but has built an online following by criticizing the

“In some cases, the small hospitals are losing more money on private insurance than they are on Medicaid, which is really kind of remarkable,” he said, “but that’s how little they get paid ... by the private insurance plans.”Low Medicaid reimbursements play a role in

, along with worker shortages and declining birth rates. More than half of rural hospitals have stopped offering labor and delivery services, another recent analysis from the Center for Healthcare Quality and Payment Reform showed. That can lead to longer travel times and awhen she was pregnant with her second child. There is no labor and delivery unit at the hospital in Rocky Mount, Virginia, and a hospital about 40 minutes away closed in 2022. Ratliff, who is Black, instead went to Salem — more than an hour away — for every prenatal visit. She ran through all of her paid time off, and had no paid maternity leave.She did, however, have a doula. The doula is Black and her services were covered by Medicaid — a benefit Virginia started offering in 2022.

“I really did want somebody else to just help advocate, especially since with women of color, the mortality rates are higher. So I was like, ‘anything can happen,’” she said. “My family members never had good experiences up here at these doctors’ offices, even just for regular appointments.”In the state to the South, immigration status can complicate health care. About 150,000

and their family members live in North Carolina. Many of them speak Spanish, lack permanent legal status and don’t qualify for Medicaid — so they’ll pay out of pocket at clinics or go without medical care.

A few organizations in the state provide mobile health clinics. Campbell University’s Community Care Clinic, in partnership with Sembrando Salud by NC FIELD did its first outreach in 2017 and diagnosed 68 people with diabetes. Four of them had very high blood sugar levels, said Dr. Joseph Cacioppo, a clinic volunteer, and chairman of the Community and Global Health program at Campbell.Joseph has no intention of returning to Europe. She has started a midwifery school, put together training programs for other health care professionals and convenes a national group of professionals and advocates who share ideas to improve maternal health and eliminate disparities over videoconference.

She figures America needs her more.“This is literally my life’s work,” she said. “I’m not stopping until it’s done.”

This story is the first in a two-part series examining how the United States could curb deaths from pregnancy and childbirth.The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Science and Educational Media Group. The AP is solely responsible for all content.