Right Start in Michigan’s Legacy Cities: Inequity Begins at Birth

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As Michigan retools for a post-industrial economy, it must address the needs of its legacy cities. These cities have borne the brunt of the state’s long sustained economic decline and dwindling resources, but they continue to be the home for a substantial share of young children. On a range of indicators of maternal and infant well-being babies born to women living in these cities are much worse off than those born in the out-county areas.

Substantial numbers of children are affected. In 2012 roughly one-quarter of all newborns in the state were born to mothers living in these 15 cities across the southern half of the state.1 On average, one of every three county births was to a legacy city resident. To improve the lives of young children, the well-being of mothers and infants in these cities must be addressed.

Despite their decline, these 15 cities still have the largest number of births among the cities in their counties.2 While Detroit had by far the largest number of births (over 10,000) among the cities, representing slightly less than half of all births in Wayne County, the cities of Lansing (Ingham) and Battle Creek (Calhoun) had the majority of births in their counties. Clearly the fate of these legacy cities not only affects the current and future well-being of many children but also the social and economic fate of the state.

Racial/Ethnic Diversity is Concentrated in Michigan’s Legacy Cities and Their Counties.

The diversity of Michigan’s newborns is concentrated in its 15 legacy cities and their counties. While these cities have only 18% of the total state population, they house one-quarter of all births and half of all infants born to mothers in communities of color. Furthermore, almost all (90%) of the state’s infants born to women of color were located in the 15 counties where Michigan’s legacy cities are situated.

In four of the 15 Michigan legacy cities, the majority of infants were born to women of color, and almost all the legacy cities experienced an increase in minority births between 2006 and 2012. Only Grand Rapids, Holland and Ann Arbor experienced slight decreases over the trend period.3 While the state’s largest city, Detroit, had the largest concentration of infants born to women of color—over 90%, Warren in Macomb County sustained the steepest jump (70%)—minority births rose from 22% to 38% of all births.

While the percentage of infants being born to women of color increased in the legacy cities, the overall number of births decreased with the largest declines occurring in the cities of Muskegon and Jackson where births dropped by roughly one-third between 2006 and 2012. Warren, with the largest increase in diversity among its infants, experienced the smallest drop in its births—only 4%.

Women Giving Birth in the Legacy Cities Are More Likely to be Uninsured and Low-Income.

The trends in the numbers of births, the racial/ethnic diversity and economic status of mothers of newborns all shape the well-being of the next generation. Women residing in the legacy cities were much less likely to have health insurance and incomes adequate for basic needs. In 2012 just over three of every five women who had a baby while living in one of the legacy cities qualified for Medicaid compared with two of every five in the out-county areas in the 15 counties. While income eligibility for Medicaid extends to almost double the poverty level (185%) for uninsured pregnant women, coverage for the mother at this income level ended six weeks after delivery and for the baby after the first year of life.4

Access to health care for women will significantly improve under the Affordable Care Act that requires comprehensive services, including preventive services at no cost and maternity benefits that have not been generally included in private coverage. The Healthy Michigan Plan will provide comprehensive coverage, including dental and vision, with minimal copays for those with income up to 133% of the federal poverty level.5 For women with income above that level, coverage is available through the market place with sliding scale premiums and cost-sharing subsidies.

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Overview of Maternal/Infant Well-Being in Michigan’s Legacy Cities.

Michigan’s legacy cities have many characteristics in common but the ranges on the following eight key measures for maternal and infant risk (see table above) also reflect substantial differences among the cities. For example, Ann Arbor had lower risk on most measures than those in the out-county. In contrast, the cities of Pontiac, Flint and Detroit have some of the highest levels of risk for mothers and infants among the cities and were worse on every measure than their out-county areas.

Overall, the legacy cities had worse outcomes than their out-county areas on the eight key measures of maternal and infant well-being tracked in this report. Three indicators reflected dramatically worse conditions for mothers.6 Compared with infants born to women from out-county areas, those in the legacy cities were:

  • more than twice as likely to be born to women without a high school diploma or GED,
  • roughly twice as likely to be born to a teenager and
  • nearly twice as likely to be born to a single parent.

In contrast, a legacy city infant had only a 20% higher risk than an out-county peer of being born too soon. These inequities in birth circumstances get amplified as children spend their growing up years in communities with sparse resources and intensify over time as fewer state-supported early prevention and intervention programs are available.

Trends in maternal and infant well-being moved in the same direction for the legacy cities and their out-county areas, only the changes are more dramatic in the cities on four of the five measures.7 Only the largest change in the out-county areas—the 25% increase in births to single women—reflected a more substantial change than the cities.

Overall for both groups only two of the five risks—teen births and repeat teen births—have declined while percentages of unhealthy births and those to unmarried women have risen. The most disturbing finding was the dramatic (24%) increase in the percentage of babies born too soon among women in the legacy cities although the 15% average increase in out-county preterm births should also be a cause for concern. The next sections review each indicator in more detail across the 15 legacy cities.

1. Teen births declined in all but one legacy city.

The percentage of teen births averaged 13% of live births across the legacy cities, and the cities with the largest percentages –Saginaw, Detroit and Flint –reflected only slight decreases over the trend period.8 While it is troubling to see the minimal decline in teen childbearing in the cities with the largest percentages of births to this age group, some cities, such as Jackson, Bay City and Lansing experienced substantial progress on this measure between 2006 and 2012. Furthermore, among the legacy cities only Warren experienced an increase in its share of births to teens although it still had the second lowest percentage (9%). Ann Arbor had by far the smallest percentage of births to teenagers—only 2% compared with 9% in Warren (the second smallest percentage).

Large percentages of births to teenagers in a community strain resources as these young women and girls are also more likely to be single and lack a high school diploma or GED. Most will not be able to compete for a job that has a wage that will allow them to support themselves and a child. Low-income women struggle to afford child care. The average cost of infant care from a licensed provider in Michigan, ranging from $529 a month in a family home to $756 in a day care center, would consume nearly half or more of the gross income from a full-time minimum wage job ($7.40 an hour or $15,392 annual). Michigan’s child care subsidy program with its per-hour payments, administrative intricacies and low rates fails to assist most low-income parents.

2. In roughly half the legacy cities one of every four teen births was to a teen already a parent.

While having a baby as a teenager can pose a major hurdle to finishing an education and getting post-secondary training, a second or third baby further intensifies parental responsibilities that can interfere with school or work—critical activities for a successful transition to adulthood. The higher costs of child care for additional children may also present a significant barrier to securing work or going to school.

In seven of Michigan’s legacy cities roughly one of every four teen births was to a teen who was already a parent. The seven cities with the highest percentages of births to teens who were already parents were within a few percentage points. The city of Jackson had the worst rate with 26% of teens giving birth being parents while Bay City and Warren had the lowest percentages, 14% and 15% respectively—still substantially higher than the state average (9%).

Bay City had the largest decrease on this measure— 37% decline over the trend period— while Jackson and Battle Creek saw their rates bump up by 12%.9

3. Non-marital births rose in all but one legacy city

While the condemnation of child-bearing among unmarried women has eased compared with previous generations, children in mother-only families in Michigan face substantial challenges to their well-being. In today’s economy most families require more than one wage earner to meet the cost of basic needs such as housing, transportation and food. Numerous studies have demonstrated that an income of double the poverty level is required (roughly $36,000 for a family of three and $44,000 for a family of four). 10

Fathers who do not acknowledge paternity may not be involved in supporting their offspring financially. Lack of support from absent parents weakens economic security for single mothers and their children since women, especially mothers, earn less than their male counterparts in similar jobs. Furthermore single parents often struggle to combine job and parental responsibilities, particularly in low-wage employment.

Non-marital births are concentrated among younger women and those with a high school degree or less, who are more likely to work in these jobs that rarely offer any flexibility or vacation or sick time. Roughly 60% of Michigan women with a high school diploma/GED who gave birth in 2013 were single compared with only 10% of those with a bachelor’s degree. Half of women with less than a high school education lose their jobs or quit after having a baby.11

Finding or affording child care can be a challenge to sustained employment. The average cost of infant care, which requires a lower ratio per provider, can easily exceed over half the net income from a minimum wage job. Michigan’s child care subsidy payment falls well below the average cost and requires extensive online documentation by the parent and provider.

A growing number of young children live in single parent households, not only in the state but in the legacy cities. Births to single women increased between 2006 and 2012 in all legacy cities except Ann Arbor, with the largest increase (41% higher) occurring in the city of Warren. In the four cities with the highest rates, three or more of every four births were to unmarried women.

4. On average, roughly one of every five babies in the legacy cities was to a woman with no high school diploma or GED.

The four cities with the largest percentages of births to unmarried women also had the largest percentages of births to women who had no high school diploma or GED: one of every three newborns in Pontiac and Detroit was born to a mother without a secondary education completion credential. Ann Arbor had the lowest rate (3%) by far: The second lowest (15%) in Warren was five times higher.

Without strong programs to help these mothers continue or complete their education and gain some postsecondary training, they will be hard-pressed to earn enough to support themselves and their children. Their only options will be low-wage jobs with little or no flexibility, vacation or sick time so their ability to engage in the health and education needs of their children will be compromised.


 5. One of every four babies was born to women who smoked during pregnancy.

Michigan has one of the highest smoking rates in the nation (23% vs. 19% US) yet spends just over $ 1 million on prevention, and well over half of the funding for its prevention programs comes from federal funds. Even more disheartening, none of the $279 million from the tobacco settlement is allocated to staunch tobacco use and its deadly consequences on children and families. The Centers for Disease Control and Prevention recommends investing at least 15% of tobacco settlement funds in a well-sustained multi-media campaign, an approach that has demonstrated success.

Smoking endangers not only the health of the prospective mother by elevating her risk for cancer, heart disease and other health problems, but it also heightens the likelihood her baby may be born too soon, too small or have birth defects. Tobacco’s harmful chemicals such as tar, nicotine and carbon monoxide, reduce oxygen supply to the baby, slowing growth and development.

Secondhand smoke also harms mothers and children. It can precipitate respiratory ailments in infants and young children who live in homes where adults smoke. While roughly 22,000 Michigan women who gave birth in 2013 reported smoking during their pregnancy, in more than half these households someone else smoked as well. An additional 8,000 stated that although they did not smoke during the pregnancy, another adult in the house did. With more restrictions on smoking in public and work spaces secondhand smoke exposure has been drastically reduced for pregnant women and young children.

Bay City had the largest percentage of births to women who reported smoking during their pregnancies—roughly two of every five newborns were affected—while Ann Arbor had the smallest percentage (8%). Port Huron, Saginaw and Jackson also had relatively large percentages of births to women who smoked during pregnancy—with almost two of every five newborns affected.

6. One of every 20 Michigan mothers in legacy cities received late or no prenatal care.

Pregnant women who start prenatal care in the last three months of their pregnancy or not at all heighten their risk of having babies with health problems and suffering from complications themselves. Women who do not receive prenatal care are more likely to give birth to a low-birthweight baby. Unfortunately the women at highest risk of unhealthy births are often the least likely to have access to timely prenatal care. Multiple barriers such as lack of insurance, unintended pregnancy, limited access to transportation, variable work schedules and traditional clinic hours can stand in the way.

new chart 1The expansion of eligibility under the Healthy Michigan Plan to all state residents with incomes below 133% of the poverty level will provide low-income women better access to health services before pregnancy to address chronic conditions that can compromise a healthy birth. Similarly, residents with income above 133% of poverty level can access private coverage through the Health Insurance Marketplace with sliding scale federal subsidies and cost-sharing assistance.

Among the legacy cities Detroit has the highest rate of late or no prenatal care with roughly 1 of every 11 mothers of newborns affected. In Bay City the percentage of mothers with late or no prenatal care was one-third (3%) of the Detroit rate.

7. One of every 10 babies in Michigan’s legacy cities was born too small.

Babies who weigh less than 5 pounds 8 ounces at birth encounter heightened risk for developmental delay, chronic disease and even death. It is the leading cause of infant mortality among African American infants, who are roughly 2.5 times more likely to die before their first birthday compared with white infants. While chronic maternal health issues such as infections, diabetes, heart defects or kidney disease can result in an underweight infant, stress, poor nutrition and lack of social support during the pregnancy have also been identified as critical factors.

Although Ann Arbor had one of the smallest percentages of babies weighing less than 5.5 pounds, the city rate sustained the largest increase (27%) in its rate over the trend period. All but three legacy cities saw larger percentages of babies born too small. Among these three the city of Kalamazoo had the most substantial decline (20%), the Detroit rate improved only slightly (4%) and the Saginaw rate remained the same.

8. Roughly one of every eight babies in Michigan’s legacy cities was born too soon.

Babies born before 37 weeks in the womb are considered preterm and experience higher risk of intellectual disabilities, cerebral palsy, hearing loss and problems with breathing, vision and digestion than babies born at term. Prevention of premature delivery has become a major focus in efforts to reduce infant mortality. Babies born too soon are often too small as well.

All but two of Michigan’s legacy cities have preterm birth rates in the double digits, and most (11) saw sharply escalating rates over the trend period. In fact, in the two cities—Flint at 19% and Saginaw at 18%—with the highest rates, rates almost doubled between 2006 and 2012. Four of the five cities with the lowest rates experienced the most substantial declines, with Lansing having by far the largest drop (20%). The exception was Ann Arbor where the rate was still the lowest but had jumped up over the trend period.


As Michigan looks to strengthen its economy and improve education outcomes among the next generation, it must address the challenge of ensuring more infants have the right start to early childhood in its legacy cities. These cities house a significant number of young children, particularly some of the most economically disadvantaged and those in communities of color. Roughly half of the state’s children of color live within these cities.

The number of births in these legacy cities ranges from slightly less than 500 in Bay City and Port Huron to over 10,000 in Detroit, which represents 40% of all births in the legacy cities. On average, roughly one of every three births in the 15 counties is to a mother in the legacy city.

All of the legacy cities except Ann Arbor reflected worse outcomes across most or all indicators for mothers and their babies than for their counterparts in the rest of the county. Ann Arbor with its large public university and highly educated population is well-suited to compete in the emerging post-industrial economy. Overall Ann Arbor was an anomaly among the legacy cities in that on most (6) measures of maternal/infant well-being, the city was better than the rest of Washtenaw County: It matched the out-county rate only for late or no prenatal care and low-birthweight babies. The relative affluence of the city contrasts sharply with the average legacy city: Only 18 percent of the city’s women giving birth were uninsured and low-income, substantially below the legacy city average (63%).

Unfortunately several cities consistently fell on the other end of the range. Flint, Saginaw, Detroit and Pontiac were often those with the worst rates. For example, although Flint had the worst outcomes for babies born too soon or too small, Pontiac and Detroit had rates within 1 or 2 percentage points on both those measures. The cities with majority of births to women of color generally had the worst outcomes. Only the incidence of smoking during pregnancy deviated from this pattern with Bay City having by far the largest percentage of births affected, which was 6 percentage points above the next largest (43% vs. 37%).

Only two of the five indicators where a trend could be calculated showed improvement. The most consistent progress across the legacy cities was on the declining percentage of births to teens. Only Warren in Macomb County experienced a worsening trend. Similarly, only six cities sustained increased births to teens who were already parents. On the other hand, unhealthy births— babies born too soon or too small— increased over the trend period in 11 of the 15 legacy cities.12 These children are at higher risk for developmental delays, chronic health problems and even death as infants than children born at term with All cities except Ann Arbor sustained an increase in the percentage of births to unmarried women between 2006 and 2012.


Provide the funding to fully implement the strategies in the state’s Infant Mortality Reduction Plan. All of the indicators examined in this report reflect a risk to mother and infant, and several are addressed in the state’s Infant Mortality Reduction Plan 2012 that outlined eight strategies to reduce infant mortality in Michigan.13 The strategies include promoting safe sleep practices for infants, expanding home visiting to high-risk women and reducing unintended pregnancies. Unfortunately, in the last two budgets policy makers have allocated only a tenth of the funding required to fully implement the plan.

Coordinate efforts across state departments to address the social/economic determinants of health, especially in the target cities – Pontiac, Saginaw, Flint and Detroit. This recommendation from the Infant Mortality Reduction Plan focuses on the legacy cities that have suffered the highest risk to maternal and infant health in recent years. While several initiatives such as Project LAUNCH (Linking Actions for Unmet Needs in Children’s Health) in Saginaw, Sew up the Safety Net in Detroit, REACH (Racial and Ethnic Approaches to Community Health) in Flint and FIMR (Fetal Infant Mortality Review) teams in Pontiac address health issues, resources from other departments, including Human Services and Education, have key roles to play in improving maternal and infant well-being. Despite increasing focus on the social/economic factors that imperil maternal and infant well-being, policies, such as increasing the Earned Income Tax Credit and the Cash Assistance grant, to reduce poverty have not been widely supported by policy makers.

Strengthen work supports and education/employment opportunities. Many women struggle to find affordable child care, and the state’s child care subsidy rate is so far below the current market rate that it provides limited access to licensed care. Most center-based care does not accept infants and fails to meet the needs of low-income women working erratic schedules during evening and week-end hours. Increasing opportunities for low-income women to complete an education or training program so they can secure better-paying jobs with more flexibility would improve their lives and those of their children. Strengthening supports to family, friend and neighbor care would be a key strategy.

Invest the recommended amount in a smoking prevention campaign. The health of Michigan’s children and their parents is compromised by the prevalence of smoking among pregnant women and the other adults in the households of young children. Tobacco is the leading cause of preventable illness and death in the U.S.: It has been linked to several different cancers as well as chronic lung diseases such as emphysema and bronchitis, and heart disease. Secondhand smoke triggers numerous health problems in infants and children, including more frequent and severe asthma attacks, respiratory and ear infections, and sudden infant death syndrome (SIDS).

Support early interventions to improve maternal and infant health. During the first three years of life roughly 85% of the brain architecture is developed, which provides the foundation for lifelong learning.14 The quality of the interaction between the child and his/her caregivers affects the emotional and social well-being as well as cognitive development. Early interventions such as home visiting have demonstrated an impact on improving maternal and infant well-being and later outcomes such as high school graduation and employment. Michigan has been able to expand its home visiting programs dramatically through its successful applications for federal funds totaling $34 million authorized in the Affordable Care Act. State funding has been erratic for these efforts.

Legacy City Profiles:

Michigan | Ann Arbor | Battle Creek | Bay City | Detroit | Flint | Grand Rapids | Holland | Jackson | Kalamazoo | Lansing | Muskegon | Pontiac | Port Huron | Saginaw | Warren


  1. Only counties with total population over 100,000 and a central city were included in this analysis.
  2. Holland Township, which actually had the largest number of births in Ottawa County and a larger share of minority births than the city (44% vs. 38%), was not included as it is not a city.
  3. In Washtenaw County, Ypsilanti Township rather than Ann Arbor actually had a larger percentage of births to women of color (45%) and to low-income uninsured women (43%).
  4. Numerous cost of living assessments have determined that income below double the poverty level(200%) is insufficient to meet the average basic needs in the modern American economy. (Poverty level income is 100%.)
  5. Those with income between 100% and 133% of poverty must pay 2% of their income for their coverage.
  6. The legacy city average is calculated on the average for each city rather than the total births to counter the disproportionate impact from the large number of births in Detroit.
  7. Only five of the eight measures could be assessed for trends between 2006 and 2012 due to changes in the birth record in 2007 for data on education level of the mother, receipt of prenatal care and smoking during pregnancy. Each reported year in the trend analysis is based on a three-year average to stabilize the estimate.
  8. Please note that the percentage of teen births can be affected by increases or decreases in the number of births to women over the age of 19 as well.
  9. Ann Arbor did not have enough incidences to calculate a rate for this indicator in 2012.
  10. Full-time income from the current minimum wage of $7.40 falls more than $3,000 short of the poverty threshold for a family of three. By the time Michigan’s recent law to increase the minimum wage to $9.25 an hour in 2018 is implemented, its value will still remain below the poverty line, which rises with inflation.
  11. Liz Ben-Ishai. Access to Paid Leave: An Overlooked Aspect of Social and Economic Inequality. Center for Law and Social Policy. April 14, 2014.
  12. Only five of the eight measures could be assessed for trends due to changes in the birth record for data on education level of the mother, receipt of prenatal care and smoking during pregnancy. Each reported year in the trend analysis is based on a three-year average to stabilize the estimate.
  13. The plan is available on-line at http://www.michigan.gov/documents/mdch/MichiganIMReductionPlan_393783_7.pdf.
  14. Jack Shankoff. Center on the Developing Child. Harvard University.