The Desertification of Maternal Care: The Post-Dobbs Impact on OBGYN Access in Rural Texas

Kayla Ann Wilson

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INTRODUCTION‍ ‍

In the wake of Dobbs[1], Texas’s criminal, civil, and licensing restrictions have transformed rural regions into reproductive and maternal healthcare deserts, curtailing abortion access and accelerating an Obstetrician/Gynecologist (OBGYN) exodus. Maternal care access has been a major public health issue in the United States, and the lack of access to these services contributes to geographic disparities, with rural counties experiencing disproportionately high rates of maternal morbidity and mortality.‍ ‍

This paper examines how the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization precipitated a wave of restrictive abortion laws in states such as Texas, advancing the “desertification” of maternal healthcare in rural and underserved regions. Next, this paper will trace how the laws have helped dismantle the already fragile obstetric and gynecologic care infrastructure in rural Texas and how it has eroded reproductive health access. Lastly, this paper will propose realistic reforms to mitigate the post-Dobbs maternal care desertification, improve rural access, and enhance OBGYN retention. While commentators often frame the post-Dobbs moment as a social or philosophical setback for women’s rights, the consequential harm is more systemic.‍ ‍ ‍

LEGAL BACKGROUND‍ ‍

Dobbs v. Jackson Women’s Health Organization overturned over fifty years of precedent recognizing a person’s fundamental right to have an abortion.[2] The Supreme Court held that the Constitution does not confer a right to an abortion because it is not deeply rooted in the nation's “history and traditions.”[3] The dissent notably observed that the majority failed to answer an urgent question: when a state must allow abortion to protect a pregnant patient’s life or health.[4] This question along with reproductive healthcare access currently poses a significant policy challenge, shaped not only by the pace of scientific advancement but also by disparities in access across marginalized and rural communities and by enduring questions of family planning and women’s autonomy.‍ ‍

TEXAS LEGAL HISTORY IN ABORTION AND MATERNAL CARE‍ ‍

Texas’s long history of abortion regulation cannot be separated from its worsening rural maternal health crisis, which these policies have only intensified over time. The state first criminalized abortion in the mid-19th century, except when necessary “to save the life of the pregnant woman.”[5] This framework remained in place until Roe v. Wade in 1973, when the United States Supreme Court struck down Texas’s criminal abortion statutes and recognized a federal constitutional right to obtain an abortion.[6]Roe v. Wade held that the U.S. Constitution protects a woman’s right to choose to have an abortion under the right to privacy implied by the Due Process Clause of the Fourteenth Amendment.[7] The Court ruled that states could not ban abortion before fetal viability and created a trimester framework.[8] The state allowed regulation as pregnancy progressed, while preserving the woman’s health and life interests.[9]In the years that followed, Texas enacted a series of incremental limitations, including parental involvement requirements, mandatory waiting periods, and targeted regulation of abortion providers.[10]‍ ‍

In 2011, the Texas Legislature cut the state family planning budget by roughly two-thirds and restructured the funding in ways that forced clinics such as Planned Parenthood to close or reduce services.[11] Access narrowed again in 2013 when the Legislature enacted House Bill 2, which imposed admitting privileges and ambulatory surgical center requirements on abortion providers, disproportionately affecting rural patients.[12] Although the Supreme Court invalidated this law in 2016 in Whole Woman’s Health v. Hellerstedt, many clinics that were forced to close never reopened.[13] During this period, Texas became the national leader in rural hospital closures, and by 2021-2022, only 40% of rural hospitals maintained labor and delivery units.[14] At a time when births in birthing centers were actually increasing by approximately 20%[15], Texas seemed to be falling behind.‍ ‍

THE POST-DOBBS IMPACT‍ ‍

In 2021, a year before the fall of Roe v. Wade, the Texas Legislature passed a so-called “trigger law,” designed to take effect automatically upon Roe’s overruling and ban most abortions in the state.[16] Same year, Texas passed the “Texas Heartbeat Act,” which bans abortions after about six weeks of pregnancy, when embryonic cardiac activity is detectable.[17] This law did not make performing an abortion a crime, instead, “it allows civil lawsuits against a physician who provides or induces such an abortion.”[18] Following Dobbs, the state’s trigger law went into effect, allowing exceptions only when necessary to save the pregnant patient’s life or prevent substantial impairment of a major bodily function.[19] Texas provides only narrow exceptions for “medical emergencies.”[20] Although the Senate bill attempts to clarify what qualifies as a life-threatening condition, it still expressly excludes exceptions for rape, incest, and fetal anomalies.[21]‍ ‍

Since Dobbs, providers seem to repeatedly seek clearer guidance on the scope of care they may lawfully provide without risking penalties. In Texas, physicians who violate the abortion bans face mandatory license revocation.[22] Texas courts have narrowed the scope of care for physicians pursuing guidance. State v. Zurawski involved several plaintiffs, including Amanda Zurawski, who developed septic shock after being denied an abortion for a nonviable pregnancy, and Ashley Brandt, who traveled out of state to obtain an abortion to save one twin after the other was diagnosed with a fatal condition.[23] Dr. Damla Karsan, a physician-plaintiff and board-certified OBGYN, testified that the standard of care is to offer abortion as a medical option in cases such as preterm pre-labor rupture of membranes and severe fetal abnormalities, where continuing the pregnancy poses significant risks to the patient, including infection, hemorrhage, and preeclampsia, and offers little likelihood of a viable or healthy birth.[24] She further testified that Texas’s abortion laws amplified physicians’ fear and reluctance to offer a patient abortion care, even when it appeared legally permissible.[25] The Texas Supreme Court refused to broaden or clarify the medical emergency exception.[26] The Court concluded that the abortion ban “does not leave the reader to wonder,” asserting that no further clarification is necessary because the statute relies on a physician’s “reasonable medical judgment.”[27] In addition, the Court held that the plaintiffs failed to demonstrate that the statute was more restrictive than the Texas Constitution permits.[28] These decisions likely left physicians without clear guidance on how to lawfully navigate these vague statutory exceptions. ‍ ‍

The resulting legal ambiguity has been arguably burdensome in rural Texas, where the OBGYN workforce is already fragile and understaffed. A 2023 survey conducted by Manatt Health for the Texas section of the American College of Obstetricians and Gynecologists shows an anticipated decade-long shortage of OBGYNs, with many providers reconsidering practice in Texas as legal risks escalate.[29] The responses obtained were from 450 practicing OBGYNs and 47 residents across Texas, where they highlighted that the new abortion restrictions, combined with unclear medical emergency exceptions, have increased professional risk and contributed to declining willingness to practice in the state.[30]‍ ‍

The March of Dimes report only supports this trend: more than 45% of Texas counties qualify as “maternity care deserts.”[31] A maternity care desert is defined as a county in which access to maternity care services is “limited or absent, either through lack of services or barriers to a woman’s ability to access that care” within the county.[32] Residents in these regions often travel over an hour to access prenatal care and even farther for emergency obstetric services.[33] The closure of rural labor and delivery units often is attributed to low patient volume and staffing shortages.[34] The risks associated with pregnancy have made rural Texans increasingly hesitant to pursue family planning and have further exposed the deep, longstanding fragility within rural reproductive healthcare systems.[35]‍ ‍

A report from the Michael & Susan Center for Health Living at UTHealth School of Public Health highlights that maternity and perinatal care deserts are growing into a public health crisis in the United States.[36] The report documents how longer travel distances to receive prenatal and delivery services impose serious health risks on low-income and rural populations.[37] Texas abortion laws have forced closures of several abortion clinics across the state, with the average one-way drive being seventeen miles to 247 miles.[38] Rural Texas residents who travel to out-of-state clinics are not only hundreds of miles away, but concentrated in states that themselves have limited capacity and were unprepared for a significant influx of Texas patients.[39]‍ ‍

Additionally, Texas is likely experiencing significant OBGYN residency program challenges. Texas currently hosts roughly twenty-seven OBGYN residency programs in large cities such as Amarillo, Lubbock, Odessa, El Paso, San Antonio, Dallas, Houston, Galveston, Austin, and Temple.[40] Meanwhile, a few of these institutions function as regional hubs for largely rural areas. With the decline in residency applicants, students are opting out of obstetrics or are avoiding the state due to strict abortion laws altogether.[41] One prominent example is Dr. Tony Ogburn, who helped build an OBGYN residency program in the underserved Rio Grande Valley.[42] After the ban, half of his full-time faculty had left, the hospital’s resident program collapsed, and Ogburn himself put his house on the market and made a plan to relocate.[43] Since Dobbs, the exodus of healthcare providers has created a surge of challenges in Texas’s rural communities as residency applications in OBGYN programs dropped 16%.[44] Similarly, a Commonwealth Fund review concludes that post-Dobbs abortion restrictions are prompting both practicing maternity care clinicians and trainees to leave or avoid ban states, further reducing the provider pool in already underserved rural communities.[45] Notably, states that protected abortion access experienced an albeit small 0.4% increase in OBGYN residency applicants.[46]‍ ‍

One story that has captured the blaring reality of the human cost of Texas’s post-Dobbs abortion laws is the death of 28-year-old Josseli Barnica.[47] Barnica died less than a month after Texas’s abortion ban took effect, after hospital staff delayed treating her miscarriage because the fetus still had cardiac activity.[48] When she arrived at a Houston hospital at approximately seventeen weeks pregnant with a dilated cervix and clear signs of miscarriage, clinicians nevertheless waited nearly forty hours to intervene.[49] According to reporting, one doctor told her family that acting sooner might have constituted a crime under Texas’s abortion bans, forcing them to wait “until the heartbeat stopped.”[50] Barnica subsequently developed sepsis and died, an outcome many experts say was preventable.[51]‍ ‍

In 2024, the Texas economy reached $2.77 trillion (current dollar state GDP)[52], and Texas's real GDP was reported to be about $2.22 trillion.[53] A 2015 report from the American Medical Association estimated that “physician services” generated an economic output of roughly $117.9 billion.[54] Additionally, the rural economy has a large footprint in Texas. A 2019 report from the Texas A&M AgriLife Extension Service valued the “food and fiber” system at about $159.3 billion, which was roughly 8.6% of the Texas GDP at the time.[55] Rural Texas serves as a major economic engine for the state; despite this, rural Texas lacks one of the most essential supports for family formation: access to maternal and reproductive healthcare. Texas’s post-Dobbs policy response has resulted in expanded abortion restrictions with continuing effects on access to reproductive healthcare in rural areas.‍ ‍

ANALYSIS‍ ‍

Texas has entered the post-Dobbs era with one of the most fragile maternal-health infrastructures in the country. The Supreme Court’s decision to end the constitutional fundamental right to an abortion has further crippled the Texas landscape of reproductive rights, with effects likely more severe in rural Texas. Texas’s decades-long campaign restricting abortion, and, in turn, access to maternal care, has been justified as an effort to preserve life. Maternal care is defined as healthcare provided during pregnancy, childbirth, and the postpartum period.[56] In the post-Dobbs landscape, Texas stands apart for the breadth and coordination of its approach limiting this type of related care. Rather than relying on a single mechanism, the state has employed multiple, mutually reinforcing strategies: imposing severe criminal penalties on providers, empowering private citizens to enforce abortion restrictions, and leveraging expansive civil liability against those who assist in obtaining care. Texas has ensured that Medicaid policy systematically excludes clinics, including Planned Parenthood[57], removing underserved and rural communities of some of the only providers willing and able to deliver comprehensive and empathetic reproductive health care. Rural communities likely face little to no maternal care access, and the growing exodus of OBGYNs has only hastened the “desertification” of care in these regions.‍ ‍

“INTERJURISDICTIONAL ABORTION WARS”‍ ‍

The Dobbs dissent warned the fall of abortion protections would create not only uncertainty over what physicians may lawfully do, but also creat conflicts between states.[58] This is likely reflected in the migration of Texas patients across state lines to obtain maternal care. New Mexico became a primary destination for Texans, particularly rural patients, seeking miscarriage management and abortion care because it affirmatively protects reproductive healthcare.[59] The clinics in Albuquerque and Las Cruces reported an over 300% increase in Texas patients after S.B.8, and again after the Dobbs trigger ban took effect.[60] This interstate migration shows a post-Dobbs reality in which Texas offloads the clinical and financial burden of emergency pregnancy care into neighboring states.‍ ‍

New Mexico and Texas both face significant gaps in rural maternity care, but Texas’s far larger rural population and its high rate of hospital and labor-and-delivery unit closures have produced far more severe and expansive maternal-care deserts. In New Mexico, the legal environment stands in sharp contrast to Texas. The March of Dimes estimates that, nationally, roughly 27–33% of U.S. counties qualify as maternity care deserts.[61] In Texas, by contrast, nearly half of all counties meet that definition.[62] New Mexico has also experienced hospital closures, but the scale is smaller.[63] New Mexico only fourteen rural hospitals still operate birthing services statewide.[64] Rural geography remains a significant barrier to maternity care even in states without Texas-style restrictions.[65] Texas, however, continues to lead the nation in rural hospital closures, leaving many residents without in-state delivery options and forcing some to travel across state lines for basic obstetric services.[66] Hospitals have cited the same drivers, such as high uninsured rates,[67] low Medicaid reimbursement, OBGYN staffing shortages, and fear of legal liability in a post-Dobbs environment. By 2030, Texas is expected to have a 15% OBGYN workforce deficit, among the nation’s largest, exacerbated by mounting legal pressures on reproductive-health providers.[68] Thus, many providers are fleeing Texas and relocating to places such as New Mexico, especially in border and metropolitan areas.[69] In fact, in 2024, New Mexico’s governor launched a campaign specifically inviting Texas medical professionals, including those affected by Texas’s abortion restrictions, to relocate to New Mexico to practice without those restrictions.[70] As medical professionals leave Texas, neighboring states with more protective legal environments have pursued recruitment strategies to attract OBGYNs fleeing Texas’s restrictions.‍ ‍

            By contrast, Louisiana and Florida are useful comparators because they are nearby Southern states where legal instability has produced the same practical barriers rural Texans face. In Louisiana, a six-week ban and narrow, ambiguous medical exceptions have led hospitals to adopt risk-averse protocols similar to those in Texas, causing dangerous delays in miscarriage and nonviable pregnancy care.[71] Florida’s six-week ban also further shifted the Southeastern care map. In Medina v. Planned Parenthood, the Court made it more difficult for Medicaid patients to challenge state efforts to exclude Planned Parenthood as a provider by holding that Medicaid’s “free-choice-of-provider” provision does not clearly create a privately enforceable right to choose a specific qualified provider.[72]‍ ‍

These ripple effects suggest a broader regional pattern in which legislative hostility to abortion may accelerate structural declines in maternal care access. At the national level, Dobbs replaced a uniform constitutional framework with a system in which individual states may regulate, and in some cases, disregard established medical standards of care as they see fit. Federal agencies such as the Health Resources and Services Administration (HRSA) and the Department of Health and Human Services (HHS) have recognized that the fragmentation of maternal health services, particularly in rural areas, undermines national maternal health goals.[73] Today, nearly half of all U.S. counties had no practicing OBGYN at all, and among women living in rural counties, 58% resided in a county with no OBGYN.[74] A KFF analysis found that in 2021-2022, there were only about thirteen practicing OBGYNs per 100,000 women in rural counties, compared to forty-one per 100,000 in metro counties.[75] The absence of any birthing hospital, birth center, or obstetric provider in affected regions deepens existing workforce and network deficiencies. This gap, in turn, reinforces and accelerates the “desertification” of maternal care that national researchers have warned about for years.[76] And Texas has nearly 50% of its counties lacking a single OBGYN[77] reflect says a longstanding national lens.‍ ‍

CONSTITUTIONAL & FEDERAL TENSIONS‍ ‍

            The American constitutional structure vests the government with a combination of enumerated and implied powers, each designed to promote and protect the public good. In this framework, privacy is not textually explicit but has developed as an implied constitutional principle through judicial interpretation under both the U.S. Constitution and the Texas Constitution.[78] The Texas Supreme Court has repeatedly held that the “Due Course of Law” clause in Article I, Section 19 of the Texas Constitution impliedly protects forms of individual privacy, often more robustly than its federal counterpart.[79] The Due Course of Law Clause is best understood to provide substantive protections for personal autonomy, including privacy in personal decision-making and private affairs. In Texas State Employees Union v. Texas Department of Mental Health & Mental Retardation, the Texas Supreme Court recognized an individual right to privacy grounded in Section 19, protecting both independence in making certain kinds of important decisions and freedom from disclosure of personal matters.[80] However, when the claimed privacy interest concerns abortion, the analysis seems to shift. In Zurawski v. Texas, plaintiffs described how forced delays in miscarriage management and emergency pregnancy care intruded upon private medical decision-making between patient and physician.[81] These delays suggest constitutional privacy concerns and also leave Texans increasingly unable to access necessary, time-sensitive care.‍ ‍

            Texas abortion bans also likely threaten federal healthcare protections. The bans have placed hospitals and clinicians in direct conflict with federal stabilization requirements under the Emergency Medical Treatment and Labor Act (EMTALA), as emergency conditions may require abortion as the only means of stabilizing a patient.[82] EMTALA mandates stabilizing treatment for emergency medical conditions, including pregnancy complications such as pre-viability membrane rupture or hemorrhage. For decades, EMTALA functioned as the only federal law meaningfully requiring hospitals to provide care regardless of a patient’s insurance status, immigration status, or ability to pay.[83] Texas law, however, threatens felony prosecution, loss of licensure, and civil liability for performing an abortion outside of the narrow statutory exception.[84] Texas sued HHS after the department reminded hospitals of their EMTALA obligations in cases where the necessary stabilizing care is an abortion.[85] The Fifth Circuit Court of Appeals held that EMTALA does not require abortion as a stabilizing treatment and therefore does not preempt Texas’s Human Life Protection Act (HLPA).[86] It affirmed the district court’s permanent injunction, concluding that HHS’s Guidance exceeded the statutory authority granted under EMTALA.[87] The U.S. Supreme Court ultimately declined to hear the case, which left the Fifth Circuit’s ruling in effect.[88] As a result, the federal government is enjoined from enforcing its EMTALA guidance against Texas hospitals, as applied within Texas.[89] Since then, rural hospitals, where transfer delays are often longer and specialists are scarce, appear to face even greater uncertainty. Many physicians now delay intervening in pregnancy-related emergencies until a patient’s condition deteriorates to the point of sepsis or other life-threatening instability.[90] Studies show that pregnancy outcomes for rural women have an increased risk of severe maternal morbidity, such as sepsis, pulmonary edema, and acute renal failure.[91] EMTALA had long served as the last remaining federal guarantee of emergency pregnancy-related care in the United States, but in the wake of Dobbs, even this baseline protection has fractured under state abortion bans that directly conflict with physicians’ federal stabilization duties.‍ ‍

            Texas’s efforts to regulate abortion across state lines have likely raised constitutional concerns as well. The civil liability aspect of Texas’s Heartbeat Act has suggested challenges for longstanding conflict-of-laws principles when applied to conduct occurring in states where abortion is legal. Some cities and counties in Texas have passed ordinances to prevent residents from traveling out of state for abortions, though these are often based on the state's existing abortion ban and rely on private lawsuits for enforcement.[92] Texas’s efforts to export its restrictive abortion policy into protective jurisdictions such as New Mexico likely face serious constitutional barriers, including limits imposed by the Full Faith and Credit Clause. The Full Faith and Credit Clause obligates each state to recognize and enforce the public acts, records, and judicial proceedings of every other state, and Congress’s implementing statute, 28 U.S.C. § 1738, requires that state court judgments receive the same full faith and credit in all other federal and state courts as they are afforded by the courts of the rendering state.[93] Scholars have noted that Texas’s Heartbeat Act, which lets private citizens sue those who violate it, has come into conflict with abortion-protective “shield” laws in other states.[94] For example, a civil lawsuit was filed against Dr. Alan Braid, a Texas physician who provided abortion care following Roe v. Wade, by a litigant who was a resident of Chicago.[95] Texas's conflicting statutes and judgments create the exact interjurisdictional clash that not only concerns Texas residents, but also the physicians.[96] Texas’s continued efforts to extend the reach of its abortion restrictions beyond its borders have already generated substantial litigation, and its reliance on an “ex post” enforcement model may further increase interstate conflict.[97] Rural Texas communities likely cannot withstand the ongoing maternal care desertification, nor survive a parallel legal desertification either. ‍ ‍

POLICY ARGUMENTS‍ ‍

Texas'slegislative choices in addressing abortion care likely transformed a clinical challenge into a structural government failure. Texas enforces one of the nation’s strictest abortion bans and appears to have worsened maternal care in underserved and rural communities with already limited resources.‍ ‍

Maternal care depends on stable provider teams, and when legal pressures drive them out, it arguably disrupts both care delivery and the communities that rely on them. Texas's intentions are stated to promote life and prioritize family,[98] but the policy choices from the legislature have likely reversed these very goals. A study by economists found that states with total abortion bans, such as Texas, experienced net out-migration of about 4.3 people per 10,000 residents in the year following Dobbs.[99] The maternal mortality rate has also risen.[100] A 2025 ProPublica-Texas Tribune investigation of hospital discharge data found a 55% rise in sepsis after the second-trimester pregnancy loss.[101] After the abortion bans, dozens more “pregnant and postpartum patients died in Texas hospitals, precisely at a time when the national maternal mortality rate was falling.”[102] And rural Texas appears to be over-represented in maternal death. A 2025 report by the Texas Advisory Committee to the U.S. Commission on Civil Rights concludes that Texas’s elevated maternal mortality rates are closely tied to the state’s large rural population and the prevalence of rural maternity care deserts.[103] Rural Texas is experiencing a health crisis marked by the near total absence of obstetrical services, leaving pregnant patients without timely prenatal, intrapartum[104], or emergency care.[105] Mothers in these communities are likely forced to travel long distances, delay treatment, and navigate a health system that cannot support safe pregnancies or healthy birth outcomes. This suggests that Texas is unable to support families who require obstetrical care for wanted pregnancies, leading to more miscarriages, more pregnancy-related morbidities, dead babies, and dead mothers.‍ ‍

These outcomes reveal a clear contradiction: a state cannot credibly claim to be “pro-life” or “pro-family” while making pregnancy and maternal care more dangerous and less accessible.[106] In fact, Texas failed to perform on every measure. It now faces one of the highest maternal mortality rates in the country[107], elevated infant mortality, and leads in rural hospital closures[108], and some of the most severe maternal care deserts in the nation, driven overwhelmingly by its rural communities. Few laws have ever been so profoundly counterproductive to their state policy goals. ‍ ‍

            Improving healthcare has also seemed to be a pitfall for the Texas government. Governor Greg Abbott has stated that “helping families also means improving healthcare for Texans. That includes access and funding for mental healthcare, especially in rural Texas…and it means increasing in every corner of the state.”[109] In 2026, Texas announced a $44 million for a Rural Health Financial Stabilization Grant.[110] While the symbolic commitment signals that the state government recognizes the rural maternal care deserts, the scale is small relative to need. The grant does not appear to target maternal care.[111] To this day, Texas has not developed a sustained, dedicated funding program capable of supporting full obstetric and gynecologic service capacity in rural communities. Texas does have one program aimed at maternal care/obstetric readiness but it is aimed at emergencies and not long-lasting situations.[112]‍ ‍

Addressing the long-standing neglect of rural health care in Texas is indisputable to the State’s public health agenda, a goal Governor Abbott seems to identify as a priority. On September 9th, 2025, the Governor stated that rural Texans “provide the food, fuel, and fiber that all Texans depend on. We must do more for rural Texas and rural healthcare…we are dramatically improving healthcare in rural Texas.”[113] Texas ranks sixth nationally for its shortage of primary-care physicians.[114] Seventy-four counties lack a hospital entirely, and the state maintains the highest uninsured rate in the country, burdens that fall disproportionately on rural communities.[115] And the gaps likely widen when OBGYNs exit, and hospitals are discontinued. Having to make a day's travel for emergency interventions such as ectopic pregnancies, preeclampsia, preterm labor, or postpartum hemorrhages will severely increase the risk of illness or even death.[116]‍ ‍

Additionally, as in many other abortion restrictive states, Texas’s post-Dobbs framework reflects a policy goal of reducing the total number of abortions performed.[117] It is also important to note that abortions were already trending downward nationally in the decades following Roe, well before the Dobbs decision.[118] Although reported abortions in Texas have declined since Dobbs, nationwide abortion rates have actually increased during the same period.[119] This may suggest that those seeking abortions are seeking abortion care or maternal care across state lines. While this may technically result in fewer abortions occurring within Texas, the overall rise in abortions nationwide suggests that the policy goal is simply being displaced across state lines, a dynamic many would view as a policy failure.‍ ‍

Ultimately, Texas'spost-Dobbs policies have not protected life, but seem to have created a collapse of the maternal health infrastructure. Even though Texas has consistently emphasized the desire to preserve life, provide rural maternal care access, and improve overall health for families seeking to get pregnant, the actions and results are out of step.[120] An incredible increase in maternal morbidity[121], the desertification of rural Texas, and an accelerating exodus of OBGYNS who are vital to sustaining safe pregnancies. These consequences do not merely weaken Texas’s pro-life narrative but seem to expose an internal contradiction. A state that compels childbirth while driving OBGYNs out of its most vulnerable, maternal care-starved communities does not protect life, but jeopardizes it. ‍ ‍

ETHICAL OBLIGATIONS IN A CRIMINALIZED ENVIRONMENT ‍ ‍

Not only has the post-Dobbs landscape left Texans, especially those in rural communities, with obsolete maternal care access and virtually no lawful avenues to obtain that care, but it has also weakened the ethical obligations that OBGYNs owe to their patients. The American College of Obstetricians and Gynecologists' Code of Professional Ethics requires OBGYNs to prioritize patient well-being, respect patient autonomy, provide honest and competent care, and uphold ethical duties even when legal or institutional barriers interfere with optimal treatment.[122] The impacts of Dobbs in Texas have challenged these ethics. In 2023, a 35-year-old woman died due to a miscarriage and hemorrhage.[123] Dozens of doctors reviewed her case and concluded she needed a dilation & curettage (D&C) procedure.[124] Instead, she was given misoprostol, which, at 11 weeks, was not going to “work fast enough”, according to Dr. Amber Truehart.[125] But because of the legal exposure D&Cs put on doctors, it has forced doctors to use less effective options, diverging from the standard of care and exposing their patients to more risks.[126] Even in cases where no fetal heartbeat is present, stigma and fear have made performing a D&C in Texas increasingly fraught and often dangerously delayed.[127] It has been increasingly clear that providing safe and medically ethical reproductive care would be effectively impossible in its current state. ‍ ‍

There is likely a misalignment between medical ethics and evidence-based care and the post-Dobbs landscape. Trust is essential to the patient-practitioner relationship because it helps patients cope with fear and uncertainty. Eroding that trust likely weakens the already fragile bond between patients and their physicians, especially OBGYNs. The American Medical Association (AMA) has detailed the important component of trust:‍ ‍

"The practice of medicine, and its embodiment in the clinical encounter between a patient and a physician, is fundamentally a moral activity that arises from the imperative to care for patients and to alleviate suffering. The relationship between a patient and a physician is based on trust, which gives rise to physicians' ethical responsibility to place patients' welfare above the physician's own self-interest or obligations to others, to use sound medical judgment on patients' behalf, and to advocate for their patients' welfare."[128]‍ ‍

Some communities have experienced the breakdown of this trust of obstetricians more recently than others. We look to the history of J. Marion Sims, often called the “father of modern gynecology”, who developed surgical techniques by repeatedly operating on enslaved Black women without anesthesia during a time when it was available.[129] This included women such as Anarcha, Lucy, and Betsy, on whom repeated experimental surgeries were performed, experiments that, within less than a decade, helped establish Sims as one of the nation’s “preeminent gynecological surgeons” early in his career.[130] In the early twentieth century, obstetricians in segregated hospitals routinely used Black women as teaching subjects for pelvic examinations, subjected them to high-risk experimental surgeries, and withheld anesthesia based on the racist belief that Black women “felt less pain.”[131] Similarly, in the 1950s, Puerto Rican women were enrolled in early clinical trials of the birth control pill without informed consent, often receiving doses many times stronger than later FDA-approved versions.[132] By the 1970s, Indigenous, Latina, and Black women were disproportionately subjected to involuntary sterilizations through federally funded programs, frequently without adequate disclosure, translation, or consent.[133] One of the most prominent institutions leading in research and policy efforts to advance sexual and reproductive health and rights worldwide[134] is named after Alan Frank Guttmacher, a former vice president of the American Eugenics Society.[135] This history has made it profoundly difficult to reconcile trust between marginalized communities and OBGYNs. ‍ ‍

Against this backdrop, OBGYNs in Texas now must navigate a post-Dobbs Texas that essentially restricts their ability to provide timely, lifesaving reproductive care while also struggling to remain a trusted provider. For practitioners, the ethical duty to protect patient health now likely collides with Texas’s legal restrictions, producing a renewed rupture in the physician-patient relationship. In a state where once routine, evidence-based, and often life-saving procedures are now being lawfully withheld when patients are at their most vulnerable, the divide between communities most in need of reproductive healthcare and the profession’s ethical commitment to “do no harm” has only deepened.[136]‍ ‍

POLICY PROPOSALS AND RECOMMENDATIONS‍ ‍

Texas’s medical emergency exception remains arguably vague, which caused a lot of fear in OBGYNs and residents, driving them out of state. In August of 2025, Texas enacted the “Life of the Mother Act” which was intended to allow physicians to intervene when a pregnant patient faces a life-threatening condition.[137] The law reads as follows:

‍ ‍

“(a) Notwithstanding any other law, a physician who treats a condition described by

‍ ‍

Subsection 170A.002(b)(2) shall do so in a manner that, in the exercise of reasonable

‍ ‍

medical judgment provides the best opportunity for survival of an unborn child.

‍ ‍

(b) It is an exception to the application of Subsection (a) that, in a physician’s reasonable

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medical judgment, the manner of treatment required by that subsection would create a

‍ ‍

greater risk of:

‍ ‍

(1) the pregnant female’s death; or

‍ ‍

(2) substantial impairment of a major bodily function of the pregnant female.

‍ ‍

(c) This chapter does not require a physician to delay, alter, or withhold medical treatment

‍ ‍

provided to a pregnant female if doing so would create a greater risk of:

‍ ‍

(1) the pregnant female’s death; or

‍ ‍

(2) substantial impairment of a major bodily function of the pregnant female.

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(d) Nothing in Subsection (c) authorizes the performance of an abortion that is prohibited

‍ ‍

by law.”[138]

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The problem is that the requirement to provide the “best opportunity for survival of an unborn child” may conflict with the medical treatment the pregnant patient requires. A decision that appears medically justified to a physician may still be challenged by a prosecutor, the medical board, or private litigants who interpret their “medical judgment” differently. The Life of the Mother Act still does not clearly define how imminent or severe the risk of death must be before a physician may intervene. In practice, many physicians may believe they must wait until a patient deteriorates to the brink of death or life-threatening infection before intervening, given the vagueness of Texas’s medical emergency exception. ‍ ‍

For example, a physician may determine that a pregnant patient is experiencing eclampsia, which is an obstetric medical emergency where a pregnant or recently pregnant patient has seizures caused by pregnancy-related high blood pressure and organ dysfunction.[139] In this case, a physician may determine, in the exercise of reasonable medical judgment, that an immediate termination of the pregnancy is the safest course of treatment. The state or a civil litigant may present their own expert witness who interprets the physician’s actions as failing to reflect appropriate medical judgment and as not providing the “best opportunity” to sustain the pregnancy. A scenario such as this limits physicians from providing medically necessary care and may chill timely intervention, ultimately costing the patient their life.‍ ‍

This approach offers no real protection for doctors or for patients. For OBGYNs in rural communities and an aggressive Texas Attorney General (AG), who often lack the financial resources to withstand months or years of investigation or litigation, these risks are untenable.[140]‍ ‍

A solution to this problem is to establish a safe harbor for good faith medical care that provides clear and precise statutory definitions and includes an explicit, non-exhaustive list of qualifying medical emergencies aligned with ACOG standards.[141] The safe harbor would provide immunity for good-faith physicians, which shifts the burden away from criminal prosecution onto the state. To also help with medical emergencies, other states have included conditions such as sepsis, severe preeclampsia/eclampsia, hemorrhage, and cardiac compromise. Texas should include these conditions, along with other medical emergencies, using language such as “where the fetus is unlikely to survive,” thereby allowing physicians to act with their medical judgment. These changes would likely substantially encourage prompt and decisive action by physicians.‍ ‍

Rural OBGYN access in Texas appears to be declining under the pressures of low delivery volumes, liability concerns, and the financial strain of maintaining labor and delivery units. Without a structural intervention, entire counties will likely be without maternity care. A Rural Obstetrics Stabilization Fund would directly address the economic conditions forcing these units to close. This fund would provide targeted grants or supplement payments to hospitals that keep obstetric services open. Unlike some federal funding programs such as the Rural Maternity and Obstetrics Management Strategies program, a Rural Obstetrics Stabilization Fund would focus on infrastructure and retention. The Fund would give hospitals the financial capacity to recruit and retain OBGYNs, promote continuity of care for pregnant and postpartum patients, and tie funding eligibility to compliance with evidence-based obstetric protocols.‍ ‍

Pairing state matching funds with Medicaid Section 1115 waivers and targeted State Plan Amendments (SPAs) would also provide a realistic and sustainable financing mechanism. A Medicaid Section 1115 waiver allows states to test new ideas in their Medicaid program that are otherwise not permitted[142], including special funding for rural hospitals or pilot programs to support OBGYN care. A SPA allows a state to make regular updates to its Medicaid program, such as raising payment rates, adding benefits, or changing the hospitals that get paid.[143] Unlike 1115 waivers, SPAs are simpler and faster to approve, allowing Texas to raise OBGYN or rural hospital payment rates without creating brand new projects. Together, a 1115 waiver and SPA offer two powerful, legally established pathways to fund a Rural Obstetrics Stabilization Fund to recruit and retain OBGYNs in these maternal care deserts.‍ ‍

Texas should also issue joint EMTALA-state law compliance guidance to provide clinicians with a single, authoritative framework for emergency obstetric care. The Fifth Circuit held that EMTALA guidance does not require abortion as a stabilizing treatment.[144] Texas’s abortion bans could include performing or assisting in procedures that may be construed as abortive when medically necessary. In the absence of a unified state-level clarification, clinicians reasonably fear exposure to prosecution. A coordinated guidance from the Texas Medical Board (TMB) and the Department of State Health Services (DSHS) would clarify that stabilizing emergency obstetric care required under EMTALA does not violate Texas law. Although the TMB’s guidance states that a physician need not wait until a patient is literally dying or until a bodily function has already suffered irreparable harm, the Board declined to identify any specific medical conditions that would categorically qualify under the medical emergency exception.[145] Clarified, EMTALA-led guidance would give hospitals a defensible statewide standard for training, documentation, and emergency protocols, reducing fear among OBGYNs and ensuring Texas facilities can meet their federal and ethical obligations. ‍ ‍

Texas should also explore a ballot-initiated constitutional amendment. States such as Michigan have used ballot initiatives to curb legislative overreach. Under the Michigan Constitution, voters have the power to propose amendments through an initiative petition. Article XII, § 2 provides that “Amendments may be proposed to this Constitution by petition of the registered electors of this State.”[146] If a majority of the electors voting on the question approve it, the amendment becomes part of the Constitution.[147] However, Texas’s current constitutional framework does not allow for a citizen-initiative ballot initiative or constitutional amendment. Texas is one of those states in which only the legislature can propose amendments to the Texas Constitution.[148]‍ ‍

Even with the current political makeup of the Texas legislature, Pro-choice challengers can still be able to challenge bans under constitutional articles. Texas’s Due Course of Law provides that “No citizen of this State shall be deprived of life, liberty, property, privileges or immunities… except by the due course of the law of the land.”[149] A plaintiff may argue that decisions about pregnancy, miscarriage management, and abortion fall within personal liberty. The penalties for violating the abortion bans could be challenged as arbitrary, oppressive, or failing rational basis review. Texas’s Equal Rights Amendment states that “Equality under the law shall not be denied or abridged because of sex, race, color, creed, or national origin.”[150] The provision goes even further than the Equal Protection Clause of the 14th Amendment and triggers strict judicial scrutiny for sex-based classifications.[151] A plaintiff could contend that abortion bans and pregnancy-related restrictions disproportionately burden women and pregnant people by denying them equal access to a life free from state-imposed constraints and oppression. Together, these constitutional frameworks provide a viable pathway to challenge Texas’s abortion bans, particularly for rural Texans facing the greatest access barriers.‍ ‍

In all, Texas’s reproductive health is currently being defined by dangerous ambiguity. Texas'smedical emergency exceptions remain vague, and OBGYNs remain pervasively fearful of their jobs, their patients, and their lives. The “Life of the Mother Act” was intended to fix this problem, but its failure to specify how close to death a patient must be provided little. Meanwhile, rural obstetric care continues to suffer. A Rural Obstetrics Stabilization Fund offers a viable mechanism to stabilize hospitals and rebuild the workforce. Texas must also issue unified EMTALA-state compliance guidance. These policy interventions and constitutional pathways offer Texas its clearest opportunity to mitigate the ongoing rural maternity care desert crisis and establish some legal approach capable of protecting pregnant Texans.

CONCLUSION‍ ‍

Looking ahead, Texas and similarly situated states face a real choice. They can keep a restrictive legal system that undermines public health or move toward an approach that protects both fetal life and maternal well-being. A post-Dobbs Texas has exposed a substantial and widening gap between the state’s stated commitment to protecting life and the realities experienced by rural pregnant Texans. As this paper has shown, Texas’s overlapping bans, vague emergency exceptions, and regulatory enforcement tactics have directly contributed to the exodus of OBGYNs, the shutting down of rural labor and delivery units, and a great rise in preventable maternal morbidity and mortality.[152]‍ ‍

And the consequences extend far beyond abortion access. They destabilize residency infrastructure, compromise hospital operations, and place rural Texans at the greatest risk. With nearly half of Texas counties lacking a single OBGYN[153], the state has effectively transformed maternal care into almost a privilege rather than a basic medical service. A post-Dobbs Texas has not strengthened families or protected fetal or maternal health, but has essentially made doctor’s fear of being criminalized more influential than sound medical care. Yet, this paper argues that the crisis is not irreversible. Texas has the second-largest GDP in the country[154] and has one the largest residency program in the nation.[155]‍ ‍

Ultimately, Texas faces a policy crossroads. The State may have a legitimate interest in protecting fetal life, but the real-world consequences of its abortion bans have proven more severe and far-reaching than many anticipated. In rural Texas, where entire regions already lack obstetric services, the state continues to demand childbirth while simultaneously making it more dangerous. That contradiction is incompatible with any meaningful vision of life preservation. Texas’s path forward will mark either a deeper desertification of rural maternal care or the beginning of a long-overdue reform.‍ ‍

‍ ‍

[1]  Dobbs v. Jackson Women's Health Org., 597 U.S. 215, 142 S. Ct. 2228 (2022).

[2]Id.

[3]Id. at 250.

[4]Id. at 393.

[5]See Tex. Penal Code ch. 7, arts. 531–536 (1857) (criminalizing abortion).

[6] Roe v. Wade, 410 U.S. 113, 164–65 (1973).

[7]Id.

[8]Id.

[9]Id. at 138.

[10]See, e.g., Tex. Penal Code. § 33.002 (parental-consent requirements); Tex. Health & Safety code § 171.012 (waiting-period requirements); see also Whole Woman’s Health v. Hellerstedt, 579 U.S. 582, 589–90 (2016).

[11]See Kari White et al., The Impact of Reproductive Health Legislation on Family Planning Clinic Services in Texas, 105 Am. J. Pub. Health 851 (2015), https://pmc.ncbi.nlm.nih.gov/articles/PMC4386528/

[12]See Wendy Davis, Amicus Curiae Brief in Support of Petitioners, Whole Woman’s Health v. Hellerstedt, No. 15-274 (U.S. Jan. 4, 2016), https://www.scotusblog.com/wp-content/uploads/2016/01/Wendy-Davis-Dechert.pdf

[13] Whole Woman’s Health v. Hellerstedt, 579 U.S. 582, 591–93 (2016) (invalidating Texas House Bill 2 and noting that the law had caused approximately half of Texas abortion clinics to close).

[14]See Tex. Hosp. Ass’n, Rural Health Care, https://www.tha.org/issues/rural-health-care/

[15] Ashley Stoneburner et al., Nowhere to Go: An Overview of Maternity Care Access Across the U.S., Seminars in Perinatology (forthcoming 2025), https://www.marchofdimes.org/sites/default/files/2024-09/2024_MoD_MCD_Report.pdf

[16]SeeDoes Texas Have Trigger Laws Related to Abortion?, Tex. State L. Libr. (June 3, 2025), https://www.sll.texas.gov/faqs/texas-trigger-law/

[17] Tex. Health & Safety Code§ 171.201.

[18]What Does the Texas Heartbeat Act Say About Abortions?, Tex. State L. Libr. (June 3, 2025), https://www.sll.texas.gov/faqs/abortion-heartbeat-act/

[19] Tex. Health & Safety Code§ 170A.002.

[20] Tex. Health & Safety Code§ 170A.002(b).

[21] Tex. Health & Safety Code§ 171.002(3).

[22]See Tex. Occ. Code Ann.§ 164.052(a)(17).

[23] State v. Zurawski, 690 S.W.3d 644 (Tex. 2024).

[24]Id. at 656.

[25]Id.

[26]Id. at 671.

[27]Id. at 662.

[28]Id. at 670.

[29] Dr. Todd Ivey, Tex. ACOG, quoted in Manatt Health Survey (2023), https://www.texastribune.org/2024/10/08/texas-obstetrics-gynecology-abortion-survey/

[30]Id.

[31] March of Dimes, Maternity Care Deserts (Apr. 2025), https://www.marchofdimes.org/peristats/data?top=23

[32]Id.

[33]Id.

[34]Id.

[35]As a Texas City Debates an Abortion Travel Ban, Maternal Care Is Scarce in Nearby Rural Counties, Texas Tribune (2023), https://www.texastribune.org/2024/06/14/rural-texas-maternal-care-access-abortion-travel-ban/

[36]Maternity & Perinatal Care Deserts, Michael & Susan Dell Ctr. for Healthy Living (Sept. 11, 2024), https://sph.uth.edu/research/centers/dell/webinars/docs/Maternity+and+Perinatal+Care+Deserts+091124.pdf

[37]Id. at 4.

[38]Impact of Texas's Abortion Ban: A 14-Fold Increase in Driving Distance to Get an Abortion, Guttmacher Institute (August 4, 2021), https://www.guttmacher.org/article/2021/08/impact-texas-abortion-ban-14-fold-increase-driving-distance-get-abortion

[39]Id.

[40]Obstetrics and Gynecology Residency Positions in Texas (TX), ResidentSwap; Obstetrics and Gynecology Residency Programs in Texas, ResidencyProgramsList, https://www.residentswap.org/obstetrics%20and%20gynecology/TX/.

[41] Stephania Taladrid, The Texas Ob-Gyn Exodus, NEW YORKER (Mag.), Dec. 2, 2024, https://www.newyorker.com/magazine/2024/12/02/the-texas-ob-gyn-exodus.

[42]Id.

[43]Id.

[44]Id.

[45] Kristen Kolb, Maternity Care Providers and Trainees Are Leaving States with Abortion Restrictions, Further Widening Gaps in Care, Commonwealth Fund (Oct. 22, 2024), https://www.commonwealthfund.org/blog/2024/maternity-care-providers-and-trainees-are-leaving-states-abortion-restrictions-further

[46]Id.

[47] Cassandra Jaramillo & Kavitha Surana, A Woman Died After Being Told It Would Be a “Crime” to Intervene in Her Miscarriage at a Texas Hospital, ProPublica (Oct. 30, 2024), https://www.propublica.org/article/josseli-barnica-death-miscarriage-texas-abortion-ban

[48]Id.

[49]Id.

[50]Id.

[51]Id.

[52] Texas Econ. Dev. & Tourism Office, Texas Economic Snapshot (2025), https://gov.texas.gov/business/page/texas-economic-snapshot

[53] U.S. Bureau of Economic Analysis, Real Gross Domestic Product: All Industry Total in Texas (TXRGSP), FRED, Fed. Rsrv. Bank of St. Louis, https://fred.stlouisfed.org/series/TXRGSP (last visited Mar. 31, 2026).

[54] American Medical Association, The Economic Impact of Physicians in Texas 5 (2018) (showing $117.9 billion in total output, jobs supported, wages/benefits), https://www.ama-assn.org/system/files/eis-report-texas.pdf

[55] Texas A&M AgriLife Extension Service, The Food and Fiber System and Production Agriculture’s Contributions to the Texas Economy (2019 estimate), https://agrilifeextension.tamu.edu/wp-content/uploads/2025/02/EXT_ImpactBrief_FoodAndFiber_2025-02.pdf

[56] American College of Obstetricians and Gynecologists & Society for Maternal-Fetal Medicine, Obstetric Care Consensus No. 9: Levels of Maternal Care (2019), https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2019/08/levels-of-maternal-care

[57]SeeCourt Allows Texas to Exclude Planned Parenthood from Medicaid, [Nat’l Health Law Program] (Mar. 12, 2021), https://healthlaw.org/news/court-allows-texas-to-exclude-planned-parenthood-from-medicaid/

[58]See Dobbs, 597 U.S. at 394.

[59] N.M. Stat. Ann. §§ 30-5-1 to -3, repealed by S.B. 10, 55th Leg., Reg. Sess. (N.M. 2021).

[60]See Kate Zernike, In New Mexico, Clinics See Surge of Texas Patients, N.Y. Times (July 2022), https://www.nytimes.com/2022/07/23/us/abortion-clinics-texas-new-mexico.html

[61] March of Dimes, Where You Live Matters: Maternity Care Access in Texas (2023), https://www.marchofdimes.org/peristats/reports/texas/maternity-care-deserts

[62]Id.

[63]See418 Rural Hospitals at Risk of Closure; Breakdown by State, Pa. Off. of Rural Health (Mar. 17, 2024), https://www.porh.psu.edu/418-rural-hospitals-at-risk-of-closure-breakdown-by-state/

[64]Id.

[65] Erika González, On the Edge of Closure: The Daily Struggle of Rural Hospitals in Texas, Reporting Texas(Nov. 7, 2025) (“Texas leads the nation in rural hospital closures”), https://www.reportingtexas.com/on-the-edge-of-closure-the-daily-struggle-of-rural-hospitals-in-texas/

[66]Id.

[67] Stoneburner et al., supra note 13, at 4.

[68] Manatt Health, The Texas OB/GYN Physician Workforce: Early Assessment of the Impact of Abortion Restrictions on the Workforce Pipeline (Oct. 2024), https://assets-us-01.kc-usercontent.com/9fd8e81d-74db-00ef-d0b1-5d17c12fdda9/34392fc8-1c9a-48a2-be8f-3f79d8a4a7d5/FINAL-TX-OBGYN-Workforce-Study_2024-10_f.pdf

[69]Carissa Lehmkuhl, Texas-based abortion provider to move Texas clinics to New Mexico, Fox7Austin (Austin), July 6, 2022, https://www.fox7austin.com/news/texas-abortion-provider-moving-texas-clinics-to-new-mexico#:~:text=NEW%20MEXICO%20%2D%20Whole%20Woman's%20Health,first%20and%20second%20trimester%20abortions

[70]Governor invites Texas healthcare professionals to New Mexico, “Free to Provide” campaign highlights reproductive health freedom (press release Aug. 5, 2024); see also David Martin Davies, New Mexico governor launches campaign to recruit Texas medical professionals to her state, texas public radio (Aug. 5, 2024), https://www.tpr.org/public-health/2024-08-05/new-mexico-governor-launches-campaign-to-recruit-texas-medical-professionals-to-her-state

[71] La. Rev. Stat. Ann. § 14:87.1 (Lexis Advance through Act 33 of the 2025 Regular Session).

[72] Medina v. Planned Parenthood S. Atl., 606 U.S. 357; 145 S.Ct. 2219; 222 L.Ed.2d 567 (2025).

[73] Health Res. & Sers. Admin., How We Improve Maternal Health, U.S. Dep’t of Health & Human Servs. (last reviewed Feb. 2025), https://www.hrsa.gov/maternal-health

[74]See Michelle Long et al., Access to OBGYNs: Evaluating Workforce Supply and ACA Marketplace Networks, KFF (July 10 2025) (showing rural/metro and county-by-county OBGYN provider disparities), https://www.kff.org/private-insurance/access-to-ob-gyns-evaluating-workforce-supply-and-aca-marketplace-networks/

[75]Id.

[76] Stoneburner et al., supra note 13, at 11.

[77] March of Dimes, Maternity Care Deserts: Texas, 2024 Report – PeriStats (last updated Apr. 2025), https://www.marchofdimes.org/peristats/data?top=23&lev=1&stop=641&reg=99&sreg=48&obj=9&slev=4

[78] Griswold v. Connecticut, 381 U.S. 479, 85 S. Ct. 1678 (1965).

[79] [Tex. Const.] art. I, § 19.

[80] Tex. State Emps. Union v. Tex. Dep’t of Mental Health & Mental Retardation, 746 S.W.2d 203, 205–06 (Tex. 1987).

[81]SeeZurawski, 708 S.W.3d 920 (Tex. 2024).

[82] 42 U.S.C.S. § 1395dd (Lexis Advance through Public Law 119-69, approved January 14, 2026, with a gap of Public Law 119-60).

[83] Ctrs. for Medicare & Medicaid Servs., EMTALA, Emergency Medical Treatment & Labor Act: Requirements and Responsibilities for Hospitals, U.S. Dep’t of Health & Hum. Servs, https://www.cms.gov/medicare/regulations-guidance/legislation/emergency-medical-treatment-labor-act

[84] Tex. Health & Safety Code § 170A.004 (Lexis Advance through the 2025 Regular Session and the 2nd C.S. of the 89th Legislature; and the November 4, 2025 general election results.)

[85] Texas v. Becerra, 89 F.4th 529 (5th Cir. 2024).

[86]Id. at 543.

[87]Id.

[88] Id. at 526.

[89]SeeId. 696, aff’d, 89 F.4th 529 (5th Cir. 2024) (enjoining enforcement of HHS guidance interpreting EMTALA to require abortion in certain emergency circumstances as applied to Texas providers).

[90]See Eleanor Klibanoff, Doctors Report Compromising Care Out of Fear of Texas Abortion Law, Tex. Trib. (June 23, 2022, 5:40 PM),

[91] Rural Health Info. Hub, Rural Maternal Health Overview, https://www.ruralhealthinfo.org/topics/maternal-health (last visited Mar. 20, 2026).

[92] Texas Observer, Four Texas Counties Now Ban Travel for Abortions, https://www.texasobserver.org/abortion-travel-ban-lubbock/

[93] U.S. Const. art. IV, § 1; 28 U.S.C. § 1738 (2024).

[94] Kara N. Carreiro, 55 U. Memphis L. Rev. 139 (2024).

[95] Eleanor Klibanoff, Texas abortion provider who violated the state’s ban loses bid to block lawsuit, Tex. Trib. (Dec. 8, 2022), https://www.texastribune.org/2022/12/08/texas-abortion-provider-lawsuit/

[96]Id.

[97]Id.

[98]See Tex. Health & Safety Code § 170A.001; H.B. 1280, 87th Leg., R.S. § 4 (Tex. 2021).

[99] Daniel Dench, Kelly Lifchez, Jason Lindo & Jancy Ling Liu, Do State Abortion Bans Impact People’s Location Decisions?, Econofact (Jan. 21, 2025), https://econofact.org/do-state-abortion-bans-affect-housing-markets

[100] Eleanor Klibanoff & From Our Partners, Rates of Pregnancy-Related Sepsis and Deaths Grow in Texas After Abortion Ban, The Texas Tribune (Feb. 20, 2025), https://www.texastribune.org/2025/02/20/texas-abortion-ban-impact-death-hospitalization/

[101] Lexi Churchill & Eleanor Klibanoff, After Texas Abortion Ban, Doctors Report Sharp Rise in Dangerous Infections Following Pregnancy Loss, ProPublica & Tex. Tribune (Feb. 11, 2025).

[102] ProPublica & Texas Tribune, Texas Banned Abortion. Then Sepsis Rates Soared, (Feb. 20, 2025) (reporting that “dozens more pregnant and postpartum women died in Texas hospitals” after the abortion ban, at a time when the national maternal mortality rate was falling), https://www.propublica.org/article/texas-abortion-ban-sepsis-maternal-mortality-analysis

[103] Texas Advisory Committee to the U.S. Commission on Civil Rights, Racial Outcomes in Maternal Mortality in Texas (Sept. 8, 2025), available at https://www.usccr.gov/files/2025-09/tx-sac-report-on-maternal-mortality.pdf

[104] Stages of Pregnancy, Osmosis, https://www.osmosis.org/answers/stages-of-pregnancy

 (last visited Dec. 15, 2025) (describing the first, second, and third trimesters of pregnancy and corresponding fetal development).

[105] Rural Texas Maternal Health Assembly, 2025 Rural Texas Maternal Health Rescue Plan (Nov. 2024), https://architexas.org/programs/maternal-health/rural-texas-maternal-health-plan-2025.pdf

[106] Governor Greg Abbott, Press Release, Statement on U.S. Supreme Court Decision to Overturn Roe v. Wade, Tex. Governor’s Office (June 24, 2022); Governor Greg Abbott, Press Release, Governor Abbott Signs Life of the Mother Act in Austin (Aug. 19, 2025).

[107]See Klibanoff, supra note 94.

[108]See González, supra note 60.

[109] Greg Abbott, Governor Abbott Delivers 2025 State of the State Address (Feb. 2, 2025).

[110] Office of the Tex. Governor, Governor Abbott Announces Over $6 Million in Grant Funding for Rural Hospitals (Apr. 2, 2025).

[111]Id.

[112]Id.

[113] Governor Greg Abbott, Press Release, Governor Abbott Signs Rural Health Sustainability Legislation (Sept. 9, 2025).

[114] Concordia University Texas, States With the Biggest Discrepancies Between Urban and Rural Healthcare Access, ABSN (2025); Kristin Liao & Katherine Sypher, Rural Health and Hospitals: A Focus on Texas, APM Research Lab (Dec. 21, 2021), https://www.apmresearchlab.org/rural-hospital-closures

[115]Id.

[116] ACOG Practice Bulletin No. 183, Postpartum Hemorrhage (2017).

[117]See Tex. Health & Safety Code § 171.202(3) (stating that Texas has a “compelling interest” in protecting “the life of the unborn child”); Tex. Health & Safety Code § 170A.002(a) (prohibiting abortion except in narrow circumstances).

[118] Pew Research Ctr., What the Data Says About Abortion in the U.S. (Mar. 25, 2024), https://www.pewresearch.org/short-reads/2024/03/25/what-the-data-says-about-abortion-in-the-us/

[119] Karen Diep et al., Abortion Trends Before and After Dobbs, KFF (July 15, 2025), https://www.kff.org/womens-health-policy/abortion-trends-before-and-after-dobbs/

[120]See Tex. Health & Safety Code, supra note 112, § 170A.002(a).

[121] Rural Health Info. Hub, supra note 86.

[122] Am. Coll. of Obstetricians & Gynecologists, Code of Professional Ethics (rev. 2021), https://www.acog.org/about/leadership-and-governace/committees/volunteer-agreement/code-of-professional-ethics

[123] Lizzie Presser et al., A Third Woman Died Under Texas’ Abortion Ban. Doctors Are Avoiding D&Cs and Reaching for Riskier Miscarriage Treatments, ProPublica, Nov. 25, 2024, https://www.propublica.org/article/porsha-ngumezi-miscarriage-death-texas-abortion-ban

[124]Id.

[125]Id.

[126]Id.

[127]Id.

[128]See AMA Code of Medical Ethics, Opinion 1.1.1-Patient-Physician Relationships,

AM. MED. AsS'N (2001), https://code-medical-ethics.ama-assn.org/principles

[129] Rachel Zellars, Black Subjectivity and the Origins of American Gynecology, AAIHS (May 31 2018).

[130]Id.

[131]See Harriet A. Washington, Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present 207–12 (2006); Deirdre Cooper Owens, Medical Bondage: Race, Gender, and the Origins of American Gynecology 82–115 (2017).

[132]See Laura M. López, The Puerto Rican Woman and the Pill Trials 45–52 (2015); see also Angela Davis, Women, Race, & Class 202–06 (1981) (describing Pill trials in Puerto Rico and lack of informed consent).

[133]See Jane Lawrence, The Indian Health Service and the Forced Sterilization of Native American Women 269–70 (2000); see also Dorothy Roberts, Killing the Black Body: Race, Reproduction, and the Meaning of Liberty 89–103 (1997) (documenting involuntary sterilization of Black women in the U.S. South); Alexandra Minna Stern, Eugenic Nation: Faults and Frontiers of Better Breeding in Modern America 122–36 (2005).

[134] Guttmacher Institute, About Us, https://www.guttmacher.org/about

[135]See The History of the Guttmacher Institute, Guttmacher Inst., https://www.guttmacher.org/history-guttmacher-institute (last visited Mar. 31, 2026).

[136] Shmerling, Robert H., First, Do No Harm, Harvard Health Publishing (June 22, 2020).

[137] Life of the Mother Act, 89th Leg., R.S., ch. 1120, 2025 Tex. Gen. Laws 2882.

[138] Tex. Health & Safety Code § 170A.0021 (Lexis Advance through the 2025 Regular Session and the 2nd C.S. of the 89th Legislature.)

[139] Preeclampsia Found., What Is Eclampsia?, https://www.preeclampsia.org/what-is-eclampsia

[140] Texas Medical Liability Trust, Meeting the Challenges Found in Rural Health Care (2-Hour CME) (n.d.),

 (noting that “rural physicians may face a higher risk of legal liability … due ,to limited resources, staff shortages, and delayed access to specialists’ services.”).

[141] American College of Obstetricians and Gynecologists, ACOG Committee Opinion No. 815: Increasing Access to Abortion (2020).

[142]See Social Security Act § 1115, 42 U.S.C. § 1315 (2024) (authorizing demonstration projects permitting states to waive certain Medicaid requirements to test innovative program designs).

[143]See 42 C.F.R. §§ 430.10–430.20 (2024) (establishing requirements for submission and approval of State Plan Amendments to modify Medicaid program administration, benefits, and payment methodologies).

[144] Becerra, 89 F.4th 529 (5th Cir. 2024).

[145] Tex. Admin. Code §§ 165.7–165.9, Tex. Med. Bd., Exceptions to the Abortion Ban (adopted June 21, 2024), available at https://www.tmb.state.tx.us/page/board-rules

[146] Mich. Const. art. XII, § 2.

(governing citizen-initiated constitutional amendments requiring petition signatures from 10% of electors).

[147]Id.

[148] Tex. Const. art. XVII, § 1.

[149] Tex. Const. art. I, § 19.

[150] Tex. Const. art. I, § 3a.

[151]SeeIn re McLean, 725 S.W.2d 696, 698 (Tex. 1987) (ERA triggers strict scrutiny for sex-based classifications).

[152] Rural Health Info. Hub, Rural Maternal Health Overview, https://www.ruralhealthinfo.org/topics/maternal-health

 (last visited Mar. 20, 2026).

[153] March of Dimes, supra note 56.

[154] U.S. Bureau of Economic Analysis, Gross Domestic Product by State, 2023, (showing Texas as the second-largest state economy).

[155] Am. Med. Ass’n, Obstetrics and Gynecology Programs with the Most Residency Positions (updated Feb. 26, 2026), https://www.ama-assn.org/medical-students/preparing-residency/obstetrics-and-gynecology-programs-most-residency-positions

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