This article is part of State of Health, a series about how Michigan communities are rising to address health challenges. It is made possible with funding from the Michigan Health Endowment Fund.

Racism is killing mothers and babies in Michigan – and initiatives across the state are working to tackle that root cause and save lives.

Michigan's Black and Indigenous mothers experience nearly three times the risk of infant death compared to white mothers. Michigan's Black mothers are more than twice as likely as white women to die from pregnancy-related causes. The sheer stress of everyday life within a racist society increases the likelihood of premature birth, the leading cause of infant death. And these disparities persist despite the mother's socioeconomic status or educational level.
Amy Zaagman.
"Obviously, there are usually medical causes at play. But when you dig down and actually listen, there's systemic racism at the core of these disparities," says Amy Zaagman, executive director of the Michigan Council for Maternal and Child Health (MCMCH). "The conditions that have been created over generations in communities are contributing to the stress level. The environment and the circumstances in which things compound create scenarios where the response is not what it would be for someone who was white. It's entrenched and long-standing, but it's something that we as a society should and could change."

While social determinants of health like income, education level, and access to healthy food, transportation, and housing affect a woman's health during pregnancy and infants' health during that first year, recent studies have concluded that racism is the underlying cause.

"Systemic racism is such a huge and ugly beast that we do not like to address in our health care systems," says Kyna King, Berrien County Health Department family health programs manager.  "Until we address systemic racism with action plans, we're not addressing this right. How do we provide the undergirding to support families while we're trying to also dismantle some of these systems?"

Road maps for birth equity

Zaagman leads MCMCH's Birth Equity Education Project (BEEP). To date, BEEP has released five policy recommendations covering doulas, rethinking perinatal care, mental health, diversifying the health care workforce, and payment reform. Recommendations on breastfeeding and substance use are in progress. 

"It's really thinking about enabling and empowering all of the individuals who have an interest in helping women achieve a healthy pregnancy and helping infants thrive," Zaagman says. 
Dr. Jennifer Torres.
Taking a boots-on-the-ground approach, the Michigan Public Health Institute's (MPHI) Achieving Birth Equity Through Systems Transformation (ABEST) project focuses on root causes, including the role of racism, and addresses relationships and power within systems. ABEST seeks to build capacity among state and local leaders to lead systems change and shift mindsets in order to decrease these disparities for mothers and babies of color.

"Having those experiences of systemic racism, interpersonal racism throughout a lifetime, that causes wear and tear on a woman's body," says Dr. Jennifer Torres, manager of the MPHI Office of Women's Health and Birth Equity. "That wear and tear then impacts the health of the woman, her pregnancy, and her baby."

ABEST currently works with the Inter-Tribal Council of Michigan (ITCM) Asabike Coalition and the Berrien County Raising Up Healthy Babies Taskforce (RUHB). RUHB's goals include developing a strategy, conducting campaigns, and changing health care systems' practices to affirm Black, Indigenous, and people of color (BIPOC) birthing individuals and families as leaders in their own care. 
Kyna King.
"We call these road maps for birth equity," King says. "I think what's really exciting is they really focus on building community power and voice, and really lift up BIPOC birthing people as leaders in their own care."

As an important first step, King took time to listen. Conversations with community partners revealed what resources the partners were already making available to pregnant women and infants. Conversations with community members helped build an understanding of what was truly important to families.

"It is very important for our families to have a voice in their own care, and we're helping them to create that voice," King says. "There's a lot of great work that's happening. A lot of times the work is happening in silos. We wanted to make sure that we had collective power with this work, so that it's not just something that was coming out of Berrien County Health Department, but we also have buy-in from our community partners to help to sustain this work and also to push it forward."

Zaagman agrees that listening to women of color's pregnancy and birth stories is vital to reducing these disparities.

"We're doing a better job of actually getting real feedback from people who have experienced losses and experienced poor birth outcomes," she says. "There are 100 women who will have severe morbidity for every one woman who dies. There's a lot to be learned from deaths and the worst outcomes, but there's also a lot to be learned from outcomes that impact Mom's health or baby's health for the rest of their lives or for a significant portion of it."

Often overlooked: Indigenous mothers and infants

The ITCM Asabike Coalition is developing a toolkit for tribal leaders, health care providers, and families that will create systems change around birth equity; devise policies and procedures that incorporate Indigenous cultural practices and belief systems; and support access and equitable options that center the whole person and family, including culture and tradition, in the perinatal experience.

Nationally, Indigenous women are approximately three times as likely to die of pregnancy-associated causes as white women. Due to the small population size, data on Indigenous mothers and babies has not yet been reliably collected in Michigan — and mothers or babies are often reported as being white when they are actually Indigenous. So their numbers of deaths are most likely even higher.
Michelle Leask.
"This is one of the things we've been working on with the state and the U.S. government, especially those who are working in maternal child health and who are responsible for putting out these statistics," says Michelle Leask, ITCM Honoring Our Children project director. "A lot of times, they don't even track the Native American rates. You'll see Black and white and maybe Latino."

ITCM's birth equity work involves building better relationships with local health care systems where members of the 12 federally recognized Michigan tribes receive care. By encouraging these systems to provide culturally competent care, free of biases, Indigenous patients will not only receive better care but also feel empowered to utilize the natural supports that their tribal communities traditionally have offered.  

"The plan that ITCM created is really around a whole-person birth experience that holds tradition and culture at the center," Torres says. "They're really looking at how we can make changes within health care systems where, when Indigenous people are giving birth, there is respect in centering their cultural practices around birth and really thinking about how Indigenous ways of knowing can be incorporated into the Western ways that often are dominant in medicine."

Leask shares examples like giving the newborn a cedar bath, allowing the mother to bring their baby's placenta home for ceremonial burial, and allowing skin-to-skin contact between baby and parents as soon as possible after birth.

"The skin-to-skin contact has always been an important part of our culture," Leask says. "Now science is definitely catching up and saying, 'Yes, this is an important, valid thing for bonding.' But there are still some health systems, especially if the mom goes through a C-section or has other complications, where it doesn't happen and still could."

Because extended families take a more active role in the birth of a new baby, Leask would like to see hospitals recognize the value of those "aunties," grandmothers, and others offering laboring women emotional support.

"In our communities, traditionally, when a baby is born, it is a gift to the entire community. And everybody is excited about a new baby and everybody rallies around," Leask says. "We're doing a lot with trying to elevate prenatal and postnatal care, to elevate the role of birth workers and those that support families and young children — home visiting programs, early Head Start. We're making sure that our Native American communities have the resources for our families to be engaged in those kinds of programs and education."

"It is about building that community power and community engagement," Torres says. "It's making sure that it's not just organizations and agencies that are driving the work but that they're doing so in partnership with, and led by, the community members — the people, the families, that are experiencing these disparities."

A freelance writer and editor, Estelle Slootmaker is happiest writing about social justice, wellness, and the arts. She is development news editor for Rapid Growth Media and chairs The Tree Amigos, City of Wyoming Tree Commission. Her finest accomplishment is her five amazing adult children. You can contact Estelle at Estelle.Slootmaker@gmail.com or www.constellations.biz.

Photos courtesy of the subjects.