Victoria Ferrell Ortiz remembers her first hospital experience after becoming pregnant in 2017. She had bad nausea, sometimes not being able to keep food down for days. She and her partner went to get it checked out, but something felt off.
“It was just a terrible experience laying down on the hospital bed,” Ferrell Ortiz said. “It hurt my back tremendously for some reason. It was just overall uncomfortable, uninviting, and it felt like it was a space that wasn't meant for me.”
The Oak Cliff resident was finishing up a nonprofit placement, which offered her a small stipend but no health insurance. She applied for Medicaid when she found out she was pregnant, in June 2017. She was proud to be from predominantly Hispanic and Latine neighborhoods in West Dallas, and wanted her child to be born in Oak Cliff. But when she started looking for options, local clinics had the same uninviting feel as the hospital.
“That experience helped me realize that I wanted something different for whenever I gave birth to my child,” Ferrell Ortiz said. “And I began researching the different pathways that I had. But I had to do that research.”
She said she spent hours calling the Medicaid support hotline to understand her coverage and which hospitals and clinics would take her insurance.
“That was a really huge privilege because it took so much time just sitting there, waiting to speak to someone,” Ferrell Ortiz said. “Sometimes the representative that I would speak to wouldn't know the answer. So, I would have to wait for follow up and hope that they actually did follow up with me.”
The whole process felt daunting, and she just wanted someone to walk her through her options in a way that felt personal.
“I wanted someone to be able to feel my humanity in a system that I felt like was trying to push down that fact,” Ferrell Ortiz said.
Medicaid eligibility in Texas for pregnant people
More than 468,000 pregnant Texans rely on Medicaid as of November 2022, the latest data available. Medicaid accounts for about half of all births in the state.
More than 5.7 million people in Texas are covered under Medicaid overall, which includes disability care, children’s Medicaid, cancer treatments and elderly care. Nationally that number is over 90 million.
In Texas, more than 49% of Medicaid recipients are Hispanic and Latine, 15% of recipients are Black, and about 17% are white, according to data from Texas Health and Human Services. The data for pregnancy enrollment is similar: 53% Hispanic/Latine, 19% Black and 23% white.
To qualify for pregnancy Medicaid coverage in Texas, people have to make about 200% below the federal poverty line. For a family of three, that means their income can’t exceed $3,800 a month, or about $45,600 a year. MIT’s living wage calculator for Dallas County estimates a family of three would need a yearly take-home of more than $67,000 to pay for food, child care, medical costs and housing.
Medicaid in Texas offers health coverage through pregnancy and two months after giving birth, everything from prenatal visits to postpartum check-ups (private insurance typically covers 12 months, and enrollment often rolls over automatically). In the 2021 legislative session, Gov. Greg Abbott signed a bill extending pregnancy Medicaid coverage from two months to six months postpartum.
That extension was denied by the federal government in the fall of 2022; The Texas Tribune reported some legislators believed “the application was rejected because of language that could be construed to exclude pregnant women who have abortions, including medically necessary abortions.”
While pregnancy Medicaid covered Ferrell Ortiz’s pregnancy and the birth of her daughter, Amelie, she couldn’t find a physician in Oak Cliff that would take her insurance. She ended up finding care more than 20 miles away, in Richardson at Lovers Lane Birth Center, with a team of doulas and midwives.
Midwifery support, especially in Black communities, existed historically up until the 1960s when birth care shifted to clinical settings with more state regulation. More recently, Black and Latin doulas and midwives have become advocates for not only their clients, but for improving state policy that impacts pregnancy outcomes. Women of color have sought out these practitioners as an alternative to the hospital system.
“I'm so grateful that I found them because they were able to connect me to other resources that the Medicaid office wasn't,” Ferrell Ortiz said.
Lack of health care coverage leads to worse outcomes for pregnant people in Texas
Kari White, an associate professor at the University of Texas at Austin and the lead investigator with the Texas Policy Evaluation Project (TxPEP), said the things Ferrell Ortiz experienced were common for people on Medicaid.
Maternal health in Texas “from a bird’s eye view is a big patchwork with some big missing holes in the quilt,” White said.
White studies the impact state policy has on people’s reproductive health. A March 2022 TxPEP study surveyed close to 1,500 pregnant Texans on public insurance. The study found “insurance churn,” where people lost health insurance in the months after giving birth, led to worse health outcomes and challenges in accessing postpartum care.
“People are either having to wait until their condition gets worse, they forego care, or they may have to pay out of pocket,” White said. “There are people who are dying following their pregnancy for reasons that are related to having been pregnant, and almost all of them are preventable.”
For example, chronic disease accounted for about 20% of pregnancy-related deaths, according to the latest report from the Texas Maternal Mortality and Morbidity Review Committee’s (MMMRC). That includes everything from high blood pressure to diabetes in a 2019 sample of pregnancy deaths across Texas. Serious bleeding, or obstetric hemorrhage, and mental health issues were among the top causes of death.
“This is one of the more extreme consequences of the lack of health care,” White said.
Black Texans, who make up close to 20% of pregnancy Medicaid recipients, are also more than twice as likely to die from a pregnancy-related cause than their white counterparts, which is a statistic in Texas that has held true for close to ten years with little change, according to the MMMRC report.
Systemic issues in the healthcare system lead to such statistics. A lack of culturally competent providers; barriers to care like “cost, transportation, childcare, lack of meaningful communication with providers;” and even medical education and implicit bias that “impacts clinicians' ability to listen to Black people's experiences and treat them as equal partners in decision-making about their own care and treatment options” contribute to worse pregnancy health outcomes for Black people.
Midwives, doulas and insurance coverage for birth workers
What made the difference for Ferrell Ortiz and many other pregnant people across the state are doulas and midwives, who explained the process of pregnancy and offered more personal support.
“I really had no idea they were an option,” she said. “I think that they really homed in on me as a unique individual. I didn't feel like just a number.”
The hospital system for Ferrell Ortiz felt “sterile and cold,” and like she was competing with so many patients for her doctor’s attention. She said she has family members who are afraid to go to the hospital because of bad experiences they’ve had with doctors.
“It’s so counterintuitive, because going to the hospital is what you should do to take care of yourself in an emergency,” she said. “And yet there is so much personal experience that is not reflective of their mission. There has been harm done. That just wasn't in alignment with what I wanted.”
It’s the reason Becky Hines left her role as an OBGYN nurse in Dallas after 16 years.
“Everything was very much about logistics,” Hines said. “What is their baby's heart rate? What is the blood pressure? There was no relationship-building. It was all just numbers.”
She’s a midwife with Dallas Birth, a group of midwives, doulas, childbirth educators, lactation counselors, social workers and mental health counselors that support people through pregnancy.
Midwives are certified nurses that provide prenatal and postpartum care, along with delivering babies at a patient’s home or a birth center. In contrast, doulas are non-medical professionals who provide emotional support during pregnancy and act as advocates during the birthing process.
Hines said when she was a nurse, typical prenatal appointments lasted about 10 to 15 minutes, “which doesn’t give the patient time to discuss their needs.”
Hines said she performs the same kinds of tests and bloodwork as OBGYN offices, but also has conversations with patients about their family dynamics and any concerns they may have, whether related to the pregnancy or not.
“With our practice, we typically spend about an hour with our clients during their prenatal health [visits],” she said. “During that time, we’re able to get to know them as individuals. There's much more of a relationship that is built.”
Midwife and doula care lead to improved health outcomes for parents and babies
Plenty of data backs up the impact of relationship-building on people’s pregnancies. One 2022 study from the National Library of Medicine and National Institute for Health showed that people who received doula care had lower odds of postpartum depression and anxiety.
A 2021 study in the Journal of Midwifery & Women’s Health discussed how midwife models led to fewer c-sections, fewer preterm births, and fewer low birth weights.
Hines said she wishes there was more trust and safety built into people’s hospital experiences.
“I'm not anti-hospital,” she said. “I'm glad that it's available when it's truly needed. But there's a huge discrepancy. For people that need solid care, their choices are so extremely limited.”
Part of those limited choices are also because of Medicaid: certified midwives and birthing centers who are enrolled Medicaid providers are covered, but doulas aren’t. For example, Ferrell Ortiz’s birth and midwife was covered by pregnancy Medicaid at Lovers Lane Birth Center, but her doula was not, and if she was transferred to a hospital because of complications, she wasn’t sure what would be covered.
“To be a Medicaid provider in the state of Texas, it’s a real hassle,” Hines said. “Medicaid makes it very difficult for us. And then we also get paid a very minimal amount comparatively [to private insurance]. It’s a mess, honestly.”
Krystal Brown, a midwife and the current owner of Lovers Lane Birth Center, said reimbursement rates for Medicaid can be 50% less than a private insurance company.
“You shouldn't have to decide between seeing a Medicaid mom versus paying your rent for the month,” she said.
Brown’s practice is one of very few in North Texas that accepts Medicaid, but she has a small team—she can accommodate between 10-12 patients a month.
“I can’t reach everybody, but I’m trying to reach whoever wants me,” she said. “That’s what I always say: I want who wants me.”
For Hines, she said the practice offers discounted rates for people that don’t have insurance, but “it’s a real shame” that there’s limited options.
“I don't know honestly what we can do to fix it,” Hines said, “other than make sure our side of the street is clean and make [doulas and midwives] much more of the norm.”
Maternal health bills in the 2023 Texas legislature
A bill in the legislature this year, House Bill 465, would introduce a pilot program for doula services to be covered by Medicaid. Other bills would extend pregnancy Medicaid coverage to 12 months postpartum.
Hines said the only way to improve maternal mortality and morbidity data is for birth workers to work in tandem with hospital systems to advocate for pregnant people.
“The Texas health care system is the only place I’ve worked professionally,” Hines said. “It’s failing. There has to be a better way. It’s going to take a long time, but I think building relationships with other area providers and trying to bridge that gap is going to be huge.”
Ferrell Ortiz’s daughter is turning five this year. Amelie is artistic, bright, and vocal in her beliefs. When Ferrell Ortiz thinks back on being pregnant, she remembers how hard of a year it was, but also how much she learned about herself.
“Giving birth was the hardest experience that my body has physically ever been through,” she said. “It was a really profound moment in my health history — just knowing that I was able to make it through that time, and that it could even be enjoyable. And so special, obviously, because look what the world has for it.”
She just wishes people, especially people of color giving birth, had the chance to get the support they need.
“If I was able to talk to people in the legislature about extending Medicaid coverage, I would say to do that,” she said. “It's an investment in the people who are raising our future and completely worth it.”
This is the first in a series of stories investigating maternal and pregnancy health in Texas. If you have questions or tips, email erivera@kera.org. You can follow Elena on Twitter @elenaiswriting.
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