Birth Outcomes of Mexican Immigrant Birth Outcomes of Mexican Immigrant Mothers: Advantages in the Midst of Mothers: Advantages in the Midst of

Inequalities?Inequalities?

Sylvia Guendelman, PhDResearch Training WorkshopSan Diego, CA May 13, 2010

Objectives for Today:Objectives for Today:

Evaluate birth outcomes of Mexican Evaluate birth outcomes of Mexican immigrantsimmigrants

Explore policy relevance, since 45% of all Explore policy relevance, since 45% of all births in California are to Mexican-origin births in California are to Mexican-origin women and 1 out of 8 births in the US are women and 1 out of 8 births in the US are in Californiain California

Defining a Paradox Defining a Paradox

Multiple studies report that Latinos in the US Multiple studies report that Latinos in the US have better or similar health to that of non-have better or similar health to that of non-Latino Whites despite having lower income, Latino Whites despite having lower income, less education and more delayed access to less education and more delayed access to health carehealth care

The better-than-expected health and mortality The better-than-expected health and mortality of Latinos has been coined: of Latinos has been coined:

““The The Latino Paradox”Latino Paradox”

Is there a “Mexican” Birth Paradox?Is there a “Mexican” Birth Paradox?

Mexico-born:Mexico-born: Birth outcomes are better than or comparable Birth outcomes are better than or comparable

to whitesto whites Birth outcomes are better than Mexican-Birth outcomes are better than Mexican-

Americans born in the USAmericans born in the US

Or more than one?

Birth OutcomesBirth Outcomes

Source: Birth Cohort Files for California, 2006

Why do foreign-born women Why do foreign-born women show favorable outcomes?show favorable outcomes?

Health migration effectsHealth migration effectsThose who choose Those who choose

to migrate are to migrate are healthier, physically healthier, physically and psychologicallyand psychologically

Salmon bias effect:Salmon bias effect: Migrants return to Migrants return to

Mexico following Mexico following illness or temporary illness or temporary unemploymentunemployment

Hypothesis:

Mexico-born in California vs. MexicoMexico-born in California vs. Mexico

(27.5%)(27.5%)

MexicoMexicoPretermPreterm

(20-37 week gest.)(20-37 week gest.) 9 - 13.7**9 - 13.7**LBWLBW

(< 2500grams)(< 2500grams) 8*8*VLBWVLBW

(< 1500grams)(< 1500grams) 0.90.9

Neonatal MortalityNeonatal Mortality 11.0 (2004)*11.0 (2004)*Postneonatal Postneonatal

MortalityMortality 1.41.4

Birth Outcomes

Source: Birth Cohort Files for California, 2003*unicef.org** Ceron Mireles, Harlow, Sanchez-Carrillo, 1996

(27.5%)(27.5%)

Mex-bornMex-born

9.79.7

5.65.6

0.90.9

2.52.5

1.31.3

Under-registration of infant deathsUnder-registration of infant deaths

May be more likely in Texas May be more likely in Texas many deliveries occur out-of-hospital and many deliveries occur out-of-hospital and

are assisted by lay midwives.are assisted by lay midwives.

Not the case in CaliforniaNot the case in California most deliveries take place in hospitals most deliveries take place in hospitals

and births are registered.and births are registered. Focus groups conducted in the 90s along Focus groups conducted in the 90s along

CA border disprove this hypothesis.CA border disprove this hypothesis.

A Data Artifact

Survival of the FittestSurvival of the Fittest

Mexico-born women Mexico-born women have higher rates of have higher rates of fetal deaths which fetal deaths which eliminates biologically eliminates biologically weaker fetuses.weaker fetuses.

Our findings do not Our findings do not corroborate this corroborate this evidenceevidence

Hypothesis:

Fetal death rate at ≥20 weeks gestation, per Fetal death rate at ≥20 weeks gestation, per 1000 live births and fetal deaths1000 live births and fetal deaths

Source: Guendelman et al. Journal of Community Health. 1994; 19(5)

OR = 1.0 0.83 (0.63-1.08)

White Latino English Speaking

Spanish Speaking

Maternal Health EvidenceMaternal Health Evidence

California Data:California Data: Linked OSHPD-birth records dataLinked OSHPD-birth records data Mexico-born women are less likely to have Mexico-born women are less likely to have

obstetric complications during labor and obstetric complications during labor and delivery compared to Mexican Americans and delivery compared to Mexican Americans and White non-Latina women.White non-Latina women.

Source: Guendelman, Thornton, Gould, Hosang. AJPH,

2005, 95(12)

Observed Maternal Morbidity during Labor and Observed Maternal Morbidity during Labor and Delivery: California, 1996-1998Delivery: California, 1996-1998

Mexico-bornMexico-born Mex-AmMex-Am WhiteWhite

Any morbidityAny morbidity 19%19% 21%21% 21%21%

Adjusted Odds Ratios*Adjusted Odds Ratios*

vs. Mex-Amervs. Mex-Amer 0.92 0.92 (0.90, 0.93)(0.90, 0.93)

vs. Whitesvs. Whites 0.92 0.92 (0.91, 0.93)(0.91, 0.93)

* Adjusted for age, parity, SES, prenatal care and hospital quality of care

Source: Guendelman et al. AJPH. 2005; 95(12)

Cultural/Social BufferingCultural/Social BufferingMore protective More protective

behaviorsbehaviors Less smoking, alcohol, Less smoking, alcohol,

illegal drug consumption; illegal drug consumption; better diets?better diets?

Norms, beliefs, practices Norms, beliefs, practices about family obligations about family obligations and relationshipsand relationships

Hypothesis:

Cultural/Social BufferingCultural/Social Buffering

Strong reliance on family Strong reliance on family rather than government aidrather than government aid

Pooling incomes in the Pooling incomes in the householdhousehold

Viewing children as assetsViewing children as assetsViewing pregnancy with Viewing pregnancy with

respectrespect

Hypothesis:

Cultural/Social BufferingCultural/Social Buffering

My observations indicate My observations indicate that Mexico-born women that Mexico-born women from communities that from communities that adhere to strong gender adhere to strong gender roles tend to show roles tend to show protective behaviors during protective behaviors during pregnancy and define their pregnancy and define their life goals around pregnancy life goals around pregnancy and motherhood.and motherhood.

Hypothesis:

Can biomarkers provide Can biomarkers provide better better evidence?evidence?

Corticotropin releasing hormone Corticotropin releasing hormone (CRH) is the major hypothalamic (CRH) is the major hypothalamic regulator of the stress response in regulator of the stress response in mammals.mammals.

Evidence suggests that high Evidence suggests that high placental CRH may trigger the placental CRH may trigger the onset of laboronset of labor

CRHCRH

In a current study, our research team In a current study, our research team is finding lower CRH levels among is finding lower CRH levels among Mexico-born working women Mexico-born working women compared to White working women.compared to White working women.

Mexican American ParadoxMexican American Paradox

What happens with acculturation

to US society?

Mexican-Americans vs. Mexico-born Mexican-Americans vs. Mexico-born or Whitesor Whites

US-born Mexican Americans have US-born Mexican Americans have worse birth outcomes than Mexico-worse birth outcomes than Mexico-born and Whitesborn and WhitesThis is surprising, given that the This is surprising, given that the longer immigrants live in the US, the longer immigrants live in the US, the greater the likelihood of experiencing greater the likelihood of experiencing better education, greater income and better education, greater income and improved access to health care.improved access to health care.

Mexican Americans vs. Mexican born and Mexican Americans vs. Mexican born and White non-LatinasWhite non-Latinas

Birth Outcomes

Source: Birth Cohort Files for California, 2006

Generational Changes Generational Changes in Healthin Health

Maternal morbidities Maternal morbidities during labor and during labor and delivery are higher in delivery are higher in Mexican- Americans Mexican- Americans (21%) compared to (21%) compared to Mexican-born women Mexican-born women (19%)(19%)

Guendelman, Thornton, Gould, andHosang. Pediatric and PerinatalEpidemiology. 2006

Erosion of Healthy BehaviorsErosion of Healthy Behaviors

Drug ConsumptionDrug Consumption

SmokingSmoking

Alcohol UseAlcohol Use

Quality of DietQuality of Diet

Intimate Partner SupportIntimate Partner Support

Pregnancies to Unmarried Pregnancies to Unmarried AdolescentsAdolescents

Potential ExplanationsPotential Explanations

LifestyleLifestyleAdoption of risky behaviors and social normsAdoption of risky behaviors and social norms

Ineffective health care?Ineffective health care?Discrimination?Discrimination?Downward assimilation?Downward assimilation?

Negative effects of acculturationNegative effects of acculturationMethodological artifacts?Methodological artifacts?

Measurement tools, wrong comparisons groups; Measurement tools, wrong comparisons groups; difficulty discerning acculturation from SES difficulty discerning acculturation from SES effectseffects

The issues are perplexingThe issues are perplexing

Some argue that the health decline is Some argue that the health decline is due to return migration; unlikely case due to return migration; unlikely case with young children or pregnant womenwith young children or pregnant women

The decline in health is larger than The decline in health is larger than expected by adoption of unhealthy expected by adoption of unhealthy behaviors alonebehaviors alone

The effects of unhealthy working The effects of unhealthy working conditions, ineffective health care and conditions, ineffective health care and becoming “a minority” are less exploredbecoming “a minority” are less explored

Unraveling the Birth ParadoxUnraveling the Birth Paradox

Requires:Requires:Improved study designs comparing the Improved study designs comparing the

Mexico-born in California with:Mexico-born in California with: Non-immigrants in their community of originNon-immigrants in their community of origin ReturneesReturnees The Mexican American middle classThe Mexican American middle class

Good birth outcomes, at risk Good birth outcomes, at risk toddlerstoddlers

Protective factors in uterus do not advance:Protective factors in uterus do not advance:Physical health of infantsPhysical health of infants ((Guendelman, English and Chavez,1995)Guendelman, English and Chavez,1995)

Cognitive health (Bayley mental test scores Cognitive health (Bayley mental test scores lower at 24 months) lower at 24 months) (Fuller et al, 2009)(Fuller et al, 2009)

Overweight Overweight Dental cariesDental caries

ConclusionsConclusions

Despite their disadvantaged social status, Despite their disadvantaged social status, Mexican immigrant women have assets Mexican immigrant women have assets that benefit maternal and infant health in that benefit maternal and infant health in the perinatal period.the perinatal period.

The protective effects wear off in early The protective effects wear off in early childhood.childhood.

A life course perspective is valuable in A life course perspective is valuable in assessing health outcomes in children of assessing health outcomes in children of immigrants.immigrants.

THANK YOU!!!!!THANK YOU!!!!!