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Missouri is one of the deadliest states for giving birth. Its abortion ban may make that worse

Doulas from the KC Women’s Ministry meet on March 6, 2023. The Raymore-based nonprofit organization serves a client base that is nearly 100% low-income, according to executive director Kristen Mason. The group provides free or sliding-cost doula services to pregnant people around the Kansas City area and sees doula access as a key component of improving maternal mortality rates.
Zach Bauman
/
Kansas City Beacon
Doulas from the KC Women’s Ministry meet on March 6, 2023. The Raymore-based nonprofit organization serves a client base that is nearly 100% low-income, according to executive director Kristen Mason. The group provides free or sliding-cost doula services to pregnant people around the Kansas City area and sees doula access as a key component of improving maternal mortality rates.

Missouri has a maternal mortality rate of 25.2 deaths per 100,000 live births, higher than the national average. Health professionals worry that the state’s near-total abortion ban will make pregnancy, childbirth and the postpartum period even more dangerous.

Kristen Mason knows that the months during pregnancy and after childbirth can be difficult, lonely and even dangerous — especially in her home state. The United States is in the midst of a maternal mortality crisis and Missouri has some of the nation’s poorest outcomes.

In her work at the KC Women’s Ministry, Mason serves as a doula and childbirth educator and the group’s executive director. The Kansas City-based nonprofit provides free or sliding-cost doula services to low-income residents in the Kansas City area who are pregnant.

While doulas are trained experts in birthing, they also serve as advocates for clients who because of their race, income and life circumstances sometimes don’t get the services they need.

That happens a lot in Missouri — and health professionals worry that the state’s near-total abortion ban will make pregnancy, childbirth and the postpartum period even more dangerous.

An average of 61 women in the state died while pregnant or within one year of pregnancy each year from 2017 to 2019, a ratio of 25.2 deaths per 100,000 live births, according to the latest report from the Missouri Department of Health and Senior Services.

Missouri’s rate outpaces the national maternal mortality rate, which in 2019 was 20.1 deaths per 100,000 live births, a number that has skyrocketed since the coronavirus pandemic. (Kansas’ maternal mortality rate in 2018 was 17.7 deaths per 100,000 live births.)

Mason knows that 75% of maternal deaths in Missouri are considered preventable, a circumstance she calls “infuriating.”

“We need to teach people how to advocate for themselves and we need to advocate for them when they don’t have the voice,” Mason said. “We’re amplifying their voice, not becoming it.”

Based on data, a chorus of voices is needed to stem the tide of pregnancy and childbirth-related deaths in Missouri.

In Missouri, mental health conditions are the top underlying cause of pregnancy-related deaths, followed by cardiovascular disease.

Despite accounting for only 15% of live births, Black women were more than three times more likely to die from pregnancy-related causes than white women.

In rankings of state maternal mortality rates, Missouri lands at a dismal 44th place. Stung by those realities, lawmakers are again attempting a bipartisan push to expand Medicaid coverage for postpartum Missourians for up to a year. Nearly 63% of pregnancy-related deaths happen between 43 days and one year after a child is born, a statistic that demonstrates for many the necessity of providing a full year of health insurance after delivery.

But better access to insurance and services isn’t the only reform Missouri needs to make pregnancy and childbirth safer.

A number of comorbidities make the months before and after delivery more dangerous in Missouri. For example:

  • The state is ranked 44th for overall mental health, due to its high rate of mental illness and limited access to care.
  • By one measure, Missouri has the fourth highest drug use among the states.  Substance use disorder contributed to nearly 33% of Missouri’s pregnancy-related deaths from 2017 to 2019. 
  • Gun violence problems in Missouri made homicide the cause for 25% of the state’s pregnancy-associated deaths in 2018.

Limited access to quality reproductive care for low-income Missourians is a big contributor to maternal mortality. Nearly half of the counties in Missouri are classified as maternity care deserts, and another 22.6% of counties have low or moderate access to maternal health care, according to a March of Dimes report.

“We should expect people to survive childbirth,” Mason said. “We should also expect them to thrive. We should be providing that for people.”

How abortion bans or restrictions worsen the problem

A protester rallies in front of Kansas City, Missouri, City Hall. She wears a pink t-shirt and holds a sign that reads, "You didn't like wearing a mask, imagine being told you have to have a baby."
Bek Shackelford-Nwanganga
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KCUR 89.3
Alexis Redfairn-Ogunyemi, a high school student from Olathe, protests the overturning of Roe v. Wade in front of Kansas City, Missouri, City Hall.

While KC Women’s Ministry focuses on care for women and avoids political interactions, other groups in Missouri are sounding an alarm about the state’s prohibition on abortion.

Over the summer Missouri became the first state to put a near-total abortion ban in place in the wake of a landmark U.S. Supreme Court decision, despite findings that limited access results in higher death rates during pregnancy and the postpartum period.

According to data compiled by the Commonwealth Fund, a nonprofit focused on studying health care policies and equity, outcomes are generally worse in states with abortion bans or restrictions, whether it is entirely banned or restricted to the very early stages of pregnancy.

The data, sourced from the Centers for Disease Control and the March of Dimes, found that maternal death rates from 2018 to 2020 were 62% higher in states that restricted abortion in some way than in states that had more open access. In abortion-restricted states, the maternal mortality ratio was 28.8 deaths per 100,000 live births, compared to 17.8 per 100,000 births in states that had more access to abortion.

According to Julia Strasser, the director of the Jacobs Institute of Women’s Health at George Washington University in Washington, D.C., access to quality reproductive care is crucial to improving maternal health outcomes.

“When you restrict access to abortion, you’re also restricting access to these other services that are related to pregnancy care. We know that abortion and other aspects of maternal care can’t be divided cleanly,” Strasser said. “We know that there’s complete overlap with the full scope of maternity services. That can include abortion care, but it can also include management of miscarriage or early pregnancy loss, and can include delivery.”

Strasser said that abortion bans or restrictions can discourage providers from offering reproductive care and counseling not related to abortion out of an abundance of caution. The Supreme Court’s Dobbs v. Jackson ruling that overturned Roe v. Wade has changed the landscape in a way that data cannot yet reflect.

“When we think about the workforce that’s providing this care — especially if the policies are punitive towards providers — they may be afraid, and rightly so, to lose their medical license or be sued or lose their livelihood for providing the care that they’re trained and qualified to provide,” Strasser said.

“So even if it’s not abortion care, but if it’s related to pregnancy loss, or anything in the scope of pregnancy care, providers may sort of opt out of that. I think we just don’t have enough data yet on whether that movement has happened.”

Reproductive health care professionals and advocates worry that with Missouri’s abortion ban in place, the state could see maternal mortality rates increase, especially for people of color.

Even before the Dobbs decision and the near-total ban on abortion in Missouri, state policies barred Medicaid reimbursement for all services obtained from providers who offered or were affiliated with abortion services, making it difficult for those on the state’s insurance program to receive adequate access to reproductive health care.

“When you look at the data to show who is most likely to access abortion care, and then you juxtapose that with who is experiencing these bad maternal health outcomes, it’s the same folks,” said Michelle Trupiano, executive director of the Missouri Family Health Council, a group that advocates for reproductive and sexual health care access.

“We’re pushing people into a system without any choices, and a system that’s already failing them.”

Can Medicaid expansion make a big enough difference?

For at least three years, the state legislature has considered bills to expand Medicaid coverage for low-income Missourians in the 12 months after giving birth. The case for doing so is strong.

So far, 29 states and the District of Columbia have voted to expand Medicaid coverage for up to a year postpartum, and maternal mortality rates have fallen.

In Missouri, some low-income residents are only guaranteed access to state-provided health insurance during pregnancy and for 60 days after giving birth. Lawmakers made a bipartisan push in 2022 to extend coverage to a year, but their proposals were derailed by infighting and dysfunction in the state Senate.

This year, two different pieces of legislation are under consideration in the General Assembly. Despite bipartisan support and a realization that women in Missouri need help, the chances of actually expanding Medicaid coverage for postpartum Missourians are tenuous.

The reason: Abortion-related politics.

Though abortion is mostly banned in the state, some lawmakers reflexively inject the issue into multiple bills, especially those related to reproductive health.

One bill currently being considered includes language inserted by conservative senators that would attempt to exclude expanded Medicaid coverage for people who received elective abortions. Similar language was attached to postpartum Medicaid expansion legislation in Texas, and the federal government has yet to approve the expansion.

According to a 2020 study, Medicaid expansion is shown to drastically improve maternal mortality outcomes, especially for people of color. Based on CDC data from 2006 to 2017, expanded Medicaid access was associated with seven fewer deaths per 100,000 live births compared to non-expansion states.

Black people see the most improved outcomes from Medicaid expansion. The extended health coverage was associated with 16.27 fewer pregnancy-related maternal deaths per 100,000 births.

Still, serious disparities exist between those on private insurance versus those on Medicaid. According to Missouri’s Pregnancy-Related Mortality Review, the rate of pregnancy-associated, not related, deaths for those on Medicaid was more than eight times higher than the ratio for those with private insurance.

Trupiano of the Missouri Family Health Council said much more needs to be done in the U.S. beyond Medicaid expansion.

“Insurance coverage is not the silver bullet to solve the maternal health crisis,” she said. “The system is broken, and it starts with institutional racism in terms of how Black and brown people are not being listened to when they are accessing health care. And so we need to come at it with multipronged solutions in order to really be able to achieve the outcomes.”

More advocates needed

One possible solution for reducing maternal mortality could lie with the groups already helping people in the state, such as an expansion of the services provided by KC Women’s Ministry and other doula groups.

A 2009 study found that in comparison to a group of 97 women receiving standard care, a group of 44 doula-paired women experienced significantly shorter periods of labor, had fewer instances of instrument-assisted birth and had better outcomes in their babies’ initial health at birth. Other studies found that those who used doulas had higher rates of breastfeeding and lower rates of comparatively more dangerous cesarean delivery.

“I can attest to that,” Mason said. “New parents and doulas report back to me on how things went. And the number of times that we were able to avoid a C-section that was definitely being pushed for is unbelievable.”

Rep. Jamie Johnson, a Kansas City Democrat, is sponsoring a bill that would include coverage of doula and midwife services to those on Medicaid in Missouri, but it has yet to receive a committee hearing.

“It would be absolutely huge,” Mason said. “You’d have all kinds of people who didn’t have access to help before. We’re talking about an entire state of people not only being able to access any doula that accepts Medicaid, but suddenly everybody would have access to that level of care.”

For Mason, the issue comes back to advocacy.

“It’s insane that we then expect them to be successful and we’re surprised if they aren’t,” Mason said. “We need to be sending them help. That should be, in my opinion, the bare minimum. We should be sending these people help.”

This story was originally published on the Kansas City Beacon, a fellow member of the KC Media Collective.

The Beacon will be reporting over the next few months on the causes and consequences of Missouri’s maternal mortality crisis. To discuss the issue or your personal experiences with reproductive care, please email hello@thebeacon.media

Corrected: March 13, 2023 at 8:50 AM CDT
An earlier version of this story misattributed a statement about abortion politics and maternal mortality to KC Women’s Ministry executive director Kristen Mason. The KC Women’s Ministry is a nonpartisan, nonprofit organization and takes no stance on access to abortion.
Meg Cunningham is The Beacon’s Missouri Statehouse reporter.
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