When Lily Nichols, a mother of two and neonatal intensive care unit nurse, became pregnant, she felt comfortable going into the birthing process, feeling as if her experience as a nurse helped her advocate for herself and know when she would need intervention or certain services and care.

As a nurse and a mother, Nichols knew the postpartum period can take a toll on one’s mental health, with fears of financial and physical stress compounding those concerns.

“Postpartum wise, you don’t really feel like yourself for a couple of months,” Nichols said. “You don’t really realize that you are not feeling like yourself until you feel yourself again.”

Financially, Nichols said she didn’t realize how expensive birth was until she received the bill from her most recent hospital visit a couple of months ago. Though Nichols chose to opt out of an epidural and had minimal intervention, the bill was upward of $2,000 with insurance.

“I remember asking my husband, ‘What do women who get all these interventions do, because they need them but don’t have the money to pay for them,’” Nichols said.

The financial stress of pregnancy and postpartum care is felt by several mothers. The passage of Senate File 2251 works to combat these stressors, expanding postpartum Medicaid coverage for women across the state of Iowa.

Nichols called the hospital’s financial aid office and asked for an itemized list of the charges, wanting to ensure she was being charged for the services she chose to receive in the roughly 12 hours she spent with her husband in the hospital.

“It is a financial stress because we are two middle-class people, and we are not super wealthy or struggling, but it is something we need to budget for,” Nichols said.

Stephanie Amundson, a neonatal intensive care unit nurse and mother, had high blood pressure and gestational diabetes during her first pregnancy. A multitude of tests, insulin, and follow-ups with her medical team were required.

“I was able to get access to the extra monitor, nonstress tests, ultrasounds, and insulin because I had comprehensive health care,” Amundson said.

As a NICU nurse, Amundson has seen the postpartum experience faced by mothers who give birth to premature babies, where establishing a maternal child bond can be particularly difficult.

Amundson said when new mothers are trying to produce breast milk, smelling and touching their baby helps maternal hormones to create more milk. However, when mothers are unable to have that connection to their babies due to barriers such as incubators, it can disrupt the bonding process.

The bill was signed by Iowa Gov. Kim Reynolds on May 8, 2024, and expanded existing postpartum Medicaid coverage from 60 days to 12 months. The bill went into effect on April 1.

The bill also reduced postpartum Medicaid eligibility from 375 percent of the federal poverty level to 215 percent of the federal poverty level or roughly $29,000 in annual income, according to the state’s nonpartisan Legislative Services Agency’s fiscal analysis of the legislation.

The fiscal analysis showed all women currently at the 215 percent poverty level are eligible for Medicaid as of Jan. 1.

Anne Discher, executive director of Common Good Iowa, said the previous 60-day coverage meant mothers could lose health insurance coverage, while postpartum health issues often extend longer than a two-month period after giving birth.

“Expanding pregnancy Medicaid allows folks who have coverage to be able to get mental and physical health care, to take care of themselves as new parents navigating caregiving and going back to the workplace,” Discher said.

According to the Iowa Department of Health and Human Services, to qualify for postpartum services, certain eligibility requirements must be met, including proof of citizenship, Iowa residency, pregnancy, and income under 215 percent of the federal poverty level.

Discher said the reduction of the federal poverty level will affect both women who are currently pregnant and those who are in the postpartum stage of their pregnancy.

“For folks who have coverage, this is a really great opportunity for them, allowing them to do what they need to do with their lives, but it also means that those who used to have access to coverage during their pregnancy no longer have access to coverage,” Discher said.

Discher emphasized the importance of understanding coverage will expand care, but there will be women who will not qualify for pregnancy coverage in the first place.

Iowa Sen. Janet Petersen, D-Des Moines, echoed a similar sentiment, stressing the need to maintain health care coverage for a year following the birth of one’s child.

“One of the most important things is having a healthy mom and a healthy baby, and we shouldn’t be cutting off health care coverage for new moms 60 days after they have given birth,” Petersen said.

Petersen said such legislation can help reduce maternal and infant mortality rates in the state, with infant mortality numbers at 5.20 for every 1,000 live births as of 2022, according to the Centers for Disease Control and Prevention.

There are roughly 40,000 babies born in Iowa annually, according to Iowa Health and Human Services.

Despite these benefits, Petersen also addressed the impacts this would have on those who will no longer be eligible for Medicaid, which is roughly 1,700 people, according to the nonpartisan fiscal note by the Legislative Services Agency on the bill.

Additionally, roughly 1,300 women will lose access to prenatal care, or before-birth care, under this new bill. In total, roughly 3,000 women will be affected under this bill.

Iowa House Rep. Devon Wood, R-New Market, said pregnant women currently on Medicaid coverage will not be removed or become ineligible from care under the grandfather clause during a House committee meeting in April 2024.

According to the Centers for Medicare and Medicaid Services, the grandfather clause allows individuals under a particular health care plan or service to maintain those services regardless of future legislation.

Reynolds has impacted maternal health care, Petersen said, by privatizing the Medicaid system, or taking away the administration of these services from the public, governmental sector and giving it to private companies and organizations.

“We have lost multiple labor and delivery departments and mental health services,” Petersen said. “Several women in Iowa live in communities that are considered maternal health deserts, making it harder for them to access care.”

What is postpartum care?

Alaina McElmeel, a birth and postpartum doula and founder and director of Kind Roots Doula and Birth Services, which serves Iowa City, Cedar Rapids, and surrounding communities, said giving birth is not only a major endeavor on the body itself, but in the period after birth as well.

McElmeel gave birth to her first son 10 years ago and remembers the countless sleepless nights and doing everything for her baby. McElmeel now provides daytime and overnight care for postpartum mothers as a doula, caring for mothers and their babies, providing support and help where it is most needed.

“A huge aspect of doing this work is creating really solid, compassionate bonds with people,” McElmeel said. “It can be a lot to accept a relative stranger into their most intimate places, where everyone needs different things.”

McElmeel said Kind Roots is a private LLC, providing birth doulas, postpartum doulas, and birth education services with doulas of various expertise and specialties in physical therapy, early education, and postpartum placenta.

Because Kind Roots is not certified by the international doula certification program, or DONA, McElmeel said they are unable to accept insurance.

For families interested in postpartum care, McElmeel recommends speaking to families and friends first and having them help offset the cost by pooling money toward doula services or other forms of postpartum care rather than traditional gifts for expecting mothers such as onesies or strollers.

“I recognize that this is a valuable service but also that families can’t always afford it,” McElmeel said. “So, I regularly talk to families about how they can help subsidize this care because we all deserve it.”

Nichols, as a NICU nurse, said it is common for mothers who fear that something can go wrong at any moment, worried about whether or not they are eating right and doing everything they can to protect their baby. This, Nichols said, can take a toll on mental health.

“It is not talked about or discussed enough,” Nichols said. “People usually don’t ask, ‘What are you anxious about?’ They just want to be excited for you.”

RELATED: Rates of postpartum, mental health stressors during pregnancy high in Iowa

Once postpartum mothers leave the home, Nichols said, there is a risk of hemorrhaging or losing blood because of a damaged blood vessel.

“You are super vulnerable, and then once you physically heal, there are the questions of ‘How are you feeling’, ‘What do you need’, ‘How are your other children,’” Nichols said. “I am blessed to have a community that will ask me those questions but am cognizant that a lot of women don’t have someone to do that for them.”

To have coverage for up to 12 months, Nichols said, is huge.

“It took me probably nine to 12 months to feel like myself again and actually feel like I could do this,”  Nichols said.

NICU mothers are routinely screened for postpartum depression at different intervals, Amundson said, to try and identify moms who might need outside resources provided by Medicaid.

Postpartum or perinatal depression is a mood disorder affecting mothers during pregnancy or up to one year after childbirth, according to the National Institute of Health.

Postpartum services included under the Medicaid coverage include lactation services, labs and X-rays, dental services, mental and behavioral health care, and more.

Some mothers left behind

Discher said for those who are no longer eligible for Medicaid because their income is too high, the process of qualifying becomes complicated.

“Medicaid is comprehensive health insurance,” Discher said. “Health insurance is the key that unlocks the door to health care. It is a way of catching potential health care problems early, and when there are challenges postpartum, it means coverage to help address those.”

Emergency Medicaid is offered to women who are uninsured during pregnancy, which can help cover the costs of labor and delivery. However, Discher expressed concerns with the program, as going through a pregnancy without health insurance means women have often gone without the recommended prenatal care.

Petersen said Democrats currently have legislation that would aid in the creation of birthing centers, or a health care facility specifically designed for labor and delivery, in Iowa, expanding Medicaid reimbursement for birth doulas, and more.

Similarly, Reynolds has introduced a House Study Bill on the expansion of rural health care in the state. HSB 191, introduced in February, aims to increase regional and rural specialty clinics in smaller regional hospitals, impacting maternal health care and access to postpartum services needed by mothers.

The bill will also increase reimbursements for health care services, including those for perinatal, pregnant, and postpartum women.

House File 887, a bill looking to reduce the cost of developing a birthing center in a state that has long been without such a facility, also works to combat the maternal health care crisis.

Increasing Medicaid reimbursement  would help provide money for health care providers and birthing hospitals, Petersen said, eliminating the shuttering of labor and delivery services where it otherwise would not have been financially viable to keep open.

Similar feelings were expressed by Amundson and Nichols, with both emphasizing the importance of prenatal care and access to coverage.

“If you told me that I didn’t have insurance coverage, and I had the knowledge that I would have a massive bill after giving birth, I honestly would have given birth at home to help minimize that financial stress,” Nichols said.