J Immigrant Minority Health DOI 10.1007/s10903-015-0178-0
ORIGINAL PAPER
Subjective Social Status, Mental and Psychosocial Health, and Birth Weight Differences in Mexican–American and Mexican Immigrant Women K. Jill Fleuriet1 • T. S. Sunil2
Ó Springer Science+Business Media New York 2015
Abstract Recent Mexican immigrant women on average have an unexpectedly low incidence of low birth weight (LBW). Birth weights decline and LBW incidence increases in post-immigrant generations. This pilot project tested the hypothesis that subjective social status (SSS) of pregnant women predicts variation in birth weight between Mexican immigrant and Mexican–American women. 300 low-income pregnant Mexican immigrant and Mexican– American women in South Texas were surveyed for SSS, depression, pregnancy-related anxiety, perceived social stress and self-esteem and subsequent birth weight. No significant difference in SSS levels between pregnant Mexican immigrant and Mexican–American women were found. However, SSS better predicted variation in birth weight across both groups than mental and psychosocial health variables. Results suggest distinct relationships among SSS, mental and psychosocial health that could impact birth weight. They underscore the relevance of a multilevel, biopsychosocial analytical framework to studying LBW. Keywords Birth weight Hispanic women Stress Status Culture
& K. Jill Fleuriet [email protected] 1
Department of Anthropology, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX 78249, USA
2
Department of Sociology and Institute for Health Disparities Research, The University of Texas at San Antonio, San Antonio, TX, USA
Background Low birth weight (LBW), defined as \2500 g (5 pounds, 8 oz), predicts infant, child, and adult ill-health. Low birth weight can result from an infant that is small for gestational age or an infant born prior to 37 weeks of gestation, i.e., preterm birth. Low birth weight is a leading cause of neonatal mortality [1–4]. It is associated with infant mortality, impaired physical and developmental health, and long-term disability [1, 2]. Low birth weight correlates with adult onset of asthma, hypertension, diabetes, stroke, heart attack, other heart disease [3], and psychiatric conditions stemming from neurodevelopmental disorders [4]. The epidemiology of LBW illustrates significant ethnic differences. In 2010, non-Hispanic Black women had the highest rates of LBW (13.53 %). Non-Hispanic White women had LBW rates of 7.14 %, while Hispanic women had LBW rates of 6.97 % [5]. Among Hispanic women, there is substantial intragroup variation. Recent Mexican immigrant and Central American women on average have a lower incidence of LBW than other Hispanic subgroups, despite little to no formal prenatal care, lower socioeconomic advantage [6–10] and lower levels of formal education [11]. Differences appear to apply only to infants at full gestational age, i.e., not LBW due to preterm delivery [12]. Yet in subsequent generations born in the United States, women with Mexican heritage tend to have higher rates of LBW and, overall, lower birth weights [10, 13]. While risk behavior such as drug and alcohol use increases [14] with succeeding generations, this change cannot account for the entirety of the variation in birth weight overall and, specifically, LBW rates among Mexican immigrant and Mexican–American women [14–16]. Controlling for age, parity, education, household income, smoking, and diet, the
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relationship continues between acculturation, average birth weight and LBW rates [11, 17, 18]. Thus far, no sufficient explanation for this persistent variation exists, though it has been suggested that one explanation could be a protective sociocultural effect [10, 19, 20]. The LBW phenomenon is one part of the larger ‘‘Latina Paradox,’’ in which recent immigrant Hispanic women have better health outcomes than subsequent US born generations. It is unclear if the cause of low LBW rates is related to the cause of other health outcomes in Hispanic immigrants.
Conceptual Framework Three possible pathways between sociocultural environments and LBW have been hypothesized: vascular, i.e., vasoconstriction; immunological, i.e., inflammatory processes; and hormonal, i.e., hypothalamic pituitary adrenal involvement through cortisol [21]. In these scenarios, sociocultural environments can mitigate or induce stress, which is expressed through one or more of these biological processes. Stress can manifest as anxiety or depression, both of which correlate with LBW [22, 23]. Stressors of low levels of interpersonal satisfaction and resources, low income and formal education, and ethnic minority status are thought to increase risk for LBW through increased perceived stress and anxiety [18–22, 24]. Mexican and Central American immigrant women with lower than expected LBW rates and African Americans with higher than expected LBW rates are notable exceptions. As noted above, Mexican and Central American women have a risk profile for LBW but have unexpectedly low rates of LBW, despite Mexican immigrant women having both ethnic minority status and relatively high levels of pregnancy anxiety [25]. Explanations for these paradoxes are thought to reside at group and community levels, notably acculturation and institutional and cultural norms and values [25–27]. For African Americans, sustained exposure to racism correlates with higher levels of perceived stress and LBW among women with high socioeconomic status [28, 29]. For Mexican and Central American immigrant women, attitudes toward social support and pregnancy are thought to mediate LBW stressors [30]. A meta-analysis of the literature [31] on LBW and prematurity among Mexican immigrants suggests that changes in meanings of family and desirability of children, access to and utilization of social support, nutrition, religious belief, and use of cigarettes and alcohol during pregnancy could be linked to observed birth weight differences. With respect to social support, a large body of psychological research suggests that close family relationships and family social support are cultural values among Hispanic populations, but neither has been found
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to be significantly different between Mexican immigrant and Mexican–American women [32]. However, two forms of social support, affective support and positive social interactions, correlate with higher birth weight in Mexican immigrant women but not Mexican–American women [32]. Anthropological research among pregnant Mexican immigrant women demonstrates that desirability of pregnancy-related affective and material support from family and friends varies among Mexican immigrant women [33]. These findings suggest that some other common cultural practice, belief, or orientation could underlie social support beliefs and practices, possibly mediating other risk factors for LBW. While sociocultural differences between pregnant Mexican immigrant and Mexican–American women that could account for the differences in birth weight have not been fully identified, Mexican–American women are more likely to be depressed and have higher levels of perceived stress and exposure to chronic stressors than Mexican immigrant women with a similar demographic and reproductive health profile, i.e., socioeconomic status, education levels, and reproductive histories [34, 35]. Mexican– American women have higher cortisol levels during pregnancy than Mexican immigrant women, perhaps a result of higher perceived stress and chronic exposure to stress [26, 36]. However, pregnant Mexican–American women have lower levels of pregnancy-related anxiety than pregnant Mexican immigrant women [14]. These psychosocial and biological differences in stress could be a result of the hypothesized protective cultural effect on LBW. A growing body of research examines cultural differences in pregnancy approaches between Mexican immigrant and Mexican–American women, although they have yet to be articulated fully within birth weight research. Anthropological and sociological research has found that some groups of Mexican immigrant women have healthier prenatal behaviors, i.e., diet and rest [37], stronger social interdependence [38], and higher regard for pregnancy and childbearing [14, 30–40]. Pregnant Mexican immigrant women tend to express the belief that pregnancy is a normal, healthy condition that is desirable; pregnancy is a time of happiness for many Mexican immigrant women and their families [14, 40]. Pregnant Mexican immigrant women are also more likely than pregnant Mexican– American women to discuss pregnancy in terms of women’s positive and valued roles of mother [39, 41]. Consistent with the foregoing, other extant data [14, 39–41] suggest that among Mexican immigrant women, pregnancy is a time of privileged social status. This pilot project hypothesized subjective social status during pregnancy could account for these cultural differences in valuing pregnancy, prenatal differences in depression, stress and anxiety, and birth weight differences in
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Mexican immigrant and Mexican–American women. Objective social status is an indicator of socioeconomic standing that most often combines income level, years or level of formal education, and occupation. Subjective social status is one’s perception of one’s social standing, which can be asked in terms of these traditional socioeconomic indicators or in terms of other community definitions of status [42]. Objective and subjective social statuses have consistently been associated with other health disparities and outcomes [43–45] but have not yet been evaluated for correlations with birth weight. In comparison with objective social status, subjective social status is more likely to be impacted by cultural beliefs, behaviors and practices [42] and appears to better predict health outcomes [42, 43, 46]. It has been associated with self-rated mental health in Mexican immigrant and Mexican–American populations [47] and pregnant Hispanic women [48] in the United States. However, research has not yet investigated the relationship between subjective social status, mental and psychosocial health, and birth weight [14, 48] or other maternal and child health outcomes. This pilot project begins this analysis by documenting subjective social status and mental and psychosocial health of pregnant Mexican immigrant women and Mexican–American women and then testing for correlations with subsequent birth weight.
Methods Participants Three hundred women were recruited over an 8-month period in 2011 at a federally qualified community health center in Harlingen, Cameron County, Texas. Harlingen is a small city 20 miles from the southern tip of Texas. Harlingen had a 2008–2012 median household income of $34,096 and a poverty rate of 33.2 % [49]. City and metropolitan area demographics illustrate its proximity to the Mexican border and its relative ethnic homogeneity. In 2010, 79.5 % of Harlingen was Hispanic [49], and Cameron County was 88 % Hispanic [50]. Cameron County’s metropolitan area consists of Harlingen, San Benito and Brownsville. In its metropolitan area, 88.0 % of the population is Hispanic, and 26.6 % are foreign-born. Among the foreign-born, 97.2 % are from Mexico [51]. Harlingen’s population in 2010 was 16.5 % foreign-born [49]. The clinic draws from both Harlingen and San Benito. It serves approximately 35,000 patients; 99 % of clients are low-income. At the clinic, 95 % of clients are Hispanic, and of those, 98 % are of Mexican descent. The clinic does not record citizenship status or birthplace. Extrapolating from clinic, city and metropolitan area data [51], it can be
estimated that approximately one-fifth of Mexican descent clinic patients were born in Mexico. The research protocol was approved by the Institutional Review Board at The University of Texas at San Antonio (#11-031). Participants were low-income pregnant women 18 years or older whose clinicians had determined they had low medical risk for having LBW infants. Clinicians determined medical low-risk as a singleton pregnancy with no maternal history of LBW infants and no maternal conditions that increased risk for LBW, including chronic conditions such as high blood pressure, uterine or cervical abnormalities, previous pregnancy problems such as fetal infections, and pregnancy-related conditions such as gestational diabetes. Participants were born in Mexico or selfidentified as Mexican–American. Data Collection All women who came through the clinic site that met the project criteria were invited to participate. Low income and low clinical risk for LBW were selection criteria, in order to focus on LBW and average birth weight variability unassociated with economic and clinical risk factors. Women were recruited in the waiting room of the clinic by a trained, bilingual research assistant. Informed consent and survey questions were available in Spanish or English, depending on participant preference. Participants could respond in writing or orally, depending on literacy level. Participants self-identified as being born in the United States with Mexican heritage or being born in Mexico. The survey took an average of 25 min to complete, after which the participant was given a $10 gift card to a local grocery store. A medium effect size (0.5) and power of 0.96 estimated the sample size of 300 using G*Power 3.1.25 [52]. Eight women were not included in the descriptive statistics due to missing data. The survey response rate was approximately 90 %. There were two primary reasons for not participating. For Mexican immigrant women, there was concern over questions about birthplace, i.e., implications about immigration status, although the recruitment script stated identifying information would be destroyed after project completion. For both groups, there was concern over childcare during survey completion. Attrition rates varied between the two groups. Between survey completion and delivery, 44 women changed clinic sites, so that their birth weights were unavailable. The sample size for analysis involving birth weights was 248. Measures Demographic and health characteristics were included in the survey: age, country of birth, years in the United States,
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marital status, annual household income, years of formal education, primary language spoken, and identification with religious belief, which included whether the respondent considered herself religious and if so, with which religion. Health characteristics included gravidity (number of pregnancies), parity (number of deliveries), gestational age at time of survey, gestational age at initiation of prenatal care, type of previous deliveries, self-report of birth weights of previous infants, and self-report of problems with previous pregnancies, including uterine infections, fetal infections, and any problems involving the placenta or cervix. Mental and psychosocial variables were measured through surveys at one point in the pregnancy of each participant in order to maximize sample size; the timing of survey completion during the pregnancy did not affect scores. Five measures were administered: MacArthur Scale of Subjective Social Status, community standing (SSS) [42]; Perceived Social Stress Scale (PSS) [53]; Rosenberg Self-Esteem Scale (SE) [54]; Personal Health Questionnaire Depression-9 (PHQ-9) [55]; and Pregnancy-related Anxiety Scale (PRA) [56]. The MacArthur Network on SES and Health developed the subjective social status scale to capture a sense of one’s place across multiple socioeconomic status and community indicators [42]. The MacArthur Scale of Subjective Social Status asks respondents to use a ladder to indicate their status position in comparison with those with the most social status at the top rungs and those with the least status at the bottom rungs. There are two versions of the ladder. The socioeconomic (SES) ladder asks respondents about status in relation to socioeconomic indicators of education, income, and occupation. The community ladder asks respondents about status in relation to however status is defined in their community [48]; Adler et al. [42] found that the most common definitions of community are neighborhood and city. The community ladder is most useful in poorer communities, where socioeconomic status may not be as important or variable as other indicators of status [42, 57]. The community ladder was used in this study for three reasons: (1) the community is largely low-income; (2) the community ladder could allow for another phenomenon, such as pregnancy, to inform the subjective status standing; and (3) Franzini and Fernande-Esquer [47] found in a similar regional population that education was not a significant variable in subjective social status, suggesting other reference categories. The PSS is a 10-item scale that measures psychosocial stress [53]. It had a Cronbach’s a of 0.76 in a study exploring stress and pregnancy among women in Mexico [58]. It was also used in Mexican and American college students and reported similar reliability scores [59, 60]. The Rosenberg Self-Esteem Scale [53] and the Personal
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Health Questionnaire Depression-9 [54, 60] scales have a Cronbach’s a of 0.88 [54] and 0.79 [61], respectively. The PRA in Spanish and English had a Cronbach’s a of 0.80 [56, 62] and a Cronbach’s a of 0.79 in a study among pregnant Mexican women [56]. Analysis Data were entered into SPSS 18.0 for statistical analysis [63]. A Chi squared test was used to test for significant associations between background characteristics of women and country of birth. In addition, an independent t test was used to test significant mean difference between all five psychosocial measures and country of birth. Pearson’s correlation coefficient tested for associations between these measures. Birth weights were extracted from participants’ medical records. Two logistic regression models were used to analyze the odds of having normal or higher weight children. The dependent variable was coded 0 for LBW and coded 1 for normal or higher weight children. Low birth weight was defined as birth weight less than 2500 g (or \5 pounds, 8 oz). Model I included the five psychosocial measures whereas control variables along with the psychosocial measures were included in Model II.
Results The selected background and psychosocial characteristics of pregnant Mexican immigrant (MI) women and Mexican–American (MA) women are listed in Table 1. Among background characteristics of women, marital status, primary language spoken, years of education, age, and average number of children were found to be significantly different between pregnant MI and MA women. Annual household income, identification with religious belief and problems with prior pregnancies were not significantly different between these two groups. Significant differences in average birth weight were found between the two groups, but differences in prevalence of LBW were not significant. Children born to MI women had higher birth weights compared to children born to MA women (119.5 vs. 112.9 oz.). The prevalence of LBW was 5.4 % among MI women and 6.9 % among MA women. Significant mean variations were observed for all measures except subjective social status. MI women had lower levels of perceived social stress and depressive symptoms but higher pregnancy-related anxiety and lower self-esteem than MA women. Table 2 shows the correlation coefficients for mental and psychosocial health measures and birth weight. Higher levels of depressive symptoms were significantly correlated
J Immigrant Minority Health Table 1 Demographic, mental and psychosocial health characteristics and birth weights of sample (n = 292)
Demographic characteristics
Mexican immigrant women n (%)
Mexican American women n (%)
Significance p \ 0.01
Marital status Never married
29 (17.8)
41 (33.3)
Married
83 (50.9)
42 (34.1)
Divorced Living with partner
2 (1.2)
2 (1.6)
49 (30.1)
38 (30.9) ns
Annual household income \$12,000 $12,001–$20,000
52 (55.9) 24 (25.8)
43 (50.0) 22 (25.6)
$20,001?
17 (18.3)
21 (24.4) p \ 0.001
Primary language spoken Spanish
145 (86.3)
10 (8.1)
English
23 (13.7)
114 (91.9) ns
Identification with religious belief Yes No
130 (82.8) 27 (17.2)
91 (74.6) 31 (25.4) ns
Problems with previous pregnancies Yes
28 (21.4)
18 (24.7)
No
103 (78.6)
55 (75.3) Mean (SD)
Mean (SD)
Significance
Years of education
10.4 (3.5)
12.0 (2.3)
p \ 0.001
Age (years)
28.3 (6.2)
24.0 (5.4)
p \ 0.001
Number of children
2.78 (1.41)
2.21 (1.32)
p \ 0.001
Gestational age at time of survey (weeks)
24.2 (10.08)
22.47 (10.03)
ns
Gestational age at which prenatal care began (weeks) Mental and psychosocial health characteristics
9.04 (6.58)
8.84 (6.46)
ns
Depression (PHQ-9)
12.2 (3.5)
13.2 (4.2)
p \ 0.05
Self-esteem (SE)
21.9 (4.3)
23.4 (4.4)
p \ 0.01
Pregnancy-related anxiety (PRA)
19.6 (4.8)
15.6 (4.7)
p \ 0.001
Perceived social stress (PSS)
22.3 (6.4)
24.3 (7.2)
p \ 0.05
Subjective social status (SSS)
6.9 (1.8)
7.1 (1.9)
119.5 (19.7)
112.9 (15.8)
ns
Birth weight Birth weight (oz)
with higher levels of pregnancy-related anxiety and perceived stress for the entire sample and within each subgroup. In addition, higher levels of depressive symptoms were significantly correlated with lower levels of subjective social status, lower levels of self-esteem for the entire sample and for MA women but not MI women. Higher levels of depressive symptoms correlated with lower birth weight for women in both groups. Higher levels of subjective social status were found to be significantly correlated with higher levels of self-esteem and lower levels of perceived stress for the entire sample
p \ 0.01
and MA women but not MI women. However, higher levels of self-esteem correlated with lower levels of perceived stress across and within the two groups. Women who reported higher levels of self-esteem tended to also have lower levels of pregnancy-related anxiety. This correlation was significant for the entire sample and MA but not MI women. In both groups, higher levels of pregnancyrelated anxiety significantly correlated with higher levels of perceived social stress. Compared with MA women, this correlation was almost twice as strong among MI women. However, higher levels of pregnancy-related anxiety were
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1 -0.175 1 -0.136* 0.407** -0.292** * p \ 0.05, ** p \ 0.01
1 1
0.256** -0.057 0.275** -0.066
1
-0.414** 0.031 -0.450** -0.004 0.589** -0.073
-0.179** 0.018
-0.144 0.024
-0.211* 0.047
-0.412** -0.011
Discussion
0.457** -0.15 0.535** -0.141*
0.202** PRA
PSS Birth Weight
1
-0.284** -0.071
1 1
-0.224** -0.132 -0.047 -0.104 0.351**
0.266**
1 1
0.105 0.207**
1 -0.258**
-0.379** -0.097 -0.229** SE
-0.104 -0.188** SSS
0.186*
MA MI All women MI
MA
MI
MA All women All women
significantly correlated with lower levels of birth weight among MA women but not MI women. Higher levels of perceived stress were found to be significantly correlated with lower levels of birth weight across the sample. Further, correlations between background characteristics such as income, marital status, education, and identification with religious belief, and psychosocial variables were not statistically significant. Two logistic regression models were used (see Table 3) along with unadjusted odds ratios. Model I included all five psychosocial measures used in the study and Model II included control variables of age, marital status, language spoken, education and country born. Only subjective social status was found to be significant in both models. That is, women who reported higher levels of subjective social status had higher odds of having normal or higher weight children as compared to women who reported lower levels of subjective social status. Yet while subjective social status was the only variable significant in predicting birth weight in both regression models, it did not correlate with birth weight. Implications of this discrepancy are discussed below.
1 -0.071
MA MI All women MA MI All women
Perceived social stress (PSS) Pregnancy-related anxiety (PRA) Self-esteem (SE) Subjective social status (SSS) Depression (PHQ-9)
Table 2 Correlations between mental and psychosocial health measures and birth weight among Mexican immigrant women (MI) and Mexican–american women (MA)
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This pilot project investigated the relationship between subjective social status, mental and psychosocial health, and birth weight in two subgroups of Hispanic women. It first tested the relationship between subjective social status and mental and psychosocial health during pregnancy and birth weight. It then compared relationships with birth weight between Mexican immigrant women and Mexican– American women. There was not a significant difference in subjective social status levels between pregnant Mexican immigrant and Mexican–American women. Yet overall, results indicate that subjective social status better predicts variation in birth weight among Hispanic women than mental and psychosocial health indicators of depression, self-esteem, perceived social stress, and pregnancy-related anxiety. That is, subjective social status scores during pregnancy could not explain the difference in birth weight between Mexican immigrant and Mexican–American women, but it could predict the likelihood of having a normal or higher weight infant across the entire sample. Given observed differences in birth weight between the two groups and the significant relationship between subjective social status and birth weight for the entire sample, one outstanding question is why significant differences in subjective social status were not found between the two groups. One possible explanation is the project design. The key difference between Mexican immigrant and Mexican– American women may be the relative boost in social status
J Immigrant Minority Health Table 3 Odds of having a normal or higher birth weight child and psychosocial characteristics (n = 156 in full model)
Variables
Unadjusted odds ratio
Model I
Exp(B)
Exp(B)
CI
Model II CI
Exp(B)
CI
PHQ
0.957
(0.853, 1.072)
0.906
(0.747, 1.099)
0.844
(0.672, 1.059)
SSS
1.222
(0.912, 1.637)
1.574*
(1.071, 2.314)
1.929*
(1.153, 3.229)
SE
0.881
(0.773, 1.005)
0.873
(0.741, 1.029)
0.931
(0.772, 1.122)
PRA
1.001
(0.906, 1.106)
0.936
(0.828, 1.057)
0.898
(0.752, 1.072)
PSS
0.98
(0.912, 1.052)
1.005
(0.905, 1.116)
Age
1.038
(0.952, 1.132)
1.063
(0.935, 1.208)
0.982
(0.871, 1.108)
Marital status Not married
1.611
(0.386, 6.722)
0.413
(0.041, 4.115)
Married
1.238
(0.4, 3.837)
0.829
(0.142, 4.849)
Speaks Spanish
1.185
(0.43, 3.263)
4.73
(0.301, 74.393)
Years of education Born in Mexico
0.978 1.294
(0.829, 1.153) (0.454, 3.689)
1.031 0.361
(0.825, 1.287) (0.031, 4.267)
-2 Loglikelihood
70.17
56.82
Nagelkerke R2
16.8
20.8
CIconfidence interval * p \ 0.05
when one becomes pregnant, particularly among Mexican immigrant women. The difference in subjective social status scores before and during pregnancy could be distinctly greater among Mexican immigrant women. Differences in preconception and prenatal scores of subjective social status could correlate with the degree of birth weight variation. To test this, a pre/post design of subjective social status before and during pregnancy would be necessary. Another question that emerged is the reason for the lack of significant correlations between subjective social status and birth weight when subjective social status is significant in predicting birth weight in the regression analysis. One possibility is that subjective social status may be influenced by other psychosocial variables. To test this, correlations between subjective social status, birth weight, and each mental and psychosocial health variables were run. One significant correlation was found: subjective social status, self-esteem and birth weight in the entire sample and the subsample of Mexican–American women, but not in Mexican immigrant women. This result led to a series of logistic regression models predicting birth weight. Among these models, subjective social status was found to not directly predict birth weight but was significantly influenced by self-esteem. This relationship will be explored with a secondary project that increases sample size and includes qualitative data about the relationship between constructions of self, social relations, and status when pregnant. Despite a lack of observed differences in subjective social status between the two groups, earlier results [64] suggested that changes in conceptualizations of status and
self-esteem occur with increased time in the United States for the immigrant generation as well as over subsequent generations. Correlations between subjective social status, self-esteem, perceived social stress, pregnancy-related anxiety and depression were different between Mexican– American and Mexican immigrant women. This is suggestive of other work demonstrating that the reference groups and variables used to determine subjective social status are different for Mexican immigrant and Mexican– American groups [47]. Future research will also incorporate comparison questions following Franzini and Fernandez-Esquer [47] to document how reference groups and variables used to determine subjective social status change with time in the United States and successive generations. This research will include a larger sample size to be able to conduct a path analysis to determine if and how the relationship between subjective social status and birth outcomes changes over time in relation to these mental and psychosocial health variables. One unexpected finding was the lack of association between identification with religiosity and birth weight. Earlier work has suggested religiosity is an influential psychosocial variable in birth weight variation [31, 65]. The lack of an association in this research may be due to the lack of variability in identification with religious beliefs between the two groups. There are several limitations to this project. First, the relative economic and cultural homogeneity of the city may restrict the generalizability of these results to regions with majority Mexican descent populations and high poverty rates. Mexican immigrants in the sample were more likely
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to be poorer, to be married, and to have completed high school than Mexican immigrants nationally [66]. Mexican– Americans in the sample were poorer and less likely to be married than Mexicans Americans nationally but had similar high school graduation rates [66]. These demographic differences as well as the status impact of living as an ethnic minority in other communities could influence subjective social status. One way to assess to the relative weight of income and ethnic identity in pregnancy-related subjective status in more heterogeneous populations would be to compare scores from the community and SES MacArthur scales, which measure potentially different constructions of subjective social status. Secondly, it is unclear at this point how subjective social status during pregnancy relates to beliefs and practices regarding pregnancy. The authors’ current project explores this possible relationship through a similar survey design with the addition of the ethnographic interviews regarding status and experiences of pregnant women. Finally, the low incidence of LBW in Hispanic populations overall requires a larger sample size to further investigate the linkage between subjective social status and LBW.
New Contribution to the Literature This pilot project employed an interdisciplinary approach, integrating anthropological, sociological, and psychological research to better understand variation in birth weight among Mexican immigrant and Mexican–American women. Mexican immigrant women have inexplicably low rates of LBW. In previous research, cultural differences have been implicated but not tested. This project tested cultural differences using the construct of subjective social status. Results were mixed. On the one hand, subjective social status was not significantly different between pregnant Mexican immigrant and Mexican–American women. As measured, it thus cannot explain differences in birth weight between these two groups. On the other hand, across the two groups, subjective social status was a better predictor of birth weight variation than perceived social stress, depression, or pregnancy-related anxiety. Self-esteem appears to influence subjective social status’ predictive ability. Subjective social status also strongly correlated with the other mental and psychosocial health measures, and the significance of these correlations, in turn, were often different in Mexican immigrant and Mexican– American women. These results suggest that psychological mechanisms and cultural changes associated with differences in subjective social status could be a key consideration in understanding differences in birth weight unexplained by traditional risk factors for LBW. One explanation for the
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relationship between subjective social status and birth weight could be that subjective social status indirectly impacts birth weight vis-a`-vis self-esteem and its correlations with depression, perceived social stress, and pregnancy-related anxiety. Subjective social status has been correlated with depression in other populations [46, 67, 68]. Results from this project also emphasize the relevance of a multilevel, biopsychosocial analytical framework to studying LBW that incorporates individual, interpersonal, group/sociocultural, and community/societal levels [21]. Among other variables, the pregnant woman’s sociocultural contexts and perceptions of status appear to influence her interpersonal, psychological and biological well-being, which in turn can impact birth weight. Acknowledgments This work was supported by the San Antonio Life Sciences Institute and the Institute for Health Disparities Research at The University of Texas at San Antonio.
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ORIGINAL PAPER
Subjective Social Status, Mental and Psychosocial Health, and Birth Weight Differences in Mexican–American and Mexican Immigrant Women K. Jill Fleuriet1 • T. S. Sunil2
Ó Springer Science+Business Media New York 2015
Abstract Recent Mexican immigrant women on average have an unexpectedly low incidence of low birth weight (LBW). Birth weights decline and LBW incidence increases in post-immigrant generations. This pilot project tested the hypothesis that subjective social status (SSS) of pregnant women predicts variation in birth weight between Mexican immigrant and Mexican–American women. 300 low-income pregnant Mexican immigrant and Mexican– American women in South Texas were surveyed for SSS, depression, pregnancy-related anxiety, perceived social stress and self-esteem and subsequent birth weight. No significant difference in SSS levels between pregnant Mexican immigrant and Mexican–American women were found. However, SSS better predicted variation in birth weight across both groups than mental and psychosocial health variables. Results suggest distinct relationships among SSS, mental and psychosocial health that could impact birth weight. They underscore the relevance of a multilevel, biopsychosocial analytical framework to studying LBW. Keywords Birth weight Hispanic women Stress Status Culture
& K. Jill Fleuriet [email protected] 1
Department of Anthropology, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX 78249, USA
2
Department of Sociology and Institute for Health Disparities Research, The University of Texas at San Antonio, San Antonio, TX, USA
Background Low birth weight (LBW), defined as \2500 g (5 pounds, 8 oz), predicts infant, child, and adult ill-health. Low birth weight can result from an infant that is small for gestational age or an infant born prior to 37 weeks of gestation, i.e., preterm birth. Low birth weight is a leading cause of neonatal mortality [1–4]. It is associated with infant mortality, impaired physical and developmental health, and long-term disability [1, 2]. Low birth weight correlates with adult onset of asthma, hypertension, diabetes, stroke, heart attack, other heart disease [3], and psychiatric conditions stemming from neurodevelopmental disorders [4]. The epidemiology of LBW illustrates significant ethnic differences. In 2010, non-Hispanic Black women had the highest rates of LBW (13.53 %). Non-Hispanic White women had LBW rates of 7.14 %, while Hispanic women had LBW rates of 6.97 % [5]. Among Hispanic women, there is substantial intragroup variation. Recent Mexican immigrant and Central American women on average have a lower incidence of LBW than other Hispanic subgroups, despite little to no formal prenatal care, lower socioeconomic advantage [6–10] and lower levels of formal education [11]. Differences appear to apply only to infants at full gestational age, i.e., not LBW due to preterm delivery [12]. Yet in subsequent generations born in the United States, women with Mexican heritage tend to have higher rates of LBW and, overall, lower birth weights [10, 13]. While risk behavior such as drug and alcohol use increases [14] with succeeding generations, this change cannot account for the entirety of the variation in birth weight overall and, specifically, LBW rates among Mexican immigrant and Mexican–American women [14–16]. Controlling for age, parity, education, household income, smoking, and diet, the
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relationship continues between acculturation, average birth weight and LBW rates [11, 17, 18]. Thus far, no sufficient explanation for this persistent variation exists, though it has been suggested that one explanation could be a protective sociocultural effect [10, 19, 20]. The LBW phenomenon is one part of the larger ‘‘Latina Paradox,’’ in which recent immigrant Hispanic women have better health outcomes than subsequent US born generations. It is unclear if the cause of low LBW rates is related to the cause of other health outcomes in Hispanic immigrants.
Conceptual Framework Three possible pathways between sociocultural environments and LBW have been hypothesized: vascular, i.e., vasoconstriction; immunological, i.e., inflammatory processes; and hormonal, i.e., hypothalamic pituitary adrenal involvement through cortisol [21]. In these scenarios, sociocultural environments can mitigate or induce stress, which is expressed through one or more of these biological processes. Stress can manifest as anxiety or depression, both of which correlate with LBW [22, 23]. Stressors of low levels of interpersonal satisfaction and resources, low income and formal education, and ethnic minority status are thought to increase risk for LBW through increased perceived stress and anxiety [18–22, 24]. Mexican and Central American immigrant women with lower than expected LBW rates and African Americans with higher than expected LBW rates are notable exceptions. As noted above, Mexican and Central American women have a risk profile for LBW but have unexpectedly low rates of LBW, despite Mexican immigrant women having both ethnic minority status and relatively high levels of pregnancy anxiety [25]. Explanations for these paradoxes are thought to reside at group and community levels, notably acculturation and institutional and cultural norms and values [25–27]. For African Americans, sustained exposure to racism correlates with higher levels of perceived stress and LBW among women with high socioeconomic status [28, 29]. For Mexican and Central American immigrant women, attitudes toward social support and pregnancy are thought to mediate LBW stressors [30]. A meta-analysis of the literature [31] on LBW and prematurity among Mexican immigrants suggests that changes in meanings of family and desirability of children, access to and utilization of social support, nutrition, religious belief, and use of cigarettes and alcohol during pregnancy could be linked to observed birth weight differences. With respect to social support, a large body of psychological research suggests that close family relationships and family social support are cultural values among Hispanic populations, but neither has been found
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to be significantly different between Mexican immigrant and Mexican–American women [32]. However, two forms of social support, affective support and positive social interactions, correlate with higher birth weight in Mexican immigrant women but not Mexican–American women [32]. Anthropological research among pregnant Mexican immigrant women demonstrates that desirability of pregnancy-related affective and material support from family and friends varies among Mexican immigrant women [33]. These findings suggest that some other common cultural practice, belief, or orientation could underlie social support beliefs and practices, possibly mediating other risk factors for LBW. While sociocultural differences between pregnant Mexican immigrant and Mexican–American women that could account for the differences in birth weight have not been fully identified, Mexican–American women are more likely to be depressed and have higher levels of perceived stress and exposure to chronic stressors than Mexican immigrant women with a similar demographic and reproductive health profile, i.e., socioeconomic status, education levels, and reproductive histories [34, 35]. Mexican– American women have higher cortisol levels during pregnancy than Mexican immigrant women, perhaps a result of higher perceived stress and chronic exposure to stress [26, 36]. However, pregnant Mexican–American women have lower levels of pregnancy-related anxiety than pregnant Mexican immigrant women [14]. These psychosocial and biological differences in stress could be a result of the hypothesized protective cultural effect on LBW. A growing body of research examines cultural differences in pregnancy approaches between Mexican immigrant and Mexican–American women, although they have yet to be articulated fully within birth weight research. Anthropological and sociological research has found that some groups of Mexican immigrant women have healthier prenatal behaviors, i.e., diet and rest [37], stronger social interdependence [38], and higher regard for pregnancy and childbearing [14, 30–40]. Pregnant Mexican immigrant women tend to express the belief that pregnancy is a normal, healthy condition that is desirable; pregnancy is a time of happiness for many Mexican immigrant women and their families [14, 40]. Pregnant Mexican immigrant women are also more likely than pregnant Mexican– American women to discuss pregnancy in terms of women’s positive and valued roles of mother [39, 41]. Consistent with the foregoing, other extant data [14, 39–41] suggest that among Mexican immigrant women, pregnancy is a time of privileged social status. This pilot project hypothesized subjective social status during pregnancy could account for these cultural differences in valuing pregnancy, prenatal differences in depression, stress and anxiety, and birth weight differences in
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Mexican immigrant and Mexican–American women. Objective social status is an indicator of socioeconomic standing that most often combines income level, years or level of formal education, and occupation. Subjective social status is one’s perception of one’s social standing, which can be asked in terms of these traditional socioeconomic indicators or in terms of other community definitions of status [42]. Objective and subjective social statuses have consistently been associated with other health disparities and outcomes [43–45] but have not yet been evaluated for correlations with birth weight. In comparison with objective social status, subjective social status is more likely to be impacted by cultural beliefs, behaviors and practices [42] and appears to better predict health outcomes [42, 43, 46]. It has been associated with self-rated mental health in Mexican immigrant and Mexican–American populations [47] and pregnant Hispanic women [48] in the United States. However, research has not yet investigated the relationship between subjective social status, mental and psychosocial health, and birth weight [14, 48] or other maternal and child health outcomes. This pilot project begins this analysis by documenting subjective social status and mental and psychosocial health of pregnant Mexican immigrant women and Mexican–American women and then testing for correlations with subsequent birth weight.
Methods Participants Three hundred women were recruited over an 8-month period in 2011 at a federally qualified community health center in Harlingen, Cameron County, Texas. Harlingen is a small city 20 miles from the southern tip of Texas. Harlingen had a 2008–2012 median household income of $34,096 and a poverty rate of 33.2 % [49]. City and metropolitan area demographics illustrate its proximity to the Mexican border and its relative ethnic homogeneity. In 2010, 79.5 % of Harlingen was Hispanic [49], and Cameron County was 88 % Hispanic [50]. Cameron County’s metropolitan area consists of Harlingen, San Benito and Brownsville. In its metropolitan area, 88.0 % of the population is Hispanic, and 26.6 % are foreign-born. Among the foreign-born, 97.2 % are from Mexico [51]. Harlingen’s population in 2010 was 16.5 % foreign-born [49]. The clinic draws from both Harlingen and San Benito. It serves approximately 35,000 patients; 99 % of clients are low-income. At the clinic, 95 % of clients are Hispanic, and of those, 98 % are of Mexican descent. The clinic does not record citizenship status or birthplace. Extrapolating from clinic, city and metropolitan area data [51], it can be
estimated that approximately one-fifth of Mexican descent clinic patients were born in Mexico. The research protocol was approved by the Institutional Review Board at The University of Texas at San Antonio (#11-031). Participants were low-income pregnant women 18 years or older whose clinicians had determined they had low medical risk for having LBW infants. Clinicians determined medical low-risk as a singleton pregnancy with no maternal history of LBW infants and no maternal conditions that increased risk for LBW, including chronic conditions such as high blood pressure, uterine or cervical abnormalities, previous pregnancy problems such as fetal infections, and pregnancy-related conditions such as gestational diabetes. Participants were born in Mexico or selfidentified as Mexican–American. Data Collection All women who came through the clinic site that met the project criteria were invited to participate. Low income and low clinical risk for LBW were selection criteria, in order to focus on LBW and average birth weight variability unassociated with economic and clinical risk factors. Women were recruited in the waiting room of the clinic by a trained, bilingual research assistant. Informed consent and survey questions were available in Spanish or English, depending on participant preference. Participants could respond in writing or orally, depending on literacy level. Participants self-identified as being born in the United States with Mexican heritage or being born in Mexico. The survey took an average of 25 min to complete, after which the participant was given a $10 gift card to a local grocery store. A medium effect size (0.5) and power of 0.96 estimated the sample size of 300 using G*Power 3.1.25 [52]. Eight women were not included in the descriptive statistics due to missing data. The survey response rate was approximately 90 %. There were two primary reasons for not participating. For Mexican immigrant women, there was concern over questions about birthplace, i.e., implications about immigration status, although the recruitment script stated identifying information would be destroyed after project completion. For both groups, there was concern over childcare during survey completion. Attrition rates varied between the two groups. Between survey completion and delivery, 44 women changed clinic sites, so that their birth weights were unavailable. The sample size for analysis involving birth weights was 248. Measures Demographic and health characteristics were included in the survey: age, country of birth, years in the United States,
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marital status, annual household income, years of formal education, primary language spoken, and identification with religious belief, which included whether the respondent considered herself religious and if so, with which religion. Health characteristics included gravidity (number of pregnancies), parity (number of deliveries), gestational age at time of survey, gestational age at initiation of prenatal care, type of previous deliveries, self-report of birth weights of previous infants, and self-report of problems with previous pregnancies, including uterine infections, fetal infections, and any problems involving the placenta or cervix. Mental and psychosocial variables were measured through surveys at one point in the pregnancy of each participant in order to maximize sample size; the timing of survey completion during the pregnancy did not affect scores. Five measures were administered: MacArthur Scale of Subjective Social Status, community standing (SSS) [42]; Perceived Social Stress Scale (PSS) [53]; Rosenberg Self-Esteem Scale (SE) [54]; Personal Health Questionnaire Depression-9 (PHQ-9) [55]; and Pregnancy-related Anxiety Scale (PRA) [56]. The MacArthur Network on SES and Health developed the subjective social status scale to capture a sense of one’s place across multiple socioeconomic status and community indicators [42]. The MacArthur Scale of Subjective Social Status asks respondents to use a ladder to indicate their status position in comparison with those with the most social status at the top rungs and those with the least status at the bottom rungs. There are two versions of the ladder. The socioeconomic (SES) ladder asks respondents about status in relation to socioeconomic indicators of education, income, and occupation. The community ladder asks respondents about status in relation to however status is defined in their community [48]; Adler et al. [42] found that the most common definitions of community are neighborhood and city. The community ladder is most useful in poorer communities, where socioeconomic status may not be as important or variable as other indicators of status [42, 57]. The community ladder was used in this study for three reasons: (1) the community is largely low-income; (2) the community ladder could allow for another phenomenon, such as pregnancy, to inform the subjective status standing; and (3) Franzini and Fernande-Esquer [47] found in a similar regional population that education was not a significant variable in subjective social status, suggesting other reference categories. The PSS is a 10-item scale that measures psychosocial stress [53]. It had a Cronbach’s a of 0.76 in a study exploring stress and pregnancy among women in Mexico [58]. It was also used in Mexican and American college students and reported similar reliability scores [59, 60]. The Rosenberg Self-Esteem Scale [53] and the Personal
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Health Questionnaire Depression-9 [54, 60] scales have a Cronbach’s a of 0.88 [54] and 0.79 [61], respectively. The PRA in Spanish and English had a Cronbach’s a of 0.80 [56, 62] and a Cronbach’s a of 0.79 in a study among pregnant Mexican women [56]. Analysis Data were entered into SPSS 18.0 for statistical analysis [63]. A Chi squared test was used to test for significant associations between background characteristics of women and country of birth. In addition, an independent t test was used to test significant mean difference between all five psychosocial measures and country of birth. Pearson’s correlation coefficient tested for associations between these measures. Birth weights were extracted from participants’ medical records. Two logistic regression models were used to analyze the odds of having normal or higher weight children. The dependent variable was coded 0 for LBW and coded 1 for normal or higher weight children. Low birth weight was defined as birth weight less than 2500 g (or \5 pounds, 8 oz). Model I included the five psychosocial measures whereas control variables along with the psychosocial measures were included in Model II.
Results The selected background and psychosocial characteristics of pregnant Mexican immigrant (MI) women and Mexican–American (MA) women are listed in Table 1. Among background characteristics of women, marital status, primary language spoken, years of education, age, and average number of children were found to be significantly different between pregnant MI and MA women. Annual household income, identification with religious belief and problems with prior pregnancies were not significantly different between these two groups. Significant differences in average birth weight were found between the two groups, but differences in prevalence of LBW were not significant. Children born to MI women had higher birth weights compared to children born to MA women (119.5 vs. 112.9 oz.). The prevalence of LBW was 5.4 % among MI women and 6.9 % among MA women. Significant mean variations were observed for all measures except subjective social status. MI women had lower levels of perceived social stress and depressive symptoms but higher pregnancy-related anxiety and lower self-esteem than MA women. Table 2 shows the correlation coefficients for mental and psychosocial health measures and birth weight. Higher levels of depressive symptoms were significantly correlated
J Immigrant Minority Health Table 1 Demographic, mental and psychosocial health characteristics and birth weights of sample (n = 292)
Demographic characteristics
Mexican immigrant women n (%)
Mexican American women n (%)
Significance p \ 0.01
Marital status Never married
29 (17.8)
41 (33.3)
Married
83 (50.9)
42 (34.1)
Divorced Living with partner
2 (1.2)
2 (1.6)
49 (30.1)
38 (30.9) ns
Annual household income \$12,000 $12,001–$20,000
52 (55.9) 24 (25.8)
43 (50.0) 22 (25.6)
$20,001?
17 (18.3)
21 (24.4) p \ 0.001
Primary language spoken Spanish
145 (86.3)
10 (8.1)
English
23 (13.7)
114 (91.9) ns
Identification with religious belief Yes No
130 (82.8) 27 (17.2)
91 (74.6) 31 (25.4) ns
Problems with previous pregnancies Yes
28 (21.4)
18 (24.7)
No
103 (78.6)
55 (75.3) Mean (SD)
Mean (SD)
Significance
Years of education
10.4 (3.5)
12.0 (2.3)
p \ 0.001
Age (years)
28.3 (6.2)
24.0 (5.4)
p \ 0.001
Number of children
2.78 (1.41)
2.21 (1.32)
p \ 0.001
Gestational age at time of survey (weeks)
24.2 (10.08)
22.47 (10.03)
ns
Gestational age at which prenatal care began (weeks) Mental and psychosocial health characteristics
9.04 (6.58)
8.84 (6.46)
ns
Depression (PHQ-9)
12.2 (3.5)
13.2 (4.2)
p \ 0.05
Self-esteem (SE)
21.9 (4.3)
23.4 (4.4)
p \ 0.01
Pregnancy-related anxiety (PRA)
19.6 (4.8)
15.6 (4.7)
p \ 0.001
Perceived social stress (PSS)
22.3 (6.4)
24.3 (7.2)
p \ 0.05
Subjective social status (SSS)
6.9 (1.8)
7.1 (1.9)
119.5 (19.7)
112.9 (15.8)
ns
Birth weight Birth weight (oz)
with higher levels of pregnancy-related anxiety and perceived stress for the entire sample and within each subgroup. In addition, higher levels of depressive symptoms were significantly correlated with lower levels of subjective social status, lower levels of self-esteem for the entire sample and for MA women but not MI women. Higher levels of depressive symptoms correlated with lower birth weight for women in both groups. Higher levels of subjective social status were found to be significantly correlated with higher levels of self-esteem and lower levels of perceived stress for the entire sample
p \ 0.01
and MA women but not MI women. However, higher levels of self-esteem correlated with lower levels of perceived stress across and within the two groups. Women who reported higher levels of self-esteem tended to also have lower levels of pregnancy-related anxiety. This correlation was significant for the entire sample and MA but not MI women. In both groups, higher levels of pregnancyrelated anxiety significantly correlated with higher levels of perceived social stress. Compared with MA women, this correlation was almost twice as strong among MI women. However, higher levels of pregnancy-related anxiety were
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123
1 -0.175 1 -0.136* 0.407** -0.292** * p \ 0.05, ** p \ 0.01
1 1
0.256** -0.057 0.275** -0.066
1
-0.414** 0.031 -0.450** -0.004 0.589** -0.073
-0.179** 0.018
-0.144 0.024
-0.211* 0.047
-0.412** -0.011
Discussion
0.457** -0.15 0.535** -0.141*
0.202** PRA
PSS Birth Weight
1
-0.284** -0.071
1 1
-0.224** -0.132 -0.047 -0.104 0.351**
0.266**
1 1
0.105 0.207**
1 -0.258**
-0.379** -0.097 -0.229** SE
-0.104 -0.188** SSS
0.186*
MA MI All women MI
MA
MI
MA All women All women
significantly correlated with lower levels of birth weight among MA women but not MI women. Higher levels of perceived stress were found to be significantly correlated with lower levels of birth weight across the sample. Further, correlations between background characteristics such as income, marital status, education, and identification with religious belief, and psychosocial variables were not statistically significant. Two logistic regression models were used (see Table 3) along with unadjusted odds ratios. Model I included all five psychosocial measures used in the study and Model II included control variables of age, marital status, language spoken, education and country born. Only subjective social status was found to be significant in both models. That is, women who reported higher levels of subjective social status had higher odds of having normal or higher weight children as compared to women who reported lower levels of subjective social status. Yet while subjective social status was the only variable significant in predicting birth weight in both regression models, it did not correlate with birth weight. Implications of this discrepancy are discussed below.
1 -0.071
MA MI All women MA MI All women
Perceived social stress (PSS) Pregnancy-related anxiety (PRA) Self-esteem (SE) Subjective social status (SSS) Depression (PHQ-9)
Table 2 Correlations between mental and psychosocial health measures and birth weight among Mexican immigrant women (MI) and Mexican–american women (MA)
J Immigrant Minority Health
This pilot project investigated the relationship between subjective social status, mental and psychosocial health, and birth weight in two subgroups of Hispanic women. It first tested the relationship between subjective social status and mental and psychosocial health during pregnancy and birth weight. It then compared relationships with birth weight between Mexican immigrant women and Mexican– American women. There was not a significant difference in subjective social status levels between pregnant Mexican immigrant and Mexican–American women. Yet overall, results indicate that subjective social status better predicts variation in birth weight among Hispanic women than mental and psychosocial health indicators of depression, self-esteem, perceived social stress, and pregnancy-related anxiety. That is, subjective social status scores during pregnancy could not explain the difference in birth weight between Mexican immigrant and Mexican–American women, but it could predict the likelihood of having a normal or higher weight infant across the entire sample. Given observed differences in birth weight between the two groups and the significant relationship between subjective social status and birth weight for the entire sample, one outstanding question is why significant differences in subjective social status were not found between the two groups. One possible explanation is the project design. The key difference between Mexican immigrant and Mexican– American women may be the relative boost in social status
J Immigrant Minority Health Table 3 Odds of having a normal or higher birth weight child and psychosocial characteristics (n = 156 in full model)
Variables
Unadjusted odds ratio
Model I
Exp(B)
Exp(B)
CI
Model II CI
Exp(B)
CI
PHQ
0.957
(0.853, 1.072)
0.906
(0.747, 1.099)
0.844
(0.672, 1.059)
SSS
1.222
(0.912, 1.637)
1.574*
(1.071, 2.314)
1.929*
(1.153, 3.229)
SE
0.881
(0.773, 1.005)
0.873
(0.741, 1.029)
0.931
(0.772, 1.122)
PRA
1.001
(0.906, 1.106)
0.936
(0.828, 1.057)
0.898
(0.752, 1.072)
PSS
0.98
(0.912, 1.052)
1.005
(0.905, 1.116)
Age
1.038
(0.952, 1.132)
1.063
(0.935, 1.208)
0.982
(0.871, 1.108)
Marital status Not married
1.611
(0.386, 6.722)
0.413
(0.041, 4.115)
Married
1.238
(0.4, 3.837)
0.829
(0.142, 4.849)
Speaks Spanish
1.185
(0.43, 3.263)
4.73
(0.301, 74.393)
Years of education Born in Mexico
0.978 1.294
(0.829, 1.153) (0.454, 3.689)
1.031 0.361
(0.825, 1.287) (0.031, 4.267)
-2 Loglikelihood
70.17
56.82
Nagelkerke R2
16.8
20.8
CIconfidence interval * p \ 0.05
when one becomes pregnant, particularly among Mexican immigrant women. The difference in subjective social status scores before and during pregnancy could be distinctly greater among Mexican immigrant women. Differences in preconception and prenatal scores of subjective social status could correlate with the degree of birth weight variation. To test this, a pre/post design of subjective social status before and during pregnancy would be necessary. Another question that emerged is the reason for the lack of significant correlations between subjective social status and birth weight when subjective social status is significant in predicting birth weight in the regression analysis. One possibility is that subjective social status may be influenced by other psychosocial variables. To test this, correlations between subjective social status, birth weight, and each mental and psychosocial health variables were run. One significant correlation was found: subjective social status, self-esteem and birth weight in the entire sample and the subsample of Mexican–American women, but not in Mexican immigrant women. This result led to a series of logistic regression models predicting birth weight. Among these models, subjective social status was found to not directly predict birth weight but was significantly influenced by self-esteem. This relationship will be explored with a secondary project that increases sample size and includes qualitative data about the relationship between constructions of self, social relations, and status when pregnant. Despite a lack of observed differences in subjective social status between the two groups, earlier results [64] suggested that changes in conceptualizations of status and
self-esteem occur with increased time in the United States for the immigrant generation as well as over subsequent generations. Correlations between subjective social status, self-esteem, perceived social stress, pregnancy-related anxiety and depression were different between Mexican– American and Mexican immigrant women. This is suggestive of other work demonstrating that the reference groups and variables used to determine subjective social status are different for Mexican immigrant and Mexican– American groups [47]. Future research will also incorporate comparison questions following Franzini and Fernandez-Esquer [47] to document how reference groups and variables used to determine subjective social status change with time in the United States and successive generations. This research will include a larger sample size to be able to conduct a path analysis to determine if and how the relationship between subjective social status and birth outcomes changes over time in relation to these mental and psychosocial health variables. One unexpected finding was the lack of association between identification with religiosity and birth weight. Earlier work has suggested religiosity is an influential psychosocial variable in birth weight variation [31, 65]. The lack of an association in this research may be due to the lack of variability in identification with religious beliefs between the two groups. There are several limitations to this project. First, the relative economic and cultural homogeneity of the city may restrict the generalizability of these results to regions with majority Mexican descent populations and high poverty rates. Mexican immigrants in the sample were more likely
123
J Immigrant Minority Health
to be poorer, to be married, and to have completed high school than Mexican immigrants nationally [66]. Mexican– Americans in the sample were poorer and less likely to be married than Mexicans Americans nationally but had similar high school graduation rates [66]. These demographic differences as well as the status impact of living as an ethnic minority in other communities could influence subjective social status. One way to assess to the relative weight of income and ethnic identity in pregnancy-related subjective status in more heterogeneous populations would be to compare scores from the community and SES MacArthur scales, which measure potentially different constructions of subjective social status. Secondly, it is unclear at this point how subjective social status during pregnancy relates to beliefs and practices regarding pregnancy. The authors’ current project explores this possible relationship through a similar survey design with the addition of the ethnographic interviews regarding status and experiences of pregnant women. Finally, the low incidence of LBW in Hispanic populations overall requires a larger sample size to further investigate the linkage between subjective social status and LBW.
New Contribution to the Literature This pilot project employed an interdisciplinary approach, integrating anthropological, sociological, and psychological research to better understand variation in birth weight among Mexican immigrant and Mexican–American women. Mexican immigrant women have inexplicably low rates of LBW. In previous research, cultural differences have been implicated but not tested. This project tested cultural differences using the construct of subjective social status. Results were mixed. On the one hand, subjective social status was not significantly different between pregnant Mexican immigrant and Mexican–American women. As measured, it thus cannot explain differences in birth weight between these two groups. On the other hand, across the two groups, subjective social status was a better predictor of birth weight variation than perceived social stress, depression, or pregnancy-related anxiety. Self-esteem appears to influence subjective social status’ predictive ability. Subjective social status also strongly correlated with the other mental and psychosocial health measures, and the significance of these correlations, in turn, were often different in Mexican immigrant and Mexican– American women. These results suggest that psychological mechanisms and cultural changes associated with differences in subjective social status could be a key consideration in understanding differences in birth weight unexplained by traditional risk factors for LBW. One explanation for the
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relationship between subjective social status and birth weight could be that subjective social status indirectly impacts birth weight vis-a`-vis self-esteem and its correlations with depression, perceived social stress, and pregnancy-related anxiety. Subjective social status has been correlated with depression in other populations [46, 67, 68]. Results from this project also emphasize the relevance of a multilevel, biopsychosocial analytical framework to studying LBW that incorporates individual, interpersonal, group/sociocultural, and community/societal levels [21]. Among other variables, the pregnant woman’s sociocultural contexts and perceptions of status appear to influence her interpersonal, psychological and biological well-being, which in turn can impact birth weight. Acknowledgments This work was supported by the San Antonio Life Sciences Institute and the Institute for Health Disparities Research at The University of Texas at San Antonio.
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