Lame Deer, Mont. – It took about an hour for Misty Pipe to start her shift at the post office. She used that time to visit a new mother who lives a few miles from this town in the heart of the Northern Cheyenne Indian Reservation.
A mother of seven, Pipes is a doula on the reservation who supports new and expectant parents. She does that work for free around her daily job. That’s because in this town of about 2,000 people, the nearest hospital delivering babies is 100 miles away.
“Women need this help,” Pipe said.
A doula prepares parents for childbirth, assists with their delivery, and can be a constant presence during the baby’s first months. study link Their work with cost-effective births and low rates of postpartum complications – especially in remote places like Lame Deer.
But that help may be scarce. As Pipe said: “Doula doesn’t pay the bills around here.”
This year things were about to change. Montana was ready to join at least 25 other states which reimburses doulas through its Medicaid programs to bridge gaps in care. Montana lawmakers approved the payments last year, allowing up to $1,600 per pregnancy. Pipe hoped the money would one day allow him to quit his job at the post office to help his parents.
But the state Department of Public Health and Human Services postponed adding doula services to its Medicaid program in late March, citing budget shortfalls due to higher-than-expected Medicaid costs.
“DPHHS will not move forward with the implementation of doula services into the Montana Medicaid benefit package at this time,” department spokesperson Holly Matkin told KFF Health News.
The news surprised Pipe — she hadn’t heard an update for some time, but the state had finalized its licensing rules for Doula in January. Last year, he helped deliver three people. He doesn’t have time for more than that. It weighs heavily on him. about half People on the Northern Cheyenne Indian Reservation live in povertyAnd the people she helps usually can’t afford to pay a doula.
“I was looking forward to serving more people,” Pipe said. “Now this is not going to happen in the near future.”
Doula Misty Pipes catches Grover Wolfvoice on her first check-in visit after his birth. Pipe says she is most concerned about clients’ health after they return home, when postpartum complications can arise. (Catherine Houghton/KFF Health News)
Weeks old Grover is being held by his father, Tory Wolfvoice. Grover’s mother, Brittany Wolfvoice, says the doula care Pipe provided during the births of her two youngest children made them feel safe for the first time in their lives and that their voices were heard in hospitals. (Catherine Houghton/KFF Health News)
Health Department head Charlie Brereton told state lawmakers in March that the agency projected a $146.3 million shortfall in federal Medicaid funds for this year. Health officials are predicting another deficit next year as states feel the impact of the Republicans’ massive tax-and-spending legislation, the One Big Beautiful Bill Act. Signed last year, that legislation is projected to reduce federal Medicaid spending by about $1 trillion over 10 years.
Matkin said it’s “unclear” whether the agency can authorize doula coverage this year. The deficit will prompt the department to seek supplemental funding from state lawmakers. When an agency makes such a request for the first year of a state’s two-year budget cycle, montana law He needs to make a plan to reduce his expenses.
Across the country, alternative Medicaid services — like doula support, home health care and dental work — are at risk of losing funding as states brace for federal Medicaid cuts to hit their bottom lines. Already, lawmakers in Idaho are considering their own cuts to Medicaid to balance the state budget. Missouri officials proposed Hundreds of millions of dollars in cuts to services for people with disabilities.
In Montana, doula services are unlikely to be the only Medicaid cut announced. “All options are on the table,” Brereton told lawmakers in March.
More than half of Montana’s counties are designated as maternal care deserts, said Stephanie Morton, executive director of Healthy Mothers, Healthy Babies-The Montana Coalition.
“Budget cuts will continue to erode trust for families with limited services in these counties,” said Morton, whose nonprofit has advocated for doula Medicaid reimbursement. “It appears this decision will be the first of many rollbacks and cuts Montanans face.”
toil alone
At check-in just outside the city, Pipe handed an awake newborn to his mother and unwrapped a new swaddle for the baby. It would be a quick meeting – he was already late for work.
Mother Brittany Wolfvoice held her newborn son in her arms while her three young daughters stood nearby. Pipe has been with Wolfvoice and her husband for the birth of their newborn son and youngest daughter.
She helped them make delivery plans. For the birth of Wolfvoice’s youngest daughter a few years earlier, Pipe brought cedar oil, a sacred plant used for prayer, and soothed Wolfvoice through her contractions. For her son’s recent birth, when there were delays involving Wolfvoice due to hospital backlog, Pipe encouraged her to regularly call the hospital to advocate for an earlier appointment. Doctors recommended this procedure to avoid complications.
Wolfvoice said, “Misty is someone I can trust to be my voice.”
If someone needs a ride to the doctor, Pipes takes the day off work and takes them. If a client goes into labor while Pipes is at the post office, she messages two other free doulas she knows on the reservation to see if they have time to help by the time her shift ends. But they also have day jobs.
Pipe herself drove 100 miles between home and hospital during labor and in the back of an ambulance. Twice, she gave birth in emergency rooms along the way. In one of her pregnancies, she had a miscarriage at home and could not get a doctor’s appointment for several days.
The long distances to receive care often required her husband to stay behind at home to care for their other children.
“I’ve worked alone many times,” Pipe said. “I just want to make sure no one is alone.”
Rural maternity care is a desert national problemEspecially when labor and delivery units remain closed continuously. In many tribal communities, the lack of care matches centuries of inequities systematic discrimination.
According to a 2024 report by the March of Dimes, predominantly Indigenous communities face the longest distances to maternity facilities compared to all other racial and ethnic groups. This is why Indigenous women are far more likely to fall ill during pregnancy at least double the chance of dying As white women.
Indigenous patients should be guaranteed access to health care through the federal Indian Health Service. But the chronically underfunded agency is seriously flawed. A small portion of its hospitals and clinics provide labor and delivery facilities. By 2024, only seven states had either an IHS or a tribal birth facility, the agency told. To help make up those shortfalls, Medicaid is Main source of health coverage According to KFF, for many Native Americans.
According to Pipe and other health workers, Indigenous women may experience mistrust of health systems, even where care exists. The US government has a long history of removing children from tribal homes and forcing Native American women to undergo sterilization.
Emily Haozous The Pacific Institute for Research and Evaluation’s Southwest Center has studied premature deaths among Native Americans. Haozous, a member of the Fort Sill-Chiricahua-Warm Springs-Apache Tribe, said data on maternal health disparities in pregnancy and postpartum often miss an important point.
“It’s not that women aren’t taking care of themselves,” Haozous said. “The system is set up for them to not have access to care.”
In addition to funding cuts, the One Big Beautiful Bill Act would add more frequent eligibility checks and work requirements to access Medicaid. Those changes, when they take effect later this year and next, will cause an estimated 5.3 million people to lose their coverage by 2034.
Native Americans were exempted from some of the new rules of the law, such as work requirements. Still, tribal patients may get entangled in administrative hurdles. This includes struggling to enroll or prove one’s tribal status in the first place. Wolfvoice, a full-time college student, said that when she became pregnant, it took about six months to enroll in the state’s Medicaid program.
Despite Montana’s long struggle with the pending Medicaid system, state officials aim to implement work requirements this summer, well ahead of the federal deadline.
‘moccasins on the ground‘
One day, after a full shift at the post office, as soon as the pipe came his way, his children ran towards him. They were also welcomed by Felicia Blindman, a 63-year-old public health nurse who worked for the tribe. The two sat in lawn chairs into the night and discussed ways to connect more women to services – such as free prenatal classes.
Pipe’s four youngest children played around him. Her 14-year-old daughter is already certified as an Indigenous doula. Their 8-year-old daughter has started helping Pipes pick up prescriptions for car-less mothers who live out of town. Pipe hopes to one day be able to do this work full-time if he wants to.
Because of the lost Medicaid payments, Pipe said, she will continue to balance her job with her birth work, even if it means convincing more people to become doulas, such as family and respected community members, to cover more ground.
“It won’t stop me from training more birth workers, more youth, more aunties,” Pipe said. “For now, I think it’s more about the grassroots, the moccasins on the ground, helping each other.”
She said that means letting pregnant people who come to the post office know that they are there to help if they need it. At least, until he’s at his day job.
