The Latina Infant Mortality Paradox: Explanations and a Policy Prescription

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The Latina Infant Mortality Paradox Explanations
and a Policy Prescription

• Michael S. McGlade
• Department of Geography
• Western Oregon University

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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 (lt2.5 kilos) are 40
  times more likely to die than normal birth weight
  babies
• preterm delivery (lt37 weeks) is the principal
  determinant of low birth weight in the US
• Infant mortality is strongly predicted by low
  birth weight and preterm delivery.

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Relevant Concepts in Social Epidemiology

• 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 dont
  explain all of the difference.

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Concepts (cont)

• 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.
• Modifiable risk factors for low birth weights are
  poor nutrition, stress and economic insecurity,
  lack of social support, substance abuse, and
  unsanitary environments.
• Neonatal mortality (1st 28 days) accounts for
  over half of infant mortality.

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Concepts (cont)

• 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.

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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.

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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.

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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

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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

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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.

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

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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

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Acculturation (cont)

• 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 cultureBirthing
  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)

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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

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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
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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.

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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.

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Public Policy Implications
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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)

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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

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