Streamline the migrant health news source

Volume 8, Issue 1 February 2002

PPoverty is a well-known determinant ofhealth. Persons of low socio-economic

status have much higher levels of morbidi-ty and mortality than do those of higherstatus.1-3 Yet recent research revealing posi-tive pregnancy outcomes within poorimmigrant groups raises the question ofwhether poverty is necessarily linked toadverse pregnancy outcomes. Are thereprotective factors that can buffer againstthe noxious effects of poverty during preg-nancy? If so, what lessons can we learnfrom immigrant and refugee women aboutpromoting healthy pregnancy outcomes?

To address these questions, this [article]attempts to identify protective factors thatmay be associated with favorable pregnancyoutcomes among Latina and SoutheastAsian women. It reports the work byGuendelman and colleagues on Latinawomen of reproductive age and extendsprevious analyses to compare Latinas andSoutheast Asians. The geographic focus ispredominantly on California since it is themost important immigrant-receiving state,absorbing approximately 40% of Latino andAsian newcomers. Favorable pregnancy out-comes among Southeast Asian women andMexican immigrants have been reported inother states, suggesting that what we learnabout these populations residing inCalifornia may be applicable elsewhere.

California’s Fertile Ground

California leads the nation in rapid diver-

sification, moving away from a White“majority” toward a predominantly Asianand Latino population. Immigration andhigh fertility have fueled the growth ofthese populations, which are increasing ata rate ten times faster than that of Whites(i.e., White non-Latinos)...

Aside from their large immigrationnumbers and high fertility rates, it wouldseem that Mexican and Southeast Asianwomen have little in common. Indeed,these ethnic grounds have very differenthistories in California. Mexicans have along history in the state, while SoutheastAsians are recent immigrants. Hence,whereas a large proportion of Mexican ori-gin women of reproductive age are U.S.born, Southeast Asian women are predom-inantly foreign born. Whereas Mexicanwomen most often come by choice, seek-ing economic opportunity for themselvesor their families, Southeast Asian womenhave been formed to flee their war-tornnative lands. Yet because Southeast Asiansare admitted as refugees, they can receiveresettlement funds and other assistancesuch as language instruction and jobtraining. Mexican immigrants, legal ornot, are ineligible for such benefits sincethey do not qualify for “political refugee”status. Such circumstances, which areoften exacerbated by anti-immigrant atti-tudes, create their own set of resettlementstresses for Mexican newcomers. In addi-tion to the differences across these popu-

lations, there are important differences inlanguage, culture, and social and politicalstanding within the Mexican andSoutheast Asian populations.

Despite these notable differences, similar-ities do exist at the population level in thegeneral socioeconomic profiles of MexicanAmericans and Southeast Asians in compar-ison to the majority White population ofCalifornia. Both populations are character-ized by low educational attainment andhigh incidence of poverty, especially amongwomen….Mexican-American women, whilemore active in the labor force and less likelythan Southeast Asian women to have fami-lies living below the poverty level, never-theless have very low incomes in compari-son with White women.

From a health perspective, Mexican-American and Southeast Asian womenalso share a high-risk profile. Both groupsof women experience delayed entry intoprenatal care, have large families withshort birth-spacing intervals, and – withthe exception of the Vietnamese – havehigh rates of teen pregnancy compared toWhite women.

Uncovering the Paradox

These socioeconomic and health risk fac-tors have traditionally predicted adversepregnancy outcomes in other populations.For instance, African Americans have risk

Immigrants May Hold Clues to Protecting Health During Pregnancy

Exploring a ParadoxSylvia Guendelman, PhD, MSW

The following material was excerpted with permission from the book entitled Promoting Human Wellness: New Frontiers for Research,Practice, and Policy, eds. Stokols, Daniel and Margaret Schneider Jamner, University of California Press, 2000

For the entire chapter with complete references, please refer to a copy of the book or contact Jillian Hopewell at MCN,jhopewell@migrantclinician.org or 530-345-4806.

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profiles that are similar to immigrants, yeton average their pregnancy outcomes aremuch worse.3,8-10 Studies of White womenwho share similar risk factors also showincreased rates of low birthweight.3,11

Surprisingly, Mexican Americans andSoutheast Asians enjoy pregnancy out-comes that are comparable to those of the overall White population despite thedramatic differences in risk profiles.

California birth cohort files for 1990-92indicate that infant mortality (birth to 364 days) and postneonatal mortality (28-364 days) rates among all MexicanAmericans regardless of nativity states andSoutheast Asians are comparable to those ofWhites. The infant mortality rates are com-parable even with the inclusion of infantsweighing less than 500 grams at birth, whoare increasingly being saved with improvedtechnology in neonatal intensive care units.

Mexican Americans do have higherneonatal (0-27 days) mortality rates (4.1 per1,000 live births) than Whites (3.7) orSoutheast Asians (3.5); however, when werestrict the comparison to births ofMexican-born women exclude U.S.-bornMexican Americans, the neonatal mortalityrates (3.9) are similar to those of Whites.Since foreign-born immigrants are evenpoorer, less educated, and face more diffi-culties in access to care than native-bornMexican Americans, their more favorablepregnancy outcomes are especially puzzling.

Birthweight data provide another strongindicator of Perinatal health, as infantswho weigh 2,500 grams or less at birthhave higher-than- average rates of morbid-ity, neurological impairments, and mortal-ity during the early years of life. AmongMexican Americans in California, the rateof low birthweight is equal to that ofWhites (5.1%) despite differences insocioeconomic status. However, Mexican-born women have significantly lower ratesthan Whites. The low birthweight ratesamong Southeast Asian women appear tobe significantly higher than Whites, possi-bly because of genetic or biological differ-ences.10 On average, Asian infants weighone-half pound less than White infants.12

Differences in birthweight distributionamong Southeast Asians, however, do not

appear to affect rates of infant mortalityadversely.

Seeking to Explain the Paradox

Research indicates that there are nostraightforward explanations for the epi-demiological paradox of positive pregnan-cy outcomes in immigrant mothers bornin Mexico and Southeast Asia. Severalhypotheses have surfaced that point todeficits in these populations, such as anunderreporting of infant deaths, ethnicmisclassification in birth and/or death cer-tificates, and the possibility that excessfetal deaths might eliminate weaker fetus-es before birth. Other hypotheses focus onthe positive or “protective” factors thatmay contribute to healthy outcomes. Forinstance, selective migration may favorhealthy mothers and healthy babies, andimmigrant mothers who relocate inCalifornia may bring with them certainattitudes, values, and behaviors that pro-tect them against stresses and otheradverse conditions associated with povertyand resettlement in a new society. This[article] will examine each of these issuesbut will emphasize a search for clues inidentifying protective factors for positivepregnancy outcomes.

Underreporting/Misclassification

It has been suggested that infant mortalityrates among immigrant groups may beartificially low because of underreportingof infant deaths. However, low rates ofout-of-hospital births in California, cou-pled with the fact that the great majorityof neonatal deaths occur before the firsthospital discharge, make it appear thatunderreporting of neonatal deaths is not asignificant phenomenon for MexicanAmericans or Southeast Asians in thisstate.13-15 Underreporting, if it does occur, ismore likely to occur in the postneonatalperiod (28-364 days), when the child isliving at home.15

Underestimation of infant mortalitycannot, however, explain more favorablebirthweight distributions among infants ofMexico-born mothers than White moth-ers, unless there are selective pressures toreturn to Mexico when a pregnancy has

complications likely to result in adversepregnancy outcomes.

Excess Fetal Deaths

Another conceivable deflator of the infantmortality rate might be excess fetal deathsamong Latinas and/or Southeast Asians,whereby biologically weaker fetuses areeliminated and only healthy ones surviveuntil birth.

Studies of fetal mortality are few, andthey offer poor comparability because ofdifferent state reporting laws. Examinationof available data in California, where thelaw mandates reporting of fetal deaths after20 weeks’ gestation, has not supported thehypothesis that excess late fetal deathsoccur in the Latina (predominantly ofMexican birth or descent) and SoutheastAsian populations. Guendelman, Chavez,and Christianson studied a large sample oflow-income women enrolled in theCalifornia Comprehensive PerinatalProgram and found that the fetal death rateafter 20 weeks’ gestation among Latinas(7.8 per 1,000 live births and fetal deaths)was actually lower than the rate amongWhites (8.4).25 These ethnic disparities per-sisted after controlling for sociobehavioralcharacteristics, such as maternal age andeducation, support systems, level of accul-turation, tobacco use before and duringpregnancy, and prenatal care.

One predictor of fetal death after 20weeks is a history of fetal loss. By self-report,Latina women indicated having had fewerprevious fetal losses than White women.

Clearly, more studies are needed tocompare the actual rates of fetal deathamong our study populations and Whites.Yet the information to date offers littlesupport for the excess fetal death hypothe-sis as a likely explanation of the epidemio-logical paradox.

Selective Migration

Several studies have shown that botheconomic and cultural self-selectionoperate in voluntary migration, as fromMexico.30-32 The unpredictability of theeconomic environment in the sendingcommunities often motivates people

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Immigrants May Hold Clues to Protecting Health During Pregnancy — Exploring a Paradox

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to want to take the risks involved inrelocation.

Evidence indicates that labor migrationdecisions are made jointly by family mem-bers within households.35 But selectionfactors may vary according to gender rolesand expectations. While Mexican malemigrants are pushed out of their commu-nities by lack of employment and pulledto the United States by labor and higherwages and social network ties that facili-tate access to employment,33-35 female par-ticipation in migration is more often ameans of keeping the family together andproviding continuity of care.36 This beingthe case, health selection factors may per-haps be stronger among Mexican men,who are most often the initiators ofmigration, than among Mexican women,who are often the implementers of house-hold decisions to migrate.

Protective Sociocultural Factors

While the hypotheses discussed to thispoint offer some hints about the healthparadox among immigrant mothers,perhaps most compelling from the “pre-vention” perspective is the idea thatimmigrants and refugees might be profit-ing from sociocultural and behavioralfactors whose benefits outweigh the risksstacked against them. It appears thatnewcomers bring to the host societyvalues, attitudes, and behaviors thatprotect them against the risks of adversepregnancy outcomes or directly contributeto healthy outcomes.

HEALTHY HABITS

Several studies have shown that the con-sumption of tobacco, alcohol, and illicitdrugs during pregnancy are associatedwith poor pregnancy outcomes. Fetalgrowth retardation has been associatedwith smoking38,39 and with moderate tohigh levels of alcohol use.40,41 Substanceuse also contributes to general pregnancycomplications and congenital malforma-tions.3,38,42,43

Cigarette Smoking

Cigarette smoking during pregnancycauses close to 10% of fetal and infantdeaths and one-fifth of all low-birthweightbirths in the united States and is the single

most importantknown cause of envi-ronmentally inducedlow birthweight.10

Women who smokeare almost twice aslikely to deliver a low-birthweight baby asare nonsmokers.44

Studies consistentlyshow low prevalencerates of tobacco useamong Mexican-American, includingMexico-born women,and Southeast Asianwomen.

Since the bulk ofevidence shows a clearand consistent associa-tion between lowbirthweight and infantmortality and smok-ing, the low rate ofsmoking in theseimmigrant populationsis clearly advanta-geous.

Alcohol Use

Alcohol use during pregnancy has beenassociated with both short and long-termnegative health effects for infants, includ-ing congenital malformations and mentalretardation.48

Women who consume large amounts ofalcohol during pregnancy have higherrates of low-birthweight babies than donondrinkers.41 While the evidence ismixed, alcohol use during pregnancyappears to be low among Mexican-American and Southeast Asian women.

While important, it does not appearthat alcohol has nearly as strong animpact on low birthweight and infantmortality as cigarette smoking.10 However,the low prevalence rate of alcohol con-sumption during pregnancy in immigrantgroups does suggest a reproductive healthadvantage.

Illicit Drugs

Prenatal use of controlled substances hasbeen correlated with fetal growth retarda-tion, prenatal death, and pregnancy and

delivery complications.56-60

Overall, foreign-born Asian and Latinawomen in this Vega et al. Study were farless likely to consume addictive substancesthan White women during pregnancy,except for alcohol among Latinas. Thesefindings indicating low consumption havebeen supported by recent studies conduct-ed by Rumbaur and Weeks49 and Newmanet al.61 in San Diego.

Although few pregnant women engagein drug abuse, it appears that those who doare generally in poorer health and obtainlimited prenatal care.48 The much lowerprevalence of illicit drug use among immi-grants suggests another health advantage.

DIETARY INTAKEA nutritious diet helps to meet the chang-ing needs of the pregnant woman and herfetus. Specific nutrients such as calcium,zinc, protein, iron, and vitamins C, A, andE and folic acid have been related topregnancy outcomes,38, 62 and there is noevidence of substantial differences in nutri-tional requirements among various ethnic

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© Alan Pogue

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groups. Guendelman and Abrams com-pared the intake of the previously namedeight nutrients between White women andMexican-American women of reproductiveage, using data from two Health andNutrition Examination Surveys.63 For thepurpose of comparison, these analyses areextended here to examine the differentnutrient intakes of Mexican-Americanpregnant women in the Hispanic HANES(n = 79), White women in the secondHANES (n = 72), and a sample of pregnantSoutheast Asian women who participatedin a Prenatal Nutrition project at theUniversity of California at San Diegobetween similar reference periods (1978-90). The latter were studied by Newman etal., who reported results based on 91Cambodian, 37 Laotian, and 59Vietnamese women.61 For all groups,dietary intake was elicited by participantrecall of food and beverage consumptionduring the preceding 24-hour period.

…[T]he five study groups did not differsignificantly with respect to age or meannumber of live births. However, they dif-fered markedly with respect to height,weight, and body mass index (BMI). Whitewomen were the tallest, while MexicanAmericans had the highest BMI. All threeSoutheast Asian groups were shorter andlighter and had a lower BMI than eitherMexican-American or White women.Despite these differences, the energy intakeamong the groups was similar.

A comparison of the mean daily intakeof each nutrient relative to the recom-mended daily allowance (RDA) standardsfor pregnant women shows that the meanintake of protein was above the RDA for allethnic groups. Yet the protein intake wassignificantly higher for Southeast Asianwomen (particularly the Vietnamese) incomparison with Mexican-Americans andWhite women. Mexican-American andWhite women did not differ significantlyin their intake of any of the eight nutri-ents, and the mean daily intake of vitaminsC and A, iron, and zinc relative to the RDAwas similar across all ethnic groups. Asidefrom protein, then, the findings do notshow a better diet for immigrant comparedto nonimmigrant pregnant women.

(Because the RDAs are estimated to exceedthe nutrient requirements of most individ-uals, intakes below the RDA for a givengroup are not necessarily inadequate, butthey do suggest an increased likelihood ofpoor dietary intake.) In fact, compared withnon-Southeast Asian women, Cambodianwomen showed a lower intake of folate,vitamin E, and calcium.

These findings were not adjusted forsocioeconomic status. White women inthe HANES sample had higher incomesthan the immigrant groups in eitherstudy, and it is possible that after control-ling for income, Southeast Asian women,all of whom were at or under 200% of thepoverty level in the Newman et al. Study,would have had better nutrient intakethan Whites. Clearly, more research, utiliz-ing larger samples and controlling forsocioeconomic status, is needed to com-pare the nutrient intake of SoutheastAsian and White women.

Somewhat more information is availablefor Mexican Americans. As with drug andalcohol use, the nutrient intake of Mexican-born women seems to be far better than theintake of U.S.-born women of Mexicandescent. According to Guendelman andAbrams in their study of generationaldifferences in nutrition,63 Mexican-bornimmigrants had significantly higherabsolute intake and higher average intakerelative to RDA standards for protein, vita-mins (A, C, E, and folic acid), and calciumthan did second-generation MexicanAmericans and Whites. Although this studydid not follow women through their preg-nancies, the results suggest that nutritionmay help to explain the much lower rate oflow birthweight among first-generationMexican-American women than amongU.S.-born women of Mexican descent.64,65

Large epidemiological studies are needed toexamine the association between dietaryintake, weight gain during pregnancy, andpregnancy outcomes among newcomerpopulations to help us further unravel theepidemiological paradox.

KIN NETWORKS AND FAMILY STABILITY

The role of social factors in explaining the

paradox is even more poorly understoodthan that of health and nutrition habits.Nevertheless, some social factors related tofamily and social networks seem to pro-vide clues to better reproductive health,even though we do not understand themechanisms by which they affect preg-nancy outcomes.

Close kin networks may confer protec-tion to the pregnant woman and compen-sate for income deficits by improvingaccess to informational and psychosocialsupport.66-69

These resources may translate into moreknowledge about healthy pregnancies, theencouragement of positive behaviors, andless stress during pregnancy, all of whichmore directly affect perinatal morbidityand mortality. They may also alter hor-monal and immunological responses asso-ciated with pregnancy complications.70

Research on Latinos and SoutheastAsians has described the centrality of thefamily in both cultures. Latinos tend tohave close kin networks and emphasizethe collective needs of the family overindividual needs.71-74 Indeed, the familyhas been described as the single mostimportant institution for MexicanAmericans.75, 76 Kinship in this case com-prises not only relatives but also theLatino compadre system, which establish-es “coparents,” in the Catholic tradition,who share broader, less formalized obliga-tions toward the children.77 Recent evi-dence further suggests that women ofMexican descent appear to have moresocial network contacts outside of thefamily66 compared with Whites as well asenhanced access to psychosocial andinformational social support. As noted,these factors may contribute to favorablepregnancy outcomes by making moreresources available to the pregnantwoman, thereby compensating for eco-nomic deficits.

Family stability also appears to influencereproductive health. For instance, a studyby Ramsey et al.69 showed that womenwho lived alone were at highest risk ofhaving smaller babies, while living with

Immigrants May Hold Clues to Protecting Health During Pregnancy — Exploring a Paradox

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extended family was correlated with high-er birthweights. Living with a husband fur-ther increased the likelihood of having aheavier baby.68 These effects might bemediated by such factors as higherincome, better nutrition, and less stress.

Family stability may play a role in thecase of teenage pregnancies as well.Scientific and popular understanding havelinked births to teenage mothers (under18 years) with poverty, welfare dependen-cy, and a host of other social problems,including alienation from family. Butteenage pregnancy among MexicanAmericans and Southeast Asians appearsto follow a different pattern. In bothgroups, pregnancy at a young age appearsto be more common and more culturallyacceptable than among Whites, andteenage mothers are often cared for andsupported by extended family.

Few studies have directly tested the rela-tionship between family networks, familystability, and pregnancy outcomes. Theprevalence of strong and stable family net-works in immigrant populations suggeststhat these factors might help to explainthe paradox of favorable pregnancy out-comes among at-risk populations.

THE EFFECT OF ACCULTURATION ONPREGNANCY RISKS AND OUTCOMES

A corollary to the protective socioculturalhypothesis is the acculturation hypothesis.According to the latter, as immigrantsspend more time in the United States ormove to the second generation, theirhealthy behaviors, norms, and attitudeschange, resembling those of the Whitenonimmigrant population or of high-riskgroups with which they come into con-tact. Shifts in health risks coupled withchanges in sociodemographic characteris-tics that occur with acculturation affectpregnancy outcomes.

Recent findings suggest that it may not take a whole generation for changesin the reproductive risk profile of Mexican Americans to become apparent.Guendelman and English found that with-in five years of moving to this country,there was notable deterioration in theperinatal health of Mexican-born womenliving in California. Long-term residentshad fewer planned pregnancies and were

more likely to smoke than newcomerswho had lived in the country for fiveyears or less. After controlling for smokingplanned pregnancy, and maternal age,long-term immigrants living in the UnitedStates for more than five years were morelikely to have pregnancy complicationsand to deliver preterm and low-birth-weight infants than newcomers.91

CONCLUSION

The rapidly growing Mexican-Americanand Southeast Asian populations inCalifornia are quite heterogeneous interms of social and cultural backgrounds.Despite the diversity, both within andacross immigrant groups, these popula-tions share a socioeconomic disadvantagecompared to White Californians.

Although research has linked lowsocioeconomic status with a host ofhealth risk factors and adverse outcomes,this relationship does not necessarily holdwhen examining the pregnancy outcomesof these immigrant women. As this [arti-cle] has shown, Mexican-American andSoutheast Asian immigrants have favor-able pregnancy outcomes despite theirsocioeconomic disadvantages. This healthparadox is more accentuated among for-eign-born women, who are even poorerthan their U.S.-born counterparts. There isstrong evidence to suggest that immi-grants bring to the United States values,attitudes, and health behaviors that mayprotect them from adverse pregnancy out-comes. Among the protective factors, thevery low use of addictive substancesstands out as an important contributor tohealthy outcomes. Other protective factorssuch as good nutrition, a strong sense offamily and social support, and a positiveattitude toward childbearing show strongpotential for contributing to favorablepregnancy outcomes.

These protective factors may bufferimmigrant women from the stresses ofpoverty or else directly contribute to posi-tive outcomes by bolstering the immuneand hormonal systems. Although severalstudies have focused on the relationshipbetween these factors and pregnancy out-comes in other populations, remarkablyfew studies have focused on immigrantLatina and Southeast Asian women. Large

epidemiological studies are needed toexamine the relationship between preg-nancy outcomes and healthy diets, weightgain during pregnancy, healthy habits,and networks that provide informationaland emotional support and reinforcehealthy behaviors among immigrants.

As this [article] demonstrates, the preg-nancy outcomes of immigrant womenvary according to nativity and increasedexposure to American society. Althoughcertain risk factors associated with preg-nancy outcomes – such as education,income, and access to prenatal care –improve among U.S.-born, second-genera-tion Mexican Americans, many protectivefactors become eroded. Compared withfirst-generation Mexican-Americanwomen, the pregnancy outcomes of sec-ond-generation women are less favorable.

While it is too early to examine genera-tional changes in birth outcomes amongthe more recently arrived Southeast Asianpopulation, we can begin to explore theeffects of acculturation among foreign-born Southeast Asian women. Researchsuggests that they may be buffered frommany of the negative effects of accultura-tion, as demonstrated by their improvingbirth outcomes in recent years. Thisresponse contrasts with that of Mexicanimmigrants who appear to show a markeddeterioration in risks and pregnancy out-comes after only five years of residing inthe United States. Such differentials maybe a result of the different ways in whichimmigrants adapt to our society. Moreresearch is needed to examine the modesof immigrant adaptation and its effect onpregnancy outcomes. We must determinewhether the differentials observedbetween the two immigrant groups are aproduct of different community receptivi-ty to these populations or a different soci-ocultural orientation that immigrantsbring to our society.

Recognizing that tremendous gaps inknowledge exist, some preliminary con-clusions can be drawn regarding whatimmigrants can teach us about havinghealthy babies.

This health paradox demonstrates —contrary to the implications of earlier epi-

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WWhile Hispanic women seem to sufferfewer complications of pregnancy,

there is at least one area where theyappear to be at higher risk. In several stud-ies that have looked at the incidence ofgestational diabetes in various ethnicgroups, Latina women in the U.S. havesignificantly higher rates of this condition,compared with non-Hispanic whites andAfrican-American women.

Gestational diabetes deserves the atten-tion of prenatal care providers since it canresult in a high birthweight baby, whichin turn may lead to a more difficult laborand birth experience, with an increasedrisk of cesarean section. Neonatal hypo-glycemia is not uncommon in infantsborn to women with gestational diabetes.

Although gestational diabetes usuallyresolves soon after delivery, probably themost significant health risk for womenwith this condition is that they are at highrisk of developing diabetes later in life.According to the American DiabetesAssociation, the prevalence of Type 2 dia-betes among Latinos is double that ofnon-Latino whites in the US. Identifyingsome of these individuals early in life mayoffer an opportunity to provide importantpreventive care, including nutrition edu-cation and periodic screening.

Recently, the practice of routine screen-ing for gestational diabetes has been ques-tioned. This has led to the development ofa “selective screening” strategy based on

risk criteria. The Fourth InternationalWorkshop/Conference on GestationalDiabetes developed a list of factors thatindicate a woman would not need to bescreened (see table). Of significance toproviders working with migrantfarmworkers, note that screening isrecommended for Hispanic women.

Screening is performed at 24-28 weeksof pregnancy and consists of a one-hourserum glucose test after ingestion of a 50gm glucose solution. The usual screeningthreshold of 140 mg/dL is used to deter-mine an abnormal result. A 3-hour glucosetolerance test is then administered fordiagnosis of gestational diabetes.

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MMCN has begun an exciting new initia-tive. At the request of the DeSoto

County Health Department in Florida,MCN is developing a pilot-tracking pro-gram for pregnant migrant women.Migrant health providers have expressedfrustration with attempting to deliver com-prehensive prenatal care to women whochange residence multiple times duringtheir pregnancies. Migrant women alsoencounter problems in finding prenatalcare as they travel. As a result of this lack of

continuity, they often miss important pre-natal screening procedures or are subjectedto duplication of expensive blood tests andsonograms. Several attempts at developingmobile records for pregnant migrantwomen have met with mixed results.

The prenatal tracking program will usethe existing tracking structure developedthrough MCN’s TB and Diabetes trackingefforts. The initial goal is to enroll andtrack 10 women through their pregnancies.Transfer of records from one location to the

next will be facilitated and women will beassisted in promptly accessing care whenthey move. Information from prenatal carerecords will be compiled to measure out-comes throughout the pilot project.Applications for funding have been submit-ted to expand this project to serve a largernumber of pregnant farmworker women.

For more information about this new initiative contact Stephanie Freedmanat sfreedman@migrantclinician.org or 512-327-2017.

Pre-Natal Tracking

Gestational Diabetes and Hispanic WomenCandace Kugel, CRNP, CNM, MS

References

1. Kieffer, EC, Carman, WJ, Gillespie, BW, Nolan, GH, Worley, SE, Guzman, JR . Obesity and gestational dia-betes among African-American women and Latinas in Detroit: implications for disparities in women’shealth. J Am Med Womens Assoc 2001;56(4):181-7, 196.

2. Steinfeld JD, Valentine S, Lerer T, Ingardia CJ, Wax JR, Curry SL. Obesity-related complications of preg-nancy vary by race. J Matern Fetal Med 2000 Jul-Aug;9(4):238-4.

3. Casey BM, Lucas MJ, Mcintire DD, Leveno KJ. Pregnancy outcomes in women with gestational diabetescompared with the general obstetric population. Obstet Gynecol 1997 Dec;90(6):869-73.

4. Carr CA. Evidence-based diabetes screening during pregnancy. Jl Midwifery & Womens Health 2001 May-June;46(3)152-8.

5. American Diabetes Association. Clinical Practice Recommendations 2001; Position Statement:Gestational Diabetes Mellitus. Diabetes Care 2001 Jan; 24 (Suppl 1).

SELECTIVE SCREENING CRITERIA FOR GESTATIONAL DIABETES

Criteria for women who do not need screening:

• Age less than 25.

• No history of poor obstetric outcome.

• Member of an ethnic group with a low prevalence of gestational diabetes(Hispanic, Native American/Alaskan, Asian/Pacific Islander, African Americanwomen do have a high prevalence and thus should be screened)

• Weight normal before pregnancy

• No known diabetes in first-degree relatives

• No history of abnormal glucose tolerance

Social Determinants of Health: Assembling Pieces of the Puzzle

The UNC-Chapel Hill School of Public Health 24th Annual Minority Health ConferenceFriday, March 1, 2002

For information about:

• Satellite and Internet broadcasts:www.minority.unc.edu/sph/minconf/2002/

• Dr. Sherman James and the Keynote Lecture:www.minority.unc.edu/sph/minconf/2002/keynote.htm

• Attending the Conference in person in Chapel Hill or dis-playing an exhibit for your organizationwww.sph.unc.edu/oce/mhc/

16th Annual California Conference on Childhood Injury Control

September 23-25, 2002Sacramento, CACalifornia Center for Childhood Injury Prevention619-594-3691www.cccip.org

2002 National Conference on Health Care and Domestic Violence

September 26-28, 2002Atlanta, GeorgiaFamily Violence Prevention Fund(415) 252-8900www.endabuse.org/health/CFA

The National Safety Council Annual Congress and Exposition

October 7-9, 2002 San Diego, California(630) 285-1121www.nsc.org

C A L E N D A RC A L E N D A R

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AA tlanta-The Centers for DiseaseControl and Prevention (CDC) has

unveiled a redesigned Web site offeringboth new and updated bioterrorismresources for health professionals and thepublic.” The site at www.bt.cdc.govaddresses the need for up-to-date andaccurate information on health threatsarising from exposure to biological, chem-ical, or radiological agents. The redesignedsite, which focuses on Public HealthPreparedness and Emergency Response, isthe official federal site for medical, labora-tory, and public health professionals toreference when providing information tothe public and for updates on protocolsrelated to health threats such as anthrax.

CDC redesigned the site in response tooverwhelming demand from the publicand professionals for credible informationduring the anthrax crisis. In October 2001,CDC experienced more than a 100 percentincrease in traffic to its main Web site,www.cdc.gov, which links directly towww.bt.cdc.gov. CDC was the most visitedfederal government Web site in the nationin October, registering more than 9.1 mil-

lion unique visits. “As a result of recentevents, we find that not only health pro-fessionals, but people from all walks of lifewant information on health threats direct-ly from our agency’s Web site,” said CDCDirector Jeffrey P. Koplan, MD, MPH.“This new site makes the most-requestedinformation on public health prepared-ness and emergency response easier tofind and update quickly.”

CDC will continue to add informationto the site as part of its increased role inresponding to health threats that involvebiological, chemical, or radiologicalagents. CDC’s other information resourcesinclude a hotline: 1-888-246-2675(English) and 1-888-246-2857 (Spanish)available Monday through Friday, 8 a.m.to 10 p.m. EST; Saturday and Sunday, 10a.m. to 8 p.m.

MCN Seeks 2002 Unsung Hero Nominations

In 1990, the Migrant Clinicians Network established its Annual Unsung Hero Awardas a way to honor one of the unrecognized clinicians in the field of migrant health.The Award winner receives an expense paid trip to the 2002 Annual Migrant HealthConference, and is introduced and applauded at MCN’s Annual Meeting.

Nominees for the Unsung Hero Award are distinguished by their demonstrateddedication to migrant health, participation in a variety of areas in migrant healthcare delivery, innovation in service delivery and prevention strategies, clinical leader-ship, and lack of previous recognition for their contributions to migrant health.

To nominate your Hero, please submit the clinician’s name, address, telephonenumber, and a short paragraph describing why you believe the nominee is aHero to: jhopewell@migrantclinician.org or mail it to Jillian Hopewell, MigrantClinicians Network, 1933 Mars Way, Chico, CA 95926, (530) 345-4806 voice andfax. Nominations should be received by MCN no later than March 4th, 2002.

CDC Releases New Bioterrorism Web Resourcesfor Clinicians, Lab Professionals, Public

demiological studies — that poverty doesnot necessarily coincide with unhealthylifestyles and that a lack of economicresources does not always mean a lack ofhuman and social resources. If we grasp thesignificance of this paradigm shift, we maybe in a better position to design health pro-motion policies that address immigrants’needs by emphasizing their socioculturalassets rather than assuming — and oftenblaming them for — their deficits.

With the advent of California’s “majori-ty-minority” population in the 21st centu-ry and the increasingly negative stereo-types placed on immigrants, as well as the

cutbacks in social programs for the poor, itis incumbent on health care providers,public health planners, and policy makersto recognize the positive health and socialaspects of immigrant communities. Suchawareness is important in order not onlyto preserve the health and healthylifestyles of immigrant women and theirchildren but also to learn ways of transfer-ring this knowledge to promote health inother communities with a high incidenceof infant mortality and low-birthweightbabies. In recognition of these positiveand protective factors and the benefitsthat they provide to all communities, the

following steps are recommended:• Health-media messages reinforcing

these protective values and behaviorsmust be disseminated broadly in ethniccommunities to counteract the influ-ences of alcohol, tobacco, and foodindustry advertising.

• Educational strategies must encourage asense of pride and confidence in thesociocultural assets that immigrant fam-ilies and communities possess.

• State funding must be maintained tosupport primary care facilities for bothlegal and undocumented immigrants.

• Research and evaluation opportunitiesmust be expanded to assess the bestways to apply the protective knowledgeand skills of Southeast Asian andMexican –American populations toother at-risk populations.

The reproductive health of California’slarge immigrant populations is a com-pelling area for future research and thedevelopment of new health promotionstrategies. Through increased attention tothese groups, we can more fully under-stand how to optimize maternal and childhealth for all Americans.

Migrant Clinicians NetworkP.O. Box 164285Austin, TX 78716

Non Profit Org.

U.S. Postage

P A I DPERMIT NO. 2625

Austin, TX

Acknowledgment: Streamline is funded by the Health Resources and Services Administration,Bureau of Primary Health Care, Migrant Health Program. The views and opinions expressed donot necessarily represent the official position or policy of the U.S. Department of Health andHuman Services. Subscription Information and submission of articles should be directed to theMigrant Clinicians Network, P.O. Box 164285, Austin, Texas, 78716. Phone: (512) 327-2017, FAX(512) 327-0719. E-mail: mcn@migrantclinician.org

Colin Austin, JD........................................................................Chair, MCN Board of Directors

Karen Mountain, MBA, MSN, RN ................................................................Executive Director

Jillian Hopewell, MPA, MA ..........................................................Director of Education, Editor

Editorial Board — Marco Alberts, DMD, Manatee County Health Dept., Parrish, FL; MatthewKeifer, MD, MPH, Harborview Occupational Medicine Clinic, Seattle, WA; Sheila Pickwell,PhD, CRNP, Dept. of Family & Preventive Medicine, Univ. of California, San Diego, CA

Immigrants May Hold Clues to Protecting Health During Pregnancy — Exploring a Paradox

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