In the past year, Christian King, a doula based in Kansas City, has supported more than 40 mothers enrolled in Medicaid through their pregnancy, birth and postpartum.
In that role, she helps educate and support families about birth and babies, but her work also takes on a more nontraditional approach.
When one mother’s water was shut off at four weeks postpartum, King helped her find reconciliation services to turn the utilities back on. When another mom couldn’t afford car repairs, King found an organization in Raytown that provided financial assistance. She helped one client secure a car seat from the local health department and another fill her closet with baby clothes.
King, 35, hopes that soon, “just like going to the dentist and going to the eye doctor, obtaining a doula and having a doula present is also one of those things that you just have to have on your team as part of services for maternity.”
Doulas do not deliver babies. They advocate for the physical and mental wellbeing of mothers and their families.
For the past 15 months in Missouri, anyone enrolled in Medicaid while pregnant and postpartum can have a doula by their side for free. Now, a group of bipartisan lawmakers are hoping to expand the program in an effort to continue combating the state’s poor infant and maternal outcomes.
“The statistics tell a devastating story of the lives lost that could’ve been saved if we put in the proper measures,” said state Sen. Barbara Washington, a Democrat from Kansas City who proposed one iteration of the legislation. “There are third-world countries that have better maternal mortality rates than we do.”
The bill is estimated to cost around $300,000. While substantial amid a predicted state budget shortfall, state Rep. Becky Laubinger, a Republican from Park Hills who also filed legislation to expand the program, said she believes the long-term savings of having fewer Missourians who require medical attention will make up for the cost.
On average, 70 women die each year in Missouri during childbirth or in the first year postpartum. Of those deaths, 80% are deemed preventable.
In Missouri, women on Medicaid were seven times more likely to die within a year of pregnancy than women on private insurance, according to a 2024 report published by the state’s Pregnancy-Associated Mortality Review that looked at women who gave birth between 2017 and 2021. A 2023 March of Dimes report gave Missouri a D- for preterm births, and also pointed to doulas as a solution.
In fall 2024, the Missouri Department of Social Services issued an emergency rule authorizing Medicaid to reimburse doula services, citing “an immediate danger to the public health, safety or welfare of pregnant women in Missouri.”
Since the program’s inception, there have been about 625 participants insured through Medicaid who accessed doulas during their pregnancy and postpartum, said Baylee Watts, a spokeswoman for the Department of Social Services. As of this month, 108 doulas were enrolled in the program.
“The department is encouraged by the level of engagement so far,” Watts said in a statement. “And views the doula benefit as an important component of broader efforts to improve maternal health outcomes across Missouri.”
Legislation filed by state Rep. Tara Peters, a Rolla Republican, has moved the farthest this year, clearing committee in February as part of a sweeping health care bill. Her bill seeks to increase the number of covered doula visits from six to 16.
The average out-of-pocket cost for a doula in Missouri is about $1,500, according to the Missouri Doula Association.
“I’ve just noticed how much extra care a doula can provide, especially for women in high need situations,” said Laubinger. “Doulas can provide some great education and support for people who maybe don’t have the extra support.”
This support can also look like serving as an interpreter between medical professionals and pregnant people, navigating insurance, ensuring access to nutritious food or coordinating transportation to medical appointments.
Laubinger, who previously served as executive director of Monarch Family Resource Center in Farmington, said expanding the number of covered visits can be particularly helpful for women who experience postpartum depression in the year after giving birth.
Her legislation, like Peters’, expands the number of reimbursable visits from six to sixteen, and includes access to doulas for prenatal, birth, postpartum and lactation support.
She said the legislation also hopes to correct some issues doulas have had getting full reimbursement after being in the room for a scheduled c-section, listed as a scheduled surgeries, a classification she said muddled the reimbursement process.
The Department of Social Services previously said the reimbursements could lead to savings for the state in the coming years, including by potentially reducing the Cesarean rate. Watts said it’s too early to get an accurate look at this result.
Laubinger said doulas can be a lifesaving set of eyes and ears in homes where women experience domestic violence, a leading cause of pregnancy-associated deaths in Missouri.
“The doula birth worker can also have a voice in those situations and see what’s going on outside of that medical office,” she said. “And maybe be able to provide some rescuing relief from dangerous situations for mom.”
To be eligible, doulas must be credentialed and certified through a national or Missouri-based doula training organization. From there, they will be added to a list of eligible doulas overseen by the Missouri Community Doula Council.
Sandra Thornhill, a social justice doula who has advocated in Jefferson City for better legislation for doulas, said it was beautiful to see this policy issue reach across the aisle. And she was happy to see some of the proposals pushing for increased visits, especially in postpartum.
She said it’s not a question of if doulas should be reimbursed, but of how the state honors the traditional practices and values of doulas in that process. She is wary of any policies that place community health workers under medical or state authority. Instead she hopes to see more collaborative models.
”My concern is not with recognizing doulas in the Medicaid policy, but with how the bill structures authority and governance over that work,” said Thornill, who describes herself as a womb warrior and policy griot. “The question is whether the policy structure strengthens community birth workers or will it place unnecessary burden or medical authority that doesn’t reflect the roots of the work.”
But she said the progress made in acknowledging and supporting doula’s work in the past few years is striking, especially as many doulas live “birth to birth” as they struggle to pay the bills.
Prior to the state’s Medicaid reimbursement plan, The Independent spoke with several doulas who spoke of giving up wages to help families in need for free as they navigated growing their families.
“They do it because they love their people and their community so much that they’re willing to make this great sacrifice,” Thornhill said. “ However, it is not healthy. And it is not fair for the community to have to suffer like that when there are resources available to change that. But again, those resources cannot come with a slap on the wrist. They cannot come with a backlash of ‘now you’re under our thumb.’”
A representative with America’s Health Insurance Plans voiced opposition to Washington’s bill in a committee hearing last month.
“We are very concerned about issues with education, standardization and making sure doulas are all on the same page and we know exactly how they’ve been trained,” he said. “There seems to be some resistance out there and a lot of independence within the organizations.”
Washington’s legislation also seeks to ensure health benefit plans offer coverage for midwifery services. She said this is especially crucial in rural parts of the state, where families don’t have access to nearby hospitals with maternity wards.
“Currently, our law does not explicitly require private health plans to cover midwifery. This would close that loophole,” Washington said, adding that this change would shift power back to patients to choose their own provider, especially in rural communities “where the hospitals are closing at alarming rates.”