Community

Needs Assessment
Nutrition Status and Healthy Pregnancies in Detroit
Mary Connolly
University of Michigan School of Public Health

Connolly
Introduction

Internationally the United States ranks poorly among its industrialized
international counterparts in maternal and child health ranking 126th in maternal
mortality rate and 167th in infant mortality rates according the to the CIA World
Factbook.1 This issue is due in part to a multitude of national health crises many stemming
from poor nutrition before, during and after pregnancy including: gestational diabetes,
anemia, hypertension, obesity, weight gain and inadequate infant feeding methods.2This
national crisis disproportionally affects women of minority and low-income groups of
which are in high population within city centers like Detroit. Within the city of Detroit the
overall infant mortality rate is alarmingly higher than the national average at 13.3 deaths
per 1000 births.3 Detroits maternal mortality rate, keeping with the trend is exceedingly
high at an average of six pregnancy-associated deaths per year.4 Conditions that can
contribute to these rates are gestational diabetes, obesity and hypertension. Sadly all of
these conditions often can be prevented and treated with nutritional intervention. In this
assessment we will look at pregnancy nutrition status in relation to maternal and infant
health outcomes within the city of Detroit. This will identify the potential need for more
nutritional resources to help support healthy pregnancies in Detroit.
Just within the state of Michigan infant mortality rates are at 6.9 deaths per 1000
births compared to the national average of 6 with a glaring race disparity of 13.1 deaths in
black infants compared to 5.7 of white infants in 2013.5 In addition to infant mortality
Michigan has the 8th highest pregnancy related maternal mortality rates within the
country.6 Nutritionally, pregnant women in Michigan experience higher percentages of
excessive weight gain during pregnancy, higher rates of anemia, and slightly higher rates
of obesity.7 While nutrition is only a small way to combat maternal and child death it can
greatly improve quality of life and reduce risk of mother and child developing chronic
diseases, especially in Detroit where there is so many other environmental hazards
threatening pregnancy health every day.
Most of these risks are solely due to city infrastructure like lack of sidewalks,
exposure to industry pollutants, social stress, and inadequate healthcare services. In
conjunction with environmental stressors Detroits population is also largely comprised of
minority populations, many of which have greater risks of developing harmful conditions
during pregnancy from exposure to more stressors. Michigan Department of Community
Health reported that in 2008 black women were exposed to 3 or more stressors more
often than white women. Education also played a major role in exposures to stressor for
pregnant women in Michigan 65.6% of women who did not finish high school were
exposed to three or more life stressors.
All these stressors are often out of womens control, but maintaining a healthy diet
is within their control if given the proper resources. Proper prenatal nutrition not only
lowers the risk of maternal complications during pregnancy, it can help to support a
healthy weight for the child which lower its risk for chronic diseases and obesity later in
life. By assessing the prevalence of healthy pregnancies in Detroit important information
on what nutritional support may be needed for women in Detroit to have access to all the
tools to maintain a healthy and full term pregnancy.

Connolly

Demographics

Detroit spans across 138.75 square miles and houses 680,250 residents and has
seen a rapid decrease in the population since its population peak in the 1950s as
illustrated in Figure 1.

Figure 1 taken from:

http://archive.freep.com/interactive/article/20130723/NEWS01/130721003/detroit-
city-population)

The female population makes up 52.7% of the population with women of childbearing
year (15-44yrs) making up approximately 21% of the population. Detroit is a younger
population with a median age of 34.8 years old compared to the state at 38.9. 8The
predominant ethnicity in Detroit is black at 82.7% of the population followed by white at
10.6% of the population and those of Latino or Hispanic race at 6.8%9 Detroit is unique in
its ethnic distribution with a black dominated population compared to the statewide
distribution which is predominately white with a minority of black and Asian residents as
shown in Figure 2.

Connolly
Figure 2 taken from:
http://milmi.org/admin/uploadedPublications/2343_Detroit_City_Demographic_and_Lab
or_Mkt_Profile.pdf

















Figure 3 taken from:
http://milmi.org/admin/uploadedPublications/2343_Detroit_City_Demographic_and_Lab
or_Mkt_Profile.pdf

Among Detroits population 21.4% of the population 25 years and older have not
achieved a high school diploma, 32% have a high school education, 33.5% have some
college, 7.6% have a bachelors degree and only 5.4% have a post graduate degree. The
combined population of people that do not have
higher than a high school diploma in Detroit is
higher than the state proportion at 53.4%
2015 Federal
compared to 40.3% .10 The dropout rate for
Persons in Poverty Level threshold
household 100% FPL
black males is especially high with only a 54.6%
1
$11,770
graduation rate compared to the 69.8% rate of
black girls. 11 More than 50% of the working
2
15,930
population in Detroit holds an associates degree
3
20,090
or less, Figure 3 contains the entire breakdown
4
24,250
as of 2011. Pre-term births are less prevalent in
women with higher education levels, but as of
5
28,410
2009 29 % of heads of household in Detroit did
6
32,570
not hold high school diplomas.12 The most
commonly used language in the home is English,
7
36,730
but 11% of children and 6% of adults speak
8
40,890
Spanish at home in the Detroit-Warren-
Dearborn area which is double the statewide rates.

The dominating industry of both residents and commuters in Detroit is health care
and social assistance followed by manufacturing and retail. The majority of the citys
working residents are black (77%), however, the majority of commuters (55.8%) are

Connolly
white. There is also a significant gender gap in the workforce in Detroit with women
making up the majority of the resident workforce (58%).13 It is important to note that the
majority of the jobs in Detroit are concentrated in the midtown region, but the city
workforce residence is spread throughout the entire span of the city. Unemployment rate
was at 14.9% in 2014, more than double the Michigan average of 7.2% and the national
average of 6.1%. Detroit also had a poverty level that was over two times the state
national average at 39.3% of the population live compared to 16.8%, figure 4 breaks down
the federal guidelines used to determine poverty level.
The median household income in Detroit from 2009-2013 was $26,325, a little more than
half of the statewide average of $48,411 and the national average of $53,046.14 The
average persons per household in Detroit were 2.7 in 2014, which is only slightly higher
than the state average of 2.53. Of those households, unmarried women ran 43%, which is
more than double Michigans rate at 17%. The percent of married couples in Detroit
households is 27%, about half the rate in Michigan at 59%.

Health Statistic Data


The leading cause of mortality in Detroit in 2013 was heart disease, followed by
cancer and accidents as shown in figure 5. This reflects the causes of mortality in the entire
state of Michigan closely as shown in figure 6. For individuals under the age of 25 the
leading cause of death shifts to unintentional injuries accounting for 19% of deaths in
Detroits population under 25. After 25 the leading cause of death stays consistent to heart
disease.15 Split between men and women Detroit mortality rates in 2013 were fairly even,
with the exception of men accounting for 66.1% of unintentional injuries, 84.2% of
suicides and women accounting for 69% of deaths from Alzheimers disease as shown in
figure 8. Wayne County (including Detroit) in 2013 ranked last in the community health
rankings report in both health outcomes and health factors. Health outcomes were
measured according to mortality and morbidity data and health factors was determined
based on a multitude of factors including tobacco use, diet and exercise, alcohol use, and
sexual activity.16

Connolly

Figure 5 taken from:
http://www.mdch.state.mi.us/pha/osr/chi/deaths/frame.asp?Topic=7&Mode=1

Figure 6 taken from:
http://www.mdch.state.mi.us/pha/osr/chi/deaths/frame.asp?Topic=7&Mode=1

Connolly

Infant mortality rate in Detroit was 13.3 deaths per 1000 births in 2013, more than
double the state and national average. There is a clear racial disparity in the state of
Michigan in infant mortality, the adjusted rate for white people in Michigan is 5.7 and for
black people the rate is 13.1.17 Figure 9 illustrates these rates in comparison to the
national averages over the past 20 years. According to the Healthy Michigan Low birth
weight is the leading cause of infant mortality for both black and white infants in Michigan,
it affects black infants much more than white infants. Low birth weight is defined as any
live birth resulting in an infant weighing less than 2500 grams. During the past decade,

black infants have been four to five times more likely to die of this condition than white
infants. Live births to black mothers in 2001 had the highest proportion of LBW, 14.2%,
compared to white (6.7%), American Indian (8.3%), and Asian mothers (7.7%)
respectively. Mothers with inadequate prenatal care had 13.7% incidence of LBW in 2001
while those with adequate care had 7.2%.18 Table 10 shows the percent of low birth
weight babies by race from 2010-2012.

Connolly


Figure 9 adapted from: "Number and Rate of Infant Deaths by Race, Michigan and US."
Number and Rate of Infant Deaths by Race, Michigan and US. Accessed November 7, 2015.
http://www.mdch.state.mi.us/pha/osr/InDxMain/infdx.ASP.









Figure 10 taken from: http://datadrivendetroit.org/birthrate/moms-place-and-low-
birth-weight-part-1-detroit/

In Detroit the rate of children born to teen mothers was 36 for every 1000. 19
Children with teen parents face an increase risk of preterm birth and fetal distress. Over
100,000 people in Detroit remain uninsured and in Wayne county 7.9% of pregnant
women never receive medical care during pregnancy.
Detroit has the second highest prevalence of obesity in the state of Michigan at
38.1% and in 2008 black females had the highest obesity rates out of any race and sex
group in the state. In 2008 obese individuals had the highest rates of asthma, angina,
stroke, diabetes, and inadequate sleep. Obesity is linked to greater ricks in complications
during pregnancy including preeclampsia, gestational diabetes, stillbirth and cesarean
delivery. 20 PRAMS 2001-2005 data found that women 28% of women at obesity status
had cesarean deliveries compared to the 17.5% at healthy weights.21 Obesity is caused by
factors including nutritional status, physical exercise habits, and genetics. Only 19.5% of
Michigan residents met the aerobic and muscle-strengthening guidelines set by the CDC
and 24.4% do not engage in any kind of leisure time physical activity. According to
Michigan PRAMMS 2008 18.3% of women who were uninsured were also obese, the
numbers were not available for cross sectional link age, obesity status, and insurance
coverage.
Michigans rate of gestational diabetes was 6.9% in 2012-2014, gestational diabetes
is often found at about 24 weeks of pregnancy and is more prevalent in women of color.
Gestational diabetes increases the infants risk of becoming overweight or obese during
childhood and adolescence. Women with gestational diabetes have an increased risk of
having a cesarean, preeclampsia, and development of permanent type 2 diabetes. GDM can
be diagnosed with an oral glucose tolerance test (OGTT). GDM is diagnosed if two or more
plasma glucose levels meet or exceed the following thresholds: fasting glucose
concentration of 95 mg/dl, 1-hour glucose concentration of 180 mg/dl, 2-hour glucose
concentration of 155 mg/dl, or 3-hour glucose concentration of 140 mg/dl.22
Detroit women had 10% incidence of hypertension during pregnancy, this is in line
with the state average of 10.1%.23 Hypertensions is especially dangerous because it puts
the expecting mother at risk of preeclampsia, or high blood pressure during pregnancy

Connolly
which can lead to preterm delivery, maternal stroke and death. Hypertension can increase
maternal risk of developing gestational diabetes.24

Nutrition Assessment Data


According to Michigan WIC Pregnancy Nutrition Surveillance 15.9% of women took
a multivitamin daily before pregnancy, but during pregnancy 83.8% of women added
taking a multivitamin to their daily regimen. Compliance with a routine of multivitamin
consumption during pregnancy can help reduce infant birth defects, maternal anemia, and
provide diet in nutrients that are harder to adequately consume with diet alone like folic
acid, calcium, and iron. Most prenatal vitamins contain essential nutrients that may be
missing from an expecting mothers diet like folic acid, calcium, iron, iodine, vitamin B6
and omega 3 fatty acids. According to the National Health and Nutrition Survey (NHANES)
the median for all pregnancies in 2005-2010 was less than adequate in iodine
concentrations (>129 g/L).25 Statewide Michigans prevalence of anemia was high in
2014 at 10.1% in the first trimester, 15.4% in the second, 39.6% in the third, and 28.7%
postpartum. Inadequate intakes of iron can lead to fatigue, infection, preterm birth, and
low birth weight.

Figure 11taken from: http://www.mdch.state.mi.us/pha/osr/natality/tab1.2.asp

According to the Michigan Department of Community Health (figure 11) only
17.4% of women age 18-24 self reported adequate fruit and vegetable consumption in
2008 this age group makes up for about 24% of Michigan women who gave birth in
2013.26 In Detroit 18.3% of the adult population consumed 5 or more servings of
vegetables a day, which is higher than the state average of 16.6%. In Michigan women had
higher rates of fruit and vegetable consumption at 19.7% of the population consuming 5 or
more servings per day. 27 A larger portion of the statewide population ate less than one

Connolly
fruit (37.7%) and less than one vegetable (24.8%) in 2013. In 2005 80% of Michigan
adults visited a fast food establishment at least once a month and 28% went two or more
times a week.28
This lack of adequate consumption may be due to built environment. Of Detroits
food retailers only 8% can be considered mainstream grocery retailers, the other 92% is
comprised of liquor stores, pharmacies, gas stations, dollars stores and other convenience
stores. These liquor and party stores accounts for the greatest number of food stamp
retailers in Detroit, figure 12 illustrates the entire spread of food stamp retailers in Detroit
and figure 13 shows the geographic distance of Detroit neighborhoods from full service
supermarkets.29

Figures 12 and 13 taken from: "Detroit Food Desert Report." 2007. Accessed November
8, 2015.30

Detroit has a poor walk score of 52 (100 being the best) meaning that most amenities are
not accessible by foot. 30 This includes grocery stores and healthcare clinic where many
women receive their pregnancy check ups.

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Connolly
Community Assets and Existing Services

Despite Detroits lack of environmental and built resources there is a robust
network of resources for expecting mothers. There is two WIC (Women Infants and
Children) offices in Detroit which offers supplemental nutrition for women, infants and
children five years and younger. WIC also offers nutrition education on topics like breast-
feeding, infant and toddler feeding, prenatal weight gain and anemia and iron deficiency.
High-risk patients are offered individualized counseling and WIC participants are provided
health care referrals and connections to social services if needed. WIC participants have
improved dietary intake, lower incidence of low birth weight babies, and lower infant
mortality than other Medicaid beneficiaries.31 Medicaid is also available to Detroit mothers
in need of insurance after becoming pregnant. Medicaid for pregnant women is available
for the duration of their pregnancy and two months after their delivery.32 Access to regular
doctors visits is vital to a healthy pregnancy so doctors can assess risk factors early and
make the necessary steps to curb the risk of mothers developing conditions like GDM and
hypertension.
In addition to government resources there are many community-based ventures
like the Women Inspired Neighborhood center (WIN). WIN offers comprehensive support
and resources to expecting mothers that extends beyond just food resources and gives
mothers access to community support they may not have received otherwise. WIN has an
abundance of online resources detailing basic physical exercises during pregnancy,
healthy eating guidelines, and advice on how to navigate financing healthcare during
pregnancy. WIN also offers help in creating a supportive community that can allow women
the resources and flexibility to commit to healthy lifestyle choices during
pregnancy.33Women who already have children can also attend meetings like Parent
Anonymous Support Group through Detroit Parent Network, which provides a safe space
for women to talk to others about their concerns and free childcare during each event.34
Focus: Hope in Detroit also offers Doula support and breastfeeding counseling which can
also help lead to the success of a pregnancy as well as food supplies for both women and
children under the age of six.35 For emergency food support GLEANERS food bank can and
332 other food pantries are available for pregnant Detroiters.36Health Emergency Lifelines
Programs (HELP) is also available for women in need of food vouchers and dietary
supplements, especially expectant mothers who are HIV positive.37 The Community Health
and Social Services Center also provides prenatal care for expectant mothers including
physical exams, weight checks, blood pressure, laboratory screening, and fetal assessment.
First time moms in this program can be eligible to Doula services up to six months post
partum.38
Besides supportive resources Detroit there are food distribution options. Six of
Detroits farmers markets accept SNAP, WIC, and participate in double up food bucks a
Michigan program that rewards bridge card holders for buying Michigan local produce by
matching what the person spends up to $20, so the card holder gets up to $20 more
groceries. The participating farmers markets are: Eastern Market, Northwest Detroit
Farmers Market, Sowing Seeds Growing Futures Farmers Market, Wayne State University
Farmers Market, Oakland Avenue Farmers Market, and Islandview Farmers Market.39
Local urban garden networks supply many of these markets like Feedom Freedom and

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Connolly
Keep Growing Detroit that supply community members with tools to produce their own
food instead of relying on the unpredictable cooperate food system in Detroit.40

Discussion

There is no specific measurement of a healthy pregnancy, but through study of
maternal and child mortality, nutrition assessments, and access to healthcare it can be
reasonably concluded that Detroit is rating poorly in prenatal care. Detroit is a unique city
with a tumultuous history of racial tensions and economic hardships. The city itself is in
disrepair with over forty square miles of vacant land, which is enough to fit the entire city
of San Francisco.41 It has the third highest arson rate in the country at 136 arsons per
100,000 people and 14,500 violent crimes committed in 2013.42 43 Detroit is highly
segregated between blacks (the majority) and whites rating a dissimilarity index of 73.5
with 0 indicating complete integration and 100 indicating complete separation.44
Since 1990 Detroit has lost over 67% of its primary care physicians due to
suburbanization and economic hardship, but maintains the highest chronic disease rates
in the metro area.45 Figure 14 highlights the disparities in chronic disease prevalence in
2010.

Figure 14 taken from:
https://www.henryford.com/documents/CommunityHealth/2013%20HFHS%20CHNA_Fi
nal.pdf

Detroit had the highest rats of arthritis and cardiovascular disease out of any other county.
Cardiovascular disease can be combatted with exercise and healthy diet; unfortunately
with Detroits high crime rate and lack of community spaces there are not many options
for outdoor physical activity. In 2013 the city closed over 50 parks leaving them to
dangerous disrepair and chose only 19 premier parks to continue maintenance on. This
means that in 2013 there was one park for every 12,280 residents.46

Despite the decreasing rates of outdoor recreational space Detroit has a booming
urban farming and gardening movement that has led to the development of over 1,300
gardens in Detroit. Community members and local nonprofits that seek to bring food
security to Detroit through local food production support these gardens. These

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movements are gaining important public recognition on the food security issue in Detroit,
but there is some concern over the safety of these urban farms. Many of these gardens sit
on vacant land that used to have a home or other building structure that has since been
torn down. These previous structures could have left behind toxic chemicals and metals
like lead and arsenic in the soil that is now being used to provide communities that already
have higher rates of chronic diseases with food.47

What does all this have to do with healthy pregnancies? Studies done in 2014
showed that African American women with high stress often have worse birth outcomes.
The sources of stress were racial discrimination, neighborhood, job or financial, and the
woman's network (family members, friends).48 Chronic stress can lead to excessive
production of cortisol, epinephrine and norepinephrine, which could cause preterm labor
and compromised immune response.49 Figure 15 shows the number of hardships during
pregnancy broken down by percent federal poverty level.

Figure 15 taken from:
http://www.unnaturalcauses.org/assets/uploads/file/Braveman_NIH_Summit_12-12-
08.pdf

Addressing these issues in conjunction with healthy pregnancies is key to creating
recommendations that include holistic care plans for pregnant women. Nutrition in any
situation is just the tip of the iceberg with health comes; it is rarely the sole cause of a
health issue with exception to cases of vitamin deficiency.

Recommendations

These findings suggest several key factors in improving the nutritional health of
pregnant women in Detroit. There are many steps that need to be taken to create
observable change in the community, though as stated earlier nutrition is just a small part
of the infant mortality crisis in Detroit. First based on the findings more than just high risk

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women need nutritional counseling with a goal of increasing maternal consumption of
fruits and vegetables. Through cooperation with Detroit public schools nutrition education
needs to begin in the classroom not just through provision of healthy food services but
also through classroom instruction on healthy diets. Through participation in cooking,
growing and consumption of food children can learn early the power food has on quality of
life. This is a long term goal with the hope that eventually Detroits population may be
equip with the tools to maintain healthy prenatal nutrition care on their own. More
immediately expectant mothers need to be provided with personalized nutrition
counseling as early as their first check up to ensure optimal prenatal nutritional health
through to help prevent GDM, hypertension and fetal abnormalities so nutrition can act as
a preventative health measure, instead of a way to curb a developed condition like
gestational diabetes.
Continuing to support local groups like WIN could help improve not only the health
status of pregnant women, but also all women. This is in mind city support of programs
like Keep Growing Detroit, Detroit Food Justice Task Force and Detroit Food Policy council
will equip community members with the tools to support healthy households. These
organizations support nutrition education, participation in urban agriculture and teach
value skills like cooking and food preservation that can help mothers and fathers provide
balanced meals to their children.
Nutrition education is vital to the continued care of a pregnancy, but what is most
vital is that women have access to the resources needed. It is recommended that the city
do a full assessment on public transportation efficiency and that local NGOs work with
partners to provide rides to women around the community to their doctors and grocery
store of choice. These non-profits also need to address the issue of childcare, as 43 percent
of the households in Detroit are single mother homes. Mothers need to be allowed
childcare on days she had appointments and they cannot always rely on the thinly spread
community. The city also needs to address the issue of food insecurity, it has already been
identified that persons of color living below the poverty line are the most vulnerable to
changes in food availability. Now that the individuals in needs have been identified
providing food resources like food pantries and soup kitchens can allow some in this
group, including mothers, maintain a healthy lifestyle. Most people signed up for SNAP
benefits are within 1 mile of a SNAP office, further outreach to people farther from these
offices need to be made.
Another huge issue in Detroit pregnancies is the prevalence of overweight and
obese women who have an increased risk of complications during pregnancy. Aside from
changes in built environment community groups and support are needed to begin to
combat these rates. Group doctors visits and meetings are a good way to encourage
positive social pressure on women to maintain a healthy pregnancy.
Better compliance with prenatal vitamins is also needed considering the rate of
anemia and iodine deficiency in Michigan mothers. Offering free and readily available
prenatal vitamins could help with compliance as well as access to resources for many
Detroit women.
The most effective plan from supporting nutritionally healthy pregnancies would
be for Detroits Department of Community Health to conduct a comprehensive community
nutrition study. With the data available right now we know that nutrition status might play
a role in perinatal health and development of conditions like gestational diabetes, but

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there is no hard data to back up these claims. Modeling an initiative like Ypsilantis Health
Improvement Plan (HIP) to conduct phone surveys to understand Detroits unique health
culture would be a good start followed by more comprehensive testing for nutritional
biomarkers in Detroits population.
There is a clear and observable disparity between birth outcomes of black women,
which make up the majority of the population in Detroit, but there is no clear evidence that
there is one identifiable cause such as inadequate nutrition. Latina and Hispanic
populations have relatively good with outcome despite poverty status it is only when you
look at the US born black population that there is clearly unfavorable outcomes. Better
access to nutrition is not going to be the answer to lower maternal and infant mortality
rates in Detroit, but obtaining more comprehensive data on the average diet and
deficiencies of Detroits population may give us important incites to the social and physical
causes of poor pregnancy outcomes, particularly that of the black community.

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Appendix

Predominant Race by 2010 Census Tracks

Taken from :
http://www.newdetroit.org/docs/press/MetropolitanDetroit_RaceEquity_Report_NewDet
roit.pdf

16

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Proximity to Food Pantry among Michigan Low Income Households

Taken from: http://www.irp.wisc.edu/publications/focus/pdfs/foc321b.pdf

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