LAME DEER, Mont. — Misty Pipe squeezes a home visit into the hour before her shift at the post office. A mother of seven, she volunteers as a doula on the Northern Cheyenne Reservation, traveling a few miles to help expectant and new parents. The nearest hospital that delivers babies is roughly 100 miles away, so Pipe provides prenatal support, comfort during labor and early postpartum help for free because most families she serves cannot afford to pay.
Doulas have been linked in studies to lower rates of expensive birth complications and better postpartum outcomes, benefits that can be especially important in remote communities like Lame Deer. Montana lawmakers had approved adding doula services to Medicaid this year, allowing up to $1,600 per pregnancy and aligning the state with at least 25 others that reimburse doulas through Medicaid. Pipe had hoped the payments would let her expand her work and eventually leave her postal job.
But state health officials announced in late March they are delaying implementation, citing a budget shortfall that officials attribute in part to higher-than-expected Medicaid spending. The Montana Department of Public Health and Human Services told lawmakers it expects a $146.3 million gap in federal Medicaid funds this year, and that further deficits could follow after the federal One Big Beautiful Bill Act reduces federal Medicaid spending by nearly $1 trillion over 10 years. The agency said it cannot move forward with adding doula coverage now and may request supplemental funding; under state rules, any new appropriation request in the first year of the two-year budget cycle must include a plan to cut spending.
Across the country, optional Medicaid benefits such as doula care, home health aides and adult dental services are vulnerable as states plan for federal reductions. Idaho lawmakers are weighing budget cuts, and Missouri officials suggested trimming tens of millions from programs for people with disabilities. In Montana, officials say they are considering a range of options. Advocates worry Montana’s decision could foreshadow rollbacks in services many families rely on — more than half of the state’s counties are considered maternity care deserts.
Pipe’s work is deeply practical and cultural. At a recent visit just outside town she handed a newborn to his mother, Britney WolfVoice, and unwrapped a fresh swaddle. Pipe has supported WolfVoice through two births, helping make delivery plans, bringing calming cedar used in prayer and advocating with hospital staff when appointments were delayed. WolfVoice says Pipe is someone she can count on to speak up for her.
When clients need rides, Pipe sometimes takes time off from the post office to drive them. If a client goes into labor while she is working she texts other local doulas — all of whom also have day jobs — to cover until she can get away. Pipe has herself endured long trips to the nearest hospital and given birth in emergency rooms; in one pregnancy she miscarried at home and could not 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 issue as birthing units close, and the problem is magnified in many tribal areas where long distances intersect with historical inequities. Predominantly Native communities face longer travel distances to obstetric facilities than other groups, and Indigenous women are at least twice as likely as white women to die from pregnancy-related causes.
Tribal patients are supposed to have care through the Indian Health Service, but the agency is chronically underfunded and provides limited labor-and-delivery services. As of 2024, only a small share of IHS facilities or tribal hospitals offer births, and just seven states had an IHS or tribal birth facility. Medicaid is the primary source of coverage for many Native Americans, but the new federal law will mean more frequent eligibility checks and work requirements that analysts say could leave an estimated 5.3 million people uninsured by 2034. Although Native Americans are exempt from some of the law’s new rules, such as work requirements, tribal members still face paperwork and administrative barriers proving eligibility or tribal status.
WolfVoice, who is a full-time college student, says enrolling in Montana’s Medicaid program took nearly six months while she was pregnant. Despite delays and system strain, Montana plans to implement work requirements this summer, ahead of some federal timelines.
Experts who study maternal health disparities emphasize that the main obstacles are structural, not individual: systems and policies limit access to care. Emily Haozous of the Pacific Institute for Research and Evaluation’s Southwest center, a member of the Fort Sill-Chiricahua-Warm Springs-Apache Tribe, says maternal-health data can miss the larger point — the system itself is set up in ways that make care inaccessible for many women.
With Medicaid doula payments on hold, Pipe and others in Lame Deer are continuing unpaid work and relying on community-based solutions. Her 14-year-old daughter is trained as an Indigenous doula, and her 8-year-old helps pick up prescriptions for mothers without transportation. Pipe plans to keep training birth workers, family members and respected community members to broaden support. After a shift at the post office she and a former tribal public health nurse sit in lawn chairs and brainstorm ways to connect more women to free prenatal classes and other services.
“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 that produces in-depth reporting on health issues and is part of KFF.