1. The Latina Infant Mortality Paradox: Explanations and a Policy Prescription Michael S. McGlade Department of Geography Western Oregon University

4. A Few Definitions: Latina: woman of Latin American origin, any race infant mortality: # deaths in first year per 1000 live births low birth weight babies (<2.5 kilos) are ~40 times more likely to die than normal birth weight babies preterm delivery (<37 weeks) is the principal determinant of low birth weight in the US Infant mortality is strongly predicted by low birth weight and preterm delivery.

5. Relevant Concepts in Social Epidemiology 1.All cause mortality is socially patterned: those of lower income, education, and job status have higher mortality. The Whitehall Study showed that there was a gradient of decreasing mortality from the bottom ALL THE WAY up the British civil servant hierarchy - highest level managers had lower mortality even than managers just below them. In the US, people at the bottom income rank have all-cause mortality rates three times those of people at the top. Behavioral factors don’t explain all of the difference.

7. Concepts (con’t) 2.Infant mortality and low birth weight show similar social patterning as all cause mortality. Parental higher income, education, and access to medical care are associated with lower infant mortality. 3.Modifiable risk factors for low birth weights are poor nutrition, stress and economic insecurity, lack of social support, substance abuse, and unsanitary environments. 4.Neonatal mortality (1 st 28 days) accounts for over half of infant mortality.

8. Concepts (con’t) 4. In high income countries, social factors are the largest predictor of mortality rates: In a California study of 401,399 white mothers, low income households had neonatal mortality 3 times that of higher income households.* *$11,000 and $25,000 were lower & upper cutoffs for median family income.

9. Latina mothers in the United States, compared with other major groups, have: lower income less formal education less access to medical care less access to prenatal care With other major ethnic groups, the above factors are predictors of higher infant mortality.

10. US infant mortality by race & ethnicity all combined: 6.9 White: 5.7 African-American: 13.5 American Indian: 8.3 Latina: 5.6 The unexpectedly favorable Latina outcomes have been referred to as an epidemiologic paradox.

11. Explanations of the paradox 1.The healthy migrant effect 2.Cultural protective factors are associated with a healthy context for reproductive outcomes. Associated behavioral advantages include healthier diets and lower rates of smoking, alcohol consumption, and drug abuse. Even controlling statistically for these factors, however, the paradox persists. 3.Social support

12. Some components of social support maternal grandmothers and other maternal figures helpful extended family members and friends life partners community-based parteras and health promoters others who provide a context for healthy maternity

13. Social support helps mitigate effects of life stressors provides role models for successful pregnancy outcomes enables pooling of household resources to mitigate effects of poverty The people and institutions that provide maternal support can be collectively thought of as informal systems of care.

14. INFORMAL FORMAL clinics clinicians immediate family friends trusted community members community health workers extended family Systems of Care and Support for Latina Mothers doulas hospitals parteras birthing centers

15. Informal systems of care help explain why: Income, education, and even prenatal care are not associated with birthing outcomes for foreign born Latinas. The informal systems of care to some degree appear to take the place of formal systems of care. US born Latinas have worse birthing outcomes than foreign born Latinas.

16. Acculturation and the paradox With increasing time spent in the US, women of Latin American origin have: –higher family income –more access to medical care –more formal education –better English skills

17. Acculturation (con’t) However, the beneficial effects of cultural protective factors and informal systems of care tend to erode with acculturation to the “descending limb” of US mass culture… Birthing outcomes worsen, and the formal medical system ends up picking up some of the costs. “For some Latinas, we take the place of the social support network” (clinicians in Multnomah County Health System)

18. Evidence of the negative effects of acculturation in a study of 22,872 Mexican American births in Illinois: Mexican immigrant women in low income census tracts had low birth weight rates of 3% US born women of Mexican ancestry in the same census tracts had low birth weight rates of 14%

19. Indirect yet strong evidence of the positive role of a supportive Latino community, and the protective effects of Mexican culture, comes from a study of over 1 million Southwest US Mexican-American infants…

20. Southwest study: Infant mortality ranged from 4.3 in counties with high proportions of Mexican births, to 5.5 in counties with low proportions of Mexican births. However, this community context association was limited to US-born Mexican mothers, whose rates ranged from 7.0 in low concentration counties to 4.4 in high concentration counties. For births to Mexico-born mothers, there was no association between community context and mortality.

21. Tentative Conclusions The so called Latina Paradox may not be a paradox at all, but rather a phenomenon consistent with the social and cultural determinants of health, some of which are not well understood. The “deficit model” of immigrant integration into society must continue to be reexamined.

22. Public Policy Implications

23. Informal systems of care make a difference. A growing body of evidence suggests that social support is the missing element in understanding why: N. Europe has much lower infant mortality than the US (~4 vs. 7) Immigrant women have better birthing outcomes than their US born coethnics (Latinas & African origin women)

25. A Recommendation: Support prenatal care programs which have elements of the informal systems. Such programs: –are community based –are relationship oriented –are low tech (but have access to modern system) –utilize community health workers –are low cost