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Transforming Rural Health Starts with Maternal Care

3 hours ago
12 min read

Updated: 2 hours ago

Maternal health care encompasses all the services that support people before, during, and after pregnancy, promoting the health and safety of both parents and infants. This care is delivered by a team of providers, which may include OBGYNs, doulas, midwives, mental health care providers, lactation consultants, and more. Ideally, maternal health care begins early in pregnancy and continues through the first year postpartum. Comprehensive care improves outcomes by preventing complications during pregnancy and birth, reducing preterm births, and supporting healthy birth weights. Preterm birth and low birth weights can impact developmental milestones and are leading causes of infant mortality.[1] By supporting parents and infants during this critical period, maternal health care lays the foundation for healthier families and better health outcomes throughout life.

 

Maternal health care services in Montana, particularly in Tribal communities and rural counties, fail to sufficiently serve families across the state throughout pregnancy and postpartum. In Montana, 13.8 percent of parents receive inadequate prenatal care, and the state's maternal mortality rate is higher than the national average.[2] Two obstacles shape maternal health care delivery in Montana: geography and investment. Historical policy choices and long-standing discrimination, such as segregation and colonization, have resulted in Black, Indigenous, and other women of color having less access to prenatal and maternal health care, leading to higher rates of low birth weights, cesarean sections, and mortality.[3] Declining access to community-based care and rural hospitals in more recent years is another challenge.[4] Furthermore, Montana can take steps to ensure that prenatal and postnatal care is reimbursed accurately.[5] Even in more urban areas of the state, hospitals have closed departments that provided care for pregnancy and childbirth.[6]


The opportunity over the next few years to improve maternal health care is unprecedented, and the Department of Health and Human Services (DPHHS) should leverage the Rural Health Transformation Program (RHTP) to build systems that support families across the state—including newer standards of care, such as those designed to address high rates of perinatal mental health needs. Effective solutions exist that require state investments and policy changes.[7] Over the next five years, Montana will receive significant federal funding through the RHTP, and it should prioritize maternal health services in allocating those funds.[8]

 

Limited Access to Prenatal Care Drives Significant Disparities in Use

Prenatal care sets the foundation of health for expectant parents and their infants, and helps identify complications early, prevents pregnancy-related death and infant mortality. [9]  Throughout a pregnancy, if a patient knows early on, they could have up to 14 prenatal visits; if the pregnancy is high-risk, the number of prenatal visits can be even higher.[10] Montana has an additional Medicaid program, Pregnancy and Postpartum Medicaid, to support pregnant people in the state who make less than 162 percent of the Federal Poverty Level (FPL), or about $34,263 for a household of two.[11][12] This program makes critical strides in improving access to prenatal care for people with low to moderate incomes. While this program is a step in the right direction, nationally, the average income eligibility for Pregnancy and Postpartum Medicaid is higher, at 220 percent FPL, or $46,530 for a family of two.[13]  While Medicaid helps to support prenatal visits, distances and travel expenses remain barriers to care. People living in rural areas are more likely to begin prenatal care in the second trimester than those in urban areas.[14] Prenatal care can also facilitate access to other resources and programs that support families during pregnancy and the postpartum period, such as the USDA’s Special Supplemental Nutrition Program for Women, Infants, and Children, commonly known as WIC. In 2023, an estimated 15,000 children eligible for WIC in Montana were not receiving benefits.[15]  Montana Medicaid covered nearly one in three births in 2024.[2]

American Indians in Montana were at least five times more likely to lack access to prenatal care than white Montanans.[14] This gap in access only increases for Tribal members living in non-metro or rural areas.  This disparity begins in the first trimester of pregnancy, where almost 1.6 times more urban white people begin prenatal care compared to urban Tribal populations. Longstanding structural and historical factors, including the ongoing effects of intergenerational trauma, discrimination, limited health care infrastructure, socioeconomic inequities, and geographic barriers to care, shape these disparities.[16] 

 

Postnatal Care Leaves Parents Without Support When They Need It Most

While someone who receives full prenatal care may have been closely monitored throughout their pregnancy, that does not continue after birth. Postnatal care typically consists of one appointment at six weeks for a full postpartum examination.[17]  While these visits include some screenings for mental health, physical recovery, and adjustment to having a new baby, a single visit offers limited opportunities to ensure the well-being of the mother and child. Due to a lack of financial resources, a lack of access to college education, racial identity, or being a young new parent, many in Montana experience high levels of post-partum depression at a rate of 12.5 percent.[18] An analysis of pregnancy-related deaths in Montana in 2020 determined that 73 percent of deaths occurred more than six weeks after birth, and that an underlying mental health condition caused 71 percent of pregnancy-related deaths in 2020 through 2022.[19] [20]  Universally offered home visiting can help fill these gaps in care and support to new parents. In a pilot program run by the DPHHS, home visits were provided during the prenatal or postpartum period, health and resource needs were screened for, parent education was provided, and referrals were made to other resources to better support families.[21]

 


Montana Fails to Provide Mental Health Care to New Parents

Accessing mental health care, particularly in rural Montana, adds another level of challenge for people seeking support and services. Montana ranks 40th in the nation based on a high prevalence of need for mental health care and low access to that care.[22] Screening for depression or other mental health issues is less common during prenatal visits than postpartum visits, even though one in four people with depression during pregnancy goes on to have postpartum depression.[18] While screening for mental health conditions is a more typical part of postpartum visits, there is limited opportunity for follow-up regarding mental health treatment. Non-OBGYN providers who provide childbirth care, such as doulas and midwives, can reduce the chances of a c-section by 52.9 percent.[23] Doulas and midwives support people throughout the birthing process. C-sections can increase the chances of complications, increase recovery time, and increase the odds of having postpartum depression and post-traumatic stress disorder after birth.[24] [25]

 

Montana Can Take Steps to Ensure Maternal Health Care is Reimbursed Accurately


Maternal health care faces financial challenges across the United States, largely due to billing practices. Maternal health care billing is bundled into a single payment rather than using a fee-for-service model for each service performed.[26] This shapes care delivery by assigning the payment rate for all routine services and maternal health care provided. This bundle also has a standard built-in that restricts the included services, and when care ends after birth. While there are some flexibilities based on complications or other factors, this standardization does not incentivize providers to go beyond the bundle, including services like screening, care coordination, and mental health care.[5] Nationally, the maternal health care bundle will be eliminated in 2027.[27] This will change the financial landscape of maternal health care, in which payments are spread among different providers, potentially across different facilities in different cities. Unbundling also creates an opportunity for providers to change their standards of care delivery by adding visits for postpartum care, mental health screening throughout pregnancy, and maternal mental health care. Reimbursement rates from private and public insurers, such as Medicaid, will significantly impact access to maternal health care across the state.[28] Ensuring the state sets adequate reimbursement rates is critical to preserving the financial stability of maternal health care providers.



Tribal Communities Need More Investment and Access to Maternal Health Care

Tribal communities need more access to culturally responsive maternal health care. Tribal access to health care is shaped by historical policies of the United States (U.S.) government during colonization over the last 150 years. In 1887, the U.S. passed the Dawes Act, which codified the policy of assimilation and made it illegal for Tribal people to live nomadically, speak their languages, and practice their culture.[29] This included ceremonies and cultural practices around pregnancy and birth. Through treaties, the federal government has obligations to provide health care to Tribal members through the Indian Health Service (IHS), and to pay all of the expenses of Tribal people on Medicaid.[30] However, IHS facilities are not required to offer labor and delivery services and are significantly underfunded compared to other federally funded health programs.[31] As a result, in Montana, only one IHS facility on the Blackfeet Reservation offers these services.[32] While reservations in Western Montana have birthing facilities that are not IHS facilities, options in eastern Montana are more limited. This places additional demands on Indigenous families who may need to seek care in health systems that have fewer opportunities to provide culturally responsive and community-informed maternity care. Culturally responsive care is a model of care that acknowledges culture, identity, context, and intergenerational trauma and experiences, and how they are interconnected with effective treatment and the health of the person being cared for.[33] Effectively serving Tribal communities requires Tribal consultation to support a holistic approach that integrates cultural perspectives across policies, curricula, services, and decision-making, so these perspectives are fully embedded in the fabric of institutions that provide services to Tribal communities, not just in specific programs or departments.[34]

 

Montanans Travel Long Distances to Get Care

Having access to a safe place to give birth with the appropriate level of care is only one piece of the puzzle. Montana has 25 birthing facilities: 16 in the western half of the state and nine in the eastern half. Out of 56 counties, only 22 have a birthing facility.[35] [6] Of these facilities, only 20 percent were assessed as able to provide care for complex cases and complications for infants, and 8 percent were equipped to handle complex cases of the parent. Maternal health is getting more complex, as those having babies are older and have more underlying health conditions.[36] National assessments of maternal health access in Montana found that 13.4 percent of women of reproductive age live more than 30 minutes away from a birthing hospital, a rate almost double the national average.[37] Travel is not limited to just giving birth; when adding in prenatal and postpartum visits, an individual could make this trip 15 times or more.

Montana Can Utilize the Rural Health Transformation Program to Improve Maternal Health

Montana should follow the example set by more than a dozen other states seeking to improve maternal health in rural areas by prioritizing maternal health services.[7] In 2026, Montana received $233 million in federal funding through the Rural Health Transformation Program, passed by Congress in 2025.[38] Montana is slated to receive a similar level of funding each year for the next five years, totaling over $1 billion in investment to rural health systems. While Montana mentioned maternal health in its ‘populations of focus’ and the need to improve access and outcomes for this population, Montana should prioritize maternal health services for future RHTP funding.7 Within the state’s RHTP plan, maternal health is only mentioned in initiative one: Develop Workforce Through Recruitment, Training, and Retention.[39] As mentioned earlier, the challenges facing maternal health care in Montana are layered and complex, and there are several opportunities within RHTP initiatives to address them.

 

Montana’s RHTP plan lists five core initiatives: workforce development, sustainable access, innovative care models, community health and prevention, and, lastly, technology innovation. Many of the challenges identified in the DPHHS proposal acknowledge barriers to delivering health care in Montana, which also inhibit maternal health care. Examples include the “unique needs of rural populations,” “shortfalls in health care access,” and “financial stress and instability for rural health care providers."[39] The department also recognized the disparity in the number of health care providers between rural parts of the state and more urban counties. While including maternal health in a single initiative may yield some improvements, all initiatives are interconnected. They should work together to make significant changes and improvements to maternal health in Montana. Other states, such as Ohio, are using funds to open low-cost birth centers operated by general practitioners and midwives to increase access.[7] In South Dakota, RHTP funds will support regional hubs, funding analysis, workforce needs, home visiting, and other community-based support services. Thirteen states have shown in their RHTP plans that maternal health is rural health and an important part of improving access to health care in rural areas. DPHHS should also prioritize maternal health, recognizing that healthy pregnancies, mothers, and births support lifelong health for individuals and families across the state. Specifically, DPHHS should prioritize the following, which fall within the current Montana RHTP framework:

 

  • Analyze the scope of maternal health deserts in the state and ways to support providers and care coordination to expand maternal health services;

  • Develop workforce across the entire spectrum of maternal health care providers, including doulas, midwives, and mental health services;  

  • Expand access to community-based care by investing in a universally offered home visiting model;

  • Prioritize labor and delivery units in the CoE assessment as essential infrastructure;

  • Reimburse the full spectrum of maternity care (pre- and postnatal) at the full cost of care; 

  • Work with Tribal governments to identify needs and better provide adequate and culturally comprehensive maternal health care in Tribal communities;

  • Improve care coordination between community-based health services and regional hospitals or facilities that provide childbirth care through both care coordination services and modernized technology;

  • Dedicate focus on emergency medical services and training for obstetric emergencies;

  • Include maternal health care in efforts to expand community-based care through school-based primary and preventive care and mobile care units.



Investment in Maternal Health Care is an Investment in the Future of Montana

RHTP presents a once-in-a-generation opportunity to strengthen Montana's maternal health system. In 2025, 1,786 babies were born to parents living in counties without a birth facility.[40] For many families, particularly those in rural and Tribal communities, limited access to maternity care creates unnecessary barriers to healthy pregnancies and safe births. Montana is making historic investments to transform its health care system. DPHHS should use this opportunity to build a maternal health system that is financially sustainable, expands access across the continuum of care, and meets the unique needs of rural and Tribal communities. The recommendations outlined above build on the state's existing Rural Health Transformation Program framework while emphasizing the specific needs of parents and families. Every parent in Montana deserves access to safe, high-quality care throughout pregnancy, childbirth, and the postpartum period, regardless of where they live. Investing in maternal health strengthens families, improves health outcomes, supports a resilient workforce, and builds healthier communities for generations to come.


Endnotes

[4] Kozhimannil, K., et al., “Obstetric Care Access Declined In Rural And Urban Hospitals Across US States, 2010–22,” Health Affairs, July 7, 2025.

[5] Burkhard, J., “Should Maternity Care Bundled Rate Really Be Considered ‘Value Based’?,” Policy Center for Maternal Health, June 18, 2026.

[7] Howard, H., McLean, J., Lopez, R., “How States are Using RHTP to Advance Maternal Health,” State Health & Value Strategies, Mar. 12, 2026.

[8] Department of Health and Human Services, “Montana Rural Health Transformation,” accessed Jul. 14, 2026.

[10] Office of Women’s Health, “Prenatal Care and Tests,” U.S. Department of Health and Human Services, Sept. 26, 2025.

[12] MBPC calculations using Healthcare.gov, “Federal Poverty Level,” accessed Jul. 14, 2026.

[13] MBPC calculations using KFF, “Medicaid Postpartum Coverage Extension Tracker,” Mar. 19, 2026.

[14] MBPC Calculations Centers for Disease Control and Prevention, National Center for Health Statistics, “Natality on CDC Wonder Online Database,” accessed Jul. 13, 2026.

[15] Urban Institute, “State of the Safety Net: Program Data,” accessed Jul. 12, 2026.

[16] Christie, S., et al., “Addressing Maternal Health Disparities in American Indian and Alaska Native Communities,” The Commonwealth Fund, July 1, 2025.

[18] Department of Health and Human Services, “Maternal Depression in Montana, 2020-2022,” Sept. 3, 2025.

[20] Department of Health and Human Services, “Mental Health and Substance Use Disorder in Maternal Mortality, 2020-2022,” Aug. 17, 2026.

[21] Department of Health and Human Services, “A Grant to Grow and Strengthen Montana's Early Childhood System,” Aug. 17, 2026.

[22] Mental Health America, “Data and Rankings,” accessed Jul. 16, 2026.

[24] Das, B., et al., “Comparing Vaginal Birth vs Cesarean Section: Short and Long-Term Maternal Health Outcomes,” Journal of Contemporary Clinical Practice, Nov. 23, 2024.

[25] Mostafavi, B., “Depression, anxiety may be linked to c-section risk among pregnant women,” Michigan Health, University of Michigan, Oct. 19, 2021.

[27] Burkhard, J., “Beyond the Bundle: Key Implementation Considerations for the 2027 Unbundling of Maternity Care Payment,” Policy Center for Maternal Health, June 18, 2026.

[28] Alexander, D., Schnell, M., “Increased Medicaid Reimbursement Rates Expand Access to Care,” National Bureau of Economic Research, Oct. 1, 2019.

[30] Indian Health Services, “Basis for Health Services,” Jan. 2015.

[31] Library of Congress, “The Indian Health Service (IHS): An Overview,” Jan. 12, 2016.

[32] Indian Health Service, “Indian Health Service: Find Care Health Map,” accessed July 15, 2026.

[33] H.E.L.P, “The Importance of Culturally Responsive Care,” accessed Aug. 25. 2026.

[35] Holman, C., et al., “Levels of Care Assessment Tool (LOCATe): Montana Report,” Rural Institute for Inclusive Communities, July 2023.

[36] Yale Medicine “Maternal Mortality is on the Rise: 8 Things to Know,” May 22, 2023.

[37] Stoneburner A, March of Dimes, “Re: Maternal Health Care Deserts in Montana,” email to Andria Schafer, MBPC, Aug. 14, 2026, on file with author.

[38] Department of Health and Human Services, “Montana Rural Health Transformation,” accessed Jul. 17, 2026.

[39] Department of Health and Human Services, “Rural Health Transformation Program Application,” Feb. 17, 2026.

[40]  MBPC calculations using Kids Count Data Center, "Total Births (1-Year Totals) in Montana, 2025 by County," Montana Budget & Policy Center Kids Count, Aug. 2026.

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