Leading causes of maternal death in Missouri from 2018 to 2022 were in order: Mental health conditions, including substance abuse disorder; cardiovascular disease; infection; and amniotic fluid embolism. According to the Missouri Department of Health and Senior Services, 18% of the 350 deaths occurred during pregnancy; 39% were up to 42 days postpartum; and 43% were 43 to 365 days postpartum. About 80% were determined to be preventable.
And Black women are two and a half times more likely to die during pregnancy and in the year after giving birth than White women. Alicia Jenkins, director of the Office of Minority Health with DHSS, said Black women account for about 13% of the births in Missouri. And low birth weight is something she sees amongst the Black population.
Veronica Peterson of Springfield has two boys – ages four years and seven months. She didn’t have any complications during her pregnancies, and she didn’t feel like it was because she’s a Black woman that, at times, she didn’t feel listened to, but she knows that can happen.
"It adds to the personal feeling internally sometimes," she said, "when you're in those situations and you are a minority and you don't know necessarily, well, should I question this or do I have ground to stand on to, you know, kind of come against this person? And so, I think that, in our situation and in many especially Black mom situations, you kind of wrestle with is now the right time to speak up or will this look badly on me or am I making too big of a deal of something, you know? All of those questions, you question yourself."
And she said Black women might not have the same trust in their healthcare provider as White women.
"There's certain biases that we all have that you can't help because we tend to listen to people who look like us or we have common ground with," said Peterson. "It's a lot simpler, a lot easier. We feel like we speak the same language, we have the same experience, so we understand and we know, and we are not great with the unknown."
Getting adequate prenatal care is important to achieving the best health outcomes for moms and babies. There are certain risk factors that can predispose women to having pregnancy complications. Martha Smith, maternal and child and health director for DHSS, said Black women tend to have more risk factors.
"Whether those be physical risk factors such as a cardiovascular condition or diabetes or other chronic condition, women who are obese as well as women who have some of those more socioeconomic risk factors and some of those social drivers of health that contribute to their overall health before they get pregnant but then can create risk scenarios and high risk for them during pregnancy," she said, "are more likely to die."
Smith said the earlier a woman knows that she’s pregnant and enrolls in health care services, the earlier she can get connected to the full scope of services available to her, and risks can be addressed sooner.
Jenkins said they work to make sure minority women are tapping into resources at DHSS, but they also work to build up programs at the local level.
"Taking an approach from the understanding that all things begin and end locally," she said, "and so whatever we can do to build up that foundation at the local level is going to be imperative for those folks to be able to go out and engage in the appropriate services that they may need, you know, and when you think about the work that we do from a population health perspective...the diabetes information that we have to enhance health literacy, the information that we have around heart disease, cardiovascular needs, our WIC (Women, Infants, Children) programs, you know, making sure that — and those are just a small few examples of the things that we have that we want to encourage, you know, our African American women to use those services if they're eligible for them."
Jenkins said, as a Missouri citizen, mom, community member and an employee of DHSS, she works to make sure women of childbearing age know the importance of getting access to good prenatal care.
"We want to make sure that they have good nutrition. We want to make sure while they're pregnant that their oral health needs are met. I mean, and we also want to make sure that we can give them options to reduce stress so that their blood pressure is not high, that, you know, if they have diabetes, we don't want them to get gestational diabetes," she said. "All those things that we can do to support them so that they can have a quality experience, as they go through, you know, their pregnancy, that is what we want to do."
MO Healthnet now covers health care a full 12 months after delivery after a state legislature decision a couple of years ago, and Smith expects that, over time, the state will begin to see positive impacts from that. Several statewide programs are in place to improve Missouri’s maternal mortality rate. She said as DHSS has listened to families, they’ve found that many of them are living in chaos "and feeling that they are barely surviving and definitely not thriving."
They're focusing specifically on maternal and infants because, she said, it's well-established that, as goes the health of moms and babies, so goes the health of the population.
"So, if you aren't doing a good job of taking care of moms and babies," she said, "you're probably not doing a really good job of taking care of your population at large. And the better you do at protecting and promoting health for moms and babies, the better everybody is."
One way the state is trying to improve the health outcomes of pregnant women is by making sure low-income women can access doula services. Doulas work alongside women to encourage healthy behaviors and to provide physical and emotional support during pregnancy, birth and the period shortly after.
According to the Pregnancy-Associated Maternal Review Board at DHSS, incorporating doulas into clinical and social care settings can improve equitable access to health outcomes for Black women. MO Healthnet offers doula services to all women enrolled in Medicaid when recommended by a physician or other licensed practitioner of the healing arts.
Despite the work being done, Smith said there’s not enough funding to meet all the needs of pregnant women in Missouri. She said they get around $12 million annually through the Title V Services federal block grant, but that amount hasn’t increased in years.
Still, Smith and Jenkins are proud of what they’re able to do.
"We have so many programs within the department that impact, you know, overall health and wellbeing that is beneficial for African American women," Jenkins said. "We try to be a voice and to say that services are for everybody, everyone is welcome. The expectation is we hope...with our partners is that the goal is to have people have a good experience and to give the quality of service that we would want our own family members and friends to receive."
She said they try to attack the problem of maternal mortality from a variety of angles and collaborating with other organizations and agencies to improve the numbers.
