Explaining the Birth Weight Paradox: Latina Immigrants’ Perceptions of Resilience and Risk In the US, prenatal care is positively associated with improved birth outcomes.. INTRODUCTION T
Trang 1Explaining the Birth Weight Paradox: Latina Immigrants’ Perceptions of Resilience and Risk
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 docu-mentation 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
Knowl-edge 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 com-munities
KEY WORDS: Birth weight paradox; Latina immigrant women; participatory research; photonarrative.
INTRODUCTION
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
1 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.
2 Research Associate, Frank Porter Graham Child Development
Center, University of North Carolina; Chapel Hill, North
Car-olina.
155
1096-4045/00/0700-0155$18.00/0 2000 Plenum Publishing Corporation
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 Fur-thermore, analysis of data from the Hispanic Health and Nutrition Examination Survey (HHANES) indi-cates that LBW is significantly related to a Mexican cultural orientation, which in turn is associated with certain protective behavioral characteristics that
pre-date pregnancy (2, 5) The birth weight paradox, as
it has been called, appears to hold constant across variations in age, marital status, or educational attain-ment (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 Latino Population in North Carolina
The Latino population in North Carolina is growing rapidly Between 1980 and 1990, the Latino
Trang 2population 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
popula-tion growth of 100% or more (10) The projecpopula-tion
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
un-likely 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
new-born and no more likely than non-Latino Whites to
have an LBW child These trends are consistent to
1 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
out-comes 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
inter-ested in knowing how does this occur, so as to foster
initiatives that help others to become less vulnerable
in the face of adversity (16)
which allows a person, group or community to
pre-vent, 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-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 expo-sure 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 investiga-tors were impressed by the resiliency of children who successfully coped with biological and psychosocial risk factors and at the strength of the protective fac-tors that aided in their transition into adulthood Protective factors may not directly promote pos-itive health outcomes but may increase resistance to adverse and hazardous events It has been hypothe-size 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 characteris-tics 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 (con-sidering 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 home-land 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 pro-tective factors that we consider useful in the context
of our study: (1) dispositional attributes of the indi-vidual; (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; sec-ond, a belief in one’s own self-efficacy and ability to deal with change and adaptation; and third, a reper-toire of social problem–solving approaches The con-cept of resilience can also be applied to groups or communities in which all of their members are
Trang 3ex-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
dam-aging effects of those adversities
Given the identification of the birth weight
para-dox, 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
pro-gramming 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
influ-ence 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
op-erative at the individual, family, and community level
that Latina women, themselves, perceive as
protec-tive 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
sub-jects as well as obsub-jects in the research process Three
interrelated strategies, (a) focus groups, (b)
photon-arratives; 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
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 5 years or less; (c) have been pregnant in the United States and given birth to a child during the previous 5 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 fo-cused group interview, the women were asked ques-tions about their use of health services in Mexico with the intent of identifying preferred cultural prac-tices 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 partic-ipated 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 pre-sentation 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 in-terviewers 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 partici-pate in the ongoing data collection as community
Trang 4photographers 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
systemati-cally categorized as related to resilience or risk
fac-tors 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
pho-tographers to raise the question of human values in
photography (Hine, p 22, Ref 26) Hine was
commit-ted 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 photono vela, 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
disadvan-taged groups (inner-city schoolchildren in Durham,
North Carolina, and peasant women in China,
respec-tively) The subjects-turned-photographers are
en-couraged to document their lives, write a story, or
generate solutions to their own most pressing
prob-lems The photograph is a medium that appears to
communicate its message effectiveness not only in
low-literacy environments or in places where
print-medium 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
interviewer chose a subset of six to eight photographs about which to tell personal stories For each photo-graph, 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 popu-lation
Documentation of Local Extended Kin Networks
During this same interview, each woman was also asked to name each of the members of her ex-tended family network who lived locally in North Carolina She was also asked to describe the kin rela-tionship of that person to herself These local ex-tended 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 pro-cess 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 Ta-ble 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)
Trang 5Table 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
im-proved 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
Access and use of health services for pregnancy
and delivery acts most directly at the individual
level Strong nuclear and extended family
relation-ships 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
en-vironment
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
two-thirds 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 5 years old or younger All but two of
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 Themes Comments by Latina immigrants Access to health-care In Mexico, if you didn’t have money, services, compari- no one would take care of you sons with Mexico, Even if the services are public, one and self-care dur- has to pay Here, by contrast, ser-ing pregnancy vices are available.
[Peasant] women never drink alcohol pregnant or not pregnant
In Mexico, we are a little more conservative.
Strong nuclear and I decided [to come to the United extended family re- States] because he sent me money, lationships, espe- but it was very difficult [to raise cially during preg- the children], because the presence nancy and early of the father is necessary It is ne-childhood cessary to be together, especially
for raising the children, and for one being alone in Mexico is very difficult.
Aspirations of a bet- Guillermo began by ironing jackets ter life in the He started work two months after United States in- I started Three or four months cluding improved later, he was promoted to manager economic status He stays in this country legally and access to re- and he speaks English.
sources Here, a poor person lives like a rich
person in Mexico.
Opportunity for a What I like is the school for my better education daughter I feel that here they are for all of one’s taught better because the children 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.
Dreams of eventual The idea of coming here was to return to Mexico build our house there, in Mexico.
as one’s homeland 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.
Unanticipated hard- Here, we live in a cage of gold, but ships and frustra- it never stops being a prison tions of life in the One comes [to the United States] United States blind.
Trang 6The 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
Access to Health-Care Services in the United States
and Comparisons with Mexico
In the United States, satisfaction with the
health-care 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
moth-ers, 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
plati-cas, en Me´xico, no.
In Mexico, it is not like here—where there are
peo-ple 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
infor-mal interaction with doctors and other personnel in
the clinic Although unusual in their life experience,
Table III Latina Women’s Kin and Pueblo Networks by Categories of Relatives and Friends Living in
North Carolinaa
Total Uncles, Friends number Husband aunts, and of people and Brothers cousins, neighbors in kin and Participant children and nephews, from pueblo pueblo
(pseudonym) (1 ! no.) sisters and nieces In-laws of origin network
Elena 4 (1 ! 3) 4 15 9 — 32
Natalia 2 (1 ! 1) 2 9 7 — 20
Ange´lica 3 (1 ! 2) 1 8 9 — 21
Clara 2 (1 ! 1) 1 4 — 22 29
Luisa 2 (1 ! 1) 3 25 8 15 53
Maria 3 (1 ! 2) 3 26 5 20 57
aAverage number of people in kin and pueblo network: 35.3.
the women found the extended nature of the encoun-ters pleasant and reassuring
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 compen-sate for the lack of extended communication with one’s mother and selected other family members dur-ing 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.
Ange´lica was hospitalized in North Carolina for 2 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 con-dition, her child was born weighing 7 pounds, 8 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 Span-ish and EnglSpan-ish 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
Pues, cuando llegue aquı´ [al hospital] me empezaron
Trang 7a 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 con 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
sec-ond 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
3 weeks before the focus group interview,
approxi-mately 1 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
pre-natal 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 7 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
re-quirements 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 2 weeks As Elena had few alternatives
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 other-wise—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 sys-tem, 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 mi-grating to the United States; each of them had re-ceived 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 3 months The delivery took place
at the Seguro Social hospital The baby weighed 3
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 5 to 6 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 prac-titioner
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, be-cause the situation is urgent
Trang 8Self-Care During Pregnancy
The women also mentioned that during
preg-nancy, 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
vita-mins Although these recommendations seem well
known as ideals by the respondents, one woman
ac-knowledged that it was difficult to do 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
rec-ommended, women in each of the focus groups also
mentioned excessive weight gain as a common
con-cern 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
con-cerned 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
Dur-ing her first two pregnancies in Mexico, she
remem-bers being malnourished, and was often dizzy Then,
there was nothing she could do 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
drink-ing, are minimal among this group of women All of
the respondents confirmed that women like
them-selves neither drink nor smoke Only among
upper-class 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
preg-nant 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
or-ange 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 partic-ipant 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 ali-mentacio´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 empha-sized that her mother could provide advice on preg-nancy, even if she did not ask, because her mother had had eight children
Adema´s, mi mama´ tuvo muchas experiencias en em-barazos Tuvo ocho hijos y no todos los embar-azos son iguales.
Besides, my mother had lots of experience with nancy She had eight children and not all preg-nancies 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 com-plain to a husband, mothers-in-law, or sister, but they did not do so nearly so often as they did to their mothers
Trang 9Ange´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
prog-ressing normally, the extra care that women received
during pregnancy seemed important—and the
parti-cipants perceived that their mothers do that best
be-cause 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
impor-tant 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 con 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
An-gelica compared the weeks following delivery in this
country with common practices in Mexico In the
United States, a woman leaves the hospital and
re-sumes one’s routine immediately It may not be heavy
work, but one must do it In Mexico, mothers and
husbands take care of women For 2!" 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
keeping the family together Seven of the women had stayed behind in Mexico when their respective husbands first came to the States After 9 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 crec-iendo 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 princi-pal reason for coming to the United States When Elena had been married for only 4 months, her hus-band 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 2 years old During those 2 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
Trang 10pro-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 con mi cun˜ado, mi hermano y mis
primos, entonces me ayudan.
We do 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
mar-ried; one sister, along with her husband and two
chil-dren; a nephew, the son of a sister who lives in
Mex-ico; 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
In-cluding 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 8 to 10
ex-tended (not nuclear) family members When the
women talk of eating together, particularly on
week-ends, 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.’’
Ma-ria’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 neigh-borhoods 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 pho-tonarratives 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 every-thing is better, bigger, and easier to get
La mentalidad que uno tiene cuando esta alla´, es la