A month after the U.S. Supreme Court overturned Roe v. Wade, Texas’ two dozen abortion clinics are slowly coming to terms with a future where their work is virtually outlawed.
Some clinics have already announced that they are shutting down operations and moving to New Mexico and other states that are expected to protect abortion access. Others, including Planned Parenthood, say they will stay and continue to provide other sexual and reproductive health services.
But keeping the doors open will likely come at a high cost for these clinics — financially, politically and psychologically — as they absorb more patients with fewer options.
“It’s really hard to find words in the English language that honor what the experience has been like,” said Dr. Bhavik Kumar, medical director of primary and trans care at Planned Parenthood Gulf Coast in Houston. “It’s just devastation.”
Planned Parenthood clinics in Texas have had to turn away patients in dire situations, according to an open letter provided to The Texas Tribune, including minors and a woman who already had children but had been told by her doctor that she could die if she carried another pregnancy to term.
“People are looking at you and asking you, like, ‘Why can’t you help me?’ ‘Can you make an exception?’” Kumar said. “We hear that all the time, and it just feels so inhumane and unethical … to have to do this over and over again.”
Kumar thought years of navigating abortion restrictions in Texas had prepared him for the overturn of Roe v. Wade. But he wasn’t prepared for the fear that his patients are feeling amid this new legal landscape.
He said he saw a patient last week who was worried about the consequences of even mentioning abortion.
“We’re here in a clinic where we’ve provided abortion care for decades. I’m an abortion-providing doctor, and I talk very openly about abortion,” he said. “But she just had so much fear and apprehension, and was uncertain if she could actually say the words out loud and ask for that help.”
Even if Planned Parenthood can’t offer abortion anymore, it’s committed to staying put and helping Texans access an array of other reproductive health services, including birth control, cancer screenings and testing for sexually transmitted diseases.
Its clinics have been dealing with a surge in demand for long-acting reversible contraception, like IUDs, and information about birth control options including vasectomies, all while expanding their education operations.
But keeping the doors open will mean continuing to contend with a Legislature intent on seeing them shut down. Texas elected officials have spent much of the last decade working to defund Planned Parenthood by removing it from Medicaid and other publicly funded programs.
Even as the state halts abortion services entirely in Texas, Planned Parenthood does not anticipate it stopping those attempts to financially hamstring its work.
“The state has been relentless because of who we are and what we stand for, and that’s unapologetic access to comprehensive sexual reproductive health care, which includes abortion,” Kumar said.
Some clinics plan to relocate
Other Texas clinics are shutting down operations entirely and relocating to “haven states” to continue providing abortions.
Whole Woman’s Health, which started in Texas in 2003 and at one point operated six clinics around the state, has announced plans to relocate to New Mexico.
The group has been slowly pivoting its operations in recent years toward states that protect abortion access, building clinics in Maryland and Virginia and a new location near the airport in Minneapolis. It has invested in a program to help patients travel to these states from Texas.
Now, the organization is closing its remaining four Texas clinics and relocating those operations to an as-yet undisclosed location in New Mexico.
“[Whole Woman’s Health] has served Texans for nearly 20 years, and our love for Texans runs deep,” president and CEO Amy Hagstrom Miller said in a statement. “Even when the courts and the politicians have turned their backs on Texans, we never will.”
Alamo Women’s Reproductive Services, an independent abortion provider, has also announced it will close its San Antonio clinic and a sister facility in Tulsa and relocate to Albuquerque, New Mexico, and Carbondale, Illinois.
New Mexico is Texas’ only direct neighbor that is expected to preserve abortion access, although “neighbor” is a relative term — Las Cruces is more than a 10-hour drive from Dallas or Houston.
The clinics that remain in Texas providing non-abortion care are preparing to serve as the conduit to these out-of-state clinics.
“We understand and deeply empathize with providers who have been forced to close their clinics and move out of state,” said Melaney Linton, president and CEO of Planned Parenthood Gulf Coast, in a statement. “We will continue to work closely with them as we help patients navigate their best options.”
But many Texans will not be able to leave the state, due to finances, child care needs or immigration status.
“Sometimes we hear that it was difficult for them to even come into the clinic that’s closer to home, maybe within 10 miles of where they actually live, let alone having to travel to another state to get that care,” Kumar said. “So it’s very, very scary for folks.”
Hanging on with ultrasounds
For many of the providers who have been on the front lines of contentious legal fights over abortion access in recent years, the overturn of Roe v. Wade was not a surprise. But now that it’s here, they say the reality is worse than they could have imagined.
Most of the patients who come to Houston Women’s Reproductive Services these days already know they want an abortion — and are willing to travel to out of state to get one. Clinic director Kathy Kleinfeld and her staff are in touch with other clinics around the country, helping patients navigate the various legal requirements, wait times and travel logistics that govern abortion access right now.
“It’s very helpful to have someone to talk this through with, who can say, ‘OK, I know this feels overwhelming right now. But have you ever lived in another state? Do you have any friends or family elsewhere?’” she said. “That gets the wheels turning, and if we’re not here to do that, they’re going to have to figure it out on their own.”
For the last month, Houston Women’s has provided only ultrasounds. Kleinfeld said it has seen a steady trickle of patients and identified ectopic pregnancies, false positives and patients who are actively miscarrying.
“In all those circumstances, women would be wasting precious time and money to travel out of state when in fact they may not need the service,” she said. “So it is important to have those ultrasounds in a medical environment where they receive accurate and compassionate care.”
Kleinfeld worries that if that option isn’t available, more people will turn to crisis pregnancy centers. These religiously affiliated nonprofits often offer ultrasounds, but some use coercive and deceptive practices to discourage clients from pursuing abortions.
Kleinfeld said she’s been encouraged by the support her clinic has received, but they’ve scaled back staff and are being realistic about how long they can remain open without their main source of income.
“We’ll do it as long as we can,” she said. “I’m not gonna sell my house and live under the bridge. I’m not going to go that far, but … I think we’re gonna see a lot of creative thinking here and a lot of innovative ideas from some of the brightest people.”
Disclosure: Planned Parenthood has been a financial supporter 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.
On Friday morning, a nurse at Alamo Women’s Reproductive Services in San Antonio ushered a patient into an exam room. She gave her a gown, told her the doctor would be in shortly, and stepped back out of the room into a changed world.
“I saw the other nurses standing in the hallway,” said Jenny, a nurse who has been with the clinic for five years and asked to be identified only by her first name for fear of being targeted by anti-abortion protesters. “And I just knew.”
In the few minutes she’d been inside the exam room, the U.S. Supreme Court had overturned Roe v. Wade, clearing the way for Texas to fully ban the procedure she had just prepped a patient for.
Jenny and four other staff members stood in the hallway, paralyzed. They had a dozen patients sitting in the lobby awaiting abortions, all seemingly unaware of the seismic shift that had just rocked the reproductive health care world.
Before they could even decide how to proceed, the door to the clinic slammed open and a young woman ran in, yelling about Roe v. Wade and saving babies. They didn’t recognize her but believed she was associated with the anti-abortion protesters who often massed outside the clinic.
The woman quickly fled, leaving the clinic staff alone with a dozen sets of eyes staring back at them from the waiting room chairs.
“Obviously, that wasn’t how we had wanted it to come out,” Jenny said.
While other nurses addressed the elephant in the waiting room, Jenny returned to the patient she had just left.
“I just said, ‘You have to get dressed and come back out to the lobby,’” she said. “I told her, ‘The doctor will explain more … but we can’t even give you a consultation today.’”
The legal status of abortion in Texas was murky in the immediate aftermath of Friday’s ruling. The state has a “trigger law” that automatically bans abortion 30 days after the ruling is certified, a process that could take a month or more.
But in an advisory issued Friday, Texas Attorney General Ken Paxton said that abortion providers could be held criminally liable immediately because the state never repealed the abortion prohibitions that were on the books before Roe v. Wade was decided in 1973.
Rather than risking criminal charges, Texas’ clinics stopped providing abortions Friday.
Andrea Gallegos, executive director of Alamo Women’s Reproductive Services, said she’s hopeful that the clinic’s lawyers may find a way to allow it to resume abortions briefly before the trigger ban goes into effect.
But either way, abortion will soon be banned in the second-largest state in the country. The clinics will close. The staff will relocate or find new jobs. And the people they would have served will melt into the shadows, fleeing over state lines, seeking out illegal abortions or quietly consigning themselves to decades of raising children they never wanted.
Bearing the bad news
The staff at Alamo Women’s Reproductive Services are no strangers to bad news. For years, they’ve had to navigate ever-tightening restrictions that force them to delay care or turn patients away.
But never have they had to deliver so much bad news in such a short period of time. Dr. Alan Braid, who owns the clinic, told the women in the waiting room — and those who had already been admitted to exam rooms — that they were halting all abortions immediately.
Some just got up and left. One woman got upset, angrily demanding that Braid go through with the abortion anyway. She had driven hours to make it to this appointment after her home state of Oklahoma banned all abortions.
“I understand why she’s upset, and she has every right to be upset, but we’re not the enemy here,” Gallegos said. “The only thing we could tell her was this wasn’t because of us, it was because of the Supreme Court.“
One woman was on her fourth visit to the clinic. She’d been too early in the pregnancy for an abortion during the first two appointments, but finally, yesterday, staff were able to detect a pregnancy on the sonogram. But Texas requires clinics to wait 24 hours after a sonogram to perform an abortion, so they sent her home.
She arrived at the clinic Friday morning, not long after the Supreme Court ruled. When staff told her the news, she was bereft — rocking back and forth, wailing, begging for the staff to help her.
“I just told her, you did everything right and we did everything that we could, but unfortunately, our hands are tied today,” clinic director Kristina Hernandez said.
Gallegos said it’s devastating to know just how easily they could have helped that patient.
“Sometimes it’s just a matter of handing somebody a pill, and for the surgical [abortion], it’s less than five minutes,” she said. “It’s fast, it’s easy, it’s safe, it’s done. It’s health care.”
Instead, they had to send her away.
After they cleared the waiting room, the staff turned to the stack of two dozen appointments scheduled for the rest of the day. They distributed the files, took deep breaths, and started dialing.
They explained, again and again: No, you can’t get an abortion here anymore. No, you can’t reschedule. No, you can’t go to another clinic in Texas, or even Oklahoma, or a lot of other states. No, it doesn’t matter if you’re under six weeks. No, not even if you come in right now. No, this isn’t our fault. No, no, no, no.
They offered a list of out-of-state clinics and groups that help fund abortions and travel that they put together when Texas banned abortions after about six weeks of pregnancy. They spent most of the day listening to the busy signals and voicemail boxes of clinics in New Mexico, where abortion will remain legal.
They make this effort because there is little else they can do. But they are well aware that many of their patients struggle to find babysitters for the duration of their appointments, let alone traveling out of state to get abortions.
And even if they can find babysitters, and get time off from work, and safely leave the state, Friday’s ruling is only going to make it harder for low-income Texans to access resources to pay for these journeys. Texas abortion funds have stopped paying for out-of-state travel and abortions until they can better assess the legal implications of their work.
Fear for the future
As the pandemonium of the morning subsided, something far worse settled over the clinic: silence. Staff sat around the check-in desk, filing paperwork and tidying up. Someone ordered pizza.
They listened in to televised press conferences, hoping to glean information about their own fates. They talked about where the fight might go from here, and some of the bigger battles they’ve had to wage over the years. They talked about what this meant for their daughters, and the patients they’d treated over the years, and those they would likely never get the chance to see.
A lot of the staff members have been working for the clinic for years. Hernandez was there with Braid when this location opened in 2015.
“This is my baby,” she said. “This is my life, right? This is what I’m good at. This is what I want to keep doing. I can’t do anything else. I mean, I can, but I don’t want to.”
When Hernandez thinks about all the patients she’s been able to help over the years, it’s overwhelming. She’s had women come up to her in H-E-B, years after she helped with their abortions, and give her hugs before disappearing into the aisles.
On days like this, she thinks a lot about a young woman she spent three hours having a theological discussion with before the woman ultimately decided to have an abortion, and her own sister, who decided not to.
The clinic plans to keep the doors open and the staff employed as long as it can. They’re holding on to hope that they may be able to squeeze in a few more patients before the trigger ban goes into effect.
And they’re still offering follow-up appointments for patients who had abortions recently — perhaps the final patients the clinic will ever get to treat.
A young woman showed up Friday afternoon for her follow-up appointment, with her 3-month-old in tow. She’s a single mom in her early 30s, raising four children already.
When she found out she was pregnant again, she decided she couldn’t responsibly raise another child. She’s already struggling financially, and she was trying to leave her boyfriend, who she said was physically abusive.
“I have to figure out who’s gonna watch my babies on the weekends so I can go to work, and it’s stressful,” she said. “So I’m not gonna bring another baby into this.”
She got the two-drug medication abortion regimen at the clinic earlier this week. It was an easy process, she said, and she was hugely relieved to hear that it had been successful.
But with four kids, if she’d been turned away, she said she wouldn’t have even tried to leave the state or find another way.
“It’s not worth all that effort,” she said. “I would have just kept it.”
Published courtesy of The Texas Tribune, a nonpartisan, nonprofit media organization that informs Texans — and engages with them – about public policy, politics, government and statewide issues.
When Dr. Roy Guerrero, a pediatrician in Uvalde, Texas, testified before a U.S. House committee Wednesday about gun violence, he told lawmakers about the horror of seeing the bodies of two of the 19 children killed in the Robb Elementary massacre. They were so pulverized, he said, that they could be identified only by their clothing.
In recent years, the medical profession has developed techniques to help save more gunshot victims, such as evacuating patients rapidly. But trauma surgeons interviewed by KHN say that even those improvements can save only a fraction of patients when military-style rifles inflict the injury. Suffering gaping wounds, many victims die at the shooting scene and never make it to a hospital, they said. Those victims who do arrive at trauma centers appear to have more wounds than in years past, according to the surgeons.
But, the doctors added, the weapons used aren’t new. Instead, they said, the issue is that more of these especially deadly guns exist, and these weapons are being used more frequently in mass shootings and the day-to-day violence that plagues communities across the nation.
The doctors, frustrated by the carnage, are clamoring for broad measures to curb the rise in gun violence.
Weeks after the Uvalde school shooting, what steps the country will take to prevent another attack of this magnitude remain unclear. The House on Wednesday and Thursday passed measures aimed at reducing gun violence, but approval in the Senate seems uncertain at best.
Many physicians agree something substantial must be done. “One solution won’t solve this crisis,” said Dr. Ashley Hink of Charleston, South Carolina, who was working as a trauma surgery resident at the Medical University of South Carolina in 2015 when a white supremacist killed nine Black members of the Mother Emanuel African Methodist Episcopal Church. “If anyone wants to hang their hat on one solution, they’re clearly not informed enough about this problem.”
The weapons being fired in mass shootings — often defined as incidents in which at least four people are shot — aren’t just military-style rifles, such as the AR-15-style weapon used in Uvalde. Trauma surgeons said they are seeing a rise in the use of semiautomatic handguns, such as the one used during the Charleston church shooting. They can contain more ammunition than revolvers and fire more rapidly.
Overall gun violence has increased in recent years. In 2020, firearm injuries became the leading cause of death among children and adolescents. Gun-related homicides rose almost 35% in 2020, the Centers for Disease Control and Prevention reported in May. Most of those deaths are attributed to handguns.
A study recently published by JAMA Network Open found that for every mass shooting death, about six other people were injured. Trauma surgeons interviewed by KHN said the number of wounds per patient appears to have increased.
“I feel we are seeing an increase in the intensity of violence over the past decade,” said Dr. Joseph Sakran, a trauma surgeon at Johns Hopkins Hospital in Baltimore. He cited the number of times a person is shot and said more gun victims are being shot at close range.
Survival rates in mass shootings depend on multiple factors, including the type of firearm used, the proximity of the shooter, and the number and location of the wounds, said Dr. Christopher Kang of Tacoma, Washington, who is president-elect of the American College of Emergency Physicians.
Several recent shootings have left few survivors.
The perpetrator of the Charleston massacre shot each of the nine people who were killed multiple times. Only one of those people was transported to the hospital, and, upon arrival, he had no pulse.
Last year, shootings at three Atlanta-area spas left eight dead — only one person who was shot survived.
The chaos at a mass shooting scene — and the presence of an “active” shooter — can add crucial delays to getting victims to a hospital, said Dr. John Armstrong, a professor of surgery at the University of South Florida. “With higher-energy weapons, one sees greater injury, greater tissue destruction, greater bleeding,” he added.
Dr. Sanjay Gupta, a neurosurgeon who is chief medical correspondent for CNN, wrote about the energy and force of gunshots from an AR-15-style rifle, the type also used in the recent mass shooting in Buffalo, New York. That energy is equal to dropping a watermelon onto cement, Gupta said, quoting Dr. Ernest Moore, director of surgical research at the Denver Health Medical Center.
Medical advances over the years, including lessons learned from the battlefields of Iraq and Afghanistan, have helped save the lives of shooting victims, said Armstrong, who trained U.S. Army surgical teams.
Those techniques, he said, include appropriate use of tourniquets, rapid evacuations of the wounded, and the use of “whole blood” to treat patients who need large amounts of all the components of blood, such as those who have lost a significant amount of blood. It’s used instead of blood that has been separated into plasma, platelets, and red blood cells.
Another effective strategy is to train bystanders to help shooting victims. A protocol called “Stop the Bleed” teaches people how to apply pressure to a wound, pack a wound to control bleeding, and apply a tourniquet. Stop the Bleed arose after the 2012 shooting at Sandy Hook Elementary School in Newtown, Connecticut, where 20 children and six adults were killed.
The CDC, which in the past two years has been able to conduct gun research after years of congressional prohibitions, has funded more than a dozen projects to address the problem of gun violence from a public health perspective. Those projects include studies on firearm injuries and the collection of data on those wounds from emergency rooms across the country.
For some doctors, gun violence has fueled political action. Dr. Annie Andrews, a pediatrician at the Medical University of South Carolina, is running as a Democrat for a seat in the U.S. House on a platform to prevent gun violence. After the school shooting in Uvalde, Andrews said, many women in her neighborhood reached out to ask, “What can be done about this? I’m worried about my kids.”
Dr. Ronald Stewart, chair of surgery at San Antonio-based University Health, told KHN that the people shot in Uvalde had wounds from “high energy, high velocity” rounds. Four of them — including three children — were taken to University Hospital, which offers high-level trauma care.
The hospital and Stewart had seen such carnage before. In 2017, the San Antonio hospital treated victims from the Sutherland Springs church shooting that left more than two dozen dead.
Two of the four Uvalde shooting victims have been discharged, University Health spokesperson Elizabeth Allen said, and the other two remained hospitalized as of Thursday.
It will take a bipartisan effort that doesn’t threaten Second Amendment rights to make meaningful change on what Stewart, a gun owner, called a “significant epidemic.” Stewart noted that public safety measures have curbed unintentional injuries in car crashes. For intentional violence, he said, progress hasn’t been made.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
The Center for Rural Health and Nursing is funded by a $4 million legislative appropriation by the state of Texas. The funding will support the center’s efforts to improve rural nursing education and the health outcomes of rural populations.
“I am very thankful of the Legislature for its support of the University’s efforts to educate and train the next generation of rural health care providers,” said Teik C. Lim, UTA interim president. “Through this new center, we can significantly expand the reach of one of the nation’s top nursing programs to improve the health of rural Texans.”
Elizabeth Merwin, the center’s executive director and dean of CONHI, hopes the center will develop and foster a model for providing nursing education to rural residents aiming to become registered nurses and nurse practitioners. This model will support and educate those students while they reside in their home communities. It will also aim to reduce the shortage of nurses and other health providers in an effort to support access to health care for Texas’ rural populations.
“Thanks to generous funding by the state of Texas, CONHI will be able to form sustainable partnerships with rural communities that improve the quality of life for underserved populations in those areas,” Merwin said. “Our goal is to form close relationships with key organizations and stakeholders within rural communities in Texas to improve access to health care by enhancing the health professional workforce.”
In its first year, the center will develop partnerships in rural communities to perform educational needs assessments of registered nurses and nurse practitioners. Once needs have been identified, the center will provide training to support the communities’ current health care providers and educate new, incoming nurses and health professionals.
“UTA has a proven track record both in Texas and nationwide as a leading center of excellence for nursing education,” state Sen. Kelly Hancock said. “I have great confidence in the university’s ability, through its new Center for Rural Health and Nursing, to bring its nationally recognized nursing education and training programs to improve both nursing education and health outcomes in our state’s rural communities.”
Aspen Drude, the center’s manager, said the center aims to support existing providers and recruit young people from rural populations to become nurses in their communities.
“We want to make sure students who are in rural high schools and community colleges have paths into our programs,” Drude said. “We hope that our continuing education programs will meet the needs of current nurses and increase opportunities for rural residents, while meeting the workforce needs of the rural community.”
The center’s nursing education initiatives will be supported by Elanda Douglas, a clinical assistant professor and nurse practitioner with extensive experience as a family nurse practitioner.
“It’s really important for nursing students to understand that when they work in rural communities, they have to be well-rounded because they could be the only nurse in the clinic,” Douglas said. “Our rural health curriculum will prepare students with a broad set of skills to meet the day-to-day demands of rural care.”
According to the Centers for Disease Control and Prevention, rural Americans face numerous health disparities compared with their urban counterparts. They are more likely to die from heart disease, cancer, unintentional injury, respiratory disease and stroke. Factors that put them at greater risk include higher rates of smoking, lower physical activity and less access to health care and health insurance. Rural communities also face unique workforce challenges and, too often, shortages of health care providers.
Reshma Thomas is a first-year student in CONHI’s Master of Science in Nursing program who has joined the center as a student nursing assistant. As a family nurse practitioner in training, Thomas is passionate about serving vulnerable rural populations.
“Nearly 25% of Texas’ population lives in rural communities and suffers from harmful health disparities and lack of care,” Thomas said. “Providing preventive care and raising the health care standards in these communities is vital.”
Stephanie Morgan, PhD, RN, FNP-BC, is no stranger to setting up and maintaining COVID-19 vaccination clinics. Thanks to her work with the team of nursing faculty and students, other health care providers, and volunteers that was formed in December 2020 when the vaccine first became available, she has been able to pull together and train teams to work with children, ages 5 to 11 in elementary and middle schools in Del Valle, an underserved community in southeast Austin.
“Depending on the size of the event we need one to two non-clinical check-in individuals, two to four vaccinators, one to two mixers, one observation individual and a clinical lead,” she said. “On the day of the event, we estimate the number of vaccines to be administered and pack vaccine and supplies according to that estimation.”
The team arrives at the event one hour before the start time to set up and prepare the first vials of vaccine. Once they assemble, they conduct a brief with team members so everyone is clear on the plan and can ask questions.
“Likewise, when the vaccine clinic event is over, we debrief to determine what worked well and identify opportunities for improvement next time,” Dr. Morgan said. “At the conclusion, an event report is required to capture a summary that includes the type of vaccine(s) administered, doses given (first, second, immunocompromised or booster) and totals. It also includes doses wasted and if the waste was in a vial or syringe.”
BSNs learn the Covid-19 vaccine routine—and pick up some clinical pediatric experience
Across town, Amayrany Maya-Mora, BSN, RN, and public health nurse at the School of Nursing’s Children’s Wellness Clinic (CWC), begins her day by checking the clinic’s refrigerator and freezer temperatures to ensure that all vaccines are maintained in the proper storage conditions. She then checks in with the front office staff to see if any children are waiting to receive vaccines during the morning walk-in clinic.
“During our daily walk-in clinic at CWC, which runs from 8 to 9 a.m., we usually serve around five to seven children,” Maya-Mora said. “I follow this up by entering vaccine data into Immtrac, the state vaccine registry, order vaccines and supplies, and prepare for any upcoming vaccine events.”
The CWC staff spent a lot of time prior to the Centers for Disease Control and Prevention authorization of the Pfizer and BioNTech SE COVID-19 vaccine for use in children 5 to 11 years old. Once the authorization was given in October 2021, the UT Austin School of Nursing was primed to begin providing it at both the CWC and the Family Wellness Clinic in addition to the area schools.
“Although the basic foundation for providing vaccinations at CWC was already in place, we still needed to provide more specific training,” Maya-Mora said. “We already give vaccines to children, but the COVID vaccine is different in its storage and reconstitution. Plus, we knew training would help boost the confidence of outside volunteers and nursing students. Vaccinating young children can be stressful if not done properly.”
“It’s important to be honest with children.”
Fortunately, Eduardo Chavez, PhD, RN, and a clinical assistant professor at the School of Nursing, had created a power-point training outlining creative ways to help volunteers feel confident and create a more relaxed atmosphere for children getting vaccinated. The slide show demonstrated how to safely hold pediatric patients, addressed appropriate needle lengths and provided communication techniques on how to talk honestly to children. “It’s important to be honest with children,” Maya-Mora added.
In addition, the team provided information to parents and others in the community.
“We made available information about studies and trials regarding the risk of side effects and what types of side effects they might expect,” Maya-Mora said. “There has been a great response, and parents have been very excited about our being able to partner with the Del Valle Independent School District and offer vaccines at their children’s schools. Unlike the CWC, not all pediatric clinics around the Austin area offer the vaccine, so we also provide Saturday clinics at Dailey Middle School and at the Opportunity Center at Del Valle High School. These walk-in clinics will be open through January from 9 a.m. to 2 p.m. It’s very important for parents to remember it’s a two-shot process.”
“Because the School of Nursing was prepared to administer vaccines as soon as they arrived, Del Valle ISD was the first Travis County school district to offer vaccinations in their schools with both doses available before the end of the year,” Dr. Morgan said. “That will amount to an average of 70 vaccinations given at each of the nine elementary schools in Del Valle. Parents who take advantage of these free clinics in their own communities can now relax, knowing that their kids — and their schools — are safer. Vaccinating children is an art, but with training, encouragement, and teamwork, we can increase the number of vaccinators and ensure that children are able to receive the COVID vaccine.”
A few weeks ago, a woman gave birth at Hereford Regional Medical Center, a critical access hospital in the Texas Panhandle.
Or, rather, the woman gave birth in the parking lot at Hereford Regional Medical Center after driving over an hour to get there, according to Jeff Barnhart, the hospital’s chief executive.
Barnhart said he’s heard it all over the years: patients giving birth at rest stops and in ambulances and in the car on the side of the road. The hospital’s patients come from a 1,600-square-mile area in the Texas Panhandle, and some of them just don’t make it in time.
But now, even patients who do make it to the hospital have another variable to contend with: critical staffing shortages and exploding COVID-19 case counts. There are days when Hereford Regional doesn’t have enough nurses to operate the labor and delivery unit, forcing it to divert patients 50 miles northeast, to Amarillo.
“We give them a medical exam and see if there’s time to get them in an ambulance to another hospital that can take them,” he said. “But sometimes, that baby’s coming and there’s just not time.”
Those patients give birth in the emergency room, an increasingly common occurrence as rural hospitals limit or cease labor and delivery services due to insufficient staffing.
Nationally, the health care system is facing an unprecedented labor shortage as nurses retire, resign, burn out or leave staff positions for more lucrative travel nursing contracts. Rural hospitals, many of which already operate with a shoestring staff, are especially hard hit.
Declining populations and cuts to Medicaid and Medicare funding have made Texas the national leader in rural hospital closings, with some 26 closures — permanent or temporary — of rural facilities in the last decade. Two-thirds of the state’s 157 rural hospitals are public, which means less flexibility in salary negotiations. Administrators also say it’s often difficult to recruit medical personnel to smaller towns in remote counties.
Struggling to survive, the remaining hospitals in Texas’ rural communities have had to cut back services. And when that happens, labor and delivery is often the first to go.
Only 40% of Texas’ rural hospitals still have a labor and delivery unit, according to the Texas Organization of Rural and Community Hospitals, leaving whole swaths of the state without access to nearby obstetrics care.
“If we’ve got nurses to cover a day, of course, we’re going to try to take care of everything that we can here,” Barnhart said. “But it’s just a scheduling crisis, and whenever we can’t make it work, we just let the hospitals in Amarillo know so they can expect it.”
Cuts to services
Adrian Billings has been delivering babies at Big Bend Regional Medical Center for 15 years, serving patients across a 2,000-square-mile area in West Texas. The hospital delivers about 200 babies a year, he said, with pregnant patients sometimes driving over 100 miles to give birth.
But in recent months, for the first time since he’s worked there, the hospital has limited the hours the labor and delivery unit is open. Over the holidays, the unit shut down entirely for two weeks. For a while, it was only open Monday through Thursday morning.
“When that happens, essentially, it’s a maternity care desert Thursday morning through Monday morning out here,” he said.
He said the hospital tried to schedule inductions during the week as much as possible, but childbirth can be hard to predict. If a patient goes into labor during the off hours, they either give birth in the emergency room or are sent 60 miles away to Fort Stockton.
A spokesperson for Big Bend Regional said in an email that the hospital recently hired additional nurses who will soon allow it to resume full-time maternity care. But many rural hospitals say they simply aren’t able to keep up in today’s ultracompetitive labor market.
“We only have six doctors at our hospital,” said Jennifer Liedtke, the director of the labor and delivery unit at Rolling Plains Memorial Hospital in Sweetwater, about 40 miles west of Abilene. “When you’re talking about a census of 20-plus patients, we’re carrying a full load trying to get everyone seen. … It’s rough.”
Rolling Plains typically tries to have three labor and delivery nurses scheduled for each shift. But recently, Liedtke said the team is scraping by with one nurse and a shift supervisor who can step in as needed. Her nurses often get pulled into other units when there are no deliveries.
“There’s not a patient back there today, so both of [the nurses] are working the COVID unit right now,” she said. “So if we do have a patient come, they have to go shower and change into all new scrubs and stuff before that patient will have to come back.”
Many of the longtime nurses at Rolling Plains retired during the pandemic, Liedtke said, and it’s been difficult to find replacements. On Monday, all five of the hospital’s ICU beds were occupied, according to state health numbers.
“We’re trying to recruit right out of school right now, but a lot of the young nurses are going into travel nurse positions,” said Liedtke, who is also a family physician and OB-GYN. “They can sign big, big contracts … and that’s just not something we’re going to be able to match.”
Liedtke said it’s especially difficult to recruit nurses to work in the obstetrics unit of a rural hospital. At a larger facility, there might be different nurses dedicated to labor and delivery, the nursery, and postpartum care. But at Rolling Plains Memorial, one nurse has to handle all those roles.
Labor and delivery is a major investment for rural hospitals, requiring specialized nurses and a recommended 2-to-1 nurse-to-patient ratio during delivery. It’s rarely a money-making enterprise for these hospitals, particularly if they’re serving uninsured or Medicaid patients.g
John Henderson, president of the Texas Organization of Rural and Community Hospitals, said struggling hospitals often see labor and delivery as an easy target for cuts. But he worries that these short-term closures and limited services will create a ripple effect that will ultimately leave rural hospitals worse off.
“You’ve compounded the problem by forcing people to leave the community when they need care,” he said.
If patients give birth at a hospital in a larger city, he worries they may be less likely to return to the local hospital for future medical care.
“It won’t just be obstetrics,” he said. “They’ll probably end up seeing a pediatrician [at the larger hospital], and the next time they have a sprained ankle, that’s where they’re going.”
Transferring to larger hospitals
Many rural hospitals have already shaved down their services as much as possible, asking nurses to do double duty or transferring patients to larger hospitals for more specialized care.
Fewer than half of the state’s rural hospitals perform surgeries or have specialists such as cardiologists on staff, and many don’t have an intensive care unit. In normal times, it’s enough. But these days, there’s a logjam of patients who are waiting for a higher level of critical care than some of these hospitals can give on a long-term basis.
In the tiny Southeast Texas town of Anahuac, the local hospital is feeling the effects of soaring COVID-19 hospitalizations in Houston, an hour east.
“All of Houston’s medical center [complex of several hospitals] is in code red, meaning everyone is at capacity,” said William Kiefer, CEO of Chambers Health, which runs Anahuac’s hospital, OmniPoint Health. “And so the downstream effect of that is that we have two patients … who require transfer. We’ve had them for days. They’re not going anywhere.”
Rural hospitals say they can usually find beds in larger hospitals for patients who need to give birth, but even that’s become more tenuous as omicron and staffing shortages rage.
Teresa Baker, an OB/GYN with Texas Tech University Health Sciences Center in Amarillo, said she can always tell when there’s been an interruption in service somewhere else in the Panhandle. Suddenly patients are coming from farther away, later in the labor process, and often arriving via ambulance.
“We’re happy to take them,” Baker said. “The hospitals are doing a very selfless thing by shipping those patients, because they know they can’t handle them without the right staffing. The altruism is apparent.”
But hospitals in Amarillo are being walloped by the omicron variant just like everywhere else. During a recent shift, Baker said, seven out of 10 of their laboring patients were positive for COVID-19.
“We just assume everybody’s positive,” she said. “If the baby is born at full term and is healthy, then we can keep the mom and baby together, and the dad, because we can isolate them in the room.”
But many of the babies the hospital delivers have to go to the neonatal intensive care unit for additional care, which becomes much more difficult if the mother has tested positive for COVID-19.
“That’s what makes your heart bleed,” Baker said, “because these moms don’t even get to see their babies or nurse their babies because they’re positive. And it’s just a terrible situation.”
She said for the first time during the pandemic, the hospital has had to figure out issues like how to discharge babies from the NICU to COVID-positive parents.
“I said, what are they going to do, just meet her at the back door with her baby?” she recalls asking the nurse. “Because she can’t come into the hospital unless she absolutely needs to.”
Vaccine misinformation impacts staff, patients
Hospitals around the state are also contending with vaccine hesitancy among staff and patients. That’s just another challenge that’s hitting rural hospitals harder than better-resourced urban facilities.
For a time, Liedtke worried the labor and delivery unit at Rolling Plains Memorial might have to shut down, thanks to a federal vaccine mandate for health care workers that is tied up in the courts.
“To be very clear, I would love to see everyone vaccinated,” she said. “But from a staffing perspective, we were probably going to lose half of our [obstetrics] nurses.”
Other hospitals report similar concerns, saying they’re aware of large percentages of their nurses and hospital staff who would resign if they were required to get a vaccine.
OB/GYN doctors and nurses are also struggling to communicate vaccine information to their pregnant patients, many of whom are wary about a perceived lack of information about the effects of the vaccine on pregnancies.
“It’s so emotional for these moms, and I know they’re trying to make the best decision they can for their babies,” said Baker. “We just have to meet them where they are and just keep revisiting it.”
Baker said she tries to remind patients that the risks associated with getting very sick from COVID-19 outweigh any potential risks from the vaccine.
Holly Dunn, a maternal fetal medicine specialist in Abilene, has seen an uptick in patients needing specialized care because they develop COVID-19 symptoms during pregnancy.
“It’s more common now for my patients to have COVID or have had COVID than not,” she said.
She said it’s her unvaccinated patients who are developing serious pregnancy complications and fetal development issues, and even experiencing stillbirths. She’s implored her patients to get vaccinated for themselves and their children, and tells them about her own experience: She recently had a healthy baby after getting vaccinated.
“So I practice what I preach,” she said. “That gives me some street cred with my patients. If we can convince even one patient, it’s a victory.”
