In the past year, Christian King, a doula based in Kansas City, has supported more than 40 mothers enrolled in Medicaid through their pregnancy, birth and postpartum.

In that role, she helps educate and support families about birth and babies, but her work also takes on a more nontraditional approach.

When one mother’s water was shut off at four weeks postpartum, King helped her find reconciliation services to turn the utilities back on. When another mom couldn’t afford car repairs, King found an organization in Raytown that provided financial assistance. She helped one client secure a car seat from the local health department and another fill her closet with baby clothes.

King, 35, hopes that soon, “just like going to the dentist and going to the eye doctor, obtaining a doula and having a doula present is also one of those things that you just have to have on your team as part of services for maternity.”

Doulas do not deliver babies. They advocate for the physical and mental wellbeing of mothers and their families.

For the past 15 months in Missouri, anyone enrolled in Medicaid while pregnant and postpartum can have a doula by their side for free. Now, a group of bipartisan lawmakers are hoping to expand the program in an effort to continue combating the state’s poor infant and maternal outcomes.

“The statistics tell a devastating story of the lives lost that could’ve been saved if we put in the proper measures,” said state Sen. Barbara Washington, a Democrat from Kansas City who proposed one iteration of the . “There are third-world countries that have better maternal mortality rates than we do.”

The bill is estimated to cost around $300,000. While substantial amid a predicted state budget shortfall, state Rep. also filed legislation to expand the program, said she believes the long-term savings of having fewer Missourians who require medical attention will make up for the cost.

On average, 70 women die each year in Missouri during childbirth or in the first year postpartum. Of those deaths,

In Missouri, than women on private insurance, according to a 2024 report published by the state’s Pregnancy-Associated Mortality Review that looked at women who gave birth between 2017 and 2021.  A 2023 and also pointed to doulas as a solution.

In fall 2024, the Missouri Department of Social Services issued an , citing “an immediate danger to the public health, safety or welfare of pregnant women in Missouri.”

Since the program’s inception, there have been about 625 participants insured through Medicaid who accessed doulas during their pregnancy and postpartum, said Baylee Watts, a spokeswoman for the Department of Social Services. As of this month, 108 doulas were enrolled in the program.

“The department is encouraged by the level of engagement so far,” Watts said in a statement. “And views the doula benefit as an important component of broader efforts to improve maternal health outcomes across Missouri.”

Legislation filed by state Rep. Tara Peters, a Rolla Republican, has moved the farthest this year, clearing committee in February as part of a  Her bill seeks to increase the number of covered doula visits from six to 16.

The average out-of-pocket cost for a doula in Missouri is about $1,500, according to the Missouri Doula Association.

“I’ve just noticed how much extra care a doula can provide, especially for women in high need situations,” said “Doulas can provide some great education and support for people who maybe don’t have the extra support.”

This support can also look like serving as an interpreter between medical professionals and pregnant people, navigating insurance, ensuring access to nutritious food or coordinating transportation to medical appointments.

, who previously served as executive director of Monarch Family Resource Center in Farmington, said expanding the number of covered visits can be particularly helpful for women who experience postpartum depression in the year after giving birth.

Her legislation, like Peters’, expands the number of reimbursable visits from six to sixteen, and includes access to doulas for prenatal, birth, postpartum and lactation support.

She said the legislation also hopes to correct some issues doulas have had getting full reimbursement after being in the room for a scheduled c-section, listed as a scheduled surgeries, a classification she said muddled the reimbursement process.

The Department of Social Services previously said the reimbursements could lead to savings for the state in the coming years, including by potentially reducing the Cesarean rate. Watts said it’s too early to get an accurate look at this result.

said doulas can be a lifesaving set of eyes and ears in homes where women experience domestic violence, a leading cause of pregnancy-associated deaths in Missouri.

“The doula birth worker can also have a voice in those situations and see what’s going on outside of that medical office,” she said. “And maybe be able to provide some rescuing relief from dangerous situations for mom.”

To be eligible, and certified through a national or Missouri-based doula training organization. From there, they will be added to a list of eligible doulas overseen by .

Sandra Thornhill, a social justice doula who has advocated in Jefferson City for better legislation for doulas, said it was beautiful to see this policy issue reach across the aisle. And she was happy to see some of the proposals pushing for increased visits, especially in postpartum.

She said it’s not a question of if doulas should be reimbursed, but of how the state honors the traditional practices and values of doulas in that process. She is wary of any policies that place community health workers under medical or state authority. Instead she hopes to see more collaborative models.

”My concern is not with recognizing doulas in the Medicaid policy, but with how the bill structures authority and governance over that work,” said Thornill, who describes herself as a womb warrior and policy griot. “The question is whether the policy structure strengthens community birth workers or will it place unnecessary burden or medical authority that doesn’t reflect the roots of the work.”

But she said the progress made in acknowledging and supporting doula’s work in the past few years is striking, especially as many doulas live “birth to birth” as they struggle to pay the bills.

Prior to the state’s Medicaid reimbursement plan, to help families in need for free as they navigated growing their families.

“They do it because they love their people and their community so much that they’re willing to make this great sacrifice,” Thornhill said. “
However, it is not healthy. And it is not fair for the community to have to suffer like that when there are resources available to change that. But again, those resources cannot come with a slap on the wrist. They cannot come with a backlash of ‘now you’re under our thumb.’”

A representative with America’s Health Insurance Plans voiced opposition to Washington’s bill in a committee hearing last month.

“We are very concerned about issues with education, standardization and making sure doulas are all on the same page and we know exactly how they’ve been trained,” he said. “There seems to be some resistance out there and a lot of independence within the organizations.”

Washington’s legislation also seeks to ensure health benefit plans offer coverage for midwifery services. She said this is especially crucial in rural parts of the state, where families don’t have access to nearby hospitals with maternity wards.

“Currently, our law does not explicitly require private health plans to cover midwifery. This would close that loophole,” Washington said, adding that this change would shift power back to patients to choose their own provider, especially in rural communities “where the hospitals are closing at alarming rates.”

is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Missouri Independent maintains editorial independence. Contact Editor Jason Hancock for questions: info@missouriindependent.com.

“Don’t underestimate the value of play,” Hartwick College’s Laurel Bongiorno warns in a for the National Association for the Education of Young Children. Cognitive, social and literacy skills, along with vocabulary and physical abilities all get a workout when the little ones play. And while nobody invented playful learning, one of the world’s most influential champions was Loris Malaguzzi, founder of child care centers and preschools .

To learn more about play’s place in the Reggio Emilia approach, Early Learning Nation magazine spoke to Brenda Fyfe, dean and professor emeritus of the School of Education at . She serves on the board of the North American Reggio Emilia Alliance and co-edited .

Mark Swartz: When did you first encounter Reggio Emilia?

Brenda Fyfe: In 1990, I was teaching at Webster University’s campus in Iceland near the NATO base. Many Nordic countries had connected with Reggio Emilia long before anybody in the U.S. did. So I visited Italy, and I was awestruck. A Reggio classroom is a lovely place to be. You want to join the play; you want to play with everything. And yet there’s a sense of calm and peace. In part because it’s very soft and it doesn’t jump out and bombard you like some classrooms do with the primary colors and the letters all over the wall and that sort of thing. It’s soft and it’s peaceful, and yet it’s rich and stimulating, because there are materials there and there’s color, but it’s done in a way that helps you to calm down and not want to jump out of your chair. I returned every year until Covid.

MS: You belonged to a generation of educators who helped to popularize Reggio in the United States.

BF: Back then, all the literature that I could find was either in Icelandic or Italian. Lella Gandini was the key liaison between the U.S. and Reggio Emilia. She had been a doctoral student in Italy, and she brought knowledge of the Reggio Emilia approach and helped to organize an exhibit called , which highlighted the brilliance of children that they uncover and make visible through that exhibit. ( is also the title of an influential book.) Leila and I built partnerships and we created programs together. In St. Louis, I organized a group of educators from about five different schools, originally, to come together as a study group.

MS: Let’s talk about Reggio and play.

BF: calls play a child’s search for meaning. Play is the way that children deal with their reality and make sense of their world. And it gives them a sense of freedom, too, and agency. Children express themselves through materials, through music, movement, construction, sculpture, drawing, painting, all of what they call expressive languages.

MS: So it isn’t just for fun.

BF: And it’s never completely free play, either. The environment is set up; the materials are chosen. It’s not just let the kids go do whatever they want, you observe and document and then study it. Reggio founder Loris Malaguzzi (alongside the two co-teachers in the classroom).

It’s the idea of using materials to communicate ideas, feelings, thoughts and experiences. And it’s done in a playful way. Children are exploring and experimenting and they’re talking while they’re painting and they’re interacting with friends, and they’re looking at each other’s work and commenting on it.

MS: How can an educator tell the play is going the way it’s supposed to?

BF: When it’s really good play, you’re negotiating your experience. If it’s a dramatic play, for example, children are talking; they’re designing ideas; they’re talking about it with each other.  We talk about this idea of design, documentation and discourse as part of the negotiated learning process. Group play is a negotiation.

George Forman and Brenda Fyfe’s chapter in The Hundred Languages of Children

MS: These are life skills. Design, documentation and discourse are things you’re going to use in the workplace and with your family and then life later on.

BF: And even with the materials, you’re kind of negotiating your own understanding of it and your use of it by manipulating it.

MS: How does this concept apply to the youngest children?

BF: Even if infants and toddlers don’t have words, they’re watching. What are they looking at? How are they approaching it or how are they touching it?

MS: What are some of American Reggio’s innovations in recent years?

BF: The first one that comes to mind is called , from 2019, where they’ve looked at children exploring the outdoors. They’ve helped children to augment their playful observations with technology. They put digital cameras into the hands of children to take a photograph of what they see, and they come back to the images later and reflect on it. So play can be very sophisticated. Play with young children can involve materials, each other, but also technology.

MS: It’s a very demanding process for educators.

BF: Yes, and it’s also very energizing in the way it makes you slow down and listen to children. When most of us think about teaching, we picture a lesson plan and a sequence of experiences, and then closure. But rather than letting the plan drive you, you let it open you up to seeing what you didn’t anticipate.

MS: Could you say more about the teacher’s role?

Fyfe: The teacher gets involved without being intrusive, without being directive, but you get into the groove of the way the children are thinking. You want children to be in that space of being free to think and act in the moment. I always think of , co-founder of the field of positive psychology, who originated the concept of “flow.” That’s the perfect image for me of what play is. We like to say the teacher’s role is to toss the ball in a way that the child wants to toss it back to you.