“See you soon!” The nurse laughed as she discharged Claudia and her new baby from the recovery wing of Labor and Delivery at Manhattan Hospital. (Pseudonyms are used throughout this article for proper names, including the hospital.) Claudia told me, “She thinks we Mexicans have so many babies that I’ll be back here again next year, but not me, I won’t be.” “Yes, you will, you’ll see!” The nurse then turned to me, “They all say the same, and then we see them again in a year.” Even while she laughed with the nurse, Claudia shook her head and repeated, “Not me!”
Achieving rapport with health care providers, sharing a laugh, and imagining that if one were to come back again in a year or more that someone would recognize her are aspects of care that patients say they admire at this hospital. Nonetheless, “knowing” their patients for some providers means locating them within larger racialized discourses about indigent patients, immigrants, and the “anchor babies” they are imagined to carry. In this dialogue, the nurse implies that she knows this Mexican patient better than the patient knows herself.
New York is among the most generous states nationwide in its inclusion of undocumented immigrants in public prenatal care. While we hear horror stories involving women delivering babies on the front steps of the emergency room in other states, in New York State, no proof of legal immigration status is required to enroll in public prenatal care, or nutritional assistance for pregnant women, infants, and children to age five. In spite of the state’s largesse, public prenatal care settings are not immune to larger discourses in the United States about immigrants and their consumption of public resources. On the contrary, it is in prenatal care clinics and labor and delivery wards that women are sometimes most directly socialized into particular ways of being patients, parents, and potential citizens. There, they are also coached to adopt particular postures and behaviors that enable them to access health care services and at the same time distance them from the practices and knowledge that they bring with them from their communities of origin.
Nationwide, recent immigrants frequently enjoy what is sometimes called “the immigrant paradox,” “birth weight paradox,” or “Latina paradox”: terms referring to the better-than-expected birth outcomes of recent immigrant women in spite of their socioeconomic disadvantage. Health researchers have documented similar effects among Latino immigrants on other health indicators including blood pressure, heart disease, asthma, diabetes, mental illness, and some cancers.
There has been a great deal of research in other regions of the United States on the birth weight paradox with researchers offering various hypotheses: that immigrants are healthier than non-immigrants on average, that immigrants’ diets are nutritionally superior, that social networks offer protective functions, etc. However, none of these studies has offered a definitive solution to the puzzle of the birth weight paradox, and many scholars have begun to ask whether the paradox is all that paradoxical.1 As the paradox is based on the assumption that Latina mothers can be expected to have poor birth outcomes, it seems to be an example of the “assumption of minority dysfunction” that assumes that health equals wealth and that poorer socioeconomic status is necessarily associated with poor health indicators. As David Hayes-Bautista suggests, perhaps researchers should instead focus on why “non-Hispanics are doing so poorly in spite of all of their advantages?”2
There is evidence that, over time, the health advantage of recent immigrants wears away, and eventually—as for most native-born populations—socioeconomic status becomes a more reliable predictor of health. What are the protective benefits of foreign birth and recent immigration? How are they lost over time? What can be done to stop that loss? These are big questions that require big nationwide studies and intervention. But what is clear is that the erosion of favorable health practices can be seen within even a few years following migration and it occurs with the participation of women themselves.
What is the evidence for the paradox in New York? In each year from 2004 to 2011, in New York City, Mexican immigrant women gave birth to 7,000-8,500 infants. The infant mortality rate for Mexican women was about two thirds that of the city as a whole, four per 1,000, as opposed to six. Likewise, low birth weight, a more sensitive measure of birth complications than mortality, is less common in births to Mexican immigrant women: 5.8% as opposed to 8.6% citywide.
Over time, it is anticipated that the rates of low birth weight and infant mortality that correspond to Mexican women will rise and come to be more closely correlated with low socioeconomic status, as is true for non-immigrant groups. Already, as new migration declines, second and third-generation women make up an increasing part of the Mexican community. While in 2004, 95.4% of births were to foreign-born mothers, by 2011, while the total number of births remained steady, the percentage of births to Mexican-born mothers decreased to 86.4%, a sharp indicator of the changing composition of the Mexican population.
Most women interviewed in this study migrated in the mid-1990s from rural areas where home birth and the use of lay midwives were still common, especially among the poor and working classes. More than half of the women in the study had previously given birth in Mexico and many of them described births that were relatively free of technological intervention: without anesthesia, chemical inducements, artificial rupture of the membranes, or cesarean sections. When asked how they felt about these birth experiences, many of the women described them as a consequence of poverty, but at the same time referred to them as “natural” and “normal” and “uncomplicated.” Delivering with a midwife or in a rural clinic was, for them, due to a lack of other options. Many of the women said that hospital births were a luxury only the rich could afford. Upon migrating to New York City and learning that even the poor and undocumented could deliver their babies in a technologically advanced hospital setting, women interpreted it as a sign of the greater opportunities afforded by migration—even in the first day of life, their infant’s chances would be improved. Nonetheless, they did not anticipate the degree of intervention into their pregnancies that such care implied, or the loss of protective habits that they had found helpful in the past.
Since they left Mexico, their home communities have also been transformed. An effort by Mexico to extend public health coverage to the entire population has led to greater penetration of the rural countryside with clinics, often staffed by medical students completing their training. Prenatal care and delivery has become increasingly medicalized in the United States and Mexico, as indicated by rates of cesarean sections. Approximately one third of infants in the United States are delivered surgically and the rates are even higher in Mexico, approximately 37%.3 Lay midwives have been increasingly marginalized in Mexico, with certification mandates ensuring that many are unable to achieve the requisites necessary to continue practicing. At the same time, in the United States, trendy natural birth movements aside, birth has become ever more medicalized with midwives delivering less than 10% of infants.
Even while Mexican immigrant women express enthusiasm for the access they are granted in New York State to a hospital birth, they are often ambivalent about the trade-offs such a birth experience requires. In the public hospital clinic observed, routine prenatal care visits are typically about seven minutes long and providers see whoever happens to have an appointment on a given day. Patients may never see the same provider twice. These factors ensure that patients are little able to develop a rapport with providers or establish themselves as conscientious and capable custodians of their own and their fetus’ health (compliant, in the hospital jargon). Instead, in what one nurse described to me as “in-the-trenches” health care, efficiency is an important goal: the application of the right quantity of resources to any one patient to ensure favorable outcomes. Too much would be wasteful, too little could result in complications and problems being overlooked, the ultimate threat to efficiency. As consumers of public resources, poor immigrant women who receive state-sponsored prenatal care are expected to deliver healthy infants—the public health objective—without disproportionately draining the public coffers. Thus, their health care becomes just part of a routine designed to be cost-effective, meet great demand with the fewest number of personnel hours and material resources, and ensure a baseline level of care. As a result, in the prenatal care encounter, women have little opportunity to share their accumulated knowledge and prior experience with pregnancy, birth and child rearing. (These logics, it must be said, are resisted by many of the providers within the public hospital, many of whom describe having entered the field of public health “to help people.”
While many women have experienced successful pregnancies in the past, they are rarely consulted about the practices and habits they used to care for themselves, and are instead told what to do, following a series of protocols mandated by the state, federal agencies, and the medical staff itself, and built on assumptions about poor women’s ability to care for themselves. For example, Marisol, a woman who experienced nausea in her second pregnancy did not have the opportunity in her prenatal visit to mention that nausea in her first pregnancy subsided when she ate her mother-in-law’s chicken soup. Instead, the doctor suggested she eat salty crackers. She was enthusiastic about this advice, finding it very practical, and conducive to life in the city, where no one had time, she said, to make chicken soup, and in any case, access to fresh farm-raised poultry and vegetables was limited. However, with a quick recommendation and in the absence of a more inquiry-based approach to pregnancy care (i.e., “what did you do to combat nausea in your first pregnancy?”), the doctor effectively ensured that salty crackers would replace chicken soup in Marisol’s care repertoire, with her enthusiastic assent.
In this way, pregnancy-care practices that women bring with them are shunted aside and eroded. These practices were developed over time—in some cases millennia and drawing on pre-Columbian knowledge bases—but are now sustained largely in poor and marginalized sectors of Mexican society due to a lack of viable alternatives. Despite their history and their efficacy these practices are not always valued inherently in and of themselves. Care practices like prenatal massage (sobada), dietary guidelines, use of herbs and plants, a 40-day quarantine following birth (cuarentena), avoidance of medications, minimization of stress and fatigue, may come to seem unnecessary or out of place when not explicitly endorsed by los de la bata blanca (those in the white coats). Out of reluctance to appear provincial or uneducated, or viewing such practices as accommodations to poverty, many women do not emphasize such practices, giving them up entirely or keeping them out of sight of health care providers. Further, as immigrant women, as recipients of Medicaid, and thought to have low levels of formal education, they are often thought to require guidance to care for themselves and their pregnancies, even when such guidance is partial or subtractive.
In this way, patients’ own embodied experience of pregnancy, knowledge drawn from personal and family experience, and capacity to demonstrate competence in their own self-care is marginalized in ways that may be harmful to the women’s health and that of their fetuses. Sound and wholesome self-care practices are relegated, along with childhoods shaped by poverty and marginalization, to the past, in favor of protocols of care driven by logics of cost-effectiveness, efficiency, and calculation of risk factors that anticipate—even while ostensibly working to prevent—poor health outcomes for poor patients. Immigrants become patients—patients who are schooled into certain modes of citizenship in which socioeconomic status is a legitimate means of organizing care. In these processes, immigrant women who enter the public health care system as strivers, seeking to provide their children with better opportunities than they experienced themselves, are influenced to adopt passive, consumer- oriented, and subtractive models of care that do not acknowledge their prior knowledge or reward past success and favorable birth outcomes.
1. Alberto Palloni and Jeffrey D. Morenoff, “Interpreting the Paradoxical in the Hispanic Paradox: Demographic and Epidemiologic Approaches,” Annals of the New York Academy of Sciences. 954 (2001): 140-174.
2. D. E. Hayes-Bautista, “The Latino Health Agenda for the Twenty-first Century,” In Latinos: Remaking America, eds. M. Suárez-Orozco & M. Páez, (Berkeley: University of California Press, 2002), 215-235.
3. Luz Gibbons, José M. Belizán, Jeremy A Lauer, Ana P Betrán, Mario Merialdi and Fernando Althabe, “The Global Numbers and Costs of Additionally Needed and Unnecessary Caesarean Sections Performed per Year: Overuse as a Barrier to Universal Coverage,” World Health Organization (2010), http://www.who.int/healthsystems/topics/financing/healthreport/30C-secti…
Alyshia Gálvez is Director of the CUNY Institute of Mexican Studies at Lehman College. This article is based on a research study on the so-called birth weight paradox among Mexican immigrant women in New York City. The study resulted in a book, Patient Citizens, Immigrant Mothers: Mexican Women, Public Prenatal Care and the Birth Weight Paradox (Rutgers, 2011).
Read the rest of NACLA’s Winter 2013 issue: “Latino New York“
