A call center aimed at providing proactive postpartum help to Arkansans will expand by the end of this year, intent on reaching every new mother in the days after she gives birth.

The center started making calls on May 1, said Dr. Nirvana Manning, director of the new Arkansas Center for Women and Infants’ Health. The Proactive Postpartum Call Center is one of three initiatives spearheaded by the center and paid for by a $5 million congressional earmark it received last fall, she said.

Rather than waiting for mothers to call with questions they might not know to ask, the call center will call them and provide information, resources and follow up care, said Manning, who is also the head of the University of Arkansas for Medical Sciences’ obstetrics and gynecology department.

Arkansas has some of the worst maternal health statistics in the United States — a point made repeatedly by speakers and panelists at a Wednesday roundtable hosted by ACWHI and UAMS and the Arkansas Hospital Association. This is especially true for people of color. Black women in Arkansas are twice as likely to have pregnancy-related complications as white women, according to Manning.

Arkansas has seen a number of its labor and delivery units close since the pandemic, worsening existing maternal care deserts in parts of the state.

Manning discussed the center’s initiatives as part of the Arkansas Maternal Health Roundtable, which focused on statewide strategies and collaboration to address the state’s maternal health crisis.

In attendance were the more than 100 administrators and clinicians from the state’s birthing hospitals; policy advocates; Republican U.S. Sen. John Boozman, who helped obtain the center’s startup funds; and state lawmakers, including GOP Reps. Aaron Pilkington of Knoxville and Lee Johnson of Greenwood.

The 2025 legislative session featured a number of bills aimed at improving maternal health outcomes in Arkansas. Pilkington’s efforts to expand postpartum Medicaid eligibility were unsuccessful, but other maternal health legislation passed with bipartisan support.

The Healthy Moms, Healthy Babies Act, supported by Gov. Sarah Huckabee Sanders, grants pregnant Arkansans presumptive Medicaid eligibility — essentially fast-tracking their applications for state insurance coverage — allows doulas and community health workers to be reimbursed by the state, and established coverage for certain kinds of pregnancy-related care.

Medicaid covers more than half of births in Arkansas, according to Arkansas Department of Human Service officials.

Cara Osborne, senior fellow at policy group Heartland Forward and a nurse midwife, said that the next steps are overcoming hesitance and barriers to embedding doulas and midwives in pregnancy care in the state.

Doulas, while not licensed in the same way that midwives or other providers are, “can provide incredible emotional and psychological support for moms” said Osborne. Doulas can give pregnant women the kind of one-on-one attention that providers sometimes can’t, she said.

“The doula should be every delivery provider’s best friend,” Osborne said. “It’s an extra set of hands and an extra voice and support as you’re trying to do the best you can to take care of the patients who often are outnumbering you pretty significantly.”

As part of a separate law passed this year, Act 965, the state will also begin to certify doulas.

Arkansas “desperately” needs more doulas and midwives, Manning said.

“Now that we have legislation that helps support the billing aspect, we need to build these programs,” Manning said. “We need to create trust and community.”

But improving access to doulas and midwives is just one issue. Pregnant women also face barriers in receiving care or knowing when they need to seek it, Manning said, and factors such as an inability to get child care or being told their symptoms are normal can prevent them from obtaining timely care.

In addition to the call center, ACWIH wants to distribute maternal health kits and bracelets with QR codes that link to postpartum education and resources at myarkansasbirth.org.

The bracelets, which the center began distributing earlier this year, also serve another purpose — providing a visual alert to doctors and people around the wearer that they recently gave birth.

“A blood pressure of 140 over 90 is not something that most ER doctors would care anything about if a patient shows up with that,” Manning said. But if a postpartum woman showed up presenting the same, “I care. I care a lot about it.”

The kits also contain diapers, wipes, vitamin D and other supplies that women will need after giving birth, Manning told conference attendees. UAMS began distributing them to its postpartum patients earlier this year.

One of the goals of the roundtable was to get all the birthing hospitals in one place to try to get them on board with the center’s initiatives, Manning said. The kits and the bracelets are also funded by the center’s federal grant, but she said they need buy-in from the state’s other hospitals to distribute them to mothers beyond UAMS.

“We need our partners, which is why we convened all of them rather than me reach out one-on-one to all these hospitals,” Manning said. “We got them all together so that we can kind of create those implementation partners.”

Arkansas Advocate is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Arkansas Advocate maintains editorial independence. Contact Editor Sonny Albarado for questions: info@arkansasadvocate.com.

Doulas have been defined as “non-clinical caregivers who provide physical, emotional and informational support to pregnant people and their partners before, during, and after childbirth.”[5] Doulas are primarily known for providing active support during the labor process, but they have increasingly taken on other important roles throughout the perinatal period (see Figure 2).

Doulas provide services either in private settings such as the home or in clinical settings. Community-based doulas — a term used to describe doulas who practice in their own communities and reflect the makeup of their communities — can provide culturally appropriate support to pregnant women who are at greater risk for poor maternal health outcomes.[6]

In contrast to licensed healthcare professionals, there is no standardized legal training requirement for doulas. Doula training and certification requirements vary significantly depending on a number of factors, including whether a state Medicaid program sets standard requirements to receive reimbursement (see the Coverage of Services section for more details). There are established doula certification programs such as DONA (Doulas of North America) International and the Childbirth and Postpartum Professional Association that have specific program requirements.[7],[8] Certificate programs for doulas typically require caregivers to complete a certain number of training hours and attend a certain number of births to qualify for certification.

Numerous studies have explored the impacts of doula services on maternal and infant health outcomes. An updated Cochrane review published in 2017 examined evidence from 27 randomized controlled trials of nearly 16,000 women who received continuous support[a] during childbirth. The review found that women who received continuous support were more likely to have spontaneous vaginal births and shorter labors, and were less likely to report negative birth experiences, undergo cesarean (C-section) births, and have low five-minute Apgar scores (Apgar is a standardized assessment given to newborns one minute after birth and again five minutes after birth that allows a physician to estimate the newborn’s condition, with a higher score indicating a healthier condition). The review found the most benefits when continuous support was provided by a doula versus a member of the hospital staff or the birthing woman’s social network.[9]

Other studies have shown that doulas offer effective interventions in addressing racial and ethnic disparities experienced by many women of color. One study found that among a population of mostly non-Latina Black mothers living in a project area in Brooklyn, New York, those who were enrolled in the Healthy Start By My Side program, which provides doula support, experienced lower rates of preterm birth and reduced rates of low-birthweight babies compared to mothers who were not enrolled in the program.[10] Another study analyzed data from a statewide, population-based survey of women who gave birth in California and found that women were more likely to report receiving respectful care during childbirth when supported by a doula compared to women without such support. When survey data were analyzed by race and ethnicity, the association between receiving doula support and reporting respectful care was found to be highest among non-Hispanic Black women and Asian/Pacific Islander women.[11]

Studies have also explored the impacts of doula care on childbirth outcomes among Medicaid recipients. One study compared birth outcomes among Medicaid beneficiaries whose labor and delivery were supported by a doula care program in Minneapolis, Minnesota, to women who had Medicaid-funded births nationally. The C-section rate was 22.3% among doula-supported births compared to 31.5% among Medicaid beneficiaries nationally, and after controlling for clinical and sociodemographic factors, the researchers found that the odds of C-section delivery were 40.9% lower for doula-supported births.[12]

Historically, most private and public health insurance plans have not covered doula services, limiting access to these supports to those who could afford to pay out of pocket. However, many state Medicaid programs now provide reimbursement for doula services, and others are in the process of implementing policies to allow reimbursement. Additionally, some self-insured and private payers are beginning to cover doula services.

As of June 2025, at least 23 states — Arizona, California, Colorado, Florida, Illinois, Kansas, Maryland, Massachusetts, Michigan, Minnesota, Missouri, New Jersey, New Mexico, Nevada, New York, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Dakota, Virginia, and Washington — and the District of Columbia provide reimbursement for doula services in Medicaid. An additional eight states are in the process of implementing doula reimbursement: Arkansas, Connecticut, Delaware, Montana, New Hampshire, Tennessee, Utah, and Vermont.[13],[14] Efforts in four of the states currently reimbursing for doula services are highlighted in Table 1.

TABLE 1: EXAMPLES OF STATE MEDICAID PROGRAM REIMBURSEMENT AND BENEFIT DESIGN FOR DOULAS SERVICES13,14

State Program Summary Number of Covered Visits Reimbursement Rates Training or Credentialing Requirements Maryland • Doula services are covered for eligible Medicaid enrollees under a state plan amendment.

• Program was initially funded for only four years, but legislation passed in May 2022 to make program permanent.

• Benefit was effective January 1, 2022. • Eight total prenatal and postpartum visits are covered per pregnancy.

• Up to four visits allowed for prenatal care and up to four visits allowed for postpartum care. • Prenatal care is reimbursed at $16.62 per 15-minute increment, with up to four units per visit.

• Labor and delivery services are reimbursed at a flat rate of $800 (state increased rate from $350 to $800 in 2023).

• Postpartum care is reimbursed at $19.62 per 15-minute increment, with up to four units per visit. • Doulas must maintain up-to-date certification through a certification program and carry adequate liability insurance.

• Medicaid program accepts certification from specified list of doula programs.

New Jersey • Doula services are covered for eligible Medicaid enrollees under a state plan amendment.

• Benefit was effective January 1, 2021. • Eight total visits and labor support are covered for those qualifying for standard doula care.

• 12 visits and labor support are covered under enhanced doula benefit for beneficiaries age 19 or under. • Standard doula care benefit are reimbursed up to a total of $1,065.

• Enhanced doula care benefit are reimbursed up to a total of $1,331.

• A $100 incentive is also available for a postpartum follow-up visit for both levels of care.

• Delivery services are reimbursed at a flat rate of $500. • Doulas must be at least 18, pass a background check, and carry liability insurance.

• Doulas must complete training through a program approved by the state Department of Human Services.

• Training includes required core competencies, including perinatal counseling, infant care, and labor support.

• Doulas are also required to receive community-based/cultural competency and HIPAA training and receive adult and infant CPR certification. Nevada • Doula services are covered for eligible Medicaid enrollees under a state plan amendment.

• Benefit was effective April 1, 2022. • Six total prenatal and postnatal visits are covered per pregnancy. • Prenatal and postnatal care visits are reimbursed at a rate of $100 each (state increased rate from $50 to $100 in 2024).

• Labor and delivery services are reimbursed at a flat rate of $900 (state increased rate from $150 to $900 in 2024).

• An additional 10% incentive is available for doulas providing care in rural areas. • Doulas must be certified by the Nevada Certification Board to be eligible for reimbursement. The board maintains a list of certification requirements for doulas.

• Doulas must also enroll as individual Medicaid providers. Oklahoma • Doula services are covered for eligible Medicaid enrollees under a state plan amendment.

• Benefit was effective July 1, 2023. • Eight total prenatal and postnatal visits are covered per pregnancy.

• Prenatal and postnatal visits must be at least 60 minutes and may be conducted via telehealth.

• Labor and delivery support is also covered and must be provided in person. • Prenatal and postnatal care visits are reimbursed at a rate of $64.45 per visit.

• Reimbursement rates for labor and delivery vary by delivery type:

-Cesarean delivery-only visit: $325.45

-Vaginal delivery only: $468.55

-Vaginal delivery after previous cesarean delivery: $527.78

-Cesarean delivery following vaginal delivery attempt: $546.50 • Doulas are required to be at least 18 years old and obtain a National Provider Identifier.

• Doulas must have at least one certification as a birth, postpartum, full-spectrum, or community-based doula.

• Medicaid program requires certification to be obtained from a list of eligible certifying organizations.

A 2023 Medicaid and CHIP Payment and Access Commission report included interviews with doulas and state Medicaid representatives on doula benefit use and challenges.[15] Barriers to implementation and utilization of doula benefits include lack of beneficiary awareness, workforce issues (such as a limited number of doulas participating in Medicaid or the absence of a community-representative doula workforce), and administrative hurdles for doulas seeking to become Medicaid providers. Some states have worked to address these challenges by actively involving doulas from historically marginalized backgrounds in discussions with Medicaid officials, including doulas serving populations with higher rates of poor maternal and infant health outcomes. Other states have worked to address administrative barriers for doulas, including New Jersey, which created paid positions within its Medicaid agency to offer individual support to doulas wanting to enroll as Medicaid providers.

Act 965 of 2025 establishes a certification process for community-based doulas and mandates reimbursement of doula services by Arkansas Medicaid and private insurers.[16] The law allows the Arkansas Department of Health (ADH) to certify a doula who is at least 18 years old and has obtained certification from the Doula Alliance of Arkansas or another organization designated by ADH. The law directs ADH to collaborate with the Doula Alliance of Arkansas in the establishment of criteria to designate certifying organizations. State certification is valid for two years but can be renewed if the doula completes 10 hours of professional development during that two-year period. ADH is also charged with creating and maintaining a publicly accessible registry of certified doulas.

Additionally, Act 965 outlines scope of practice requirements for certified community-based doulas, specifying that they may perform only the following services: providing childbirth education; helping pregnant women navigate the healthcare system; advocating for pregnant women before, during, and after birth; connecting pregnant women with resources; and providing continuous emotional and physical support through labor and birth and intermittently during the prenatal and postpartum periods.

Act 965 also establishes a reimbursement path for certified, community-based doula services through Arkansas Medicaid and private insurers. On or before December 31, 2025, the Arkansas Department of Human Services must promulgate rules on doula reimbursement in Medicaid.

As of April 2025, two states (Louisiana and Rhode Island) required coverage of doula services by private insurers. Five additional states (Arkansas, Colorado, Delaware, Illinois, and Virginia) are in the process of implementing a requirement for private insurers to cover doula services.[17] In 2021, Rhode Island became the first state to implement a doula coverage requirement for fully insured commercial plans. Under the law, each plan may define coverage for the doula benefit as it relates to reimbursement, credentialing, and contracting requirements. One plan, offered by Blue Cross and Blue Shield of Rhode Island, covers up to six total prenatal and postnatal visits, along with labor and delivery services, for eligible members, with up to $1,500 reimbursable for doula care.[18]

A self-insured employer, Arkansas-headquartered retail giant Walmart, began piloting doula services for its employees in Georgia, Louisiana, Indiana, and Illinois in 2021. In October 2023, the company announced that the doula service benefit would be expanded nationwide. The company requires that doulas be credentialed through either DONA International or the National Black Doulas Association.[19]

TRICARE — a healthcare program of the U.S. Department of Defense that provides civilian health coverage for U.S. Armed Forces military personnel, retirees, and their dependents — began providing coverage for doula services through a pilot demonstration that began January 1, 2022, and will continue through December 31, 2026. TRICARE covers up to six visits by a certified labor doula, which can be used prior to and after birth. A separate visit is also covered for labor and delivery support.[20]

The federal Health Resources and Services Administration (HRSA) has provided funding to support doula services and workforce expansion through the Healthy Start program, which aims to improve health outcomes before, during, and after pregnancy in communities with high rates of poor maternal health and infant mortality.[21] In 2021, HRSA launched a supplemental funding opportunity for Healthy Start program awardees to increase the availability of doulas in Healthy Start service areas disproportionately affected by infant and maternal mortality.

The University of Arkansas for Medical Sciences (UAMS) has received HRSA funding through the Healthy Start Community Based Doula Awards to support the Healthy Start-Jined Ilo Kobo program, which assists Marshallese clients in Northwest Arkansas. The program has recruited and trained seven community-based doulas to provide prenatal, birthing, and postpartum support to Healthy Start clients. Since 2021, the doulas have served 124 Healthy Start clients enrolled in the program (Moore, S., personal communication, December 19, 2023). The UAMS Institute for Community Health Innovation is working to increase the doula workforce in Arkansas by training 80 doulas through a program administered in partnership with Ujima Maternity Network and Birthing Beyond. The program includes a scholarship which covers the full cost of training and is available to individuals throughout the state.[22]

In December 2023, the Centers for Medicare and Medicaid Services (CMS) Innovation Center announced the Transforming Maternal Health (TMaH) Model, which supports participating state Medicaid agencies in developing a whole-person approach to pregnancy, childbirth, and postpartum care.[23] The whole-person approach will address physical, mental, and social needs experienced during pregnancy, with the goal of improving outcomes and healthcare experiences for mothers and newborns while reducing overall program expenditures. The model aims to improve access, infrastructure, and workforce capacity in maternal health care, with increased access to perinatal community health workers and doulas a key part of that effort. Arkansas was one of the states awarded the TMaH grant and will receive $17 million in funding to support maternal health initiatives in the state.[24]

Community health workers — frontline public health workers who are trusted members of or have an unusually close relationship with the community served — also play an important role in the development of community-based maternal supports. Community health workers can complement services provided by doulas by helping pregnant and postpartum women navigate the healthcare system and addressing health-related social needs such as housing, transportation, and food needs.[25]

Doulas can play a key role in providing educational, physical, emotional, and informational support throughout the birthing journey. Evidence has demonstrated the positive impact of doula support in reducing C-section rates, improving birth experiences, and helping to address racial and ethnic disparities. While many states, including Arkansas, provide or are working to provide Medicaid reimbursement for doula services, barriers persist, including limited awareness and workforce challenges. Private payers and self-insured payers are increasingly recognizing the value of doula support, including Walmart with its nationwide expansion of a doula benefit for its workforce. Federal initiatives, including HRSA’s support for doula services through the Healthy Start program and CMS’ launch of the TMaH Model, also signal a growing recognition of the importance of comprehensive maternal support and the potential to impact outcomes.

[a] The Cochrane review defined continuous support as “support provided from at least early labor (or within one hour of hospital admission), through until at least the birth, and provided by a person whose sole responsibility is to provide support to the woman.”

[1] Cho, H., Lee, K., Choi, E., Cho, H. N., Park, B., Suh, M., Rhee, Y., & Choi, K.S. (2022). Association between social support and postpartum depression. Scientific Reports, 12(1), 3128. https://doi.org/10.1038/s41598-022-07248-7

[2] Yee, L. M., Silver, R., Haas, D. M., Parry, S., Mercer, B. M., Wing, D. A., Reddy, U., Saade, G. R., Simhan, H., & Grobman, W. A. (2021). Association of health literacy among nulliparous individuals and maternal and neonatal outcomes. JAMA Network Open, 4(9), e2122576. https://doi.org/10.1001/jamanetworkopen.2021.22576

[3] March of Dimes. March of Dimes maternity care deserts dashboard. Accessed June 19, 2025. https://www2.deloitte.com/us/en/pages/life-sciences-and-health-care/articles/march-of-dimes-maternity-care-deserts-dashboard.html

[4] The White House. (2022, June). White House blueprint for addressing the maternal health crisis. https://bidenwhitehouse.archives.gov/wp-content/uploads/2022/06/Maternal-Health-Blueprint.pdf

[5] March of Dimes. (2022, March 29). Doulas can improve care before, during, and after childbirth. https://www.marchofdimes.org/find-support/blog/doulas-can-improve-care-during-and-after-childbirth

[6] Knocke, K., Chappel, A., Sugar, S., De Lew, N., & Sommers, B.D. (2022, December 13). Doula care and maternal health: An evidence review. ASPE Office of Health Policy. https://aspe.hhs.gov/sites/default/files/documents/dfcd768f1caf6fabf3d281f762e8d068/ASPE-Doula-Issue-Brief-12-13-22.pdf

[7] DONA International. Birth doula certification. Accessed June 19, 2025. https://www.dona.org/become-a-doula/birth-doula-certification

[8] CAPPA. Training and certification. Accessed June 19, 2025. https://cappa.net/training-certification/

[9] National Partnership for Women & Families. (2018). Continuous support for women during childbirth: 2017 Cochrane review update key takeaways. The Journal of Perinatal Education, 27(4):193–197. https://doi.org/10.1891/1058-1243.27.4.193

[10] Thomas, M. P., Ammann, G., Brazier, E., Noyes, P., & Maybank, A. (2017) Doula services within a Healthy Start program: Increasing access for an underserved population. Maternal and Child Health Journal, 21(Suppl 1):59–64. https://doi.org/10.1007/s10995-017-2402-0

[11] Mallick, L. M., Thoma, M. E., & Shenassa, E. D. (2022). The role of doulas in respectful care for communities of color and Medicaid recipients. Birth, 49(4):823–832. https://doi.org/10.1111/birt.12655

[12] Kozhimannil, K. B., Hardeman. R. R., Attanasio, L. B., Blauer-Peterson, C., & O’Brien, M. (2013). Doula care, birth outcomes, and costs among Medicaid beneficiaries. American Journal of Public Health, 103(4):e113–e121. https://doi.org/10.2105/ajph.2012.301201

[13] Hasan, A. (2024, April 16). State Medicaid approaches to doula service benefits. National Academy for State health Policy. https://nashp.org/state-medicaid-approaches-to-doula-service-benefits/

[14] National Health Law Program. Doula Medicaid Project. Accessed June 19, 2025. https://healthlaw.org/doulamedicaidproject/#current-efforts-at-expanding-access-to-doula-care

[15] Medicaid and CHIP Payment and Access Commission. (2023, November). Doulas in Medicaid: Case study findings. https://www.macpac.gov/wp-content/uploads/2023/11/Doulas-in-Medicaid-Case-Study-Findings.pdf

[16] Arkansas Act 965 of 2025. https://arkleg.state.ar.us/Home/FTPDocument?path=%2FACTS%2F2025R%2FPublic%2FACT965.pdf

[17] Herbert. K. (2025, April 21). Private insurance coverage of doula care: Spring 2025 state of the states. National Health Law Program. https://healthlaw.org/private-insurance-coverage-of-doula-care-spring-2024-state-of-the-states/

[18] Chen, A., & Rohde, K. (2023, March 14). Private insurance coverage of doula care: A growing movement to expand access. National Health Law Program. https://healthlaw.org/private-insurance-coverage-of-doula-care-a-growing-movement-to-expand-access-2/

[19] Woods, L. (2023, October 24). Walmart accelerates family building support for associates by expanding doula services nationwide. https://corporate.walmart.com/news/2023/10/24/walmart-accelerates-family-building-support-for-associates-by-expanding-doula-services-nationwide

[20] TRICARE. TRICARE Childbirth and Breastfeeding Support Demonstration. Accessed June 19, 2025. https://www.tricare.mil/CBSD

[21] Health Resources and Services Administration. Healthy Start. Accessed June 19, 2025. https://mchb.hrsa.gov/programs-impact/healthy-start

[22] Wise. D. (2025, January 7). UAMS, partners offer comprehensive doula training. University of Arkansas for Medical Sciences. https://news.uams.edu/2025/01/07/uams-partners-offer-comprehensive-doula-training/

[23] Centers for Medicare and Medicaid Services. Transforming Maternal Health (TMaH) Model. Accessed June 19, 2025. https://www.cms.gov/priorities/innovation/innovation-models/transforming-maternal-health-tmah-model

[24] Arkansas Department of Human Services. (2025, January 6). Arkansas awarded $17M grant to support maternal health initiatives. https://humanservices.arkansas.gov/news/arkansas-awarded-17m-grant-to-support-maternal-health-initiatives/

[25] Bakst, C., Moore, J. E., George, K. E., & Shea, K. (2020, May). Community-based maternal support services: The role of doulas and community health workers in Medicaid. Institute for Medicaid Innovation. https://medicaidinnovation.org/wp-content/uploads/2022/09/2020-IMI-Community_Based_Maternal_Support_Services-Report.pd

Medicaid Postpartum Coverage Extension Tracker Print Email Copy Link

The Medicaid program finances about 4 in 10 births in the U.S. Federal law requires states to provide pregnancy-related Medicaid coverage through 60 days postpartum. After that period, some postpartum individuals may qualify for Medicaid through another pathway, but others may lose coverage, particularly in non-expansion states. To help improve maternal health and coverage stability and to help address racial disparities in maternal health, a provision in the American Rescue Plan Act of 2021 gave states a new option to extend Medicaid postpartum coverage to 12 months via a state plan amendment (SPA). This new option took effect on April 1, 2022 and was originally available for five years; however, the option was made permanent by the Consolidated Appropriations Act 2023. The Centers for Medicare and Medicaid Services (CMS) released guidance on December 7, 2021 on how states could implement this option.

States that sought to implement extended postpartum coverage prior to April 1, 2022 have done so through a section 1115 waiver or by using state funds. This page tracks state actions to implement extended Medicaid postpartum coverage, including states that have implemented a 12-month postpartum extension, states that are planning to implement a 12-month extension, states with pending legislation to seek federal approval through a SPA or 1115 waiver, and states that have proposed or received approval for a limited coverage extension.

Medicaid Postpartum Coverage Extensions: Approved and Pending State Action as of January 17, 2025

Medicaid Postpartum Coverage Extensions: Approved and Pending State Action as of January 17, 2025

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Stakeholders in Arkansas Maternal Healthcare Improvements Come Together

By Linda Satter

The Arkansas Maternal Health Roundtable, hosted by the Arkansas Center for Women and Infants’ Health at the University of Arkansas for Medical Sciences (UAMS) and the Arkansas Hospital Association (AHA), featured talks by speakers who are approaching the state’s maternal health crisis from different angles and wanted to learn about and empower each other’s efforts, to jointly improve health outcomes.

Nirvana Manning, M.D., professor and chair of the UAMS Department of Obstetrics and Gynecology and director of the center, welcomed more than 100 attendees who gathered in the Cultural Living Room at the Arkansas Museum of Fine Arts.

“Whether you’re joining us from the Delta, the Ozarks or central Arkansas, your presence in this room signals your commitment to healthier mothers, healthier babies and a stronger Arkansas,” she said. “This roundtable was created with one goal in mind: to align, connect and empower the clinical and administrative leaders driving maternal health across our state. It’s a space for honest dialogue, policy understanding, service innovation and shared accountability.”

Among the topics discussed were the center’s initiatives to improve the state’s dismal maternal and infant health statistics, and the Healthy Moms, Healthy Babies Act of 2025, which Gov. Sarah Sanders signed into law in February.

The center’s initiatives, funded by a $5 million congressional appropriation to UAMS in 2024 that was championed by U.S. Sen. John Boozman, focus on education and standardizing discharge procedures for all postpartum moms in Arkansas. They began in February as pilot projects at UAMS and are in the process of expanding to all 33 birthing centers statewide.

The center’s three initiatives are:

Standardized postpartum education for mothers and babies with Mother & Infant Supply Kits, which are given to mothers of newborns as they leave the hospital,

“I Gave Birth” bracelets, which are distributed to postpartum mothers to alert health care providers and others that the wearer has recently given birth and is at risk of complications,

A Proactive Postpartum Call Center in which nurses call postpartum women seven to 10 days after discharge to ensure they are receiving the care they need.

“We hope to scale up our call center with the goal of calling every postpartum patient in Arkansas by the end of the year,” Manning said.

The new state law allocated more than $45 million to establish presumptive Medicaid eligibility for pregnant women, allow reimbursement for doulas and community health workers as well as coverage for remote patient monitoring, and unbundle Medicaid payments so more services can be covered.

Boozman said he and other members of the state’s congressional delegation “are very appreciative that UAMS has stepped up to play in addressing this challenge,” adding, “Dr. Manning has been a tireless champion and trusted voice for women’s health.”

“Sometimes the best tool in our toolbox is simply bringing people together,” he said. “Because our state is so rural, there are important benefits to working together to leverage expertise, experience and networks that bring out real results for patients.”

Noting that UAMS provides quality care throughout the state, Boozman said, “Today represents the next chapter in the pursuit of a healthier outlook for more Natural State moms.”

Manning said the state Maternal Mortality Review Committee, on which she serves, determined that nearly 90% of all Arkansas maternal deaths are preventable, “which is why we created this center.”

“Arkansas is a largely rural state,” she said, “and many of our communities are health care deserts, meaning they lack access to essential medical services, including maternal and prenatal care. For women in these areas, getting the care they need during labor, pregnancy and the postpartum period can be extremely difficult.”

She said social determinants like income, education, transportation and housing “also play a huge role in the maternal health crisis. These factors affect not only access to health care, but also a woman’s ability to stay healthy during and after pregnancy.”

“While people think of maternal mortality as something that happens during labor or delivery, the reality is that more than half of these maternal deaths occur after birth,” Manning said. “It means that women are often falling through the cracks after they leave our hospitals.”

“Women are at risk for a serious range of complications,” Manning said, “many of which can be missed or overlooked as normal if you’re not looking for them. Some of the most common causes of postpartum maternal mortality are hemorrhage, hypertensive disorders like preeclampsia, infections, blood clots, cardiac conditions and mental health crises. Each of these complications is preventable or treatable with the right care, but too often, women are not getting the follow-up they need to catch these issues, or fail to see the signs and seek help.”

She said several symptoms of serious complications “can be very subtle,” and more than 40% of women don’t attend their postpartum doctor visit, “which is crucial for identifying and addressing potential health care issues.”

Some women or their families dismiss maternal warning signs as “just part of the recovery process,” Manning said, while “others struggle trying to find childcare, navigate transportation or simply prioritize their own health while taking care of a newborn baby.”

Pearl McElfish, director of the UAMS Institute for Community Health Innovation, was part of a four-person panel on policy and reimbursement rates. She told the group that a $17 million federal Transforming Maternal Health Model grant the state received in January intentionally overlaps with other policies and initiatives to support the maternal health collaborations.

While the roundtable’s main focus was the critical role of hospitals in resolving Arkansas’ maternal health crisis, other panels focused on maternal health advocacy efforts during the 95th General Assembly, as well as ongoing initiatives to integrate doulas and midwives into clinical care and to deliver tailored resources to postpartum moms through an app.

Data sources and data collection

The High-Risk Pregnancy Program was established as a collaboration between the Institute for Digital Health & Innovation at the University of Arkansas for Medical Sciences and the Arkansas Department of Human Services with the support of the Arkansas Medical Society. The Perinatal Outcomes Workgroup through Education and Research (POWER) is a statewide outreach component of the High-Risk Pregnancy Program that provides outreach and education to support perinatal quality improvement at all birthing hospitals in Arkansas. As a part of POWER nurses with obstetric/perinatal experience provide education and quality improvement coaching to birthing hospitals in Arkansas, centered on maternal safety bundles from the Alliance for Innovation in Maternal Health (AIM). Each of the five nurses on the POWER team is assigned to hospitals within one of five public health regions in Arkansas, and meets quarterly with the nursing management of the labor & delivery units. The consistent contact between the POWER nurses and their assigned hospitals facilitates a strong, trusting relationship, and allows the POWER nurse to tailor QI coaching to the context of each hospital. The POWER team began providing education and coaching in 2017, and this coaching has continued each year, with a focus on AIM’s bundles addressing obstetrical hemorrhage and severe hypertension in pregnancy.

In addition to quality improvement outreach and coaching, the POWER team offers free staff to all 37 participating hospitals through in-person sessions and interactive video platforms. The team performs simulation drills, quantitative blood loss measurement, triage, and medication-specific education on obstetric topics. The obstetrics emergency simulation drills, one of the important educational opportunities offered by the POWER team, play a critical role in training labor and delivery staff statewide to prepare them for handling uncommon emergencies that may arise during childbirth and post-delivery periods. These simulation sessions emphasize the application of patient safety bundles, algorithms, and checklists to facilitate prompt recognition and intervention for hypertensive crises, severe postpartum hemorrhages, and instances of shoulder dystocia.

In 2022, the POWER team initiated a survey-based checklist assessment tool to evaluate the extent of the implementation of the AIM bundles for obstetrical hemorrhage [25] (Supplementary Table 1) and severe hypertension in pregnancy [14] (Supplementary Table 2) across Arkansas’ birthing hospitals. Five nurse facilitators perform quarterly data collection on the implementation of bundles from the 37 participating hospitals. During the POWER facilitation visit, the appointed facilitator conducts a survey-based assessment of the implementation of practices from both safety bundles using the checklist assessment tool. The authorized nurse manager or educator at each participating hospital completes the survey tool. These individuals lead AIM bundle implementation at their facility, and self-reported measures from nursing unit leaders have been utilized in other studies of maternal safety bundle implementation [22, 26]. The current study utilizes checklist data collected during the third quarter of 2023.

Study Measures

The survey-based checklist assessment tool includes practice elements from the four original domains of the maternal safety bundle including Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. The tool contains 18 discrete practice elements for the obstetrical hemorrhage bundle and 29 practice elements for the severe hypertension in pregnancy bundle (Additional File 1). To illustrate the types of practice elements assessed in the surveys, examples from the obstetrical hemorrhage bundle include: “Availability of a hemorrhage cart with supplies, checklist, and instruction cards for intrauterine balloons,” “Establishment of massive and emergency release transfusion protocols,” and “Assessment of hemorrhage risk prenatally.” For the severe hypertension bundle, example items include: “Rapid access to medications used for severe hypertension/eclampsia,” “Facility-wide education standards on signs and symptoms of hypertension and preeclampsia,” and “Facility-wide standard protocols with checklists and escalation policies for the management and treatment of severe hypertension.” Each of these elements is assessed dichotomously. If hospitals report adopting a specific bundle practice element, they receive a score of 1 for implementation; otherwise, they will receive a score of 0, indicating that they have not implemented that particular bundle element. A hospital’s overall bundle implementation index score is created by calculating the percentage of all possible/recommended bundle elements implemented by a hospital. To examine the implementation status in different domains of the safety bundle, domain implementation index scores are calculated as the percentage of adopted practice elements within each domain.

Hospital characteristics, drawn from the 2021 American Hospital Association hospital database, include hospital region (rural, urban), hospital teaching status (yes, no), critical access status (yes, no), hospital ownership (for-profit, nonprofit, state-run), hospital size (small, medium, large), provision of neonatal intensive care beds (yes, no), provision of neonatal intermediate care beds (yes, no), total full-time registered nurses, total full-time facility personnel, total obstetricians/gynecologists, annual number of live births, total bassinets in neonatal intensive and intermediate care units, total licensed beds, and obstetric unit care level ([1] uncomplicated maternity and newborn cases, [2] uncomplicated cases, the majority of complicated problems, and special neonatal services, [3] all serious illnesses and abnormalities, supervised by a full-time maternal/fetal specialist).

Statistical analysis

For this study, we calculated descriptive statistics for participating hospitals’ characteristics and implementation of the safety bundle practices, using checklists completed in the 3rd quarter of 2023. We also visually displayed the variations in the implementation of both individual practice elements and domain practice elements within each maternal safety bundle using Tableau (Version 2023.3). To further assess the implementation differences across the four domains within each maternal safety bundle, we used Friedman’s test to conduct within-bundle comparisons. Using Wilcoxon signed-rank test, we performed post hoc pairwise comparisons between the different domains within each safety bundle. To account for the 6 pairwise comparisons between the four domains, we followed the Bonferroni adjustment technique and used a significance level of (0.05/6 = 0.0083) for each individual pairwise comparison. To examine the implementation differences between the two safety bundles, the Wilcoxon-Mann-Whitney test was conducted. To investigate the association between hospital characteristics and bundle implementation, we utilized several statistical tests, including two-sample t-test and one-way analysis of variance (ANOVA) for categorical characteristics as well as non-parametric Wilcoxon-Mann-Whitney and Kruskal-Wallis H tests. To examine the relationship between continuous characteristics and bundle implementation, we used Spearman’s correlation. We conducted additional analyses focusing on practices adopted by fewer than 76% of hospitals. We compared adoption rates between rural and urban hospitals and between hospitals with ≤ 500 versus > 500 annual live births (a cutoff point that approximated the median in this sample and is consistent with other studies) [27]. We used Chi-Square tests and Fisher’s Exact Tests as appropriate based on expected cell sizes. All analyses were performed in SAS 9.4. Except in the case of the pairwise comparison, we used a two-sided p-value less than 0.05 to determine statistical significance.