When Lauren Thomas became pregnant with her son Ayo six years ago, she and her husband didn’t have health insurance. So she enrolled in Medicaid to receive prenatal care.
Thomas, who has two older children, often attended appointments alone while her husband was working. She said she felt judged by healthcare providers and seen as a single pregnant Black woman on Medicaid.
The first thing her prenatal nurse asked – before Thomas’ first examination even began – was about her plans for birth control after pregnancy.
“And I’m just like, ‘What, this baby hasn’t been born yet!’ And I was already being stifled,” Thomas said. “I was rushed. I wasn’t listened to. It felt like [the nurse] was exhausted with me and my kind being pregnant.”
Outcomes for Black mothers and babies in Detroit are grim. According to state statistics, the rate of pregnancy-related maternal deaths between 2015-2019 for Black Detroit women was 43.7 per 100,000 live births – the same metric for white women in Detroit during that time period was zero.
Black infants are faring poorly, too. Black infant mortality in Detroit reached a historic low in 2019 at 12.2 per 1,000 live births. To celebrate, Mayor Duggan held a press conference crediting state, city, and private programs like the city’s SisterFriends, which pairs pregnant women with community mentors and offers rides to prenatal appointments.
But since then, mortality among Black infants in Detroit has rebounded — in 2021, it was 18.1 per 1,000 — among the highest it’s ever been. Infant mortality among white babies in Detroit also spiked, from less than 1 per 100,000 to 12.1 per 100,000 in 2021.
The experience of racism and bias drives disproportionately high maternal and infant mortality and morbidity rates among Black women, according to Dawn Shanafelt, director of the Division of Maternal & Infant Health for the Michigan Department of Health & Human Services.
“The most significant challenge is systemic racism and bias that results from systemic inequities,” Shanafelt told Planet Detroit. “And it’s intersectional. Being Black and being a woman are two significant challenges facing Black mothers. It multiplies the effect of systemic oppression and impacts health outcomes.”
Across Michigan, Black women were 2.8 times more likely to die from pregnancy-related causes (29.8 and 10.7 per 100,000 live births, respectively) between 2015 and 2019.
Pregnancy-related deaths occur while a woman is pregnant or within one year of the end of pregnancy from causes directly related to or aggravated by the pregnancy or its management.
Overall, maternal death has been rising steadily since 2018 across all races, according to new data from the Centers for Disease Control & Prevention, with Black women faring worst. The maternal mortality rate for 2021 was 32.9 deaths per 100,000 live births, compared with a rate of 23.8 in 2020 and 20.1 in 2019.
The reasons for this, experts say, are multifactorial. They point to social determinants of health – the non-medical factors believed to account for 80-90% of health outcomes. That includes things like housing stability, environment, and racism.
“It’s really important to listen to Black pregnant and postpartum individuals regarding their experiences,” Shanafelt said. “Just really listen to what’s happening, so we can act on it.”
What’s driving high rates of Black maternal and infant mortality?
Sonja Bonnett is a community legal advocate for the nonprofit Detroit Justice Center. Much of her work centers on helping Detroiters returning from incarceration with housing and transportation – factors that disproportionately impact Black women and mothers.
Black women renters get evicted at twice the rate of white renters, according to research from the ACLU and Princeton’s Eviction Lab. Just 18% of Black households – a significant proportion of which are led by single mothers – have vehicle access – the lowest of all racial and ethnic groups. And female-headed households are less likely than male-headed households to have access to a vehicle for all racial and ethnic groups.
“Poverty has to be fixed,” Bonnett said. “You cannot talk about fixing this thing without starting at the root, and the root is poverty.”
But studies show that education and wealth do not protect Black mothers and their babies, who experience the highest maternal and infant mortality rates of any group in the United States.
“What comes up, again and again, are stories of bias,” Shanafelt said. “Whether it’s clinical systems, whether it’s community organizations, we hear that time and time again. It needs to be addressed.”
The leading causes of mortality among Black mothers between 2016–2017 were preeclampsia, eclampsia, and cardiomyopathy, according to vital statistics mortality data analysis.
But the roots of those causes go much deeper than what ends up listed on death certificates. Multiple, interrelated factors – those social determinants of health – underlie those ultimate causes of death, many of which, the study’s authors note, are preventable.
Dr. Kimberlydawn Wisdom, senior vice president of community health & equity at Henry Ford Health, remembers the celebration back in 2019 when Detroit’s infant mortality reached its historic low.
She has been working on the issue since 2008, forming the Detroit Regional Infant Mortality Reduction Task Force in partnership with four major health systems serving Detroit. She also launched the Women-Inspired Neighborhood (WIN) Network: Detroit, a cohort-based program that pairs pregnant women with community health workers to help them navigate pregnancy and access services.
“Of course, we were happy, but one data point does not make a trend,” she said. “So we felt, okay, let’s keep doing good work and anticipating that we can continue to drive it down.”
But then, she said, COVID happened.
“That just changed everything,” she said. Wisdom notes that the pandemic impacted maternal and infant health both directly and indirectly. An internal analysis of hospital system data, she said, showed that pregnant women who got COVID were more likely to have a preterm birth, cesarean section, gestational diabetes, and preeclampsia.
COVID impacted pregnant women indirectly as well, Wisdom said. Pregnant women were afraid of being exposed to COVID, causing them to forgo prenatal care. Social needs – access to the basics like housing, food, and transportation to prenatal care – were exacerbated.
Dr. Claudia Richardson, medical director for the Detroit Health Department, also attributes some of the rise in Detroit’s infant mortality to the COVID-19 pandemic.
“Our medical and support systems were fragmented,” she said. “We’re still trying to unpack all of this. We lost services, businesses, coalitions, and interdisciplinary groups that helped make those improvements.”
Wisdom points to the concept of weathering, the theory that racism and discrimination are bad for individuals’ health. One derided when it was introduced during the 1960s; the idea is gaining traction.
“People of color are vulnerable, not just at a psychological or biological level, but at a chromosomal level,” Wisdom said. “You’re stressed, you can’t pay your utility bills, and you’re short on food, you’re short on money, you’re not working, you know, all those cortisol levels are on overdrive. And that has deleterious effects on the body and blood pressure and an infant in utero.”
State epidemiologist Chris Fussman agrees that the pandemic likely bears some responsibility for the spike in Detroit’s Black infant mortality numbers.
But one significant cause of the increase in Detroit’s Black infant mortality, he said, may relate to concurrent increases in sleep-related death. He said the number of sleep-related infant deaths within the city of Detroit more than doubled from 2019 to 2020. The department is still verifying data for 2021 and will release it later this year.
Fussman cautioned it’s important to look at more than one data point before considering it a trend.
“When it comes to infant mortality, the reasons why rates fluctuate are often multifaceted, and thus it can be difficult to identify one specific action that caused the rate to change,” he said.
Environmental advocates also point to the inequitable burden of pollution and water shutoffs on Detroit’s Black mothers.
“The conditions that determine women’s health and survival during pregnancy and after giving birth extend well beyond medical care,” Amy Schulz, a professor at the University of Michigan School of Public Health, said. “Exposure to air pollution increases women’s health risks during pregnancy and affects the health of their babies.”
Monica Lewis-Patrick, president and CEO of the water advocacy group We the People of Detroit, points to evidence showing that water insecurity – a lack of access to clean drinking water and water shutoffs contributes to maternal and infant mortality.
“We need to lift up the intersectionality between water and Black maternal health,” Lewis Patrick said. “Water is the building block for creating and sustaining life and health. We know that the body is composed of 70% water. And an unborn child in the womb is surrounded by water and depends on it for protection and for nutrients that enable survival while in utero.”
Advocates point out that Black women experience higher risks of high blood pressure during pregnancy (preeclampsia/eclampsia), blood clots/stroke, and heart disease – all conditions that contribute to maternal mortality and are linked to air pollution. Black women in Detroit are more likely to be exposed to air pollution than white women in the United States. The American Lung Association gave Wayne County a failing grade for ozone and particle pollution.
“Women who live near roads with heavy truck traffic are exposed to air pollutants that increase the risks of high blood pressure, stroke, and asthma-related deaths during pregnancy. Detroit moms deserve better,” Simone Sagovac, Southwest Detroit Community Benefits Coalition, said.
“While there are many facets of this problem, there are easy and reasonable steps that can be taken to prevent women from dying during their pregnancies,” she added. “Limiting heavy truck traffic near where people live would quickly reduce air pollution. It would save many lives, including those of pregnant women.”
Advocates want to see actions taken to protect Black mothers, including not permitting new air pollution in heavily polluted areas, enforcing permit violations, and taking action to ensure that air pollution is below the health-based federal standards.
“We have the knowledge and at least some of the tools we need to protect Black mothers from toxic air,” Donele Wilkins, CEO of Green Door Initiative. “We need elected officials and regulators to recognize Black families’ right to breathe clean air.”
Addressing the problem
As the pandemic wanes, Wisdom and Richardson hope they can begin to reverse the city’s poor maternal and infant health outcomes and mortality rates.
According to Richardson, one bright spot is that Michigan has extended Medicaid postpartum coverage for mothers and babies for 12 months. She hopes other insurance companies will follow.
“The postpartum period is very important, and moms need the support and access to care to help identify problems in terms of their own health and also the health of their babies,” she said. She is also thrilled that as of Jan. 1, doula services are covered under Michigan Medicaid. A 2022 Lancet study found that doula services reduced cesarean deliveries, postpartum depression, and anxiety among Medicaid participants.
Richardson also hopes additional federal funding will allow the city to scale up its SisterFriends program. A survey of participants revealed that nearly half of participating moms stated they would have missed prenatal visits without transportation provided through SisterFriends Outcomes included 87% of infants born at a healthy weight, 88% full-term, and 80% of moms initiating breastfeeding. The WIN network program cites similar positive outcomes.
State public health officials have launched a statewide listening tour to gather information about Black mothers’ experiences to inform an update to its Mother Infant Health & Equity Improvement Plan, which guides state policy and programming.
Wisdom would like more resources for Black women, including economic and mental health support. She points out that Black women experience stark wage gaps and that Black moms are less likely to return to the workforce than their white counterparts.
Thomas would like to see programs like SisterFriends and WIN expand their services to help counter bias in the medical setting. They point to the Detroit Justice Center’s model of training community legal advocates, noting that the concept could be adapted to train community mentors to be medical advocates.
She’d also like to see more Black physicians providing medical care. One recent Florida study found substantial improvements in mortality for Black babies cared for by Black physicians.
“Making pathways early on for more Black kids, especially those who are coming from poverty, coming from the city, to become doctors, to become nurses, to get into the medical field,” she said. “And making that a clear pathway and making it accessible. And by accessible, I mean making it free.”
Wisdom hopes the jump in Detroit’s 2021 infant mortality numbers is temporary.
“I’m hoping it’s a spike, and then we’ll come back down,” she said. “We don’t know what the next trend will look like. But mind you, there will be remnants of COVID – people will still be fearful. People are still going to be skeptical. We haven’t solved the social needs challenges that people have.”