1. Birth Outcomes of Mexican Immigrant Mothers: Advantages in the Midst of Inequalities? Sylvia Guendelman, PhD Research Training Workshop San Diego, CA May 13, 2010

2. Objectives for Today:  Evaluate birth outcomes of Mexican immigrants  Explore policy relevance, since 45% of all births in California are to Mexican-origin women and 1 out of 8 births in the US are in California

3. Defining a Paradox Multiple studies report that Latinos in the US have better or similar health to that of non- Latino Whites despite having lower income, less education and more delayed access to health care The better-than-expected health and mortality of Latinos has been coined: “The Latino Paradox” “The Latino Paradox”

4. Is there a “Mexican” Birth Paradox?  Mexico-born:  Birth outcomes are better than or comparable to whites  Birth outcomes are better than Mexican- Americans born in the US Or more than one?

5. Birth Outcomes Source: Birth Cohort Files for California, 2006

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

7. Health migration effects  Those who choose to migrate are healthier, physically and psychologically  Salmon bias effect:  Migrants return to Mexico following illness or temporary unemployment Hypothesis:

8. Mexico-born in California vs. Mexico (27.5%)Mexico Preterm (20-37 week gest.) 9 - 13.7** LBW (< 2500grams) 8* VLBW (< 1500grams) 0.9 Neonatal Mortality 11.0 (2004)* Postneonatal Mortality 1.4 Birth Outcomes Source: Birth Cohort Files for California, 2003 *unicef.org ** Ceron Mireles, Harlow, Sanchez-Carrillo, 1996(27.5%)Mex-born9.7 5.6 0.9 2.5 1.3

9. Under-registration of infant deaths  May be more likely in Texas  many deliveries occur out-of-hospital and are assisted by lay midwives.  Not the case in California  most deliveries take place in hospitals and births are registered.  Focus groups conducted in the 90s along CA border disprove this hypothesis. A Data Artifact

10. Survival of the Fittest  Mexico-born women have higher rates of fetal deaths which eliminates biologically weaker fetuses.  Our findings do not corroborate this evidence Hypothesis:

11. Fetal death rate at ≥20 weeks gestation, per 1000 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) WhiteLatinoEnglish Speaking Spanish Speaking

12. Maternal Health Evidence California Data: Linked OSHPD-birth records data Linked OSHPD-birth records data Mexico-born women are less likely to have obstetric complications during labor and delivery compared to Mexican Americans and White non-Latina women. Mexico-born women are less likely to have obstetric complications during labor and delivery compared to Mexican Americans and White non-Latina women. Source: Guendelman, Thornton, Gould, Hosang. AJPH, 2005, 95(12)

13. Observed Maternal Morbidity during Labor and Delivery: California, 1996-1998 Mexico-bornMex-Am White Any morbidity 19%21%21% Adjusted Odds Ratios* Adjusted Odds Ratios* vs. Mex-Amer 0.92 (0.90, 0.93) vs. Whites 0.92 (0.91, 0.93) * Adjusted for age, parity, SES, prenatal care and hospital quality of care Source: Guendelman et al. AJPH. 2005; 95(12)

14. Cultural/Social Buffering  More protective behaviors Less smoking, alcohol, illegal drug consumption; better diets? Less smoking, alcohol, illegal drug consumption; better diets?  Norms, beliefs, practices about family obligations and relationships Hypothesis:

15. Cultural/Social Buffering  Strong reliance on family rather than government aid  Pooling incomes in the household  Viewing children as assets  Viewing pregnancy with respect Hypothesis:

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

17. Can biomarkers provide better evidence?  Corticotropin releasing hormone (CRH) is the major hypothalamic regulator of the stress response in mammals.  Evidence suggests that high placental CRH may trigger the onset of labor

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

19. Mexican American Paradox What happens with acculturation to US society?

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

21. Mexican Americans vs. Mexican born and White non-Latinas Birth Outcomes S ource: Birth Cohort Files for California, 2006

22. Generational Changes in Health Maternal morbidities during labor and delivery are higher in Mexican- Americans (21%) compared to Mexican-born women (19%) Guendelman, Thornton, Gould, and Hosang. Pediatric and Perinatal Epidemiology. 2006

23. Erosion of Healthy Behaviors  Drug Consumption Smoking  Alcohol Use  Quality of Diet  Intimate Partner Support  Pregnancies to Unmarried Adolescents

24. Potential Explanations  Lifestyle Adoption of risky behaviors and social norms  Ineffective health care?  Discrimination?  Downward assimilation? Negative effects of acculturation  Methodological artifacts? Measurement tools, wrong comparisons groups; difficulty discerning acculturation from SES effects

25. The issues are perplexing  Some argue that the health decline is due to return migration; unlikely case with young children or pregnant women  The decline in health is larger than expected by adoption of unhealthy behaviors alone  The effects of unhealthy working conditions, ineffective health care and becoming “a minority” are less explored

26. Unraveling the Birth Paradox Requires: Improved study designs comparing the Mexico-born in California with: Non-immigrants in their community of origin Non-immigrants in their community of origin Returnees Returnees The Mexican American middle class The Mexican American middle class

27. Good birth outcomes, at risk toddlers Protective factors in uterus do not advance:  Physical health of infants (Guendelman, English and Chavez,1995) (Guendelman, English and Chavez,1995)  Cognitive health (Bayley mental test scores lower at 24 months) (Fuller et al, 2009)  Overweight  Dental caries

28. Conclusions  Despite their disadvantaged social status, Mexican immigrant women have assets that benefit maternal and infant health in the perinatal period.  The protective effects wear off in early childhood.  A life course perspective is valuable in assessing health outcomes in children of immigrants.

29. THANK YOU!!!!!