From 2019 to 2023, 340 Missourians died while pregnant or within a year after pregnancy. Of those, 108 deaths were classified as pregnancy-related — meaning caused or aggravated by the pregnancy itself — and nearly 80% of them were preventable.
The findings were part of the sixth annual Pregnancy-Associated Mortality Review, published this month by the Missouri Department of Health and Senior Services. Cardiovascular disease and mental health and substance use disorders remain the leading causes of pregnancy-related mortality in Missouri. Infections, hemorrhage and amniotic fluid embolism are among the other less-common causes of death.
Missouri has long ranked among the states with the worst outcomes for infant and maternal health.
“Preventing maternal deaths in Missouri is complex. Health disparities, the opioid crisis and lack of access to healthcare all impact the health of moms across the state,” this year’s report concludes. “ … Studying maternal mortality cases is the first step in helping Missouri moms have healthy pregnancies and postpartum outcomes.”
The latest report does not yet account for deaths in 2024 and 2025, at which point the state began rolling out several programs and initiatives aimed at reducing poor maternal outcomes.
While the latest data virtually holds steady to the numbers seen in years prior, Martha Smith, the Missouri maternal child health director for the health department, is confident that the outcomes will soon start improving.
“Sometimes there’s not a magic bullet, so to speak,” she said. “Sometimes it is more of this process, and systems work to build the infrastructure and then train everybody and get everybody on board to use the same framework and build on the same infrastructure enough when you can really start the massive push to see a shift. I kind of think of it like a tidal wave to create that momentum to really change how things are done.”
While the statewide efforts are expansive — bringing together government, hospitals, researchers, providers and community health workers — maternal health advocates on the community level worry how budget cuts at the state and federal levels could impact the work in years to come.
Across Missouri, maternal health deserts are expanding and safety net care is shrinking.
“Community based organizations are struggling to provide basic care that they’ve been providing as safety nets, they’re just being cut, and the projected policies that are on the ballot are lined up to do even greater harm,” said Lora Gulley, chief operating officer at Generate Health, a St. Louis-area nonprofit focused on addressing racial disparities in maternal and infant health. “So we do have our work cut out for us in advocacy.”
The warning comes as the money behind that work is thinning. State funding for maternal health services was cut in half in this year’s budget, lawmakers eliminated the capital gains tax last year and a measure on the Aug. 4 ballot would begin phasing out the state income tax — pressures advocates fear will fall hardest on the community groups already working with less.
Mental healthcare
All of the 24 deaths in the report associated with mental health conditions, including severe postpartum depression and substance use disorders, were found to be preventable.
Kyra Betts-Patton, a community-based maternal health strategist in St. Louis, said she wasn’t diagnosed with postpartum depression until she was 13 months postpartum with her first child. Five months later she was pregnant again, and on her third type of antidepressant medication after the first caused gastric issues and the second caused insomnia.
For Betts-Patton, who is also a doula and a PhD student studying public health at Washington University, the experience only reinforced how difficult it can be to identify and then treat mental health disorders postpartum.
“We are starting to get some providers who have some perinatal behavioral health training,” she said. “Not enough, not enough for the number of us that experience the severe depression and anxiety that leads to maternal mental health being one of the leading causes of maternal death.”
This year’s report identified several contributing factors to the mortality rates, while also noting that without autopsy results for a majority of the cases, it’s difficult to pinpoint the exact cause of death.
Only 36% of the women in the report had an autopsy performed. The report recommends that autopsies be performed in all cases.
Betts-Patton said the lack of an autopsy lets systems and providers off the hook. For example, she said, a woman battling a severe infection postpartum might take additional pain medication to cope. If her death is then documented as an accidental overdose, then it might overlook the infection as an underlying cause.
Where more information was available, the board determined that a failure of a provider to complete a health assessment, including a postpartum mental health screening, factored into 38 of the deaths.
Other provider-level contributing factors include failure to provide quality care, such as failure to treat hypertensive disorders; failure to coordinate continuity of care, such as failure to coordinate prescription changes in pregnancy; and discrimination, including dismissed symptoms.
Lack of knowledge of risk factors or warning signs was listed as the most prevalent risk factor for patients, factoring into an estimated 26 deaths.
The report also highlighted system-level contributing factors in the women’s deaths, including barriers to accessing care, such as an inability to afford care, or a lack of reliable transportation to get to that care.
Statewide efforts to reduce deaths
Black women continue to die at 2.5 times the rate of white women, according to the report. Women enrolled in Medicaid were nearly 3 times as likely to die as those on private insurance, a rate that has decreased since a 2022 report, which encompassed maternal deaths from 2017 to 2019, found women on Medicaid were eight times more likely to die than those on private insurance.
In 2023, the Missouri legislature expanded Medicaid coverage through the first year postpartum. About 40% of women in Missouri who give birth are on Medicaid at the time of delivery.
This is one of several recommendations by the board over the past several years that has since been rolled out. Other efforts include support for doula training programs and coverage of doula services for pregnant women on Medicaid beginning in 2024, followed by an expansion of those services that was signed into law this year.
Also signed into law this year was a statute expanding the scope of the mortality review board to include studying the state’s maternal healthcare deserts, tracking the level of prenatal and postnatal care given to women who die in childbirth or postpartum and making recommendations to combat racial inequities in maternal deaths.
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In 2024, the Missouri Perinatal Quality Collaborative launched the Ask Me 5 Campaign aimed at establishing more trust between providers and patients while discussing critical health and safety information.
The state is currently in the process of implementing the Postpartum Pathway program published late last year that aims to create standardized postpartum care across the state. The initiative was the result of state funding spurred by the mortality board’s previous findings.
Gulley said the report proves it’s possible to “create space where collaboration can happen between and amongst both those that are providing those critical care and services and families that are trying to access them so that we’re in alignment.”
It also proves there’s no one lynchpin to be found.
“When we talk about listening to community, that better helps us understand what things we need to address or tackle,” she said.
For example, among the new recommendations this year was an urging by the board for local housing authorities to create policies prioritizing housing for pregnant and postpartum women. The board also called on local governments, state agencies and community-based organizations to invest in community violence intervention programs with the goal of reducing the number of pregnant and postpartum women killed in homicides.
“We know there’s a direct correlation with stress and cortisol in your body. It’s not an ideal environment for a baby to be growing in.” Gulley said. “That leads to hypertension, it leads to preeclampsia. It can lead to other chronic illnesses that stress exacerbates.”
It’s often community organizations working on the ground to address social determinants of health, like housing and food insecurity, violence and environmental hazards. The task is made all the more difficult when investment dollars start drying up.
In 2023, Gov. Mike Parson signed off on a budget that invested $4.3 million in improving quality and access to maternal health services.
That funding was cut in half in the budget signed by Gov. Mike Kehoe for the 2027 fiscal year, Smith said, but they still have some continued funding. Some of the state programs also rely on federal grants as well as MO Healthnet funds.
Betts-Patton said she fears how budget line items like the doula training program might fare in leaner years, despite research showing their effectiveness in improving maternal outcomes.
“There have been people in this work for over a decade, still advocating before there was a PAMR report,” she said. “There were still people who had that anecdotal community level experience that something was happening. Is still happening.”