January 2023

Rhode Island KIDS COUNT Issue Brief

Racial and Ethnic Disparities in
Maternal, Infant, and Young Children’s
Health in Rhode Island

Pregnancy is the beginning of development for a child. Maternal health before, during,
and after pregnancy impacts the overall health and well-being of a child in both the
short and long-term.1,2 Currently, there is a maternal health crisis both nationally and
in Rhode Island.3 Beyond that, there are unacceptable and persistent disparities in
maternal, infant, and child health outcomes by race and ethnicity that disproportionally
impact Black, Indigenous, People of Color (BIPOC) women and children.4,5 Addressing
these disparities will require a focus on the important connection between birthing
parents and their babies and focus on the health and well-being of both individuals.
Pregnancy-Related Women Ages 35-44
Mortality Rate per 100,000 With One or More Risk Factors for
by Race/Ethnicity, Birth Complications by Race/Ethnicity,
United States, 2016-2018 United States, 2018-2021**
50 100%
41
40 80%

30 27 60%
40%
20 40% 32%
14 14 27% 25%
11
10 20%

0 0% *
American Asian Black Hispanic White American Asian Black Hispanic White
Indian/ Indian/
Alaskan Alaskan
Native Native

Source: Pregnancy Mortality Surveillance System, Source: Blue Cross Blue Shield: The Health Report of
2016-2018. America. (2022). *Data not available, ** Only
includes commercial insurance.

◆ Nationally, Black women are three times more likely than white women to die of
pregnancy-related complications.6,7 Racial disparities in maternal mortality span all
levels of education, age, income, and insurance status.8,9 Risk factors such as
hypertension, asthma, diabetes, and substance use increase the risk of having
pregnancy-related complications that result in unintended short or long-term
outcomes.10
◆ Black women ages 35-44 have the highest rate of risk factors, pregnancy
complications and death.11,12 Complex structural, social, and economic interactions
related to racism have led to an increase in risk factors for Black women.13,14
 Root Causes of Disparities in Maternal and Infant Health:
A Legacy That Continues to Harm Rhode Island’s Children and Families
Health care only accounts for 10-20% of an individual’s overall health outcomes and is just one of the social
determinants of health, which is defined as the conditions and environments where people are born, live, learn,
work, and play that greatly impact health outcomes.15 These social determinants of health, including economic
stability, education access, neighborhood and the built environment, and social context account for over 80% of
health outcomes.16 Disparities in social determinants of health can be traced back to the founding of the United
States and continue to impact the longstanding racial and ethnic disparities in health, including maternal and
infant health.17 Removal of Native Americans from their lands and use of Africans as enslaved labor prevented
the country’s first People of Color from fully participating in the economy while simultaneously building wealth
for the country and its white citizens. Racism became an economic tool infused into laws, policies, and practices
that have harmed Asian, Black, Latinx, Native American and low-income white people for centuries.18,19,20
Unequal access to economic opportunities, stability, and growth impacts educational access, environmental
conditions and well-being.

Increased Diversity Among Rhode Island Children and Births

◆ Racial and ethnic diversity has increased in the United States over the last several decades and is projected to rise in
the future. Since 2000, all of the growth in the child population in the U.S. has been among Children of Color.21,22

◆ In Rhode Island between 2010 and 2020, the Hispanic child population grew by 22% while the non-Hispanic
white child population declined by 22%.23,24 In 2020, 47% of children in Rhode Island were Children of Color,
up from 36% in 2010.25

◆ Nationally, fertility rates have declined across all racial and ethnic groups; however, Black and Hispanic women
have higher fertility rates than Asian and white women.26,27

◆ In 2020 in Rhode Island, 46% of babies born were Babies of Color.28

Percentage of Population Identified as People of Color By Age, Rhode Island, 2019

100%

80%

60%
46% 43%
40% 37% 35%
21%
20% 12%
0%
Ages 0 to 4 Ages 5 to 14 Ages 15 to 24 Ages 25 to 44 Ages 45 to 64 Ages 65+

Source: U.S. Census Bureau, Population Estimates, 2019.

Use of Terms
5
This brief uses both women-specific terms and gender-inclusive terms (e.g., birthing people). “Maternal”
health and other gendered terms are widely used in the research and data collection efforts of past and
current projects about pregnancy and childbirth-related inequities. Much of the data is collected and reported
this way by the references used in this brief. The terminology may not reflect the lived experiences or
identities of all birthing people.

2
 The Need for More Data: American Indian Population

◆ In Rhode Island, research and data collection on the American Indian/Native American population is limited due
to the small population size, making it difficult to evaluate disparities in maternal and infant health outcome
disparities at the state level. However, nationally Native American people are twice as likely to die of pregnancy-
related causes than white people.29 Between 2016 and 2018, the pregnancy-related maternal mortality rate was 27
per 100,000 live births for Native Americans, compared to 14 per 100,000 for their white peers.30 A majority of
deaths were determined to be preventable.31
◆ Racism in social determinants of health-related policies has disproportionally harmed Native Americans in the
United States. Genocide, forced land removal, slavery, and breaking of treaties have had a devastating impact on
Native wealth, culture, and health. The disparities that exist today between Native American and white
households can be traced back to the wealth-building policies that overwhelmingly benefited white citizens at the
expense of Native Americans.32,33,34
◆ More data is needed both in Rhode Island and nationally to better understand the lived experiences of Native
Americans and to address the disparities in maternal health.35 In December of 2022, the U.S. Department of
Health and Human Services launched a national campaign to improve Native American maternal health
outcomes by raising awareness of life-threatening warning signs during and after pregnancy and improving
communication between health care providers and their patients.36

The Need for More Data: Diversity Among Asian Population

◆ The Asian American community is very diverse and is the fastest growing population in the United States.37
Asian communities are diverse groups with varying characteristics and experiences that influence their health
and health care. Aggregated data on all Asian people mask disparities and challenges facing subpopulations
within the community.
◆ Native Hawaiian, Pacific Islander, and Southeast Asian youth are less likely to have private health insurance
coverage and more likely to be covered by Medicaid, with half (50%) of these children being covered by
Medicaid or the Children’s Health Insurance Program (CHIP) compared to 25% of all Asian children and 29%
of white children. Nationally, although the Asian population has the lowest infant mortality rate, there are
significant differences within subgroups. The Filipino infant mortality rate (4.52) is significantly higher than all
other Asian subgroups. Enhancing availability of disaggregated data for Asian, Native Hawaiian, Pacific Islander,
and Southeast Asian people will be important for efforts to advance health equity.38,39

Impact of COVID-19 on Maternal Health

◆ In the U.S., the maternal mortality rate increased during the first year of the pandemic. In 2020, the maternal
mortality rate was 24 deaths per 100,000 live births, up from 20 in 2019. The 2020 mortality rate for Black
women increased significantly from 44 per 100,000 in 2019 to a rate of 55 per 100,000 in 2020. The maternal
mortality rate also significantly increased for Hispanic women during this same time period (from 13 to 18 per
100,000).40
◆ This initial national data reflects the increased hardships on people giving birth, including limited access to
prenatal and health care, increased stress, and lack of social support before, during, and after birth.41

3
 Maternal Health

◆ Maternal health includes the period before pregnancy (preconception), during pregnancy, after birth
(postpartum) and beyond. In Rhode Island, there are racial and ethnic disparities throughout this entire period
of time that impact health outcomes.42

◆ Healthy People 2030 is the latest iteration of a national initiative to set measurable objectives to improve the
health and well-being of people over the next 10 years.43 Health Equity and Social Determinants of Health are
two of the key priorities of the initiative to eliminate health disparities, achieve health equity, and attain health
literacy to improve the health and well-being of all.44

Before Pregnancy/Preconception

Insurance Status before Pregnancy by Race/Ethnicity, Rhode Island, 2016-2020

RIte Care/Medicaid Uninsured

100%

80%

60%
42%
56% 43%
40% 33% 29%
21% 20%
20% 8% 9%
4% 6% 21%
0%
Hispanic/Latina Non-Hispanic Black Non-Hispanic White Other All Races

Source: Rhode Island Department of Health, Pregnancy Risk Assessment Monitoring System (PRAMS), 2016-2020.

◆ In Rhode Island, Women of Color are more likely to be uninsured and be covered by RIte Care/Medicaid before
their pregnancy than white woman. Between 2016 and 2020, 21% of Hispanic/Latina women and 8% of non-
Hispanic Black women, did not have insurance compared to only 4% of non-Hispanic white women.45
◆ Health care before pregnancy is important for maintaining women’s reproductive health and ensuring that they
can access the reproductive health services they may need to become pregnant, if and when they want to.
Women of Color also report that they have different preconception experiences with providers. In Rhode Island
between 2016 and 2020, only 26% of Latina and 27% of Black women reported that before conception, a
provider talked to them about preparing for a pregnancy, compared to 35% of white women who reported
having these conversations.46,47
◆ Currently, Rhode Island law prohibits health insurance coverage for abortion access for Rhode Islanders covered
by state-funded insurance, including those working in the public sector and those covered by Medicaid. This
policy disproportionally impacts access to reproductive health services for Black and Hispanic Rhode Island
women and contributes to inequities in health care access.48,49
◆ Access to contraception, preventative health care services, and the overall health and economic well-being of
individuals impact pregnancy intention.50 Non-Hispanic Black women have the highest unintended pregnancy
rate of all racial and ethnic groups. Unintended pregnancies occur when a pregnancy is mistimed or unwanted.51
Health outcomes for intended pregnancies are better than for those that are unintended. Barriers to prenatal care
include not knowing one is pregnant, not being able to get an appointment or start care when desired, lack of
transportation or child care, inability to get time off work, and financial constraints (including lack of insurance
or money to pay for desired care).52,53 Rhode Island women with delayed or no prenatal care are more likely to
report their pregnancy was unintended than women who initiated care in the first trimester. Between 2012 and
2015 in Rhode Island, 65% of women whose prenatal care was delayed had unintentional pregnancies.54

4
 During Pregnancy

Women With Delayed Prenatal Care by Race/Ethnicity, Rhode Island, 2016-2020

30%
25% 23.6%
21.6%
20% 18.0% 18.2%
15.8%
15% 13.5%
10%
5%
0%
American Indian Asian* Black* Hispanic White* All Races
and Alaskan Native

Source: Rhode Island Department of Health, Center for Health Data and Analysis, Maternal and Child Health Database, 2016-2020. * Race categories are non-Hispanic.

◆ Between 2016 and 2020 in Rhode Island, American Indian and Alaskan Native women (23.6%), Black women
(21.6%), Hispanic women (18.2%), and Asian women (18.0%) were more likely to receive delayed prenatal
care than white women (13.5%).55 Although the overall rate met the Healthy People 2030 goal of 19.5%, both
Black and American Indian and Alaskan Native women show a persistent disparity, with respective rates of
delayed prenatal care exceeding the target.56
◆ Early prenatal care is an important way to identify and treat health problems as well as influence health
behaviors that can affect fetal development, infant health, and maternal health. Women receiving late or no
prenatal care are at increased risk of poor birth outcomes, such as having babies who are low birthweight or who
die within the first year of life.57,58
◆ Effective prenatal care screens for and intervenes with a range of maternal needs including nutrition, social
support, mental health, smoking cessation, substance use, domestic violence, and unmet needs for food and
shelter. A prenatal visit is the first step in establishing an infant's medical home and can provide valuable links
to other services. Early prenatal care is especially important for women who face multiple risks for poor birth
outcomes, as is ensuring access to health care services before pregnancy.59,60

Teen Births

◆ In Rhode Island, the statewide five-year average teen birth rate declined 58% between 2007-2011 and 2016-
2020, from 25.5 births per 1,000 teen girls to 10.6. The teen birth rate in the four core cities (Central Falls,
Pawtucket, Providence, and Woonsocket) declined 56% during that time but remains more than three times
higher than the remainder of the state.61
◆ Despite declines among all racial and ethnic groups, disparities still exist in teen birth rates.62 In Rhode Island
between 2016 and 2020, the teen birth rates for Hispanic (28.3 per 1,000), Native American (15.9 per 1,000),
and Black (14.6 per 1,000) teens were higher than the rates of their white (6.4 per 1,000) and Asian (3.2 per
1,000) peers.63

Rhode Island’s Health Equity Zones

◆ Rhode Island’s Health Equity Zone Initiative works to build a healthy and resilient Rhode Island by investing
in communities and their capacity to affect change, honoring the expertise of those who live and work in
those communities, and challenging the systems and structures that perpetuate health inequities. A focus of
the Woonsocket Health Equity Zone is reducing the rates of teen pregnancy by providing comprehensive
sexual health education and providing students with additional programming and after-school support.64,65

5
 Maternal Mortality and Morbidity

◆ In Rhode Island, maternal mortality numbers are too small to report. To better measure maternal health
during pregnancy and after childbirth, Rhode Island reports the prevalence of Severe Maternal Morbidity,
which is defined as unintended outcomes of labor and delivery that result in significant consequences to a
woman’s health.66,67

Severe Maternal Morbidity Rate per 10,000 deliveries by Race/Ethnicity, Rhode Island, 2016-2020
200
155
150
106
100 96
86

50

0
Black Hispanic White All Races

Source: Rhode Island Department of Health, Center for Data and Analysis, 2016-2020.

◆ In 2020, the Rhode Island severe maternal morbidity rate was 88 per 10,000 delivery hospitalizations down
from 122 per 10,000 in 2019. Black (155 per 10,000) and Hispanic (106 per 10,000) women all had higher
rates of severe maternal morbidity than white women (86 per 10,000) between 2016-2020.68

Root Causes of Disparities: Quality of Care/Implicit Biases in the Medical System

◆ Pervasive racial bias and unequal treatment of Black women and birthing people in the health care system
often result in inadequate treatment for pain and lead to significant unintended outcomes and
disparities.69,70 This, coupled with stress from racism and racial discrimination, contribute to the
unacceptable health outcomes among Black women and their infants.71,72 Medical racism and interpersonal
discrimination historically has impacted Black health and continues to impact Black birthing people today.
According to data from the Centers for Disease Control, 80% of maternal deaths are preventable,
signaling that there are deaths that could have been due to poor timeliness, quality of care, or inaccuracies
in listening to patients’ needs.73,74,75

6
 Low-Risk Cesarean Births

◆ Cesarean deliveries, or C-sections, may help prevent injury and death in birthing people and newborns who are
at higher risk of complicated deliveries or have unexpected complications. However, C-sections are linked to
increased risk of infections and blood clots, and many women who are not at high risk for delivery
complications get unnecessary C-sections.76,77
Low-Risk Cesarean Rate, Rhode Island, 2017-2021
100%

75%

50%
28% 27% 28% 31% 30%
24%
25%

0%
2017 2018 2019 2020 2021 Healthy People
2030 Objective

Source: Rhode Island Department of Health, Center for Data and Analysis, 2017-2021.

◆ In 2021, the percentage of low-risk cesarean births in Rhode Island (30%) was higher than it was in 2017
(28%) and continues to be above the Healthy People 2030 national objective of 24%.78,79 Nationally, Black
birthing people have higher rates (31%) of low-risk cesarean births than white birthing people (25%). Between
2017-2021 in Rhode Island, Native American, non-Hispanic white, and Hispanic women had the highest rates
of low-risk cesarean births.80,81

Maternal/Postpartum Depression

◆ Maternal depression is an overarching term for longer-lasting depression that occurs during pregnancy and/or
the first 12 months after the birth of a new child. Symptoms often interfere with a mother’s ability to care for
herself and/or her child. Between 2018 and 2020, 12.2% of women reported symptoms of postpartum
depression.82,83
Depression During or After Most Recent Pregnancy by Insurance Status, Rhode Island, 2018-2020
50%

40%

30% 29%
26%
22%
20% 18%

10%

0%
Private Insurance Medicaid/Rite Care Military, Parents, Other No Insurance

Source: Rhode Island Department of Health, Pregnancy Risk Assessment Monitoring System (PRAMS), 2018-2020.

◆ One of Rhode Island’s Psychiatry Resource Networks, MomsPRN, provides same-day clinical consultation
services and mental health referral services for primary care providers of perinatal patients. This program
supports Rhode Island primary care providers by enabling them to provide more comprehensive care for their
patients more promptly and avoid lengthy wait times for specialized care.84
◆ During FY 2022, the RI MomsPRN line fielded 679 initial encounter calls from 251 unique providers at 125
practices across the state. In total, 586 perinatal patients (including 209 pregnant women) were helped as a
result of their provider calling the RI MomsPRN teleconsultation line during this time.85
◆ Integrating behavioral health needs into primary care is a key component of the patient-centered medical home
model and expands primary care to be coordinated and include mental and behavioral health care.86
7
 Rhode Island’s Doula and Community Support

◆ A doula is a trained professional who provides support and education for pregnant women and birthing
people before, during, and after pregnancy. Doulas positively impact birth-related outcomes and overall
experience and can increase feelings of respect and care, especially for Birthing People of Color and
people with Medicaid.87,88 States can remove barriers to doula care by reducing administrative burdens,
increasing and improving payment models, and facilitating and supporting doulas in the hospital setting.
In Rhode Island, the doula community and other maternal health advocates have led improvements for
certified perinatal doula access for all birthing people, especially People of Color, during their perinatal
experience.89
◆ In 2021, legislation passed making doula services eligible for reimbursement through private insurance
and Medicaid. The Doula Reimbursement Act made Rhode Island the first state to reimburse doula
services for both Medicaid and private insurance at a rate of $1,500 for all prenatal, labor, birth and
postpartum services.90
◆ The Urban Perinatal Education Center (UPEC) provides perinatal education and supports, childbirth
education classes, lactation support and the Easy Access Clinic. UPEC provides culturally congruent and
racially representative care. RI's Easy Access Clinic provides prenatal and postpartum care and services to
supplement and support existing maternal health systems. UPEC focuses on wholistic well-being,
especially emotional and mental health during the early weeks and postpartum. UPEC also hosts the RI
Doula Referral Hotline to help the Black and BIPOC community find doulas who accept their
insurance.91

Rhode Island Supports for Breastfeeding

◆ All 50 states have passed legislation that provides mothers with the explicit right to breastfeed in all public or
private places.92 Since 2015, Rhode Island law has prohibited job discrimination based on pregnancy, childbirth,
and related medical conditions and requires employers to make reasonable accommodations for workers for
conditions related to pregnancy and childbirth, including breastfeeding.93 Other barriers to supporting
breastfeeding include accessibility and accommodations for lactation in the workplace and community.94
◆ In 2014, Rhode Island became the first state in the U.S. to establish licensure for International Board-Certified
Lactation Consultants (IBCLCs). State-certified and trained lactation consultants provide comprehensive
lactation support and counseling for pregnant and postpartum women. In January 2023, Rhode Island had 70
licensed IBCLCs.95,96
◆ Access to paid leave increases the overall duration of breastfeeding and the likelihood of breastfeeding for at least
six months.97 Rhode Island was a leader in paid family leave, establishing a program in 2013, but has since fallen
behind 11 other states, offering the lowest wage replacement rate and fewest number of weeks of leave.
Improving the state’s paid family leave program to meet national standards is an essential investment for Rhode
Island to make to become a great state to raise a family.98

8
 Infant Health

◆ Infancy is a critical and vulnerable time for development. In their first year of life, infants’ brains are growing
and developing quickly. Birth outcomes (preterm birth, low birthweight) can have both short and long-term
consequences including infant mortality.99
Preterm and Low Birthweight Infants by Maternal Race/Ethnicity, Rhode Island, 2016-2020
Preterm Birth Infants Low Birthweight Infants

15%

12% 13.1%
11.2% 11.1%
9% 9.7%
9.2% 9.0%
8.1% 8.2% 8.1% 8.2% 7.7%
6% 6.8%
3%

0%
American Indian Asian Black Hispanic* White All Races
and Alaskan Native

Source: Rhode Island Department of Health, Center for Health Data and Analysis, Maternal and Child Health Database, 2016-2020. *Hispanic mothers can be of any race.

◆ Preterm birth is the leading cause of infant death in Rhode Island. Between 2016 and 2020, 69% (157) of all
infant deaths were preterm (born before the 37th week of pregnancy).100 The preterm birth rate varies by
race/ethnicity, with non-Hispanic Black women (14.4%) continuing to have the highest preterm birth rate in
the U.S. in 2020. Hispanic women had a preterm birth rate of 9.8% in 2020 and non-Hispanic white women
had a rate of 9.1%. The rate decreased for each group between 2019 and 2020.101 Nationally, racial and ethnic
disparities affect the outcomes of preterm infants, with the preterm-related infant mortality rate for Black
infants about three times the rate for white infants in 2013.102
◆ Rhode Island women who deliver a low birthweight infant are more likely to report smoking while pregnant,
feeling unsafe in their neighborhood, delayed or no prenatal care, a depression diagnosis, and domestic violence;
as well as health issues during their pregnancy (such as high blood pressure or hypertension) than those with a
normal weight baby.103,104 There are racial and ethnic disparities in rates of low birthweight. In Rhode Island
between 2016 and 2020, 9.2% of American Indian and Alaskan Native infants, 8.2% of Asian infants, 11.1% of
Black infants, and 8.1% of Hispanic infants, were born at low birthweight, compared to 6.8% of white infants.105
◆ Infant mortality is defined as death through the first year. While infant mortality has declined nationally across
all racial and ethnic groups, disparities remain. The Black infant mortality rate is the highest of any racial or
ethnic group even after controlling for risk factors such as socioeconomic status and educational attainment.
Structural racism as well as exposure to discrimination and racialized stress in the workplace and community
negatively impact birth outcomes for Black women and their babies.106,107 In Rhode Island between 2016 and
2020, the Black infant mortality rate was 9.8 deaths per 1,000 live births, which is more than three times the
white infant mortality rate of 2.7 deaths per 1,000 live births.108

Infant Mortality Rate per 1,000 Live Births by Race/Ethnicity, Rhode Island, 2016-2020
10
9.8
8

4 5.1
4.2^ 4.4
2 2.7
0
American Indian Asian Black Hispanic* White All Races
and Alaskan Native**
Source: Rhode Island Department of Health, Center for Health Data and Analysis, Maternal and Child Health Database, 2016-2020. ^The data are statistically unstable
and should be interpreted with caution. *Hispanic infants can be of any race. ** Rate or percentage is too unstable to report.

9
 Substance Exposed Newborns and Screening Practices

◆ Neonatal abstinence syndrome (NAS) refers to a withdrawal syndrome that can occur in newborns exposed
to certain substances, including opioids. Neonatal opioid withdrawal syndrome, more specifically, refers to
the withdrawal symptoms related to opioid exposure. Not all substance exposed newborns are diagnosed
with NAS.109,110
◆ Women of Color are less likely to report smoking or heavy drinking, but they are more likely to report that
perinatal providers asked or talked about it.111
◆ Pregnant people who use substances are also wary of child welfare involvement. There is a need for universal
protocols when working with parents, children, and families impacted by substance use and a critical need to
address discriminatory attitudes and beliefs about maternal substance use and substance exposed children.112

Rate of Babies Born with Neonatal Abstinence Syndrome per 10,000 Newborn Hospitalizations
by Race/Ethnicity, Rhode Island, 2016-2020
175
146
150
125
96
100
75 70
49
50 29
25
0
Black* Hispanic White Unknown All Races

Source: Rhode Island Department of Health, Center for Health Data and Analysis, 2016-2020. *Due to small numbers, please interpret rate with caution.

◆ Between 2016 and 2020, white infants were diagnosed with Neonatal Abstinence Syndrome (NAS) at a rate of
146 per 10,000 newborn hospitalizations, compared to only 29 per 10,000 Hispanic infants and 49 per 10,000
Black infants.113

Breastfeeding

Breastfeeding and Formula Feeding at Birth by Race/Ethnicity, Rhode Island, 2016-2020

Any Breastfeeding Formula Feeding

100%
19% 36% 36% 23% 27%
80%
80% 76%
60% 71%
62% 62%
40%

20%

0%
Asian Black Hispanic* White All Races

Source: Rhode Island Department of Health, Center for Health Data and Analysis, KIDSNET, 2016-2020. Breastfeeding and formula feeding are defined as intended
feeding method at hospital discharge.* Hispanic infants can be of any race. Totals may not sum to 100% because data on feeding methods were not available for all
births.

◆ Between 2016 and 2020, 71% of new mothers in Rhode Island indicated that they intended to breastfeed when
discharged from the hospital and 27% intended to formula feed.114 Black and Hispanic infants are less likely to
be breastfed than white and Asian infants, due to structural, interpersonal, and cultural barriers that Women of
Color face. Structural barriers include lack of support and discrimination within the health care setting and
minimal paid family leave. Interpersonal barriers include lack of family support and inadequate workplace
policies for breastfeeding moms.115

10
 Young Children’s Health Insurance

◆ Younger children are more likely to live in low-income families compared to older children and therefore are
more likely to meet the income-eligibility threshold for RIte Care (up to 261% of the federal poverty level).
Approximately 57% of children under the age of three were enrolled in RIte Care/Medical Assistance in
2021.116,117,118
◆ Children who have health insurance coverage are healthier and have fewer preventable hospitalizations than
those who are uninsured.119 Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
benefit entitles children to all age-specific pediatrician-recommended services to grow and thrive, including
primary and preventive medical and dental care, specialists and Early Intervention services. Children with RIte
Care have fewer unmet health needs than uninsured children. Evidence indicates that the Children’s Health
Insurance Plan (CHIP) has reduced racial/ethnic disparities in access and utilization, improved educational
outcomes, and shielded children from poverty.120,121,122

Developmental Screenings and Early Intervention for Young Children

◆ During the first few years of life, children develop the basic brain architecture and social-emotional health that
serves as a foundation for all future development and learning. Infants and toddlers with developmental delays
and disabilities and those who face significant family circumstances need extra help and should receive high-
quality Early Intervention services to develop essential language, social-emotional, and motor skills to reduce the
need for services when they are older.123
◆ The American Academy of Pediatrics recommends routine developmental screening using standardized tools to
identify children who would benefit from Early Intervention (EI) services.124,125 In 2021, 65.2% of children
under age 3 with RIte Care insurance had a developmental screening completed, compared to 59.5% in 2020.126
◆ As of June 30, 2021, nine certified EI provider agencies served 2,102 children in Rhode Island. Of these
children, 56% were white, 32% were Hispanic, 7% were Black, 3% were multiracial, 2% were Asian, and <1%
were American Indian or Alaska Native.127

Lead Poisoning

◆ Homes, schools, and child care settings can be contaminated with lead from paint or paint dust if built before
1978 when interior lead paint was banned. Children can also be exposed to lead poisoning through corrosion of
lead service lines where the water pipe from a house or building connects to the public water main.128
◆ Lead poisoning is a preventable childhood disease. Infants, toddlers, and preschool-age children are most
susceptible to the toxic effects of lead because they absorb lead more readily than adults and have inherent
vulnerability due to developing central nervous systems.129 Lead exposure, even at very low levels, can cause
irreversible damage, including slowed growth and development, learning disabilities, behavioral problems, and
neurological damage. Though rare, severe poisoning can result in seizures, comas, and even death.130,131
◆ There is no safe lead level in children. In 2021, the Centers for Disease Control and Prevention lowered its
blood reference value from 5 µg/dL to 3.5 µg/dL. This new lower reference value will allow parents and health
officials to take corrective actions sooner.132

11
Children Under Age 6 Living in Old Housing By Race/Ethnicity, United States and Rhode Island, 2016-2020
United States Rhode Island

100%
100%
81%
75% 71% 70% 73%
57% 54% 53%
48% 50%
50% 44% 41%

25%

0%
American Asian or Black Hispanic White All Races
Indian Pacific Islander

Source: U.S. Census Bureau 2016-2020 5-year American Community Survey, Public Use Microdata Sample (PUMS).

◆ Between 2016 and 2020, more children under age 6 in Rhode Island lived in older housing (73%) than the rest
of the United States (50%). American Indian and Hispanic children under six were most likely to live in older
housing compared to Black, white, and Asian/Pacific Islander youth.133
◆ In Rhode Island, children living in the four core cities where more than three-quarters (77%) of children are
Children of Color live, are at increased risk for lead exposure because the housing stock tends to be older.134,135
In 2021, 602 (2.7%) of the 22,385 Rhode Island children under age six who were screened had confirmed
elevated blood lead levels of ≥5 µg/dL. Children living in the four core cities (4.4%) were three times more likely
than children in the remainder of the state (1.4%) to have confirmed elevated blood lead levels of ≥5 µg/dL.136

Asthma

◆ Asthma is a chronic respiratory disease that causes treatable episodes of coughing, wheezing, shortness of breath,
and chest tightness, which can be life threatening when not controlled. Asthma attacks can be triggered by
respiratory infections, air pollutants (such as high levels of ozone), cigarette smoke, allergens, and exposure to
cold air. While the exact cause is unknown, various genetic, environmental (such as long-term exposure to traffic
pollution), birth, and health factors have been linked to an increased risk for asthma.137,138
◆ Nationally, asthma is the most common chronic condition among children. Current asthma prevalence among
9
U.S. children fell from 8.4% in 2015 to 7.0% in 2019.139 Despite the decline in asthma prevalence, disparities
in asthma rates continue to persist. Racial and ethnic differences in asthma prevalence are believed to be
correlated with poverty, exposure to air pollution, stress, acute exposure to violence, and access to health care.140,141
Asthma* Emergency Department and Hospitalization Rates by Race/Ethnicity,
Rhode Island Children Under 5, 2016-2020**
ED Visits Hospitalizations***

20
(rate per 1,000 children)

17.2
15.0
15

10 7.9

5 4.3
2.3 1.9
1.3 0.8
0
All Races Black Hispanic+ White

Source: Rhode Island Department of Health, Emergency Department Visit and Hospital Discharge Data, 2016-2020; U.S. Census Bureau, Census 2010. *Rates are for
primary diagnosis of asthma. **Asthma-related emergency department visits and hospitalizations decreased substantially in spring 2020, due to the COVID-19
pandemic. ***Tests for diagnosing asthma are not always accurate for children under five, who are usually diagnosed with wheezing, trouble breathing, and shortness of
breath +Hispanic children can be of any race.

◆ In Rhode Island between 2016 and 2020, Black children and Hispanic children under age five were the most
likely to visit the emergency department or be hospitalized as a result of asthma. Children of all ages were more
likely to visit the emergency department than to be hospitalized for asthma.142
12
 Centering the Lived Experiences of Women and Birthing People of Color: SISTA
Fire’s Community-led Participatory Action Research and Birth Justice Demands
◆ SISTA Fire’s Community Participatory Action Research engaged 300 womxn in one-on-one interviews,
street outreach, conversations with birth workers, community listening sessions, and online forums on the
state of Black women and Women of Color in Rhode Island. This research specifically focused on Women
and Infants Hospital, which delivered a majority (82%) of all births in the state between 2017 and 2021.143

◆ Key findings from this research included:

• Patients are not being communicated to about their condition in their own language. Medical providers
often discuss patients and offer recommendations in front of them in a language they do not fully
understand.
• Patients are not being asked about their trauma histories by providers so they can be provided care that
is trauma informed.
• Patients reported that their severity of pain was not acknowledged or adequately treated. There were
many reports of Black and Brown womxn saying they did not feel believed.
• Many patients felt that the hospital does not see postpartum care on a continuum that exists outside of
the hospital setting. The hospital needs to improve strategies for informing patients about and
connecting patients to available community resources, such as mental health counselors, birth workers,
doulas, lactation consultants, etc.

◆ This research produced community-led solutions and birth justice demands related to culture and
approach, translation and interpretation, workforce development, doula engagement, an independent
community review board, and Community Resource Space.
Source: SISTA Fire Key Findings, Birth Justice Demands.

The Need for a Diverse and Culturally Competent Workforce

◆ While local, state, and national infrastructure and policies can help support maternal health, a racially and
ethnically inclusive workforce is needed to provide compassionate, respectful care to women and birthing people
throughout their pregnancy. This workforce should include a diverse array of providers including primary care
physicians, nurses, midwives, doulas and support personnel in and out of the hospital setting. It is important to
focus on workforce development, recruitment, and retention to address racially diverse representation in the
workforce to reduce disparities in maternal and infant health care.144,145
◆ Implicit biases can impact care and lead to adverse outcomes for Birthing People of Color. Having a racially and
ethnically diverse workforce as well as people who are culturally and linguistically matched can provide more
satisfactory care and increase feelings of respect and satisfactory care. Intensive training for a culturally
competent workforce should be delivered by lived experiences subject matter experts.146,147

13
 Legislative Efforts to Expand Health Coverage to
Address Racial and Ethnic Disparities in Rhode Island

◆ 12-Month Medicaid Postpartum Extension: The FY 2023 budget extended postpartum Medicaid coverage
from 60 days postpartum to 12 months postpartum and allows for state funds to be used to provide coverage
regardless of immigration status.148
◆ Cover All Kids: The Cover All Kids Act, which passed which passed as part of the FY 2023 budget, has restored
Rhode Island’s policy of allowing all eligible low-income children, regardless of immigration status, to enroll in
RIte Care and will help insure more kids.149
◆ Continuous Medicaid Coverage from Birth through 5: Once enrolled in RIte Care, it is critical that children
stay continuously covered. Even a short gap in coverage can result in a child missing needed care such as
treatment for a chronic condition. Starting in January 2024, states are required to allow children to remain
enrolled for a full year (12 months). Providing children with continuous coverage leads to greater coverage rates
which are associated with better health, reduced school absenteeism, and higher academic achievement for
children and, potentially, fewer lost workdays and lower medical debt for their parents. Continuous coverage
promotes health equity by limiting gaps in coverage for low-income children who experience disproportionate
rates of health disparities, particularly Children of Color. Providing continuous coverage from birth through age
5 would go even further and help infants and young children get off to a healthy start in life.150
◆ Infant and Early Childhood Mental Wellness Act: In 2022, the General Assembly passed the Infant and
Early Childhood Mental Wellness Act that requires the state to create a plan to use Medicaid to help improve
early identification and treatment of mental health challenges in young children (birth through 5). The
Executive Office of Health and Human Services has created an Infant and Early Childhood Mental Health
Task Force to develop this plan. Prevention and early identification and treatment of mental health challenges
in young children could reduce expulsions from child care and preschool and suspensions in the early grades
and address.151,152

Equity Impact Statements

◆ Equity impact statements are a tool for lawmakers to evaluate how proposed legislation will impact racial and
ethnic disparities prior to adoption and implementation. Similar to fiscal impact statements, equity impact
statements assist legislators in detecting unforeseen policy ramifications so legislative proposals can be modified
and avoid worsening existing racial disparities and ideally reduce or eliminate disparities. Nine states (Colorado,
Connecticut, Florida, Iowa, Maine, Maryland, New Jersey, Oregon, and Virginia) have implemented
mechanisms for developing and considering equity impact statements.153
◆ In Rhode Island during the 2022 legislative session, legislation was introduced that would have required the
General Assembly to include combined race, ethnicity, gender and disability impact statements in any legislation
related to human services; medical, dental or behavioral health care; disability services; housing or housing
assistance; education; employment and labor; land use and transportation; criminal justice; and legislation that
will have economic or environmental impacts on communities. The legislation did not pass out of committee.154

14
 Recommendations
Data Collection
◆ Support community-led data collection efforts that produce community-led solutions that reflect the
lived experiences of Rhode Island’s Asian, Black, Latino, and Native American communities.
◆ Increase data collection and reporting of data disaggregated by race and ethnicity, including data on the
Native American and diverse Asian and Pacific Islander populations.
◆ Ensure that Rhode Island’s Pregnancy and Postpartum Death Review Committee collects and reports
timely and comprehensive data on maternal mortality to inform prevention efforts.
Equity
◆ Monitor implementation of recent legislation and processes that impact health coverage, including Cover All
Kids, 12-month postpartum extension, and Medicaid redetermination efforts.
◆ Provide equitable access to comprehensive reproductive health care and address factors that contribute to
poor health outcomes, including through passage of the Equality in Abortion Coverage Act.
◆ Pass legislation that requires the General Assembly to include equity impact statements in any legislation
related to health.
◆ Implement policies that support recruitment, development, and retention of a racially, culturally, and
linguistically representative and competent workforce, including scholarships for BIPOC students,
adequate compensation, and training for current health care workforce.
◆ Improve the RI Works program by allowing a first time pregnant person to receive cash assistance from
verification of pregnancy.
Maternal Health
◆ Engage collaborators including community-engaged leadership to enhance the implementation of innovative
strategies like SISTA Fire’s Birth Justice Demands.
◆ Ensure access to health care for the treatment of chronic diseases, reproductive health, mental health, and
preconception care within a comprehensive coordinated medical system.
◆ Ensure access to culturally and linguistically competent and respectful health care providers through
quality improvement practices, standards of care, and accountability policies.
◆ Reduce barriers to doula care and other community-based supports by facilitating insurance
reimbursement, ensuring that hospital policies recognize the value of these supports, and implementing
policies that help doulas work within their systems.
◆ Support and invest in maternal mental health programs such as MomsPRN.
Infant Health
◆ Improve Rhode Island’s paid family leave program by increasing the wage replacement and expanding the
number of weeks offered to families to meet or exceed the policies of our neighboring states.
◆ Ensure workforce protections and implement breastfeeding accessibility for breastfeeding people, including
supporting lactation consultants.
◆ Review screening practices and protocols to ensure equitable, compassionate, timely, and quality care for
infants and caregivers exposed to substances.
Young Children
◆ Implement continuous Medicaid coverage from birth through age 5 to ensure that children have
consistent coverage during a critical developmental period.
◆ Create and enact equitable lead remediation plans for homes and water supply lines, including full lead
service line replacement.
◆ Address air pollution and environmental conditions in communities where Children of Color live.
◆ Ensure that recent rate increases are adequate to recruit and retain qualified staff in Early Intervention
programs so families do not have to wait for critical services.
15
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Acknowledgements
We are very grateful to
Rhode Island KIDS COUNT would like to thank Deborah Garneau, Aidea
Blue Cross & Blue Shield
Downie, Dora Dumont, William Arias, Jim Beasley, Margo Katz, Rhode Island
Department of Health; Ditra Edwards, Charmaine Porter, Keyanna Benton, of Rhode Island for its
SISTA Fire; and Quatia Osorio for their contributions towards this Issue Brief. support of this Issue Brief.