The birth of Keri Ingle’s daughter was a medical emergency.
The umbilical cord was wrapped around the baby’s neck, and Ingle started bleeding profusely.
The hospital team intervened, and everything turned out all right. But the close call gave Ingle — who went on to become a Missouri state representative — a new understanding of the individual horror stories that together make up the state’s persistently high rate of deaths due to pregnancy and childbirth.
“I could have been one of those statistics,” Ingle, a Lee’s Summit Democrat, said during a legislative hearing earlier this year.
A renewed debate over abortion is roiling Missouri, with the state’s last provider in danger of losing its license and, starting in August, a near-total ban on abortions after eight weeks of pregnancy.
While state law increasingly reflects a desire to see women carry pregnancies to term and give birth, Missouri remains one of the most dangerous places in the developed world to do so.
Republicans who support the new abortion restrictions — and control state government — say they’re also addressing maternal mortality, which they see as a largely separate issue. Democrats say the new restrictions will worsen maternal mortality, and health policy researchers say more could be done to make pregnancy safer — if the state is willing to put up some money.
Maternal mortality is defined as deaths from any cause related to or aggravated by pregnancy or childbirth. The United States has long had one of the worst rates among industrialized nations, at about 20.7 deaths per 100,000 births and climbing.
Even with that low bar, Missouri is one of the worst states in the U.S., with a rate of 32.6 deaths per 100,000 births, ranking 42nd in 2018, according to the United Health Foundation.
If Missouri were a country, it would rank 111th in maternal mortality worldwide, roughly on par with Tajikistan and just behind Romania.
And the rate is much higher still among Missouri’s black women, which Rep. Cora Faith Walker, a Democrat from St. Louis County, reminded her colleagues during a debate on the abortion bill in February.
“If I get pregnant, the likelihood of me dying in childbirth is four times greater than one of my white counterparts here,” Walker said. “That is the reality of the situation.”
Other states have figured out how to get their rates in line with the top countries in the world. California’s maternal mortality rate has fallen steadily for more than a decade and is now a best-in-the-nation 4.5 deaths per 100,000 births.
But in Missouri, where women are much more likely to be uninsured, more likely to smoke during pregnancy and more likely to suffer from post-partum depression, the rate has continued to grow.
Now there’s debate over how the abortion law could affect that rate.
The abortion connection
The new law includes a clause allowing abortions when the mother’s life is in immediate danger. But “what constitutes a medical emergency and how the law would be interpreted and enforced involve vast gray areas and vague standards,” according to an op-ed by the dean of the Washington University School of Medicine and the CEO of BJC HealthCare (which includes Barnes-Jewish Hospital) published last week in the St. Louis Post-Dispatch.
The possible loss of their license or even criminal charges, they said, will instill fear and hesitation in some doctors, even when they think their patients might be in danger.
State Sen. Bob Onder, a Republican who supported the abortion bill and is also a St. Louis area physician, said he doubts that will be the case. The language in the “life-of-the-mother” exemption has been used in other state laws for some time, and doctors have understood how to navigate it.
“What relationship might there be between a state’s abortion laws and maternal mortality, I just don’t see it,” Onder said. “I don’t see the connection there. I guess I would challenge someone who asserts such a thing.”
Experts say there’s not enough data to prove the case either way. An oft-cited spike in maternal deaths in Texas after that state enacted abortion restrictions turned out to be due largely to reporting errors.
Some Missouri Democrats have also raised the specter of more women dying because they would seek unsafe abortions to get around the law.
“I expect maternal deaths are going to go way up soon, unfortunately,” said Rep. Sara Unsicker, a St. Louis area Democrat.
Historical data is sketchy, but based on what’s available, deaths due to so-called “back alley” abortions were fairly rare in the years just before Roe v. Wade legalized the procedure nationwide, thanks largely to medical innovations like antibiotics. And Missouri women will still be able to get legal abortions just across the border — in Overland Park to the west and in Granite City, Illinois, to the east, something thousands are already doing.
Randall Williams, the director of the Missouri Department of Health and Senior Services, said he’s not expecting a spike in maternal deaths due to botched clandestine abortions.
“That has not been borne out (elsewhere),” Williams said. “I don’t believe that would be true.”
Like Onder, Williams said he sees maternal mortality as a largely separate issue from the debate over abortion restrictions.
He also said it’s important to put the numbers in context. Missouri has about 70,000 births a year, which means the number of pregnancy-related deaths is usually in the 20s (there were 84 from 2015 through 2017, or about 28 a year).
“We lament all of those and one is too many,” Williams said, but the vast majority of Missouri women give birth safely.
Williams, who is himself an OB-GYN, said the state remains committed to decreasing the maternal mortality rate. Under his leadership the department has embarked on at least four initiatives to partner with hospitals, physicians and other state agencies to share data on pregnancies and spread best practices for treating some of the most common complications.
It has also expanded the scope of the state’s Pregnancy-Associated Mortality Review Committee — experts who analyze every maternal death in the state.
Republicans in the General Assembly say they have taken other key steps.
Lawmakers passed a bill writing the Pregnancy-Associated Review Committee into law, so that future administrations must carry it forward. It also requires the committee to submit an annual report about its findings to the governor and the General Assembly.
Unsicker pushed the bill unsuccessfully last year. But it passed without opposition this year after Republican Gov. Mike Parson said he wanted legislators to be open to any ideas for reducing maternal and infant mortality, no matter which party they sprang from. He spoke during a stop at Truman Medical Center on a tour of the state to discuss health issues.
Onder put it on the agenda this year in the Senate health committee he chairs.
“Teasing out exactly what the factors are related to Missouri’s high maternal mortality rate is a very valuable undertaking,” he said.
Last year the General Assembly passed a bill sponsored by then-Rep. Marsha Haefner, a Republican from the St. Louis area, extending Medicaid coverage so women can get substance abuse treatment for up to 14 months after they give birth.
Williams said drug addiction is a significant factor in indirect maternal deaths — the stress of having a newborn makes women more prone to relapse — and Missouri is the first state with such a law.
“We’re actually a thought leader on that idea,” Williams said, while adding that it’s still pending federal approval.
Most other states already offer new mothers substance abuse treatment through expanded Medicaid.
House Speaker Elijah Haahr has also touted tax credits Republicans passed for faith-based crisis pregnancy centers (those centers are controversial because they’re not required to provide medically accurate information).
But the Republican-controlled General Assembly has declined other initiatives that studies suggest would help make pregnancies safer, like Medicaid expansion and screening for post-partum depression.
States that expanded Medicaid under the Affordable Care Act were more likely to reduce both maternal mortality and infant mortality (Missouri ranks 30th nationally in infant mortality, which includes all deaths of children under age 1), according to research by the Georgetown University Center for Children and Families.
Medicaid expansion, which is funded 90% by the federal government and 10% by the states, allows anyone who makes less than 138% of the federal poverty line (about $29,000 for a family of four) to qualify for coverage. Missouri is one of 14 states (including Kansas) that have so far refused to take the federal money and implement it.
Joan Alker, the executive director of the Georgetown center, said that’s one of the key reasons Missouri’s rate of uninsured women of child-bearing age, at 13.9%, is significantly higher than the 9% rate in expansion states.
“Health coverage before, during, and after pregnancy is essential to the health and well-being of both mother and child,” Alker said. “Medicaid expansion is the single most effective way to help women of childbearing age get continuous health coverage during this critical stage of life.”
Missouri currently has some of the strictest Medicaid limits in the country. Childless adults can’t qualify unless they’re disabled. Pregnant women qualify if they have income up to 305% of the poverty rate, but they can’t apply until they know they’re pregnant, which could be several weeks, or even months into their pregnancies.
That means that before they get pregnant and soon after, many Missouri women are missing out on coverage that could help them address risk factors by doing things like quitting tobacco or getting their diabetes under control, said Beth Simpson, the president of the Missouri chapter of the American Academy of Pediatrics.
“Ensuring that moms and babies have healthcare is vital for Missouri families,” Simpson said. “This report shows that when Medicaid expansion increases a mother’s access to healthcare, both she and her baby do better and that child has a better chance for a healthy childhood.”
Williams said that Parson is focused first on shoring up the current Medicaid program and making sure it’s functioning well. But he hasn’t ruled out expansion.
“The governor has said that when it comes to health care in Missouri that everything is on the table,” Williams said. “That’s from him.”
But Haahr told the Post-Dispatch last year that he didn’t see much of an appetite for expansion among Republican legislators.
Onder said that in his experience most maternal deaths are caused well after women qualify for Medicaid based on their pregnancy, and he’s skeptical of research that shows a benefit from expanding Medicaid.
“I’d have to look at those studies because sometimes those studies get done by advocates of Medicaid expansion,” Onder said.
Missouri women also face a coverage cliff after giving birth. The state boots women off Medicaid 60 days after their pregnancy ends, unless they make no more than 21% of the federal poverty line — about $6,000 a year for a family of four. The only exception is an extension of coverage for contraception and sexually transmitted disease treatment.
Serious complications of pregnancy and labor can last well beyond 60 days, which is why the American College of Obstetricians and Gynecologists recommends that women have continuous coverage for at least 12 months after giving birth.
One of the most common complications is post-partum depression, a mental health condition caused by a combination of hormonal changes and the stresses of caring for a newborn. It’s a risk factor for suicide, which causes about 20% of deaths in the months following childbirth.
According to the United Health Foundation, about 14% of Missouri women who gave birth last year had post-partum depression, which was higher than the national average of 12.8%.
But that number is almost certainly low, because the state doesn’t have any comprehensive program to screen new mothers for the condition. Sen. Jill Schupp, a Democrat from the St. Louis area, introduced a bill this year that would have required health care providers to provide information about post-partum depression to new mothers and offer them screening.
Those who screen positive before their 60 days of Medicaid coverage are up would then receive an extension of mental health coverage for up to 12 additional months.
Schupp said the bill was directly aimed at preventing new mothers from taking their own lives.
“These deaths are preventable, the underlying issues are treatable, and this legislation can help keep new families healthy and safe,” Schupp said.
The bill got a hearing in Onder’s committee, but he never put it up for a vote. He said it had merits, but he had a technical concern: The bill not only required the mothers’ physicians to offer them screening but also required pediatricians to offer it to them at well-baby checkups.
That didn’t make sense, Onder said, because the pediatrician is the baby’s doctor, not the mother’s. Still, he said he’s open to working on the issue in the future.
“I think there are issues women can have beyond the 60 days (of Medicaid coverage),” Onder said. “I think it’s worth looking at expanding that window for patients who have specific medical or psychiatric illnesses.”