The Latina Infant Mortality
Paradox:
Explanations and a Policy
Prescription
deaths per 1000 live births
Reductions in Infant Mortality, 1960-2000
150
100
1960
50
2000
0
Developed
Less Developed
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
3.5
3
2.5
2
1.5
1
0.5
0
<$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 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
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.
Systems of Care and Support for
Latina Mothers
INFORMAL
immediate family
extended family
FORMAL
community
clinics
health workers
friends
trusted community
members
doulas
parteras
birthing
centers
clinicians
hospitals
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 lifestylebased 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
Age-Adjusted Mortality Rate
Relationship Between Social Trust
and Mortality Rates, US States
970
920
870
820
770
720
0
10
20
30
40
50
Percent Responding: "Most people would try to take
advantage of you if they got the chance"