Explaining the birth weight paradox lati

Journal of Immigrant Health, Vol 2, No 3, 2000 Explaining the Birth Weight Paradox: Latina Immigrants’ Perceptions of Resilience and Risk Deborah E Bender1 and Dina Castro2 In the US, prenatal care is positively associated with improved birth outcomes However, among Mexican-born Latinos, rates of low birth weight are lower than those of US-born counterparts despite the fact that recently arrived Latino immigrants are less likely to have received adequate prenatal care The ‘‘birth weight paradox,’’ identified through analysis of the HHANES, appears to hold constant across variations in age, marital status or educational attainment The authors explore Latina immigrant’s perceptions of resilience factors related to these better birth outcomes through focused group interviews, photonarratives, and documentation of local kin networks The women’s responses are grouped into five resilience factors and one risk complex that have the potential to further explain the HHANES findings Women’s responses, the stories of their photographs, and kin networks are presented Knowledge of these protective and risk factors can be useful to health professionals and Latino advocacy groups in the design of community-based interventions that protect health status and promote the practice of protective health behaviors within immigrant families and communities KEY WORDS: Birth weight paradox; Latina immigrant women; participatory research; photonarrative INTRODUCTION 5.0% of the infants of Mexican-born mothers were of low birth weight (LBW), compared to 6.3% of infants of U.S.-born Mexican-origin mothers and 5.7% of infants of white non-Hispanic mothers Furthermore, analysis of data from the Hispanic Health and Nutrition Examination Survey (HHANES) indicates that LBW is significantly related to a Mexican cultural orientation, which in turn is associated with certain protective behavioral characteristics that predate pregnancy (2, 5) The birth weight paradox, as it has been called, appears to hold constant across variations in age, marital status, or educational attainment (4, 6) Stereotypic impressions of poor health status and health services in developing countries, which are inadequate in coverage and quality, sharpen the paradox implicit in this finding The Birth Weight Paradox In the United States, prenatal care is positively associated with improved birth outcomes for both mother and child Most well known is the association between early and consistent use of prenatal care and the reduction of low birth weight in infants (1) However, among Mexican-born Latinos, rates of low birth weight are lower than those of their U.S.-born counterparts despite the fact that recently arrived Latino immigrants are less likely to have received adequate prenatal care (2, 3) According to a 1985 nationwide study (4), only Research Associate Professor, Department of Health Policy and Administration; School of Public Health; The University of North Carolina; Chapel Hill, North Carolina 27599-7400; Fax: 919 966 6961; E-mail: deborah_bender@unc.edu Research Associate, Frank Porter Graham Child Development Center, University of North Carolina; Chapel Hill, North Carolina The Latino Population in North Carolina The Latino population in North Carolina is growing rapidly Between 1980 and 1990, the Latino 155 1096-4045/00/0700-0155$18.00/0  2000 Plenum Publishing Corporation 156 population in North Carolina increased more than 35%, from 56,000 to 77,000 persons (7–9) During the 1990–1997 time period, approximately half of North Carolina’s 100 counties experienced Latino population growth of 100% or more (10) The projection for July 1, 2000, calls for a resident population of 121,000, an increase of 56% over the previous decade (11) These numbers may be an underestimation of the actual number of Latinos residing in the state because of difficulties in locating immigrants and their limited reading ability (12) Reports of increases in the proportion of Latinos in the daily census of hospitals and health departments in North Carolina add to the perception that the Latino population is growing at a rate that exceeds projections Births to the Latino population increased from 1,752 in 1990 to 6,917 in 1997, the latest year for which data are available (13) The most recent North Carolina data available indicate that Mexican mothers were especially unlikely to receive prenatal care in the first trimester (14) However, they were still less likely than other ethnic groups to have a very low birth weight newborn and no more likely than non-Latino Whites to have an LBW child These trends are consistent to year of age, where the infant death rate of Latinos is similar to or below the non-Latino White rate and well below that of the non-Latino Black rate (14) Resilience versus Risk in Health Outcomes The concept of resilience offers a conceptual framework for the study of the birth weight paradox Studies of risk factors have shown variability in outcomes among people exposed to the same adverse circumstances, with many of them able to escape from serious negative consequences (15) Researchers in various disciplines—health, education, psychology, and social sciences—have become increasingly interested in knowing how does this occur, so as to foster initiatives that help others to become less vulnerable in the face of adversity (16) Resilience is defined as ‘‘a universal capacity which allows a person, group or community to prevent, minimize or overcome the damaging effects of adversity’’ (17, 18) The concept of ‘‘resilience or protective factors,’’ which focus on positive factors that guard or promote health status and well-being, are the positive counterpart of ‘‘risk factors,’’ which focus on illness or other deficits These protective factors include trusting relationships, emotional sup- Bender and Castro port outside the family, encouragement of autonomy and hope, responsible risk-taking, a sense of being lovable, unconditional love for someone, school achievement, a belief in God, and a strong moral sense It is useful to note that the work by Werner and colleagues (16) on resiliency grew out of earlier work on children’s vulnerability—that is, a child’s susceptibility to negative developmental after exposure to serious risk factors, such as perinatal stress, poverty, or disruptions in the family unit During the course of the 10-year follow up, the same investigators were impressed by the resiliency of children who successfully coped with biological and psychosocial risk factors and at the strength of the protective factors that aided in their transition into adulthood Protective factors may not directly promote positive health outcomes but may increase resistance to adverse and hazardous events It has been hypothesize that protective factors may operate through three different mechanisms that will result in a resilient response: compensation, challenge and immunization (19) In the compensatory model, stressful/adverse events can be counteracted by individual characteristics and/or external sources of support (e.g., family network) In the challenge model, stressful events, such as poverty and discrimination in an earlier life in Mexico, can potentially enhance competence (considering the degree of stress not to be excessive) Finally, in the immunization model, protective factors modulate the impact of stressors on the quality of adaptation, but may be not identifiable in the absence of stress For example, the stresses of life in the United States for the Latino families is mediated by aspirations of a better life in this country and by dreams of an eventual return to Mexico, the homeland These models may operate simultaneously or successively in the adaptive repertoire of a resilient individual After reviewing a number of studies on risk and resilience, Werner (16) identifies three types of protective factors that we consider useful in the context of our study: (1) dispositional attributes of the individual; (2) affectional and socialization practices within the family; and (3) external support systems that reinforce competence Rutter (20) pointed out that resilience seems to involve several elements First, a sense of self-esteem and self-confidence; second, a belief in one’s own self-efficacy and ability to deal with change and adaptation; and third, a repertoire of social problem–solving approaches The concept of resilience can also be applied to groups or communities in which all of their members are ex- Birth Weight Paradox: Latina Women’s Perspectives posed to the same stressful or risk conditions (i.e., lack of access to health services, discrimination, and racism) (15) In this case, resilience is the group’s capacity to prevent, minimize, or overcome the damaging effects of those adversities Given the identification of the birth weight paradox, there is clearly a need to identify factors that promote the resilience and protect the health status of immigrant Latino populations Recognizing the unique cultural attributes of the population and strengthening those characteristics through local programming in health, educational, and social domains have the potential to prevent the disappearance of these protective factors, thus maintaining the gains in LBW outcomes for this population It is the concept of resilience as it is protective of health status for an immigrant Latino population that is of primary interest to the investigators This paper focuses on the identification of themes related to resilience that have potential to positively influence birth weight, a key birth outcome The use of qualitative methods that included Latina women as active participants in the data collection process has enabled the authors to identify resilience factors operative at the individual, family, and community level that Latina women, themselves, perceive as protective of their health status These factors are less likely to be found as variables in national surveys such as those in which the birth weight paradox has been identified The authors also make recommendations for ways in which the strengths of the immigrant Latino population can be promoted, thus sustaining health status and, ultimately, reducing health care costs METHODS The investigators selected multiple research methods designed to include the interviewees as subjects as well as objects in the research process Three interrelated strategies, (a) focus groups, (b) photonarratives; and (c) documentation of local extended kin networks, were used Together these methods enabled women to document their strengths and felt needs having the potential to affect birth outcomes The use of these participative methods is essential to increase our understanding of resilience and risk factors that may affect birth weights while at the same time eliciting valid (rather than simply socially appropriate) responses from Latina women 157 Focused Group Interviews The data collection began with focused group interviews (21) Focus group interviews were held with Latina women, recent immigrants, who were living in Orange County, North Carolina Women who participated met the following study criteria: (a) born in Mexico; (b) lived in North Carolina as a settled-out migrant for years or less; (c) have been pregnant in the United States and given birth to a child during the previous years The objectives of these interviews were (a) to document women’s experiences with prenatal care services in the United States, and (b) to identify themes of resilience and risk that have the potential to explain the birth weight paradox During the focused group interview, the women were asked questions about their use of health services in Mexico with the intent of identifying preferred cultural practices that the women would like to ‘‘import’’ to this country, if that were possible Three focus groups were held between June 1996 and March 1997; between three and six women participated in each group Each focus group was held in the home of one of the Latina women The interviews were recorded using a microcassette; additional notes were taken by one of the investigators The women were assured that their responses were confidential Names of the women have been changed in the presentation of these results After completion of the focus group interviews, the tapes were transcribed for later analysis The analysis of both the focus groups and the women’s photodocumentaries was conducted in Spanish, then translated for presentation to an English-speaking audience By conducting the analysis in Spanish, the investigators were able to preserve subtleties in meaning that may be lost when texts are translated to English earlier in the research process Photonarratives After the focus groups were completed, the interviewers invited the women to assist in the second step of the data collection by taking photographs of themes that were important to them The women, in their roles as community photographers, took photos of people, places, and things that were a part of their daily lives—that they regarded as important to their well-being (22, 23) Because the invitation to participate in the ongoing data collection as community 158 photographers was so proximate to the focus group interviews, the link to health, as a concept central to well-being, was a guiding theme, although implicit in the actual instructions for taking photos The photonarrative method was experimental; the investigators expected (and hoped) that the women would select themes that could be systematically categorized as related to resilience or risk factors These factors, in the aggregate, may have the potential to exert a protective effect on health status during pregnancy and infancy (24, 25) The method has multiple roots In the early 20th century, they are found in the method used by documentary photographers to raise the question of human values in photography (Hine, p 22, Ref 26) Hine was committed to social change, particularly the elimination of child labor, through his photography; in fact, he coined the term photostory to describe his technique of communicating his message through combining photographs and words (27) A similar tool, called the photonovela, was used by the Peace Corps as a strategy for community development (28) Other documentary photographers have used photographs to tell the story of the inner lives of culturally distinct individuals or communities to a broader audience (29, 30) Peter McFarren (31) used photographs and text to document the challenges posed to traditional culture and the community’s health and well-being due to urban migration of the younger generation of villagers from Vilacayma in the South American country of Bolivia More recently, photographers, including Ewald (32) and Wang and Burris (33), have placed cameras in the hands of members of disadvantaged groups (inner-city schoolchildren in Durham, North Carolina, and peasant women in China, respectively) The subjects-turned-photographers are encouraged to document their lives, write a story, or generate solutions to their own most pressing problems The photograph is a medium that appears to communicate its message effectiveness not only in low-literacy environments or in places where printmedium materials are not readily available, but also across populations and time Each woman was loaned a Canon automatic camera, loaded with a 24-print roll of 35-mm film Two weeks later, the film and camera were retrieved and the film developed The following week, one of the investigators returned to conduct an individual, in-depth interview based on the photographs with each woman At the beginning of the interview, each woman was given a set of the photographs for herself as a token of appreciation Then, the woman and the Bender and Castro interviewer chose a subset of six to eight photographs about which to tell personal stories For each photograph, each woman was asked to describe (a) who was in the picture; (b) what was happening; and (c) why the picture was important to the woman The interviewer noted the story and related details with pad and pencil for later transcription Before the close of the interview, each woman was asked if she would like to comment on any other photographs Women gave the interviewers permission to display the photographs in community settings, such as the local Fiesta del Pueblo, that are intended to promote acceptance and integration of the immigrant population Documentation of Local Extended Kin Networks During this same interview, each woman was also asked to name each of the members of her extended family network who lived locally in North Carolina She was also asked to describe the kin relationship of that person to herself These local extended kin networks were then diagrammed The complete research protocol was reviewed and approved by the Institutional Review Board on Protection of Human Subjects at the University of North Carolina Analysis of Data The texts provided by the focus groups and the photonarratives were analyzed independently by the two Spanish-speaking authors (Bender and Castro) using standard techniques for analysis of qualitative data In the analysis, both ‘‘sought’’ and ‘‘emergent’’ themes were identified (21) Approximately 30 topics related to resilience and risk were identified The two authors then met to combine their individual topical lists and to regroup the topics into broader categories Six principal themes emerged from this review process The first five themes are those likely to provide insight into factors that may be protective of birth outcomes in recent immigrants; the sixth theme may constitute a risk to these same outcomes in the longer term The six themes identified are presented in Table I The first five of these factors appear to promote resilience and mediate risk through the overlapping mechanisms of the individual, the family and the larger community or society mentioned earlier (19) Birth Weight Paradox: Latina Women’s Perspectives Table I Themes of Resilience and Risk Identified by Recently Arrived Latina Immigrants Access to health-care services, comparisons with Mexico, and self-care during pregnancy Strong nuclear and extended family relationships, especially during pregnancy and early childhood Aspirations of a better life in the United States, including improved economic status and access to resources Opportunity for a better education for all of one’s children Dreams of eventual return to Mexico as one’s homeland Unanticipated hardships and frustrations of life in the United States 159 the women also participated in the photonarrative interviews and offered a description of their local kin networks, one of these moved away during the project In addition, one woman returned to Mexico for the birth of her children, although she was in the United States during her pregnancy Table II Comments Made by Latina Immigrants Related to Themes of Resilience and Risk Access and use of health services for pregnancy and delivery acts most directly at the individual level Strong nuclear and extended family relationships help to counter adverse or stressful events as well as enhancing competence through interpersonal support Aspirations for a better life, including a strong and enduring faith, and a conviction that education is important for one’s children certainly enhance the competence of individuals and families as well as serve to modulate the impact of external stressors, as described in the immunization model The dream of eventual return to one’s homeland appear to diminish the effect of negative events, enabling the person block the insult by reminding herself that the situation is only temporary The sixth theme, in its multiple expressions (explained below) seems to encapsulate the challenges to the more optimistic resilience factors Although the mechanisms can be described separately, they are in fact overlapping when operating in a dynamic environment RESULTS Description of the Participants Three groups of women participated in the focus groups All were from Mexico; they had come from the states of Guanajuato, Jalisco, San Luis Potosi, and Mexico City Approximately one-third of the women had migrated from urban areas, and twothirds had lived in small rural villages Two of the women had attended college, but none of the rest had completed schooling beyond the primary level Half of the participants were employed at the time of the interviews All currently lived with their husbands and children Each of the participants had at least one child years old or younger All but two of Themes Access to health-care services, comparisons with Mexico, and self-care during pregnancy Strong nuclear and extended family relationships, especially during pregnancy and early childhood Aspirations of a better life in the United States including improved economic status and access to resources Opportunity for a better education for all of one’s children Dreams of eventual return to Mexico as one’s homeland Unanticipated hardships and frustrations of life in the United States Comments by Latina immigrants In Mexico, if you didn’t have money, no one would take care of you Even if the services are public, one has to pay Here, by contrast, services are available [Peasant] women never drink alcohol pregnant or not pregnant In Mexico, we are a little more conservative I decided [to come to the United States] because he sent me money, but it was very difficult [to raise the children], because the presence of the father is necessary It is necessary to be together, especially for raising the children, and for one being alone in Mexico is very difficult Guillermo began by ironing jackets He started work two months after I started Three or four months later, he was promoted to manager He stays in this country legally and he speaks English Here, a poor person lives like a rich person in Mexico What I like is the school for my daughter I feel that here they are taught better because the children practice it and in Mexico don’t I wanted to study, but my father couldnot afford it and in addition to that, he would not let the girls study The idea of coming here was to build our house there, in Mexico We will have our own house now, to enjoy ourselves alone because before [coming to the United States] we lived with my mother-in-law Here, we live in a cage of gold, but it never stops being a prison One comes [to the United States] blind 160 Bender and Castro Themes the women found the extended nature of the encounters pleasant and reassuring The concerns that the women addressed were consistently repeated in focus group interviews, in the photonarrative interview, and in the kin network mapping These concerns are presented below, grouped under the six themes related to resilience and risk referred to above Findings from the focus groups and the photonarrative interviews are grouped and summarized in Table II; examples of local kin networks are presented in the section on ‘‘nuclear and extended family relationships’’ and summarized in Table III Casi no salı´a de la clinica, porque ahı´, tambie´n, pues, hay que platicar y todo eso There, I almost can’t leave the clinic, because one has to chat and all of that In the United States, informal interactions at the health clinic, when they occurred, seemed to compensate for the lack of extended communication with one’s mother and selected other family members during pregnancy Ange´lica was very pleased with the quality of care she had received A mı´, me atendieron de primera To me, they gave the very best care Access to Health-Care Services in the United States and Comparisons with Mexico Ange´lica was hospitalized in North Carolina for months before the birth of her child due to gallstones During that time period, nurses who spoke Spanish attended her She realized and commented on the fact that the quality of care she received may have been due to her high-risk condition Despite her condition, her child was born weighing pounds, ounces, and healthy In contrast, Catalina felt that the quality of the attention she received in North Carolina was not as good as that she had received in California She attributed the differences to the fact that few health professionals in North Carolina speak Spanish In Los Angeles, the majority of the nurses spoke Spanish and English Here, Catalina found that when she tried hard to prove that she could understand and speak at least some English, the quality of care which she received improved In the United States, satisfaction with the healthcare services received is often closely aligned with the quality of the interpersonal communication that occurs during visit For recently arrived Mexican women, accustomed to confiding only in their mothers, the interest on the part of doctors and clinic staff helped to alleviate their sense of loneliness and distance from extended family members En Me´xico, no es como aquı´—[donde] hay personas que le van a ayudar para el embarazo, que hay platicas, en Me´xico, no In Mexico, it is not like here—where there are people who are willing to help you with the pregnancy to teach you in Mexico, that doesn’t happen Women also commented on the extent of informal interaction with doctors and other personnel in the clinic Although unusual in their life experience, Pues, cuando llegue aquı´ [al hospital] me empezaron Table III Latina Women’s Kin and Pueblo Networks by Categories of Relatives and Friends Living in North Carolinaa Participant (pseudonym) Husband and children (1 ϩ no.) Elena Natalia Ange´lica Clara Luisa Maria 2 (1 (1 (1 (1 (1 (1 ϩ ϩ ϩ ϩ ϩ ϩ 3) 1) 2) 1) 1) 2) Brothers and sisters Uncles, aunts, cousins, nephews, and nieces 1 3 15 25 26 Average number of people in kin and pueblo network: 35.3 a In-laws Friends and neighbors from pueblo of origin Total number of people in kin and pueblo network 9 — — — — 22 15 20 32 20 21 29 53 57 Birth Weight Paradox: Latina Women’s Perspectives a tratar un poco mal Yo no hablo ingle´s, pero hablo un poquito Entonces al ver que yo me defendı´a un poco me empezaron a tratar mejor, porque me daba a comunicar ellas Well, when I arrived [at the hospital] here they began to treat me a little badly I don’t speak English, but I speak a little Then, when they saw that I could speak some English, they began to treat me better, because I was trying to communicate with them Although many Latina women in the United States delay initiation of prenatal care until the second trimester, the presence of a strong social network may result in a woman seeking care early in her pregnancy Amanda had arrived in the United States weeks before the focus group interview, approximately month pregnant Her sister, who was already here, insisted she make a prenatal care appointment At the time of the interview, Amanda had already been seen for her first prenatal care visit at a nearby clinic Others, like Catalina, delayed initiation of prenatal care due to the pressure of work With her pregnancy she did not begin prenatal care until the fifth month She explained that she did not go because of the pressure of her two jobs She did realize that she had taken a risk in delaying the start of prenatal care, and was relieved that her daughter had been born weighing a full pounds and completely healthy Several women shared their continued surprise for the number of services that were available without charge in this country En Me´xico, cuando va uno a atenderse, si no lleva uno dinero para pagar no lo atienden Aunque sea un lugar pu´blico, aun asi uno tiene que pagar Para los que tenemos hijos que han nacido aquı´, a uno le dan facilidades de pago, y la ventaja que uno puede agarrar el Medicaid In Mexico, if you didn’t have money, no one would take care of you Even if the services are public, one has to pay Here, by contrast, services are available Those who have children who were born here, know that one is given different payment options and also has the possibility of being supported by Medicaid Still, despite the availability of free services in some clinics, the women expressed frustration at not knowing how the system works—i.e., what the requirements are establishing eligibility for services Concern for multiple forms and long waiting periods were mentioned repeatedly For example, Elena went to get an eligibility card just before her third child was to be born When she presented the card to the hospital at the time of delivery, the nurse told her she would have to pay because she had had the card for less than weeks As Elena had few alternatives 161 at the moment, she had to pay the costs associated with the birth Later, when she went to the infant’s 2-week check-up, the attending doctor told her otherwise—that she had the right to services from the moment she received her eligibility card After this frustrating encounter with the U.S health-care system, Elena said that she was no longer sure whether even the people who worked in the agency knew the rules! Six women had delivered in Mexico before migrating to the United States; each of them had received prenatal care and had delivered in hospitals or maternity clinics In Mexico, Hortencia went for prenatal care at the Seguro Social in her town; her first visit was at months The delivery took place at the Seguro Social hospital The baby weighed kilos (6 lb, 11 oz) at birth Another woman, Carmen, believed strongly that children should be born in the land where their parents were born Mis hijos deben de nacer en el paı´s donde nacieron sus padres, y yo decidı´ que mis hijos nacieran en Me´xico Children ought to be born in the country of their parents I decided that my children would be born in Mexico Although she was already living in the United States, Carmen had returned to Mexico at to months during each of her pregnancies so that her children could be born in their homeland Carmen made the decision to return to Mexico, even though she had a green card for residency in the United States and could have remained here without any impediments In Mexico, many women deliver at home; this may be due to lack of resources, as described below, or because of a preference for a traditional practitioner Hay mucha gente en Me´xico que no tiene medios para estar en clinicas o en sanatorios para tener bebes There are many people in Mexico who don’t have the resources to go to hospitals or clinics to have their babies A ‘‘partera’’ or ‘‘comadrona de la comunidad’’ uses home remedies, herbs, and massages to encourage the delivery Others, noting that poor women are treated badly in hospitals, said that many women in Mexico wait until delivery is imminent before going to the hospital Then, they are treated promptly, because the situation is urgent 162 Bender and Castro Self-Care During Pregnancy The women also mentioned that during pregnancy, Mexican women are encouraged to eat greater quantities of fruits and vegetables, to drink more milk, and to eliminate salt and sweets Some women also mentioned that they were advised to buy vitamins Although these recommendations seem well known as ideals by the respondents, one woman acknowledged that it was difficult to these things because of lack of resources Tiene que comprar algunas vitaminas, [pero] no las puede comprar You should buy vitamins, but many women don’t have the money Although changes in diet were commonly recommended, women in each of the focus groups also mentioned excessive weight gain as a common concern in Mexico That is, if a woman is gaining a lot of weight, she is advised to lose weight, because the baby may be growing too big The women were concerned that a baby that was too large would cause the birth to be too difficult for the mother Elena compared the differences between her pregnancies in Mexico and in the United States During her first two pregnancies in Mexico, she remembers being malnourished, and was often dizzy Then, there was nothing she could about it; she had no money to buy food or vitamins In the United States, although food is more expensive, salaries are higher and no one is hungry in ways that she had seen in her country Behavioral risks, related to smoking and drinking, are minimal among this group of women All of the respondents confirmed that women like themselves neither drink nor smoke Only among upperclass women or, more recently, among women in Mexico City, you find women who smoke and drink Las mujeres nunca toman alcohol ni embarazada ni no embarazada en Me´xico [somos] un poco ma´s conservadores [Peasant] women never drink alcohol pregnant or not pregnant In Mexico, we are a little more conservative The women, when asked, also commented that pregnant women should avoid sudden frights and being angry during pregnancy and breastfeeding, as these attacks of anger are very bad for the child In their photographs, women also chose to show off their kitchens In one, cans of pineapple and orange juice, a carton of eggs, and several boxed mixes sat on the countertop Ange´lica explained, with a certain pride, that in the United States you can have all of the foods you want Another focus group participant commented: Bueno, en el aspecto econo´mico, uno vive un poco ma´s tranquilo Puede surtir su despensa Aunque hay mucha gente en Me´xico quiera tener una buena alimentacio´n—un vaso de leche, huevos—no lo tiene porque es muy humilde Tiene que comprar algunas vitaminas, pero no las puede comprar En Me´xico eso es muy comun Well, from an economic perspective, you can live more calmly here You can have whatever you want Although many people in Mexico would like to eat a good diet during pregnancy—a glass of milk, eggs—they can’t, because they are so poor You should buy vitamins, but you can’t In Mexico, that is very common Still another woman commented on the presence of refrigerators in all of the apartments, reminding us that few families can afford such a luxury in Mexico Strong Nuclear and Extended Family Relationships Maintaining strong family relationships was the theme expressed repeatedly by all of the women The six women who had been pregnant since arriving in the United States commented at length on the extent to which they missed the advice and support of their own mothers during that time period Luisa emphasized that her mother could provide advice on pregnancy, even if she did not ask, because her mother had had eight children Adema´s, mi mama´ tuvo muchas experiencias en embarazos Tuvo ocho hijos y no todos los embarazos son iguales Besides, my mother had lots of experience with pregnancy She had eight children and not all pregnancies are the same During pregnancy, the need to talk over one’s fears with one’s own mother was mentioned repeatedly Luisa had visited with her mother daily when she was pregnant and still in Mexico A mother is the person to whom one could most easily complain and receive a sympathetic ear Other women in the group agreed that mothers were an important source of support during pregnancy, as well as at other times Sometimes, the women added, they were able to complain to a husband, mothers-in-law, or sister, but they did not so nearly so often as they did to their mothers Birth Weight Paradox: Latina Women’s Perspectives Ange´lica was pregnant with her first child in this country Her sister was nearby during her pregnancy, and there was one other woman to whom she could talk However, she still found it necessary to call her mother in Mexico to talk about her fears When she talked to her mother, even though the latter was far away, she was reassured by hearing her mother describe signs and symptoms of a normal pregnancy Even more than knowing the pregnancy is progressing normally, the extra care that women received during pregnancy seemed important—and the participants perceived that their mothers that best because they are the ones who understand best La mama´ siempre escucha; la mama´ siempre ayuda; el papa´ te protege Aquı´ no Aquı´ no te protegen, aquı´ no te escuchan, aquı´ nadie te mima A mother always listens; a mother always helps; a father protects you Here, no Here, nobody protects you; nobody listens, nobody pampers you Ange´lica’s mother also cautioned her not to go out during an expected eclipse of the moon; doing so could harm the unborn baby This latter caution, and the affirmation of its importance by other women in the group, suggests that mothers also play an important role in transmitting traditional beliefs during pregnancy The importance of regular telephone contact was emphasized through one woman’s photograph of a telephone hanging on an otherwise blank wall The photographer, Carmen, explained her choice of the photograph: El tele´fono es muy importante para la comunicacio´n Te comunicas tu familia alla´ No se considera un lujo en este paı´s, sino una necesidad No es como en mi paı´s Aquı´ hay lı´neas por todo lado The telephone is very important for communication You can communicate with your family [in Mexico] It is not considered a luxury in this country, but a necessity It is not like in my country; here the lines go to everywhere The quality of this emotional support translates into exceptional care during the postpartum period Angelica compared the weeks following delivery in this country with common practices in Mexico In the United States, a woman leaves the hospital and resumes one’s routine immediately It may not be heavy work, but one must it In Mexico, mothers and husbands take care of women For months they tend to her, urging extra rest, preparing special foods, and taking care of the household chores The women also talked about the importance of 163 keeping the family together Seven of the women had stayed behind in Mexico when their respective husbands first came to the States After months in the United States, Hortencia’s husband was not happy living apart from his family and considered returning to Mexico It was a difficult time for them both Hortencia’s husband was determined to reunite with his family; he told her that either she would have to come to the United States or he would return to Mexico Hortencia finally decided to come to the United States El [mi esposo] tambie´n a veces me decı´a, ‘‘Quisiera estar junto a mi hijo para verlo como diario va creciendo y lo que hace y reirnos juntos de sus travesuras.’’ He [my husband] also told me sometimes, ‘‘I would like to be with my son to see how he grows everyday and what he does and laugh together at his pranks.’’ The importance of a father’s presence in raising children was mentioned by most women as the principal reason for coming to the United States When Elena had been married for only months, her husband migrated to the United States She was pregnant with their first child Elena’s husband did not return to Mexico until their son was almost years old During those years, Elena received money from her husband; she lived both at her parents’ home and her parents-in-law’s home On his return, Elena’s husband was not content and soon decided to return to the United States He asked Elena to return to the United States with him Elena remembers not wanting to come She stayed behind, partly because she was pregnant When her daughter was 19 months old, Elena finally decided to join her husband in the United States Yo me decidı´ porque e´l me mandaba dinero pero era muy difı´cil [criar a los hijos] porque siempre hace falta el papa´ Es necesario estar juntos, sobretodo por la educacio´n de los nin˜os, y uno solo en Me´xico es muy difı´cil I decided [to come to the United States] because he sent me money, but it was very difficult [to raise the children] because the presence of the father is necessary It is necessary to be together, especially for raising the children, and for one being alone in Mexico is very difficult In addition to immediate family members, most of the women interviewed also had close relatives living nearby The women explained that when one member of the family comes to the United States, that person would gradually bring other members of the family—including his wife and children, brothers and their wives, and cousins The early arrivers pro- 164 Bender and Castro vide support for the others to start here, including shelter and food As newcomers start working, they begin to contribute to the cost of rent and utilities, making life here more affordable for all in the family Each family, typically, also sends part of its earnings to Mexico to help support family members there No vivimos nada ma´s una familia en un apartamento, esta´n mas familiares, primos y hermanos, ya se reduce lo de la renta y todo, cable, luz y dema´s Como yo ahorita vivo mi cun˜ado, mi hermano y mis primos, entonces me ayudan We not live just one family in an apartment, there are other relatives, cousins and brothers This reduces each one’s expenses in rent and everything, cable, power and so on Like in my case, right now I live with my brother in-law, my brother and cousins, then they help me An illustrative example of how extended family networks are composed is Elena’s kin network (Fig 1) She lives with her husband and three children Some relatives live with them in the same apartment Still others live in other units in the same apartment complex Elena’s relatives living in North Carolina include her three children; her three brothers, along with the wives and children of the two who are married; one sister, along with her husband and two children; a nephew, the son of a sister who lives in Mexico; two cousins (brothers) and the wife and child of one of the two; and four cousins (one sister and three brothers), one brother with wife and children Elena’s husband, Severo, has one brother, three nephews, and one cousin who also live close by Including Elena, 33 relatives lived locally at the time of the interview These networks are extensive—larger than the authors had anticipated given our earlier focus-group conversations with the women Even smaller networks of these women had to 10 extended (not nuclear) family members When the women talk of eating together, particularly on weekends, it is with this extended network Each family unit brings a dish or two, and all gather at one family’s home or at a local recreational park The gathering is an opportunity to live as though they were at home, in Mexico, at least for these several hours The case of Maria (not diagrammed) is similar, except that she and her family have also helped friends from their pueblo to come to the United States and have supported them, as did Elena’s family on their arrival She said, ‘‘It is as though we have moved our little village from Mexico to here.’’ Maria’s relatives living in North Carolina include one sister, her husband, and two children; two brothers (one is married but his wife and children are still in Mexico); two uncles; two nephews; and 17 cousins Maria’s husband, Luis, has three cousins living nearby In addition, there are about 20 other persons from her village living in the same or nearby neighborhoods Clearly, in the beginning the presence of extended family members and other friends provides emotional support and insulation from the challenges posed by live in the United States An extension of the strong emphasis on family is the recognition of the central role that the belief in God and Jesus Christ play in guiding family and community One photograph, taken by Angelica, showed her gathered with her family On the wall was a framed print of the Last Supper Angelica told the interviewers that the print was the first thing that the family had purchased when they had saved a little extra money The raised hands of the Lord reminded Angelica and her family to give thanks at each of their meals and was a symbol of the family’s strong faith Aspirations of a ‘‘Better Life’’ in the United States Women in each of the focus groups recalled the dreams they had had of the ‘‘good life’’ when they were asked why they had decided to migrate to the United States This theme also emerged in the photonarratives Ange´lica took several photographs of her children in the park to show the bushes and the things they had for children in the United States (24, 25) A friend of hers, Antonia, added that she had been told that it was more comfortable here and that it was easier to have things here than in Mexico The two added that there were also opportunities in the United States for a better education—even English lessons were free Se piensa que aquı´ es un paı´s donde uno puede llegar a tener e´xito; que puede conseguir trabajo; que se puede ser alguien [In Mexico] people think that here is a country where one can be a success; where one can get a job; and be someone For Catalina, life in the United States seemed magical Others nodded in agreement Before coming to the United States, they thought they would be able to have everything Ange´lica explained that when people return from the United States, they tell stories about how pretty things are there and that here everything is better, bigger, and easier to get La mentalidad que uno tiene cuando esta alla´, es la Birth Weight Paradox: Latina Women’s Perspectives 165 Fig One immigrant woman’s local extended kin network ambicio´n de todo Hispano, ‘‘Lo primero que voy hacer cuando este alla´ es trabajar y comprarme un carro, porque en mi paı´s no lo puedo tener.’’ The idea that one has there [in Mexico] is the dream of every the Hispanic, ‘‘The first thing that I am going to is work and buy myself a car, because in my country, I could not have one.’’ Hortensia took a photograph of her family’s car, explaining: No tenı´amos auto en Me´xico Es la primera vez que tenemos uno y por eso cuando subimos, no nos queremos bajar de e´l We did not have an automobile in Mexico This is 166 Bender and Castro the first time we have one, and for that reason, when we are in the car, we don’t want to get out Although there is much that all women agreed is good—the food, vitamins, and salaries—the reality of life here is very different from these womens naăve expectations Carmen had been in Dallas, where her husband was a construction worker, for months After that, her husband was offered a construction position in Charlotte, North Carolina After months, he was offered a position with the same company for a better salary, but the position required a move to Pennsylvania The family moved and stayed there for year, before moving again to North Carolina A few months after this study finished, the investigators learned that Carmen had moved again All of the women agreed that the economic benefits of being in this country were great Salaries were higher and one could afford to buy things that one never had in Mexico Things like a car and clothes, shoes and toys for the children were within reach of the Latina’s budget in the United States Ange´lica gave an example to illustrate the difference in income in the two countries Alla´, no se compra uno zapatos cada ocho dı´as, ni cada mes, sino cada an˜o Aquı´ no, aquı´ uno se puede comprar un par de zapatos cada ocho dı´as, aunque sea de segunda pero hay There, one can’t buy oneself a pair of shoes, not every eight days, nor every month, but once a year Here, one can buy a pair of shoes every eight days, even though they may be second hand and not the best quality but you can [buy them] The other women nodded again in agreement, acknowledging the aptness of the analogy Although housing and food were more expensive in the United States, salaries were also higher It was possible to save, if one shared the cost of rent and sometimes ate meals together Lo que pasa es que aquı´ vive uno de pobre como un rico en Me´xico A poor person here lives like a rich person in Mexico Another component of the economic benefits of this country according to the women is that, if you really want it, you can get a job Zoila came and worked so as to help her parents who were still in Mexico She sent money every month or two to Mexico Hortensia took a photograph of a friend, Guillermo, in the dry-cleaning establishment where both worked Guillermo entro´ planchando sacos, dos meses despue´s que yo comenze´ Tres or cuatro meses despue´s lo ascendieron a ‘‘manager.’’ El esta´ legal y habla ingle´s Guillermo began by ironing jackets He started work two months after I started Three or four months later, he was promoted to manager He stays in this country legally and he speaks English In North Carolina, where this study was conducted, rates of unemployment are low, at around 3% In addition, the immigrant Latino population has earned the reputation of being good workers As a result, workers may be rewarded with promotions and wage increases Opportunity to Receive an Education Education for one’s children was a second important reason mentioned by the women for agreeing to come to the United States They reported that education was expensive in Mexico, especially secondary education For Hortencia and her husband, this was an important reason to bring the whole family to the United States She said that if they had stayed in Mexico, their son would not have been able to attend high school because they could not afford it Maria is convinced that education is better in the United States than in Mexico A mı´ lo que me gustado es la escuela de mi hija Yo siento que aquı´ los ensen˜an mejor porque lo practican y en Me´xico, no Aquı´ tienen aparatos para hacer las cosas y les dan todo, es muy difı´cil tener a los hijos en la escuela [en Me´xico] Para tenerlos en la secundaria es muy difı´cil What I like is the school for my daughter I feel that here they are taught better because the children practice it and in Mexico don’t Here, there is the equipment to things and they give the children everything they need [to learn] It is very difficult to have one’s children in school [in Mexico] To have them in high school is very difficult Another aspect mentioned by the women was the inability of women to get an education in the villages in Mexico In families with low incomes and many children, parents often chose to send only boys to school Education of girls was not a priority Maria told us that she had had to struggle to finish primary education Tenı´a ganas de estudiar, pero a mi papa´ no le alcanzaba y aparte que no le alcanzaba, a las mujeres no las dejaba estudiar I wanted to study, but my father could not afford it Birth Weight Paradox: Latina Women’s Perspectives and in addition to that, he would not let the girls study Luisa, one of two participants who had attended college, described how she had finished high school and enrolled in a vocational school against her father’s will and without his financial support Vendı´a tortillas Sufrı´ mucho para estudiar, pero me siento muy orgullosa de haberlo hecho yo sola A veces no tenı´a ni para un chicle en la escuela, le digo Me gustaba mucho estudiar I sold tortillas I suffered a lot to be able to study, but I feel proud I could it by myself Sometimes I did not have enough money to even buy a gum at school I Iiked studying very much In a closely related theme, Carmen, the other participant who had attended college, described a photograph of herself with her English as a second language (ESL) teacher She talked of the importance of learning English so as to be able to manage one’s own daily life Sabiendo Ingle´s, ya puedes resolver ma´s tus cosas o problemas que se presentan Antes mı´ esposo tenı´a que acompan˜arme al me´dico, al dentista, al banco, al correo, y e´l perdı´a de trabajar Ahora, ya no dependo tanto de e´l Knowing English, you can solve problems that happen to you better Before, my husband had to go with me to the doctor, the dentist, the bank, and the post office He was losing time from work Now, I not have to depend so much on him Knowing English clearly increase one’s independence as well as securing better treatment at health services, as described earlier Dreams of Mexico as One’s Homeland When talking about their reasons for coming to the United States, some of the women talked about wanting to earn money in the United States so as to return to Mexico With their earnings, they would be able to improve their living conditions there Clearly, these women considered their time in the United States to be temporary Clara said that she, her husband, and her daughter had lived with her motherin-law before coming to the United States because her husband’s salary was not enough for them to buy a house She dreamed that all would be different on their return Nosotros no teniamos ni casa, ni nada Ahora, bendito sea Dios, el trabajo de mi esposo ya estamos haciendo nuestra casita [en Me´xico] 167 We did not have a house nor anything else Now, may God bless you, with my husband’s work, we are now building our house [in Mexico] Luisa echoed Clara’s words La idea de venirnos para aca´, pues, fue para hacer nuestra casa alla´ en Me´xico Ya tenemos una casa propia, para estar a gusto solos pues antes viviamos mi suegra The idea of coming here was to build our house there, in Mexico We will have our own house now, to enjoy ourselves alone because before [coming to the US] we lived with my mother-in-law Another woman, Maria, said that she and her husband had a house in Mexico When her husband had come first to the United States to find work, she decided to join him, hoping that she, too, could find work Her dream was to be able to move to a more desirable neighborhood on return to Mexico Nuestra casa esta rentada Le ido bien a mi esposo y a nosotras (ella y su hermana venden comida) y tenemos otra casa, pero ma´s al centro del pueblo La primera casa esta en una colonia [lejos del centro].’’ Our house is rented My husband’s and our work is going very well (she and her sister sell Mexican food) and we have another house now, but this one is closer to downtown The first house is in a neighborhood [far from downtown] Even as the women spoke of their dreams of returning to Mexico, something in their words suggested that these dreams might not be realized The opportunities for work and economic gain seem to take priority over preferences for a calmer and more traditional life style Luisa already knew that her husband had little intention of returning Ya despue´s a mucha gente, ya estando aquı´ y disfrutando de todas las comodidades dicen pues ‘‘¿Para que voy a Me´xico?’’ Una vez le decı´a a mı´ esposo, ‘‘Cuando nos vamos para Me´xico,’’ el me dijo, ‘‘Yo ya no me voy a imponer a trabajar en Me´xico, no me voy a conformar a ganar 200 pesos a la semana mientras que aquı´ gano eso en un solo dı´a.’’ After a while many people who is living here and enjoying all the comforts say ‘‘For what reason would I come back to Mexico?’’ For example, when I ask my husband, ‘‘When are we going back to Mexico?’’ he answers, ‘‘I am not going to put myself in the position of working in Mexico, having to resign myself to earn 200 pesos per week while here I earn that money in a day.’’ The last question in the focus group asked the women about what they would bring from Mexico, if they could, to make their lives in the United States better All women said that they would like to bring 168 Bender and Castro their parents and sisters and brothers For them, ‘‘family’’ means more than the nuclear family, it includes all members of the extended family Adema´s, aquı´ hay ma´s presio´n; no le perdonan a uno el alquiler hasta el cable tiene uno que pagar No existe la posibilidad de postergarlo La foto la tome´ el dı´a que vino a decir que se regresaba Pues amigas, aquı´ se puede hacer uno de nuevas amigas y las dema´s [que tenı´a uno en Me´xico] alla´ que se queden, pero padres solo unos It is my brother, Raul He has already returned to Mexico He was here for eight months, but he was not happy Here, life is go-to-work and come-backhome There are not dances [or parties] to attend Besides, here there is more pressure; there is no way of postponing the rent Even the cable you have to pay There is no possibility of postponing it I took the photograph the day he came to say that he was going back Friends, one can make new friends and the others [the ones we had in Mexico] can stay there, but one’s parents are unique Unanticipated Hardships and Frustrations of Life in the United States Although economic opportunity in the United States has enabled the families of the women who participated in the focus groups to create a ‘‘better life,’’ each woman spoke of unanticipated difficulties she and her family had faced The decision to come to the United States is often made naively, as noted above, often on the basis of glowing but incomplete conversations with others The decision to migrate often was made quickly, after discussing the idea with only one or two persons Catalina expressed the lack of preparation for the change Uno viene como ciego One comes [to the United States] blind Several women remembered their thoughts about the United States while still in Mexico In those recollections, the thought of overcoming whatever challenge might be was uppermost in their mind Now, they reflected much more concretely on the effort required From a distance, everything appeared so easy; only now was it clear how little they had thought about how they would survive, how they would communicate, or keep themselves healthy in such a new and different place Alla´ uno no piensa que es problema, pero llega aquı´ y se le cae a uno el mundo There, no one thinks it is a problem, but on arriving here, it is as though the world fell on your head The adjustment is even harder for single persons, usually young men, according to the women Amanda talked about a picture of her brother, whom she had photographed, head down, twisting his fingers around a small string Es mi hermano, Raul Ya esta´ en Me´xico Estuvo´ aquı´ ocho meses, pero no estaba a gusto Aquı´ la vida es a trabajar y a la casa No habı´a bailes para ir The women tended to agree that their inability to communicate with the larger society was the most difficult adjustment for them Because she could not communicate in English well enough to buy groceries for the family or clothes for her children, Catalina remained at home during the week She would only go out with her husband on weekends Even then, she was sometimes subject to shameful discrimination The room fell silent as she repeated one particular incident It was in a convenience store, shortly after she arrived here She didn’t speak much English and was uncomfortable about it She purchased some sodas and snacks The clerk, in returning her change, ‘‘accidentally’’ dropped it on the floor As Catalina stooped to pick up the change, she was poignantly aware of the clerk’s double message Antonia picked up the conversation, reflecting on the incident ‘‘A woman feels powerless, because one hasn’t [even] said anything One is humiliated when one comes to this country.’’ Elena took a photograph showing the wrought iron staircase in an otherwise dark entrance to her apartment Three women are about to ascend the stairs; the viewer sees only their backs She explained to the interviewer that living conditions are better in the United States than in Mexico, but there were also risks here, too In Mexico, everyone knew every one else; it was safe It was not like that here, and often women were afraid to go out Elena summarized: Aquı´, vivimos en una jaulita de oro, pero que no deja de ser una prisio´n Here, we live in a cage of gold, but it never stops being a prison Elena’s eloquent but simple words describe the paradox of life in the United States for Latino immigrants DISCUSSION AND RECOMMENDATIONS This study represents an important step in explaining the birth weight paradox that goes beyond Birth Weight Paradox: Latina Women’s Perspectives the findings presented through analysis of the HHANES survey The photonarrative method linked to focus groups, as we have used it, appears to be an effective means of eliciting Latina women’s perceptions of factors that strengthen or pose a risk to their health and well-being The method, as it has been used in this study, is experimental and innovative Focus groups have been used many times to explore dimensions of a little understood or emerging problem in health research (21, 34) However, the stories told by the women in explaining their photographs build on and extend the focus group method The women’s photographs and accompanying stories are completely their own The women, through their participation, have contributed thoughts and ideas, that contribute substantively to answering question posed by ‘‘the paradox’’ (35) Their answers, as well, generate questions appropriate to further research exploration In asking the women to take photographs of themes—people, places, and things—that are important to them, the investigators hoped (and anticipated) that the women would select themes that could be systematically categorized as related to resilience or risk factors In fact, the photographic choices of the women were exquisite; their stories no less poignant (24) Furthermore, each woman was articulate in her explanation of the importance of the selected persons or objects in the photograph in her life These themes appear to represent factors including demographic characteristics, medical risks and behavioral and environmental risks that are recognized as exerting a protective effect on health status during pregnancy and infancy (1) The results presented from this pilot study are descriptive, not analytic or causal However, the descriptions provided by Latina women and their descriptions of extended kin networks suggest a set of resilience factors that appear to help explain the birth weight paradox That is to say, increased prenatal care use and the support provided through by health professionals, especially nursing personnel, an improved diet, and supplemental use of vitamins, and negative sanctions on the use of alcohol and cigarettes are factors that have been identified as contributing to improved birth outcomes The social support provided by other local family members and neighbors who have also migrated from Mexico provide needed social support that is effective in reducing stress and buffering against the demands of the majority culture Women’s use of the telephone to lean on their mothers in Mexico during pregnancy is a 169 particularly notable example of how patterns of traditional culture are sustained in spite of changes in geography and residence The dreams that each women harbors for improved economic circumstances, educational opportunity for children and eventual return to the homeland, although perhaps naăve, provide protection during a difficult transition They are dreams waiting to be realized For a time, it seems, these protective factors, associated with birth outcomes, hold negative outcomes at an arm’s length This study has some interesting parallels with another recently published study that tests the hypothesis that migration selectivity accounts for differences in birth weights to Mexican born women delivering in the United States (36) The two studies arrive at quite similar recommendations, although the two sets of authors arrive there through quite different paths Weeks and colleagues (36) examine six hypotheses using a dataset constructed from birth records and interviews for Mexican women giving birth in Tijuana, Mexico, and Mexican-born women, U.S.-born Latinas, and U.S.-born non-Latina Whites delivering in San Diego After testing the models with multivariate analyses and logistic regression analysis, the investigators conclude that the effects of culture on Mexican-born women delivering in the United States ‘‘ameliorate risk and promote salutogenic behavior’’ (p 88) They state further that ‘‘access to better housing, cleaner water, more effective sanitation, and more readily accessible health care may immediately improve health for an immigrant’’ (p 89) The noted cultural patterns include reference to nonuse of alcohol, tobacco, and drugs, but unfortunately not include any reference to the availability of an improved diet, notably an increase in total carbohydrates and use of vitamin supplements Nor does the study capture the probable protective effects of social support of simultaneous migration of extended family members and neighbors from hometowns in Mexico Nonetheless, the authors conclude that their findings suggest the need for programs designed not only to increase access of Mexican immigrants to prenatal care, but also to encourage the maintenance of cultural behaviors related to positive health outcomes RECOMMENDATIONS FOR SUSTAINING RESILIENCE The resilience factors identified in the study reported here may indeed be a result of reservoir of 170 coping mechanisms accrued through successful responses to stressful circumstances in Mexico The authors not dispute this possible alternative explanation What is of more urgent interest is the need to ‘‘focus on protective processes that bring about changes in life trajectories from risk to adaptation’’ (Rutter, p 511, Ref 16) In the Kauai Longitudinal study, Werner (16) found these protective processes included, among others: (a) structure and rules in the household; (b) time spent with caring adults outside the family circle; (c) the promotion of competence and self-esteem; and (d) the achievement of effective reading skills Werner was concerned for the promotion of these protective processes in children and adolescents, but an analogy can be made to Latina immigrant women, many of whom have barely graduated from adolescence themselves If circumstances of recent Latino immigrants not improve steadily over time, and the authors refer particularly to the wave of immigrants currently arriving in North Carolina, it is reasonable to assume an increase in the prevalence of risk factors (and a related decrease in the protective effect of resilience factors) among longer-term Latina residents Referring specifically to the results of this study, the authors found that access to health-care services and self-care were valued by the women during their pregnancies However, studies of Latino women find that they are less likely to use prenatal care (2, 3) Also, Weeks and colleagues (36) have found evidence [inconsistent with Scribner’s (3) analysis] of a positive correlation between a low number of prenatal care visits and the percentage of low birth weight babies among Mexican-born women in San Diego in a recently published study based on birth records and interviews Furthermore, although while many health departments and clinics offer prenatal care and delivery services, and childhood immunization services at no or minimal charge, the same largess is not available for episodic care and other preventive services To counter limited access to health services, we recommend additional examination of ways in which cultural and familial factors sustain self-care practices, including improved diet and use of vitamins (6) and protection against the use of negative health practices, including cigarette smoking and alcohol consumption (37, 38) Pressures to acculturate, that are particularly strong among school age children (39) and limitations on the growth potential of income may curtail residential options for Latinos, thus exposing younger members of the family to adverse influences (40) Bender and Castro The Mexican influence on a strong nuclear and extended family relationships, especially during pregnancy and early childhood, is one of the four protective processes identified by Werner (16) known to promote resilience There are pressures on family members, especially children, to conform to ‘‘American ways,’’ however, current widespread concern for the whereabouts of the American family may provide an opportunity in disguise In a recent appearance on National Public Radio (NPR), Nolo Martinez, the director of the North Carolina State Office of Hispanic and Latino Affairs, suggested that the strong family values of the Latino population will help (41) That is, their values will help to strengthen through contributions in culture, community, and family values Advocates at the state level in North Carolina, like Martinez and others leading efforts to form county (42), city (43), and community level (44) coalitions, are helping to promote awareness of the strengths of this immigrant population–and at the same time encouraging Latinos not to let go of their ‘‘best.’’ The women in this study spoke frequently of the opportunities for employment resulting in improved economic status and access to resources and aspirations for a better life in the United States Most of the opportunities they spoke of were for their husbands Although the women shared in the fruits of the increased access to resources, they were somewhat less enthusiastic about their migration experience Several stated that they had come for the children Although it is true that family income improves on arrival in this country, it is also true that many Latinos continue to live in relative poverty Earnings for employed women of Mexican origin (at $8,110) as compared to that of white women (at $11,241) are among the lowest for any economic group in the United States (40) Women’s presence reunites the family unit, and reinstates accepted norms for family behaviors—at least within the family circle Werner (16) makes reference to rules within the household and the promotion of sense of competence as processes that promote resilience Being together, while not a guarantee, is one condition necessary to sustaining these values The resilience factor associated with increased economic resources is complex, as the same level of income has substantially different meanings over time Also, while the will to work, and work hard, is earning Latinos in this region the reputation as ‘‘excellent workers,’’ low levels of formal education will limit the ability of many to sustain the gains made on immigration For women, who are more Birth Weight Paradox: Latina Women’s Perspectives likely to report that they are not working than their male counterparts, the potential for eventual employment may be more limited due to fewer opportunities to learn and refine English language skills An opportunity related to improved economic circumstances is the chance for one’s children to receive an education In some instances in Mexico the women stated that they had earned so little that they were unable to afford the costs of books and school supplies for their children The respondents appeared to place a strong value on education, and spoke of it (or its lack) as one cause of limited employment opportunities for themselves or husband The Latina women did not address the difficulties that some children are known to be having in some schools due to limited English proficiency and being different (45, 46) Several of the interviewees did talk about the importance of learning English For these women, not only were ESL lessons helpful, but the Americans who worked with them were identified as a helpful and highly valued resource in making sense of and managing the dominant U.S culture Asking for assistance with studying for a driver’s license, help with adjustments to bills, and understanding which and why certain forms were necessary for completion of a particular application were among the tasks for which the Latina women had requested assistance Although the ESL training itself helped respondents to adapt to their new surroundings, the support offered by the ESL volunteers seems to offer at least some of the ‘‘emotional support outside the family’’ and the ‘‘encouragement of autonomy’’ that is thought to promote resilience in stressful circumstances Dreams of eventual return to Mexico, as one’s homeland, are probably protective against a multitude of stressed during early periods of adjustment in the United States Women spoke of sending money Mexico to buy a plot of land against their eventual return, in addition to the funds they send to help other relatives At the same time, as a greater proportion of income is needed for expenses here and cultural differences between here and there, particularly given children’s adaptation to their day-to-day reality, holding on to the dream may be stressful due to the dissonance between the dream and the emerging reality The authors have not found this aspect of risk addressed in published literature, but there are multiple experiences among colleagues (including the Latina author of this paper) and friends to suggest that the phenomenon is well known among immi- 171 grant populations This is a topic that requires further research Unanticipated hardships and frustrations of life in the United States grate against resilience factors The long-term challenge of maintaining close ties to relatives in a different time and place, the effort of working two or three jobs, the slowness of gaining command of a second language, the costs of unexpected events such as injuries or illnesses without health insurance, and the stress that these factors place on marital and family relationships are among the risk factors that each woman and her family is still to face (44, 46) The reserves stored from early life experiences in one’s homeland and the ‘‘luck of the draw’’ for immigrants in the United States may determine the proportion of resilience and/or risk in any particular family As acknowledged earlier, this research cannot pretend to provide answers to the larger questions it has raised What the research has done is to push our understanding of possible factors contributing to the birth weight paradox far beyond the answers that have been able to be provided through the analysis of the HHANES survey These explanations, obviously, need to be tested through further research, using both cross-sectional and longitudinal data analyses The addition of a comparison group with Latino women who have resided in the United States for 10 years or more would strengthen the analytic results The parallel use of the photonarrative method would be worthwhile with longer-term residents to assess changes in perceived patterns of family support and other health related behaviors according to the respondents Still, an additional analysis of interest is the incidence of secondary migration (migration of Mexican families from California to North Carolina) as compared to primary migration (migration directly from Mexico to North Carolina) The results of this study will be useful in the design of an intervention research initiative using community-based (47) and participatory methods (35) Drawing the attention of recently arrived Latinos to the protective factors in their culture through leadership training and related interventions designed to promote efforts that maintain these protective factors, and, in turn, health and well-being, ought to be included as an objective of such a study One such community-based model was the WashingtonHeights–Inwood Healthy Heart Program (48) The intervention focused on the promotion of low-fat milk, exercise clubs, and a Spanish-language smoking-cessation program An essential component of 172 the campaign strategy was building support from key community organizations and leaders Assistance was also provided by churches, newspapers, radio stations, schools, and voluntary parent associations (49) Additional factors to be emphasized in the intervention include concepts of family and community, the importance of language skills, influence of prayer and spiritual elements in the lives of Latinos, and the identification of community-based partners (39) For instance, the presence of an extended family network appears to provide much-needed emotional support in the recent immigrant Latina population Gainful employment and the opportunity for advancement are related factors that appear to have a protective effect on the health of pregnant women and their infants These two factors are closely interrelated, pulling family members to the United States for employment and in order to maintain family integrity The short-term economic gain has a reassuring effect and, in part, serves to insulate against the feelings of loneliness and separation from one’s extended family Educational messages that increase awareness of the power of these protective factors, could extend their worth in the longer-term Perhaps knowing patterns of increased risk that have occurred to longer-term residents through presentation of case studies will enable recent immigrants to take steps that are protective and continue to help maintain and promote the positive health outcomes that have come to be identified with this recent immigrant group Bender and Castro 10 11 12 13 14 15 ACKNOWLEDGMENTS 16 The authors would like to thank the Duke– University of North Carolina Institute for Latin American Studies for its support of this project, given 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