After a hospital stopped delivering babies, Deep East Texas faces a growing maternity care crisis

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This reporting was supported by the International Women’s Media Foundation’s Reproductive Rights Reporting Fund.

JASPER — Ginger Kalafatis burst through the doors of Jasper Memorial Hospital, straight into her worst nightmare.

It was Labor Day 2019 when two women showed up at the hospital, ready to give birth. Kalafatis, a longtime labor and delivery nurse, assessed the situation, her heart racing. One woman was delivering prematurely; the other had previous cesarean sections and no prenatal care.

This shouldn’t have been difficult. For 50 years, the labor and delivery unit at this small rural hospital near the Louisiana border had helped women safely bring their babies into the world.

But not anymore. Just three days prior, hospital administrators closed the unit, intending to get out of the business of delivering babies.

Kalafatis knew these women needed the higher level of care provided by a labor and delivery unit. But the closest facility was an hour away. Even by ambulance, even by helicopter, she worried about the risk to four lives if the hospital tried to transfer them.

Briefly, Kalafatis let the anger in. She’d tried to warn about the consequences of losing the last labor and delivery unit in this five-county region larger than the state of Connecticut. Now, just as she’d predicted, lives were on the line.

But anger wasn’t going to deliver these babies. Kalafatis took a deep breath and got to work.

The hospital was able to safely transfer one of the women. But the other was too far along. She would have to deliver vaginally in the emergency room, a potentially risky proposition after having had previous C-sections.

A spokesperson for Christus Health, the hospital system that operates Jasper Memorial, declined to comment on this case, citing patient privacy concerns.

As Kalafatis prepared this woman for labor, she heard voices she recognized — family physicians who had delivered babies at this hospital for years. These women weren’t their patients, “but of course they came,” she said.

“Someone called them, so they came,” she said. “That’s just what you’d do in Jasper.”

Together, doctors and nurses safely delivered the baby. Kalafatis left the hospital that day, relieved. Surely now, she thought, hospital administrators would see how desperately her community needed a place to give birth. They would find a way to recruit more physicians, better staff the hospital, and turn the lights back on.

But more than three years later, the unit remains closed. Jasper Memorial Hospital has joined the 60% of rural Texas hospitals that no longer deliver babies, leaving this corner of the state a virtual maternity care desert.

Women instead travel over an hour to Lufkin or Beaumont. To get there, they drive past Jasper Memorial Hospital, where, until recently, there was a sign out front warning about the lack of obstetrics services before they even got a chance to set foot inside.

Welcome to Jasper

Jasper is connected to the rest of the world by a two-lane highway, flanked by pine trees growing so close to the road they seem intent on reclaiming it. Gaps in the thicket reveal sparkling lakes, wide fields and, all of a sudden, a town of about 7,000 people.

Jasper is a place where money once grew on trees. While log-laden trucks still lumber through town, this region, like many rural areas, has struggled to recover from the Great Recession and now the pandemic.

Even as the “jewel of the forest” has lost some of its sparkle, Jasper remains an economic hub, saving residents of surrounding counties the hour long trip to Lufkin or Beaumont for shopping and dining. Jasper has the Walmart and a Lowe’s, hotels, restaurants, banks and, most important, a hospital, greeting people as they drive in on U.S. Highway 190.

The wide, low-slung building was built in the late 1960s, after the Texas Legislature created the Jasper Hospital District, a locally elected board empowered to raise taxes to fund the creation, care and upkeep of a new hospital.

Kalafatis’ parents worked in health care and moved to Jasper to help open the new facility. In December 1968, Kalafatis was born at the old hospital, a two-story storefront downtown that now serves as the county health district. Soon after, Jasper Memorial Hospital opened its doors and started delivering babies.

Kalafatis grew up in the halls of Jasper Memorial. She shadowed her mother, a nurse anesthetist, and attended her first C-section when she was in eighth grade. Friends and neighbors would approach her parents at high school football games with medical questions.

“I’ve been connected to that hospital all my life,” she said. “I have more than just a clinical interest in the building. It’s my family. It’s my heritage.”

That connection, though, came with a front-row seat to the health care inequities that have long plagued East Texas — the preventable illness, injury and death the rest of the state seems content to leave hidden behind the Pine Curtain.

If this 35-county region was a state, it would rank among the worst in the nation for heart disease, cancer and stroke mortality, according to analysis from the University of Texas at Tyler.

East Texas is older, sicker and poorer than the rest of the state. While Texas ranks 24th among states for overall mortality, this region alone would rank 44th.

Since Texas is in the tiny minority of states that haven’t expanded Medicaid, a staggering number of adults in East Texas cannot easily access preventive care, manage chronic conditions or treat anything short of their most urgent medical needs.

Medicaid does make it easier for pregnant Texans to get health insurance — at least 70% of births in this region are paid for by Medicaid, according to the Lufkin-based T.L.L. Temple Foundation, compared with about 53% of all births in Texas.

But a third of pregnant women in this region don’t see a doctor until at least the second trimester. Lack of prenatal care worsens other pregnancy risk factors, including the region’s high rates of smoking, obesity and diabetes.

Kalafatis saw it all when she graduated from nursing school and returned to the area. Women showed up for the first time nine months pregnant. Or they were diagnosed with gestational diabetes and weren’t seen again until it was time to deliver. She saw preeclampsia, premature babies, tiny high school freshmen preparing for childbirth.

She helped deliver them all.

“Nurses don’t judge, we really don’t,” she said. “We live here too. We know how hard it is to get prenatal care, to get time off work and get to those appointments. We know how far these women have to travel.”

And it’s only gotten worse over the course of her career. Texas, a mecca of world-class hospitals and cutting-edge care, has allowed rural health care in communities like Kalafatis’ to wither into nothing.

Jasper County has lost three hospitals since the mid-1980s. Newton County, next door, hasn’t had a hospital in three decades. In 2013, a few weeks after a hospital in nearby Shelby County closed, an 18-month-old choked to death on a grape while her parents frantically searched for medical care.

Other hospitals remain open but have been stripped of anything resembling comprehensive care, forcing people to weigh their health needs against lengthy drives, the cost of gas, and the ability to find child care or get time off of work.

Jasper Memorial Hospital was not immune to the forces that felled its neighbors. In the late 1990s, the fragile economics of rural health care, combined with financial mismanagement, threatened the hospital.

At the time, health care chains were snapping up independent hospitals nationwide, promising stability through streamlining services, reducing overhead costs and balancing the books on the back of more profitable services at larger facilities.

In 1997, the Jasper Hospital District voted to lease the hospital to Sisters of Charity of the Incarnate Word. The Texas-based Catholic hospital system would pay the hospital district more than half a million dollars a year for the next decade, with the sole option to renew for up to an additional 15 years.

Kalafatis was excited about the change. She went to nursing school at what is today University of the Incarnate Word in San Antonio, and she liked the nonprofit’s mission to “extend the healing ministry of Jesus Christ.”

Soon after taking over Jasper Memorial, Sisters of Charity merged with another Catholic system to become Christus Health, at the time one of the 10 largest Catholic health systems in the country.

Today, Christus is a billion-dollar health care conglomerate, with facilities in three states and four countries, including a hopscotch up the length of East Texas, from Beaumont to Texarkana.

In 2020, the CEO made $13.5 million in salary and other compensation. The president of Christus Southeast Texas, the Beaumont subsidiary overseeing Jasper Memorial Hospital, made more than $1 million in total compensation in 2021.

Seemingly overnight, Jasper Memorial went from a community hospital to a cog in a much larger system.

For one thing, Christus would not “provide services inconsistent with its values, especially in the areas of respect for life,” the lease said. The U.S. Conference of Catholic Bishops prohibits Catholic hospitals from providing abortions, prescribing contraception, or performing tubal ligations or vasectomies.

A spokesperson for Christus declined to confirm executive salaries or the hospital’s contraception policy, saying these are “new issues [that] have been unfairly raised by the Tribune that we believe are not relevant to this situation.”

“CHRISTUS Health is a values-based organization, and patient care decisions start with a patient-centered focus involving the patient and how best to deliver safe and quality care to the communities we are fortunate to serve,” said spokesperson Leigh Strope, in a statement.

Leasing the hospital to Christus came with trade-offs. But it allowed Jasper to remain an obstetrics oasis in an increasingly arid health care desert.

The disappearing family physician

Ron McMurry grew up in Jasper, where his family has lived since the days when Texas still belonged to Mexico. McMurry’s father, a pipeline foreman, was never able to afford health insurance for his wife and six children.

McMurry remembers, as a child, seeing his mother turned away at the doctor’s office because she couldn’t pay upfront. Years later, while serving as an army medic, McMurry was reminded of that experience when he helped reopen an old hospital in rural Vietnam.

“I’ve seen what can be done in isolated areas with just minimal resources,” he said. “I learned then that if people have an intent to do something, they are capable of doing it.”

After medical school, McMurry returned to Jasper. He opened his family practice and vowed to never turn someone away because they couldn’t pay. He served a stint as director of the Jasper Newton County Public Health District, expanding access to prenatal care, and was elected to a term on the hospital district board.

“We had a lot of problems in rural areas at that time, some of which were worse than Third World countries as far as access,” McMurry said. “So I just tried to do whatever I could to address that as much as I could.”

As a rural doctor, McMurry did a little bit of everything, caring for friends and neighbors from the time they were born to the day they died. He was, at certain points during his career, one of the only doctors delivering babies in a seven-county region. Some women traveled more than three hours to Galveston, hoping they wouldn’t deliver on the ferry.

He estimates he’s delivered just over 1,000 babies.

“At one point, I had 11 women in the hospital in labor at once,” he recalled. “I don’t know how I got through that, but I did.”

As family physicians like McMurry will tell you, theirs is the only speciality that provides comprehensive health care to the entire patient population — young, old, male, female, anyone who walks in the door. Family physicians are certified to deliver babies vaginally or by C-section.

Family physicians are often the entire health care system in rural areas where the patient load can’t sustain a wide range of specialists. A patient in Houston may see half a dozen specialists for the same services provided by one physician in Jasper.

But full-scope rural family physicians like McMurry are a dying breed, or at the very least, a retiring breed. McMurry, now 74, hung up his white coat in 2008 and closed his private practice.

“We have always had a physician shortage out this way,” he said. “But things really became critical as physicians grew older and retired, or left the area. We lost services, primarily because we did not have a good physician recruitment effort.”

It’s not just Jasper: The entire country is facing a critical shortage of primary care physicians. In 2021, only five Texas counties had enough primary care physicians by federal standards, down from 34 counties in 2019, according to the APM Research Lab.

Why is not a mystery.

Family physicians treat a wider range of patients but earn, on average, 40% less than specialists. In rural areas, family physicians may have fewer resources and less support as they try to care for an older, sicker, poorer client base.

“We’ve got really passionate, really smart people in family medicine,” said Emily Briggs, a family physician in New Braunfels and president of the Texas Academy of Family Physicians. “We just have very few compared to what we need, because family medicine is not paid appropriately compared to other specialties.”

Over the years, Texas has tried to lure more medical students into rural family practice with residency programs and physician loan repayment. But these long-term investments are frequent targets for budget cuts. When the Legislature eviscerated the funding for these programs in 2011, the president of the Texas Medical Association at the time issued a dire warning.

“You’re not going to see [it] immediately, but nine years down the line … you’re really going to feel the effects,” Dr. Bruce Malone told The Texas Tribune in 2011.

He was right. More than a decade later, Texas’ family physician pipeline is significantly clogged, with rural areas feeling the effects most acutely. And when rural hospitals have to make tough decisions about scaling back services, obstetrics is often first to go.

A rural hospital can bring in a cardiologist weekly or monthly, depending on demand. But an obstetrics unit has to be staffed around the clock, with at least two nurses and a doctor on call.

“If you have one or two doctors on call 24/7, and they take a vacation or aren’t available, that hospital can’t provide obstetrics services,” Briggs said.

Facing that difficult math — fewer physicians and diminishing births, as well as nursing shortages, skyrocketing costs and reduced reimbursement rates for Medicaid births — many hospitals just close the unit.

When McMurry retired, he was confident that the remaining doctors would allow Jasper Memorial Hospital to keep delivering babies. But over the next few years, he started to hear rumblings that they were getting burned out and thinking about stepping back.

McMurry hoped Christus would wield its vast resources to recruit more doctors and lighten the load. Kalafatis said word around the hospital was that management was working on recruiting an obstetrician. But Christus determined there wasn’t enough demand for a full-time OB-GYN, hospital administrator Wayne Moore said.

The cavalry wasn’t coming, so in 2018, McMurry took matters into his own hands and ran for the Jasper Hospital District board. A born rabble-rouser, McMurry immediately began haranguing his fellow board members about the physician shortage. When he didn’t get the response he hoped for, he went to the press.

McMurry warned in a 2018 op-ed that two area doctors, a married couple, were planning to resign at the end of the year and that Christus was going to close the obstetrics unit.

“The loss of appropriate health care services means fewer people will retire here, fewer businesses will relocate here, and the population will be spending hours on the road for basic health needs,” McMurry wrote. “As it happened with the ancient Greeks, we will slowly slip into a downward spiral of decay.”

Moore dismissed McMurry’s concerns, writing in a counter op-ed that Christus was working closely with its physician partners to continue to provide “these valuable services.”

“We have no intention of stopping the provision of obstetrical (OB) services to those expectant moms and their families,” Moore wrote in November 2018.

Moore, a 30-year Christus Southeast Texas employee, came to Jasper Memorial after serving as vice president of clinical operations and leading the now-shuttered Christus hospital in Port Arthur. Last year, he earned more than $400,000 in total compensation.

In a recent interview, Moore said that at the time, the hospital was offering doctors $1,000 a day to take on-call labor and delivery shifts. But after two of the doctors resigned, it became impossible to keep the unit staffed.

“We can’t do it without physicians, regardless of how much we wanted to have OB,” Moore said.

In August 2019, Jasper Memorial Hospital closed its labor and delivery unit, consigning women in deep East Texas to drive over an hour to give birth. Along the entire eastern border of the state, between Texarkana and Beaumont, there is nowhere to have a baby.

“I think [Christus] does a good job, but they’re a multistate, international health care organization,” McMurry said. “When they get a new physician, they go to where their system needs them the most. I guess that just wasn’t Jasper.”

When McMurry first started practicing medicine in Jasper 40 years ago, he thought he was helping the region build a foundation for a better future. He never imagined that decades later, pregnant women would be in the same position they were when he started out, driving through the forest for health care they’ve been denied in their hometown.

“It’s sad when you realize that someone that goes into labor in Jasper County has to travel 50, 70 miles to deliver,” he said. “That is a public health hazard in and of itself.”

Lives on the line

As soon as Chloe Walker saw blood and mucus in the toilet, she knew something was wrong.

Walker had been braced for this moment for weeks. After she’d started prematurely dilating, the 18-year-old spent the final months of her senior year of high school on bed rest, trying to hold off labor long enough for her baby to have a chance of surviving outside the womb.

But now she’d expelled her mucus plug, which can be an early sign of labor.

“I called my mom into the bathroom, and she was just like, ‘Don’t freak out,’” Walker said. “But the way she said it sort of freaked me out even more.”

Walker lives in Newton County, Jasper’s even more sparsely populated neighbor. Newton doesn’t have a full-scope family physician, so normally, she drove 20 minutes to Jasper for health care. But now, she was driving close to 90 minutes to Lufkin every time she needed a checkup — or worried she might be going into labor.

The on-call nurse at the hospital in Lufkin said she should wait to see if she started to contract, and then wait even more, until contractions were three to five minutes apart, Walker recalls.

“I was just like, ‘Excuse me?’” Walker said. “I am expected to go into preterm labor, I am already 2 centimeters dilated and I am an hour away from the hospital. I can’t wait until I’m three to five minutes apart.”

While Walker sat in the bathtub, practicing her deep breathing, her then-fiance started throwing their bags in the car. He was the one who would have to drive her over an hour through a national forest with no cell service to the nearest hospital, and as he often reassured her, he was prepared to drive 110 miles an hour to do so.

This anxiety had permeated her entire pregnancy. She was always scrambling for gas money or borrowing her grandmother’s car to make the 140-mile round trip. She worried constantly about going into labor and having to give birth on the side of the road.

After one labor and delivery unit in Minnesota closed, pregnant women in the area reported a tenfold increase in anxiety, which can lead to miscarriage, low birth weight and birth complications.

As time passed and her panic subsided, Walker realized she wasn’t contracting. Part of her still wanted to go to the hospital to make sure she and her baby were OK. But she had another appointment coming up, and she couldn’t justify making the trip twice in a matter of days.

When she did go into labor, several weeks later, she was already in Lufkin for a checkup. Her location proved lifesaving: The umbilical cord was wrapped around her daughter’s neck three times. Every time Walker contracted, her daughter’s heart rate plummeted. With trained medical staff on hand, Walker delivered safely and took her daughter home a few days later.

Her daughter is now almost a year and a half and, according to Walker, quite the handful. Her husband says he knows where she gets it from.

“He always says that’s why she has a bad attitude, because I was so anxious all the time when I was pregnant with her,” she said.

Dr. Jerry Johnson, Walker’s OB-GYN, sees this anxiety every day. His practice at Woodland Heights Medical Center in Lufkin saw an increase in patients since Jasper’s unit closed, but it’s nothing new — several surrounding communities lost their obstetrics units in recent years.

Many of his patients come from over an hour away.

“They just have no other choice now,” he said. “We just have to work really hard to educate them on what to expect and when to come in.”

With an uncomplicated pregnancy, Johnson said, he typically schedules an induction to save a stressful, mid-labor drive through the forest. Woodland Heights also recently opened a women’s clinic in Jasper, staffed with a nurse practitioner who can provide prenatal care closer to home.

But Lufkin, a city of 35,000 people, is facing the same challenges as Jasper. Several area obstetricians, including Johnson, are closer to retirement than residency. Johnson said they’ve had no luck replacing an OB-GYN who left over a year ago.

“It seems like when physicians finish residency, they are not looking for a small community,” he said. “If you go to Houston, you work in a big facility, you have an in-house [maternal-fetal medicine specialist], in-house hospitalists, you can go home at 5 p.m., turn off your pager and sleep all night.”

Johnson, on the other hand, takes most of his own calls. It’s fine, he said, since he lives near the hospital. Like many rural practitioners, Johnson was looking for community-centric care when he set out, and he feels his mission ever more acutely as services dry up across the region.

John Henderson, CEO of the Texas Organization for Rural and Community Hospitals, said this is their pitch to young doctors.

“If you’re getting into medicine to serve people and work where you’re needed, I’d make the argument that you’re needed much more desperately in these communities than in downtown Houston,” Henderson said. “It’s pretty simple: We can’t do it without you.”

Without an influx of doctors to deliver babies, pregnancy will only become more dangerous than it already is in a country that ranks worst in maternal mortality among developed nations.

Women in Texas are more likely to die from pregnancy or childbirth compared with the U.S. overall. Black women are particularly at risk: In 2013, Black women accounted for 11% of live births in Texas but 31% of maternal deaths. Those trends have persisted since.

Black women in Deep East Texas know the risks of pregnancy because they’ve heard the stories from their mothers, sisters, friends and neighbors. Destiny Williams tells anyone who will listen about her experience, in hopes it might save another life.

Williams, 24, lives 20 miles north of Jasper. She delivered two babies at Jasper Memorial, but when she went into labor with her third child last year, she had to make the hour long drive to Lufkin.

She made it in time and delivered safely. As she prepared to head home, she stood up from the bed and picked up her new baby girl.

“And it was all of a sudden like a murder scene,” she said. “Just blood everywhere.”

Williams was hemorrhaging. Doctors and nurses rushed in and got her on the bed as her blood pressure dropped. They pressed on her stomach so hard it felt like she was in labor again, she said, and pumped her with medicine to stop the bleeding.

“I thank God I had some good nurses that knew what they were doing,” she said. “I didn’t have to have a blood transfusion, and I didn’t lose my life.”

Obstetric hemorrhage is the leading cause of maternal death in Texas, particularly among Black women. While complications from obstetric hemorrhage declined in Texas in recent years, Black women saw a nearly 10% increase.

Like many postpartum complications, hemorrhage doesn’t always happen immediately. Nearly a third of maternal deaths occur more than a month after childbirth, according to state data.

“Thank God I was still at the hospital because if I would have made it home and did that, and had to drive all the way to Lufkin, I probably would not be here right now,” Williams said. “I would have lost so much blood just on the drive.”

When she looks at her three children, it’s sometimes too much to even imagine what could have happened.

“I think I’m done having kids,” she said.

These are the fears women in Deep East Texas live with every day, shaping their decisions about pregnancy, childbirth, family and their futures. There’s the foster mother who stopped taking in pregnant teenagers, the midwife who worries about her clients needing emergency care. It’s even changed how the area tries to recruit new businesses to town.

Eddie Hopkins, executive director of the Jasper Economic Development Corporation, wants to attract major employers, and their young employees. He thinks he’s got a good pitch: cheap cost of living, beautiful surroundings, a warm, tight-knit community.

“But the first thing they ask, almost always, is about schools and health care,” Hopkins said. “I just have to be honest with them. And I personally cringe thinking about going through two pregnancies with my wife, and could we have made it to Beaumont? Could we have made it to Lufkin?”

Mary Goodwin, director of nursing for Jasper Memorial Hospital, said the hospital is equipped to deliver babies and provide lifesaving care in the emergency room. But its priority is serving the community as it exists today.

“I don’t think the hospital can drive growth in population or anything like that,” she said. “We have … a very high geriatric population, and so I think we respond to the needs as we see them with what we have.”

Goodwin said the hospital’s role is as a safety net, a place to stabilize patients until they can get to a bigger facility for more significant care.

Ask around town, though, and that’s not what most people in Jasper want. They want a community hospital providing comprehensive care, from birth to death and everything in between. They want a hospital worthy of the “jewel of the forest,” and the people who live there.

Without that, it’s hard to know what the future of Jasper looks like. This is the existential question facing rural communities across Texas as they fight to stave off extinction: Without a place to give birth, what’s left but to die?

Stabilizing the system

When the labor and delivery unit closed in 2019, McMurry felt like the community was finally waking up to the health care crisis he’d been warning about for years. He used that outrage to recruit candidates for the first competitive hospital district board elections in years.

“The real solution is where the problem is,” McMurry said. “It’s with the people that are suffering, and getting them to believe that they can do something, and then getting them the resources to do it.”

The hospital district has resources — 20 years of rent payments from Christus translates to about $10 million in the bank, according to the board’s executive director. The new board is batting around big ideas, like partnering with another health care system or opening a birthing center, where midwives and nurse practitioners can deliver uncomplicated pregnancies.

For McMurry, the answer is simple, if not easy.

“We’ve got a place to practice. We’ve got patients,” he said. “We have everything but the doctor.”

But it’s a tough sell. To avoid the on-call burnout that closed the unit in the first place, Jasper will need to recruit several physicians willing to deliver babies — on the promise that, one day, there will be a place to do so.

There is some hope on the horizon. The T.L.L. Temple Foundation is helping fund three medical residency programs in East Texas, hoping to flood the region with new doctors.

“Most providers will stay within about 50 miles of where they do their residency,” said Kevin Lambing, the T.L.L.Temple Foundation’s senior program officer for health services. “But 90% of residency programs are in urban areas. So bringing the programs to our rural counties is going to help us have more providers.”

In five years, Lambing said, those programs will graduate 72 new physicians. The foundation is also funding loan forgiveness for those who stay in the region.

“If I can get you here for two years of training, then I get you here for four more years because I’m paying off your student loans … you’re probably going to stay here, right?” Lambing said. “If we keep even 50% of them, that’s 36 doctors we didn’t have before.”

McMurry is thinking even longer term, starting with high school and college students from the area.

“Getting your homegrown people to go to medical school and come back to practice is … really the only system that works on a permanent basis,” he said. “They may just need some financial support, so we’d be negotiating with them to make sure that their dreams can be made to come true.”

McMurry is optimistic about the long-term future of obstetrics in Jasper. But he knows none of these efforts, no matter how successful, will help this generation of pregnant women.

This is part of why some rural hospitals still deliver babies — as hard as it is to keep going, it’s nearly impossible to restart once they’ve stopped.

“They don’t do it because it’s profitable,” said Henderson, with TORCH, the rural hospital organization. “They do it because people need them.”

But it’s getting harder to hold on. Federal COVID-19 funding helped shore up rural hospitals, but workforce shortages and surging costs predict a bleak few years. According to a consultant’s report commissioned by the Texas Hospital Association, as many as 1 in 10 Texas hospitals may be on the brink of closure.

“It will probably, unfortunately, never get back to where it was previous to the pandemic,” said John Hawkins, THA president and CEO. “Right now, we’re just focusing on trying to stabilize the system.”

Stability takes money, Hawkins said — money for hospitals, money for doctors, money for nurses.

Texas has money: a $27 billion surplus this legislative session. Even a sliver of that pie would help maintain and possibly restore health care services to desperate regions, rural health advocates say. Many promising programs already exist, like loan forgiveness, medical education and enhanced Medicaid reimbursement for rural areas.

They just need to be consistently and significantly flooded with money.

In the last two sessions, the Legislature appropriated what amounted to an additional $500 reimbursement for each rural Medicaid birth, Henderson said.

“We are appreciative of that appropriation,” he said. “But if $500 helps, imagine what a difference $1,000 would do, for example.”

The biggest thing legislators could do, advocates say, is make it easier to get health insurance. While the Republican-dominated Legislature is unlikely to expand Medicaid, there is momentum around allowing women to stay on postpartum Medicaid for a year after childbirth, a leading recommendation to reduce maternal mortality.

The proposal passed in the House last session but was knocked down in the Senate. Republican House Speaker Dade Phelan, who represents the Jasper area, has said it remains a top priority, especially in light of Texas’ new, near-total bans on abortion.

“The Senate refused that proposed extension for vulnerable mothers who chose life, so ultimately we landed on extending coverage to six months,” Phelan told ProPublica and The Texas Tribune in July. “The Texas House has and will continue to make certain that we support Texas women and children.”

On the recently and radically redrawn reproductive health care map, Deep East Texas has ended up particularly isolated. It’s surrounded by abortion bans in Louisiana, Texas, Arkansas and Oklahoma; the nearest abortion clinic is nine hours away, in Wichita, Kansas.

Republican lawmakers have vowed to support all the new babies born as a result of these bans — and the women who will bring them into the world. But even in this deeply conservative corner of the state, the last few years have left little patience for promises.

“I am so totally pro-life,” Kalafatis said. “But that’s not where the responsibility ends. We have to help these women throughout the pregnancy and after they give birth, and a big part of that is them having a place to give birth.”

“That’s just the bare minimum,” she said.

More than three years after Jasper Memorial Hospital closed its labor and delivery unit, Kalafatis is still grieving the loss. When she sees a pregnant woman in line at the grocery store or walking around Lowe’s, she’ll ask where she plans to deliver.

“They say Lufkin, or Beaumont, and it breaks my heart a little,” she said.

Sometimes, during the conversation, Kalafatis realizes she helped deliver the woman’s other babies, or her nieces, or sometimes the woman herself. She misses these “grand-deliveries” the most, helping bring multiple generations of new life into her community.

She’s still hopeful the hospital will restore obstetrics services one day. She’d come back in a heartbeat if they did. With one foot always in Jasper, she’s struggled to find solid work since the unit closed.

Recently, though, Kalafatis got hired as a labor and delivery nurse at a Christus hospital in Tyler, three hours away. She can’t help but think about all the people in Jasper who provide health care, and all the people who need health care, and all the driving they’re all doing these days.

As she makes her weekly pilgrimage through the forest, she says a little prayer for the mothers, the babies and her hometown — may they be safe and may they survive.

Reporters Pooja Salhotra and Sneha Dey, video journalist Jinitzail Hernández and data visualization fellow Caroline Covington contributed to this story.

Disclosure: The T.L.L. Temple Foundation, Christus Health, the Texas Hospital Association, the Texas Medical Association, the Texas Organization for Rural and Community Hospitals, and Walmart Stores Inc. have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune’s journalism. Find a complete list of them here.