Missouri women have more limited access to health care and worse outcomes than any other state in the Midwest, a new study of the nation’s health care system found.
Missouri ranks 40th out of 51 states plus the District of Columbia on the 2024 state scorecard on women’s health and reproductive care, published by the Commonwealth Fund, a private foundation focused on health care issues.
The study assessed and compared 32 pieces of information derived primarily from public data sources in 2022, which was after most of the major effects of COVID had been felt, but before most abortion bans had really started to impact data findings, the creators of the scorecard said.
Missouri continues to see maternal and infant mortality rates, breast and cervical cancer death rates, preterm births, congenital syphilis and depression leading up to or during pregnancy at rates that are higher than the national average.
There are more women in Missouri between the ages of 18 and 44 reporting they hadn’t seen a doctor in the past year because of the cost than all but 10 other states.
“One thing is absolutely clear,” Joe Betancourt, president of the Commonwealth Fund, told reporters when the study was published last week. “Women’s Health in the U.S. is in a very fragile state.”
Missouri ranked among the states with the lowest low-risk c-section rates, postpartum depression and up-to-date pneumonia vaccines for post-menopausal women. But it fared among the worst nationally for breast and cervical cancer deaths, up-to-date pap smears, and mental health among women ages 18 to 64.
It also ranked poorly when analyzing access to abortion clinics. Nearly every abortion became illegal in Missouri in 2022. A citizen-led ballot measure is hoping to enshrine abortion rights in the Missouri constitution.
“We are seeing a deep and likely growing geographic divide in U.S. women’s ability to access vital health services and maintain their health,” said Sara Collins, a co-author on the Commonwealth Fund study. “Particularly among women of reproductive age.”
Ashley Kuykendall, director of service delivery for the Missouri Family Health Council Inc., a nonprofit working to strengthen health care access across the state, said one of the most stark findings of the report was the combination of lack of access to wraparound care paired with poor health outcomes.
But solutions exist, she said.
One such solution: a women’s health omnibus bill that failed to pass in the statehouse this year despite widespread bipartisan support, that would have expanded birth control coverage, increased congenital syphilis testing and eased access to mammograms and STI testing.
“The state legislature has an incredible power and responsibility to support better care for people across the reproductive health spectrum,” Kuykendall said. “Especially, as this report highlights, for folks who are pregnant or postpartum.”
Health and reproductive care outcomes
Missouri ranked 43 of 51 for this category, which includes maternal and infant mortality and physical and mental health issues.
Some data was analyzed using the Centers for Disease Control and Prevention’s Pregnancy Risk Assessment Monitoring System. Missouri is among 33 states who participate in this federal program. Of those states, Missouri had the highest percentage of women who recently gave birth and reported experiencing intimate partner violence before, during or after their pregnancy.
Missouri has some of the highest pregnancy-associated maternal mortality rates in the United States, which already ranks worst among countries of similar economies for high maternal deaths.
In Missouri between 2018 and 2020, women on Medicaid were 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 210 pregnancy-related deaths over those three years in Missouri, the majority were deemed preventable.
Mental health conditions were the leading underlying cause of death, including due to suicide and substance use.
The latest study found Missouri had one of the highest percentages of women between the ages of 18 and 64 who reported poor mental health, landing 48 of 51.
Coverage, access and affordability
Missouri ranked slightly better — 39 of 51 — in this category, which includes insurance coverage and health care affordability and access.
Of the 33 states that provided data around health insurance coverage, Missouri ranked third-worst for women uninsured the month before becoming pregnant, and sixth-worst for women who didn’t have health insurance during a recent pregnancy.
This is despite Missouri legislators’ decision to expand postpartum Medicaid coverage from 60 days to a year in 2023.
A better-funded, better-staffed and more accessible public health safety net is also critical, said Kuykendall.
This summer, Gov. Mike Parson signed into law a bill ending Medicaid reimbursements to Planned Parenthood, including for patients who go to the clinic for preventive exams, family planning and STI testing. Those opposed to the bill warned such a law would strain the state’s already fragile public health safety net.
“The need for these services far outweighs the current capacity for the safety net to provide them,” Kuykendall said. “Any funding cuts to those providers not only limits patients’ ability to access care, but also puts further strain on the health care workforce and will undoubtedly worsen these outcomes.”
Recent surveying by the health care nonprofit found that wait times across the state’s overburdened safety net clinics averaged between five and seven weeks. These 68 clinics receive Title X funding and do not turn anyone away, regardless of their ability to pay.
The study found that approximately 5.6 million women across the country live in counties that are considered maternity care deserts.
In Missouri, 41% of counties are designated maternity care deserts, meaning there are no maternity care providers or birthing facilities. Missouri’s rate is higher than the national rate of 32%, according to a separate 2023 report from the March of Dimes. Across the state, 10% of women do not live within 30 minutes of a birthing hospital.
In the last decade, 19 hospitals across Missouri have closed, according to the Missouri Hospital Association.
“There is an issue of access that’s very real,” Kuykendall said.
The authors of the study were also deliberate in considering outcomes in states with abortion bans and restrictions.
“There’s concern that abortion bans or limits will further reduce the number of providers offering maternity care owing to increased risk of legal action that provider’s face,” said David Radley, a senior scientist with the Commonwealth Fund. “Especially when states’ laws are ambiguous.”
A recent study showed states with abortion bans saw a significant decrease in the number of medical residents applying to be in their OB-GYN programs.
Missouri saw a 25% drop in applicants since 2022, the highest drop in the nation second only to Arizona.
“These inequities are long standing, no doubt, but recent policy choices and judicial decisions restricting access to reproductive care have and may continue to exacerbate them, Commonwealth Fund president Betancourt said of the study’s findings when related to states with abortion bans.
“It also serves as a glaring reminder that where you live matters to your health and health care.”
Health care quality and prevention
Missouri landed in slot 35 of 51 for this category, which includes c-section rates, preventative care, pre and post-partum care and mental health screenings.
In better news, Missouri ranked 15 of 51 among states with the lowest rates of c-sections during low-risk births, which Kuykendall attributed in part to the state health department’s increased focus on doula programs.
Missouri was slightly below the national average for the percentage of women eligible for mammograms who underwent the breast cancer screening in the past two years (75%), and the percentage of women ages 21 through 65 who had a pap smear, which screens for cervical cancer, in the past three years (78%).
Among the more concerning data points to Kuykendall was a report that 19% of women between the ages of 18 and 44 in the past 12 months had put off seeing a doctor because of the cost.
This data resonates with what she hears often from Missourians, who say it can be difficult to access even the most basic health care for reasons including cost, lack of transportation and lack of options.
“It was a positive step that Missouri expanded Medicaid,” Kuykendall said, “And I think we have a long way to go in terms of ensuring everyone who should have access to care in that new environment actually does.”
This story was originally published by the Missouri Independent, part of the States Newsroom.
