Christian King watched her sister lie sick in a hospital bed for days after suffering a placental abruption while giving birth.

Finally, after their mother pleaded with hospital staff to run more tests, they learned her blood count was dangerously low. Two blood transfusions later, she was back on her feet.

The power of having an advocate during birth stayed with King. Not long after, she became a doula.

It’s why King, a single mom of three working two jobs, has agreed to cut or eliminate her fees in order to ensure women on Medicaid can afford to access her doula services in the Kansas City area. Doulas offer support for families during pregnancy, delivery and postpartum, but do not deliver babies.

She’s not alone. In order to serve some of Missouri’s most vulnerable women, doulas say they have been giving up wages to make their services affordable to those who need it the most.

In Missouri, doulas are not guaranteed a reimbursement through Medicaid for low-income patients.

And as more rural areas of the state are labeled maternal health care deserts, birth centers, which can provide an alternative to hospitals in low-risk pregnancies, say they can help. The problem? They are impossible to license under current law. Without licensure, they are not eligible for Medicaid reimbursements, either.

A bipartisan group of lawmakers have introduced a number of bills looking to make both doulas and birth centers more accessible across the state.

Identical bills filed by state Reps. Wendy Hausman, a Republican from St. Peters, and Jamie Johnson, a Democrat from Kansas City, would allow doulas registered with the state to be reimbursed through insurance. Both bills passed through committee Wednesday.

“There are many women who do not have faith in the medical community and they prefer to explore other avenues and other options for healthcare,” Hausman said during a hearing last month. “I believe that women deserve to be taken care of in a way that they’re most comfortable during this very complex time.”

A third bill from state Rep. Kent Haden, a Republican from Mexico, would de-designate birthing centers as ambulatory surgical centers, which would allow them to get licensure, and then Medicaid reimbursements. It has not yet been voted on in committee.

Birth centers don’t perform surgeries, so they shouldn’t have to meet the requirements of a facility that does, Haden said. He hopes the bill could be a solution for rural Missouri, which is in a “real conundrum” as rural hospitals continue to close.

Haden said he’s also in support of the doula bills.

A year ago, he didn’t know what a doula was. Now he’s convinced that without them, “we probably won’t change our maternal death loss postpartum or prepartum.”

Doulas ‘a necessity,’ not a luxury

Driving the conversation is Missouri’s abysmal maternal mortality rate.

In Missouri, women on Medicaid are 10 times more likely to die within a year of pregnancy than women on private insurance, according to a 2023 report from the state’s Pregnancy-Associated Mortality Review. Black mothers were three times more likely to die within a year of pregnancy than white mothers.

Of the 70 or so pregnancy-related deaths each year in Missouri, the majority were deemed preventable.

Last year, the Missouri legislature extended postpartum Medicaid coverage from 60 days to one year. Several months after he signed the bill, Gov. Mike Parson announced a plan to invest $4.3 million to improve the state’s birth outcomes, which he called “embarrassing and absolutely unacceptable.”

But he has said more action is still needed.

Johnson pointed her colleagues to a 2023 March of Dimes report that gave Missouri a D- gradefor preterm births. Doulas are one of the solutions suggested by the report.

King, 33, has been a PRN doula through Uzazi Village for five years. The non-profit, which sits in one of Kansas City’s poorest zip codes, strives to improve Black birth outcomes in part through training and hiring doulas.

She learned about Uzazi Village after birthing her third child at a Kansas City hospital. With her mother unable to attend, King called on her friends, who showed up ready to work.

They held her hands, readied washcloths, took photos, fed her, advocated for her.

“It was beautiful the way everyone was in action,” King said. “They made me laugh when I wanted to laugh. It was the best birth experience I have ever had having just my village doing what women do for each other.”

Now King, who is also an 8th grade math and social studies teacher, has walked about 100 women through pregnancy as a doula. Mikia Marshall, 33, of Kansas City, was one of the latest.

“I’ve never done this before and I’m scared,” Marshall told King when they met in Uzazi Village’s colorful community room in late February. “What if he gets stuck? What if I can’t push?”

Marshall, then 37 weeks pregnant with her son, said when her mother could no longer be at her birth, she found help at Uzazi Village, desperate to have someone with knowledge by her side.

King walked Marshall through the steps of labor. She laid out her birth options, including pain medications available to her and whether she wanted to delay umbilical cord clamping. If Marshall preferred, she could request only female or Black providers.

Pressing on Marshall’s lower back, King demonstrated ways her boyfriend could help relieve pain during labor. She wrapped Marshall in an African wrap called a kanga cloth, to help take some pressure off her stomach in the home stretch.

King turned on a Christian hypnobirthing playlist and gave Marshall a briefing on breastfeeding.

“It’s about to be the hardest job you’ve ever done,” King said. “He’s never done this before. You’ve never done this before. So be graceful to yourself and give grace to him.”

Marshall is on Medicaid. While King is paid by Uzazi Village to be her doula, that wasn’t always the case. Over the years King, who was also on Medicaid when she had her first child, said she’s taken on clients outside the nonprofit who had no money to pay her but were clearly in need of support.

One of the leading causes of pregnancy-related death in Missouri is linked to mental health. King said that while doctors can’t be in homes for postpartum visits, doulas can. And they’re watching for signs of depression, addiction and violence, all causes of death postpartum.

“Why continue to feed into doulas being a luxury and for those who can afford to pay out of pocket for them,” King said. “When in our Black communities and low-income communities, doulas are not a luxury, they are a necessity.”

The movement to pay doulas has grown across the United States in recent years. According to the National Health Law Program’s Doula Medicaid Project, more than half the states either have Medicaid coverage for doulas or are working towards it.

“Doulas really do make a difference in birth outcomes,” said Hakima Payne, co-founder and CEO of Uzazi Village. “And lots of entities are benefiting off the efforts of doulas, and those are the entities that should be paying doulas.”

Payne, who has worked in the birth space in Kansas City for decades, said it’s all too common for doulas to forgo a living wage to help a family in need.

Thanks to a doula pilot program through the city of Kansas City,combined with scholarships through Uzazi Village, Payne said all her doulas are now paid about $25 an hour and can take on anyone as a client, regardless of insurance. But that’s not the norm everywhere.

Okunsola Amadou knows many doulas who trade their pay for other family’s health.

Amadou, the founder and CEO of Jamaa Birth Village based in Ferguson, the oldest community-based doula organization in the St. Louis region, said the going rate for doula services should be $1,500. Instead, many work on a sliding scale of affordability.

This increases some access to care, but it also guarantees doulas are burning out. As many doulas as Jamaa Village has trained — more than 400 doulas since 2016, including in rural Missouri communities like Hickory County and the bootheel — Amadou said there’s still a huge need.

The Missouri bills garnered support this year from the American College of Obstetricians and Gynecologists and the Missouri Hospital Association. No one testified to the committee in opposition to the bills

“Doulas have shown me the light,” Shannon Cooper, a lobbyist for America’s Health Insurance Plans, said while testifying last month. “There is a spot for doula services in today’s health care world.”

Missouri has no freestanding licensed birth centers

Concerned after his local hospital between Columbia and Hannibal closed, Haden decided to spend part of last summer scoping out Missouri’s health care options.

More than 41% of counties in Missouri are designated maternity care deserts, higher than the national rate of 32%, according to a 2023 report from the March of Dimes. Across the state, 10% of women do not live within 30 minutes of a birthing hospital.

Haden’s trip included a tour of New Birth Company in Overland Park, Kansas, where he was surprised to learn about half the women opt for water births. He said the experience opened his eyes to a real fear “whether it’s founded or not,” of hospital births.

Others in the birth center space say the benefits of delivering low risk pregnancies outside of hospitals include a lowered risk for unnecessary medical intervention and an opportunity to labor more freely.

Lindsey Wilson is a certified nurse midwife who used to practice in rural Missouri. Now clinical director at New Birth Company, she said of the 3,000 babies they’re delivered in the past 14 years, about half are by mothers from Missouri.

“It is not uncommon for women to travel one to two hours easily in active labor in order to come to our birth center,” Wilson said. “And we’ve had car births because they cannot get to us quick enough, which is extremely unsafe.”

Cassaundra Jah, executive director of the National Association of Certified Professional Midwives, said birth centers and midwifery are about access.

One of the best ways to fight health disparities is to have more culturally matched providers, she said. Enter midwifery, an occupation much more accessible to most than medical school.

A barrier she often sees to legislation promoting birth centers and midwives is fear by lawmakers for their constituents’ health. Jah said much of her work is focused on educating state leaders that midwives and birth centers only serve low risk pregnancies. They also have transfer agreements with local hospitals in case a birth turns into a medical emergency.

“Missourians do need the option of birth centers, especially since hospitals are closing and those high acuity services are further and farther between,” Payne said. “Birth centers can absolutely stand in the gap.”

As of 2021, there were more than 400 birth centers across the United States, according to the American Association of Birth Centers. Birth Center Equity, a group advocating for more diversity in birthing center spaces, has only identified 20 birth centers across the U.S. owned by people of color.

Both Amadou at Jamaa Birth Village and Payne at Uzazi Village want to help grow that number.

They plan to open birth centers in their prospective cities. Payne knows of others in rural Missouri hoping to do the same. If the “noxious” regulations aren’t eliminated, she said, they will only be able to serve women who can pay out of pocket, or through donors.

Amadou, who is a certified professional midwife, plans to break ground on abirth center and postpartum retreat centerthis summer regardless of the legislation. But she hopes it doesn’t come to that.

“We know that hospitals are overwhelmed. They’re understaffed. Providers in the hospital are exhausted and doulas can only support so much,” Amadou said. “So we’re able to open a birthing center and also train additional midwives, additional Black midwives, in clinical care practices and we can really help to advance maternal health.”

Payne said when she started taking proposals for legislation around birth centers and doulas to lawmakers more than a decade ago, many of her ideas were considered radical.

Not so much anymore. She’s hopeful this time, she’ll be heard.

“Missouri needs to make this happen. We’re ready for it; we are ripe for it,” Payne said. “And these things will matter. They will make a difference.”

This story was originally published by The Missouri Independent, part of the States Newsroom.