Dozens of protesters still camp outside Austin Women’s Health Center each week. Perched above a small creek in South Austin and shaded by towering trees, the independently owned clinic, founded in 1976, has historically provided abortion care. That is, until the U.S. Supreme Court overturned Roe v. Wade in June 2022, allowing a statewide criminal “trigger ban” to take effect, barring nearly all abortion procedures. Despite the fact that the clinic no longer performs abortions, activists continue to rally at the clinic, many prompted to do so by their church leaders and the activist group 40 Days for Life.

A few weeks ago, Julie Smith, the clinic’s former office manager, had to remind a demonstrator to stand behind the property line. The woman, elderly and walking with the assistance of a cane, appeared dehydrated, so Smith brought her water. Smith then informed her that because of state law, the clinic no longer offers abortion care.

“She was shocked . . . but she still felt like we must be doing ‘something wrong’ and ‘couldn’t be trusted,’ so she stayed,” says Smith. “I’m considering putting up a sign that says ‘We no longer do abortions, so please go home!’ but I think they’d still be here.”

While a nuisance, dealing with protesters is the least of Smith’s problems at the moment. After nearly five decades in operation, Austin Women’s Health Center is struggling to stay afloat. The clinic serves largely low-income patients; many are uninsured or enrolled in Medicare or Medicaid. Profits from abortion procedures—often paid out-of-pocket by patients—were used to help support the center’s daily gynecological practice and comprehensive reproductive care.

After Texas’s Senate Bill 8, which banned abortions after about six weeks, took effect in 2021, the small clinic had to lay off employees, shrinking its staff from 25 to 14. After Texas’s full abortion ban went into effect in 2022, that number fell to 7. Those cutbacks included Smith’s own position which she’d held since 2008; she now serves as a contract clinic consultant, working on fundraising initiatives, media relations, and grant research. Facing a “crisis point,” the center is dipping into its savings to cover costs, an unsustainable strategy, says Smith. They’ve also launched a GoFundMe campaign, with a $75,000 goal, and are in the process of applying for grants. But none of this ensures the last independent reproductive health clinic in Central Texas will keep its doors open. “We’ve been thrown into chaos,” says Smith. “It’s just been a grim, painful process trying to figure out this new normal.”

The clinic’s potential closure underscores the demise of the state’s reproductive health network following the U.S. Supreme Court’s Dobbs decision and resulting state abortion ban. From 2017 to 2022, eighteen independent clinics in Texas shuttered or stopped abortion services; today only two are still standing. The other, Houston Women’s Reproductive Services, was similarly forced to undergo drastic downsizing following Dobbs.

Vanishing independent clinics often mean weaker community health overall, says Nikki Madsen, executive director of the Abortion Care Network, a national association of independent clinics. “Independent clinics like Austin Women’s Health Center play such a critical role in the community, especially for patients with the fewest resources,” she said. “And they have that long-rooted history, so they acutely understand the needs of the community.”

In 2022, 42 independent clinics in the country were forced to close or stop providing abortion care, a figure likely to continue to rise. Their closures create an outsized impact as indie clinics have historically provided more than half of all abortion procedures despite representing just a quarter of all facilities offering care. “Nationally, and in states like Texas, independent clinics really lack the institutional support, visibility, name recognition, and fundraising capacity of national health centers, which makes it more difficult to keep their doors open,” says Madsen. “The reality is, since Dobbs, these clinics have either had to close, relocate, or change their services to survive.”

Today, just nine former abortion clinics that still offer health services in some capacity remain in Texas out of at least twenty prior to Dobbs, with Planned Parenthood comprising seven of those. (Even with major institutional support, Planned Parenthood sees its own existential threat as it faces the possibility of bankruptcy from a state-led lawsuit claiming purported fraud.)

Houston Women’s Reproductive Services, founded in 2019, has been able to stave off closure by slashing its staff by more than half, moving from a five-thousand-square-foot to eight-hundred-square-foot space, and limiting its services to pre- and post-abortion ultrasounds.

“We’ve trimmed down to the bare bone,” says clinic founder and director Kathy Kleinfeld. “We are living on reduced pay and reduced hours. And we are willing to do that so we can still be here for our patients. We are committed to serving them; this is our passion and our life’s work.”

With roughly two hundred patient ultrasound visits a month, the Houston clinic diagnoses an ectopic pregnancy at least once a month, and over a six-month time frame discovered fifteen miscarriages—specifically, empty gestational sacs, allowing the patients to refrain from making long and costly trips out of state for abortion care. Kleinfeld calls their work an “essential component” of reproductive health care that may fly under the radar.

“We help people find out that they may be further along than they realize,” says Kleinfeld, “or that they got a false positive pregnancy test, or that they have an ectopic pregnancy. Sometimes they have clots or need emergency care.”

Perhaps the most recognized former independent clinic in the state, Whole Woman’s Health, which oversaw four clinics in Texas before shuttering in July 2022 after nearly two decades, ultimately felt the best way to serve patients was to relocate to New Mexico, where abortion remains legal. For abortion rights advocates, it was an especially somber move given the organization’s history of challenging state abortion laws, such as its 2016 victory over House Bill 2 at the U.S. Supreme Court. “Many of these independent providers also serve as lead plaintiffs in important court battles against abortion laws,” says Madsen. “So when we lose them we also lose those who will really fight for us in court.”

Since he completed medical school in Texas and opened up Austin Women’s Health Center in the late seventies, Dr. Tad Davis has weathered the maze of state abortion restrictions over the years. He’s also been party to several legal challenges to them, such as one that would force abortion patients to bury or cremate their embryonic or fetal tissue and joining Whole Woman’s lawsuit against House Bill 2, which imposed several onerous restrictions on providers and clinics before being struck down by the U.S. Supreme Court. But the clinic has never faced the threat of closure like it does today. To help the center he founded survive, Davis hasn’t collected a salary in more than a year.

Davis says he’s often found himself on the other end of morbid remarks from colleagues about his own safety (“They haven’t shot you yet, I see,” his doctor friends would comment wryly) or vitriol from anti-abortion activists. After Dobbs, some physicians who were no longer able to practice abortion care in Texas fled to a nearby state where abortion remains legal, such as New Mexico. But Davis, who has been part of the community for decades, says he couldn’t part with his long-time patients; nearly 30 percent of them have been seeing him their whole lives. “I just couldn’t give up and abandon them,” Davis tells me.

While the clinic can no longer provide abortion care, Austin Women’s Health Center provides pre- and post-abortion ultrasounds for patients traveling out-of-state as well as miscarriage management. Davis recalls a patient who recently visited for an ultrasound simply to see how far along she was in pregnancy. The clinic discovered she was facing an ectopic pregnancy—a potentially life-threatening condition—without any obvious symptoms. The patient’s OB-GYN would not be available for emergency surgery for another three weeks, but Davis managed to ensure she was seen the same day. It was just one of many ectopic pregnancy procedures the clinic has expedited, Davis says.

“I wish people would fully understand that the abortion clinics that are closing left and right did not just offer abortion but so many other essential health care services, largely for underserved communities,” says Smith. “Without them, patients don’t have anywhere to go.”

The reproductive health clinic offers primary care and annual exams, as well as OB-GYN care, STD and pregnancy testing, UTI treatment, contraception, and tubal sterilization, among other services. Austin Women’s Health Center says it has provided more than 1,000 ultrasounds, 250 post-abortion follow-ups, counseling for 25 miscarriages, and 150 long-acting reversible contraceptive devices between June 2022 and June 2023. In total during this time, it served about 3,000 patients, compared to only 2,400 who sought that type of care in 2021.

Still, the patient numbers today are roughly half of what they were prior to Dobbs, says Davis, largely in part to the eradication of abortion care: In 2021, the clinic saw an additional 3,700 patients who visited for abortions. The clinic also spends considerable time allaying fears in the community, as some patients, confused by state abortion laws, are too “intimidated” to visit, even for an ultrasound.

Troubling clinic leaders, the closures of independent reproductive health clinics have provided a growing opportunity for anti-abortion advocates to fill a void. Since 2019, two Whole Woman’s locations—its flagship clinic in Austin and one in McAllen—have become crisis pregnancy centers. CPCs have been reported to deter pregnant clients from choosing abortion care, dispense inaccurate medical information, and proselytize religious beliefs to clients. With nearly two hundred CPCs in Texas, the centers vastly outnumber reproductive health clinics—and they see record-level taxpayer funding from the Texas Legislature. Last month, Attorney General Ken Paxton targeted online search provider Yelp for offering disclaimers that note CPCs provide only “limited medical services” and “may not have licensed medical professionals onsite.” (Yelp has since filed its own lawsuit against Paxton and changed its language to only note that CPCs do not provide abortion, yet Paxton is still claiming the company should pay penalties that could exceed $1 million.)

The Source—a network of Christian-based CPCs in Houston and Austin, which includes the clinic that took over the Whole Woman’s Health’s facility—says it saw a 76 percent increase in women served after the Dobbs ruling. In addition to offering baby clothes and parenting classes, the network has expanded its services to include well-woman exams and STD testing in an attempt to fill the need reproductive health clinics have left behind. They also advertise “Bible study, Christ-centered spiritual support, and prayer” as services.

Smith worries that if Austin Women’s Health is forced to close its doors, some of its patients will end up at a CPC, which largely don’t offer a full range of reproductive health care, including birth control.

For now, Smith’s main focus is salvaging the health center so many patients in her community rely on. The funds the Austin clinic has raised so far would likely allow them to continue existing for no more than six months, she says. After that, the clinic’s future is uncertain.