Mothers are dying at high rates in Kansas and Missouri. Most are preventable, reports say

Despite three decades of advances in medical science, it is roughly just as dangerous now for new mothers in Missouri as it was 30 years ago, said Traci Johnson, a doctor at University Health.

It shouldn’t be that way, she said.

New reports from state agencies in Kansas and Missouri found that maternal outcomes had been getting worse in both states as of 2020, when the analyzed data ends. The majority of deaths that were recorded in both states were found to be preventable.

“That’s what I think is the biggest public health disaster,” said Johnson, who serves as chair-elect of the board that conducted the Missouri report, acknowledging the 30-year difference was an estimate.

Medical providers in Missouri “know how to prevent deaths from postpartum hemorrhage,” Johnson said. “We know that cardiovascular disease is a problem…We know that the screening tools work, but we don’t use them. We know that gun violence is a problem, but it’s political.”

State agency reports released this month in Kansas and Missouri showed an increase in deaths and illness during or within a year after pregnancy.

The reports were the first for each state to include data from the COVID-19 pandemic and follow a Centers for Disease Control and Prevention report that showed a dramatic increase in maternal deaths nationwide during the height of the pandemic. The U.S. remains the most dangerous wealthy country for pregnant women and new mothers in terms of maternal outcomes.

But even predating the pandemic, the data showed deepening problems for maternal healthcare in Kansas and Missouri that disproportionately harm women of color.

Between 2018 and 2020, 210 Missouri women died while pregnant or within one year of pregnancy, according to the report released this month from the Missouri Department of Health and Senior Services

The report, conducted by Missouri’s Pregnancy-Associated Mortality Review Board, determined that the mortality ratio in those three years was 32 deaths per 100,000 live births, an increase from 25.2 deaths between 2017 to 2019. Most of those deaths — 84% — were preventable, the report determined, which is nine percentage points higher than the previous report.

In Kansas, a report summary published last week by the Kansas Maternal Mortality Review Board found 105 cases in which a woman died while pregnant or within a year of pregnancy between 2016 and 2020. It determined that 29 of those were determined to be pregnancy related, 79% of which were preventable. While the report found an increase in deaths between 2018 and 2020 versus 2016 to 2018, the report said the number was statistically insignificant.

Roughly two-thirds of the pregnancy-related deaths in Kansas were among women of color, while Black women in Missouri were three times more likely to die within a year of pregnancy than white women.

“The progression of medical care has not benefited some populations in the same way it benefited others,” said Sharla Smith, an associate professor at the University of Kansas Medical Center and founder of the Kansas Birth Equity Network. She noted that nationwide Black maternal and infant mortality rates are worse now than they were 15 years before the end of slavery.

Reports, Smith said, have found inequity in maternal outcomes came as a result of bias, systemic racism, mental health and weathering, the stress bias has on bodies over time.

“It really is kind of the canary in the coal mine in terms of — what are we doing around health in this country?” said Tracy Russell, executive director of Nurture KC, a group focused on reducing infant mortality and improving family health. “When you look at these rates for Black mothers in particular, it’s irrefutable that there are systemic issues that are playing an outsized role in these outcomes.”

Extending Medicaid coverage

The release of the Missouri report comes after lawmakers this year passed legislation that allows low-income pregnant mothers to receive Medicaid benefits for a year after they give birth — up from the previous two months.

The American Rescue Plan Act, a COVID-19 relief package signed by President Joe Biden in 2021, allowed states to expand postpartum coverage up to a full year. Forty-seven states have expanded coverage since according to the Kaiser Family Foundation.

Missouri is among 10 states currently implementing the extension.

Renee Wilde, a spokesperson for the Missouri Hospital Association, based in Jefferson City, said there hasn’t been enough emphasis on helping women pre- and post-pregnancy to get to the root causes of the high maternal mortality rate.

Extending Medicaid coverage to a full year after birth was a “huge step in the right direction,” she said.

Lawmakers from both parties hope that the legislation will improve the survival rate of women in Missouri.

“I’m hopeful that by giving new mothers access to health care, including mental health care, which is an important part of it, that we’re giving them the tools they need to stay healthy,” said Missouri state Sen. Lauren Arthur, a Kansas City Democrat who sponsored a version of the legislation.

The policy has been in place in Kansas for just over a year.

“Before the extension when they were dropping off at 60 days they were not being screened for all the potential things they had,” Linda Sheppard, a senior analyst at the Kansas Health Institute, said of new mothers. “If they already had hypertension or they already had diabetes or they already had mental health issues, for that matter as well, those things are not being screened for and not being treated.”

Data on whether the program improved outcomes in Kansas is not yet available. But a Texas study showed women take advantage of more mental health, substance abuse and postpartum services when care is extended.

Early prevention in Kansas

In both states mental health issues and substance abuse were major contributors to deaths. In Kansas, the review board found that substance abuse disorder, obesity and mental health conditions were common contributors each contributed to one in four deaths.

“It’s only recently that we’ve even looked at the mental health aspects around pregnancy and postpartum and that’s something that hasn’t been invested in at all,” said Russell with Nurture KC. “When you see that’s the leading driver, it’s a problem.”

Mariah Chrans, program director at Cradle KC and a member of the Kansas Maternal Mortality Review Board, said more work needed to be done to address mental health, substance abuse and family planning before a pregnancy.

“We need to do a better job at wraparound support,” Chrans said. “We know that the better supported a person is and the better supported a community is and the better supported a community is the healthier they are.”

“In this region we are not doing well. Our numbers indicate that and we have to go for the things that do well but are hard and take a long time to really address infant and maternal health. We have to invest in changing our systems.”

In Missouri, the MHA has been working to improve the health outcomes of mothers and babies, said Wilde. This includes providing better care for moms with high blood pressure and distributing at-home blood pressure cuffs.

“We’ve been working on designing ways to have those sensitive but essential conversations about substance use and mental health disorders that can affect the patient and the child both short and long term,” she said.

A major barrier to that early intervention in Kansas, advocates say, is the state’s continued resistance to expanding Medicaid. About two-thirds of the 105 deaths in Kansas were among women on Medicaid, without insurance or with an unknown insurance status. The leading cause of death was motor vehicle accidents, accounting for 19 deaths, followed by cardiovascular conditions and homicide.

Kansas is one of 10 that has not expanded Medicaid. As a result, a coverage gap remains for Kansans who do not qualify for Medicaid but cannot afford coverage through the Affordable Care Act.

Smith said Kansas has taken good steps, referencing training she’s been involved in at KU, postpartum extensions and efforts to address the cost of living through eliminating the food sales tax and affordable housing initiatives.

But the most impactful step the state could take, she said, would be Medicaid expansion.

“Based on the data and on states that have improved their rates and improved the health of their population, that’s one of the factors we see as being extremely different than what we have here,” Smith said.

But Rep. Brenda Landwehr, a Wichita Republican, said Medicaid expansion wouldn’t help because she believed the problem stemmed from cultural issues and people not seeking out prenatal care. Expansion is heavily opposed by GOP leadership in the state Legislature.

Existing resources in the state, like community mental health centers and crisis pregnancy centers, provide the needed help, Landwehr said.

“I just want to get away from ‘government has to be the answer to everything,’ because that’s not the case,” Landwehr said.

Missouri voters approved an amendment to the state constitution that expanded Medicaid in 2020, but data is not yet available to show its maternal health impact.

High suicide and homicide rates in Missouri

The Missouri report found that the number of suicide deaths of pregnant women and new mothers doubled since the state’s previous report. Of those suicides, 50% involved the use of a firearm. And 75% of pregnancy-related homicides also involved guns. Kansas’ report summary did not describe method of homicide or suicide.

“That just speaks to how comfortable and how accessible guns are and how bad mental health is,” Johnson said.

In cases where a death is both pregnancy-related and a homicide, the state determined “that the pregnancy initiated a chain of events that led to the homicide,” said Sarah Ehrhard Reid, chief of the Office on Women’s Health at DHSS. In each of the cases, the perpetrator was a current or former partner and half of the records indicated a history of domestic violence or intimate partner violence.

“Our hope is that by including every pregnancy related death, we can show all the ways that providers and communities can help prevent these tragedies,” she said in an email.

Arthur, who acknowledged that she could not say definitively why homicide rates would be so high, said Missouri has become “a very dangerous place for people in violent partnerships.”

She pointed to the state’s lax gun laws, which do not bar those convicted of domestic violence from purchasing firearms and a state law that prevents pregnant women from filing for divorce.

“I just see different threads that could tie together and explain why Missouri has a long way to go to protect women,” she said.

Advocates expressed some optimism that, with increasing alarm over the issue of the high maternal mortality rate, there would be increasing attention. But there is still a lot to learn.

“It is really trying to figure out what is really happening with these moms and experiences they are having with their healthcare services when they’re pregnant,” Sheppard, with the Kansas Health Institute, said.

If you or someone you know is at risk of self-harm, the National Suicide Prevention Lifeline provides 24-hour support at 988.