The hospital is quiet, the halls mostly empty, when Dr. Jeremy Johnson walks back into the labor and delivery unit.

It's past 3 p.m. now, more than 12 hours since Johnson arrived at the rural hospital in Jacksboro. For most of those hours, his patient -- a mother in labor -- seemed to be making no progress.

All day, Johnson and the two medical students on rotation with him had checked on her, periodically.

They checked on her before Johnson dialed in to a hospital board meeting. They checked on her while he and the students talked through patient reports and charts. They checked on her in between clinic appointments and ultrasounds. Each time, the answer was the same: little progress. It had become, the doctor said, a "marathon induction."

Business Briefing

Become a business insider with the latest news.

Or with:

Google

By signing up, you agree to our Terms of Service and Privacy Policy.

Over a barbecue lunch, Johnson worried his patient would need a C-section. She didn't want the procedure and it would be a shame, Johnson said, since she delivered her other children vaginally.

Now, back in labor and delivery, the monitors suddenly look promising.

Johnson and the medical students head into Suite 1. At last, Johnson says, it's time.

A maternal care crisis

In large swaths of rural America, the maternal care system is either crumbling or non-existent.

Nationwide, according to a March of Dimes report, more than 2.3 million women of childbearing age live in maternity care deserts, which are areas with no obstetric providers. An additional 3.3 million live in areas with limited access to maternity care.

Nearly half of all Texas counties are considered maternity care deserts. Texans who live in rural areas sometimes travel an hour and a half, or further, to see a doctor who can provide obstetric care.

And as rural hospitals shutter labor and delivery units, the number of people without easily accessible maternity care is only growing.

In Texas, many of the rural doctors providing maternal care are not OB-GYNs; They are instead family medicine physicians who also practice obstetrics. For those doctors, such as Johnson, that means caring for a broad population, often with limited resources and little or no backup.

"I see everything," Johnson said. But it's a job he views as a calling.

"God has sent me here to do this, I feel like."

It can be difficult for Johnson to predict exactly how each day will go. On this particular Friday in mid-August, he dialed into a board meeting, saw nine clinic patients, delivered a baby and, in all, stayed at the hospital for more than 12 hours.

For him, a slow day.

Clinic

Johnson's plan for this Friday was to make a 125-mile circuit around rural North Texas.

After driving in from his home in Olney, Johnson predicted an early morning delivery at Faith Community Hospital. The Jacksboro hospital is a 17-bed facility that's small and distinctly rural enough to be a filming location for the television series "Landman."

Then, a quick trip to check on some patients at Olney Hamilton Hospital, a 25-bed facility that no longer has a labor and delivery unit but holds the distinction of the oldest operating rural hospital in the state. Then, over to Graham for his scheduled clinic patients, before heading back to his home in Olney.

By 8 a.m., the doctor's schedule was off-track. He'd already slept for a few hours at the Jacksboro hospital, dialed in to the board meeting for the hospital in Olney, and bought a strawberry banana protein drink from the hospital cafe.

What he hadn't done yet was deliver a baby.

So Johnson did what doctors in rural Texas do every day: He made it work. The hospitalized patients in Olney would have to be tended to by another provider. And the patients scheduled for the Graham clinic would have to come to him, at the hospital in Jacksboro.

As Johnson went about his day, nearly all of his patients agreed to let The Dallas Morning News observe their medical appointments.

Terry Thompson, a former steer wrestler, was the first clinic patient. He was wearing a plaid button-up shirt and a Ruidoso Downs trucker hat, and he told Johnson that he was pulling into the parking lot at the Graham clinic when he got the call that he'd have to drive to Jacksboro instead. Johnson owed him for the switch-up, Thompson said.

"A steak dinner will take care of it," Thompson told his doctor.

"Give me a call," Johnson said, "We'll go eat out."

The inconvenience is a tack-on effect of the lack of rural obstetricians, Johnson said, an indirect impact on other patients created by the dearth of maternal care in rural areas.

Johnson asked about Thompson's medication, told him about dropping his oldest son off at college, gave him a steroid injection, and walked him through the reasons why taking certain dewormers -- similar to ivermectin, an anti-parasitic used largely for animals that rose to public prominence during the COVID-19 pandemic -- can cause liver damage.

In between patients, Johnson sometimes asked one of the two medical students on rotation with him to check on the laboring mother, who was also being monitored by other staff in the labor and delivery unit. Each time, the report was the same. No major changes.

Johnson continued his clinic appointments. There was a one-week check up for a newborn baby named Henley, delivered by Johnson the previous week. There was an appointment with a patient having autoimmune symptoms. And there were five ultrasounds of pregnant mothers.

In the back-to-back ultrasounds, Johnson went through the same routine. He asked each reclined patient how she felt and how her family was doing. As they talked, he tucked a white towel into the top of her waistband and squirted a swirl of blue-tinted gel on her belly.

Sometimes, one of the medical students -- Alexis Van Pelt and Kristen Miguel, both in their third year at UNT Health Fort Worth -- took over a step. Sometimes, the chit chat was in Spanish instead of English. Sometimes, the expecting mother or father asked a question.

When the clinic patients had all been seen, and with the laboring mother still at a stalemate, Johnson suggested lunch -- barbecue, at Treviño's Craft Smokehouse in Jacksboro, just over a mile from the hospital.

The waiting game

Johnson doesn't always have time to eat an actual meal. A few days earlier, he said, he had more than 40 patients in a day. He'd already delivered five babies so far this week, not counting the one he expects to deliver today.

On the days when there isn't enough time even to eat, Johnson said, he snacks when he can. The medical students offered up examples of the things they've seen him eat on busy days: Wheat Thins and pimento cheese (H-E-B brand cheese, Johnson interjected); cashews; salami that he'd heated up on the dash of his truck. Johnson added that the students saw him eat a container of blueberries recently, too, and he also eats a lot of dried fruit.

Over lunch, Johnson predicted he'd have to do a C-section for the laboring mother back at the hospital. He hoped he wouldn't have to, because it wasn't what the patient wanted, but at some point it would have to be done.

After lunch, Johnson swung by the nearby nursing home -- he's the director of that, too -- to sign some paperwork. He was gone for more than an hour, although the nursing home is a few minutes' drive from the hospital.

When Johnson walked back into the hospital, he had a saga to tell. An elderly woman, recently transferred to the nursing home, had gone outside and refused to go back in. When Johnson pulled up, the woman was sitting in the shade of a tree, alongside a staff member who was helpless to convince her to move.

Without using physical force, the staff could do nothing and neither could Johnson. They'd decided to call the local sheriff's office.

Anyway, just another day. Johnson checks the monitors for the laboring mother and then heads into Suite 1.

'Happy birthday'

After hours without progress, the mother won't need a C-section after all. It's time. The baby is coming.

Johnson pulls out a cart of supplies, whipping a drape from the top, and dons blue paper shoe covers. As the medical students do the same, Johnson turns to them.

"Who's catching?" he asks. Van Pelt and Miguel talk for a moment, and they decide it's Miguel's turn.

Johnson puts on the glasses that have hung around his neck all day. He and the medical students are copies of each other now, wearing matching blue gowns and boot covers, masks over top.

Miguel stations herself between the laboring mother's legs, which are hiked up onto plastic stirrups, and Johnson stands just behind her. He asks her, professor-like, what will happen as the baby emerges, based on the current position. She'll have to angle the baby, he says, to make sure his shoulders don't get stuck.

Johnson tells the mother to push. She bears down without a word. "Mas, mas, mas," he tells the mother, as Miguel hunches in close.

"Get ready, get ready, hold the head," he says to Miguel. Tiny shoulders appear, and Miguel maneuvers them down at a slight angle. And then, with the mother still quiet, the baby pops out, covered in a milky film.

For a moment, a beat, the baby is silent. Then he opens his mouth and lets out a jittery sob.

It's about 4:25 p.m., a little over 15 minutes from when Johnson called out that it was time for the delivery.

The father of the baby cuts the umbilical cord. The labor and delivery staff place the baby on his mother's chest, skin-to-skin, and his small cries are muffled as they towel him dry. Miguel, still stationed between the mother's legs, gently pulls the white-gray placenta into a shallow bucket.

The team takes the baby for a moment, checking him all over and stamping his feet onto a piece of paper. "Happy birthday," one of them says to the baby. Johnson checks him, too, pointing out his wrinkly feet and the cartilage in his ears.

Johnson is pleased, happy that his patient didn't have to undergo an unwanted C-section and that the baby is fully cooked and healthy.

He steps out of the labor and delivery suite and sits down in front of a computer. He'll wait here, for a little while longer, to make sure the baby and mother are still doing well.

Johnson has now delivered six babies this week.

Next week, the slate will wipe clean, and the count will start again.

From newborn to nursing home: In rural Texas, a family physician does it all