Amid increasingly stringent abortion laws, doctors who provide maternal care have been fleeing the state.

Eight months after the fall of Roe v. Wade, Vanessa Garcia lay on a hospital table in Texas’s Rio Grande Valley, as a technician performed an ultrasound. Garcia had given birth to two children with no complications, but her third pregnancy seemed alarmingly different. The ultrasound revealed that her placenta was covering her cervix—a condition, known as placenta previa, that heightened her risk of hemorrhage or preterm birth.

Garcia was referred to a maternal-fetal expert at D.H.R. Health Women’s Hospital, in Edinburg, Texas, and began going in for weekly ultrasounds. She approached the visits as an opportunity to catch a glimpse of her daughter, whom she had named Vanellope. Before driving to appointments, she got in the habit of drinking half a gallon of water, hoping that it would contribute to a clearer image. During scans, she gazed at the monitor, watching raptly when Vanellope lifted her hand to her eyes, as if gently rubbing them.

At the start of her second trimester, Garcia returned to the hospital and followed a now familiar routine, uncovering her belly and resting on a table. On this visit, though, the technician kept moving the probe across her skin for an unusually long time, without ever turning the monitor to face Garcia. Then she rose and left the room, without saying a word.

Alone, Garcia couldn’t resist examining the images. The baby was curled into a ball, looking eerily still. Instinctively, Garcia snapped a photo and texted it to her husband, Erick Escareño, a manager at a supermarket chain. He was checking inventory as he opened the text and told himself, “This isn’t real.” Then a doctor walked in and informed Garcia that her daughter’s heart had stopped.

Garcia was fifteen weeks into her pregnancy, and, in cases of miscarriage in the second trimester, the safest treatment is a surgical removal or a medical induction of labor. Instead, she was “discharged to home self-care,” as her chart notes. All Garcia could do was wait until she had a natural miscarriage. The thought of it terrified her. What if she hemorrhaged in the middle of the street? Or in the car, picking up her children from school? Her doctor’s only departing instructions were: if you start bleeding or develop a fever, check into the hospital immediately. (The doctor did not respond to requests for comment.)

A mournful silence settled in Garcia’s home. Escareño busied himself, but there were only so many times he could empty the trash or mow the lawn. Garcia spent most of her days lying in bed. In a corner of their bedroom sat purchases she had made for Vanellope: diapers, a snuggly blanket, and now a small urn.

Garcia’s situation was not unique. Across Texas, reports were surfacing of women being sent home to manage miscarriages on their own. In 2021, the state had passed a law known as S.B. 8, banning nearly all abortions after electrical activity is detected in fetal cells, which typically happens around the sixth week of gestation. The law encouraged civilians to sue violators, in exchange for the possibility of a ten-thousand-dollar reward.

From a medical standpoint, the treatment for abortion and miscarriage was the same—and so, even though miscarriage care remained legal, physicians began putting it off, or denying it outright. After Roe was overturned, the laws in Texas tightened further, so that abortion was banned at any phase of pregnancy, unless the woman was threatened with death or “substantial impairment of a major bodily function.” Violations could send practitioners to prison for life.

After a week of increasing pain and anxiety, Garcia noticed that her belly seemed to be flattening, and she couldn’t help wondering if Vanellope was still there. Finally, she asked Escareño to drive her to the hospital. In the emergency room, a nurse advised her just to keep waiting and “let the tissue pass.” Garcia shot back, “Tissue or baby? Law-wise, it’s a baby, but now you’re telling me it’s a tissue?”

Eventually, her family doctor referred her to another physician: Tony Ogburn, the founding chairman of the ob-gyn department at the nearby University of Texas Rio Grande Valley. Ogburn, a tall man of sixty-four, with white hair and rimless glasses, had come to the Valley eight years before, with a mission to improve health care for women. When he read Garcia’s file, he was outraged. After carrying the dead fetus for weeks, she risked needing a full hysterectomy. Why had she had to wait this long?

When they met, though, Ogburn reassured Garcia that she had options: his team could induce delivery, or perform a dilation and evacuation—a D. & E., as it’s known. The latter option was “emotionally better for most patients,” Ogburn told me. In his experience, it was traumatic enough for a mother to lose a child, without having to go through labor to deliver a corpse. “For a lot of people, the tipping point is, ‘You mean I can go to sleep, and when I wake up it’ll be done?’ ”

Garcia was torn. For weeks, she had sustained the hope of holding Vanellope at least once. But she couldn’t summon the resolve to go through labor and return home without her child. Ultimately, she opted for surgery, and the procedure was scheduled for the next day. “I’m sorry,” Ogburn told her. “You should never have gone through this alone at home.”

In the recovery room, when the anesthesia wore off after the surgery, Garcia’s eyes filled with tears. “My first thought was, She’s gone,” she said. But Ogburn had provided a memento: with her permission, he had recorded Vanellope’s hand- and footprints on a sheet of paper. “I didn’t get to carry her, but I have that part of her,” Garcia said. Back home, she put the diapers, the blanket, and the urn in storage, and replaced them with Vanellope’s prints, set in a wooden frame.

Garcia felt grateful to have been referred to Ogburn, but there were few other choices: hardly any physicians in the Valley were trained to perform a D. & E. Amid the tightening restrictions on maternal care, doctors had started leaving Texas; others were contemplating early retirement. Within a few months, Ogburn would leave the Valley, too, and the program he’d started would be shut down.

In the summer of 2016, Ogburn looked on as fifty-five student physicians lifted their right hands to recite the Hippocratic oath. They were the inaugural class at the University of Texas Rio Grande Valley’s medical school—a new facility that, in the words of university officials, promised to “forever transform the lives of our children and grandchildren.”

For years, aspiring medical students in the Valley had moved to San Antonio, or farther north to Houston, Austin, or Dallas. They rarely returned home. The United States averaged almost three hundred practicing doctors for every hundred thousand people; even in the most populous county of the Rio Grande Valley, the ratio was less than a third of that. Though the Valley included some of the poorest cities in the nation, there wasn’t a single public hospital. The school intended to turn things around. To attract residents, the administrators called in Ogburn, who had spent a career providing care in underserved places.

Ogburn had begun thinking about what doctors owed their patients before he finished medical training. As a student, in the nineteen-eighties, he served for a month at Kayenta Health Center, in Arizona. Situated on the Navajo reservation, the center served a community of about twenty thousand people. Some patients rode horses to appointments. Others—who didn’t have running water at home, much less a phone—hailed rides from strangers.

Each week, Ogburn was sent into the countryside with a translator and a nurse, who carried a list of people who had missed appointments. “We would drive twenty miles down a washboard creek bed to get to a hogan out in the middle of nowhere,” Ogburn said. “Nobody was there to make a lot of money. They were there to provide good health care.”

After finishing his residency, Ogburn moved to Gallup, New Mexico, with his wife, Jane, planning to stay a year or two. Instead, they spent six years there, and had two children. Ogburn’s next job, at the University of New Mexico, lasted almost two decades. Early on, he worked part time at a clinic on the Kirtland Air Force Base, east of Albuquerque. It was a “socialized-medicine environment,” he said. Neither he nor his patients had to worry about whether they could afford imaging tests or prescriptions—the government bore all medical costs. The university, too, used a portion of its public funding to care for the indigent. “It was a place where the social determinants of health, which we didn’t have vocabulary for back then, came into play,” Eve Espey, a longtime colleague of Ogburn’s there, said.

Ogburn conducted studies on how to improve health outcomes for women, and advocated for abortion care to be a part of every medical student’s education. He eventually became a leader of the university’s obstetrics-and-gynecology practice. In 2015, a recruiter called to tell him about the effort to build a medical school in the Rio Grande Valley. The region faced needs that were similar to New Mexico’s, but it had never had an ob-gyn residency program. Would he want to start one?

The idea was to create a practice staffed by doctors who would also teach at the med school and oversee residents at the hospital. Ogburn visited medical facilities around the country, seeking talent. His pitch was meant to counteract the stereotype of the Valley as a region defined by clashes between smugglers and Border Patrol agents—what Ogburn described as “people with machine guns driving around in pickup trucks.” But what stood out most was the moral urgency of his message. “He was the only person that talked about human rights,” Zoe Kornberg, one of the residents he recruited, said. She emerged with a galvanizing idea: “It’s a radical act to make somebody feel cared for and empower them, if they’ve never had that before.”

Most of the Valley’s population occupies a string of cities connected by Highway 83, known locally as the world’s longest main street. The region is bordered by vast ranches and fields of mesquite, as well as colonias, where thousands of agricultural workers live in trailer homes. The area is defined less by violence than by poverty: the per-capita income hovers around twenty thousand dollars a year.

Even in Texas, which has the largest share of uninsured residents in the nation, the Valley had unusually high numbers. Women suffered and died from cervical cancer at inordinate rates. One ob-gyn routinely performed surgeries on cancer patients without being board-certified in oncology. “You’re talking about a huge chunk of Texas where you didn’t have a place for physicians to pursue a medical education—nothing,” Adela Valdez, a respected doctor in the Valley, said. “It was an area that was forgotten.”

Residents and physicians around the country signed on to Ogburn’s program, convinced that he would instill a higher standard. In the fall of 2015, Ogburn and his team began working at D.H.R. Health Women’s Hospital, a sand-colored building with a colonnaded entrance. They focussed on starting the residency program and building a series of practices, including one in complex family planning, designed to treat some of the most delicate complications that arise in pregnancy. The consensus, according to Valdez, was that Ogburn would institute “the kind of health care for women that they deserved.”

At the hospital, Ogburn was a calm, observant presence. One night during my visit, he stopped by a glass-panelled room, known as the fishbowl. Inside was a wall lined with screens showing the heartbeats of mothers about to deliver. One of the lines was peaking constantly—a sign, Ogburn said, that the mother was in the middle of contractions. Right above it was the baby’s heartbeat. “If it’s wiggly and has what are called accelerations, it’s fine,” he said. “When it’s straight, or low, it might not be.” Near the center of the wall, one mother’s monitor flashed a dipping line. It was a variable deceleration, Ogburn explained, meaning that the baby was likely in the birth canal, where heart rates tend to slow. It was, in a way, a prelude to the first breath.

When Ogburn and his team started working at D.H.R., they quickly discovered that it was “practicing how most hospitals did twenty years ago,” he said. They found that episiotomies, or perineal incisions, which were regarded as an outdated practice, were not unusual there. C-section rates were high—exceptionally so among some doctors. Ogburn said that women who came to the E.R. with heavy bleeding were typically given a transfusion and then sent home, only to return later with even more severe hemorrhages. When he performed pelvic exams on a group of these women, he determined that they all had cervical cancer. (D.H.R. declined to comment on specific patient encounters but stated that it was “committed to providing prompt, compassionate care in accordance with Texas state law, maintaining evidence-based practices.”)

Ogburn’s colleagues noticed similarly troubling patterns. Jennifer Salcedo, an ob-gyn who left a practice in Honolulu to move to the Valley, recalled that early on she was rushed into an operating room where a physician had attempted to perform a D. & E. but hadn’t fully dilated the woman’s cervix—a mandatory first step. “He was just kind of standing beside the patient,” Salcedo said. “There was over a thousand millilitres of hemorrhage.” (Women hemorrhage in less than six per cent of D. & E. procedures, and when they do they generally lose only half that much blood.) Salcedo realized that the doctor had used tools reserved for an early pregnancy, even though the patient was well past the twentieth week.

When Vanessa Garcia was fifteen weeks pregnant, tests found that her baby’s heart had stopped. A nurse advised her to go home and “let the tissue pass.”

Like many other hospitals in the Valley, D.H.R. was a for-profit institution. It was also physician-owned, which meant that doctors took a cut of the proceeds—giving them an incentive to bring in patients. “Volume means money,” Ogburn said. When he began working with D.H.R., the hospital was averaging about eight thousand annual deliveries, making its maternity ward one of the busiest in Texas.

The volume of patients presented an opportunity for the new residents: the more conditions they were exposed to, the more they learned. Ogburn insured that anyone who walked in, irrespective of her ability to pay, could see a resident. “It was a win for the patient, it was a win for the residents, and it was a win for the hospital,” he said. Soon after he arrived at D.H.R., it became the first institution in the Valley to have ob-gyns on-site around the clock. In the past, doctors were hardly ever at the hospital at night, so they had to be called in for after-hours emergencies; often, they ended up just giving nurses instructions over the phone. Now if a woman’s uterus ruptured halfway through labor, there would be someone to treat her. Eventually, the hospital qualified for Level IV status, signifying that it was equipped to handle the highest-risk pregnancies.

Part of Ogburn’s goal was for residents to “serve beyond the walls of the hospital.” That included holding community health clinics and working with institutions connected with underserved populations. Among the uninsured patients who turned up at D.H.R. were referrals from Holy Family, one of the oldest birthing centers in Texas. Previously, physicians had rarely wanted to collaborate with Holy Family—midwifery was viewed in the Valley as a pseudoscience. According to Sandra de la Cruz-Yarrison, the center’s executive director, if a patient faced a life-threatening complication or received a midpregnancy diagnosis of cancer, and couldn’t afford care, there was nowhere to refer her to. “They all went untreated,” she told me. After Ogburn arrived, she said, “his support got us through that door.”

Not everyone at D.H.R. was happy about the university’s influence. According to Efraim Vela, the hospital’s chief medical officer, some saw residents as “ten-year-olds with sharp knives in their hands, running around the house.” Others rolled their eyes whenever a Holy Family patient walked through the door. “I didn’t join D.H.R. to practice at an indigent hospital,” Ogburn was repeatedly told.

The staff tried to contain these tensions, but they became harder to ignore with the passage of S.B. 8, which had the controversial provision that encouraged anyone suspecting a person of “aiding or abetting” an abortion to file a lawsuit. In some instances, nurses openly challenged doctors, invoking their right to sue. “People were so hair-triggered to be looking for a crime,” Zoe Kornberg, the resident, said.

Ogburn began meeting with patients behind closed doors and instructing his residents not to offer counselling over the phone. “You never know who’s on the other end listening,” he told them. By then, “nobody felt comfortable talking about anything,” Elissa Serapio, one of the ob-gyns, said.

The list of conditions that could be treated narrowed substantially. If a woman came to the hospital with a lethal fetal anomaly, she had no option but to carry the pregnancy to term. The outcome was traumatic for both the mother and her doctors. “Several people had babies die in their arms,” Ogburn said. Doctors were even reluctant to treat life-threatening complications such as ectopic pregnancies. “It’s the standard of care everywhere in the world,” Ogburn remembers telling an anesthesiologist. “And you’re telling me you can’t treat an ectopic?”

A majority of women didn’t know that the laws had changed, and many of those who did know were not in a position to seek care out of state. A somewhat simpler solution was to cross the border into Mexico and buy abortion pills over the counter. Misoprostol, which causes uterine contractions, often comes in blister packs of twenty-eight. Women would call the hospital to ask if the twenty-eight pills should all be taken at once. The answer was no—four was typically the recommended dosage. But even such vital counsel could now be construed as aiding and abetting.

Ogburn referred patients to his former colleague Eve Espey, who had gone on to lead the University of New Mexico’s ob-gyn department. She, too, was feeling the effects of S.B. 8: the majority of her patients now came from out of state. But it took weeks, if not months, for many women to secure the money and the free time to travel hundreds of miles for care. When patients made it to Albuquerque, Espey said, the most vulnerable of them presented hemorrhages so severe that only a hysterectomy could keep them alive.

In the coming months, a new reality set in for ob-gyns in Texas. As Ogburn told his colleagues, “The standard of care can now be construed as a felony.” Many of the doctors had moved cross-country to join him at the university, but now the law complicated their work. “I see horrible things go wrong all the time in people’s pregnancies, and the law has made it so that there’s no guarantee that the right thing can be done,” Serapio told me. Even after getting all the mandatory clearances from lawyers and administrators, she added, “you still don’t know if you’re going to have an anesthesiologist who will agree to do it. By that time, the person has bled out and could die.”

Some of Ogburn’s colleagues were applying for their board certifications in complex family planning. What if they didn’t meet the requirements after operating in such a constrained environment? Residents who were interested in family-planning programs had similar concerns. To minimize the damage for them, Ogburn reached out to colleagues around the country and found rotations in states that offered clinical abortion training, like California or Connecticut.

But the new laws were already having an effect on the health-care system. Across Texas, residency applications in ob-gyn dropped significantly. Data from the Gender Equity Policy Institute revealed a fifty-six-per-cent spike in maternal deaths in the state between 2019 and 2022. When the Supreme Court overturned Roe v. Wade, Texas was no longer an outlier; in the weeks after the ruling, thirteen states moved to ban abortion. By then, Serapio and Salcedo had already left Texas. Another ob-gyn at the practice, Pam Parker, would follow soon.

A year after the fall of Roe, Ogburn sat in his office surrounded by empty cardboard boxes, which he was filling with the records of his work in the Valley. D.H.R. was ending its partnership with the medical school. The hospital didn’t offer an official explanation, but the motives weren’t hard to guess. “Our healthcare mission no longer aligns with a for-profit, physician-owned health system like DHR Health,” the university’s president, Guy Bailey, declared at the time. The residents were dismayed. Many had purchased homes there; some had signed mortgages shortly before the decision was announced. Ogburn convened an all-hands meeting to discuss what to do.

No other hospital in the region had as high a volume of patients as D.H.R., so the program couldn’t simply be transferred elsewhere. Besides, Ogburn had already lost half his full-time faculty to S.B. 8. He spent weeks making a new round of calls to medical leaders outside the Valley, to find hospitals where his residents could finish their training. Nearly all of them would end up leaving Texas.

The clinic was uncharacteristically quiet when I visited; Ogburn had stopped seeing new patients. No one was comparing notes in the hallway or hustling from one examination room to another. The offices adjacent to Ogburn’s, which had belonged to three ob-gyns who had followed him to the Valley, were all empty. The doctors had relocated to New York, California, and Arizona. On a shelf facing Ogburn’s desk was a pile of unopened dilators, which are used to perform D. & E.s. He arranged them in a box and taped it shut.

Down the corridor, in a room ringed with computers, two residents were typing in the records of their last patients. Martha Chapa, a thirty-year-old with long brown hair, was the only member of her class to pursue a practice in Texas. Chapa had been born in the border town of Laredo, and remained committed to improving health care in the Valley.

During her youth, Chapa explained, whenever there was a family medical emergency, her parents would drive across the border into Nuevo Laredo. That’s what they had done when, as a toddler, she dropped her father’s machete on her foot, and when, years later, she developed an ovarian cyst. “I ended up having surgery in Mexico, as a medical student in the United States,” she told me. Now her parents had insurance, but it was still cheaper for them to see a doctor across the border, she said. They were the reason why her reaction to D.H.R.’s decision wasn’t “Fuck Texas, I’m out.”

That night was Ogburn’s last time on call at D.H.R. He put on scrubs and toured the hospital’s corridors. At the fishbowl, he waved to the residents, who would also be gone the next day. He and his wife had just put their house on the market. He planned to take a yearlong break, then move to San Antonio, where his daughter was doing a residency in orthopedics. He would work at a hospital there part time, caring for women who came to deliver—his version of an easy schedule.

His cell phone rang: it was Kornberg, who was also on call. A patient had come in through the E.R. with severe bleeding and cramping, but, when Kornberg asked a nurse what her cervical check had shown, she got a blank stare. The nurse admitted that she hadn’t examined the woman. Did she feel comfortable doing so? Kornberg asked. The answer was no—so Kornberg took over the patient’s care. Ogburn thanked her warmly. Neither mentioned that in twenty-four hours they would both be gone.

Close to midnight, I caught up with Kornberg. There were three women in the antepartum unit whose amniotic sacs had ruptured before the fetuses were viable, she told me. Their babies had little chance of surviving, and elsewhere the women would have been given the option to terminate their pregnancies. “I can’t do that in this state,” Kornberg said. Instead, the women were all told, “We’re going to give you these medications, to give the baby the best chance, though it may not survive.” The reality, Kornberg added, was even bleaker: “You have a baby that’s probably not going to survive, and we’re going to keep you here. And you’re going to sit alone in this room for three, four months, and maybe you’ll die of sepsis.”

Kornberg was moving to Los Angeles to finish her residency. Like the doctors who had left before her, Kornberg had come to see herself as “part of the problem,” she said. “I have the knowledge, all the support staff, everything to be able to help this person avoid one of these horrible outcomes—and they’re begging me to do it, but I’m not allowed to.” The bans felt like a personal attack, she said: “The state sees you as a felon.” When the act of caring for pregnant women in Texas could carry the same penalty as murder, the inevitable conclusion for Kornberg was “You don’t want me here? Fine, I’ll leave.”

Texas authorities are not keeping track of the exodus of doctors, at least not officially. Yet among practitioners there is a quiet sense of doom. “The pipeline is drying up,” Charles Brown, a maternal-fetal expert and a former Texas regional chair of the American College of Obstetricians and Gynecologists, said. A growing number of residents who trained in the state were leaving, Brown told me, and many established doctors were contemplating it, too. “We’re just not going to have enough people to take care of women in this state,” he said.

A report released last month by Manatt Health, a health-care consultancy based in Los Angeles, confirmed Brown’s fears. Manatt surveyed hundreds of ob-gyns in Texas to examine the impact of abortion bans. Seventy-six per cent of respondents said that they could no longer treat patients in accordance with evidence-based medicine. Twenty-one per cent said that they were either considering leaving the state or already planning to do so; thirteen per cent had decided to retire early. The report found “historic and worsening shortages” of ob-gyns, which “disproportionately impact rural and economically disadvantaged communities.” As in the Rio Grande Valley, the bans were shrinking the field’s future workforce: residency programs across Texas have seen a sixteen-per-cent drop in applications.

Texas is among the twenty-one states where abortion is banned or severely restricted. In Idaho, nearly a quarter of the state’s ob-gyns have left since the ban went into effect, and rural hospitals have stopped providing labor and delivery services. In Louisiana, three-quarters of rural hospitals no longer offer maternity care. Half a year after Ogburn left the Valley, another doctor submitted her resignation. The school’s Department of Obstetrics and Gynecology was folded into a new unit: the Division of Women’s and Children’s Health. By then, the department had shrunk to three doctors, one of whom plans to leave next spring.

After the departures, I sat down with Efraim Vela, the chief medical officer, to talk about D.H.R.’s future. A burly, clean-shaven man of seventy, with graying hair and a slight limp, Vela compared the severed relations between his hospital and the school to a tumultuous divorce. “The kids will obviously suffer,” he said.

Patients had shown up at Ogburn’s clinic only to find a closed door. Others had come for appointments and learned that the residents they knew had moved on. “They’re going to be an asset to someone else, somewhere else,” Vela said, fighting tears.

After more than four decades of practicing in the Valley, Vela understood that it was singularly difficult to draw people there. Ogburn had managed to do it, and, Vela said, doggedly, “I’m hoping to rebuild.” D.H.R. had attempted to start its own ob-gyn residency program twice since Ogburn’s departure, and on the second attempt the organization that accredits such programs had approved the application. Even so, it would be five years before the residents could graduate and start a practice in the Valley.

Until then, with the residents gone and so many specialists departed, it was unclear how high-risk pregnancies would be handled at D.H.R. Vela had initially asked seven doctors to take turns covering night shifts, and then brought in a hospitalist to work full time. D.H.R.’s Level IV status is set to expire next year, but Vela was adamant that the hospital would not lose it—“as long as I sit here,” he said, gripping the sides of his chair. Where, I wondered, would uninsured patients turn now? Vela said that D.H.R. was still accommodating those with Medicaid, and doing what it could for the rest. But, he concluded, echoing the most skeptical voices at D.H.R., “we can’t run a charity hospital.” ♦

https://www.newyorker.com/magazine/2024/12/02/the-texas-ob-gyn-exodus