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American Journal of Public Health
The Latina Paradox: An Opportunity For Restructuring Prenatal Care Delivery
By McGlade, Michael S; Saha, Somnath; Dahlstrom, Marie E
1 December 2004
Volume 94; Issue 12; ISSN: 00900036
Latina mothers in the United States enjoy surprisingly favorable birth outcomes despite their social disadvantages. This "Latina paradox" is particularly evident among Mexican-born women.
The social and cultural factors that contribute to this paradox are maintained by community networks-informal systems of prenatal care that are composed of family, friends, community members, and lay health workers. This informal system confers protective factors that provide a behavioral context for healthy births. US-born Latinas are losing this protection, although it could be maintained with the support of community-based informal care systems.
We recommend steps to harness the benefits of informal systems of prenatal care in Latino communities to meet the increasing needs of pregnant Latina women. (Am J Public Health. 2004; 94:2062-2065)
ALTHOUGH RATES OF EARLY prenatal care in the United States rose steadily during the latter part of the 20th century, significant racial/ethnic disparities have persisted.1 To address this problem, Oregon participants in the National Public Health Leadership Institute (NPHLI) launched a 2-year project in the fall of 2001 that focused on access to prenatal care among Latina women. Data from the 2000 Pregnancy Risk Assessment and Monitoring System Survey showed that only 57% of Mexican-born women who lived in Oregon received first-trimester prenatal care compared with 78% of non-Latina women (Suzanne Yusem, Office of Family Health, Oregon Department of Human Services, written communication, August 2003).
To generate innovative solutions to this disparity, the Oregon NPHLI team held a Latina Prenatal Summit in September 2003 that brought together a diverse group of community leaders and prenatal care experts. In preparation for the summit, a planning committee held a series of meetings to discuss options for improving prenatal care among pregnant Latinas. A recurring theme in these discussions was the "Latina paradox"-the well-documented observation that despite socioeconomic disadvantage, Latinas in the United States have birth outcomes comparable to those of White women2-6-and its implications for restructuring prenatal care systems to improve their effectiveness. These discussions resulted in the development of a conceptual framework that described an "informal system" of prenatal care delivery within Latino communities. This system consists of family, friends, community members, and lay health workers who collectively form a social support system that maintains the protective social and cultural factors responsible for the better-than-expected birth outcomes. In this commentary, we describe the conceptual framework and make recommendations for tapping the informal system of prenatal care to improve prenatal care access and, in turn, birth outcomes in Latino communities.
THE LATINA PARADOX
Epidemiological research has shown that despite their parents' socioeconomic disadvantages, Latino infants experience low-birthweight and mortality rates that are generally lower than the national averages.2-6 Overall, the US Latino population had a lowbirthweight incidence of 6.5% in 2002, while the incidence was 6.9% among non-Latino Whites and 13.4% among African Americans.7 At first this observation was believed to be artifactual and was attributed to the effects of migration or other biases in data collection.8,9 However, as additional studies reported the same pattern, favorable birth outcomes became accepted as part of the larger Latino paradox of health, which is now known to also include all-cause mortality rates among most age groups, with the exception of young adult males.10-11 Favorable birth outcomes among Latinos are particularly striking because of the strong and consistent association between socioeconomic status and birth outcomes12 and because Latinos as a group are among the most socioeconomically disadvantaged racial/ethnic populations in the United States.13 It should be noted, however, that the term Latino refers to a diverse mix of peoples who have roots in the primarily Spanish-speaking regions of North and South America. Favorable birth outcomes are not uniform across these populations. In general, Mexican American and other women of Central American origin have the strongest advantages in birth outcomes, while Puerto Rican women have a less favorable profile.2,14
EXPLAINING THE PARADOX
Proposed explanations for the Latina paradox can be classified, with some overlap, as migratory-selection processes, cultural protective factors, and social support.
The healthy-migrant theory posits that it is generally the healthiest Latinas who immigrate to the United States and that this health advantage is responsible for their relatively positive birth (and other health) outcomes. Landale et al. have provided some evidence that supports the healthy-migrant theory.15 After they controlled for a variety of confounding factors, Landale et al. found that infant mortality among Puerto Ricans was lower among recent migrants to the United States than among nonmigrant families in Puerto Rico. This differential between migrants and nonmigrants can be seen in statistics from other countries as well. Overall, Latinas in the United States have a low-birthweight incidence of 6.5%,7 while the incidence is 9% in Mexico; 10% in Peru; and 13% in Guatemala, Nicaragua, and El Salvador.16 Although these statistics may indicate that emigrating women are healthier than their compatriots, they also may reflect the general environmental and economic disadvantages of mothers in Latin American countries compared with mothers in the United States.
Most studies that have examined cultural protective factors have focused on the largest subgroup of the Latino population, Mexican Americans. Protective factors include a strong cultural support for maternity, healthy traditional dietary practices, and the norm of selfless devotion to the maternal role (marianismo).17 These protective factors are believed to provide a healthy normative and behavioral context for maternity, and they enable immigrant mothers to resist adopting the negative risk behaviors of the new host society, particularly those related to smoking, alcohol abuse, and diet.18-20
Cultural protective factors are interrelated with the role of social support networks, i.e., informal systems of health care.21 The informal systems of prenatal care that support maternity among Latina mothers are diverse, but many share at least several of the following components. First, there is a strong tradition of intergenerational knowledge transfer through which healthy behaviors are passed down from one generation of mothers to the next. Second, many mothers benefit from the support of other family figures, particularly sisters and extended family members.22 Third, Mexican women often take responsibility for the health needs of those beyond their nuclear households,23 and supportive Mexican fathers also play a positive role in birth outcomes, although their effect is generally smaller.24
Friends and neighbors also may provide informal prenatal and postpartum support to pregnant Latinas. The tradition of women helping other women in the community is very strong in Latin America, and the high value placed on warm interpersonal relationships (personalismo) of Latin American societies persists to the present.25 Finally, parteras-lay midwives-who have various levels of training have always been an important part of the delivery process in Latin America.
The direct mechanisms through which family and social support contribute to positive birth outcomes are not entirely clear. Such support may mitigate the adverse effects of poverty through the pooling of resources.26 It also may have a stress-buffering effect that improves the psychological and physiological milieu in which pregnancies occur.27 Whatever the mechanisms, mothers who have this support generally experience better birth outcomes than those who do not.21
ACCULTURATION AND THE LATINA PARADOX
Since birth outcomes among Latina women are generally positive, should poor access to formal (clinical) prenatal care be considered a problem? Two lines of evidence show that it should be. First, prenatal care helps Latina mothers: in a study of 1.1 million births to Mexican American women, infant mortality was 2.5 times greater among women who did not receive prenatal care compared with those who did.28
Second, the social and cultural protective factors responsible for positive birth outcomes among immigrant Latin American women appear to erode in subsequent generations. For example, a study of more than 22 000 Mexican American births in Illinois showed that US-born mothers experienced worse birth outcomes than immigrant women from Mexico.14 In low-income census tracts, Mexican-born mothers had low-birthweight rates of 3%, while US-born Mexican American mothers had low-birthweight rates of 14%. Notably, maternal age, education, and trimester of prenatal care initiation were associated with the prevalence of low birthweight among US-born Mexican American mothers but not among foreign-born mothers. This finding supports the hypothesis that social and cultural protective factors-maintained in immigrant communities by an informal system of care-are a substitute, at least in part, for formal prenatal care.
This loss of advantage in birth outcomes is caused in part by the process of acculturation to the norms of mainstream American society. In an analysis of data from the Hispanic Health and Nutrition Examination Survey, higher levels of acculturation among Mexican American women, as measured by language preference, ethnic identification, and nativity status, were associated with higher rates of low birthweight.29 Cobas et al. reanalyzed these data with structural equation modeling that showed part of the association between acculturation and low birthweight was caused by smoking and nutrition, which reflects the fact that Mexican American women take up more unhealthy behaviors as they assimilate from a Mexican cultural orientation to a US cultural orientation.30 However, even after they controlled for diet and smoking, acculturation was a still significant predictor of low birthweight, which indicates that other protective health behaviors or social support-factors that were not modeled in the aforementioned studies-may contribute to the Latina paradox.
A study of more than 1 million Southwest-US Mexican American infants showed that both lifestyle factors and social support are important variables in the Latina paradox. In this study, infant mortality ranged from 4.3 in counties that had high proportions of Mexican births to 5.5 in counties that had low proportions of Mexican births.31 However, this association in a community context was limited to US-born Mexican American mothers, whose rales ranged from 7.0 in low-concentration counties to 4.4 in high-concentration counties. Interestingly, among births to Mexican-born mothers, there was no association between community context and mortality. This suggests that continued exposure to a Mexican cultural orientation may support and reinforce healthy behaviors that Mexican American women, particularly those born in the United States, may otherwise lose through acculturation.31 Another implication is that areas that have a high concentration of Mexican Americans may provide better access to culturally appropriate prenatal care, e.g., care provided by bilingual bicultural clinicians, community health workers, or both.
In summary, there is direct and indirect evidence that health behaviors associated with both Mexican cultural norms and the social support systems maintained in Mexican American communities may contribute to paradoxically low rates of low birthweight within these communities. However, this support tends to erode with increases in acculturation. While this erosion bodes poorly for future birth outcomes of the rapidly acculturating Latin American women who currently reside in the United States, it also suggests a solution at the programmatic and public policy level.
A POLICY PRESCRIPTION
Latinos in the United States are among the most medically underserved populations in the industrialized world. In 2000, 40% of Latino adults aged 19 to 64 years lacked any form of health insurance.32 In today's political and economic climate, the prospects for expanding insurance coverage seem dim, particularly in light of the crisis many state Medicaid programs are facing because of budget shortfalls. Lack of access to prenatal care threatens the health of an entire generation of Latinos, who have the highest birth rate among racial/ethnic groups in the United States.7
We hypothesize that maintaining the positive birth outcomes experienced by first-generation Latinas within existing financial resource limitations can be achieved by harnessing the benefits of the health-promoting cultural and social milieu within Latino communities, that is, the informal systems of prenatal care. While this system of care can thrive in the more collective, community-based Latin American context, it will likely deteriorate in the United States if it is not supported.
This is not to discount the value of formal (clinical) prenatal care. The benefits of prenatal care services are incontrovertible and apply to both non-Latinas and Latinas, particularly nonimmigrants.28 Informal systems of care, however, can complement formal systems. We suggest an approach that merges elements of these 2 systems of care by expanding the roles of individuals who participate to some degree in both systems. These individuals include community health workers (promotoras), lay midwives (parteras), and caregivers who provide support during labor and the post-partum period (doulas). These lay practitioners, who are typically members of the communities in which they work and who have had formal or informal training in maternal and child health, can serve several integrating functions. First, they can provide outreach to ensure pregnant women are aware of and access formal prenatal care services. Second, they can deputize members of the community, particularly older immigrant women, whose experience and knowledge are integral to maintaining the benefits that appear to be lost with acculturation. Deputizing these women validates their beliefs and practices, which may be looked down upon by more acculturated women, and it empowers the women as community leaders, which may help preserve within the community the traditional Latino cultural context that appears to confer positive health effects. Third, lay practitioners can organize community members to provide the type of social support system for pregnant mothers that exists in most areas of Latin America but often disintegrates in the United States. Finally, the personal contact provided by community-based lay practitioners serves some of the functions and roles of the informal system of care.
La Clinica del Cariño in Hood River County, Oregon, provides one example of the potential for integrating formal and informal systems of care. This clinic, which serves a predominantly rural Latino population, including many seasonal farm workers, began its Perinatal Health Promoter Program in 1987. In this program, promotoras are recruited from the community served by the clinic and are trained to both communicate the need for and to provide basic clinical prenatal services. The promotoras work in the communities and in the clinic. Their knowledge of, and integration within, the communities ensures that they are aware of nearly all pregnancies that occur within their communities. Nearly all pregnant women are or eventually become aware of the promotoras, who then become case managers for these women by providing prenatal counseling and by facilitating access to the clinic, which is a federally qualified health center. In addition to prenatal services, the promotoras provide early postpartum care and family planning services. They work closely with physicians in the clinic and discuss all cases, particularly high-risk pregnancies. Records from the clinic have shown that more than 85% of Latina mothers who accessed services at the clinic received prenatal care within the first trimester of pregnancy (Helen Bellanca, MD, oral communication, August 2003).
The Latina paradox can partly be explained by the functioning of informal prenatal systems of care that confer culturally and socially mediated benefits; however, these benefits disintegrate as Latinas accullurate within the United States. Supporting the functions of these informal systems of care and integrating them with formal prenatal services through the expanded use of lay health practitioners has the potential to both improve prenatal care access and improve birth outcomes at a relatively low cost.
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Latina mothers in the US enjoy surprisingly favorable birth outcomes despite their social disadvantages. This Latina paradox is particularly evident among Mexican born women. Furthermore, community networks--informal systems of prenatal care that are composed of families, friends, community members, and lay health workers, maintain the social and cultural factors that contribute to this paradox. McGlade et al recommend steps to harness the benefits of informal systems of prenatal care in Latino communities to meet the increasing needs of pregnant women.
Copyright American Public Health Association Dec 2004 | Michael S. McGlade, PhD, Somnath Saha, MD, MPH, and Marie E. Dahlstrom, MA | About the Authors | Michael S. McGlade is with the Geography Department, Western Oregon University, Monmouth. Somnath Saha is with the Section of General Internal Medicine, Portland VA Medical Center, and the Departments of Medicine and Public Health and Preventive Medicine, Oregon Health and Science University, Portland. At the time of the writing, Marie E. Dahlstrom was with the Susannah Maria Gurule Foundation, Portland, Ore. | Requests for reprints should he sent to Somnath Saha, MD, MPH, Portland VAMC (P3MED), 3710 SW US Veterans Hospital Rd, Portland, OR 97239 (e-mail: firstname.lastname@example.org). | This article was accepted July 6. 2004. | Contributors | M.S. McGlade originated the framework of the article and was the primary author. S. Saha contributed to refining the framework and to writing/revising the article. M. E. Dahlstrom originated, organized, and implemented the Latina Prenatal Summit and contributed to refining the framework. | Acknowledgments | S. Saha was supported by a Research Career Development Award from the Department of Veterans Affairs Health Services Research and Development Service and a Generalist Physician Faculty Scholar Award from the Robert Wood Johnson Foundation. | The Latina Prenatal Summit was made possible by the work of the Oregon participants in the National Public Health Leadership Institute: Marie E. Dahlstrom, MA, Barry S. Kast, MSW, John Lee, MBA, MPH, BBA, and Lillian Shirley, RN, MPH, MPA. The authors also wish to thank Alberto Moreno, MSW, Julie M. McFarlane, MPH, and all the members of the Latina Prenatal Summit Planning Committee.