristone after more than 20 years on the market. Kacsmaryk previously litigated against abortion access as a religious liberty lawyer.

On Thursday, the U.S. Supreme Court unanimously rejected the case, ruling those doctors did not have standing to sue. Mifepristone remains on the market.

And then there’s the travel ban. Amarillo debated passing the “sanctuary city for the unborn” ordinance for months before wholly rejecting it during their last council meeting on Tuesday. The legally dubious policy aimed to outlaw using local roads and Amarillo’s airport as means for an abortion out of state.

By the time the ordinance reached Amarillo’s council chambers, anti-abortion activists had successfully swept through nearby conservative cities and counties and pushed the ordinance through. This worried health care advocates who thought Amarillo city leaders would fall in line with the other municipal lawmakers.

When they didn’t, the city became further embroiled in the next fight over abortion access.

The Amarillo Women’s March holds a health care rally in front of the Potter County Courthouse in Amarillo on Jan. 20. (Credit: Mark Rogers for The Texas Tribune)

In the winter, London with the Amarillo Reproductive Freedom Alliance and other women against the ordinance marched through frigid temperatures in downtown Amarillo while Eric Trump was in town for a GOP meeting. In the spring, it was Amarillo’s Jana May, among other residents, gathering signatures to force the council to reconsider passage. Residents routinely filled the council’s chambers wearing red or green — a code to signal where their support lies — to join an hours-long queue to speak for their allotted three minutes.

If enacted, the ordinance does not punish pregnant women. Instead, it punishes the people — family, friends, and anyone in between — who support and transport her for an abortion outside of the state. London said it’s a technicality, and women are still punished by being forced to go through a traumatic experience alone.

“It feels like the cruelty is the point,” London said.

At the center of this fight is Dickson. The Longview native has become the face of the “sanctuary city for the unborn” movement, traveling around the country arguing against abortion rights for women, all in his signature backward baseball cap.

Dickson applauds that state law does not allow an exemption for rape — allowing it signals that people born from those circumstances are “worth less,” he said. Dickson also believes the complications women have faced were caused by their doctors, not state law.

Mark Lee Dickson speaks at an Amarillo City Council meeting on May 28. (Credit: Mark Rogers for The Texas Tribune)

“They’re not giving them the proper treatment the law clearly allows them to give,” Dickson said. “It’s not the law that’s the problem, it’s the doctors who are not following these laws as they’re meant to be.”

Dickson announced in October that he had temporarily moved to Amarillo, to ensure the ordinance passed.

Dickson set his eyes on Amarillo for a reason. Interstates 40 and 27 run through the city, with I-40 eventually connecting to neighboring New Mexico, where abortion is legal and the closest clinic is nearly 280 miles away.

Interstate 27 connects to Oklahoma and other roads toward abortion clinics in Colorado and Kansas. The closest clinic in Colorado is in Pueblo, about 320 miles from Amarillo, while the closest in Kansas is in Wichita Falls, 354 miles away. Amarillo is closer to both clinics than to the Texas Capitol — nearly 490 miles away.

Motorists travel west on I-40 in Amarillo, a route traveled by many to seek abortion health care while headed out of Texas. (Credit: Mark Rogers for The Texas Tribune)

Dickson has rarely faced opposition on his crusade to help strip away abortion rights, but Amarillo has been a different story. He has support in the city — one man claiming to drive for Uber offered him free rides wherever he needed outside a council meeting in December. But he’s faced sharp criticism too and frequent fights with council members.

Dickson has given just as much criticism as he’s taken. He does not hesitate to question council member’s loyalty to the Republican Party. When the council has criticized parts of the proposal, Dickson is quick to suggest it’s a criticism of state lawmakers. Dickson has accused the council of favoring the Amarillo Reproductive Freedom Alliance.

Debate likely to continue until November

The City Council rejected the ordinance by a 4-1 vote Tuesday, but the fight is not over.

The committee behind the petition is expected to put the issue on the ballot. The other side is gearing up for another long campaign against the ordinance and, by proxy, Dickson. London questions if Dickson sincerely cares about Amarillo, or if he sees the city as a challenge on his quest.

“I think we’re a trophy,” London said.

Dickson disputes claims he doesn’t care about the city, and admits part of his interest is it being the largest city in Texas that connects to three states offering abortions. But, he said it’s not the size of the city that matters.

“If this was all about a trophy and notches on my belt, why would I spend all my time on Amarillo?” Dickson asked. “I could’ve racked up a lot of cities in the amount of time I’ve spent here. But, I care about the people and what has happened here.”

In response to the maternal health care desert, Dickson claims the proposed ordinance equips women with knowledge of where their resources are. The ordinance lists programs that encourage childbirth and offer alternatives to abortion. Dickson offered an anecdotal example of an Abilene OB-GYN who pointed out the ordinance “doesn’t require anything more from hospitals than state law already does.”

“People are acting like this is going to make doctors not want to come to Amarillo, but I don’t think that’s true,” Dickson said. “It might, but that’s because they may not like the conservative nature of Amarillo.”

While people routinely criticize Dickson during council meetings, and he criticizes those against his ordinance, his supporters have big influences — 20 Texas lawmakers signed a letter in support of the “abortion trafficking” ordinances. Amarillo lawmakers Rep. Four Price and Sen. Kevin Sparks – both Republicans – did not sign the letter. Sparks previously said it’s problematic for communities to try and pass more regulations on abortion than what’s in state law. Rep. John Smithee, R-Amarillo called the ordinance a “cookie cutter resolution” that does not have to be adopted. Neither responded to requests for comment from The Texas Tribune.

Regardless of how Dickson is perceived or questions about his sincerity, the battle lines have been drawn, sides have been chosen, and the community is divided as the election in November is looming.

What will happen to the Panhandle’s maternity care desert, and the women searching for aid, remains to be seen.

This story was reported with the assistance of the Journalism and Women Symposium (JAWS) Health Journalism Fellowship, supported by The Commonwealth Fund.

Disclosure: Texas Hospital Association, Texas Tech University and Texas Tech University Health Sciences Center have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.

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