The Latina Infant Mortality Paradox: Explanations and a Policy

Prescription

Michael S. McGladeDepartment of GeographyWestern Oregon University

Reductions in Infant Mortality, 1960-2000

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2000

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.

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.

Relative Risks of All-Cause Mortality by Household Income, USA

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0.5

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1.52

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3.5

<$15,000 <$20,000 <$30,000 <$50,000 <$70,000 >$70,000

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 (1st 28 days) accounts for over half of infant mortality.

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.

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.

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.

Explanations of the paradox

1. The healthy migrant effect2. 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

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

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.

INFORMAL FORMAL

clinics

clinicians

immediate family

friends

trusted community members

community

health workersextended family

Systems of Care and Support for Latina Mothers

doulas

hospitalsparteras

birthingcenters

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.

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

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)

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%

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…

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.

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.

Public Policy Implications

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)

General Attributes of Systems of Care

Informal Systems of Care Formal Systems of Care

inexpensive

expensive

culturally specific, relationship

oriented

modern & sometimes alien

abundant human resources

scarce human resources

emphasis on early lifestyle-

based prevention, reproduction as a normal process

emphasis on technology

and medicine

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

Relationship Between Social Trust and Mortality Rates, US States

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Percent Responding: "Most people would try to take advantage of you if they got the chance"

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