Ashley Jones’ three children were born in three different places — a hospital, a birth center, and at home.
Jones, who is 31 and lives in Belgrade, Montana, said she had “zero control over what was going on” during her hospital birth. Jones wanted a midwife to help deliver her third child, and after finding one she clicked with, she decided to go with a home birth.
“I felt like I was in control of everything and she was there to listen to what I needed from her,” Jones said.
The only downside, from Jones’ perspective, was that her insurance didn’t cover home births attended by a midwife as an in-network service. Jones paid about $5,500 out-of-pocket.
Home births surged nationally during the pandemic. In Montana, they accounted for 2.85% of all births in 2021, behind Idaho’s nation-leading 3.56% but still the sixth-highest rate in the country. Women who choose home births say they can provide a more familiar setting and a more natural experience than a hospital birth, along with the greater control cited by Jones. Doctors say hospital births are generally safer but that home births can also be a safe choice for many low-risk pregnancies.
Montana’s Republican-dominated legislature this year moved to support home births with a measure requiring they be covered by Medicaid and another that expands the types of drugs midwives can administer. Republican Gov. Greg Gianforte signed the bills into law in April.
Montana Republicans touted the moves as evidence of their commitment to women and families at a time when they were passing strict abortion limits. Since the legislative session ended in May, Gianforte has signed into law bills limiting abortion access, including a ban on dilation and evacuation procedures after 15 weeks. The governor also extended postpartum care for new mothers on Medicaid to 12 months in the state budget, and approved an adoption tax credit.
“Advancing his pro-life, pro-child, pro-family agenda, the governor supported extending Medicaid coverage for mothers to 12 months postpartum, and proudly introduced an adoption tax credit and a child tax credit in his Budget for Montana Families,” Gianforte spokesperson Kaitlin Price said via email.
The child tax credit has not been signed into law.
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Kelly Baden, vice president for public policy at the Guttmacher Institute, a national research and policy organization that studies reproductive rights, said the new home-birth laws and postpartum care expansion are among the supports reproductive safety professionals have been pushing for decades.
“Anything a state can do that helps improve the economic or health care coverage of people is important,” Baden said, adding that those things don’t need to be done as political cover for abortion restrictions.
The new laws would not have helped Jones: Whether insurance covers home births in Montana varies by policy, and Jones’ insurance declined to cover her home birth because it was out of network.
But the passage of House Bill 655, which adds most home births to Medicaid-covered services, is a boost for women enrolled in the federal-state health coverage program for low-income residents. The average cost of having a baby in a hospital in Montana is $11,938.
Lindsey Erin Ellis, co-founder of the Montana Birth Collective, is a doula, or someone who provides emotional support during pregnancy rather than the medical care of a midwife. She said while the cost of giving birth outside a hospital is less, the out-of-pocket expense for a patient can be more if they lack insurance coverage.
“Having Medicaid is huge because those midwives can then accept those clients and be paid for their work,” Ellis said.
The legislation on the medications midwives can administer brings Montana into alignment with the nearby states of Idaho, Colorado, and Washington, and enhances patient safety, said Amanda Osborne, vice president of the board of the Montana Midwifery Association.
That measure, House Bill 392, allows midwives to administer IVs, antibiotics to prevent infections in babies, oxygen, and prescription drugs that help stop hemorrhaging, all of which Osborne described as the “standard of care for pregnant women” and which midwives have the training to administer. The bill does not address pain medications.
Prior to the 2023 law, Osborne said, midwifery laws in Montana were last updated in the 1990s and midwives were not able to administer basic, lifesaving medications.
“I think women and babies deserve safe care no matter where they decide to give birth,” Osborne said.
Home births are a safe option for low-risk pregnancies and healthy babies, Osborne said. If a pregnancy becomes higher-risk, the patient is transferred to a physician’s care. High-risk indicators include high blood pressure, gestational diabetes, and carrying twins, Osborne said.
Recent trends suggest home births will continue to tick up. And while some practitioners praised the new laws, issues of cost and access aren’t going away.
Averee Chifamba, who has a midwifery practice in Bozeman called Saddlepeak Birth, was the midwife for Jones’ home birth. Of the roughly three dozen licensed midwives in Montana, there are eight — soon to be nine — in Bozeman, Chifamba said, and most of the home-birth practices there are full.
Chifamba said HB 392 increases midwives’ drug prescribing privileges to the standard of care for other health care professionals. But HB 655 is a “hard one” for her because the Medicaid reimbursement rate is so low, Chifamba said.
“We love the idea that it opens up the availability, that if we want to serve Medicaid families as a small business, we can now; it’s just whether that’s going to be worth the hit the midwife is going to take financially,” Chifamba said.