In Summary:

• Michigan’s citizens experience numerous health disparities based on factors like race and social class.
• Racial differences in maternal mortality are among the most glaring and most preventable health disparities.
• Addressing health equity is an essential factor to ensure that everyone has an opportunity for life, liberty, and the pursuit of happiness.

During the course of the COVID-19 pandemic, racial disparities have been well documented throughout the United States. People from marginalized groups are more likely to work in frontline essential worker positions that facilitate viral exposure. They also are more likely to live in overcrowded housing conditions that make physical distancing difficult, if not impossible. They may have trouble accessing health care services, meaning they are in a later, more serious condition when receiving treatment. Additionally, they may lack a primary care provider, affecting access to both testing and health care. These facts, compounded by various social determinants of health, mean that they generally also have a higher probability of underlying health conditions

The SARS-CoV-2 virus doesn’t itself discriminate, but it has served to illuminate problems that have long existed in our society, including inequitable differences in health. The current spotlight on these glaring health disparities creates an opportunity for policymakers to address issues of health equity.

Black Maternal Health Week

The White House designated this week as “Black Maternal Health Week” and declared that “a person’s race should never determine their health outcomes, and pregnancy and childbirth should be safe for all.” The Michigan Senate likewise adopted a Resolution introduced by State Senator Erika Geiss to commemorate Black Maternal Health Week in Michigan.

Maternal deaths have been increasing in the U.S. for decades, and the rate of death due to complications from pregnancy and/or childbirth are magnitudes higher in the U.S. than in other wealthy countries. Even though most pregnancy-related deaths are preventable, racial and ethnic disparities in pregnancy-related deaths have also persisted over time.

Nationally, Black women, as well as American Indian/Alaskan Native women, are two to three times more likely to die from a pregnancy-related cause than white women. In Michigan, pregnancy-related mortality is 2.4 times higher among Black women compared to white women.

Black mothers also endure a greater burden of morbidity and other complications related to pregnancy. According to state data, the most common causes of pregnancy-related deaths in Michigan are infection/sepsis, hemorrhage, and thrombotic pulmonary/other embolism. Cardiovascular conditions, non-cardiovascular chronic diseases, and mental health conditions are also important factors in pregnancy-related deaths. 

Health disparities experienced by Black women also affect birth outcomes. In Michigan, the infant mortality rate is nearly three times as high for Black mothers as for white mothers.

While differences in socioeconomic status contribute to this massive disparity, poor birth outcomes among Black mothers cannot be explained solely by factors of socioeconomic position nor by behavioral factors. Indeed, immense disparities in maternal health persist even among Black women with a college degree and/or higher income levels. For this reason, the ways heath may be affected by the direct experience of discrimination and racism are also important to consider.

In tandem with stress and depressive symptoms, exposure to racism may increase the risk of preterm birth (and, by extension, increase infant mortality), particularly in women with lower baseline risk. Various barriers to health care access and a history of lower health care quality received by black mothers continue to contribute to disparities in maternal and infant morbidity and mortality. 

Racism as a Public Health Crisis

Many Michigan cities began declaring racism a public health crisis last year, beginning with the city of Ypsilanti on June 3^rd, 2020. On August 5^th, 2020, Michigan Governor Gretchen Whitmer followed suit with an executive directive recognizing and addressing racism as a public health crisis. Michigan is not unique in this regard; numerous state and municipal governments have done the same.

Governments are not alone in describing racism as a public health crisis. The same has been said by numerous leading public health and medical associations, including the American Public Health Association, American Medical Association, American Psychiatric Association, American Academy of Pediatrics, American Association of Medical Colleges, and many others. The Centers for Disease Control and Prevention (CDC) has also launched a new web portal on racism and health.

While structural racism may be fueled in some cases by private prejudice, it is largely a function of public policy. It is neither accidental nor surprising that groups subjected to large degrees of poverty, segregation, and discrimination (sanctioned in many cases by governments and social institutions—e.g., “redlining”) have the poorest health outcomes.

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. A public health issue, then, is not only something that causes disease, injury, or death, but also things that have adverse social effects—in particular when these social factors impede a person’s opportunity to live a healthy, happy, and prosperous life. Racism clearly fits this definition. The longstanding existence of extreme racialized health disparities in the U.S. demands that racism be recognized and addressed as a threat to public health.

Reducing Maternal Mortality

Michigan can take direct actions to reduce racial disparities in maternal mortality. Even if these disparities were entirely eliminated, however, Michigan would still have maternal mortality rates that exceed most other wealthy nations. Public policies must therefore be targeted to eliminate all preventable pregnancy-related and pregnancy-associated deaths, while taking additional steps to ensure health equity and eliminate adverse factors like racism that contribute to health disparities. Michigan’s Mother Infant Health & Equity Improvement Plan is making great strides in advancing equitable maternal and infant health, but more work can still be done.

While there is no single policy solution to prevent maternal mortality, recognizing the problem is an important first step. Directing state and local resources to improve public health data collection and vital records is also fundamental for both developing and evaluating policy interventions related to maternal mortality (and a litany of other public health issues).

Ensuring equitable health care access, including quality services during pregnancy (in addition to during and after childbirth), is essential for preventing maternal deaths. The WIC and Medicaid programs offer avenues for direct state actions, but the state should also adopt policies to encourage reforms and equity within the healthcare system. The American Public Health Association recommends that all maternal deaths should be identified and reviewed by maternal mortality review boards and quality collaboratives.

Reducing large disparities in maternal mortality also demands recognition of implicit (and explicit) bias among health providers. The Michigan Department of Licensing and Regulatory Affairs is nearing the end of the process to establish implicit bias training standards as part of the licensure process for health professionals in Michigan. 

Quality health care services are only valuable if people can access them, and insurance coverage is rarely the only barrier to access. Paid sick leave and parental leave policies are not only part of a pandemic response strategy; they broadly improve public health by preventing the spread of disease, reducing workplace injuries, and facilitating increased use of preventative health services. Paid leave is also associated with an array of improved maternal health outcomes, including better maternal mental health. The lack of state and federal policies to provide paid leave to all workers disproportionately impacts low-income households and communities of color.

The factors that contribute to maternal deaths are not entirely confined within a nine-month period of time; factors throughout a woman’s life affect her health during pregnancy and the health of her baby. A healthy lifestyle is therefore an important aspect of pre- and perinatal health. Public policies should ensure that all people have access to the knowledge and resources needed to make healthy choices, and should further work to ensure that healthy choices are the easiest ones for people to make. Nutrition and housing have a profound impact on maternal health, and these social determinants of health may be addressed through the social safety net. Access to contraceptives and family planning services also reduce maternal deaths.

Societies are often judged by their treatment of the vulnerable. If Michigan wants to be judged well, providing high quality care for our mothers and babies—and taking extra steps to ensure equitable care for our Black mothers and babies—is a logical, ethical, and moral requirement.