Abstract
Objectives. In the United States, Hispanic mothers have birth outcomes comparable to those of White mothers despite lower socioeconomic status. The contextual effects of Hispanic neighborhoods may partially explain this “Hispanic paradox.” We investigated whether this benefit extends to other ethnic groups.
Methods. We used multilevel logistic regression to investigate whether the county-level percentage of Hispanic residents is associated with infant mortality, low birth weight, preterm delivery, and smoking during pregnancy in 581 151 Black and 2 274 247 White non-Hispanic mothers from the US Linked Birth and Infant Death Data Set, 2000.
Results. For White and Black mothers, relative to living in counties with 0.00%–0.99% of Hispanic residents, living in counties with 50.00% or more of Hispanic residents was associated with an 80.00% reduction in the odds of smoking, an infant mortality reduction of approximately one third, and a modest reduction in the risks of preterm delivery and low birth weight.
Conclusions. The health benefits of living in Hispanic areas appear to bridge ethnic divides, resulting in better birth outcomes even for those of non-Hispanic origin.
The US Hispanic population is predicted to double by 2050, by which time it will constitute nearly one third of the total US population.1 In the process, the characteristics of many communities will change, and this has potential implications for public health. Neighborhood socioeconomic context and many other characteristics of communities, such as the physical environment and social cohesion, are known to have an impact on the health of residents.2–5
The US Hispanic population has rates of infant mortality and low birth weight (LBW) that are comparable to those of non-Hispanic US Whites6 despite Hispanic mothers being more likely to live in socioeconomically deprived areas and to have low socioeconomic status.7 This well-known phenomenon is termed the “Hispanic paradox.”8 Potential explanations for it include the selective migration of healthy women,8 social support and access to kin networks,9 and the promotion of healthier behaviors in Hispanic cultures.10 Recent research also suggests that high Hispanic density, that is, a high proportion of Hispanic residents in a community, is associated with better pregnancy outcomes (lower infant mortality and higher birth weight) and lower pregnancy smoking rates for Hispanics, regardless of their individual socioeconomic status or health-related behaviors.11–13
Explanations offered for these protective effects of Hispanic density include the ideas that Hispanic neighborhoods may act as enclaves that protect people from stigma and prejudice,14,15 may increase social support, and may lower communication costs because of the shared culture and language.13 Interestingly, US-born mothers of Hispanic origin receive greater reductions in risk of infant mortality11 and smoking during pregnancy12 from living in areas of high Hispanic density than do immigrant mothers. Similarly US-born mothers of Mexican origin have been shown to have infants with lower rates of LBW when they live in immigrant enclaves.13 Second- or later-generation Hispanic mothers are generally more acculturated and more likely to adopt the social and cultural norms of the dominant society instead of, or in addition to, the culture of their ethnic origin.16 Thus it appears that the benefits of living in Hispanic communities may be strongest for US-born Hispanic mothers. This raises the question of whether the salutary benefits of living in Hispanic communities are restricted to those of Hispanic heritage or whether they extend to other ethnic groups living in those communities.
The only studies we are aware of that have investigated the impact of Hispanic density on birth outcomes among non-Hispanic and multiethnic population samples focused on birth weight. Morenoff found that, after adjusting for each individual resident’s ethnicity, there was a nonsignificant positive association of the percentage of Mexican Americans living in Chicago, Illinois, neighborhood clusters with higher birth weight for mothers of all ethnicities.17 By contrast, Masi et al.18 found that higher Hispanic density measured at the level of census tracts in Chicago had an adverse association with birth weight and risk of preterm birth for White but not Black mothers, and Peak and Weeks19 found that the proportion of Hispanic residents in census block groups was associated with an increased risk of LBW for non-Hispanic White mothers living in San Diego, California. The limited evidence so far suggests that living in communities with higher proportions of Hispanic people might be associated with reduced risk of some, but not all, maternal and infant health outcomes for some non-Hispanics in some places.
We previously examined the impact of Hispanic density on Hispanic maternal and infant health using a nationally representative sample from the US Linked Birth and Infant Death Data Set, 2000.12 We found that Hispanic mothers living in US counties with a higher Hispanic density had lower rates of infant mortality and smoking during pregnancy but limited evidence of associations with LBW and preterm birth. We investigated whether these demonstrated benefits of Hispanic density are transmitted to other ethnic groups. Specifically, we examined whether non-Hispanic White and non-Hispanic Black residents in counties with high Hispanic density have lower risks of infant mortality, LBW, preterm delivery, and maternal smoking during pregnancy than did their counterparts living in counties with low-Hispanic density.
METHODS
We used data from the US Linked Birth and Infant Death Data Set, 2000.20 The US National Center for Health Statistics created the data set by collating data from birth certificates for all infants born live in 2000 with the death certificates of those who died in their first year; the data set is estimated to contain 99% of all US births.21 Under special license we obtained data that enabled us to link to the US Census 2000 Summary File 322 by the mother’s county of residence at the time of the infant’s birth for all counties irrespective of their population size. The analytic sample included US resident mothers of singleton births.
We used maternal race/ethnicity as defined on the infant’s birth certificate. Mothers indicated whether they were of Hispanic ethnicity and what race they considered themselves to be. We analyzed mothers describing themselves as non-Hispanic White, non-Hispanic Black, and Hispanic White, hereafter termed White, Black, and Hispanic, respectively. There were 2 274 237 White mothers living in 3139 counties, 581 151 Black mothers living in 2215 counties, and 763 201 Hispanic mothers living in 2664 counties.
We derived the Hispanic density for each mother’s county of residence from Summary File 3 of the 2000 US Census.22 Research has shown that the relationships between neighborhood characteristics and health may not be linear,23,24 so we allocated counties into the following categories of Hispanic density: 0.00% to 0.99%, 1.00% to 4.99%, 5.00% to 14.99%, 15.00% to 49.99%, and 50.00% or greater. We chose these categories because they enabled us to identify changes in county ethnic composition at low densities while facilitating the investigation of the effects of high Hispanic densities.
We took 3 outcome measures from birth certificate data: LBW (< 2500 g), preterm delivery (< 37 weeks gestation), and smoking during pregnancy (smoking ≥ 1 cigarettes a day during pregnancy). Smoking in pregnancy was not recorded for residents of California, whom we therefore omitted from the relevant analyses. We used death certificates to ascertain whether the infant had died by its first birthday. We failed to match birth and death certificates in only 1.3% of records.20
In all analyses, we adjusted for potential individual- and area-level confounding factors. Individual-level factors included parity, maternal age, marital status, and socioeconomic status as indicated by maternal education. County-level measures included socioeconomic status, measured as median household income and the percentage of Black residents in each county; we included the latter factor to ensure that we were examining the specific impact of Hispanic density and not the displacement of Black residents.
We conducted separate analyses for White and Black mothers. We described sample characteristics using means and percentages. The data have a 2-level structure, with individual infants and mothers at level 1 and counties at level 2. We used multilevel mixed effects logistic regression, using the XTMELOGIT command in Stata version 10.0 (StataCorp LP, College Station, TX)25 to estimate the contextual effects of Hispanic density in a random intercept model, adjusting for individual- and county-level sociodemographic characteristics.
RESULTS
Table 1 shows the characteristics of mothers and infants by the mother’s ethnicity. We included Hispanic mothers and infants in Table 1 for comparison. For infant mortality, Black infants were the most disadvantaged relative to Hispanic and White infants, who had comparable infant mortality rates. White mothers had fewer LBW babies and preterm births than did Hispanic mothers, who in turn had more favorable birth outcomes than did Black mothers. This contrasts sharply with smoking during pregnancy; White mothers were more likely to smoke during pregnancy than were their Black and Hispanic counterparts, the latter being the least likely to smoke.
TABLE 1—
Descriptive Statistics of White, Black, and Hispanic Mothers and Their Infants Born in 2000: US Linked Birth and Infant Death Data Set, 2000
| Variable | White Mothers, No. (%) or Mean ±SD | Black Mothers, No. (%) or Mean ±SD | Hispanic Mothers, No. (%) or Mean ±SD |
| Mortality | |||
| Surviving | 2 263 055 (99.51) | 574 078 (98.78) | 759 442 (99.51) |
| Died | 11 192 (0.49) | 7073 (1.22) | 3759 (0.49) |
| Birth weight, g | |||
| ≥ 2500 | 2 161 120 (95.13) | 515 056 (88.71) | 722 148 (94.67) |
| < 2500 | 110 656 (4.87) | 65 556 (11.29) | 40 678 (5.33) |
| Gestational age | |||
| Term birth | 1 937 008 (91.47) | 446 193 (84.42) | 624 512 (89.83) |
| Preterm birth | 180 654 (8.53) | 82 321 (15.58) | 70 725 (10.17) |
| Smoking status | |||
| Nonsmoker | 2 964 205 (89.20) | 494 008 (91.81) | 493 940 (97.12) |
| Smoker | 358 872 (10.80) | 44 044 (8.19) | 14 627 (2.88) |
| Parity | |||
| 1 | 952 100 (42.01) | 220 620 (38.09) | 285 348 (37.59) |
| 2 | 763 874 (33.71) | 171 655 (29.64) | 231 326 (30.47) |
| 3 | 359 481 (15.86) | 102 106 (17.63) | 141 863 (18.69) |
| 4 | 122 160 (5.39) | 46 553 (8.04) | 60 755 (8.00) |
| ≥ 5 | 68 655 (3.03) | 38 227 (6.60) | 39 885 (5.25) |
| Maternal age, y | |||
| < 15 | 1801 (0.08) | 3674 (0.63) | 2479 (0.32) |
| 15–19 | 200 249 (8.81) | 113 132 (19.47) | 122 280 (16.02) |
| 20–24 | 511 174 (22.48) | 190 038 (32.70) | 232 515 (30.47) |
| 25–29 | 628 805 (27.65) | 131 655 (22.66) | 204 255 (26.77) |
| 30–34 | 588 743 (25.89) | 87 092 (14.99) | 131 245 (17.20) |
| 35–39 | 285 900 (12.57) | 45 144 (7.77) | 57 879 (7.58) |
| 40–54 | 57 303 (2.52) | 10 333 (1.78) | 12 445 (1.63) |
| Maternal education, y | |||
| 0–8 | 38 253 (1.70) | 13 743 (2.40) | 161 846 (21.67) |
| 9–11 | 241 412 (10.70) | 131 901 (23.08) | 207 902 (27.84) |
| 12 | 701 506 (31.10) | 227 898 (39.88) | 222 386 (29.78) |
| 13–15 | 550 590 (24.41) | 131 674 (23.04) | 99 202 (13.28) |
| ≥ 16 | 723 825 (32.09) | 66 261 (11.59) | 55 525 (7.43) |
| Marital status | |||
| Married | 1 765 905 (77.67) | 180 461 (31.06) | 440 331 (57.72) |
| Unmarried | 507 725 (22.33) | 400 523 (68.94) | 322 602 (42.28) |
| Maternal nativity | |||
| US | 2 149 559 (94.70) | 517 678 (89.52) | 289 767 (38.06) |
| Outside US | 120 201 (5.30) | 60 621 (10.48) | 471 653 (61.94) |
| Hispanic density, % | |||
| 0.00–0.99 | 644 995 (28.36) | 133 414 (22.96) | 12 407 (1.63) |
| 1.00–4.99 | 1 005 200 (44.20) | 252 790 (43.50) | 118 567 (15.54) |
| 5.00–14.99 | 531 441 (23.37) | 149 503 (25.73) | 365 678 (47.91) |
| 15.00–49.99 | 89 049 (3.92) | 45 160 (7.77) | 221 268 (28.99) |
| ≥ 50.00 | 3562 (0.16) | 284 (0.05) | 45 281 (5.93) |
| Black density, % | |||
| 0.00–0.99 | 422 818 (18.59) | 2594 (0.45) | 80 326 (10.52) |
| 1.00–4.99 | 589 648 (25.93) | 25 928 (4.46) | 183 365 (24.03) |
| 5.00–14.99 | 733 951 (32.27) | 147 376 (25.36) | 313 446 (41.07) |
| 15.00–49.99 | 506 483 (22.27) | 344 618 (59.30) | 182 062 (23.86) |
| ≥ 50.00 | 21 347 (0.94) | 60 635 (10.43) | 4002 (0.52) |
| Median income, in $10 000s | 4.39 ±1.10 | 4.09 ±0.97 | 4.33 ±1.03 |
White and Black mothers were considerably less likely to have been born outside the United States than were Hispanic mothers. White mothers were more likely to be married, older, better educated, and less likely to have high parity. Black mothers had higher education than did Hispanic mothers but had the highest rates of teenage motherhood, were least likely to be married, and were most likely to have high parity. Black mothers were also the most likely to live in counties with a low median household income. More White than Black mothers lived in counties of high Hispanic density, whereas more Black than White mothers lived in places with moderate Hispanic densities (5.00%–14.99%), and in both relative and absolute terms, very few Black mothers (n = 284) lived in counties (n = 9) of high Hispanic density.
Table 2 shows the results of multilevel models estimating associations between Hispanic density and maternal and infant outcomes. Hispanic density was protective for all ethnic groups with respect to infant mortality. For White and Hispanic mothers, the effects increased with each categorical increase in Hispanic density. For Black mothers the strongest protective effect was for those living in counties with Hispanic densities of 15.00% to 49.99%, with no significant association of Hispanic density identified for the very small number of Black mothers living in counties with Hispanic densities of 50.00% or greater. The confidence interval (CI) for the latter association was wide, reflecting the rarity of the outcome and the small number of counties of this type in which Black mothers resided.
TABLE 2—
Effects of Hispanic Density on Birth Outcomes and Smoking During Pregnancy for White, Black, and Hispanic Mothers: US Linked Birth and Infant Death Data Set, 2000
| White |
Black |
Hispanic |
||||
| Variable | OR (95% CI) | P | OR (95% CI) | P | OR (95% CI) | P |
| Mortality, % | ||||||
| 0.00–0.99 (Ref) | 1.00 | 1.00 | 1.00 | |||
| 1.00–4.99 | 1.00 (0.96, 1.05) | .957 | 0.96 (0.88, 1.03) | .255 | 0.89 (0.70, 1.14) | .351 |
| 5.00–14.99 | 0.90 (0.84, 0.97) | .004 | 0.86 (0.77, 0.96) | .005 | 0.81 (0.64, 1.04) | .098 |
| 15.00–49.99 | 0.72 (0.63, 0.83) | < .001 | 0.66 (0.55, 0.79) | < .001 | 0.73 (0.57, 0.95) | .019 |
| ≥ 50.00 | 0.60 (0.33, 1.07) | .085 | 1.09 (0.34, 3.55) | .882 | 0.53 (0.38, 0.73) | < .001 |
| Low birth weight, % | ||||||
| 0.00–0.99 (Ref) | 1.00 | 1.00 | 1.00 | |||
| 1.00–4.99 | 0.96 (0.94, 0.98) | < .001 | 0.97 (0.94, 1.00) | .083 | 0.92 (0.85, 1.01) | .071 |
| 5.00–14.99 | 0.95 (0.92, 0.98) | .002 | 0.96 (0.92, 1.00) | .038 | 0.91 (0.83, 0.99) | .033 |
| 15.00–49.99 | 1.01 (0.95, 1.07) | .816 | 0.91 (0.85, 0.98) | .018 | 0.99 (0.90, 1.10) | .899 |
| ≥ 50.00 | 0.75 (0.61, 0.92) | .007 | 0.98 (0.63, 1.52) | .918 | 0.95 (0.83, 1.10) | .508 |
| Preterm birth, % | ||||||
| 0.00–0.99 (Ref) | 1.00 | 1.00 | 1.00 | |||
| 1.00–4.99 | 0.96 (0.94, 0.98) | .001 | 0.96 (0.93, 0.99) | .011 | 0.98 (0.91, 1.05) | .487 |
| 5.00–14.99 | 0.95 (0.92, 0.98) | .001 | 0.95 (0.91, 1.00) | .042 | 1.01 (0.94, 1.08) | .863 |
| 15.00–49.99 | 1.00 (0.94, 1.06) | .931 | 0.99 (0.90, 1.08) | .759 | 1.07 (0.99, 1.16) | .082 |
| ≥ 50.00 | 0.99 (0.82, 1.18) | .879 | 1.24 (0.84, 1.84) | .273 | 1.10 (0.99, 1.23) | .075 |
| Smoking during pregnancy, % | ||||||
| 0.00–0.99 (Ref) | 1.00 | 1.00 | ||||
| 1.00–4.99 | 0.96 (0.90, 1.04) | .313 | 0.93 (0.84, 1.03) | .17 | 0.60 (0.53, 0.68) | < .001 |
| 5.00–14.99 | 0.82 (0.72, 0.92) | .001 | 0.66 (0.56, 0.78) | < .001 | 0.38 (0.32, 0.44) | < .001 |
| 15.00–49.99 | 0.61 (0.51, 0.73) | < .001 | 0.71 (0.53, 0.94) | .017 | 0.31 (0.25, 0.38) | < .001 |
| ≥ 50.00 | 0.19 (0.11, 0.33) | < .001 | 0.14 (0.04, 0.51) | .003 | 0.09 (0.06, 0.14) | < .001 |
Note. CI = confidence interval; OR = odds ratio.
There was some evidence that Hispanic density was protective for LBW in each ethnic group; however, the effects were modest and inconsistent. For White mothers, relative to the 0.00% to 0.99% category there was some evidence of a protective effect for all categories apart from the 15.00% to 49.99% category, with the protective effect being strongest for mothers living at Hispanic densities of 50.00% or greater. For Black mothers there was also some evidence of protection with respect to LBW for increases in Hispanic density up to 50.00%; however, although statistically significant, the associations were modest. For Hispanic mothers, Hispanic density was only protective for densities of 5.00% to 14.99%.
Relative to mothers living at Hispanic densities of 0.00% to 0.99%, there were significant but modestly reduced odds of preterm birth for White and Black mothers living in counties with densities of 1.00% to 4.99% and 5.00% to 14.99%. This contrasts with Hispanic mothers, for whom increased Hispanic density was not significantly associated with risk of preterm birth.
Hispanic density was associated with a lower likelihood of maternal smoking during pregnancy for all ethnic groups. For White and Hispanic mothers, there was a clear reduction in risk of smoking during pregnancy with increasing Hispanic density. For Black mothers, higher Hispanic densities were generally associated with lower rates of maternal smoking during pregnancy and, given that the CIs were wide, the trend is consistent, with each increase in Hispanic density category being associated with reduced odds of smoking during pregnancy.
DISCUSSION
Living in counties with a higher proportion of Hispanic residents was associated with a lower risk of infant mortality and maternal smoking during pregnancy for Black and White mothers, and the magnitude of these associations was similar to results previously reported for Hispanic mothers.12 In addition, there was some evidence that Hispanic density was associated with lower risk of LBW for all ethnic groups, whereas weak protective effects in relation to preterm birth were found for White and Black (but not Hispanic) mothers living in counties with Hispanic densities of 1.00% to 4.99% relative to the reference category of 0.00% to 0.99%.
Our findings of modest associations between Hispanic density and LBW and preterm birth are consistent with the results of Morenoff17 but differ from those of Masi et al.18 and Peak and Weeks,19 who both found adverse effects of Hispanic density. We coded Hispanic density using 5 categories that placed an emphasis on investigating the effects of living at low-Hispanic densities, whereas both Masi et al.18 and Peak and Weeks19 simply dichotomized the data; thus, their reference categories may have combined both advantaged and disadvantaged communities.
Alternatively, the differences in results could be because of the size of area used to measure Hispanic density. The block groups and census tracts that Peak and Weeks19 and Masi et al.18 used are much smaller than were the counties we investigated. Small areas may not reflect the wider environment in which people work or spend their leisure time. The larger boundaries of a county are likely to encompass a greater proportion of residents’ day-to-day activities and encounters. The ability to explore effects by size of geographic areas was limited in our study, but when we stratified counties by tertiles of population size, we found no evidence that population size influenced the association of Hispanic density with smoking during pregnancy among White mothers, the strongest association in our study.
Our results suggest that White and Black mothers and their infants have better health when living in Hispanic communities. This indicates not only that communities may play an important role in explaining the Hispanic paradox but also that the benefits of living in Hispanic communities can cross ethnic divides. In this epidemiological study, we were unable to explore the responsible pathways and can only speculate on whether there are aspects of Hispanic culture that encourage positive interactions with other ethnic groups and therefore extend a generalized benefit through social cohesion and norms related to healthy behavior.
Qualitative studies suggest that Hispanic concepts such as respeto (the importance of respecting others)26 and simpatía (the desire to avoid confrontational interactions)27 may lead to increased numbers of positive interethnic interactions26 while placing limits on antisocial behavior. However, other qualitative studies describe how prejudice can divide multiethnic communities. Although non-Hispanic residents have sometimes reported that an influx of Hispanic residents makes an area feel safer, some may not react positively to such a change.26 Although studies suggest that Hispanic communities may be particularly hospitable and social, no clear picture emerges from qualitative research.
Quantitative research also provides a mixed picture of how non-Hispanic people interact with Hispanic communities. Higher percentages of Hispanic and Mexican American neighborhood residents have been associated with lower scores on scales of social cohesion and collective efficacy.28,29 However, these measures may not be valid in diverse communities. One of the items included in the scales of collective efficacy and social cohesion asks if people in the same neighborhood share the same cultural values. Thus areas with diverse populations and cultures will tend to score lower on collective efficacy regardless of actual levels of trust or community cohesion. Alternative measures of neighborhood social interactions suggest a different picture for multiethnic communities. The neighborhood percentage of Mexican Americans has been associated with more social ties for Black residents, Mexican Americans, and non-Mexican Latinos.28 Thus the effects of Hispanic communities on birth outcomes among non-Hispanics may be mediated by larger social networks, and increased levels of social support at both the individual and the area level are associated with better birth outcomes.30–33 However, there is little evidence to suggest that the percentage of Mexican Americans in a neighborhood is associated with White residents’ social ties.28
Social and cultural norms are often cited as explanations of the Hispanic paradox.8,27 Support for pregnant women living in Hispanic communities may be especially strong because concepts of motherhood and family (familismo), are very important in Hispanic culture.8,10,34 In addition, Hispanic culture is likely to encourage mothers to adopt healthier behaviors during pregnancy.34 The focus on mothers’ adoption of healthier behaviors may also explain why a recent study suggests that the benefits of Hispanic density for self-rated health among adults is restricted to Hispanic women and does not extend to Hispanic men.35 The benefits for women, mothers, and infants of living in counties with a high density of Hispanic people may result not solely from the adoption of positive aspects of Hispanic culture but also from the dilution of negative aspects of American culture, such as high rates of smoking in pregnancy among Whites of low socioeconomic status.
Exposure to violence and neighborhood safety have been linked to birth weight,17 infant mortality,32 and smoking,36 and there is evidence that crime rates are lower in immigrant neighborhoods.37 Sampson has argued that this reduction occurs because the culture of immigrants may penetrate communities and dilute those aspects of American culture that increase violence. He argues that the American culture of violence may be a remnant of frontier mentality in which there was little formal justice and disputes were settled by violent retaliation37 or it may be a legacy of racism and the attitudes developed under racial segregation. For Blacks, living in Hispanic communities may limit exposure to violence as well as to racism.
Whatever the mechanisms explaining the associations between Hispanic density and better birth outcomes, it has been suggested that Hispanic neighborhoods are generally hospitable and vibrant38 with active street communities that make people feel safer.39 Although Hispanic communities may commonly be perceived as poor communities,7 they are also often home to recent migrants who, although not necessarily having much material capital, may create neighborhoods with high levels of social capital.
These possible explanations for the associations between higher proportions of Hispanic density and better birth outcomes are necessarily speculative. Research in public health on Hispanic communities, although growing, is more limited than is research on Black neighborhoods.
A strength of this study is that it includes all US births, providing the power to examine effects on infant mortality. However, data available from vital records and the census are limited in scope, and we were unable to control for a full range of individual- and neighborhood-level factors that might confound or mediate the effect of Hispanic density on maternal and infant health. In addition, Hispanic ethnicity encompasses people from diverse national origins and migration histories,40 and these differences may help future research exploring the specific aspects of Hispanic culture that are related to better maternal and infant health.
Acknowledgments
This study was funded by the UK Medical Research Council (grant R1032101) and the UK National Institutes of Health (award PAS/03/07/CSA/014 to K. E. P.).
The authors thank the US National Center for Health Statistics for providing the restricted use data set and Karl Atkin, Kathleen Kiernan, and Richard Wilkinson for ongoing discussions about ethnic density and health.
Human Participant Protection
No protocol approval was needed because this was a secondary analysis of anonymized data.
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