t music) - The health of the mother is the health of the child.

If the mother is not healthy, how could you expect her to take care of the child?

- The care in this community for healthcare is very limited and our families are really suffering.

- There's just a lot of gaps in care that happen because of language.

- Latinos have the lowest health literacy of any ethnic or racial group.

- Some of the women that are new to this country don't know what to expect.

The support that they have in their own country is family.

(bright music continues) - [Rivera] There's a lot of people who don't care about what happens here, right, about communities of color.

(speaking in a foreign language) - [Narrator] It isn't unusual for Maria Rivera, the mayor of Central Falls, Rhode Island, to be handing out donated supplies to the families in her town.

- Nice to see you.

- Nice to see you too.

- And thank you.

- You're welcome.

These are pretty heavy.

- It's all right.

Okay.

- Yeah, good.

- [Narrator] It's one way the mayor connects with her community.

It also allows her and her team at City Hall to connect families to other resources they may need beyond the food and toiletries in these bags.

- Thank God you got one, right.

There are a lot of different issues, medical issues that our community faces here.

(speaking in foreign language) Thankfully, there are resources out there that we can connect them with, but if we don't connect them with those resources, they will never know about them.

(speaking in foreign language) - [Narrator] More than 70% of the residents of Central Falls are Latino.

(speaking in foreign language) Most are Spanish speaking and many are undocumented.

It's a community living on the edge, and the mothers here are particularly vulnerable.

- I wish we had a enough to give to everybody so it breaks my heart.

This is family.

This is what a community is.

- [Narrator] In our series of reports, we've examined the shockingly high rates of pregnancy related deaths and complications in this country.

We know that black and brown birthing people fare the worst, but one of the more alarming trends in recent years is the rapidly growing race of death for Hispanic women.

According to the Centers for Disease Control, the maternal mortality rate for Latinas jumped by 54% from 2020 to 2021, the highest increase of any group.

- So we are going in the wrong direction.

Instead of getting better, we are getting worse.

We cannot continue in this path.

- [Narrator] These statistics are significant in Rhode Island, where 17% of the population is Latino and it's growing fast.

Providence is now 43% Hispanic.

- The interesting part about them is that they are the youngest population in the state.

Some of the numbers say that as much as 30% of children are Latino, so we are looking at the future of the state being an immigrant Latino future.

- [Narrator] There's no way to singularly describe the Hispanic community in Rhode Island.

It includes undocumented new arrivals to second generation people born here, as well as families who have been here for generations.

- It's not an easy community because there's a lot of different needs here and they're all different, right?

We come from so many different parts of the world.

- They come from all different places, but the overwhelming majority are Dominican, Puerto Rican, Colombian, Guatemalan.

Those are the biggest groups that have settled here.

- [Narrator] In 2020, the COVID Pandemic shed new light on health issues for the state's Hispanic population.

Dr. Beata Nelken opened her pediatric practice in Central Falls just one month before COVID hit.

- What COVID did is kind of put a magnifying glass on all the disparities of healthcare in our system.

The people who were most marginalized were hardest hit, and it wasn't because of some genetic predisposition.

It turns out that the access matters, information that matters, prevention matters.

- [Narrator] Central Falls is just one square mile, but densely populated with more than 22,000 residents.

Many multi-generational families are packed into small homes.

It became ground zero during the pandemic.

- Central Falls was the worst hit city for the state, the region, the United States at one time, and even the world at one time by CDC statistics, - That community had rates of COVID that were comparable to the worst countries, not just the worst states, the worst countries in the planet, and that is a result of the social determinants of health.

- [Narrator] The social determinants of health are the conditions in which people live that impact their quality of life.

They're strongly associated with disparities in health outcomes.

- The places where people work, people live, people worship, people get educated, those have an incredible impact.

Latinos, specifically, the fact that they work in places that do not allow them to be remote.

They work in places where they're standing next to each other, and then you go home where there's only one bathroom, where two families are living, you know, in a reduced space, and we saw entire families, you know, becoming infected with COVID and losing more than one member of the family as a result.

- [Narrator] City Hall sits just across the street from Jenks Park Pediatrics in Central Falls.

- Hello.

- Hi guys.

- Hello.

- [Narrator] Mayor Rivera and Dr. Nelken forged a relationship in the fire of COVID.

- What you're doing with the services for women is such a huge need here.

- [Narrator] They worked tirelessly to connect their largely uninsured community to health services during the pandemic.

Now that COVID has abated, they're seeing the toll it has taken on the health of mothers here.

- Women's health, we're about to expand from two days to three days now.

I'm getting a third provider.

We're really trying to address the need of the community as we see it and as we hear it from the community itself.

The moms who came to me in pediatrics kept asking for care.

(speaking in foreign language) Basically, the moms of our community here forwent all of their own healthcare, mental health, and otherwise, so that means Pap screens.

That means primary care.

That means all of what the moms generally need to get.

(speaking in foreign language) - [Narrator] It's why Dr. Nelken's pediatric practice is expanding to offer gynecological care for women, including the uninsured.

For pregnant women in Rhode Island, health insurance is not an issue.

Legislation passed in 2022 guarantees coverage for all pregnant people regardless of immigration status, but many dangerous underlying conditions that create a high risk pregnancy develop before a woman becomes pregnant during the time she is not insured and skipping primary and preventative care.

- It's gonna take time for us to be able to get the word out there, for these women to know that they're gonna be able to go there and get the screenings that they need.

- [Narrator] Once a woman does become pregnant, a critical provider of maternal healthcare in the community is Blackstone Valley Community Healthcare in nearby Pawtucket.

Blackstone Valley is a federally qualified health center, or FQHC.

These clinics provide comprehensive care to underserved communities.

- I'm gonna weigh you first.

- Okay.

- [Narrator] Most patients who come here fall below the poverty level.

Two thirds of them are Hispanic and most are Spanish speaking.

(speaking in foreign language) - Without this clinic, there are tens of thousands of people not getting the care that they need and that they deserve.

Because it's challenging to travel to other locations, it's challenging to walk in the door of someplace where they don't speak your language.

Whereas here, they know they can come in, walk in the door, and someone can explain to them in their language how to access the care they need.

(speaking in foreign language) - [Narrator] Blackstone Valley provides full obstetric care for its patients.

The same social determinants that impacted health outcomes during COVID, impact families here: economic instability, food and housing insecurity, lack of transportation and language barriers, all play into poor maternal health outcomes.

Rachel Ballester, a nurse midwife and the medical director here is assessing those factors with every pregnant and postpartum mother she sees.

Her patients often require much more than a medical checkup.

- The concerns that patients come to you with are very different.

There was a patient who was scheduled for a postpartum visit, and she was just very upset because of her housing situation.

She needs new housing, her housing isn't safe.

There's roaches, there's mice.

She's worried about them crawling all over the newborn baby.

She's got other kids at home.

She doesn't have a safe place to go.

She also doesn't have money to buy diapers.

- [Narrator] Before that mother left the clinic, a community health worker had connected her with an organization that could provide free food and diapers, and a behavioral health counselor had met with her to talk about the stress she was under.

- I think it's really important, especially when working with an underserved population to be able to provide those comprehensive services.

It's really important to have that extra support, and if you don't look at the full picture of health, you're gonna miss everything.

If you're just thinking about somebody's diabetes diagnosis, but you're not thinking about whether they have access to food or what kind of food they have access to, or do they work overnights or do they work a job where they can't stop and check their blood sugar, things like that, you just really have to think through the full picture to be able to provide the best care.

(speaking in foreign language) - [Narrator] Of all the challenges women in this community face, care providers say mental health is one of the biggest, and yet it's one, they say, patients often don't talk about - Pregnancy can be happiness, but can be sadness too.

- [Narrator] Yuli Paula, a behavioral healthcare provider at Blackstone Valley, says, it's especially hard for Latina mothers to admit they're struggling.

- I'm supposed to be happy because I'm going to have a new baby and I'm a Latina woman, We think like, be pregnant is always be a positive.

Yes, can be positive, but can Be overwhelming too.

You know, financially, emotionally, how I gonna manage this?

There's a lot of stigma around talking about that.

- [Narrator] Maternal anxiety and depression are the most common complications of childbirth in the US.

One out of every five pregnant or postpartum people suffers from mental health conditions, and the CDC has identified it as the leading underlying cause of pregnancy-related deaths.

Blackstone Valley has what is called integrated behavioral healthcare or whole person care.

- Any depression in the past weeks?

- No.

- [Narrator] Obstetric patients who come here are screened for anxiety, depression, and substance abuse at every visit.

And care providers like Paula are on hand to meet with patients during their regularly scheduled visits.

- Even though sometime we do the screening tool for depression and everything is fine, but when I go on to talk to them one-on-one, I say, so how is sleeping?

How you appetite?

How you feel about this pregnancy?

And sometimes you need to go beyond so they can talk about it, because in our country, we don't talk about mental health.

(speaking in foreign language) - [Narrator] Having care providers like Paula, who speak the language and understand the culture is critical here.

- I believe when you speak with the same language, people connecting more with you because they identify more with you, there have to be a connection there.

It takes time for people to open it.

- I think there's a lot more just trust that's built when you can communicate with a patient in the language that they're speaking.

Patients develop those relationships over time too.

And there's also just, you know, cultural understandings.

- [Narrator] Another group of care providers who recognize the need for culturally appropriate care are doulas.

Doulas provide emotional and physical support for pregnant, birthing and postpartum people, and often serve as their advocates in healthcare settings.

Doulas Conectadas is a group of community doulas now providing care for Spanish speaking mothers in Rhode Island.

- Conectadas means connected, so we're connected doulas, and the connection is that we're connected to our roots, to our heritage, culture, to our community.

It's absolutely an overlooked community, and that's why we feel that we can make a difference.

- [Narrator] Sara Castaneda co-founded the group last year after the Doula Reimbursement Act went into effect in Rhode Island.

The law requires insurance providers to cover doula care for all pregnant people.

Until then, the cost was prohibitive for most.

- The doula bill passing that just changed the game for people accessing doula services.

The word doula does not translate in Spanish, let alone what a doula does.

How to access it, you know, a doula was only covered privately by people that could afford it.

- There's a lot of education that we're actually having to do with Latina families around what a doula is, why they might want one.

When we know that black and brown families are the ones that are facing poorer outcomes, and so we need to make sure we're reaching them, even in just exposing them to this new benefit.

(speaking in foreign language) - [Narrator] Evidence shows doulas help improve birth and postpartum outcomes and may reduce racial disparities in maternal mortality and morbidity.

(speaking in foreign language) - [Narrator] Blackstone Valley Community Healthcare has started referring patients to Doulas Conectadas and Castaneda is working with Dr. Nelken, meeting with pregnant mothers who come to her pediatric practice making sure they know about doula care.

(speaking in foreign language) Ana Maria Balanta came to the US with her husband a year ago and is now expecting her first baby.

Like many newcomers, her extended family is not here.

(speaking in foreign language) - [Narrator] In Columbia, her family would support her for the birth.

Instead, Castaneda will be by her side.

- Language is definitely a barrier for her, so she feels comfortable having a doula that can speak her language, but that can also be of an additional support.

It's just to have a little bit of peace of mind knowing that you have somebody that understands what the process is and that I'll be her advocate.

- To have a doula at your side as an advocate in your native language, being your coach and mentor through the process makes a world of difference for people from who are not English speaking, who are not in the system, who don't know how this process works.

So the community still needs to learn more about what a doula is, so part of our onus is to teach them.

(speaking in foreign language) - Dr. Pablo Rodriguez, a clinical associate professor of obstetrics and gynecology and longtime public health advocate, has spent his professional life working to educate Latinos about their health.

- Latinos have the lowest health literacy of any ethnic or racial group.

74% of Latinos, 74% of Latinos have low health literacy.

41% have below basic health literacy.

Below basic.

That means that they cannot read a prescription, they cannot read a label, they cannot understand instructions.

- [Narrator] To combat the problem, he created NuestraSalud, which includes a Spanish language radio show, podcast, and a website.

- NuestraSalud in Spanish means our health.

It's been my life's mission to improve our health.

I have created a resource where people can go and find the right answers in order to make the right choices for their health.

- [Narrator] He's also trying to make sure they get accurate information, and he has a presence on all of the social sites.

- So misinformation is a huge problem in the Latino community, especially social media, where Latinos get most of their information is just ripe for unscrupulous people that are just spreading misinformation.

And because we speak Spanish, we get misinformation from 40 countries.

- [Narrator] NuestraSalud contains comprehensive information about a wide range of health topics, but there is a focus here on women.

- There is a lot of women's health in it, obviously because of my specialty, but there's a logic to my madness: women are the greatest deciders when it comes to healthcare of their families.

And if we can get women to be health literate, we can save the world.

(speaking in foreign language) - [Narrator] Better health literacy will go a long way in improving overall health outcomes for birthing people.

But among Latinos in the US, there is also a unique and troubling disparity in health outcomes between new immigrants and their US-born children, and it's not what you would expect.

- The interesting thing about Latinos and where you can really see a clear contrast is the newly arrived versus the ones that are acculturated and have been born here and are second and third generation.

Something that we call the immigrant paradox, where, you know, women that crossed the desert pregnant have a better outcome than their daughter or their granddaughter that are born here.

- [Narrator] Historically, the rates of pregnancy related complications and deaths for Hispanic women in the US was lower than the rate for white women, but that is changing as second and third generation Latinas account for more high risk pregnancies.

- It's a high risk community.

A lot of our patients have complications like gestational diabetes or hypertension.

We have about twice the rate of gestational diabetes as the general population.

- [Narrator] More attention is now being paid to the role stress plays in creating the dangerous underlying conditions that lead to complications in pregnancy.

- In the context of socioeconomic mobility, what does it mean to arrive?

- [Narrator] University of Michigan, professor, Dr. Arline Geronimus studies the effects of systemic oppression on health.

She calls it weathering and says it takes a heavy toll on the bodies of minoritized communities like US-born Latinas.

- For many decades, we thought they had lower risks of these poor birth outcomes, but the reality is it was only limited really to first generation immigrants.

And if you think through a weathering lens, you can begin to understand why that is, because the first generation, you know, is happy to have come to the United States, and they live in ethnic enclaves where they're still speaking Spanish, and so their whole cultural frame is very supportive, and they're less often in these situations that will arouse this physiological stress reaction.

- Their children, on the other hand, are coping in predominantly white schools and jobs, code switching between those places and home and often feeling out of place.

- The process of acculturation creates a big change in the culture of the families.

Once that woman is born here in the United States, once their daughter and their granddaughter are living in the United States, then they are getting exposed to racism.

They're getting exposed to isolation, and they're getting exposed to all the social determinants of health that immigrant people are exposed in the United States, and that all conspires to provide for worse outcomes.

- [Narrator] Over time, that chronic stress erodes their health and sets them up for more dangerous underlying conditions that can show up in pregnancy.

Systemic oppression is part of the long list of social determinants of health impacting the pregnancy outcomes of Latinas in this country.

Single solutions will not turn the tide of the rising number of Hispanic women dying.

- It's going to take the entire community to be involved in improving maternal health.

It's not just the providers.

It's not just the midwives, the doctors, the doulas, it's the legislature, the community-based health centers, trying to change the conditions that make people sick.

Because if we better the circumstances that surround the lives of people that are at risk, we can reduce the number.

- [Narrator] In our series of reports, we've examined the staggering problem of pregnancy-related complications and deaths in this country.

And we've explored efforts to help turn the tide on the crisis here in Rhode Island, particularly for black and brown birthing people.

It's no longer necessarily a matter of better medical interventions.

A new approach is needed to better support mothers through pregnancy, childbirth, and postpartum.

- The maternal mortality and morbidity statistics are stuck.

The one bright light is that we are shining the light on it.

My dream is that 5 to 10 years from now, we will say we used to have very bad statistics in maternal morbid and mortality, but we are making progress.

- [Narrator] If there is one thing we heard from the care providers we talked with, it's that they see change coming with a new understanding of the problems and a new generation of medical professionals.

- I am hopeful about the new generation of nurses, the new generation of doctors, the new generation of midwives who are coming into this institution like women and infants, and are truly asking us to stand in the fact that we need to recognize this crisis.

They ask all the important questions.

They ask, why is this happening?

Where are the solutions?

And I am super hopeful that there's a change coming.

- I think the passion that all of my colleagues here have for making this better, gives me an enormous amount of hope.

I think seeing the trainees that we're rounding with that are beside us and their enthusiasm, their commitment to making sure we're doing better, gives me hope.

- I do feel hopeful.

I feel so invigorated to do the work that I do more than ever because I think that with these statistics, this is a call to action, right?

This says to every doctor and every healthcare provider, every nurse and every politician, right?

Everybody who has an opportunity to do something about this, needs to be doing that now.

(bright music) (bright music continues) (bright music continues) (bright music continues) (bright music ends)