In the 1950s, the United States ranked sixth in the world in infant mortality, but, by the 1980s, the U.S. rank increased to twenty-second in the world. Correspondingly during these thirty years, the black-white infant mortality ratio increased from 1.6 to 2.1. During the late 1980s, the infant mortality rate for both non-Hispanic whites and Mexican-Americans was 8 deaths per 1000 live births, but the rate for blacks was 18 per 1000, a greater than twofold excess in risk. Although blacks and Mexican-Americans are both socioeconomic disadvantaged groups, paradoxically, the excess infant mortality occurs only among the black population. While differences in prenatal utilization appear the most obvious explanation, national data shows that Mexican–American women were less likely to receive timely prenatal care than black women. Furthermore, both blacks and Mexican-Americans experience racial discrimination, which has been shown to result in both physical and psychosocial stress that may adversely affect the health status. Thus, the author explores this paradoxical phenomenon in the literature.

Becerra and coworkers (1991) observed that among Mexican-American women, women born in Mexico were less likely to give birth to low birth weight infants and the these infants had lower mortality in the first year of life than Mexican women born in the US. Thus, a woman’s place of birth may influence the likelihood of having a low birthweight infant and the infant survival in the first year. Scribner and Dwyer (1989) state that adherence to a traditional Mexican cultural orientation may function as a protective factor. Lower prevalence of smoking and alcohol and fewer births among unmarried women are correlates of traditional Mexican culture. The cultural adherence association was determined to be independent of age, parity, education, income and cigarette smoking, risk factors for low birth weight and infant mortality. Although the Mexican-American women may experience physical deprivation, their cultural orientation may provide psychological benefits due to a reduced emphasis on confirming to the American value system.

In contrast, most native-born African-Americans are Americanized and thus may experience psychological marginalization. Cabral et al ((1990) observed a similar phenomenon among foreign-born and U.S.-born black women. Both groups delivered babies in Boston City Hospital in 1985 to 1986. The foreign-born black women tended to be older, better educated, married, less likely to smoke, drink alcohol, use illicit drug, and have more prenatal care visits than their US-born counterparts. Infants of foreign-born black women had statistically significant higher mean birthweight, which was independent of the above risk factors. While the odds of premature delivery, low birthweight, and mortality was lower than for their U.S. born counterparts, the outcomes were not statistically significant.

An alternative conceptual model that recognizes the strong connections between cultural and social factors and individual-level variables is needed to understand the poor pregnancy outcomes among minorities. Socially and economically disadvantaged racial and ethnic minority women are often exposed to physical and social environmental stressors, such as inadequate housing, poor nutrition, violence and discrimination. In the absence of protective cultural forces, these women may turn to unhealthy behaviors like smoking, alcohol and drug use to alleviate their stress. The prevalence of social and physical stressors does not negate the importance of quality and timely prenatal care. Buescher et al (1987) conducted a study among two groups of predominantly black, low-income women in which women were assigned to receive prenatal care from Health Department or community based physicians in North Carolina during 1984. Controlling for the identified risk factors, the most statistically significant variable to predict low birthweight was the source of the prenatal care. The Health Department prenatal care program focused on addressing the psychosocial need of the women as well as providing the traditional physiological component of prenatal care. In contrast, the private physicians supplied only the routine prenatal care.

The author concludes that past research that focused on proximal determinants, the individual-level risk factors such as alcohol and smoking, did not explain the racial differences in infant mortality or low birth weight. However, a more comprehensive representation should include contextual factors, both economic and cultural and their interplay, that shape the distribution of these proximate risk factors across different ethnic and racial populations. African-Americans have “been thwarted in almost every conceivable way by the larger society in its efforts to develop cultural as well as economic strengths.” Thus, comparison of health outcomes between various U.S. racial and ethnic groups must consider current circumstances of the groups as well as their unique socioeconomic and cultural histories. Ultimately, in order for a prenatal care program to be effective, it must focus on economic and cultural factors and needs of the community as well as of the needs of the women.