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Story Publication logo April 9, 2024

Forgotten Mothers of Arkansas: State With Worst Maternal Health Outcomes Fails To Support Postpartum Mothers


The postpartum period is the deadliest stage of the pregnancy journey.


A home near Conway Lake in Arkansas, one of the most rural states in the United States, on November 9, 2023. Image by Florence Middleton. United States.

Nine weeks after giving birth to her fourth child, Rudy Gibson’s eyes were watery from exhaustion. She had not slept well the prior two nights, but still, she woke up at 4:45 a.m. and began her routine.

Gibson quietly climbed off the air mattress on her living room floor while her newborn son slept peacefully in a crib a few feet away. It was dark, but she began doing her hair in the living room mirror. She only had a few minutes before it was time to feed her son. Her 1-year-old daughter, snuggled up in a pink, fuzzy blanket, slept on the couch.

With four children and two under 2 years old, Rudy Gibson plans her children’s outfits for the week and lays them out the night before to make her morning routine a little less stressful. Image by Florence Middleton. United States, 2023.

By 7:00 a.m., Gibson had fed her newborn, washed, dressed, and fed her 1-year-old, finished her own hair and makeup, made sure her 10-year-old was ready, woke up her 16-year-old, and loaded her kids into the car. They drove off to begin their day. Gibson was starting a new job at a day care center and her two youngest were coming with her. 

Gibson, of Jonesboro, Arkansas, described her postpartum experience as chaotic.

“It has not been a good time for me,” said Gibson, reflecting on the moment her postpartum experience took a turn.

Three days after her son was born, Gibson called her doctors to schedule a much-needed dentist appointment and the standard six-week postpartum visit. To her surprise, she discovered that her Medicaid—the U.S. public health insurance offered to people who qualify as low-income—was suddenly terminated. 

Gibson’s early postpartum period was not a time of rest and recovery. Instead, she spent her early postpartum period fighting for health insurance while caring for her children. At four weeks postpartum, she got pink eye. At eight weeks postpartum, she started her new job. Many evenings, she applied eyelashes for clients in her living-room-turned-beauty-parlor. 

The Guidelines for Perinatal Care recommends that women with uncomplicated pregnancies receive 15 checkups before birth but only one after birth, despite alarming postpartum maternal mortality and morbidity statistics. Still, 40% of women do not receive a single postpartum health care visit. Image by Florence Middleton. United States, 2023.

The maternal mortality rate in the United States is the worst in the world among high-income countries. Arkansas, where Gibson resides, has the highest rate in the nation. But most of the deaths do not occur during pregnancy or birth. According to the Centers for Disease Control and Prevention (CDC), 65% of pregnancy-related deaths occur during the postpartum period, or the first 365 days after birth. Despite this, many women in the U.S. navigate their postpartum period with little support and without health care. 

Medicaid covers 41% of all births in the United States and 44% in Arkansas. In Arkansas, postpartum health care coverage ends after two months for many Medicaid recipients. In 2023, the federal government gave states the opportunity to permanently extend this coverage to 12 months after birth. Arkansas was one of only three states to decline. 

“It’s a tragedy,” said Dr. Zenobia Harris, executive director and president of Arkansas Birthing Project, a nonprofit that supports some of Arkansas’ most vulnerable mothers during pregnancy and through one-year postpartum. “Two months after the baby's born, they don't have coverage anymore. If people have undiagnosed hypertension or diabetes and they're not getting care, they're more likely to die.”

And for some like Gibson, mothers are losing their health insurance even earlier than two months without understanding why.

Rudy Gibson worked as a welder in Jonesboro, Arkansas, but was required to stop working when she learned of her pregnancy. Research evidence suggests that the job’s manual labor and exposure to hazards, such as welding fumes, increase adverse pregnancy outcomes, including fetal loss. Image by Florence Middleton. United States, 2023.

Arkansas’ maternal health crisis

According to the CDC, Arkansas had 43.5 maternal deaths per 100,000 live births between 2018 and 2021, compared to the national rate of 23.5 deaths per 100,000.

Aware of the crisis, the Arkansas legislature passed House Bill 1440 in 2019 to establish the Arkansas Maternal Mortality Review Committee (AMMRC). The committee launched the following year through the Arkansas Department of Health with the goals of improving maternal health and reducing maternal deaths by collecting and analyzing data and making recommendations.

Republican state Rep. Aaron Pilkington, shown in the Arkansas Capitol on November 6, 2023, has a background in health and works in administration for a federally qualified health center. He has focused much of his legislative career on maternal health. Image by Florence Middleton. United States.

The Arkansas state Capitol in Little Rock on November 6, 2023. Image by Florence Middleton. United States. 

According to the Arkansas Maternal Mortality Review Committee 2022 Legislative Report, the primary causes of pregnancy-related deaths in the state are cardiomyopathy, cardiovascular conditions, hemorrhage, hypertensive disorders of pregnancy, and infection. Ninety-one percent of the deaths are preventable, the report said. Many of these deaths occur during the postpartum period. 

Rudy Gibson with two of her daughters, Chosen Gibson, 1, and Alexis Smith, 10, at their home in Jonesboro, Arkansas. on November 6, 2023. Image by Florence Middleton. United States.

Harris, former regional director with the Arkansas Department of Health, said complications arise because many Arkansans enter their pregnancy with existing health issues, whether they know it or not. Many of the issues are chronic.

“We have a huge obesity issue in many of our communities, which is taxing on the cardiovascular system. Women with undiagnosed diabetes don't receive care and then get pregnant. That puts stress on all their major organ systems,” said Harris. “They develop eclampsia and pre-eclampsia and go into cardiac arrest.”

Additionally, many women live in rural counties considered maternal health deserts. Forty-one percent of Arkansans live in rural counties compared to 14% of Americans, according to the state of Arkansas. The March of Dimes reports that 60% of Arkansas’ counties have no or low access to obstetric care.

The Arkansas state seal is projected on the floor of the Capitol on November 8, 2023. Image by Florence Middleton. United States.

Loretta Alexander, former health policy director at Arkansas Advocates for Children and Families, said that even when obstetric services are available, many Black women receive inferior care because medical practitioners do not listen to their health concerns.

“No matter what their economic status is, no matter what their education status is, no matter how much money they have, no matter how good their health insurance is, no matter how good their doctors are,” Alexander said. “They are having more problems, and the problems are more deadly.”

The AMMRC found that for all pregnancy-associated deaths in the state, Black mothers are twice as likely to die compared to white mothers.

Before the sun rises on November 8, 2023, Rudy Gibson gets ready in the early morning while her 1-year-old daughter and 2-month-old son are still asleep. Many nights, Gibson sleeps in the living room with her two youngest children so that she can get them ready in the mornings without waking others in the house. Image by Florence Middleton. United States.

An opportunity for change

In Arkansas, an individual qualifies for Medicaid if they earn less than 138% of the federal poverty level for a single-person household, or $20,120 in 2023. If a woman is pregnant, the threshold is higher–-214% of the federal poverty level for a two-person household, or $42,200 in 2023. Once the mother gives birth, her coverage terminates after 60 days. If she earns less than 138% of the federal poverty level, she can reapply. If she earns more, she no longer qualifies. 

This policy, Alexander said, is causing women to lose their health insurance during a vulnerable time. 

The women who no longer qualify need to buy health insurance elsewhere, and they may have to change medical providers. They are likely going to have a gap in service, she said. 

In 2021, the Congressional Budget Office estimated that after 60 days, 45% of postpartum women in the U.S. would be uninsured.

Rudy Gibson applies makeup while holding her newborn son, Kulture, on November 8, 2023. Image by Florence Middleton. United States.

Searching and paying for new health insurance shortly after giving birth can be daunting, said Alexander.

When pregnant, Rudy Gibson suddenly lost her Medicaid coverage around month four because of administrative errors at the Department of Human Services, she said. She did not receive prenatal care for about three months, during a time when she feared she may have had gestational diabetes. Gibson made it a habit to contact Medicaid every one to two months thereafter to try to maintain her coverage. Image by Florence Middleton. United States, 2023.

“What I tell people is: Close your eyes and imagine having a difficult prenatal problem, having a tough delivery, and having a sick baby that maybe spent some time in the hospital. You may have spent some time in the hospital yourself. And two months out, you're looking at postpartum depression. Then all of a sudden, you get this letter saying, ‘Oops, bye!’ Are you really gonna get up and go look for some more insurance?” Alexander said. “No, you're going to pull the cover over your head and say, ‘I just can't.’”

Harris added that even women who do qualify to stay on Medicaid struggle to keep their coverage. They must submit paperwork to get reverified, and many struggle to get re-enrolled in a timely manner. 

According to the Arkansas Department of Human Services' policy, Medicaid coverage for pregnant women in the state extends through 60 days postpartum. However, three days after giving birth, when Gibson tried to schedule a postpartum checkup and a dentist appointment, her providers informed her that her Medicaid was no longer active. She was surprised, she said, because she never received a termination notification from Medicaid. When she called the Department of Human Services to get answers, she was told she needed to go to the office in person. Just days after giving birth and caring for four children, she could not do it. 

When Gibson went to the Department of Human Services more than a month later, she was told that pregnant women lose coverage immediately after giving birth, she said, despite the 60-day postpartum policy. She was instructed to apply for the standard Medicaid and to wait. 

“Women [experience] challenges in getting their applications in and getting them processed in a timely manner. Some of it is because the Department of Human Services often is understaffed, so applications might sit for a longer period of time than what's really desired. The requirements can be so stringent, it's difficult to put all your ducks in a row,” Harris said. “It's not made to be an easy process.”

Flags fly above an Arkansas Civil War monument in Jonesboro, where Gibson lives, on November 8, 2023, recognizing the birthplace of several Confederate military companies in the 1860s. Image by Florence Middleton. United States.

Prior to 2022, health insurance terminated after 60 days postpartum for many women receiving Medicaid in most U.S. states. But that year, the American Rescue Plan Act gave states the option to temporarily extend the insurance from 60 days to 12 months to prevent coverage disruptions. In 2023, the Consolidated Appropriations Act gave states the option to make the extension permanent. With the extension, a new mother’s coverage would continue after birth for a full year despite any changes in her circumstances such as income or household composition.

In 2022, the Arkansas Maternal Mortality Review Committee and Arkansas Advocates for Children and Families urged the state legislature to address the maternal mortality crisis by permanently adopting the Medicaid postpartum coverage extension. In late 2022, state Rep. Aaron Pilkington, R- Knoxville, introduced House Bill 1010 to propose the extension.

Rudy Gibson feeds her daughter Chosen breakfast on November 8, 2023. Image by Florence Middleton. United States. 

That same year, after the U.S. Supreme Court overturned Roe v. Wade, Arkansas adopted one of the nation’s strictest abortion bans by prohibiting abortions entirely, except to save the life of the mother. Pilkington, who opposes abortion, said the ban creates a renewed focus on his maternal health efforts.

“If we say we care about the baby, it means taking care of the mother, too, and making sure that after the baby is born, they have everything they need to have a healthy postpartum experience,” said Pilkington. “If you're going to say that you're pro-life, put your money where your mouth is.”

Rudy Gibson dresses her daughter on November 8, 2023. Image by Florence Middleton. United States.

In May 2023, the Arkansas legislative session closed without passing House Bill 1010.

“We have all this data. We know what's going on. And yet, there's very little happening to address it in a timely and efficient manner,” said Harris. “We just don't seem to have the political will to address the needs of these people. That's the real deal of it.”

Although Pilkington sponsored the bill, he did not present the bill for formal debates or voting during the 2023 legislative session. He did not feel he had the support required to pass it, he said.

“Hearing that you're going to basically expand Medicaid,” Pilkington said, “[legislators] always get a little nervous about that.”

Pilkington projected that maintaining postpartum coverage for 12 months would have cost approximately $2 million. But overall, he believes the expansion would have resulted in cost savings to the state by reducing health complications through preventive care and by reducing the number of emergency room visits.

Rudy Gibson applies eyelashes for a client in her living room on the evening of November 6, 2023. Next year, Gibson hopes to enroll in school to change careers. She is interested in cyber security because she can work remotely and still care for her children. Image by Florence Middleton. United States.

Pilkington said the barriers are not just cost-related. Maternal health is not widely discussed or understood by legislators, who are predominantly male, he said.

In February, Arkansas Gov. Sarah Huckabee Sanders, a Republican, said during a maternal health roundtable discussion that she does not support extending Medicaid postpartum coverage to 12 months. Instead, she created a maternal health steering committee that will draft recommendations within six months on how to increase women’s enrollment in existing services. 

Sanders did not include Pilkington on the committee. 

The 2024 Arkansas legislature was scheduled to convene its fiscal session on April 10 and adjourn in May. By the time the committee's report is complete, Pilkington said, the 2024 legislative session will be closed. It will be too late to incorporate any new policies this year that would support the recommendations. 

“I waited for over a year,” Pilkington said, referring to last year’s legislative session that failed to extend postpartum Medicaid. “I'm not going to wait around and not pursue a policy that can help.”

While he hopes it is successful, Pilkington is concerned that Sanders’ new approach will miss the mark. Mothers are often aware of existing services, he said, but the access barriers are complex, changing government systems to improve access is slow, and public awareness campaigns are oftentimes ineffective.  

Increasing access to care in maternal health care deserts

Nicolle Fletcher travels across Arkansas to improve maternal outcomes in her own way. She is the owner of Nurturing Arrows Doula Services and co-founder, visionary, and executive director of Ujima Maternity Network Inc. Multiple times a week, Fletcher, a certified doula and certified lactation counselor, drives her minivan to some of Arkansas’ most rural areas to support and advocate for her clients during their pregnancy, birth, and postpartum periods. She is also a doula trainer and an apprentice midwife.

Nicolle Fletcher of Conway, Arkansas, is an apprentice midwife who is aiming to become Arkansas’ only certified professional midwife of color in 2024. Certified professional midwives, or lay midwives, work outside hospital settings and frequently provide health care for pregnant, birthing, and postpartum women in their homes. Image by Florence Middleton. United States, 2023.

Fletcher drives hundreds of miles each month because she feels a responsibility to address the poor maternal health outcomes in her state, she said. She has witnessed serious health complications arise more than 60 days after birth and sees these problems exacerbated for Black mothers. 

In 2019, Fletcher received a frantic call from a client, a Black mother who was nine weeks postpartum. Her client was suddenly bleeding profusely, and her pad was overflowing with blood. Fletcher advised her client to call the hospital, but when the mother did, she was told to just lie down. Fletcher told her to go to the emergency room immediately. When she arrived at the emergency room, her client was made to wait for 10 hours and almost lost consciousness multiple times.

“You need to listen. You need to believe what I'm saying. And even if you don't believe it, act like you do and then prove me right or prove me wrong. But do your due diligence,” said Fletcher. “Women are suffering and dealing with foolishness because urgent matters are not being taken urgently. She was a morbidity and could have very easily become a mortality.”

“If I could just be truthful, it’s hard. It’s beautiful, but it’s taxing, hard work,” said Nicolle Fletcher as she reflects on her work as a doula driving hours across Arkansas. When she becomes a licensed midwife, she expects the work to be even more demanding. Image by Florence Middleton. United States, 2023.

Fletcher believes that expanding the midwifery model across Arkansas would help address the state’s maternal health crisis by increasing the quality of care in maternal health deserts.

The Guidelines for Perinatal Care recommend that postpartum women receive one medical checkup within the first six weeks after birth. In Arkansas, some mothers travel one to two hours to their obstetrician for their care. 

Fletcher offers checkups at 24 hours, day four, weeks one, two, four, and six after birth, which is a standard midwifery approach, she said. Frequently, midwives travel to their patients’ homes, alleviating the stress of traveling with a newborn shortly after giving birth.

Nicolle Fletcher outside her clinic in Conway, Arkansas, on November 8, 2023, where she provides doula services to clients two days per week and trains other women to become doulas. Other days, Fletcher drives to clients, sometimes traveling more than 100 miles to provide services in their homes. Image by Florence Middleton. United States.

While both models conclude formal care at six weeks postpartum, the midwifery model’s approach emphasizes preventive care, Fletcher said. If there are signs of complications, a midwife can extend care or refer the patient to a doctor as needed.

Through Ujima Maternity Network Inc., Fletcher hopes to train more midwives throughout the state so that women, even in rural areas, can receive specialized care from midwives in their own communities. Currently, there are no certified professional midwives of color who deliver and care for mothers outside hospitals.

While Fletcher is building something that does not currently exist, she dreams of restoring a tradition that previously existed for generations.

For generations, skilled Black women known as “granny midwives” were the primary providers of prenatal, delivery, and postpartum care. However, in the early 1800s, new legislation called for the regulation and licensing of midwifery care. Many granny midwives had been denied access to education, were illiterate, and were no longer allowed to practice. Some granny midwives continued to serve Black women who were denied access to hospitals and poor white women. Eventually, no granny midwives remained.

The junction where the Little Maumelle River and the Arkansas River meet in Little Rock, on November 8, 2023. Image by Florence Middleton. United States.

Women should have the choice to receive care from medical providers from their own communities, Fletcher said.

Arkansas Gov. Sarah Huckabee Sanders announced in February that she does not support extending Medicaid postpartum coverage to 12 months. Instead, she created a committee in March to explore ways to connect mothers to existing services. Republican state Rep. Aaron Pilkington worries mothers will continue falling through the cracks. Image by Florence Middleton. United States, 2023.

“While we may not be able to [do everything] like a hospital or OB-GYNs, in these maternal health care deserts, we can train direct entry midwives to provide these services like it once was. Then we don't have this big void,” said Fletcher. “We have some support available.”

Currently, Arkansas’ Medicaid program does not cover the cost of certified professional midwives who provide maternal care outside hospitals.

Maternal health experts across Arkansas believe that to improve maternal health outcomes in Arkansas, it’s going to take a multipronged, collaborative approach.

Pilkington continues working with legislators and the Department of Human Services to better understand where mothers are falling through the cracks. He plans to run the Medicaid postpartum health care extension bill again during the legislative session launching on April 10.

Fletcher hopes to receive her midwifery license in 2024, which would make her the only Black certified professional midwife in Arkansas providing maternal care to women directly in their homes.

“This is one of the most important issues we're facing right now in our state. It's going to affect everybody, whether they think it's going to affect them or not,” said Pilkington. “How can we expect people to live in Arkansas if they’re afraid to have a baby because the outcomes are so terrible? Why don't you help me make Arkansas the best place to have a baby? Right now, we're the worst. Let's make it the best.”

Gibson finally had her “six-week postpartum visit” at eight weeks after birth, but she had to pay out of pocket—$276. She eventually got approved for standard Medicaid and was able to go to the dentist to take care of her overdue root canal and go to the eye doctor to address her possible glaucoma. Gibson waited nearly three months after giving birth with no health care coverage before she was re-enrolled in Medicaid again. 

Light streaks across an open field during a calm moment amid a storm in Cash, Arkansas, on November 8, 2023. Image by Florence Middleton. United States.