She's lived in Durham for six years since immigrating from Mexico City and, last December, she gave birth to her third child, Carlos. It wasn't until her second trimester of pregnancy that she signed up for prenatal care through the government-funded Baby Love program at Lincoln Community Health Center. Her husband was away on a construction job in Charlotte when she went into labor, so friends took her to Durham Regional Hospital, where she delivered her baby by cesarean section.
Carlos was hardy at nearly 7 pounds when he was born, and his mom made a smooth recovery. "Fue todo muy rapido," Carmen says, bouncing her wide-eyed son on her lap in the living room of the family's one-bedroom house near Ninth Street.
Decades of scientific research have posited low income and lack of access to early prenatal care are the biggest predictors of unhealthy births. But when it comes to immigrant Latinas, a surprising and mysterious phenomenon kicks in: Although they get less prenatal care and are more likely to be living in poverty, studies show first-generation Latinas--especially those from Mexico--have healthy babies. Having fewer low birthweight and pre-term babies (those born before 37 weeks) means lower infant mortality. Nationally, the rate of infant deaths per 1,000 live births for Latinas is 5.6, compared to 5.7 for whites and 13.5 for African Americans.
A report by a statewide task force to be unveiled early next month reveals that what's known as the "Mexican Paradox" is at work in North Carolina. The report found that between 1996 and 2000, the rate of infant deaths per 1,000 live births to Mexican-born women was 6.1, compared to 6.6 for whites and 15 for African Americans. (For non-Mexican Latinas, it was 5 and for U.S.-born Latinas, 6.3.) [See chart in sidebar Culture is key to improving health] This, despite the fact that a greater proportion of Latinas in North Carolina had annual incomes below $14,000 and started prenatal care after the first trimester.
The paradox should be big news in a state that ranks 47th in infant mortality. But the figures on Latina births are likely to be overshadowed by larger issues in the task force report, such as barriers Spanish-speaking newcomers face in getting health care.
The numbers are no surprise though, to researchers who've been exploring the phenomenon for more than two decades--ever since data on ethnicity began to be included on U.S. birth certificates. That data revealed that immigrant Latinas, especially Mexicans, have an advantage when it comes to births that outweighs other risks they face.
Its source remains a mystery.
"Numerous factors are intertwined," says Bob Meyer, director of North Carolina's Birth Defects Monitoring Program, who helped analyze statistics for the task force report. "There's diet and lifestyle issues, such as lower rates of smoking among Mexican women. Certain genetic factors come into play. But we're not any closer to understanding it."
Health scientists have discounted the possibility that the paradox can be explained by the fact that new immigrants tend to be relatively healthy. (You have to be tough to pick up and start life over in a new country, the theory goes.) Besides behaviors such as low rates of smoking and drinking during pregnancy, researchers have identified threads in Latino culture that form a protective blanket for expectant moms. These include a diet rich in protein and vitamins, extended family ties, strong religious beliefs and an up-on-a-pedestal approach to pregnant women. (One 1995 study proposed that the Mexican religious symbol of the Virgin of Guadeloupe may encourage healthy births through its power as an icon for expectant mothers.)
Still, clear links between traditional culture and lower infant mortality have yet to be made. That's one reason why academic discussions of the paradox have been slow to translate into health policy. Until now, North Carolina has lacked the large Latina populations of states like California and Texas where much of the research on the paradox has been done. "It's all assumptions," says Pierre Buekens, chair of the Department of Maternal and Child Health at UNC-Chapel Hill and a leading researcher in the field. "We're still trying to understand the whys."
Not only is the Mexican Paradox a window on a little-known strength of the Latino community, it also frames the weaknesses of American society.
"We look on pregnancy as an individual thing--that's our culture's instructions," says Deborah Norton, a family planning physician at a Raleigh prenatal clinic run by Wake County Human Services. "But that's not the reality for everybody. Latino culture really supports pregnant women. But in our culture, you don't get any breaks."
For Latino leaders, the power of the paradox is that it shatters negative stereotypes of immigrant communities.
"It helps us appreciate the fact that traditional culture can be good for your health," says Andrea Bazan Manson, director of the Raleigh-based advocacy group El Pueblo, which played a leading role on the task force. "We have here in North Carolina the fastest-growing Latina community in the nation. It's a community that's underserved, but also has some strengths that we need to let people know about."
But there's a paradox within the paradox: Those strengths disappear the longer Latinas live in this country. Nobody knows exactly why or when that happens. But national studies show that as Latinas become Americanized, their infant mortality rates begin to rise.
Further, the paradox's protective umbrella doesn't shelter all Latinas. Puerto Rican women, for example, don't have the healthy birthweight babies common to those from Mexico, Central and South America. Spanish-speaking migrant farmworkers have infant mortality rates that are 25 percent above the national average. And Latinas--nationally and in North Carolina--have higher rates of children with certain birth defects, including neural tube defects and Down syndrome.
Given such complexities, it's no surprise that health and social-service workers are still searching for ways to put the lessons of the paradox to practical use. But with that promise dimming the faster Latinas adopt American culture, community advocates warn this is no time to sit back.
"It's very difficult to get funding for programs for populations that have healthy babies," says Pamela Frasier, an assistant professor of Family Medicine at UNC-Chapel Hill who helped create the Immigrant Health Initiative at Chatham Hospital in Siler City. "My concern is that we're being shortsighted. We have an opportunity to intervene now to prevent that third generation from going downhill."
Latinas aren't the only ones who have a stake in staving off that slide. Some health-care leaders believe that if better understood, the paradox could energize efforts to roll back the double-digit death rates of African-American infants.
Nationally, blacks have twice the infant mortality of whites--14.3 infant deaths per live births compared to 6 for whites, according to the U.S. Department of Health and Human Services. North Carolina's gap is even wider at 15 deaths per 1,000 live births for African Americans compared to 6.6 for whites.
In trying to explain these disparities, past research has turned to familiar benchmarks: more poverty and less prenatal care for African-American women, adding up to more low-weight and pre-term babies. But officials at the federal Centers for Disease Control and Prevention have begun calling for a new approach that takes into account what a recent article in Maternal and Child Health Journal called the "social and political impact of being an African American woman in the United States, racism, and the combined effects of gender, racism, and relative social position" on pregnancy and birth.
The existence of the Mexican Paradox bolsters the idea that access to resources alone can't explain why some women have healthy babies and others don't. But whether Latinas could provide a model for reducing infant mortality in other communities is a sensitive subject.
"It's never a good idea to present one community as healthier than another," says Bazan Manson, who used to be a research associate at the North Carolina Office of Minority Health. "I hesitate to say we could be a model for African Americans. If you look at the harsh statistics, you see tremendous disparities between African Americans and whites. And then there's this Latina group that doesn't quite fit in anywhere."
On the other hand, she says, some Latino traditions echo those of African Americans. "The kinship networks, the support for pregnant women are very similar," Bazan Manson says. "But more research needs to happen."
And the clock is ticking. Ida Dawson is a Wake County physician's assistant and a team member of Perinatal Periods of Risk, a national group that's exploring ways to prevent black infant deaths. As director of Wake County's Clinical Services for women, she's seen the paradox at work in the healthy babies her Latina clients routinely deliver. But Dawson, who is African American, wonders how quickly the positives they bring with them will fade from exposure to the negatives of their adopted culture--including the racism and discrimination her community has known for generations.
"Down the road, that's the worry," she says. "Right now, these Spanish-speaking people are still new and still in their communities. We've got to change the way we do things now, so we can protect the good nutritional habits and the other things they're doing right."
But how do you protect something you don't fully understand?
Like many front-line health-care workers, Elisabeth Palmer's been wrestling hard with that question. As a maternity care coordinator for Durham County's Baby Love program at Lincoln Community Health Center, she's tried to reinforce healthy behaviors she sees in her Latina clients. At the same time, she's constantly bumping up against weightier problems they face, such as lack of health insurance, decent housing or even adequate food.
Funded with state Medicaid dollars, Baby Love was launched in 1987 with the specific aim of reducing infant deaths among low-income North Carolinians. The program offers a range of services for new and expectant moms for up to 60 days after the birth of a child--everything from helping families sign up for food stamps to arranging donations of baby clothes, to giving advice on breastfeeding.
Palmer works with 50 families at a time and all of her clients are Spanish-speaking. The two most obvious reasons she cites for the healthy babies she sees are that few of the women smoke or drink alcohol during pregnancy and they eat well-balanced, home-cooked meals.
"Whenever I get a donation to get a family some groceries, I'll look at the list of things they've asked for and it's always whole food, nothing processed," says Palmer, a tall woman with short blonde hair and dangling earrings. "And all these women know how to cook. Even the 14- and 15-year-olds know how to cook."
Her observations are backed up by studies showing Mexican-born immigrants have higher intakes of nutrients important to pregnancy--protein, vitamins A,C, E and folic acid, and calcium. A 1995 study by leading paradox researcher, Sylvia Guendelman, at the University of California at Berkeley, found that while low incomes for non-Latinos correlated with less healthy diets, the reverse was true of first-generation Mexicans whose low incomes were associated with more healthy diets.
On this sunny December morning, Palmer's behind the wheel of her station wagon, heading for a visit with a mother she knows from the health center. We arrive at Azucena's home around midmorning. Her two daughters are in school and her husband's working at a construction site, so the house is quiet enough to hear the traffic going by on Holloway Street just beyond the front lawn.
Azucena has lived in Durham for nearly six years. At first, her family rented an apartment on Ivy Street in the inner city. Just last year, they bought a two-bedroom house on the outskirts of the eastern Durham neighborhood once known as Joy Land.
In her yellow-walled kitchen, she prepares a lunch of homemade corn tortillas, beans, cheese, salsa verde and salad. The air has a slight sting from the spicy chilies in the salsa. Every few minutes, she turns to flip tortillas warming on a stove-top griddle.
In Mexico, when Azucena was carrying Jimena, now 6, she ate "everything natural--no hamburgers." But making healthy meals was more difficult when her daughter, Sharon, was born in Durham a year later. There were no relatives to help out while her husband and father-in-law were at work. She didn't know how to drive or even where to get fresh food.
"With the first child I ate lots of fruits and vegetables," says Azucena, who worked as a nurse in Mexico and would like to do the same here someday. "Pero aqui no."
Traditional food was also the first thing Diana missed when she came to the United States from Ecuador three years ago. "Our food is really different," says Diana, a Baby Love client whose second child, Andres, was born in September. "We don't like too much pre-cooked."
As soon as she gets home from her job as an administrative assistant at George's Garage in Durham (her husband works for another of the owner's restaurants), "I start to cook," Diana says. "I'm always cooking--rice, vegetables, chicken." Ingredients she can't find in large grocery stores come from the smaller tiendas that have sprung up in neighborhoods around town.
Even more than the food, Diana misses the web of support that encircled her when Juan, her eldest, was born in Ecuador nine years ago. Her parents and her two siblings--even her aunts and uncles--were there to lend a hand and give advice. "All the family," she says. "When one of us gets pregnant, all the family is considered--all the opinions."
Recently, she's arranged for an aunt to come and live with them so she'll have help with the baby. It means their two-bedroom apartment will be a little more crowded, but Diana doesn't mind. "In the old times, women didn't work," outside the home, she says. "But I have to work and my husband has to work. I had my mom beside me when I had Juan Jose and she could tell me what to do. Now, I always call her."
While relatively little scholarly attention has been given to the effect of cultural forces like kinship networks and religious faith on pregnancy, many local clinic workers rank them high on the list of reasons their Latina clients have healthy babies. Communal rituals like baptisms and the presence of extended family under one roof create a welcoming climate for babies.
"There's a sense of community and valuing families," says Dawson, of Wake County's prenatal clinic. "It reminds me of how things used to be in this country years ago."
It's intangibles like these that seem most vulnerable to the pressures of modern-day American life. And once the cultural supports are gone, health workers say, behaviors begin to change. For example, traditional practices like breastfeeding and periods of rest for pregnant women and new mothers are hard to sustain when you're holding down a low-wage manufacturing or service job--the sectors where most Latinas in North Carolina are now employed.
The messages newcomers receive about mainstream culture can also work against good health.
Diana was surprised when doctors at Duke asked her whether she would be breast or bottle-feeding her new baby. "In our country, it's always thought you will do breastfeeding," she says. "The doctors always try to do that. It's cheaper and easier." And studies show it boosts infant immune systems and speeds the mom's post-partum recovery.
But "breastfeeding's not seen as cool or American," notes Laura Oberkircher, who heads a Wake County nonprofit called Healthy Mothers Healthy Babies Coalition. "A lot of the women become more hesitant about it."
Messages come from other sources, as well.
"People arrive here and see all the worst things advertised on TV," says Mary DeCoster, a Latino parent educator at Durham County's Welcome Baby, which offers free classes to expectant moms. "Pretty soon they're eating worse than most people here--they're actually eating Doritos for lunch."
An informal survey conducted last year by the Immigrant Health Initiative revealed that respondents were eating between five and seven meals a week at fast food restaurants.
Such findings lead Pierre Buekens, the UNC Health researcher, to this conclusion: "Acculturation is bad for babies," he says. "It's not bad for everything, but it's bad for babies."
Preserving the paradox
Just how bad has yet to be seen in North Carolina, where the Latino population is relatively new and unstudied. But researchers and community leaders agree that if left unattended, the paradox could quickly disappear.
Meaningful efforts to preserve it--and improve health care generally for Latinos--should take the culture of new immigrants into account by building "upon the strong family values and connections within the Latino community" the task force report states. Several of those approaches are detailed in the report's "best practices" section, with special attention given to grassroots efforts to train Spanish-speaking immigrants to become their own health educators and advocates. [See sidebar Drawing on inner resources.]
When it comes to pregnancy, for example, "it's good to foster programs that continue to create networks amongst women," says Angelina Schiovane, interim executive director of El Centro, which runs just such a lay health adviser program. "So maybe they don't have any longer their mother who can provide advice. But they have other friends of different ages and experiences to continue that support network."
Such programs are a start. But more needs to be done--and soon--health-care leaders say, if the next generation of Latinas is to continue having healthy babies.
"We need to do more learning about what are the strengths of Latinas and develop strategies to maintain them," says Oberkircher, of the Healthy Mothers Healthy Babies Coalition. "Because once they're gone, it's hard to get them back."
The last appointment on Palmer's schedule is a visit to 18-year-old Hilda, one of her newest Baby Love clients. Hilda came to the United States from Guatemala two years ago with her boyfriend and lived in Michigan before moving to Durham in October. Last month, she gave birth to her first child, Rafael. He was healthy, at 6 pounds 15 ounces. But her present circumstances are a sobering reminder of what the future might hold.
Hilda spends her days in a cinderblock apartment in East Durham that she shares with her boyfriend and two male cousins. Towels act as makeshift curtains for the windows. Water pools outside the front door and inside, trickles across the kitchen linoleum. The concrete floor in the living room where she sits on an old cot cradling her son is bare and cold.
When social workers at Duke Hospital referred her to Baby Love, Hilda was hesitant about getting help. She worried that if she signed up for the program, health officials might take custody of her baby or send her back to Guatemala.
Now, she's better informed. Later this afternoon, Hilda plans to apply for food stamps and Medicaid for Rafael, whose tiny face is an echo of his mom's elfin features. She and Palmer discuss the services he's eligible to receive.
But when Palmer asks, "What would help you most right now?" Hilda fixes on something far less bureaucratic.
"To be with family," she replies.
Reporter's note: Translation for this story was done by Elisabeth Palmer of Durham County's Baby Love program, Georgina Uresti of the Immigrant Health Initiative in Siler City and Mary DeCoster of Durham's Welcome Baby program. Only first names were used in some instances to protect the privacy of social-service clients.