News Maternity and Birthing

Using Special Powers, Brazil’s President Passes Law Requiring Compulsory Registration of All Pregnant Women

Beatriz Galli

A new law passed in the dead of night by Brazilian President Dilma Rousseff violates all women’s right to privacy by creating compulsory registration to control and monitor her reproductive life.

In the dead of night on December 27, Brazilian President Dilma Rousseff enacted legislation that will require all pregnancies to be registered with the government. Provisionary Measure 557 (PM 557) created the National System of Registration, Vigilance and Monitoring Women’s Care during Pregnancy and Post Childbirth for the Prevention of Maternal Mortality (National Registration System).

She used a provisionary measure—intended only for urgent matters—that allows the president to pass a law without congressional approval. Congress only gets to debate and approve the law once it has been enacted. Rousseff claims that PM 557 will address Brazil’s high rates of maternal mortality by ensuring better access, coverage and quality of maternal health care, notably for high-risk pregnancies. Both public and private health providers must report all pregnancies—providing women’s names—with the National Registration System so the state can then track these pregnancies, from prenatal to postpartum care, presumably to evaluate and monitor health care provided.

How does simply monitoring pregnancies reduce maternal mortality? There is no guarantee that care will be available to all pregnant women and no investment in improving health services included in the legislation.

And what’s the benefit to women? PM 557 does authorize the federal government to provide financial support up to R$50.00 (roughly US$27) for registered pregnant women for their transportation to health facilities for pre-natal and delivery care. However, to receive the stipend women must comply with specific conditions set by the state related to pre-natal care. Let’s face it, that paltry sum may not even cover the roundtrip for one appointment depending on where a woman lives.

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In fact, PM 557 does not guarantee access to health exams, timely diagnosis, providers trained in obstetric emergency care, or immediate transfers to better facilities. So while the legislation guarantees R$50.00 for transportation, it will not even ensure a pregnant woman will find a vacant bed when she is ready to give birth. And worse yet, it won’t minimize her risk of death during the process.

The biggest problem with maternal mortality in Brazil is not access to health-care services but rather the quality of health care in public health facilities. The majority of preventable maternal deaths actually take place in public hospitals, disproportionately affecting poor women, women who live in rural areas, youth and minorities.
Last but certainly not least, MP 557 violates all women’s right to privacy by creating compulsory registration to control and monitor her reproductive life. In fact, it places the rights of the fetus over the woman, effectively denying her reproductive autonomy. A woman will now be legally “obligated” to have all the children she conceives and she will be monitored by the State for this purpose.

It’s unclear why Rousseff sought to enact this legislation so quickly and with so little opportunity for debate or public opinion. What is clear though is that women’s real interests and health needs are not the focus here—just their uteruses.

Analysis Maternity and Birthing

Pregnant Women Are Being Shackled in Massachusetts—Even Though It’s Been Illegal for Years

Victoria Law

According to a new report, not a single jail or prison facility in the state has written policies that are fully compliant with the law against restraining pregnant women behind bars.

Korianne Gamble was six months pregnant in November 2014 when she arrived at the Bristol County Sheriff’s Office Women’s Center, a jail in North Dartmouth, Massachusetts. Six months prior, the state had passed “An Act to Prevent Shackling and Promote Safe Pregnancies for Female Inmates.”

According to the new law, the jail should have been prohibited from using any type of restraint on Gamble during labor, and using of leg and waist restraints on her during and immediately after her pregnancy. It also guaranteed her minimum standards of pregnancy care and required—as with everyone incarcerated while in their second or third trimesters—that she be transported in the jail’s vehicles with seat belts whenever she was taken to court, medical appointments, or anywhere outside the jail.

But that wasn’t the case for Gamble. Instead, she says, when it came time for her to give birth, she was left to labor in a cell for eight hours before finally being handcuffed, placed in the back of a police cruiser without a seatbelt, and driven to a hospital, where she was shackled to the bed with a leg iron after delivering.

According to a new report, Gamble isn’t alone. Advocates have been monitoring pregnancy-related care since the law’s passage. After obtaining and analyzing the policies of the state’s prison and jail system, they found that no facility has policies that are fully compliant with the 2014 law. They issued their findings in a new report, Breaking Promises: Violations of the Massachusetts Pregnancy Standards and Anti-Shackling Lawco-authored by Marianne Bullock of the Prison Birth Project, Lauren Petit of Prisoners’ Legal Services of Massachusetts, and Rachel Roth, a reproductive-justice expert.

In addition to analyzing policies, they spoke with women who were pregnant while in custody and learned that women continue to be handcuffed during labor, restrained to the bed postpartum, and placed in full restraints—including leg irons and waist chains—after giving birth.

“The promise to respect the human rights of pregnant women in prison and jail has been broken,” the report’s authors concluded.

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Medical experts, including the American Congress of Obstetricians and Gynecologists, the American Medical Association and the American College of Nurse-Midwives, have all agreed that shackling during pregnancy is unnecessary, inhumane, and dangerous. Shackling increases the risk of falling and injury to both mother and fetus while also preventing medical staff from assessing and assisting during labor and delivery. In 2014, both the Massachusetts legislature and then-Gov. Deval Patrick (D) agreed, passing the law against it.

“The Massachusetts law is part of a national trend and is one of the most comprehensive in protecting pregnant and postpartum women from the risks of restraints,” said Roth in an interview with Rewire. “However, like most other states, the Massachusetts law doesn’t have any oversight built in. This report clearly shows the need for staff training and enforcement so that women who are incarcerated will be treated the way the legislature intended.”

Gamble learned all of this firsthand. In the month before her arrest, Gamble had undergone a cervical cerclage, in which a doctor temporarily stitches up the cervix to prevent premature labor. She had weekly visits to a gynecologist to monitor the development of her fetus. The cerclage was scheduled to be removed at 37 weeks. But then she was arrested and sent to jail.

Gamble told jail medical staff that hers was a high-risk pregnancy, that she had had a cerclage, and that her first child had been born six weeks prematurely. Still, she says she waited two months before seeing an obstetrician.

As her due date drew closer, the doctor, concerned about the lack of amniotic fluid, scheduled Gamble for an induction on Feb. 19, 2015. But, she says, jail staff cancelled her induction without telling her why.

That same evening, around 5 p.m., Gamble went into labor. Jail staff took her to the medical unit. There, according to Gamble, the jail’s nurses took her blood pressure and did a quick exam, but did not send her to the hospital. “They [the nurses] thought I was ‘acting up’ because my induction was canceled,” she told Rewire.

She was placed in a see-through cell where, as the hours progressed, her labor pains grew worse. “I kept calling to get the [correctional officers] to get the nurse,” Gamble recalled. By the time a nurse came, Gamble was bleeding. “The nurse made me pull down my pants to show her the blood—in front of a male [correctional officer]!” Gamble stated. Still, she says, no one called for an ambulance or made arrangements to drive her to the hospital.

At 1:45 in the morning, over eight hours after she first went into labor, the jail’s captain learned that Gamble was in labor. “[He] must have heard all the commotion, and he called to find out what was going on,” she said. He ordered his staff to call an ambulance and bring her to the hospital.

But instead of calling an ambulance, Gamble says jail staff handcuffed her, placed her in the back of a police cruiser without a seatbelt—in violation of the law—and drove her to Charlton Memorial Hospital. “My body was already starting to push the baby out,” she said. She recalled that the officers driving the car worried that they would have to pull over and she would give birth by the side of the road.

Gamble made it to the hospital, but just barely. Nine minutes after arriving, she gave birth: “I didn’t even make it to Labor and Delivery,” she remembered.

But her ordeal wasn’t over. Gamble’s mother, who had contacted Prisoners’ Legal Services and Prison Birth Project weeks earlier, knew that the law prohibited postpartum restraints. So did Gamble, who had received a packet in jail outlining the law and her rights from Prisoners’ Legal Services. When an officer approached her bed with a leg iron and chain, she told him that, by law, she should not be restrained and asked him to call the jail to confirm. He called, then told her that she was indeed supposed to be shackled. Gamble says she spent the night with her left leg shackled to the bed.

When the female officer working the morning shift arrived, she was outraged. “Why is she shackled to the bed?” Gamble recalled the officer demanding. “Every day in roll call they go over the fact that a pregnant woman is not to be shackled to anything after having a baby.” The officer removed the restraint, allowing Gamble to move around.

According to advocates, it’s not unusual for staff at the same jail to have different understandings of the law. For Gamble, that meant that when the shift changed, so did her ability to move. When the morning shift was over, she says, the next officer once again shackled Gamble’s leg to the bed. “I was so tired, I just went along with it,” Gamble recounted.

Two days after she had given birth, it was time for Gamble to return to the jail. Despite Massachusetts’ prohibition on leg and waist restraints for women postpartum, Gamble says she was fully shackled. That meant handcuffs around her wrists, leg irons around her ankles, a chain around her waist,g and a black box that pulled her handcuffs tightly to the waist chain. That was how she endured the 20-minute drive back to the jail.

Gamble’s jail records do not discuss restraints. According to Petit, who reviewed the records, that’s not unusual. “Because correctional officers don’t see it as out of the ordinary to [shackle], they do not record it,” she explained. “It’s not so much a misapplication of the extraordinary circumstances requirement as failure to apply it at all, whether because they don’t know or they intentionally ignore it.”

While Bristol County Sheriff’s Office Women’s Center’s policies ban shackling during labor, they currently do not prohibit restraints during postpartum recovery in the hospital or on the drive back to the jail. They also do not ban leg and waist restraints during pregnancy. Jonathan Darling, the public information officer for the Bristol County Sheriff’s Office, told Rewire that the jail is currently reviewing and updating policies to reflect the 2014 law. Meanwhile, administrators provide updates and new information about policy and law changes at its daily roll call. For staff not present during roll call, the jail makes these updates, including hospital details, available on its east post. (Roll call announcements are not available to the public.)

“Part of the problem is the difference in interpretation between us and the jurisdictions, particularly in postpartum coverage,” explained Petit to Rewire. Massachusetts has 14 county jails, but only four (and the state prison at Framingham) hold women awaiting trial. As Breaking Promises noted: “Whether or not counties incarcerate women in their jails, every county sheriff is, at minimum, responsible for driving women who were arrested in their county to court and medical appointments. Because of this responsibility, they are all required to have a written policy that spells out how employees should comply with the 2014 law’s restrictions on the use of restraints.”

Four jurisdictions, including the state Department of Correction, have policies that expressly prohibit leg and waist restraints during the postpartum period, but limit that postpartum period to the time before a woman is taken from the hospital back to the jail or prison, rather than the medical standard of six weeks following birth. Jails in 11 other counties, however, have written policies that violate the prohibition on leg and waist shackles during pregnancy, and the postpartum prohibition on restraints when being driven back to the jail or prison.

Even institutions with policies that correctly reflected the law in this regard sometimes failed to follow them: Advocates found that in some counties, women reported being restrained to the bed after giving birth in conflict with the jail’s own policies.

“When the nurse left, the officer stood up and said that since I was not confirmed to be in ‘active labor,’ she would need to restrain me and that she was sorry, but those were the rules,” one woman reported, even though the law prohibits restraining women in any stage of labor.

But shackling pregnant women during and after labor is only one part of the law that falls short. The law requires that pregnant women be provided with regular prenatal and postpartum medical care, including periodic monitoring and evaluation; a diet with the nutrients necessary to maintain a healthy pregnancy; written information about prenatal nutrition; appropriate clothing; and a postpartum screening for depression. Long waits before transporting women in labor to the hospital are another recurring complaint. So are routinely being given meals without fruits and vegetables, not receiving a postpartum obstetrician visit, and waiting long stretches for postpartum care.

That was also the case with Gamble. It was the middle of the night one week after her son’s birth when Gamble felt as if a rock was coming through her brain. That was all she remembered. One hour later, she woke to find herself back at the hospital, this time in the Critical Care Unit, where staff told her she had suffered a seizure. She later learned that her cellmate, a certified nursing assistant, immediately got help when Gamble’s seizure began. (The cell doors at the jail are not locked.)

Hospital staff told her that she had preeclampsia, a pregnancy complication characterized by high blood pressure. Postpartum preeclampsia is rare, but can occur when a woman has high blood pressure and excess protein in her urine soon after childbirth. She was prescribed medications for preeclampsia; she never had another seizure, but continued to suffer multiple headaches each day.

Dr. Carolyn Sufrin is an assistant professor of gynecology and obstetrics at Johns Hopkins Medicine. She has also provided pregnancy-related care for women at the San Francisco County Jail. “Preeclampsia is a leading cause of maternal mortality,” she told Rewire. Delayed preeclampsia, or postpartum preeclampsia, which develops within one to two weeks after labor and delivery, is a very rare condition. The patient suffering seizures as a result of the postpartum preeclampsia is even more rare.

Postpartum preeclampsia not only needs to be treated immediately, Sufrin said, but follow-up care within a week at most is urgent. If no follow-up is provided, the patient risks having uncontrolled high blood pressure, stroke, and heart failure. Another risk, though much rarer, is the development of abnormal kidney functions.

While Sufrin has never had to treat postpartum preeclampsia in a jail setting, she stated that “the protocol if someone needs obstetrical follow-up, is to give them that follow-up. Follow through. Have continuity with the hospital. Follow their instructions.”

But that didn’t happen for Gamble, who was scheduled for a two-week follow-up visit. She says she was not brought to that appointment. It was only two months later that she finally saw a doctor, shortly before she was paroled.

As they gathered stories like Gamble’s and information for their report, advocates with the Prison Birth Project and Prisoners’ Legal Services of Massachusetts met with Rep. Kay Khan (D-Newton), to bring her attention to the lack of compliance by both county jails and the state prison system. In June 2015, Khan introduced An Act to Ensure Compliance With the Anti-Shackling Law for Pregnant Incarcerated Women (Bill H 3679) to address the concerns raised by both organizations.

The act defines the postpartum period in which a woman cannot be restrained as six weeks. It also requires annual staff trainings about the law and that, if restraints are used, that the jail or prison administration report it to the Secretary of Public Safety and Security within 48 hours. To monitor compliance, the act also includes the requirement that an annual report about all use of restraints be made to the legislature; the report will be public record. Like other statutes and bills across the country, the act does not have specific penalties for noncompliance.

In December 2015, Gamble’s son was 9 months old and Gamble had been out of jail for several months. Nonetheless, both Gamble and her mother drove to Boston to testify at a Public Safety Committee hearing, urging them to pass the bill. “I am angered, appalled, and saddened that they shackled her,” Gamble’s mother told legislators. “What my daughter faced is cruel and unusual punishment. It endangered my daughter’s life, as well as her baby.”

Since then, both the Public Safety Committee and Health Care Financing Committee approved the bill. It is now before the House Committee for Bills in the Third Reading, which means it is now at the stage where it can be taken up by the House for a vote.

Though she has left the jail behind, Gamble wants to ensure that the law is followed. “Because of the pain I went through, I don’t ever want anyone to go through what I did,” she explained to Rewire. “Even though you’re in jail and you’re being punished, you still have rights. You’re a human being.”

Analysis Health Systems

How Louisiana Slashed Medicaid Funding for Pregnant Women and Blamed a Typo

Katherine Don

Louisiana health officials appear to have cut funding for the state’s Medicaid program for pregnant women based on a typo on the Affordable Care Act website, Healthcare.gov.

Over the last several months, the Louisiana Department of Health and Hospitals made a series of announcements about LaMOMS, the state’s Medicaid program for pregnant women—first announcing cuts to the program, then a plan to reevaluate those cuts, and then that the cuts were being rescinded. Health Secretary Kathy Kliebert explained in a series of interviews with the Baton Rouge Advocate that this seesaw of decisions was caused by an unspecified change in federal policy related to the Affordable Care Act (ACA).

The $11 million in cuts, which passed as part of the 2013-2014 state budget in June, were added back into the budget in November. But the reversal dictated that the category of women who were slated to be dropped from LaMOMS are now instead covered through the state’s Medicaid program for children, LaCHIP. This means that the Medicaid funds are now technically for “unborn children,” not for the pregnant women themselves, and these women will lose postpartum care coverage. These changes went into effect in January.

Rewire spoke with the Louisiana health department and ACA policy experts for clarification on why an ACA policy affected Louisiana’s longstanding LaMOMS program. A closer look reveals an odd story wherein officials planned to cut the LaMOMS budget by taking advantage of an ACA loophole—a loophole that, it turns out, did not exist. Rather, state health officials appear to have changed the state’s Medicaid funding of pregnant women based on a typo on the ACA website, Healthcare.gov.

When Louisiana officials discovered their mistake, they blamed the mixup on the Federal Centers for Medicare and Medicaid Services (CMS), the department that oversees ACA implementation.

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The saga represents a troubling example of the anti-ACA, anti-women maneuverings of the administration of Louisiana Gov. Bobby Jindal.

The Federal Policy Change That Wasn’t

The initial Medicaid cuts that passed in Louisiana’s 2013-2014 state budget established new income eligibility requirements that drastically reduced the number of pregnant women eligible for Medicaid in Louisiana. Previously, women earning up to 200 percent of the federal poverty level (FPL)—or up to $22,980 annually—were eligible for prenatal, childbirth, and 60 days of postpartum care through LaMOMS. But the reductions were slated to reduce eligibility to 133 percent, creating a new gap in coverage for women earning between $15,280 and $22,980.

Federal law requires that all states provide Medicaid to pregnant women, with an eligibility cap of at least 133 percent. The vast majority of states opt for much higher thresholds, as high as 380 percent.

“Eligibility is higher for pregnancy because we consider this to be a particularly important time period for health outcomes,” Laura Gaydos, assistant professor in the Department of Health Policy and Management at Emory University, told Rewire. “This is something that pretty much everyone agrees about.”

The reason Louisiana’s health department provided for the LaMOMS reduction was that women in the 133 to 200 percent FPL range are now eligible for subsidies on the federal health marketplaces under the ACA (which provide subsidies to individuals earning between 100 and 400 percent the FPL). In other words, the state didn’t want to continue funding Medicaid for women who might also be eligible for ACA subsidies.

Jan Moller, director of the Louisiana Budget Project, a nonprofit that monitors government spending, told Rewire that prenatal care “has been a huge priority for this administration because Louisiana ranks very poorly with birth outcomes.” Moller’s understanding of the cuts was that Louisiana officials believed women in the 133 to 200 percent range would sign up for private insurance on the ACA marketplace. “And of course, this was a way for the state to save money,” he added.

But there was a glaring problem with this strategy. What would happen if an uninsured woman didn’t enroll during ACA’s annual open enrollment period, and then became pregnant? She can’t sign up on the ACA, and she now no longer qualifies for Medicaid, which provides immediate access to no-cost care. Such a woman would be left with virtually no options for receiving care.

It turns out that Louisiana officials were operating under the false belief that becoming pregnant is a circumstance that triggers a “special enrollment period,” allowing women to sign up on the ACA marketplaces outside of the open enrollment period. When officials later realized this wasn’t the case, they reversed their Medicaid cuts, alleging that a change in federal policy had caused their confusion. As reported in an October Baton Rouge Advocate article titled “Rules Change Impacts Low-Income Pregnant Women”:

The federal Centers for Medicare and Medicaid Services has thrown the state a curve … a new interpretation of the term “qualifying life event” would leave some of those women in the gap without prenatal care, [health secretary] Kliebert said. The definition of a qualifying event to enroll in the new health insurance exchange outside of the open enrollment period removed the event of becoming pregnant.

“Federal policy messed us up,” Health Secretary Kliebert said in November, during her announcement that the previous Medicaid eligibility levels would be restored.

However, a Centers for Medicare and Medicaid Services spokesperson told Rewire that there had been no policy change.

In order to understand the issue at hand, it’s important to examine the concept of special enrollment periods, which are not unique to the ACA; anyone who has experience enrolling in private health insurance will be somewhat familiar. Specific events, such as losing a job, getting a new job, or gaining a dependent, trigger special enrollment periods that temporarily allow individuals or families to sign up for insurance outside of open enrollment periods.

For ACA insurance plans, pregnancy is not a qualifying life event. So Kliebert’s assertion that a new federal policy removed pregnancy from the list of such events is impossible: It couldn’t be removed from a list that it was never on. The rules for qualifying life events are available to the public and listed in subpart D of the Affordable Care Act.

“In no insurance situation that I’m aware of, whether in the ACA or outside of the ACA, is pregnancy a qualifying life event,” Professor Gaydos told Rewire.

Indeed, pregnancy as a qualifying life event runs counter to the fundamental logic of private insurance plans. Insurance companies don’t typically allow individuals to enroll upon changes in health status, such as becoming pregnant, because that would cause “adverse selection,” a concept predicting that costs throughout the market increase if individuals sign up for insurance only when they become sick. Medicaid access for uninsured pregnant women is thus a unique system allowing low-income, uninsured women to gain immediate coverage upon becoming pregnant.

“You would not have a special enrollment period for women who become pregnant,” said Judy Solomon, vice president for health policy at the Center on Budget and Policy Priorities. “I don’t know what Louisiana could have meant when they thought pregnancy was included.”

The Culprit Behind the Confusion

Rewire contacted the Louisiana Department of Health and Hospitals for information about the federal policy change that led to it questioning the LaMOMS cuts. The department provided the following in an email statement from Secretary Kliebert:

The federal government’s website recently changed the definition of a qualifying life event to enroll in the new health insurance exchange outside of the open enrollment period, removing the event of “becoming pregnant,” … After seeking clarification, we’ve received multiple and conflicting answers … Our last communication with federal officials indicated that becoming pregnant will not trigger a special enrollment period for women.

A federal website hadn’t been mentioned in the Advocate articles, so this was a clue about the persistently vague references to a change in “federal policy.” The mystery was solved when a health department official told Rewire that the answer can be found in Kliebert’s September 2013 testimony before Congress regarding her department’s concerns about the ACA.

During her congressional testimony, Kliebert stated that “until very recently, HHS’s primary Exchange website, Healthcare.gov, had included in its definition of qualifying life event the example of when you ‘become pregnant.’ However, the information on the site recently changed to state that it is the birth of the baby that qualifies the woman for coverage.”

Kliebert included two screenshots that she said were taken “weeks apart” revealing photos of the same webpage, with one omitting “become pregnant” from the list of qualifying life events:

healthcare_gov

These screen shots aren’t dated, but it appears that for some unknown amount of time, this piece of misinformation was posted at Healthcare.gov. Kliebert’s testimony was in September, so it seems that this rather serious error was fixed prior to the website’s October 1 public launch.

In her anti-ACA testimony, Kliebert presented the Healthcare.gov error as an example of the difficulty her department experiences when communicating with federal officials. However, Kliebert did not mention that the glossary error had prompted Louisiana to revoke Medicaid coverage for low-income, uninsured pregnant women.

It’s unclear why Louisiana officials hadn’t consulted the rules of the ACA itself or contacted health-care experts before going ahead with the Medicaid cuts.

“A glossary is not a law,” said the Center on Budget and Policy Priorities’ Judy Solomon. “Pregnancy is not on the list. You can Google it.”

“It sounds like misinformation was presented [at Healthcare.gov], and then they did not go far enough in looking into the actual rule from CMS [Centers for Medicare and Medicaid],” said Professor Gaydos.

Yet, in lieu of admitting the mistake, Kliebert spoke to the press about an unnamed “federal policy” that “messed up” decisions surrounding the LaMOMS program.

Kliebert is an appointee and close ally of Republican Gov. Jindal, a vocal opponent of the ACA and the Medicaid expansion. In his Wall Street Journal op-ed about the health-care law, Jindal pinpointed the bureaucracy of state-federal interaction as the prime problem with the ACA:

Fifty-five working days before the launch of the ObamaCare health-insurance exchanges on Oct. 1, the administration published a 600-page final rule that employers, individuals and states are expected to follow in determining eligibility for millions of Americans. Rather than lending clarity to a troubled project, the guidelines only further complicated it. If the experience of those working with the ObamaCare implementation at the state level had been taken into account, progress might have been possible, but the administration has treated states with mistrust.

What’s so unsettling about the LaMOMS debacle is that Jindal’s administration was fast to cut LaMOMS funds in the dubious hope that women would instead receive subsidies on the very federal marketplaces that Jindal vehemently opposes. Jindal has deemed the ACA a “one-size-fits-all approach” that impedes a governor’s ability to “care for our most vulnerable citizens,” and yet was eager to siphon pregnant women into the ACA marketplace—and then blame the ACA when it didn’t work out, as if federal officials had forced the cuts onto LaMOMS in the first place.

The Jindal administration performed a similar about-face last summer. They quietly applied to participate in Community First Choice, a little-known ACA program that increases federal Medicaid funds for disabled and elderly care services. But then they withdrew the application, citing “new federal rules” and “complicated federal stipulations.” There is speculation that the real reason behind the withdrawal was presidential-hopeful Jindal’s reticence to be caught with his hand in ACA’s cookie jar.

The LaMOMS changes are part of a long list of Jindal administration cuts to health services for moms and children. In the 2012-13 budget, the state eliminated funds for dental services for pregnant women, an in-home nursing program to educate moms about infant care, and mental health services for low-income children. Further Medicaid cuts enacted this January included complete closure of the state’s Disability Medicaid program. Louisiana is thus not merely among the 25 states refusing to join the Medicaid expansion—it’s also cutting existing Medicaid programs, joining Wisconsin and Maine as the only three states to decline the expansion while at the same time dramatically reducing existing programs.

The Aftermath for Louisiana Women

Although the LaMOMS cuts were technically reversed, women will still be affected: Those in the 133 to 200 percent FPL range will now receive Medicaid through the state’s Medicaid fund for children, rather than through LaMOMS. Since the unborn fetuses will now be the ones receiving Medicaid, it’s unclear whether health services that don’t directly affect the fetus will be covered. Further, women will no longer receive the 60 days of postpartum care that is required through LaMOMS.

Louisiana has the second highest infant mortality rate in the nation, and infants born to mothers who do not receive prenatal care are five times more likely to die. In early November, when Louisiana’s health department was still considering whether to rescind the LaMOMS cuts, March of Dimes released new statistics on preterm birth, showing that Louisiana had improved very little despite pledges to address the problem.

“We urge policy-makers to expand insurance coverage, including Medicaid, for women of childbearing age,” the March of Dimes wrote on its “F” grade report card for Louisiana.

In the area of maternal health, Louisiana’s situation is so bad that the state was singled out for censure at last year’s UN General Assembly Millennium Development meeting on maternal health. The state has high rates of maternal death, too few practicing obstetricians, and a high proportion of uninsured women—27 percent of women of child-bearing age have no insurance, according to the Centers for Disease Control and Prevention. Given these serious problems, it’s alarming that LaMOMS was ever considered a target for budget reductions.

Uninsured Louisianans in the 100 to 400 percent FPL range are indeed now eligible for ACA subsidies. But for those who don’t enroll in the ACA marketplace during open enrollment and then become pregnant, it’s important that Medicaid continue to provide these women with free, immediate care.

In most Republican-governed states, pregnant women are eligible for Medicaid only during their pregnancy, but are then dropped from the program. This is the case in Louisiana, which provides little Medicaid to non-disabled adults: Only adults with dependent children who earn up to $2,727 a year are eligible. This means that if a low-income woman earns more than $2,727, she loses her Medicaid coverage 60 days after giving birth, when LaMOMS coverage ends.

Some 242,000 Louisianans would gain insurance if the state participated in Medicaid expansion.

“What’s really unfortunate is you have a lot of very low-income women in Louisiana who have no opportunity to get [Medicaid] coverage until they are pregnant,” Solomon said. “These women need coverage.”