LAME DEER, Mont. — Misty Pipe had about an hour before her post office shift and used it to check on a new mother who lives a few miles outside town on the Northern Cheyenne Indian Reservation. A mother of seven, Pipe is a doula who supports expectant and new parents. She does the work for free, around her day job, because the closest hospital that delivers babies is about 100 miles away.
Doulas prepare parents for childbirth, support deliveries and help in a baby’s first months. Studies link their work with lower rates of costly birth and postpartum complications, especially in remote places like Lame Deer. But in a community where nearly half of residents live in poverty, the families Pipe serves usually cannot afford to pay a doula, so she provides care without pay.
Montana had planned a change this year: lawmakers approved adding doula services to Medicaid, authorizing up to $1,600 per pregnancy, joining at least 25 other states that reimburse doulas through Medicaid. Pipe had hoped the payments would allow her to expand her work and eventually leave the post office. Instead, state health officials postponed implementing doula coverage in late March, citing a budget shortfall driven in part by higher-than-expected Medicaid costs. “DPHHS will not be moving forward with the implementation of doula services in the Montana Medicaid benefit package at this time,” department spokesperson Holly Matkin told KFF Health News.
The agency told lawmakers it projects a $146.3 million shortfall in federal Medicaid funds for this year. Health officials expect further deficits after the federal One Big Beautiful Bill Act, signed last year, reduces federal Medicaid spending by nearly $1 trillion over 10 years. Matkin said it is unclear when the state can add doula coverage; the deficit will prompt a supplemental funding request and, under Montana law, require an agency plan to reduce spending if it seeks new appropriations in the first year of the two-year budget cycle.
Across the country, optional Medicaid services — such as doula care, home health services and dental care — are at risk as states brace for federal reductions. Idaho lawmakers are considering cuts to balance their budget, and Missouri officials proposed trimming tens of millions from services for people with disabilities. In Montana, health officials say “all options are on the table.” Advocates warn the state’s move could be the first of many rollbacks to services families rely on; more than half of Montana’s counties are designated maternity care deserts.
At a check-in just outside town, Pipe handed a newborn to his mother, Britney WolfVoice, and unwrapped a new swaddle. Pipe has supported WolfVoice through two births, helping craft delivery plans and providing comfort — once bringing cedar oil, a sacred plant used in prayer, to calm contractions. When a planned induction was delayed because of hospital backlogs, Pipe repeatedly called the hospital and urged WolfVoice to press for an earlier appointment. “Misty is one person who I can count on to be my voice,” WolfVoice said.
When clients need rides to appointments, Pipe sometimes takes time off work to drive them. If a client goes into labor while she is at the post office, she texts other local doulas to cover until she’s free; they also have day jobs. Pipe herself has labored on the long trip to the hospital and given birth in emergency rooms along the way. In one pregnancy she miscarried at home and couldn’t get a doctor’s appointment for days. “I labored alone so many times,” she said. “I just want to make sure no one’s alone.”
Rural maternity care deserts are a national problem as birthing units close. In many tribal communities, distance to care intersects with long-standing inequities caused by centuries of systematic discrimination. Predominantly Native American communities face the longest distances to obstetric facilities compared with other groups, and Indigenous women are at least twice as likely to die from pregnancy-related causes as white women.
Tribal patients are supposed to have access to health care through the Indian Health Service, but the chronically underfunded agency provides limited labor-and-delivery services. As of 2024, only a small fraction of IHS facilities or tribal hospitals offer births, and just seven states had an IHS or tribal birth facility. Medicaid is the main source of health coverage for many Native Americans, but the new federal law will add more frequent eligibility checks and work requirements. Those changes are expected to leave an estimated 5.3 million people uninsured by 2034. Native Americans are exempt from some of the law’s new rules, such as work requirements, but tribal patients can still face administrative hurdles proving eligibility or tribal status.
WolfVoice, a full-time college student, said it took about six months to enroll in Montana’s Medicaid program while she was pregnant. Despite delays in the state’s Medicaid system, Montana officials plan to implement work requirements this summer, ahead of federal deadlines.
Experts who study maternal health disparities stress that barriers are structural. Emily Haozous of the Pacific Institute for Research and Evaluation’s Southwest center, a member of the Fort Sill-Chiricahua-Warm Springs-Apache Tribe, said maternal-health data often misses the point: “It’s not that women are just not taking care of themselves. The system is set up for them to not have access to care.”
For pipe and others in Lame Deer, the loss of Medicaid doula payments means continuing unpaid work and relying on grassroots solutions. Pipe’s 14-year-old daughter is already certified as an Indigenous doula, and her 8-year-old helps pick up prescriptions for moms who lack transportation. Pipe plans to keep training birth workers, family members and respected community members to expand support. After a full shift at the post office, she and Felicia Blindman, a former tribal public health nurse, sit in lawn chairs and brainstorm ways to connect more women to services like free prenatal classes.
“It’s not going to stop me from training more birth workers, more young people, more aunties,” Pipe said. “For now, I guess it’s more about grassroots, moccasins on the ground, helping each other.”
KFF Health News is a national newsroom producing in-depth journalism about health issues and is part of KFF.