We're not doing great in Missouri.

We're currently the-- the seventh highest in maternal mortality.

60% of the mortality issues are related to substance use disorders, mental health disorders, depression, suicide, all of those kind of things.

Southwest Missouri is known for one of the highest rates of child abuse, neglect, and domestic violence.

We have some rural areas that do not have obstetrics providers.

I have several patients who drive one to two hours to come see me for each prenatal visit.

For a country that spends more than any other country on prenatal care and pregnancy, and has some of the worst outcomes to show for it, we got to change something.

[SLOW TEMPO MUSIC] KIMBERLY COSTELLO: A few years ago, the state gathered a committee to start the PAMR report, the Pregnancy-Associated Maternal Review report.

And when they gathered that research, that's when they determined that there are a lot of mothers that are passing away because they were not able to access health care.

And so that really brought a lot of awareness at the state level, that Missouri is 44th out of 50 states, and that 80% of those deaths were preventable.

COURTNEY BARNES: Based on the 2025 data, we have about 32 deaths per 100,000 women compared to the national average of 22 deaths per 100,000 women.

Almost half of our counties are what we consider maternity care deserts, which just means that people have less access to doctor's appointments, and resources, and support.

So compared to the nation, we're not doing super great.

MARTHA SMITH: We know that Black women are two and a half to three times more likely to die during pregnancy or the first year after pregnancy, the postpartum period, as white women.

Those moms that have more 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 that contribute to their overall health before they get pregnant, are more likely to die.

COURTNEY BARNES: About 10% of pregnancies are affected by hypertensive disorders, whether that's gestational hypertension, or preeclampsia, or HELLP syndrome, which is even more complex.

We know those ladies are much more likely to have heart disease down the road, develop hypertension, have cardiovascular disease.

JENNIFER BROOKS: Preeclampsia used to be this obscure disorder that nobody ever saw, but we see it so common.

There's really been an uptick in the rise of preeclampsia, which is high-blood pressure that's induced from pregnancy.

And we also see a lot of increase in gestational diabetes with our patients.

So it's-- it's important to get early detection and early management of those.

Postpartum hemorrhage is a big risk factor for maternal morbidity and mortality.

That's why I recommend that every woman have access to even a birthing center.

Whether it's low intervention or at the hospital, we want women to have a safe delivery.

COURTNEY BARNES: One of the biggest causes of maternal mortality is cardiovascular disease, cardiomyopathy.

Those are really complex medical conditions that require a multidisciplinary group to treat.

So making sure that we tap those patients into all of those services because it can be quite overwhelming.

When you came into pregnancy thinking you were healthy and you leave with a cardiomyopathy, that can be really overwhelming, especially when you have a new baby at home to care for.

How do we make sure that not only are we saying, hey, you have some risk factors for the future, but we're also saying, hey, how do we support you with diet, nutrition, stress management, making sure your cholesterol is staying low, you know, making sure you're-- you have access to all of those services.

And so that's probably the biggest one that we see.

But certainly, mental health, substance use disorders bridging patients to the right place that can treat those conditions.

KAITLYN THOMAS: One of the biggest causes of maternal mortality overall and then in the postpartum period is mental health.

And we just know that there's not enough mental health providers.

Even if they feel that their mental health is good at the time, I always ask them about history because, if they have a history of depression or anxiety, they will be at increased risk for postpartum depression or anxiety.

I make it a point to let them know that, if they do experience those issues, then they are not alone, and it's important for them to talk to us and reach out to us rather than trying to deal with it on their own because it can be serious.

I reassure patients, there's nothing wrong with you.

This could be a normal part of hormone fluctuations, and we can seek help.

So we do use antidepressants a lot in pregnancy for patients who struggle with depression and anxiety.

KIMBERLY COSTELLO: We have identified some of the top needs that we always see over, and over, and over again with the families that we serve, substance use disorder, mental health concerns, traumatic experiences.

One thing about substance use it is a coping skill, and it's an effective one.

It's not a healthy one, but it's an effective one.

Whenever there's trauma, especially early on before the brain can really process it, it's just, how do I feel better?

And for a lot of people, the answer is to use drugs.

And so trauma really is a gateway to substance use and to addiction.

If we're gonna treat the substance use and addiction, then we really have to look at that trauma piece because we have to help families and individuals learn how to have that trauma exist, but to deal with it and cope with it in healthier ways.

When moms are struggling with postpartum depression, it may make their trauma responses more heightened.

It may make their past trauma feel more present.

So they are gonna kind of snowball off of each other.

Postpartum can be really hard.

Some of the key drivers, unfortunately, of maternal death during the postpartum period are mental health and cardiovascular disease.

That affects anyone and everyone.

It doesn't discriminate based on race or income.

We see through the grant that we work with substance use as a primary problem for our clients.

So we see a lot of substance use.

We see a lot of unsheltered families, so a lot of moms that could be possibly living out in the street and still pregnant.

I am a certified peer specialist, and I also have my MAADC II, which allows me to do alcohol and drug substance use counseling.

One of the qualifications for being a peer support is having lived experience.

So I struggled with substance use.

Not only that, but I did struggle with substance use through pregnancy.

When my youngest son was born, he was taken into state's care.

And at that time, I was told about the grants and became a client.

It used to be very taboo.

Moms were separated from their children when they gave birth.

And now we don't see that as much, thank goodness.

Facilities are more educated on substance use.

Children thrive more when they're coming off of being exposed if moms are with them in the NICU.

We know that they thrive more being able to have that time with mom, being able to be breastfed.

And so I think part of our job is to educate providers, educate the community, and what that looks like.

Besides modeling better behavior, the best thing that we can do with our kids is to talk about these things.

I don't love having the conversation with my kids that I used to use substances, but it's necessary if I want them to do differently.

I'm very passionate about being a voice and a support for moms because I know how paramount it was for me to have that.

COURTNEY BARNES: Thank goodness the tide is changing a little bit on mental health disorders, where people are more willing to talk about it.

You can tell a lot just from listening to people, talking to them about how it's going.

And you get to know people so well during their pregnancies.

We have a lot of resources now for women, and there's really no reason for women to go through pregnancy or even just their everyday health without having appropriate treatment for mental health disorders.

From my experience, there's a lot of moms that just say, oh, well, we've had the baby, we've made appointments, and they're more focused on getting their child to the pediatrician for follow-ups and not really themselves.

And so encouraging the mom, no, we need to take care of you too because you can't take care of a baby if you're not well.

I realized how life-changing this program was for me and my family, and just knew that my story matters and that I would be able to help people and other moms like me.

I feel like a lot of times, there's-- there's a lot of advocacy for-- for children, but there's not really a lot of support for moms.

You know, you can't feed somebody from an empty cup, so to speak.

You can't-- you can't help nurture other people if you're not willing to take care of yourself.

And that's-- that's a thing that we see across the board with moms, I think, of all ages.

A lot of this is generational.

They grew up in a house where there was domestic violence, and substance use, and poor communication skills, and mental health was never talked about.

And I think that when we open the conversation up and we talk about these real issues, even though they're unpleasant, that's really one of the first steps in breaking these generational curses.

I think some people are pretty shameful to share that, so a lot of women don't go to appointments because they don't want somebody to know that they're using that.

There's really nothing to be scared of.

We will take care of you just the same.

We want to approach everything in a non-judgmental way.

I would say, probably 90% of my clients, I feel like, grow in their self-esteem and their confidence and their self-respect.

And really, that's-- that's my goal.

Outside of the grant, like, that's-- that's what I'm hoping to achieve with these women.

How healthy you are before you get pregnant can impact the outcome of your pregnancy, and understanding the need to take care of yourself and your health to the best that you can.

Those can all create barriers to adequate health care and positive and-- and optimal outcomes.

In some of the cities in Missouri, you will see barriers to health care look very different in the urban settings than they do in the rural health settings.

Food insecurities and homelessness are huge determinants as well for pregnancy-associated deaths.

And so are they able to get to their doctor's appointments and get the health care that they need if they are challenged with some of these other social determinants of health that are keeping them from getting the care that they need?

There are also a lot of historical barriers.

If people have had a bad experience in the past, then-- you know, with a health care provider, then they're much less likely to trust health care providers.

And so that can be a barrier to then-- them seeking and receiving care.

As a provider, that is our job is to be educating our patients, giving them recommendations, the risks versus benefits to those recommendations.

And I always let the patient know, you decide, with that information, what you feel is best for you.

Pregnancy and delivery can be unknown.

We prepare for every situation.

And I feel at Mercy, we have all those resources and access needed to keep patients and their babies safe.

People need to understand that access to care is not the same for every person.

If you live in a city that has a hospital that's delivering babies, then you-- you are very fortunate.

In the state of Missouri, we have many counties.

Over half of our counties do not have a delivering hospital.

With the closure of additional real hospitals as well as OB units, we know it's getting harder and harder and people have to drive long distances to care.

JENNIFER BROOKS: Within Greene County, we have access to care for maternal health and prenatal care.

But unfortunately, all the surrounding counties, we have more of like a maternity health desert, and we don't have a lot of access to care.

So we serve as a catchment system for many of the surrounding communities.

It doesn't really help to have a team of people that, like you, that live an hour and a half away.

Really, what we need to do is we need to partner with local services.

So local health workers, community health workers, social workers.

And we can do so many things by telehealth now.

We have technology.

And so it's really just figuring out, how can we provide that care from a distance and still offer them support?

There is a lack of resources available within our counties that creates concern for our pregnant women.

Usually, that comes with transportation.

So with our women coming from eight counties, getting to their appointments is very hard.

Coming to one place to get all your resources is definitely ideal for somebody that doesn't have transportation.

Specifically in a rural area, because if they're from a different county, they're going to get, you know, maternity care here.

But then they're going to have to go to the other county to get their WIC benefits, or food stamps or food pantry, whatever that is.

It could be multiple stops.

So providing it all in one stop is definitely ideal.

We have a ToRCH program.

Within that ToRCH program, we've worked with WIC and our Polk County Health clinic where they are providing WIC on site.

We want to set them up with all resources available.

We actually work with a platform, it's called Unite Us.

And we can send resources for that person while they're in clinic.

And they would get a phone call to follow up the next day to connect them to their resources.

A vast majority of our pregnant women, especially, are on Medicaid, and we utilize those programs heavily.

Medicaid, I believe, covers about 40% of the births in our state.

In 2023, Missouri actually expanded Medicaid coverage through 12 months postpartum.

Previously, it was only through 60 days.

And so that really signaled an opportunity to hopefully address some of those drivers of maternal mortality for some of our most vulnerable populations.

Especially for a woman who is uninsured outside of that pregnancy and postpartum period, that assures that for that time period, they can receive health services that they need, including behavioral health, which would include substance use identification and treatment, as well as other mental health conditions.

We believe that over time, we will see positive impacts for that.

Medicaid covers a year after.

That's not long enough.

You got to think a lot of women aren't seeking mental health resources until six months to seven months after, and then they're not getting the full year of benefit that they need in those services.

And let's be honest, they need more than a year.

The earlier that a woman knows that she's pregnant and goes ahead and gets enrolled in health services, then the earlier she also can get connected to the full scope of all the resources available to her.

All of our Medicaid HMOs like UnitedHealthcare, they also have programs set up for women who are pregnant.

So you can, like, be reimbursed for gas to and from your appointment.

They also provide breast pumps.

They also provide food.

So medically-tailored meals to a pregnant woman is something you can get through your HMO.

We want all moms to get the care that they need and them to have a healthy pregnancy.

If you are a mom on Medicaid in Missouri, you are eight times more likely to die of a pregnancy-associated death.

Most of that is because of access to care and someone helping you with community navigation and getting those resources you need.

You know, if you think about poverty, you think about some of those other conditions, whether it's mental health or substance use, the ripple effect of those, that's very complex and nuanced as to why women who receive Medicaid coverage are more likely to die.

And I think there are a lot of different factors that impact that.

We do talk about-- a lot about postpartum mood disorders and anxiety and depression that can lead to those deaths.

And so are we identifying those, bringing awareness to them so that then how do we fight that battle?

How do we give them the support that they need?

A saying that I've come across in doing this work is that we often think about the baby as the candy and the mom as the wrapper.

And sometimes after delivery, we kind of discard the wrapper, discard mom, and don't give her as much attention.

And that really is, unfortunately, reflected, I think, in our maternal and mortality results.

And that's something we really hope to change.

Women tend to access care at three times in their life.

When they're born, when they have a baby, and when they develop a chronic illness.

So how do we get women bridge to health care after their pregnancy?

This new 12-month postpartum pathway became a very urgent matter that we needed to address and identify, how can we support these families and these moms in that 12-month postpartum period, give them the support, the resources that they need to prevent these deaths?

Our maternal mortality results aren't great.

They aren't.

But what I've seen in our state is that we have a lot of grassroots effort and energy around this topic, and a lot of alignment across the people doing the work.

Whenever people don't feel well in their lives or don't feel safe in their lives and don't have the support they need, don't have access to resources, it's absolutely going to impact the quality of their care.

Our Perinatal Quality Collaborative out of our Missouri Hospital Association, as well as the Maternal Child Learning Action Network that they lead, really lead statewide efforts around quality improvement for what we term perinatal health, which is that full scope from the time a woman finds out she's pregnant through that first 12 months, including the infant's care and health as well.

We also provide a lot of opportunities for engagement and collaboration.

So not just the birthing hospitals, but really any clinical or non-clinical providers of-- of maternal and infant care.

We provide a lot of technical support and assistance.

We have some structured projects.

Those are called Quality Improvement Collaboratives.

And it really is an opportunity for those birthing hospitals to come together around a structured plan to implement those evidence-based practices around key topics, including things like hemorrhage and hypertension, mental health and substance use.

As well as neonatal abstinence syndrome and cardiac conditions of obstetric care.

Everything we do is founded in the data that comes out of PAMR.

So the Pregnancy Associated Mortality Review Board reviews all maternal deaths in our state, and that includes pregnancy and through one year postpartum.

So all of our priorities really come out of that.

Our clinical topics that we focus on, that we provide quality improvement around, as well as our focus on postpartum, those things really help to drive action and the conversations that we're having.

The PAMR board, over the past several years, identified that there are a variety of topics that just kept getting missed.

And this really speaks to the preventability of maternal death.

KAITLYN THOMAS: The Ask Me 5 campaign is really just simple resources that are for anyone providing care during that prenatal period or during the 12-month postpartum period to support them, and having conversations with our patients around some key topics.

So the topics include high-blood pressure, emotional and mental health, access to care, recognizing substance use, and trauma abuse and safety.

And really, the goal here is to build trust and facilitate openness with your patients around these topics, so that you can help connect them to resources, you can help them feel supported, and make sure we're addressing these things because these are often what we're missing.

One of our big efforts over the last couple of years has been around postpartum health.

Unfortunately, when looking at maternal mortality in our state, the largest portion of those deaths actually occur in the postpartum period.

When we think of postpartum, traditionally, we think of six or 12 weeks after delivery.

But the majority, about 43% of those deaths, actually occur between six weeks and 12 months postpartum.

We need to focus on a mom that has just given birth with more than just that one six-week follow-up visit.

There needs to be a more coordinated effort of, again, integrating clinical settings with non-clinical and with community-based organizations to make sure that 12 months is successful, making sure not only baby is safe, but also families and moms are safe and have the support that they need.

When you're carrying a child, when you're going through all of the changes in your body and your hormones, sometimes, you don't have all of the faculties that you need to ask the right question.

Sometimes, you don't have all of the knowledge.

And so you are trusting your health care provider.

And you're having difficult conversations.

And sometimes, you don't know what to say or how to represent yourself.

And so it's always good when you have people in your corner and around you.

It really is important to be able to advocate for yourself and advocate for your family members.

Being familiar with those urgent maternal warning signs can be really helpful because those really need medical attention immediately.

You have to find a provider that you can build a healthy rapport with.

I think that, a lot of times, you don't feel like you have options, but you do.

We all see the person in front of us through our own lens.

So trying to teach that cultural humility is part of what we're doing.

It's really hard to get kid care from someone if you're not feeling respected or supported.

We tend to listen to people who look like us or we have common ground with.

It's a lot simpler, a lot easier.

We feel like we speak the same language and we have the same experience, so we understand and we know.

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 I think that health care providers who take the-- the time to let you know that, I do see you and I do realize that there's a difference, but I respect you.

And I know that that can be intimidating, but I'm here for you.

That's always good.

Continuous labor support, whether it's in the form of a doula or it's in the form of a family member who really cares about you, we know it improves outcomes.

So we know that it decreases epidural rate, decreases C-section rate, decreases birth trauma, helps breastfeeding outcomes.

All those-- those things are really good.

But really, what I think it boils down to is patients feeling safe.

If you go to a hospital where nobody looks like you, nobody speaks your language, that is scary.

It would be very difficult to advocate for yourself under those circumstances.

So having someone who's on your side, who looks like you, who knows you, we know that helps outcomes.

And so it's really about having just an extra piece for communication, making sure we're all on the same page, make sure we're communicating adequately with the patient, understanding one another.

And I think that's where doula services come in.

A lot of people are familiar with traditional doula services, where a support person or a doula that is non-medical will help a family that is expecting, and provide some prenatal support, and attend the labor and delivery with that family.

What makes us unique is that we are a community-based, non-profit organization.

Our team is certified as a birth and postpartum doula, and a perinatal community health worker.

And we provide not only the prenatal, postpartum education and the labor support, but also trauma-informed care.

We identify any challenges that they're facing, barriers to care, and then we will address those with helping provide care coordination, and helping them with community navigation and getting to the resources that they need to help them thrive as a family.

COURTNEY BARNES: We know it's important to get prenatal care.

We know it's important to get your labs and your ultrasound, and be counseled, and offered all the screening.

I mean, all that stuff is pretty basic, but it's more than that.

It's about feeling supported, feeling safe, feeling heard.

And you don't necessarily need a doctor to do those things.

So I really think it's about expanding what we offer patients.

And we know that there are things that work.

Midwifery, model of care, we know that works.

We know that doula services improve outcomes.

Those things don't involve physicians.

And there are people out there that love to provide that care and are very good at providing that care.

We love working with doulas.

We think that they bring, really, a special aspect of care to the patients, and helping them work through different pain management and different positions.

And all of our patients have had a really good experience with the doulas that we work with.

Not only are we improving maternal health outcomes for these families, we're providing successful outcomes.

They're reducing C-section rates.

We're reducing children going into the NICU, and preterm and low-birth weights.

We are actually providing those education pieces and that support piece to reduce stress and anxiety surrounding the birth.

But also, that comes to equate to a cost savings for the state if, every dollar that we spend in prevention, we're saving $7 to $10 on the other side of cost for the state with Medicaid dollars.

They do a lot of that physical support early on after baby's born.

That's really helpful for our moms that tend to get overwhelmed because it can be very overwhelming, especially when they don't have an in-home partner and they're doing it by themselves.

So the doula foundation is a great resource for our moms.

I'm a firm believer that every woman would benefit from having a doula.

I mean, having that person that can advocate for you, that can let you know what's going on, who's focused on you and your needs, and assuring that they do everything in their power to help you and this baby go through this process in the most healthy way possible.

We are not done until every mom receives doula support because we know how vital it is in reducing stress and anxiety, and giving that support specifically to someone giving birth and preparing for birth.

And then in that postpartum period that we know is so vital as well, giving them that support that really traditionally did not exist.

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