1. Rethinking the Hispanic Paradox: Favorable Low Birth Weight Outcomes Obscure a Hidden Epidemic of Large-for-Gestational-Age Births in Colorado University of Colorado Denver sharon.devine@ucdenver.edu Rethinking the Hispanic Paradox: Favorable Low Birth Weight Outcomes Obscure a Hidden Epidemic of Large-for-Gestational-Age Births in Colorado Sharon Devine, JD, PhD University of Colorado Denver sharon.devine@ucdenver.edu Table 2. Hispanic Paradox: Fully Adjusted Odds Ratios by Race/Ethnicity N=356,389 WhiteHispanicBlackOther LBW1.001.18 (1.13-1.23)2.16 (2.01-2.33)1.64 (1.52-1.77) Preterm1.00*1.01 (0.98-1.05)1.42 (1.34-1.51)1.16 (1.09-1.23) SGA1.001.18 (1.15-1.12)1.98 (1.86-2.09)172 (1.63-1.82) LGA1.000.95 (0.91-0.99)0.59 (0.54-0.65)0.68 (0.62-0.74) * Statistically insignificant. Objectives 1.To test the expected social gradient of health on 4 birth outcomes by race/ethnicity and to identify any paradoxical outcomes;. 2.To test the expected social gradient of health on birth outcomes by nativity of mothers of Mexican origin and to explore the healthy migrant and healthy immigrant hypotheses as explanations for any paradoxically better birth outcomes experienced by Mexican-born mothers; 3.To explore potential reasons for differential outcomes among Mexican-born mothers and U.S.-born mothers of Mexican origin.Objectives 1.To test the expected social gradient of health on 4 birth outcomes by race/ethnicity and to identify any paradoxical outcomes;. 2.To test the expected social gradient of health on birth outcomes by nativity of mothers of Mexican origin and to explore the healthy migrant and healthy immigrant hypotheses as explanations for any paradoxically better birth outcomes experienced by Mexican-born mothers; 3.To explore potential reasons for differential outcomes among Mexican-born mothers and U.S.-born mothers of Mexican origin. Background: The Hispanic Paradox An extensive and sometimes contentious literature suggests that Hispanic mothers deliver “healthier” babies than should be expected based on the social gradient of health. Critics argue that “Hispanic” does not represent a homogenous ethnicity and must be broken down by country of origin. Others suggest that the paradoxically better outcomes are attributable to foreign-born immigrants and a “healthy migrant” selection bias or “healthy immigrant” effect based on better health behaviors than U.S. born women of the same ethnicity. The paradox has been tested primarily using low birth weight. Background: The Hispanic Paradox An extensive and sometimes contentious literature suggests that Hispanic mothers deliver “healthier” babies than should be expected based on the social gradient of health. Critics argue that “Hispanic” does not represent a homogenous ethnicity and must be broken down by country of origin. Others suggest that the paradoxically better outcomes are attributable to foreign-born immigrants and a “healthy migrant” selection bias or “healthy immigrant” effect based on better health behaviors than U.S. born women of the same ethnicity. The paradox has been tested primarily using low birth weight. Methods Design: Design: Mixed method design with quantitative analysis predominant; qualitative interviews and analysis to explore quantitative findings. Outcomes Outcomes Low birth weight ( 90th percentile weight for gestation). All outcomes have similar adverse sequelae over the life course. Quantitative data: Quantitative data: All singleton births reported in the official birth records of Colorado during 2000 through 2005 (N=356,389) testing differences by race/ethnicity; N=85,775 testing differences by nativity of mothers of Mexican origin. Multiple logistic regression using block entry of variables to test various hypotheses. Interview sample: Interview sample: 15 interviews. 5 key informants including a Mexican- trained physician working in the U.S., a U.S.trained OB/GYN working in a public safety net hospital in Colorado, a midwife serving Hispanics in Colorado, an RN working in the Nurse Family Partnership in Colorado, and a research physician studying biological mechanisms associated with delivery of large-for-gestational-age babies. 10 interviews with new mothers of Mexican origin, 5 born in the U.S. and 5 born in Mexico.Methods Design: Design: Mixed method design with quantitative analysis predominant; qualitative interviews and analysis to explore quantitative findings. Outcomes Outcomes Low birth weight ( 90th percentile weight for gestation). All outcomes have similar adverse sequelae over the life course. Quantitative data: Quantitative data: All singleton births reported in the official birth records of Colorado during 2000 through 2005 (N=356,389) testing differences by race/ethnicity; N=85,775 testing differences by nativity of mothers of Mexican origin. Multiple logistic regression using block entry of variables to test various hypotheses. Interview sample: Interview sample: 15 interviews. 5 key informants including a Mexican- trained physician working in the U.S., a U.S.trained OB/GYN working in a public safety net hospital in Colorado, a midwife serving Hispanics in Colorado, an RN working in the Nurse Family Partnership in Colorado, and a research physician studying biological mechanisms associated with delivery of large-for-gestational-age babies. 10 interviews with new mothers of Mexican origin, 5 born in the U.S. and 5 born in Mexico. Table 1. Data Elements Entered by Block Block 1- Race/Ethnicity (N=356,389)N% Non- Hispanic White219,02961.46% Hispanic106,29129.82% Black/African American15,4484.33% All Other15,6214.38% Block 1 - Nativity of Mexican-Born Mothers (N=85,755) Mexican-born53,27162.12% U.S.-born32,48437.88% Block 2 - Sociodemographic Factors 100% data for all cases analyzed Age, parity, education, marital status, adequacy of prenatal care, and altitude of residence of mother Block 3 - Pregnancy-Related Medical Conditions One or more of 22 medical risks or conditions Block 4 - Health Behaviors Smoking, drinking alcohol, weight gain during pregnancy Conclusions  Although the “Hispanic Paradox” exists for Mexican-born mothers in Colorado for low weight birth outcomes, it does NOT hold for large-for-gestational-age births.  The idea of the paradox has outlived its usefulness; it can dangerously mask adverse outcomes among the same population.  Neither the Healthy Migrant nor the Healthy Immigrant hypotheses explain birth outcomes among mothers of Mexican origin in Colorado.  Interviews with mothers of Mexican origin identified abrupt changes for the worse in diet and exercise levels upon immigration; prenatal care and WIC need to address these contributors to LGA.Conclusions  Although the “Hispanic Paradox” exists for Mexican-born mothers in Colorado for low weight birth outcomes, it does NOT hold for large-for-gestational-age births.  The idea of the paradox has outlived its usefulness; it can dangerously mask adverse outcomes among the same population.  Neither the Healthy Migrant nor the Healthy Immigrant hypotheses explain birth outcomes among mothers of Mexican origin in Colorado.  Interviews with mothers of Mexican origin identified abrupt changes for the worse in diet and exercise levels upon immigration; prenatal care and WIC need to address these contributors to LGA. Table 5. Odds Ratios of Outcomes of Mothers of Mexican Origin by Nativity N=85,775 Model 1 Nativity Model 2 Add Demographic & SES Block Model 3 Add Medical Risk Block Model 4 Add Health Behavior Block LBW U.S.Born1.00 Mexican Born0.73 (0.69-0.77)*0.95 (0.85-1.07)*0.91 (0.81-1.02)*0.93 (0.83-1.05) Preterm U.S. Born1.00 Mexican Born0.80 (0.76-0.84)1.14 (1.01-1.30)*1.08 (0.96-1.23)*1.08 (0.95-1.23) SGA U.S. Born1.00 Mexican Born0.72 (0.69-0.75)0.73 (0.70-0.77)0.73 (0.70-0.76)0.74 (0.71-0.78) LGA U.S. Born1.00 Mexican Born1.53 (1.44-1.63)1.43 (1.44-1.63)1.41 (1.32-1.52)1.45 (1.35-1.55) Social Gradient Hispanic mothers have the worst social profile of all groups, even worse than Blacks: More teen births Lower levels of education Less prenatal care More medical risks Higher rates of low weight gain But for the Hispanic Paradox, we would expect outcomes worse than those of Whites and more like those of Blacks. But that’s not what we see. Social Gradient Hispanic mothers have the worst social profile of all groups, even worse than Blacks: More teen births Lower levels of education Less prenatal care More medical risks Higher rates of low weight gain But for the Hispanic Paradox, we would expect outcomes worse than those of Whites and more like those of Blacks. But that’s not what we see. 0 0.5 1 1.5 2 2.5 LBWPretermSGALGA Birth Outcome Odds Ratios White Hispanic Black Other Expected Outcomes If the Health Migrant (selection bias) theory is valid, we would expect tchange in odds ratios between Models 2 and 3. If the Health Immigrant (healthy behaviors) is valid, we would expect tchange in odds ratios between Models 3 and 4. We see no statistically different change in odds for LBW, Preterm birth, and SGA. The paradox exists but is not explaned by these theories. We do not see the paradox for LGA. Mexican born mothers have 45% higher odds that U.S. born mothers of Mexican origin. But this result is not simply a shift in the population curve of birth weights, because Mexican born mothers have better odds of having an appropriate-for- gestational-age baby (1.08 [1.04-1.12]). Expected Outcomes If the Health Migrant (selection bias) theory is valid, we would expect tchange in odds ratios between Models 2 and 3. If the Health Immigrant (healthy behaviors) is valid, we would expect tchange in odds ratios between Models 3 and 4. We see no statistically different change in odds for LBW, Preterm birth, and SGA. The paradox exists but is not explaned by these theories. We do not see the paradox for LGA. Mexican born mothers have 45% higher odds that U.S. born mothers of Mexican origin. But this result is not simply a shift in the population curve of birth weights, because Mexican born mothers have better odds of having an appropriate-for- gestational-age baby (1.08 [1.04-1.12]).