“There’s a good amount of research looking at associations between the neighborhood environment and various health outcomes,” says Julia G. Carter, lead author on the study, , published in JAMA Obstetrics and Gynecology. “When I was reviewing the literature, I saw a lack of research on the mother’s subjective experience, which is what our study looks at.”

Because individuals who live in the same community can encounter the same environment in radically different ways, Carter says the research team from Northwestern University’s Feinberg School of Medicine wanted to go beyond the data about exposure to crime and other adverse conditions to look at how the mother’s view of her personal safety affected her and her infant’s well-being.

The researchers took their data from the (PRAMS), a project of the Centers for Disease Control and Prevention (CDC) which, along with state, territorial and local health departments, collects targeted, population-based attitudes on maternal attitudes and experiences surrounding pregnancy. The survey asked set questions of respondents in the participating 46 U.S. states, territories, District of Columbia and New York City, which creates data on 81 percent of all live births in the U.S. Individual states have the option of selecting additional questions to deepen their understanding of their own populations.

For their study, the Northwestern researchers analyzed responses PRAMS had gathered from 2016 to 2020 from the states that had asked respondents how they perceived their neighborhood safety.

Eight states — Illinois, Louisiana, Minnesota, Missouri, Pennsylvania, Rhode Island, Virginia and Wisconsin�� — asked respondents, “During the 12 months before your new baby was born, how often did you feel unsafe in the neighborhood where you lived?” Answers were then categorized as always or often unsafe, sometimes unsafe, rarely unsafe and never unsafe. To assess interpersonal physical and emotional abuse, one item asked whether respondents had been pushed, hit, slapped or physically hurt by another individual in the 12 months before they got pregnant. After 1829 exclusions, 29 987 respondents were included in the Northwestern study. Most of the respondents (78 percent) reported that they never felt unsafe. At the other end of the scale, 3 percent said they always or often felt unsafe.

The researchers then analyzed respondents’ birth outcomes including low birth weight, self-reported depression during pregnancy or postpartum, attending more than eight prenatal care visits, attending a postpartum visit, and breastfeeding for at least eight weeks.

After controlling for maternal age, race and ethnicity, and other sociodemographic factors to test the independent significance of perceived neighborhood safety, the researchers found that, compared with respondents who never felt unsafe in their neighborhoods, those reporting that they always or often felt unsafe had nearly 25 percent higher odds of having a low birthweight baby and 100 percent higher odds of perinatal depressive symptoms. The group that felt unsafe had 10 percent lower odds of attending more than eight prenatal care visits.

Although the Northwestern researchers’ cross-sectional study didn’t assess the factors that could determine why a pregnant person might choose not to seek prenatal care, their study cited an in-depth Canadian published in the BMC Journal of Pregnancy and Childbirth that analyzed the motivators associated with inadequate prenatal care among eight inner-city Winnipeg, Manitoba, neighborhoods. Researchers from the University of Manitoba found that, although the women in their study lived in the same group of disadvantaged neighborhoods, psychosocial, attitudinal, economic and structural barriers and a variety of motivators, separated those women who received adequate prenatal care from those who did not. The study highlights the diversity among inner-city women with respect to their experiences with prenatal care and their perceptions of factors that help or hinder them in accessing this care.

Psychosocial issues that increased the mothers’ likelihood of not receiving adequate care included feeling stressed, having family problems, being depressed and worrying that child welfare officials might take the baby. Being abused by their husband or boyfriend also prevented several of the women from obtaining adequate prenatal care. Structural barriers included not knowing where to get prenatal care or having a long wait to get an appointment. Problems with transportation or child care were mentioned by nearly half the women who didn’t receive adequate prenatal care.

The good news, Carter says, is that these factors have policy implications, which means they can be addressed. Solutions are more likely to be found in such initiatives as providing access to social workers who can help with scheduling and follow up, providing mental health resources, or addressing systemic issues such as the lack of bus stops near clinics.

A reverse image of the neighborhood perception study can be found in the paper, “,” published in the International Journal of Environmental Research and Public Health, which looks at the relationship between favorable social and environmental neighborhood conditions and perinatal outcomes.

Researchers from the University of Albany looked at nearly 300 mother-infant pairs in small cities, suburban regions and rural areas in upstate New York. The neighborhoods were analyzed according to the (COI), a multidimensional indicator of a neighborhood’s favorable social, environmental and educational community attributes. The study, the first to analyze the COI in association with pregnancy health and birth size, demonstrated that positive neighborhood attributes cumulatively contributed to healthy pregnancies and favorable birth outcomes.

While the idea that better neighborhoods make for better health may seem like a foregone conclusion, the contrast among the studies underscores an important point. The factors that give one neighborhood a high COI score and make other neighborhoods a source of fear and concern for mother and child, are all malleable and subject to change.

In their neighborhood perception paper, the Northwestern researchers point out that social and economic interventions that combat neighborhood and domestic violence may be more beneficial in reducing adverse pregnancy outcomes than biomedical interventions. Reducing expensive, often counterproductive police crime-prevention initiatives and mass incarceration in favor of resources that strengthen low-income communities may go further to create a sense of safety not only for pregnant people, but for the entire community.

“The main question,” Carter says, “is what are we going to do about it? That is outside the scope of our study, but assessing the situation is the first step in having this conversation. There are still a lot of steps to make improvements and develop solutions.

“With these social determinants of maternal health, the truth is, there’s no quick fix. But to have the data and the commitment to collectively do something about it makes a big difference.”

Further Reading

��Children from neighborhoods perceived as unsafe by parents engaged in one less day per week in physical activity. Children from neighborhoods perceived as unsafe were less likely to use recreational facilities compared with children from neighborhoods perceived as safe, and children from less affluent families across rural and urban areas had half the odds of using recreational facilities compared with children from the wealthiest families living in urban areas.

Neighborhoods can be a potential source of psychosocial stressors associated with childhood asthma. Parents who perceive their neighborhoods as sometimes or never safe reported asthma at higher rates than those living in neighborhoods parents perceived to be always safe.

Babies born to mothers on Medicaid died at almost twice the rate of babies born to mothers with private health insurance.

That may read like an indictment of the federal Medicaid program, but it isn’t. Rather, it’s a reflection of the program’s limitations, the complicated circumstances of mothers experiencing poverty, and sometimes a simple matter of geography.

“Medicaid is fantastic and undoubtedly has improved outcomes for mothers and babies. But even though it’s beneficial, it isn’t as good as private insurance,” says Dr. Colm P. Travers, neonatologist and assistant professor of pediatrics for the University of Alabama at Birmingham School of Medicine. “Babies don’t get to choose who their parents are, how much money their parents make or what they do for a living. The baby shouldn’t suffer because of their parents’ socioeconomic status.”

Travers led a recent study on how insurance status relates to infant outcomes in the U.S. The study, “,” was published in the October 2023 issue of JAMA Network Open. The study used data from the birth and infant death records database of the Centers for Disease Control and Prevention (CDC) from 2017 to 2020. Researchers analyzed data of more than 13 million infants; 54% born to mothers with private insurance and 46% to mothers with Medicaid. The study found that those with private insurance had a significantly lower risk of infant mortality — almost half the rate of mothers with Medicaid — as well as a lower risk of low birth weight, vaginal breech delivery and preterm birth. They were more likely to receive prenatal care in the first trimester compared with those with Medicaid.

Prenatal care is foundational for positive outcomes because the first trimester is such a crucial time for both mother and baby, says the study’s first author, Desalyn Johnson, a soon-to-be MD from the University of Alabama at Birmingham.

“From a biological standpoint for the fetus, that first trimester is when organogenesis occurs,” Johnson says. “The other two trimesters see more growth of the body, but the first trimester is when the heart, the lungs — all the organs — are formed. It’s also a time for recognizing the mother’s baseline risk factors that might put a pregnancy at risk, such as high blood pressure or diabetes. You really want mothers to have access to prenatal care at that critical time.”

Presumed Eligible

Because the prenatal period is so crucial, many states provide presumptive eligibility for low-income mothers, meaning that they can start prenatal care as early as possible in their pregnancy. General guidelines for Medicaid eligibility are set by the federal government, but each state sets up their own requirements for eligibility, which differ from state to state. In states that don’t allow presumptive eligibility, the process for approval can send applicants through an administrative tangle that takes weeks and involves multiple steps to navigate the bureaucracy — at a time when the clock is ticking for both mother and fetus.

“One of the big differences we found in infant outcomes was that the Medicaid population had delayed or inadequate prenatal care, possibly because of the process they have to go through before they can even get an appointment for their first prenatal visit. That can mean by the time they get approved, they’re delayed in their prenatal care, or they haven’t received adequate care in those first months. They’re already behind,” she says.

Sometimes whether an expectant mother can receive adequate care boils down to whether she can get to it, Johnson adds.

“Here in Alabama, a lot of our population is very rural,” she says. “Some must travel great distances to receive healthcare. When you’re trying to access Medicaid services, it adds to the barrier when you have to go to this county clerk or that building to fill out paperwork and then back and forth. It can be difficult.

“A lot of times, researchers look at urban health, which is very important, but we also need to consider this rural aspect, especially in the Southeast.”

Nowhere to Go

Once a pregnant person does get signed up for Medicaid, there is no guarantee that they will be able to find a health professional to care for them or their babies. According to a research letter published in JAMA Network Open, “,” in 2020, the number of general pediatricians in the entire U.S. was 56,800. Only 2,900 of these doctors worked in rural counties; 86 worked in completely rural counties, which the defines as a county with open countryside, fewer than 500 people per square mile and no towns with more than 2,500 population. Nationwide, 1,391 counties had no pediatrician; 1,156 of these were rural counties; 331 counties had neither general pediatricians nor family medicine physicians (FMPs).

The March of Dimes’ 2022 report, “,” finds that about 36% of all U.S. counties have no maternity care, whether obstetric providers, certified nurse midwives, or hospitals or birth centers offering obstetric care — a number that appears to be growing. Maternity care deserts are associated with a lack of adequate prenatal care during pregnancy, treatment of pregnancy complications and an increased risk of maternal death. More than 2.2 million U.S. women of childbearing age 15 to 44 live in maternity care deserts.

Among all highly industrialized countries, the March of Dimes report states, the U.S. is considered one of the most dangerous developed nations in the world in which to give birth.

, counties with neither general pediatricians nor FMPs were more likely to have higher percentage of non-Hispanic Black children, higher child uninsured rates, higher child poverty levels and fewer children enrolled in K-12. The issue of health professional deserts is so pervasive now in the U.S. it even gets its own acronym, HPSA (health professional shortage areas).

This shortage helps explain — though not entirely — why babies, especially post-neonatal intensive care unit (NICU) babies, born under Medicaid don’t receive the same level of postnatal care, such as oxygen monitors and ventilators, as babies born to privately insured mothers. The babies born on Medicaid also face increased risk of dying from trauma, accidents, and — a serious neonatal illness most common in premature babies, especially NICU babies who don’t get human milk.

Lifesaving Alternatives

These negative outcomes don’t have to be assumed for mothers living in poverty, the researchers say. Multiple studies have shown that expanding Medicaid prenatal care can dramatically improve things for both mothers and babies. For example, found that expanding Medicaid to cover prenatal care for undocumented immigrant women in Oregon was associated with more prenatal care visits and improved care, a reduction in the number of babies born with extremely low birth weight, and lower infant mortality rate. Additionally, the mothers’ access to prenatal care was associated with an increased number of well child visits and increased rates of recommended screening and vaccines during the child’s first year.

A study of Medicaid-sponsored provided strong evidence that the program improves the lives and health of mothers and babies. A team of nurses, social workers and other specialists work with the pregnant person’s doctor and local providers to care for mother and child throughout pregnancy and the child’s first year, including a well-regarded . The study found that enrollment in the program significantly reduced the odds of babies dying within their first year.

Ruling Out Race

Aware of important racial disparities in infant outcomes in the U.S., researchers adjusted their health insurance study for race, so the results reflected the difference between mothers on Medicaid and mothers with private insurance, not race-based differences.

“Race is largely a social construct,” Travers says. “Increasingly, medical and genomic studies are showing that there is little basis for race-based medicine in the U.S. In this study, we adjusted for the effect of race in our analysis, not to eliminate race, but to try to take it out of the equation. We purposely looked at insurance and adjusted for race so that we could get at the question of socioeconomic status and insurance specifically.”

For example, a recent from the National Institute of Child Health and Human Development found that newborns of Black patients had the worst perinatal outcomes. But once the study adjusted for insurance status, the difference was no longer significant.

The researchers also adjusted for sex of the newborn, maternal pregnancy risk factors, education level and tobacco use to analyze the differences between the two groups. The difference boiled down to who had the better health care. In other words, infant mortality outcomes are not fully explained by those external factors but are associated with the mother’s socioeconomic status, and access to insurance and adequate health care. Populations that are entirely self-pay, such as undocumented immigrants, may have even poorer outcomes than Medicaid patients —a subject for future study, the researchers say.

The results reflected in these studies don’t point to Medicaid’s failure but to the work remaining to be done to ensure that pregnant women of all socioeconomic circumstances receive the timely, adequate care they and their babies need.

“The draw of pediatrics for us as doctors is that when we’re working with children, we can lay the foundation for them to have healthy and successful lives,” Johnson says. “But if you don’t lay that foundation in the dawn of life, it can have repercussions for their entire lifespan. ��“We’ve now documented that, yes, these findings are what we expected. The next steps now are to decide how we as physicians, as policymakers, can address these issues and improve the outcomes for these babies.”

Further Reading

: In 2020, 42% of all births in the U.S. were covered by Medicaid. About one in nine women of childbearing age (11.6%) in the U.S. was uninsured. About one in 18 children younger than 19 was uninsured.

An interactive map showing which of the states have adopted Medicaid expansion coverage for nearly all adults with incomes up to 138% of the Federal Poverty Level ($20,783 for an individual in 2024) and the 10 states that have not done so.

Updated, May 12

Just 10 years old at the time, it was as if Eva Torres’s world fell in when COVID claimed the life of her grandmother in April 2020.

Abuela, as the girl called her, had lived just a block from the Bronx apartment she shared with her parents and two older brothers. Grandma was the one who would pick her up from school each day and “hear her 10,000 stories,” said Eva’s mother Angela Torres, “even if she was repeating it for the 20th time.”

After Eva’s grandmother passed, the elder Torres watched her daughter’s grades slip. Her once-bubbly girl seemed withdrawn, weighed down by anxiety.

“[That kind of loss,] it’s something that you carry with you,” the mother told ����Ӱ��. “It permeates into your very soul.”

The Torres children are three of the 8,649 youth in New York City believed to have lost a parent or caregiver to COVID. That’s roughly equivalent to the of Manhattan’s Battery Park/Tribeca district — or 1 out of every 200 youth in the entire city.

The U.S. reached 1 million recorded COVID deaths this week, a grim and once inconceivable milestone. President Joe Biden on Thursday on government buildings to fly at half-staff for five days.

“One million empty chairs around the dinner table,” Biden said in a statement. “Each leaving behind a family, a community, and a nation forever changed because of this pandemic. … [Americans] must not grow numb to such sorrow.”

Yet having experienced the loss of a caregiver to the virus, some parents say schools aren’t adequately reckoning with the fallout for bereaved students.

“We don’t talk about the people we’ve lost. That conversation is completely not occurring,” said Brooklyn mother Melissa Keaton.

Two years after the April 2020 death of Keaton’s father who lived with the family in their Flatbush apartment, Melissa’s daughter, Melanie, still mourns the loss of her grandfather. The 9-year-old used to end each evening by calling out, “Goodnight, Papa.” Now the missing ritual provides a daily reminder of his absence, said Keaton.

“With grief, there’s no time limit,” explained the mother.

Though much of the nation is eager to put the pandemic in the rearview mirror, life will never return to a pre-pandemic normal for children like Melanie who have endured the trauma of losing a loved one, said Keaton.

That’s a reality educators are now forced to contend with. On average in the U.S., each school serves .

In New York City, which became the global epicenter of the pandemic in spring 2020, the issue is even more acute. Many schools in neighborhoods that were hard hit by the virus now serve over a dozen students who lost a caregiver during the pandemic, school social workers told ����Ӱ��. Researchers said they fear the number in some schools may be of a much higher magnitude, as many as 100.

The New York City Department of Education did not provide an estimate confirming or denying those figures.

In the city’s high-poverty, predominantly Black and Hispanic neighborhoods, which suffered disproportionate COVID deaths, it became difficult to track and absorb the losses during the harshest moments of the pandemic, said Ilka Rios, a Bronx public school parent.

“Daily, I would log into social media and it was ‘Rest In Peace,’ ‘Rest In Peace,’” she said.

Racial disparities in caregiver loss have been in New York City than in the rest of the country, with Black and Hispanic children experiencing the death of a parent or caregiver at 3.3 and 2.6 times the rate of white NYC children, respectively. Nationally, Black and Hispanic children also suffered greater loss than their white peers, but the difference was less dramatic, at 2.1 times.

The 8,649-youth total itself is likely an undercount, said University of Pennsylvania researcher Dan Treglia. The , for whom Treglia did the work, provided the tally of COVID-bereaved children to ����Ӱ��, derived, he said, by combining the city’s coronavirus death numbers from the Centers for Disease Control and Prevention with household-level data from the 2019 American Community Survey.

“These estimates are a lower bound,” said Teglia. “Because New York City was hit so early, we were still figuring out how to recognize and code COVID-19 deaths.”

‘Slipping through the cracks’

But as the city continues to grapple with the fallout, advocates fear that governmental systems are ill-equipped to identify the young people left behind.

“We don’t know who these children are,” said Catherine Jaynes of the COVID Collaborative. “There’s no systematic way to identify them.”

The nation’s largest school district has no internal mechanism letting them know when a student experiences the death of a loved one. Death certificates do not list whether deceased individuals were a parent or guardian and no agency, as far as representatives for the Department of Health were aware, cross-checks records to identify bereaved children. Instead, the onus to let teachers and school leaders know of a recent loss falls on the grieving family.

“We are alerted to a death in the family by other family members or people who are close to the family,” said DOE Press Secretary Nathaniel Styer in an email.

Teachers ought to be aware of the circumstances students are going through, said Nkomo Morris, a counselor at Harvest Collegiate High School in Manhattan.

If you know a student has recently experienced the death of a family member, “you’re not going to be like, ‘Why are you late to class?’” she said. “You’re gonna pay more attention to them, you’re going to be a little sweeter to them.”

When students at her school experience trauma in their outside lives, it gets recorded in an internal system called , which automatically sends an email notifying the student’s teachers and counselors, said Morris.

But on other campuses, the response is less streamlined. Danielle Shapiro-Nussen works as a special education teacher at a District 75 school in the Hunts Point section of the Bronx and suspects there may be students who have experienced the death of a caregiver without the school becoming aware.

“It’s possible that some of these families have gone through a tremendous loss … and we don’t know,” she told ����Ӱ��. “Unless a family member said, ‘Yes, we lost a [loved one],’ there’s probably no way we would have known.”

“I think there are thousands of children who are slipping through the cracks,” said Ayana Bartholomew, a former program officer overseeing efforts to support COVID-bereaved children at the who left the organization in mid-April.

A introduced mid-April in the City Council seeks a more complete accounting, requiring the Administration for Children’s Services to produce quarterly reports on the impact of the death of parents or caregivers dating back to January 2020.

The country as a whole has not done enough to account for the “downstream consequences” of caregiver loss through the pandemic, said the Collaborative’s Treglia.

Bereaved youth have than those who have not lost parents, he pointed out. They are more than twice as likely to show impairments in functioning at school and at home, even seven years later, meaning these children need both immediate and long-term counseling and support to deal with such a traumatic loss.

President Joe Biden used memo to draw attention to the long-term effects of COVID, including the fallout for young people who lost caregivers, but the announcement “doesn’t outline any plan or commitment,” Rachel Kidman, a social epidemiologist at Stony Brook University, says in a recent in The Atlantic. Although the administration has disbursed some funds to grieving families, including to defray funeral costs and for mental health supports, “no law or executive order has provided any resources specifically for pandemic orphans,” the story points out.

Supporting COVID-bereaved families

The COVID Collaborative’s report calls for a more robust nationwide response.

“We recommend a White House Executive Order to provide for screening (for COVID-related caregiver loss) in public and publicly subsidized schools, early childhood education and healthcare settings, along with public-private partnerships to facilitate screenings in other circumstances,” the authors write.

No such program yet exists, but on a smaller scale, efforts have cropped up to identify and provide aid to those who lost a caregiver to the virus. Montefiore Health System launched its “” in 2020, combing through medical records to identify New York City and Lower Hudson Valley households with children that lost a parent to COVID. By filtering COVID deaths by age and cross-checking the notes recorded by health care workers, such as whether nurses helped the patient FaceTime loved ones, the initiative reached 475 families.

“It was a heavy lift,” admitted Deirdre Sekulic, assistant director of social work at the Bronx hospital, who personally made many of the phone calls to eligible households.

“Lots of these were families that were kind of OK before the pandemic. They might have been paycheck to paycheck, but they were going along surviving,” she said. “The unexpected death of somebody just destabilized them.”

Through the program, each household received $2,000 in cash assistance and were connected with social programs such as disability benefits or food stamps. A measure under consideration by the California legislature would create , with as much as $8,000 available to eligible youth when they turn 18.

And though not COVID related, experts point to an effort in Allegheny County, Pennsylvania as a stand-out example of local government systematically identifying youth who lost caregivers. A hotbed of the opioid epidemic with an overdose rate triple the national average, the county’s Department of Human Services matched death records to birth certificates and identified 18 or younger who had lost a parent to an overdose.

“A first step [for localities looking to support grieving youth] could be … understanding where these bereaved children are located,” said Treglia. “Then you can develop a more targeted approach to finding them and you can tailor interventions to their needs.”

‘So much pain’

Even without a systematized method for identifying COVID-bereaved youth, New York City schools have implemented other measures to help students in mourning. In spring 2021, the city announced it would hire .

“There was a clear understanding that they would need more of us,” said April Gurley, a 10-year veteran who this year stepped into the role of supervisor of North Queens school social workers. “We were [responding to] this massive amount of trauma and grief that was happening in our city.”

The Department of Education has also invested in professional development for teachers, with trained in grief sensitivity by David Schonfeld, founder of the .

One positive result that has come of the pandemic, said the expert, is that far more educators have become attuned to the needs of grieving students. conducted by the New York Life Foundation and the American Federation of Teachers, three-quarters of educators reported that COVID has opened their eyes to the immense impact of grief and loss.

Teachers serving children who have experienced the death of a loved one should acknowledge the loss rather than ignore it, Schonfeld advises.

“There’s a tendency to avoid talking with children who have been through a crisis or dealing with a death because you don’t want to upset them,” he said. “Saying nothing is exactly the wrong thing to say because it communicates either that you’re unaware or you’re unwilling to provide support.”

But professional development is only a first step, said Morris, of Harvest Collegiate.

“Being trained in this and actually doing it with a real teen are two very, very different things,” the counselor said.

Last year, in a college advising session, a student disclosed to Morris that they had lost a grandparent. The student was not close with their parents and “their sense of themselves as a person came from that grandparent,” Morris recalled.

“I was shocked,” she said. “They were experiencing so much pain.”

On the fly, she had to figure out how to support the teen, who she said had largely checked out of their academics. She referred them to the social work team, but touched base periodically over email and text. “Hey, how are you doing?” she would ask. “What can I do to help?”

Unfortunately, many NYC students dealing with grief aren’t lucky enough to receive support from a counselor like Morris. When Melissa Keaton, the Flatbush mother whose father passed away, sought out mental health support for her daughter, the therapists she contacted were at capacity, she said, and the school mental health services did not reach out to the family.

Meanwhile, a book the class read called features a young protagonist whose parent has just died. The reading triggered painful memories for Melanie.

“I did email the teacher to let her know that it’s a sensitive topic,” recalled Keaton. “And she just said, ‘OK, well, I’ll keep that in mind,’” but provided no accommodations.

Such instances, said the DOE, are outliers.

“Every one of our schools is a caring and supportive environment where our students can connect with one another, communicate with a caring adult, and access the resources they need to heal as we emerge from the pandemic,” said spokesperson Suzan Sumer.

But despite educators’ best efforts, pandemic circumstances continually put teachers in emotionally charged situations that they don’t always know how to best navigate, said Shapiro-Nussen.

Recently, a first-grader who had lost a parent in September was exiting the classroom when she turned and asked whether the Bronx special education teacher planned to see her mother after school. Shapiro-Nussen was unsure of what to say; she herself had lost her mom to COVID.

“No, sweetie, I’m not gonna see my mom for a really, really long time,” the educator responded. “My mom is on a really, really long vacation.”

“Was it the right choice?” wondered Shapiro-Nussen. She asked the school counselor. Next time, be honest, the counselor advised.

Angela Torres, for her part, turned to those around her for support processing the loss of her mother. She created a COVID bereavement group that met regularly over Zoom in 2020 and grew to about 20 members through word of mouth, Facebook posts and circulating information at her church. Those conversations allowed her to finally begin to heal, she said.

Schools can take a page out of that book, she said, and facilitate conversations between peers and caring adults to help grieving students like her daughter recover.

“Community,” said Torres. “That’s our ticket out of this.”

Illustration by Marianna McMurdock for ����Ӱ��.

When he fell ill from the coronavirus in April 2020 and went to the hospital during New York City’s deadly first wave, the young girl, then just 7, turned to her mother.

“He’ll be OK, right?” she asked.��

Her mother, Melissa Keaton, days later had to tell her daughter that their beloved “Papa,” who was 61, wasn’t coming back to the Flatbush apartment he had shared with them and where he helped care for his granddaughter.

“My father was in the hospital,” Keaton told ����Ӱ��. “We never heard from him. We were never able to see him or speak to him. Once he passed, [Melanie] didn’t get to see that visual, final goodbye.”

The young Brooklynite is one of more than who are believed to have lost parents or caregivers to COVID during the pandemic — roughly 1 in every 450 young people in the U.S. under age 18.

The count updates the already-staggering October estimate that had lost caregiving adults to the virus, and is four times more than a springtime tally that found nearly had experienced such loss. In a Dec. 9 titled “Hidden Pain,” researchers from the and published the new total, which they derived through combining coronavirus death numbers with household-level data from the 2019 American Community Survey.��

The death toll further underscores the daunting task facing schools as they seek to help students recover not just academically, but also emotionally, from a pandemic that has already stretched 22 months and claimed more than 800,000 American lives. It’s an issue of such elevated concern that Surgeon General Vivek Murthy, on Dec. 7, used a rare public address to warn Americans of the pandemic’s . An accompanying calls out the particular difficulties experienced by young people who have lost parents or caregivers to the virus.

“As the nation looks to recover from the COVID-19 pandemic, there is an urgent need to address the crisis of children left behind,” said COVID Collaborative CEO John Bridgeland in a addressing his organization’s co-published research.

Bereaved children have higher rates of depression and post-traumatic stress disorder than those who have not lost parents, according to that followed grieving children for multiple years. They are more than twice as likely to show impairments in functioning at school and at home, even seven years later, meaning these children need both immediate and long-term counseling and support to deal with such a traumatic loss.

“For these children, their whole sky has fallen, and supporting them through this trauma must be a top priority.”

The sky had indeed fallen for the Keaton family.��

After having suffered a single seizure three years prior, Melissa Keaton said she developed full-blown epilepsy after losing her father, experiencing multiple uncontrolled fits. Melanie witnessed her mother in spasms on the floor on at least one occasion.

The elementary schooler’s virtual classroom was unequipped to help the young child process her multiple traumas, her mother said, and the school mental health services did not reach out to the family. Meanwhile, COVID-related lessons — for example, on the vaccine — triggered painful pandemic memories for Melanie, making online class occasionally upsetting, with her school missing signs she was struggling emotionally.��

Of all children who have lost caregivers to the virus since COVID-19 struck, a disproportionate share are Black. Those losses among African-American youth like Melanie have come at more than twice the rate of white young people, according to data in the new report. Indigenous, Hispanic and Asian youth have also suffered outsized losses, the numbers show.

“The children most likely to lose a caregiver to COVID-19 are also most likely to have faced previous adversities,” said Dan Treglia, co-author of the report and associate professor at the University of Pennsylvania. That ups the stakes, he added, on providing support to help those young people heal.

Also particularly vulnerable are the 70 percent of all COVID-bereaved children who are 13 years old or younger. More than 13,000 children of all ages lost their only in-home caregiver.

Despite dire need, however, professional help often remains inaccessible. In Melanie’s case, Melissa Keaton said she turned over every possible stone seeking mental health support for her daughter, but was unable to secure counseling. Well before the pandemic drove greater demand, reported offering mental health services to students and 52 percent said that inadequate funding was “a major limitation” in their ability to provide those services, according to 2017-18 data from the National Center for Education Statistics.

“Trying to find a therapist or someone for her to talk to, it was impossible,” she explained. “Calling, you know, office after office and everyone is at capacity, there’s nothing available.”

The COVID Collaborative and Social Policy Analytics report recommends that policymakers devote resources to grief camps, group counseling and therapy to support children like Melanie as they move forward and recover. They recommend the creation of a bereavement fund for affected families, similar to that which was created for relatives of Sept. 11 victims. Schools, the researchers say, can play a critical role in ramping up mental health services and mentoring for students.

The American Rescue Plan, which will send a total of $122 billion to U.S. schools, includes funding that some campuses are using to responding to students’ mental health needs, especially when it comes to pandemic-related traumas. So far, of school systems have invested some of their relief money in social-emotional learning materials, according to a Dec. 13 tabulation from the data service Burbio, which has tracked how districts are using the influx of federal dollars.

But with or without support, the Keaton family will continue to feel a gaping hole in their household. The holidays, Melissa Keaton said, are especially hard. They always used to spend Thanksgiving watching football with her father. His Dec. 23 birthday was a regular part of their Christmas routine.

“We have these people who have lost family members, and they’re kind of forgotten, the unknowns. We don’t talk about it because everyone wants to get past it and get back to normal,” she said.��

“But for people who have lost someone, certain things will just never be normal.”