Advancing State Maternal and Child Health Policymaking Through Boundary Spanning Leadership

May 08, 2024 | Maria Gabriela Ruiz, Ramya Dronamraju

young-woman-snuggles-happy-baby-kitchen.jpgMissouri is addressing a critical maternal health crisis characterized by rising pregnancy-related deaths, socioeconomic disparities, and limited postpartum coverage. This challenge prompted a bipartisan push for Medicaid postpartum coverage extension and the need for a cohesive, comprehensive state system involving diverse stakeholders to improve outcomes for pregnant and postpartum women. As a result, the Missouri Department of Health and Senior Services (DHSS) team joined the Promoting Innovation in State and Territorial Maternal and Child Health (MCH) Policymaking (PRISM) Learning Community in 2021: a partnership between ASTHO and the Association of Maternal and Child Health Programs.

Through PRISM, Missouri worked to increase access to quality healthcare for pregnant and postpartum women through innovative policy solutions. The team established three overarching goals based on state priorities:

  1. Advocate for extending postpartum Medicaid coverage to 12 months.
  2. Establish a multi-sector action network to provide a multidisciplinary system of care, promoting health equity and ensuring appropriate care coordination for women and mothers with mental health and substance use disorders.
  3. Improve access to quality healthcare for low-income pregnant and postnatal women, including Medicaid coverage of services provided by professional midwives, doulas, and community health workers.

Boundary Spanning Leadership Training


As part of DHSS’ engagement with PRISM, Missouri participated in a Boundary Spanning Leadership to improve partnerships, develop solutions to address the emerging needs of the MCH population, and foster trust among partners dedicated to improving maternal and infant health in Missouri.

Boundary spanning leadership (BSL) is defined as the capability to establish direction, alignment, and commitment across boundaries to achieve a higher vision or goal. The main vision of Missouri’s BSL training was to build momentum on their PRISM goals and improve MCH outcomes in the state by strengthening relationships with relevant stakeholders. BSL training participants included representatives from DHSS and Departments of Social Services, Mental Health, Elementary and Secondary Education, along with other critical partners from community-based organizations, academic institutions, and local public health agencies.

BSL introduced tactical skills to create psychological safety as a cross-sector team and respect for the values and unique challenges of each team/organization represented. This space provided the direction, alignment, and commitment that participants to leverage in addressing challenges among the MCH population.

Lessons Learned

  • Recognizing Shared Barriers: A central aspect of the BSL training is for participants to align on shared barriers and concerns. Participants identified funding as a challenge when developing programmatic and policy initiatives, highlighting complex state and federal funding structures, bureaucracy, and sustainability.
  • Collaboration and Coordination: Participants discussed the disconnect between the availability and accessibility of MCH services in Missouri, which results from fragmented communication between agencies, leading to duplication of efforts and straining already limited resources as well as personnel. Throughout the BSL training, participants discovered ways to work together to amplify available resources, coordinate programmatic efforts, and reduce barriers to access for MCH populations.
  • Public Health Workforce Capacity: The COVID-19 pandemic resulted in workforce turnover and decreased capacity, leading to further disruptions in service delivery, quality, and efficiency. BSL participants highlighted acquisition, training, and staff retention as priorities to focus on moving forward.

State Successes

Enacting Key Legislation

In May 2023, Missouri passed SB 45, which extended Medicaid for birthing people to 12 months postpartum, including coverage for mental health and substance use disorder treatment. The extension of coverage for 12 months after delivery is estimated to cover more than 4,000 women who would otherwise become uninsured two months after the end of pregnancy.

Developing a Coordinated Approach

Since the in-person BSL training in April, Missouri has developed interagency connections and relationships to bolster MCH progress in the state. One example is a partnership forged between the DHSS Office of Dental Health and leadership at Uzazi Village, a community-based health organization that provides “adjacent models of care” for Black and Brown childbearing families to restore health, vitality, and joy to communities of color during the perinatal period.

These organizations collaborated to bring oral healthcare to pregnant and postpartum people without access to dental care services. The State Dental Director and MCH Director coordinated the donation and transport of the larger dental equipment and the purchase of smaller equipment and supplies needed for the clinic; the State Dental Director also connected Uzazi with a dental provider. Missouri is poised to capitalize on the connections established during this training and further enhance collaborative efforts to improve MCH outcomes.

Next Steps

Missouri achieved all three of their goals through engagement in PRISM, exemplifying a proactive approach to addressing critical maternal health challenges. The team has made significant progress in advancing policy initiatives to improve access to quality healthcare for pregnant and postpartum women.

Developing a coordinated approach to addressing MCH issues remains a priority as Missouri continues to foster collaboration among diverse stakeholders. The team will be able to leverage its new connections to address emerging issues, such as the current, which is disproportionately affecting children and families. Moving forward, Missouri is well-positioned to build upon its successes and further strengthen interagency connections to continue making impactful strides in maternal and child health.

A very special thank you to Martha Smith and Nina Nganga from the Missouri Department of Health and Senior Services, as well as Alice Schenall, ASTHO’s Director of Cross Sector Leadership and Facilitation, for informing this blog post.