Maternal healthcare deserts in West Texas

Abstract

Objective: Hospital and obstetric unit closures in U.S. counties often lead to expansion of maternal healthcare deserts, defined as counties without a birth center offering obstetric care. This study describes the maternal demographic profile and geographic scarcity of obstetric care across the large and sparsely populated west Texas region.

Materials and Methods: Aggregate population data are obtained from the U.S. Census and American Community Survey. Maternal healthcare centers for 107 counties across west Texas, defined here as public health regions 1, 2, 9, and 10, are identified using data from the Texas Collaborative for Healthy Mothers and Babies.

Results: Across west Texas, 76 of 107 counties are maternal healthcare deserts, with no available obstetric care. Approximately 82,000 women of childbearing age live in these counties, with about 5,000 reporting having given birth in the past 12 months. Level II or higher obstetric care is available in just 12 (about 11%) of west Texas counties.

Conclusion: A majority of rural counties across the large geographic area of west Texas lack labor and delivery services, leading expectant mothers to travel to neighboring counties for obstetric care, or further for high-risk care. Greater coordination between higher level maternal care centers and rural hospitals and providers, as well as telehealth and community health worker outreach, may provide some level of connection to obstetric services for women in rural areas.

Introduction

Rural hospital and obstetric unit closures in U.S. counties, typically driven by financial pressures, workforce shortages, and low patient volume, often lead to expansion of maternal healthcare deserts, defined as counties without a birth center offering obstetric care^{1, 2)}. This phenomenon most acutely impacts rural counties served by a single hospital, such that a single closure forces women to obtain all maternal care services in another county. The U.S. average for distance to obstetric care services is 8.1 miles, compared to 28.1 miles for women in maternal care deserts¹⁾.

As of 2018, over half of rural U.S. counties are estimated to lack obstetric services³⁾. Births in rural counties with hospital obstetric unit closures have been associated with increase in preterm births and births outside of a hospital, and a roughly 3% increase in births at a hospital without an obstetric unit. These effects may be more pronounced in rural counties that are not adjacent to an urban county⁴⁾.

Approximately 8.1% of Texans, or 2.4 million, live in the state’s 181 rural counties⁵⁾. Although population change in many of these counties is stagnant or declining, women who reside in rural counties more often have children, and a higher number of children, compared to women in urban counties⁶⁾. Rural hospital births are more often attended by a family physician than an obstetrician/gynecologist, but notably, even family providers may encounter significant barriers to offering obstetric care, as liability insurance may be double that of a family physician offering no obstetric care⁷⁾.

West Texas is a large geographic region in the second largest U.S. state, both by area and population. The expansive size of Texas, combined with the concentration of population on the eastern half of the state, results in a large geographical area with relatively few residents and limited healthcare access. Although national studies have mapped maternal healthcare deserts in the U.S., this report focuses on highlighting the population profile of west Texas of west Texas women of childbearing age.

Materials and Methods

Data for this study are derived from multiple sources. Maternal health deserts are identified using the map of maternal care centers from the Texas Collaborative on Healthy Mothers and Babies⁸⁾. This resource identifies four levels of maternal care centers across Texas, as defined by Texas Administrative code. Level I maternal healthcare facilities offer healthcare services to pregnant and postpartum women who are deemed low risk and employ a skilled staff who maintain up-to-date training⁹⁾. Level I facilities must transfer patients to a higher level of care if risk is deemed to be greater than the capacity of their facility⁹⁾. Level II facilities provide care for pregnancies triaged as low-to moderate-risk and must have an available physician with obstetrics training within 30 minutes of the hospital at all times⁹⁾. Level III facilities must have capacity to provide care to high-risk obstetric patients, including provision of intensive care services, and must maintain a clinical staff comprised of a wide range of subspecialists⁹⁾. Level IV represents the highest level of maternal healthcare facility and requires the facility to maintain staff and infrastructure to handle the most complex and high-risk maternal and fetal cases. These facilities must provide capacity for major surgery and intensive care, maintain a Maternal Fetal Medicine Critical Care Team, and often serve as referral centers for area hospitals^{6, 9)}.

Population and geographic estimates are obtained from the U.S. Census, Texas Demographic Center, and American Community Survey^10,11,12). Although the demographic grouping for women of childbearing age is often reported as ages 15–44, the U.S. Census provides estimates for women ages 15–50, which is used for this study.

Rural counties are defined using U.S. Office of Management and Budget (OMB) categories of micro-areas and counties outside of metro or micro areas, i.e. counties with a population under 50,000¹³⁾. This definition separates the 9 west Texas counties that contain the 8 largest regional hub cities from the other 98 counties, categorized as rural. The smallest urban county, Tom Green, contains 120,397 people, whereas the largest rural county, Brown County, contains 38,621 people. The city of Amarillo spans two counties, Potter and Randall, and although both hospitals offering obstetric services are located at the southern edge of Potter County, we do not categorize Randall County as a maternal healthcare desert because it is served by those hospitals.

This study examines Texas Public Health Regions 1, 2, 9, and 10, which cover the majority of the area traditionally considered to be west Texas¹⁴⁾. This report used aggregate U.S. Census data and did not require Institutional Review Board approval. County mapping is performed using the “spmap” program in Stata 16.1^{15, 16)}. Texas GIS files were obtained from Texas Tech University Center for Geospatial Technology¹⁷⁾.

Results

U.S. Census 2023 estimates report a population of 2.99 million residents in the 107 west Texas counties in this study, about 9.8% of the estimated 30.5 million Texas residents (Table 1)⁹⁾. Despite making up under 10% of the state’s population, the land area of these four public health regions is 128,085 mi², roughly 49% of the land area of Texas and collectively larger than 46 individual U.S. states^{10, 18)}.

Table 1. Texas and West Texas U.S. census 2023 estimates.

	Population	Land area (square miles)	Women who had a birth, past 12 months	Women age 15–50
Texas	30,516,218	261,232	413,078	7,296,984
West Texas	2,987,760	128,085	43,881	688,141
Urban*	2,201,557	8,593	33,610	529,194
Rural	786,203	119,492	10,271	158,947

Data sources: Texas Demographic Center⁹⁾, U.S. Census¹⁰⁾, American Community Survey¹¹⁾.

*Urban counties defined using Office of Management and Budget (OMB) definition of population >50,000: Ector, El Paso, Lubbock, Midland, Potter, Randall, Taylor, Tom Green, and Wichita.

Seventy-four percent, or about 2.2 million, west Texas residents live in the 9 largest counties, defined in Table 1 as “urban”, and comprised of Ector, El Paso, Lubbock, Midland, Potter, Randall, Taylor, Tom Green, and Wichita counties. The remaining 98 counties, defined as “rural”, hold a total population of about 786,000 residents. For comparison, over 23 million Texans, about 76% of the state’s population, live in the 66 counties of the “Texas Triangle”, formed by the vertices of the Dallas/Fort Worth, Houston, and San Antonio/Austin metropolitan areas^{10, 19)}.

In the entirety of west Texas, 2 counties have hospitals with Level IV maternal care centers: El Paso (2) and Lubbock (2). Five counties in the region have Level III maternal care centers: El Paso (2), Potter, Taylor, Midland, Ector. Seven counties in the region have Level II maternal care centers: Potter, Andrews, Brown, El Paso, Reeves, Tom Green, and Wichita. Twenty additional hospitals have Level I maternal care centers, with 19 of these being the only maternal care center in their respective county. The remaining 76 counties are defined as maternal healthcare deserts, with some clusters representing large geographical areas with limited obstetric care access (Figure 1).

Figure 1.

Map of West Texas Counties by maternal care centers

Data source: TCHMB⁸⁾.

In the 107-county region, 2023 American Community Survey estimates indicate about 43,800 women gave birth in the past 12 months, over 33,600 of those births from the 9 urban counties (Table 2). Over 71% of counties in west Texas (n=76) are defined as maternal healthcare deserts. These counties have a population of over 82,000 women ages 15–50, of whom approximately 5,000 gave birth in the past 12 months. About 6.4% of women ages 15–50 in west Texas gave birth in the past 12 months, compared to about 5.7% across the state. Level I maternal care centers provides meaningful obstetric support across approximately 1/5 of the west Texas region, although more specialized care is limited to the larger urban areas.

Table 2. Populations by maternal care center level.

		Women Age 15–50	Women who gave birth, past 12 months	Number of counties
Highest level of maternal care center
	Level 4	294,503	18,687	2
	Level 3*	177,764	12,311	5
	Level 2	71,931	3,307	5
	Level 1	61,781	4,573	19
	No Maternal Care Center	82,162	5,003	76
Total		688,141	43,881	107

Data Sources: Texas Demographic Center⁹⁾, American Community Survey¹¹⁾.

*As noted above, Amarillo spans Potter and Randall Counties, and as such, both counties’ totals are included in the Level 3 sum above.

Discussion

Seventeen Texas rural hospital obstetric units closed between 2011 and 2021, leaving only 40% of Texas rural hospitals offering these services²⁰⁾. Level I maternal healthcare centers provide care for low- to moderate-risk pregnancies with the scope to detect, stabilize, and initiate management of the patient until they can be transferred, but these facilities are not suited for high-risk deliveries that require complex medical and surgical care from sub-specialty physicians²¹⁾.

Rural populations are more likely to have high-risk pregnancies due to higher rates of obesity, diabetes, hypertension, and adverse pregnancy outcomes including hypertensive disorders of pregnancy^{22, 23)}. Pregnant women in rural areas have a higher risk for maternal ICU admission and a two-fold higher risk of maternal mortality than their urban counterparts²⁴⁾. While many rural Texas counties have an emergency department that could deliver a patient if needed, these centers are not equipped to provide appropriate pre- and post-natal medical services.

The Rural Texas Maternal Health Assembly introduced a 2025 rescue plan to propose comprehensive solutions for the maternal health crisis in Texas²⁵⁾. Their solutions focused on retaining rural health care facilities and professionals by providing competitive reimbursement, boosting the rural maternal health workforce pipeline, increasing women’s preventive care by fully funding the state’s women’s health programs, and alleviating non-clinical barriers to care. The rescue plan contributed to Texas House Bill 18, enacted into law in 2025, aiming to support rural hospital reimbursement and financial management, and providing additional reimbursement for rural hospitals that provide obstetric services²⁶⁾.

Conclusion

Rural hospitals in west Texas counties with declining maternal age populations will continue to face financial challenges due to small numbers that may result in closure of obstetric units²⁷⁾. Regional coordination and strategic planning, combined with technological solutions such as telemedicine may provide adequate, if imperfect, solutions for bridging gaps in care²⁸⁾. Despite the relatively small number of births in west Texas maternal healthcare deserts, the well-being of thousands of new mothers and infants each year depends on appropriate coordination and financial support for facilities and providers who serve them.

Conflict of interest

The authors have no conflict of interest to report in reference to this manuscript.

Funding

None.

Ethics approval and consent to participate

This study uses only aggregate births and population data from publicly available data from the U.S. Census, and did not require IRB review. No human subjects were contacted for this study and no individual information is analyzed or reported.

Consent for publication

This manuscript is not under review at any other journal and is being submitted for consideration only to the Journal of Rural Medicine.

Author contributions

Dennis compiled data, wrote the methods and results sections, and edited the final manuscript. Lakey contributed to the discussion and manuscript editing. Lowry contributed to the introduction.

Data availability

All data for this study is freely and publicly available at the Web sources cited above, including data.census.gov, https://www.tchmb.org/pped#map, and https://demographics.texas.gov/