Christian King, a doula with Uzazi Village in Kansas City, wraps Mikia Marshall, 33, with a kanga cloth to help take pressure off her stomach on Feb. 27, 2024 (Anna Spoerre/Missouri Independent).

In an effort to address Missouri’s deplorable maternal mortality rates, the state issued an emergency rule Monday allowing doulas to be reimbursed through Medicaid for the next six months. 

Doulas — who offer support for families during pregnancy, delivery and postpartum, but do not deliver babies — have been lifted up as one solution to improving maternal and infant health outcomes, especially among low-income families.

Missouri ranked among the bottom half of states for maternal deaths between 2018 and 2022, according to the Centers for Disease Control and Prevention.

“There are evident disparities in the risk of maternal mortality by ethnicity and race, maternal age, access to care, and socio-economic status. Utilizing doula services may reduce maternal mortality, health disparities and improve maternity care for women in Missouri,” the rule states. 

The state Department of Social Services will begin reimbursing doula services to low-income women through MO HealthNet, the state’s Medicaid program, on Tuesday. The program will last through March 28 in the hopes of improving birth outcomes. 

News of the rule change was first reported by the St. Louis Post-Dispatch.

The emergency rule is only six months, but a longer term plan is in the works. On Sept. 27, the Department of Social Services provided public notice of intent to submit a permanent plan.

The program reimburses six total prenatal and postpartum doula visits, attendance at a birth, lactation education services and help navigating community services. Doulas often visit new mothers at their homes during the postpartum period, watching for signs of depression, addiction and violence, all of which have been found to be leading causes of death for women in the year after giving birth.

“There is potential for an offsetting savings in year two and beyond based on the potential reduction in the Cesarean rate as well as other improved birth outcomes,” the rule said.

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.

“I’m pleased to see that ruling,” Hakima Payne, co-founder and CEO of Uzazi Village, said Monday. “It’s a step in the right direction for improving maternal and infant health in Missouri and I’m glad to see the state taking that step.” 

Payne, whose Kansas City nonprofit works to improve birth outcomes, including through doula training programs, said she hopes to see the reimbursement made permanent.

Missouri has long been among the states with the worst maternal health outcomes in the country. 

In Missouri between 2017 and 2021, women on Medicaid were seven times more likely to die within a year of pregnancy than women on private insurance, according to a report published Aug. 30 by the state’s Pregnancy-Associated Mortality Review. 

In those five years, 349 Missouri women died while pregnant or within a year of pregnancy. Black mothers in that time frame were 2.5 times more likely to die within a year of pregnancy than white mothers. 

Of the 70 or so pregnancy-associated deaths each year in Missouri, 77% were deemed preventable. Cardiovascular disease and mental health conditions were among the main causes of pregnancy-related deaths.

“DSS finds an immediate danger to the public health, safety or welfare of pregnant women in Missouri, which requires this emergency action,” Monday’s emergency rule stated. 

A 2023 March of Dimes report gave Missouri a D- for preterm births, and also pointed to doulas as a solution.

The report recommends that health care facilities work with social workers, community health workers and doulas during patients’ pregnancy and post-partum periods, in part to address social determinants of health. 

Missouri doulas give up wages to serve women on Medicaid. Legislators hope to fix that

Okunsola Amadou said formal conversations between doulas and the state around Medicaid reimbursements go back years.

Amadou is founder and CEO of Jamaa Birth Village in Ferguson, the oldest community-based doula organization in the St. Louis region.

In spring 2022, Amadou and Payne were among several people who co-authored a policy brief that highlighted the benefits of doulas on health outcomes and urging “innovation” to bring doulas to more women, particularly those with high-risk pregnancies.

“This policy brief was the trusted, evidence-based document that informed the entire state of Missouri on the importance of doulas,” Amadou said.

When the emergency rule was announced, Amadou said she finally breathed a sigh of relief.

She noted that while the emergency rule, which holds until a permanent plan is finalized, would not financially cover every woman who could benefit from a doula, organizations like Jamaa Birth Village and Uzazi Village will continue to offer scholarships programs for doula services as well.

“We will always back up our community where the state is still trying its best to answer the call,” she said. “ … We have to start somewhere, and I just want to applaud the state for starting somewhere.”

Christian King, a doula in Kansas City who in March told The Independent she had reduced or given up wages to provide services to women on Medicaid who couldn’t afford the assistance, said Monday the state just created a huge opportunity. 

“I hope that with government funding, our hospitals and health training institutions begin to welcome doulas,” King said. “But also respect us and allow us to support birthing persons and their families without a power struggle.”

The order came months after identical bills that would’ve allowed doulas registered with the state to be reimbursed through insurance died before the end of session. The legislation was filed by state Reps. Wendy Hausman, a Republican from St. Peters, and Jamie Johnson, a Democrat from Kansas City. 

Improving the state’s birth outcomes has been heralded as a bi-partisan issue.

In 2023, the Missouri legislature extended postpartum Medicaid coverage from 60 days to one year. Several months after he signed the bill, Gov. Mike Parson called on the state to do more to improve birth outcomes, which he called “embarrassing and absolutely unacceptable.”

This story was updated at 11 a.m. to clarify the financial cost and timeline of the emergency rule, and to add comments from Okunsola Amadou, with Jamaa Birth Village in Ferguson.