Multi-scale impacts of the Flint water crisis on maternal health disparities

Maternal health disparities are a growing health concern that disproportionately subject Black women to a three times greater risk of morbidity than White women. When factoring in an environmental hazard, the risk of morbidity for Black women nearly doubles. Maternal health disparities are defined by the difference in the rate of severe maternal morbidity (SMM) between Black and White women. The overall aim of this dissertation is to examine the impact across multiple geographic scales of an environmental hazard on maternal health disparities. A secondary aim is to identify key areas of interventions to reduce adverse outcomes. This dissertation has three independent but linked research objectives. The first objective is to examine the baseline trend of maternal health disparities in Michigan two years prior to the Flint Water Crisis (FWC). The second objective is to determine the impact of the FWC on maternal health of women in Flint, Michigan. The third objective is to examine the different perspectives on the quality of maternal health care services from women who gave birth in Flint post-FWC. The study timeframe overall is 2012 through 2017. Anonymized data was collected from the Michigan Inpatient Database System (MIDB) and used to address Study 1 and Study 2's objectives individually. For Study 3, I collaborated with an ongoing, community-based randomized control trial (RCT) to collect additional maternal health disparity data from their baseline survey. Each study was self-contained and deployed a range of statistical analyses including descriptive statistics, odds ratios, difference-in-difference (DID) models, and logistic regression analyses. At the broadest geographic scale, I found that the maternal health disparity trend in Michigan has increased over time. At the urban geographic scale, I found that despite an environmental hazard posed by the FWC and living within similar socioeconomic and demographic communities as White women, the burden of maternal health disparities still falls on Black women. At the individual scale, I found that Hispanic women had a greater experience of severe maternal morbidity than non-Hispanic women. I also found that Black women experienced discrimination within the maternal health care system despite delivering in a race concordant city more than White women. In conclusion, there are two driving factors across geographic scales that significantly impact a women's maternal outcome despite an environmental hazard: race and age. Thus, depending on the age range and if a woman identifies as Black, the odds of experiencing a SMM is significantly higher than a White woman in Flint even when accounting for multi-scale factors such as socioeconomic status, place of residence, community factors, delivering in a race concordant city, and the Flint Effect in the presence of an environmental hazard.