(dramatic music) - In 2023, the maternal health crisis is not getting better.

In fact, it is getting worse.

- We absolutely have a crisis on our hands People giving birth in the US are increasingly more likely to die now than they were decades ago.

- We are going in the wrong direction in this country, not only compared to ourselves, but compared to the rest of the world.

- They don't talk enough about what moms go through, what birthing people go through.

- I didn't know anything about postpartum depression.

I had no idea that it could get that bad.

(dramatic music continues) (gentle music) - I thought I would have five more weeks before the baby came.

I woke up and was not feeling great.

When I stood up from my bed and saw this like pool of blood accumulating at my feet, there was a real feeling that I would die and the baby would die.

- [Narrator] A perfectly healthy pregnancy became a medical emergency in an instant for Katie Kleyla.

One month before her baby was due, Katie began hemorrhaging at home.

She was able to get to the ER within minutes, - And they took me straight back and got me on the fetal monitor.

And like when I heard the baby's heartbeat, I was just like, you can't, you can't describe it.

You can't describe like just knowing that like at least he's alive.

He's still alive.

- [Narrator] Katie and her baby both survived, but she became part of the troubling trend in maternal health outcomes in this country.

A steady rise over the past 20 years of pregnancy-related complications and deaths.

In 2021, more than 1200 women died of pregnancy-related causes in the US.

- We've seen most recently a very concerning increase from 2020 to 2021, where the CDC shows us that the rate of death went from about 23 people dying per 100,000 births to 33 people dying per 100,000 births.

A real shocking increase.

- [Narrator] Some of the increase can be attributed to COVID.

Still, it's a trend not seen in other countries.

- The US has the highest rate of maternal mortality among wealthy nations.

- [Narrator] As much as 10 times the rate of countries like Japan, Spain, and Germany.

And for every new mother that died in the US, it's estimated that 80 others suffered from life-threatening complications.

- I do think it's important to acknowledge that this crisis is not just of maternal mortality, but it is a crisis of maternal morbidity and of birth trauma as well.

- Oh my God, I can't believe it.

- You did it.

- You did it.

- You- - For Katie, her joy of being a new mother has to coexist with the trauma of the birth.

(baby speaking) - Here, you want your lion?

Having a traumatic birth experience can be very isolating.

So it's kind of this weird like private club that so many people are a member of, but you don't know who the other members are.

(baby whining) - Do we know how far along she is?

- [Narrator] Dr. Methodius Tuule came to Providence to lead obstetrics and gynecology at Women and Infants Hospital three years ago with a clear objective.

- I am sick and tired of seeing reports.

The next steps are what do we do to move the needle?

- [Narrator] If there is one place that can help move the needle, it is here.

More than 80% of the babies born in Rhode Island are delivered at Women and Infants Hospital.

Rhode Island is so small, the number of deaths here is low, but morbidity, meaning the severe conditions that can lead to death, are twice the national average.

- Mortality is only the tip of the iceberg.

In fact, if we want to drive down mortality, where we should be looking is morbidity.

By the time we are looking at mortality, it's already too late.

Sounds good.

And listen to your lungs.

Taking deep breaths for me.

- [Narrator] The most common pregnancy-related morbidities include hemorrhaging, cardiac and coronary issues, blood clots, infection, and hypertension.

- So we see that pregnancy is a stress test.

So many physiological changes of pregnancy, such as increase in the blood volume, increase work of the heart, and all of those things really stress the human body.

- [Narrator] And there are some groups impacted far more than others by that stress test.

Black women in this country die at nearly three times the rate for white women.

This is not new.

For decades, it's been known that black and brown women come to pregnancy with more underlying conditions that can lead to complications and death.

The fix is not necessarily better medical interventions, but something perhaps even more difficult to get at.

- A pregnant person comes to pregnancy with their whole life an intergenerational story.

So our black and brown patients have a disproportionately higher rate of mortality.

We believe these are rooted in structural racism and the structures that have been set up for healthcare, which were not designed for these populations.

In fact, in many cases, historically, they've been excluded.

- [Narrator] until we address those issues, Dr. Tuule says we won't see significant improvements in maternal health outcomes.

- There are a number of things, as an organization, we are doing.

The first is to go towards this idea of structural racism and our own implicit biases.

- [Narrator] Unconscious biases based on cultural or racial stereotypes are believed to contribute to healthcare disparities.

- We mandated training for all our providers.

Now, that is not enough.

Training is necessary, but not sufficient to make change.

The next to that is then designing specific programs to tackle the challenges.

(Maria speaking in Spanish) - [Narrator] Along with implicit bias training, the hospital is adding more translators in more languages to better serve the immigrant communities in Rhode Island.

And they're now screening patients for what are called social determinants of health, other factors that may affect health outcomes like food or housing instability and transportation issues.

The work being done at Women and Infants to address racial disparities is a response to the statistics, but it's also a response to community pressure.

- Women and Infants had to become aware of itself.

- [Narrator] Five years ago, the grassroots community organizing group, Sista Fire, started surveying black women about their birth experiences at the hospital.

- That felt like the best kept secret.

The secret was that multiple women were having unhealthy experiences at Women in Infants Hospital at that time.

- [Narrator] What they heard was that black women in the community did not feel they were listened to and had a deep distrust of the hospital.

- Why are people leaving your hospital and not feeling like they've been treated well or that they have been seen or heard?

You don't know that unless you ask the questions.

- [Narrator] Since then, Edwards and Sista Fire have been working with Women and Infants to address the issues impacting the birthing experiences of black women here.

- We did a session on reproductive justice.

They were like, how do we take that and turn it into something for people at the hospital?

And that's what we did.

There's so much that still has to go on.

What we have seen though is increasing in centering of the conversation around black maternal health.

To me, that's the biggest change.

So it feels more intentional around passing policies, the hospital actively participating in the change process with communities.

- We have a very strong community advisory board to listen to what the priorities of the community are, because while we may be well-meaning, there may be some things that we don't think are as important as the community perceives them or things that we frankly, you know, are not on our radar.

- [Susie] Well, all three of you are waiting for births right now.

- You too?

- Yeah, I have an induction that started at 8:00 PM but I just checked in with her and all is quiet.

- [Narrator] Sista Fire and other community groups were behind another important strategy to improve maternal health outcomes in Rhode Island, building a network of doulas.

- A doula is a traditional birth companion, and so we are a support and companion person throughout the pregnancy.

- Hi.

- Hi.

- Throughout the birth, whether that ends in a birth or in a miscarriage or a loss, and through the postpartum period.

So we're kind of walking with people through this whole process, and they have that connection to us.

- [Narrator] Doulas provide non-medical support to birthing people and are by their sides to help them think through the options when things don't go as planned.

Births assisted by doulas have significantly lower cesarean rates, up to 39% fewer surgeries by some reports, which results in better health outcomes for new mothers.

- They started mentioning the word c-section very soon, like right when we got up to the room.

- [Narrator] Katie's heavy bleeding was caused by a detached placenta, which was pulling away from the womb, a dangerous condition for her and the baby.

- This was not my plan.

I wanted to try as much as I could to have as natural a birth as possible.

So at that point I was like, this is not happening.

This is going to be the complete opposite of what I wanted.

We are now introducing every possible intervention into this birth experience, which was very scary.

Oh, you're looking sleepy and cuddly.

- I know.

- [Narrator] Susie was at Katie's side from the moment she arrived at the ER.

- People need different things depending on how their birth is unfolding, what their emotional state is like, how much they understand is happening.

And it is not uncommon for me to remind people, do you wanna ask for time to even figure out what your questions are?

What do you need right now?

What is your heart telling you?

- Finding your voice is so hard.

Susie was so wonderful at giving me the questions, you know, like, "Why don't you ask them what if we tried this?"

And just being able to have the prompts to facilitate a conversation about how it could be different, I absolutely believe that that is why I did not have a c-section.

- Oh, my baby.

- 30 hours after arriving at the hospital, fearing she had lost her son, Katie gave birth to Luca.

- Say hi to the world.

I just could not believe that it was over.

I could not believe that we both survived.

(baby whining) - The community of doulas in Rhode Island has grown dramatically since the state legislature passed the Doula Reimbursement Act in 2021.

The groundbreaking bill requires private insurance plans to cover doula services, making them available to all pregnant people, not just those who can afford to pay out of pocket.

It took a coalition of doulas, community leaders, and lawmakers to pass the bill.

For Marcia Ranglin-Vassell, who sponsored the bill as a state representative, it was personal.

- It was so important for me to initiate the doula bill, now doula law in Rhode Island, because of my own story and because of my near death experience.

- [Narrator] It happened 27 years ago after a healthy pregnancy and the birth of her twin boys.

- I left the hospital with these precious babies, and about five days later I had the biggest headache of my life.

I have never had a headache that was so excruciating.

And I remember opening the freezer and putting my head in there just to relieve myself of the pain.

- [Narrator] Ranglin-Vassell returned to the hospital where she was diagnosed with postpartum preeclampsia, severe high blood pressure which led to a ruptured brain aneurysm.

- I was there and I remember clearly saying, "I can't die.

I just can't die 'cause I've got boys to raise and things to do."

- [Narrator] She believes a doula may have helped by telling her to return to the hospital sooner.

And more than 20 years later, she used her own experience to get other lawmakers on board with the doula bill.

- By sharing my story over and over and over again in the assembly, people that hadn't heard about black maternal health, people that hadn't heard about doulas were able to start seeing it.

- [Narrator] Doulas also provide a continuity of care for new mothers once they leave the hospital.

The postpartum period is a vulnerable time.

- Stand up, baby.

- And yet, mothers are often sent home with no support from healthcare teams.

(baby whines) - The baby comes into the world, they hand you your baby, you leave the hospital and they say, "All right, we'll see you in six weeks."

That's not right.

I believe that it is like criminal, that like women are not supported and women are not like treated with the care and dignity that they deserve after something that is so physically and emotionally explosive.

- [Narrator] Startling new statistics released by the CDC in September, 2022, back this up.

For the first time, information was gathered for a full year postpartum and showed that over half of maternal deaths, 53%, happen in this period.

- This CDC report, I think, really clarified the magnitude of that problem.

That all the heavy lifting we do during pregnancy and the immediate postpartum period can reduce only half of the maternal deaths that happen.

And unless we look at the one week to a year period more seriously, we'll not be making a dent.

So this has led to the concept of what is called the fourth trimester, which is the one year after delivery.

- [Narrator] The fourth trimester is a critical new focus for care providers.

- Hi.

- Hi.

I'm Danielle from the Blood Pressure Program.

Nice to meet you.

- Nice to meet you.

- This is Maria.

- Hi.

- At Women and Infants Hospital, a new care team is dedicated to combating the number one issue that causes mothers to return to the hospital, hypertension.

- Blood pressure can spike about one week after delivery in some patients, and it might be so severe that they need a readmission.

- [Narrator] Spiking blood pressure can lead to preeclampsia, which quickly becomes very dangerous.

New mothers at risk of hypertension are trained on how to take their blood pressure and sent home with their own cuff.

- There are a lot of no-show rates for postpartum blood pressure checks.

I'm just gonna take a quick listen to your heart and your lung sounds, okay?

They have so much on their plate, and those are our high-risk populations that we're targeting.

Good.

This program provides them with the tools necessary to go home if they have any blood pressure issues, and they're able to log in their blood pressures via telehealth.

So less than 140 over 90.

- [Narrator] Those numbers are monitored by Danielle and Maria daily.

If they see an issue, they're on the phone.

- [Maria] Do you have any symptoms like the ones we mentioned before, like a headache, changes in vision- - [Narrator] In the first six months of the program, they cut hospital readmissions for hypertension by an astounding 50%.

(Maria speaking in Spanish) And check-ins go beyond blood pressure.

Danielle and Maria are listening for other things that might be happening with their new mothers.

- It is actually a quick checkup.

We just wanna know a few things.

How the blood pressure is, if they're still taking them at home, and also how are they feeling overall.

Do you have a primary care provider right now?

We do ask a different question as, is there anything you need?

Are you good with transportation, food?

Are you lacking on your household?

Okay, we're here for you.

If you need anything, just give us a cal.l - [Narrator] In this way they can connect patients to other resources they may need in those first weeks after giving birth.

- [Danielle] Give us a call.

We're here Monday through Friday from 08:00 to 16:00, okay?

All right.

Bye-Bye.

- [Narrator] Another known danger for new mothers in the fourth trimester is postpartum depression.

But again, not until the latest CDC report did healthcare providers understand the full impact of mental health issues.

- So the CDC report showed that mental health is the number one contributor to maternal mortality.

I think that was surprising to many of us.

Although we knew that mental health plays an important role, we did not appreciate it as the number one cause.

- [Narrator] 23% of maternal deaths are associated with mental health issues.

In fact, one out of every five pregnant or postpartum people are impacted by mental health.

For some that ends in suicide or overdose.

- [Tyler] (gasps) Well, you're awake.

I never thought that this would happen to us.

Not in a million years.

- [Narrator] Tyler Sutton is the father of newborn twins, Rowan and Everly, and a vibrant four-year-old, Melody.

And he's now parenting on his own.

- There she is.

- That's Everly.

It's your sister - [Narrator] His wife, Ariana, took her own life just nine days after giving birth to the twins.

- It happened at such an alarming rate that no one was ready for.

Not her therapists, psychologists, or OB.

No one was prepared for what was happening in front of them.

♪ Face to the sea ♪ - Joyful and outgoing, Ariana owned a local dance studio with her sister.

- [Tyler] She was an accomplished dancer and a great choreographer, cared a lot about her students.

(group cheering) It took up a good portion of her life that she enjoyed very much - Go.

Pop it.

(balloon pops) (group cheers) - Then we decided to have Melody.

The birth went very well, and when we came home, everything seemed fine initially.

There was no cause for concern or any immediate changes in her behavior.

Some weeks later, it started off small where she became obsessive over certain things.

She became concerned with the cleanliness of the house.

Her first few changes didn't really seem like it was a problem.

It seemed like a simple change from her being a new mother.

Eventually, she started to obsess over things such as the tap water.

- [Narrator] Ariana developed an irrational fear that there was something harmful in the water.

The obsessive compulsive behaviors were early warning signs.

- But again, I didn't know that this was postpartum depression yet, because I didn't know anything about it.

I didn't even know it existed.

It became a real problem when it started to affect her ability to care for Melody.

That's when it started to become nerve wracking.

There was a morning where I came home from a midnight shift, 8:00 in the morning, and Melody was crying upstairs in her crib, and Ariana could clearly hear her.

She's still in bed.

She looked at me with tears in her eyes saying like she knew something was wrong and was having horrible thoughts.

And she said, "I need to go to the hospital."

- [Narrator] Ariana would end up being hospitalized twice for her mental health issues before they found the right balance of medication and therapy that would lift her out of it.

(baby calling) - Look at the video.

- [Tyler] And then when that happened, she was the ideal mother, loved being a mother.

She was Melody's favorite person in the world.

- [Narrator] But the episode with postpartum depression hung over Ariana.

- It was sort of a lingering shadow behind her, something that always followed her throughout the last four years.

It always upset her that we let it get that bad because of sheer ignorance.

If we had been more well-informed, then there was a good chance she never would've been hospitalized in the first place.

- [Narrator] Four years later, when Ariana decided she wanted to have more children, she and Tyler approached it with caution.

- She met with her OB, her psychiatrist, her therapist, and they came up with a plan.

And it was a good plan.

- [Narrator] When she became pregnant with twins, they were happy.

They always wanted a larger family.

- She seemed very confident, excited.

And towards the end of the pregnancy, she was ready for them to be born.

- [Narrator] But the twins were born sooner than expected, coming prematurely at just 34 weeks.

- Once the children were born, you could see that she was upset that they were born early, that there might be something wrong with them.

But even while we were in the hospital, in the special care ward where the twins were being kept, all these nurses that deal with twins on a daily basis were saying they're fine.

- [Narrator] Five days after giving birth, Ariana was released, but Everly and Rowan stayed in the hospital.

- That was definitely a big trigger, her coming home without her babies.

So that was definitely something that hit her hard.

So she blamed herself on some level for the early childbirth.

- [Narrator] Ariana was once again having irrational fears.

- Her anxiety was back, and she kept telling me that she was taking her medication.

And everyone, therapist, psychologist, and myself thought we had time.

- [Narrator] day she died, Tyler left the house planning to pick her up later for their daily visit to see the twins.

- As I was leaving the house, she was going through her normal routine.

She was getting her breast pump machine ready, putting all the bottles together.

Everything about the morning seemed normal.

- [Narrator] But by the time Tyler returned home, Ariana had ended her life and left a note.

- She described herself as a burden, which she was not.

She was a great mom.

But she truly believed that, so much, that she took her own life.

(gentle music) You're all right.

Just stay here for a moment.

Okay.

- [Narrator] Tyler is now committed to talking about Ariana's struggle to bring awareness to the issues of perinatal mental health and postpartum depression.

- Hold on.

It is very difficult for for women to come forward and discuss it because of the sense of guilt that they feel, the sense of desire to fix the problem themselves.

So because of that, I think the responsibility does fall to the medical community to address it.

- [Narrator] He's calling on obstetric care providers to make it a priority to discuss mental health with their patients at every visit, and to provide families with information and resources before they need it.

- And it's not a huge ask.

It's just simply adding it to the list of things to discuss at your regularly scheduled, already scheduled appointments.

And as the time goes on and the discussions become more in depth, they should be given contact information for a therapist.

And that way, if something is making you nervous, you actually do have somebody to call.

- Learn about our patient.

See how she's doing.

I think that call to action, to check in with people to say, "How are you doing?

What's going on," at every visit every time is really powerful.

But I don't think that's enough.

Hello.

- [Narrator] Dr. Emily Miller is a maternal mental health expert at Women and Infants.

- We're good.

- I think we have to have a way for obstetric clinicians, when a person answers, "It's not going great," to be able to link them to care.

And that gap in identification and linkage to care in many communities is so wide that we've got a lot of work to do to start building bridges.

- [Narrator] Until recently, mental health was not considered part of perinatal care, and doctors are not trained to look for it.

- We really don't focus on mental health.

When we're training our medical students, our residents, our fellows, we think about sepsis, heart conditions or high blood pressure or preeclampsia.

But mental health conditions get, truthfully at best, maybe an hour of lecture time over the course of someone's training.

- [Narrator] Even today, screening for mental health issues consists of 10 questions a patient answers, rating how they're feeling.

But clearly, if mental health issues account for 23% of maternal deaths, more is needed.

Dr. Miller is working to establish what's called a collaborative care model at the hospital and its outpatient clinics.

Once in place, it will provide a way to systematically integrate mental health into obstetric care by adding a care manager with behavioral health expertise to the team and having a weekly interdisciplinary check-in.

- Medicine is so fragmented.

We don't have a chance to talk across disciplines as much as we really need to to impact care.

And so in these settings, we have an obstetric clinician, the care manager and a supervising psychiatrist sit together and talk about every single person that comes into the program that's not getting better.

And we talk about how we can adjust their care plan until they do get better.

- [Narrator] For Tyler and Ariana, this sort of collaborative care model might have meant earlier diagnosis, avoiding the traumatic hospitalizations, and ultimately may have even prevented Ariana's death.

- If they approach it as more of a preventative method rather than waiting for it to become a problem so that we don't have to hospitalize people or wait until it starts to affect them to the point where they think that they've done something wrong or that they feel like a burden.

- Maternal mortality isn't just the devastating mortality of that individual, but the impact on that individual's family, on that community is so profound.

And so we have to do everything we can to prevent it.

We know what works.

We just have to have the commitment to implement it.

- [Narrator] It will take commitment to turn the tide on maternal mortality and morbidity in this country, and not just from doctors and healthcare providers, but from the entire community.

We have enough data to know that more than 80% of pregnancy-related deaths in this country are preventable.

That means that nearly a thousand women did not have to die in 2021.

(soft music) (gentle music) In our second episode of "The Risk of Giving Birth," we focus on black mothers and the impacts of structural racism on their bodies.

- Why do so many of us have these issues?

- [Narrator] We examine what that looks like and how racial bias infects the healthcare system.

- You know, we hear all the time now, I think, doctors don't listen to black women.

But what does that mean?

- [Narrator] And what is being done to address the disparities in the numbers of black women dying?

(dramatic music) (dramatic music continues) (dramatic music continues) (no audio)