MIAMI — Midwife Sheila Simms Watson leaned to gently press on the pregnant woman’s belly. Me’Asia Taylor lay on a bed fitted with tie-dyed purple printed sheets in the corner of the RV.

Far from a typical camper, this RV houses a mobile midwifery clinic for prenatal, postpartum and women’s general health care.

“Roll when you’re getting up, and we can help you. You can sit there for a moment, all right, so you’re not lightheaded, not dizzy,” said Watson, whom patients and doulas call “Mama Sheila.”

Calm and slow, led by Watson’s soothing and attentive demeanor, the appointments are unrushed.

Run by the Southern Birth Justice Network, the mobile midwifery clinic brings care to majority-Black and Latino neighborhoods across Miami-Dade County several times a month. The clinic aims to offer a more relaxed setting, where women are comfortable and heard, their cultures are integrated, and they can connect with doulas from diverse backgrounds.

On the half-moon bench inside the RV, Watson, a doula and a midwife in training sit with patients. They take blood pressures and draw blood. They ask the women about their lives: How is their mental health and sleep? Do they have support at home? Do they want to give birth at a hospital or birth center with a midwife?

Taylor said pre-eclampsia, a dangerous pregnancy condition, runs in her family. She wanted to make sure she had space and time to express her concerns about her first pregnancy.

Taylor said she wants a midwife for her delivery. Many women of color have reported feeling marginalized or dismissed in medical settings. “I’ve just seen too many people have bad experiences,” Taylor told Watson.

The U.S. has markedly higher maternal mortality and infant mortality rates compared with other high-income countries, and women and babies of color fare the worst. Black women’s maternal death rates are three times higher than those of white women, and American Indian and Alaska Native women’s rates are twice that of white women. Researchers point to implicit bias, less regular access to prenatal care and higher rates of poverty.

OB-GYN shortages and labor and delivery units closing continue to make getting care harder. Last year, more than two dozen hospital labor and delivery units across the nation closed, including some in South Florida. And pregnant patients living miles away, or feeling uneasy about going to the doctor, may even forgo care.

Midwives can help fill gaps, maternal health equity advocates say, and mobile clinics can meet patients where they are.

“It really helps to disrupt this idea that patients must navigate these complex systems to receive care — and instead, (mobile midwifery) reimagines care as something that should be responsive to the needs of patients and should be community-centered,” said Tufts University professor and maternal health scholar Ndidiamaka Amutah-Onukagha.

But mobile units are not as common for midwifery as they are for other areas of care, such as dentistry or family medicine, the American College of Nurse-Midwives told Stateline. Other prenatal mobile outreach efforts in the state include an OB-GYN-run mobile unit by the University of Florida that serves areas around north-central Alachua County and an operation called The Midwife Bus in Central Florida.

To increase access to care, maternal health advocates are also pushing states to change regulations that restrict midwifery. The American College of Nurse-Midwives recently filed a lawsuit against Mississippi for requiring nurse-midwives to have agreements with physicians in order to practice. This week, Jamarah Amani, a midwife and the executive director of the Southern Birth Justice Network, joined other plaintiffs in filing a lawsuit against Georgia over its restrictions. But supporters of the rules say they are meant to protect patients and foster communication between clinicians.

Offering culturally centered prenatal care that women are more inclined to use can help address inequities in maternal health, Amani said. The group trains doulas, offers telehealth, provides referrals such as to mental health therapists, and advocates for equitable policies across the South.

Most of the mobile clinic’s clients — about 70% — are on Medicaid or uninsured, and the clinic is funded through federal and university grants, as well as donations.

“(Midwifery) presents like a luxury concierge-type of service,” Amani said. “Our goal is to really change that and to bring it back to the community in a very grassroots way.”

Preserving tradition

The Southern Birth Justice Network keeps a small drum on a table at a nearby booth. It represents the heartbeat, and ancestral reverence, Amani said. Drums are a universal language, and the instrument is meant to symbolize culture.

For doulas and many midwives like Amani and Watson, bringing their profession to communities today is the continuation of a significant part of Black American heritage.

Throughout history, Black midwives were venerated in their communities. Many practices were rooted in West African traditions. These midwives were the keepers of Black ancestral records, and delivered many white women’s babies. Enslaved women who were midwives traveled for deliveries. Some routes, long and traversed by foot, were dangerous in the deep rural South. During the Jim Crow era, Black Americans were denied care at hospitals or given inferior care.

“They only had protection if someone would send a carriage for them if they were going to deliver a white woman’s baby. But to care for the Black families, they often had to go in the middle of the night, alone,” Amani said. “We talk about the legacy of Black midwives as health care providers, but also as social pillars, as community leaders, as resistors of oppression.”

In the 20th century, medical institutions began to oppose midwifery, sometimes using racist and sexist campaigns to target the practice. They argued it was unhygienic and lobbied across states to dismantle midwifery. At the same time, while developing the field of obstetrics, doctors conducted gynecological experiments on Black women. The American College of Obstetricians and Gynecologists has acknowledged this history and said it’s committed to fighting racism and inequities.

Dr. Jamila Perritt, an OB-GYN and president and CEO of Physicians for Reproductive Health, said that in order to address structural barriers and close gaps, policies have to prioritize access to care, such as allowing midwives to expand their practices. Throughout the South especially, states still restrict midwives from practicing independently, despite widespread maternal health care deserts. She also pointed to research showing midwifery is associated with fewer C-sections, less preterm labor and better patient satisfaction.

“Expanding access to midwifery care, and expanding collaborations between physicians and midwives, only improves outcomes,” Perritt said.

Cultivating trust

On a recent breezy and brisk Saturday morning, the Southern Birth Justice Network’s midwives and doulas were stationed in the parking lot of the Freedom Lab, a local community center that hosts food and clothing distribution and a free urgent care center.

At the booth by the mobile clinic, under the shade of a royal-purple awning, meditation music, low-key and mellow, reverberated from a small speaker. There was a cooler filled with oranges, water and other snacks for the clinic’s pregnant patients.

“I’m going to keep giving you food. You need to eat enough,” one doula told a patient, handing her an orange and a liter of spring water.

Staff had surveys to help assess a new patient’s needs, and Florida-specific pamphlets on pregnant patients’ rights. The group is working on other state-specific guides for Louisiana, Massachusetts, Tennessee and Texas.

The table also held a portrait of the late midwife Ada “Becky” Sprouse, who started the mobile midwife clinic around 2008. She’d drive it to the city of Homestead, an agricultural hub in Miami-Dade County. There, she offered free midwifery care to migrant farmworkers, many of whom couldn’t afford care throughout their pregnancies.

Sprouse passed the clinic on to Amani, who relaunched the mobile unit and broadened the scope of the Southern Birth Justice Network.

Patients told Stateline trust was one of the main reasons they sought out the clinic. One patient said she spent 2 1/2 hours on public transit that day so that she could see the team.

For now, deliveries take place at hospitals or neighboring birth centers, where some of the group’s midwives also work. But the organization recently bought a building to open its own freestanding birth center, aiming for next year, along with a larger RV.

One patient, Isis Daaga, turned to Amani to deliver her other children after her first birth at a hospital. Despite the pressure she felt and her need to push during labor, Daaga recalled, hospital staff prevented her from delivering.

“They literally held my knees together,” Daaga said. “They were like, ‘the doctor’s not here yet,’ and the nurses were scared to deliver the baby.” In many hospitals, protocol is to wait for the doctor in case an emergency occurs.

By the time the doctor came, Daaga had a severe perineal tear, and she delivered the baby in one push. She had been in labor for 15 hours.

“I was in pain, I was upset,” said Daaga, a mental health therapist who is 35 weeks pregnant.

At the mobile clinic and with the midwives, Daaga said she feels supported.

“They make me feel the way I try to make my clients feel, like, it’s a safe space. You’re not judged here. I have a lot going on,” she said. “If I’m MIA or something, most of them will call and text me and (say), ‘Girl, you need to come in.’”

Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org.

All 41 states that expanded Medicaid eligibility under the Affordable Care Act will see fewer people covered due to new federal work requirements and more frequent eligibility checks. But the percentage of recipients who lose coverage will vary greatly from state to state, depending on how state officials implement the new rules, according to a new report.

The report, released this week by the Urban Institute with support from the Robert Wood Johnson Foundation, projects that in 2028, between 4.9 million and 10.1 million people will lose coverage as a result of the federal policy changes included in the broad tax and spending measure President Donald Trump signed last summer. That prediction is roughly in line with estimates by the Congressional Budget Office, which projected last fall that the changes would increase the number of people without health insurance by 7.5 million in 2034.

Whether the actual number ends up at the low end or the high end of that estimate will depend on state policy, according to the researchers. States that automatically check eligibility using data-matching, impose the minimum work requirements allowed under federal law and broadly define certain exemptions, such as those for “medical frailty,” will minimize the number of people who lose coverage.

On the other end of the spectrum, states that require stricter documentation of work hours and implement narrower exemptions will see more people dropped from the rolls.

With stricter state policies, the report projected that eight states — Connecticut, Massachusetts, Maryland, Minnesota, Missouri, New York, Vermont and Wisconsin — would see a decline in enrollment of 60% or more. (Wisconsin hasn’t expanded Medicaid under the ACA, but it was included in the study because it received a federal waiver that makes some of its Medicaid enrollees subject to work requirements.)

Arkansas, Idaho, Montana, North Dakota, Nebraska, New Mexico, Oklahoma and Oregon would have the smallest declines under strict policies, but would still see losses ranging from 37% to 46%.

With the least stringent policies, North Dakota and South Dakota would have the smallest declines — 18% and 19%, respectively. Even under lax rules, six states — Connecticut, Massachusetts, Maryland, New York, Virginia, Vermont —- would see declines of 30% or more.

Nationwide, between 19% and 37% of people who already work will lose Medicaid coverage, according to the analysis, due to challenges such as fulfilling the documentation requirements to prove that they work.

States have to enforce work requirements by next January. They may enforce them earlier via a waiver or state plan amendment, but so far only one state, Nebraska, has announced a plan to implement the requirements earlier, in May.

Some groups are exempt from the work requirements, including American Indian and Alaska Natives, people deemed “medically frail,” households receiving benefits through the Supplemental Nutrition Assistance Program, caretakers for children under age 13 or for those with disabilities, foster care youth and former foster care youth under age 26, among others.

Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org.

Federal Medicaid cuts could exact a heavy toll on psychiatric units at hospitals across the country, many of which are already struggling to keep their doors open but provide essential mental health care to people who need it.

Psychiatric units are costly and, like labor and delivery services, typically lose money for hospitals and tend to be reimbursed at lower rates than other health services. In contrast, some specialty units, such as cardiovascular care, are lucrative: Cardiologists can generate up to seven times their salaries for hospitals.

Between 2023 and 2024, 126 hospitals across the U.S. shut down their inpatient psychiatric units, according to data provided to Stateline by the American Hospital Association.

“(Psychiatric units) are often in the red, and, for lack of a better word, kind of subsidized by the rest of the health system,” said Sarah Steverman of the National Association for Behavioral Healthcare. Steverman oversees regulatory affairs and is the liaison for a committee of hospital psychiatric unit administrators and clinicians.

The One Big Beautiful Bill Act that President Donald Trump signed into law last year will add to the strain, Steverman and other experts say.

The law is projected to cut federal Medicaid spending by an estimated $886.8 billion over the next decade, largely because new work requirements will push people off the rolls, according to estimates by the Congressional Budget Office. CBO estimates that it could increase the number of people without health insurance by 7.5 million in 2034.

Those cuts will have a significant effect on mental health care because Medicaid, jointly funded by the federal government and the states, covers more people with mental illness than any other public or private insurer — roughly 29% of the estimated 52 million nonelderly adults with mental illness, or about 15 million people, according to health research group KFF.

Behavioral health policy experts say the Medicaid changes will force hospital psychiatric units to provide care to many more people who don’t have insurance. Even before the law, Medicaid often didn’t fully reimburse hospitals for the cost of mental health care, unit administrators said.

Along with increasing the number of people without insurance, the One Big Beautiful Big Act places new limits on states’ ability to maximize federal funding and reimburse providers.

The federal government allows states with contracted Medicaid managed care organizations running their Medicaid programs to direct them to pay providers more. But beginning in 2028, the One Big Beautiful Bill Act will cap these state-directed payments, forcing state Medicaid programs to reduce reimbursement rates by 10 percentage points each year until they reach either 100% or 110% of what Medicare pays.

The federal law also caps provider taxes, a strategy states have used to boost the Medicaid dollars they get from the federal government.

As a result, states will face the choice of replacing the lost federal money with state dollars, scaling back services or providing coverage to fewer people.

Conservatives who have backed the Medicaid cuts say such tools are accounting tricks that states have used to draw down more federal money. Some have even called the provider taxes a “money laundering” scheme. Eliminating them, they say, will force states to be more accountable for their Medicaid spending.

“States are gaming the system — creating complex tax schemes that shift their responsibility to invest in Medicaid and rob federal taxpayers,” Dr. Mehmet Oz, the administrator of the federal Centers for Medicare & Medicaid Services, said in a news release last year.

But Angela Kimball, chief advocacy officer at Inseparable, a mental health advocacy organization, said the tools are essential, and that the cuts will be detrimental.

“For the mental health system, and particularly for facility-based care, it (Medicaid) is the financial foundation. And when you simultaneously reduce who’s covered, what providers get paid, and limit the tools states have to make up the difference, you’re not just trimming around the edges; you’re undermining the whole structure,” Kimball said.

The mental health field is also struggling with workforce shortages across states, especially in rural areas. As of December 2024, more than 122 million Americans lived in designated mental health professional shortage areas.

Dr. Arpan Waghray, a psychiatrist and CEO of Providence’s Well Being Trust, serves as a member of the American Psychiatric Association’s Council on Healthcare Systems and Financing. Providence has 16 psychiatric units across Alaska, California, Oregon and Washington state, and Medicaid and Medicaid HMOs account for 42% of patients across those units. That number increased as the states expanded eligibility under Obamacare.

In contrast, Medicaid pays for roughly 13% of oncology inpatients and about 10% of cardiology inpatients across the hospital systems.

“Inpatient psychiatric units, especially when they’re part of larger hospitals and academic centers, like our community hospitals … they generally tend to operate on a loss,” Waghray said. “We are no exception to that.”

He noted that estimates show psychiatric units have a negative operating income of about 37%.

“We don’t want to make a profit on psychiatric units,” he said, adding the goal is to at least “break even.”

Waghray said if more units are forced to shutter, that will lead to more crowding in emergency rooms and jails. Often, jails and prisons — facilities with inadequate care — end up being mental health care providers for people who lacked access to care. People in crisis also may be forced to wait for a psychiatric bed to open up elsewhere.

“It has this cascading effect that touches everyone’s lives,” Waghray said. “The two places where people get care if they don’t get care in the right setting is the inpatient (psychiatric) unit, and you cut that, then essentially you have emergency departments that are overcrowded or jails that are overcrowded.”

Health economist John McConnell, director of the Center for Health Systems Effectiveness at Oregon Health and Sciences University, said “the whole mental health system is really going to get hit with a shock here.”

“Crisis care funding is all over the place, and there’s not really a consistent way of funding it, and it’s often underfunded,” he said. “You had a fragile system … made more fragile with a lot of the executive orders from the Trump administration — and then (the new federal law) has sort of further chipped away at it.”

Steverman said that people with severe mental health emergencies — such as acute psychosis, mania or suicidality — who need urgent treatment after emergency room intake often require multiple clinical staff and observation.

Gretchen Clark Bower, senior director of Behavioral Health Services at Providence Regional Medical Center Everett, in Washington state, said the hospital’s inpatient psychiatric unit, which opened about five years ago, relies heavily on Medicaid: Roughly 80% of psychiatric inpatients are covered by Medicaid, and many have severe illnesses.

“It has been a stretch financially for a long time,” Bower said. “The costs of providing care are far more than what we’re getting reimbursed. And that is extremely challenging.”

Everett’s average psychiatric hospitalization is about 16 days. But sometimes, insurers will only cover up to a certain number of hospitalization days for mental health, Bower said. That leaves the hospital to absorb the rest of the costs.

“We want to make sure that we are discharging people when they are safe to discharge — not just when their insurance stops paying,” Bower said.

Bower said she worries the cuts will destabilize people if their care gets interrupted after losing coverage, putting more pressure and costs on the health system.

“It worries me a lot,” she said. “How do we continue to take care of our community into the future, and how do we sustain ourselves financially as we do that? It’s an incredibly difficult task.”

A report from the American Psychiatric Association found that states that had expanded Medicaid eligibility saw smaller increases in suicide compared with nonexpansion states: Medicaid expansion was associated with about 0.4 fewer suicides per 100,000 people yearly.

“Combined with workforce shortages and long-standing insufficient reimbursement for psychiatric services, further reductions in Medicaid will increase pressure on already struggling facilities,” said Ben Teicher, spokesperson for the American Hospital Association. “Our members have been worried about their psych units for a long time, and any further erosion of what Medicaid pays for would make it even worse.”

Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org.