Missouri Weaves Addiction Care Into Pregnancy Care to Cut Maternal Deaths

Missouri is building addiction treatment into the places where pregnant women already receive prenatal care, an effort that state reviewers say addresses a small but entirely preventable share of maternal deaths. Seven of the 108 pregnancy-related deaths the state reviewed from 2019 through 2023 were attributed to substance use disorder, and the Pregnancy-Associated Mortality Review Board classified every one of those deaths as preventable.

The state's approach is not a single program but a set of them, run through community health centers, hospital systems and a perinatal quality collaborative that is testing whether peer recovery specialists can reach women that clinical staff cannot. The common thread is that a pregnancy creates roughly two years of repeated contact with the health system — prenatal visits, delivery, postpartum checkups — and that window is the best chance anyone gets to start treatment.

"You don't have to be pregnant to have a substance use disorder, but when you have it, we know that we have a higher capture rate of that person's attention," Alison Williams, who directs the Missouri Perinatal Quality Collaborative, told The Beacon. "So we have about two years with this individual where we can reach in and try to make a difference."

A referral with nowhere to go

For years, the referral itself was the bottleneck. Shari Cook, a family nurse practitioner at Missouri Ozarks Community Health in Ava, told The Beacon that some programs would accept women but not if they were pregnant, while others had openings hours away from the patient's family. Missouri recorded nearly 1,500 drug-related deaths in 2024, according to state Department of Mental Health data, and rural residents face longer distances to any specialized care.

Missouri Ozarks eventually opened its own treatment program, which lets Cook connect a pregnant patient to a substance use counselor in the same building where she receives prenatal care. That co-location is the model the larger state programs are scaling. At University Health in Kansas City, the EMBER program — Empowering Motherhood through Behavioral Health, Education and Recovery — launched in August 2025 and put ultrasound services in the same building as addiction and psychiatric care. In St. Louis, the BRAVE program, for Building, Recovery, Advocacy, Validation and Empowerment, uses telehealth to connect pregnant and postpartum patients with addiction, psychiatric and obstetric specialists at once.

Dr. Kimberly Brandt, who chairs the mortality review board and leads work on BRAVE, said telehealth extends reach into counties that have no psychiatrist at all. The alternative for a patient three hours from St. Louis is not a lecture about treatment; it is an emergency department, or nothing.

What the review board keeps finding

The deaths the board reviewed were not, for the most part, cases of people who never touched the health system. Dr. Traci Johnson, a maternal-fetal medicine specialist at University Health who sits on the board, told The Beacon that some of the most troubling cases involved women who were already in care and already on medication for opioid use disorder when they died.

"We see things like people having opioid use disorder, they are in care, receiving care and have medications on board for opioid use disorder, and because of a lack of understanding in how to care for the population, clinicians will mess around with their medications, which sets off a constellation of events," Johnson said. "And then it ends in overdose."

That finding cuts against the simplest version of the treatment gap story. Methadone and buprenorphine are the recommended treatment for opioid use disorder in pregnancy, and a JAMA study published last week found that maternal dose and umbilical cord drug levels did not predict how severe a newborn's withdrawal would be — evidence that undercuts the rationale for cutting doses in pregnancy, which the earlier coverage examined. The clinical failure the board describes is not a missing prescription. It is a prescription that gets interrupted by clinicians who are uneasy managing it.

Transportation, the barrier coverage does not remove

Missouri's extension of Medicaid coverage through the first year after delivery gives providers more time to hold a treatment plan together after the baby arrives. But coverage is not access, and the practical obstacles — a ride that never arrives, a childcare gap, a shift that cannot be missed — sit on top of the benefit.

Johnson estimates that about 80 percent of patients in the EMBER program do not have consistent access to transportation, so the program picks them up. Cook told The Beacon that even when Medicaid covers a ride, patients report vans that never came and appointments missed because they were not scheduled far enough in advance. A pregnant patient with an opioid use disorder may also need psychiatric care for a co-occurring condition, counseling, and help with housing or a legal problem, all of which compete for the same hours in a week.

The reimbursement question under the pilot

The peer recovery piece is where the state's experiment is most exposed. Project STORK, launched earlier this year by the Perinatal Quality Collaborative, places certified peer recovery specialists with additional maternal health training at Chestnut Health Systems, Compass Health and Centerstone. Peers draw on their own history of substance use and recovery, which Williams said helps with patients who are reluctant to disclose anything to a clinician who might document it.

"I think the barrier is really trying to figure out who the women are," Lori Epley, who runs program outreach at Chestnut Health Systems, told The Beacon. "Because I think they're very scared and fearful to disclose that information to anyone, because there could be potential consequences with their children."

Whether that model survives depends on billing. Epley said Chestnut can bill Missouri's Medicaid program for some peer recovery services, but certain case management activities are not reimbursable — an arrangement that leaves the transportation help, the home visits and the paperwork assistance resting on grant funding rather than a payment stream. Williams said her team will track whether assigning a peer increases the share of women who enter treatment and how long they stay in it, results that could inform whether Medicaid should cover more peer recovery work for pregnant and postpartum patients.

The deaths Missouri is trying to prevent are, in each case, a mother with a treatment history the system had already seen. The programs now being assembled across the state are an argument that the fix is integration and follow-through rather than a new medication. Families looking for care can start with medication-assisted treatment programs, opioid treatment programs that dispense methadone, and substance use disorder treatment listings that include programs accepting pregnant patients.