Maternal Practices That Influence Hispanic Infants' Health and Cognitive Growth

DOI: 10.1542/peds.2009-0496 2010;125;e324-e332; originally published online Jan 25, 2010; Pediatrics

Rabe-Hesketh and Alice Kuo Bruce Fuller, Edward Bein, Margaret Bridges, Neal Halfon, Sunyoung Jung, Sophia

Maternal Practices That Influence Hispanic Infants' Health and Cognitive Growth

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Maternal Practices That Influence Hispanic Infants’Health and Cognitive Growth

WHAT’S KNOWN ON THIS SUBJECT: Epidemiological researchhas shown that birth outcomes are surprisingly strong amongfirst-generation Hispanic mothers, although most are situated inlow-income communities. This is known as the “epidemiologicalparadox” or “immigrant paradox.”

WHAT THIS STUDY ADDS: This study reports differences amongHispanic subgroups, compared with white mothers, in prenatalpractices that explain generally robust birth outcomes amongHispanic newborns. These protective factors are eclipsed asother factors slow the cognitive growth of Hispanic infants.

abstractOBJECTIVES: Infants born to immigrant mothers, including Hispanicmothers, display birth weight and mortality advantages, comparedwith other disadvantaged groups. We examined prenatal biologicalfactors and maternal practices that account for this advantage. Thenwe estimated the extent to which healthy birth outcomes, along withmaternal and family factors, contribute to the health and cognitivefunctioning of Hispanic infants.

METHODS: A representative US sample of 8114 newborns, including 1450newborns of Hispanic mothers, was drawn randomly in 2001. We com-pared the mean attributes of infants in subgroups that vary in maternalpractices, family attributes, and acculturation levels. We accounted forvariations in newborns’ gestational age and size for gestational age andtheir health status and cognitive functioning at 9 months of age.

RESULTS: Mexican-heritage and less-acculturated mothers were nomore likely than white mothers to bear premature or small-for-gestational age infants, despite large social class disparities, whichwas explained in part by Hispanic women’s low level of prenatal to-bacco use. Parenting practices and lower class status of Hispanicmothers then began to slow infants’ cognitive development, comparedwith white infants, because of weaker maternal education and cogni-tive facilitation during interaction tasks and larger family size.

CONCLUSIONS: These findings extend earlier research, detailinghealthy births among most immigrant Hispanic women. Robust birthoutcomes contribute to the early health and cognitive growth of His-panic infants, but risk factors linked to maternal and home practicesovertake these early protective factors by late infancy. Robust birthsand early health indicators displayed by Hispanic infants should notdistract pediatricians from attending to uneven cognitive growth.Pediatrics 2010;125:e324–e332

AUTHORS: Bruce Fuller, PhD,a Edward Bein, PhD,a

Margaret Bridges, PhD,a Neal Halfon, MD,b SunyoungJung, PhD,a Sophia Rabe-Hesketh, PhD,a and Alice Kuo,MDb

aGraduate School of Education, University of California, Berkeley,California; and bDepartment of Pediatrics, School of Medicine,University of California, Los Angeles, California

KEY WORDScognitive development, health policy, Hispanic health care,infancy, parental influence

ABBREVIATIONSNCES—National Center for Education StatisticsSGA—small for gestational ageLGA—large for gestational ageNCATS—Nursing Child Assessment Teaching Scale

Portions of these findings were presented at the NationalInstitutes of Health and the National Center for EducationStatistics; Conference on the Early Childhood Longitudinal Study,Bethesda, Maryland, May 8–10, 2007.

www.pediatrics.org/cgi/doi/10.1542/peds.2009-0496

doi:10.1542/peds.2009-0496

Accepted for publication Aug 19, 2009

Address correspondence to Bruce Fuller, PhD, University ofCalifornia, Berkeley, Graduate School of Education, Tolman Hall3659, Berkeley, CA 94720. E-mail: b�[email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2010 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

e324 FULLER et al



Earlier epidemiological studies re-vealed comparatively strong birthoutcomes for newborns of Hispanicmothers, despite large average so-cial class disparities, relative to mid-dle class populations. This “epidemi-ological paradox” is evidenced by thelower infant mortality rate for His-panic newborns, equaling 5.4 deathsper 1000 live births in 2001, comparedwith 5.7 deaths per 1000 live births fornon-Hispanic white newborns and 13.5deaths per 1000 live births for blacknewborns.1 In 2001, 6.5% of live birthsto Hispanic mothers were of low birthweight (�2500 g) and 1.1% of very lowbirth weight (�1500 g), comparedwith 6.8% and 1.2%, respectively, forwhite mothers.2

Little is known about whether the ep-idemiological paradox operates dif-ferently across Hispanic subgroups,perhaps stemming from selective in-migration by healthier members ofpopulations or from protective bene-fits of culturally bounded parentingpractices. We do know that more-acculturated Mexican adults use to-bacco products more frequently andrely heavily on cheese and friedfoods, compared with the nutritiousdiets of first-generation immigrants,who consume fresh vegetables andfruits.3–5 The causal pathway linkinghealthy prenatal practices androbust births by immigrant moth-ers seems to weaken for later-generation Hispanic mothers.6,7

Beyond the benefits of the epidemio-logical paradox for newborns, little isknown about whether these benefitspersist in health and cognitive do-mains during infancy. Social factorsrelated to maternal practices and fam-ily poverty, especially for immigrantpopulations, may come to outweighthe biological advantages resultingfrom healthy births. We focus on 5 setsof intervening factors, including (1)themother’s intention to become preg-

nant and knowledge of prenatalcare,8,9 (2) early parenting practicesthat facilitate the infant’s cognitivegrowth,10,11 (3) the mother’s mentalhealth and relationships with familymembers,12–14 (4) ethnic group mem-bership, and (5) the mother’s levelof acculturation.15,16 We investigatedwhether these home and social factorsreinforce or begin to eclipse the bene-fits of healthy births displayed bymanyHispanic newborns. Specific maternalpractices may pertain only to certaindevelopmental periods, and thesepractices likely vary between Hispanicand white populations, as well asamong Hispanic subgroups.

METHODS

Population

A total of 10 700 (unweighted) house-holds were visited in 2002 and 2003 byfield staff members of the NationalCenter for Education Statistics (NCES),drawn from a nationally representa-tive sample of hospital births in 2001as part of the Early Childhood Longitu-dinal Study, conducted with the Na-tional Institutes of Health. This homevisit occurred �9 months after thebirth and was conducted by field staffmembers who were matched with re-spect to ethnicity and language inmostcases. The number of child cases forour starting sample with completedata at 9 months equaled 8100 chil-dren (7450 births, counting twins,with rounding to the nearest 50cases, according to NCES reportingrules). The sample was further re-duced by excluding children who didnot reside with the birth mother, afew children who suffered from seri-ous birth defects (such as spina bi-fida or heart defects), 2 children as-sessed at�7 months of age, and 132children assessed at �16 months,given our focus on the infancyperiod.

Measures

Child Outcomes at Birth and 9 Months

The child’s gestational age was re-ported from birth certificates, alongwith whether the newborn was smallfor gestational age (SGA) (�10 percen-tile), appropriate for gestational age,or large for gestational age (LGA) (�90percentile) or was born prematurely.Scores for the 5-minute Apgar assess-ment of heart rate, respiration, reflexresponse, and muscle tone wereavailable for most newborns, al-though mean differences among eth-nic groups proved insignificant.16

Given the skewed distribution (mostinfants tend to score high), scalescores were recoded as a 3-level ordi-nal variable (scores of 0–6, 7–8, or9–10), but result differences amonggroups were insignificant. At the9-month home visit, themother’s inter-view asked the standard child healthquestion, “Would you say [child’s]health is . . .”, with a 5-level set of re-sponse categories, ranging fromexcel-lent to poor. The infant’s weight (ingrams) was measured by field staffmembers at 9months. Themother wasasked whether the child had experi-enced an ear infection or respiratoryillness. We report only descriptive re-sults for the latter 2 measures, givenprevious concerns regarding underre-porting by some ethnic groups.2,15

Two observational measures of the in-fant’s cognitive proficiency were as-sessed at 9 months. A reduced form ofthe Bayley Scales of Infant Develop-ment included 31 mental developmentitems, focusing on use of wordsand comprehension, purposeful actionwith objects, and simple “problem-solving” (eg, putting toys in a cup).17

The secondmeasure was derived fromthe researcher’s assessment of thechild’s engagement and attentivenessduring the Bayley scale tasks andyielded 5 items in a single-factor solu-tion (Cronbach’s � � .55; moderately

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correlated with the Bayley scale, r �0.39).

Biological and Social Factors

We tested for possible effects ofmater-nal attributes, including the mother’sage and her family’s social status, asreflected on a 10-point scale devisedby NCES statisticians that incorpo-rated data on the mother’s and fa-ther’s (if present) educational levelsand occupational status.17 Biologicaland prenatal factors proximal to thehealth of the fetus and newborn in-cluded the consumption of cigarettesduring the third trimester, 3 levels ofalcohol consumption in the third tri-mester, whether the mother partici-pated in a fertility intervention, andwhether the focal child was a memberof a multiple birth.

When estimating child health and cog-nitive proficiency at 9 months, we in-cluded 5 blocks of predictors, movingfrom proximal biological factors tomore-distal family and social factors.

These predictors included questionsregarding the mother’s use of birthcontrol, whether she stopped usingcontraception to become pregnant,and the extent to which she read aboutpregnancy and child development(that is, intentionality of the pregnancyand planning for child rearing).18

For assessment of early parentingpractices, the mother reported on thefrequency of breastfeeding and dailyprovision of nutritionally balancedmeals (not defined in the protocol).Five maternal practices were derivedfrom knowingly videotaped interactivetasks with the infant, including theNursing Child Assessment TeachingScale (NCATS).19 This assessment in-volves mother-led teaching and grossmotor tasks. Field staff members weretrained toachieve interrater reliability of0.90 for each observational assessmentconducted in the home. Scoring for theNCATS tasks yielded 5 factors, derivedfrom principal-components analysis,

that is, praise and encouragement of thechild’s effort (NCATS-1,� � .80), respon-siveness when the child is distressed(NCATS-2, � � .76), display of warm af-fect and emotional support (NCATS-3,� � .79), cognitive fostering and verbalspecificity (NCATS-4,� � .57), and avoid-ance of negative utterances or affect(NCATS-5, � � .59).

Measures of the mother’s relation-ships and home setting included ques-tions pertaining to parenting efficacy,indicating whether the infant was verydifficult or of average difficulty toraise; the scaled closeness of themother’s relationship with her ownparents; and the ratio of children �5years of age to adults (�18 years ofage) resident in the home. The shortversion of the Center for Epidemiolog-ical Studies-Depression scale was ad-ministered to assess the mother’s de-pressive symptoms.20

To test the effects of Hispanic or Mexi-can ethnic membership, we included

TABLE 1 Child Health and Cognitive Proficiency Outcomes at Birth and 9 Months, According to Mother’s Ethnicity and Home Language

Race/Ethnicity Hispanic Mothers’ HomeLanguage

Black White Mexican Non–Mexican-HeritageHispanic

Spanish English

Birth outcomesSubsample, n 1200 3750 950 450 500 300Gestational age, mean� SD, wk 38.2� 0.11 38.8� 0.04 38.6� 0.09 38.5� 0.16 38.6� 0.11 38.3� 0.17Premature newborns, no. per1000 births

127 59 65 101 70 80

Birth weight, mean� SD, kg 3.1� 0.21 3.4� 0.11 3.3� 0.29a 3.2� 0.42a 3.3� 0.29 3.3� 0.43SGA, no. per 1000 births 117 90 96 140 110 80LGA, no. per 1000 births 106 119 120 120 110 140Child outcomes at 9 moSubsample, n 1350 4200 1000 500 550 350Weight, mean� SD, kg 9.5� 0.07 9.4� 0.06 9.7� 0.06b 9.8� 0.11b 9.7� 0.08 9.6� 0.10Bayley scale infant cognitivescore, mean� SD

76.8� 0.43 77.4� 0.30 76.7� 0.46 77.3� 0.45 76.6� 0.41 77.5� 0.72

Task engagement responsiveness(standardized factor) score,mean� SD

0.11� 0.08 0.33� 0.06 �0.04� 0.10a 0.19� 0.08 0.09� 0.08 0.04� 0.18

Child’s health rated excellent, % 59 67 52c 62 52 60Respiratory illness, % 15 15 13 8b 12 12Ear infection, % 39 45 39a 33c 38 40

NCES weighting rules (rounding to nearest 50) were applied. Sampling strata were combined in some cases for statistical tests for mean differences. The significance of mean differencesbetween Hispanic subgroups and white children is reported. Data for Asian children were excluded for brevity (available from authors).a P� .05.b P� .01.c P� .001.

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dichotomous flags for Mexican origin,distinct from other Hispanic mothers.As indicators of acculturation status,we included whether the mother’shome language was Spanish or an-other non-English language (referencegroup: English speakers), whether themother was native or foreign-born,

and her years residing in the UnitedStates.

Statistical Analyses

We used logistic regression for esti-mating the likelihood of dichotomousbirth or child health outcomes (SGA,LGA, prematurity, and health status);

weighted least-squares regressionwas used to estimate continuouschild outcomes. The NCES calculatedsample weights, given the samplingframe and depending on the protocolused. For proper estimation of re-gression coefficients and SEs, givensampling weights and the clustering

TABLE 2 Attributes of Mothers and Children According to Ethnic Group and Acculturation Status (Home Language at 9-Month Home Visit)

Race/Ethnicity Hispanic Mothers’ Home Language

Black White Mexican Non–Mexican-HeritageHispanic

Spanish English

Subsample, n 1200 3750 950 450 500 300Block A: background control subjectsChild’s age, mean� SD, mo 10.3� 0.10 10.3� 0.06 10.3� 0.09 10.3� 0.17 10.1� 0.13 10.4� 0.20Mother’s age at visit, mean� SD, y 26.4� 0.23 29.3� 0.18 26.3� 0.27a 28.3� 0.53a 26.9� 0.36 27.3� 0.53

Block 1: proximal biological and prenatalfactors

Smoking in last trimester, packs per dayper 1000 mothers

18 66 11a 21a 0 10

Drinking alcohol at least once per week,no. per 10 000 mothers

20 177 2a 115 0 99

Fertility treatment, no. per 10 000 mothers 12 94 8a 47a 0 0Block 2: mother’s intentionality and

informationPregnancy intended, % 24 60 46a 43a 47 43Read prenatal care or parenting books or

magazines, %59 76 69a 76 70 76

Gave birth before focal child, % 61 58 58 51b 57 57Block 3: early parenting practices and social

interactionObserved task interaction score,

mean� SDNCATS-1 (praises effort and encourageschild)

1.7� 0.06 2.1� 0.05 1.7� 0.10a 2.0� 0.12 1.75� 0.14 2.0� 0.17

NCATS-2 (responds to child distress) 3.8� 0.09 3.9� 0.04 3.7� 0.10c 3.7� 0.15b 3.73� 0.12 3.83� 0.12Early nutrition practicesBreastfed in previous 7 d, % 8 22 19 18 24 14Fed child cow’s milk in previous 7 d, % 20 23 19b 19 16 21Mother able to provide balanced mealsto child, %

94 97 92c 98 93 97

Knowledge of child development score,mean� SD

5.9� 0.06 7.7� 0.08 5.4� 0.10a 6.0� 0.17a 4.95� 0.16 6.29� 0.17

Block 4: maternal support, social class, andrelationships

Father resides at home, % 43 91 84c 78a 84 75Mother completed some college, % 39 65 28a 45a 27 42Social class index z score, mean� SD �0.44� 0.03 0.25� 0.03 �0.52� 0.04a �0.13� 0.07a �0.55� 0.04 �0.16� 0.07Maternal employment, %Full-time 43 32 27c 36 27 35Part-time 16 25 15a 19b 14 20No. of children�18 y of age in household,

mean� SD2.4� 0.05 2.0� 0.03 2.3� 0.07a 2.0� 0.08 2.32� 0.11 2.29� 0.12

Child covered by health insurance, % 97 98 91 95 92 96Depressive symptom score, mean� SD 18.4� 0.23 16.6� 0.12 16.7� 0.25 16.2� 0.28 16.37� 0.31 16.86� 0.44Mother reporting close to own mother, % 95 93 90 91 40 28Raising focal child very difficult, % 5 6 9 10 11 4Block 5: ethnic membershipBlock 6: acculturation statusMother foreign-born, % 9 3 57a 56a

Primary home language, %English 97 98 37a 44a

Spanish 0 0 61a 51a

Other non-English 3 2 2 5

NCES weighting rules (rounding to nearest 50 cases) were applied. Sampling strata were combined in some cases for statistical tests for mean differences. The significance of meandifferences between Hispanic subgroups and white children is reported. Data for Asian children were excluded for brevity (available from authors).a P� .001.b P� .05.c P� .01.

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of families in 114 primary samplingunits, we used the suite of “svy” com-mands in Stata (Stata, CollegeStation, TX).21 Primary samplingunits were sometimes combined forweighting of means and calculationof SEs.

RESULTS

Differences in Birth and 9-MonthOutcomes According to Mother’sEthnicity and Acculturation

Table 1 reports small to insignificantdifferences in birth outcomes, in-cluding the incidence of SGA or LGAstatus, between Mexican and non-Hispanic white mothers, consistentwith the epidemiological paradox.22

Infants were more likely to be LGAwhen born to more-acculturated His-panic mothers (English as dominantlanguage). Mean birth weights weresignificantly lower for newborns ofMexican and other Hispanic mothers(3.3 and 3.2 kg, respectively), com-pared with white mothers (3.4 kg;both P � .05). By 9 months of age,infants in each Hispanic subgroupweighed significantly more than didwhite infants (P � .01), which indi-cated rapid weight gain and laterrisk of obesity.

At 9 months, a smaller proportion ofMexican mothers reported that theirinfants were in excellent health, com-pared with white mothers (52% and67%, respectively; P � .01). Non-Mexican Hispanic mothers reportedlower incidences of respiratory illnessand ear infections, compared withwhite mothers (both tests, P � .01 orstronger). No significant differenceswere observed for Bayley scale cogni-tive scores. Mexican-heritage infantsscored significantly lower on the taskengagement ratings, compared withwhite infants, at 9 months (0.18-SDgap, on the basis of raw scores; P �.05).

Differences in Maternal Practicesand Family Attributes

Table 2 reports differences in maternalattributes and practices, alongwith fam-ily attributes. InfantsofMexicanmothersand those in Spanish-speaking homeswere slightly younger (10.1 months) atthe9-monthhomevisit thanwere infantsof non-Mexican mothers and mothers inEnglish-speaking homes (10.4 months),which justified the child-age controls ineachmultivariate model. Hispanic moth-ers were significantly younger at the9-month home visit, which reflected ear-

lier child-bearing. Differences in proxi-mal biological and prenatal factors(block 1 predictors) included strikingand beneficial prenatal practices amongMexican and less-acculturated mothers(home language of Spanish), comparedwith white mothers. The incidence ofsmoking in the last trimesterwas low forMexican mothers (11 packs per 1000mother-days) and less-acculturated His-panic mothers (�1 pack per 1000mother-days), compared with whitemothers (66 packs per 1000 mother-days; both mean differences, P� .001),

TABLE 3 Estimation of Birth Outcomes From Proximal Biological Factors, Maternal Information andPractices, Social Status, Ethnic Group Membership, and Acculturation Status

Odds Ratio� SE

PrematureBirth

SGA LGA

Predictor block A: age F� 8.23a F� 6.53a F� 4.73b

Mother’s age 0.66� 0.18 1.05� 0.26 0.77� 0.33Mother’s age squared 1.01� 0.01 1.00� 0.01 1.01� 0.01Mother’s age cubed 1.00� 0.00 1.00� 0.00 1.00� 0.00Predictor block 1: proximal biological andprenatal factors

F� 3.92b F� 2.99a F� 4.81a

Alcohol consumption 1 1.24� 0.36 1.61� 0.49 0.35� 0.15c

Alcohol consumption 2 1.35� 0.52 1.21� 0.53 0.59� 0.31Smoking behavior 1.97� 0.27a 2.00� 0.40b 0.22� 0.12b

Multiple births 22.65� 2.41a 1.04� 0.17 0.89� 0.17Diabetic condition of mother 1.25� 0.21 1.11� 0.27 1.73� 0.40c

Fertility intervention 1.22� 0.29 1.61� 0.47 0.56� 0.24Predictor block 2: mother’s intentionality andinformation

F� 20.34a F� 3.57c F� 5.86b

Pregnancy intended 0.80� 0.08c 1.10� 0.14 0.95� 0.12Previously gave birth 0.54� 0.04a 0.66� 0.07a 1.68� 0.22a

Read pregnancy and parenting materials 1.02� 0.08 1.02� 0.11 1.16� 0.15Predictor block 4: support and social class F� 48.02a F� 20.73a F� 0.18Social class index 0.72� 0.04a 0.68� 0.06a 1.01� 0.08

Predictor block 5: ethnic group membership F� 13.77a F� 1.78 F� 0.26Hispanic, Mexican heritage 0.94� 0.14 0.76� 0.11 1.32� 0.27Hispanic, other heritage 0.97� 0.14 1.31� 0.28 1.18� 0.27Black 1.87� 0.16a 1.06� 0.14 1.01� 0.14Asian/Pacific Islander 1.22� 0.25 0.97� 0.16 1.25� 0.25Predictor block 6: acculturation status F� 0.50 F� 1.88 F� 3.83b

Spanish as home language 0.80� 0.16 0.92� 0.25 1.01� 0.25Other non-English language as homelanguage

0.86� 0.12 1.16� 0.22 0.92� 0.17

Foreign-born 1.18� 0.28 1.97� 0.51c 0.68� 0.17Years resident in United States 1.00� 0.01 1.02� 0.01 1.01� 0.01No. of cases (nearest 50) 7200 7050 7050F for complete model 82.05a 3.53a 2.83a

Total with sufficient dataStrata 88 88 88Primary sampling units 177 177 177

Results are from logistic regression analyses.a P� .001.b P� .01.c P� .05.

e328 FULLER et al



and rates of alcohol consumptionduringpregnancy were similarly low for Mexi-can mothers.

Parentingpracticesdiffered forHispanicmothers (block 3), including lower levelsof praise for the infant during problem-solving tasks (P� .001) and less respon-siveness to the infant when in distress(P � .01) among Mexican dyads, com-pared with white dyads. Hispanic moth-ers scored lower in their knowledge ofchild development, comparedwithwhitemothers (a gap equal to 1.2 SD for Mexi-can mothers).

Risk factorswerequiteapparentwith re-spect to the social status of Hispanicfamilies (block 4predictors). Only 28%ofMexicanmothershadcompletedanycol-lege courses, compared with 65% ofwhitemothers. Mexican families fell 0.77SDbelow themean (standardized) socio-economic status index forwhite families.More children resided in Mexican fami-lies (2.3 children) than in white families(2.0 children; P� .001).

Accounting for Variation in BirthOutcomes

Hispanic newborns benefited from ma-ternal prenatal practices in terms oflower rates of prematurity and SGA (Ta-ble 3). The likelihoods of a premature orSGA birth were twice as great for moth-ers who smoked in the third trimester.This benefited infants born to Mexicanand less-acculturated Hispanicmothers,given their low rates of tobacco use. Thelikelihoods of prematurity or SGA statuswere lower for infants of mothers whohad given birth previously, which bene-fited Hispanic newborns, whose moth-ers displayed higher mean fecundityrates.

The likelihood of giving birth to a SGAnewborn was 24% less for Mexican-heritage mothers. Newborns of otherforeign-born Hispanicmotherswere atrisk of SGA status (interaction of the 2odds ratios: 1.31� 1.97� 2.58).

TABLE 4 Estimation of Child Health Outcomes at 9 Months of Age From Birth Status, MaternalPractices, Social Status and Support, Ethnic Group Membership, and Acculturation Status

Child in Excellent Health,Logistic RegressionEstimate� SE

Child’s Weight,WeightedLeast-SquaresEstimate� SE

Predictor block A: basic child attributes F� 1.75 F� 90.51a

Female child 1.18� 0.09b �0.59� 0.05a

Child’s age of 9–10 mo 1.15� 0.13 0.28� 0.07a

Child’s age of 11–12 mo 0.98� 0.15 0.79� 0.11a

Child’s age of 13–14 mo 1.28� 0.26 1.21� 0.12a

Child’s age of 15–16 mo 1.50� 0.44 2.13� 0.16a

Predictor block B: child’s birth status F� 5.80a F� 36.96a

Gestational age 1.06� 0.02a 0.06� 0.01a

SGA 1.09� 0.13 �0.69� 0.07a

LGA 1.31� 0.18b 0.65� 0.09a

Multiple birth 1.11� 0.15 �0.21� 0.07c

Fertility intervention 0.98� 0.21 �0.10� 0.10Predictor block 2: early parenting practices andsocial interaction

F� 6.08a F� 4.55a

NCATS-1 (praises effort and encourages child) 0.99� 0.02 �0.03� 0.01b

NCATS-2 (responds to child distress) 1.03� 0.02 0.01� 0.02NCATS-3 (warm affect and emotional support) 0.91� 0.03c 0.03� 0.02NCATS-4 (cognitive fostering and verbal specificity) 1.18� 0.06c 0.04� 0.04NCATS-5 (avoids negative sanctions) 1.50� 0.35 �0.12� 0.14Breastfeeding in previous 7 d 1.26� 0.16 �0.36� 0.09a

Formula in previous 7 d 0.93� 0.13 �0.06� 0.09Milk in previous 7 d 0.95� 0.14 0.11� 0.10Ability to provide balanced meals to child 0.92� 0.15 �0.07� 0.17Physician visit 0.77� 0.22 0.09� 0.23Knowledge of development 0.96� 0.02 0.00� 0.02Predictor block 4: maternal support, social class, andrelationships

F� 14.25a F� 3.33a

Child of average difficulty to raise 0.65� 0.06a �0.05� 0.06Child very difficult to raise 0.64� 0.10c 0.10� 0.14Fairly close relationship with own mother 0.80� 0.06c �0.06� 0.06Not close relationship with own mother 0.59� 0.08a �0.03� 0.09Maternal depression 0.98� 0.01b �0.01� 0.00c

Father at home 0.92� 0.12 �0.05� 0.08Social class index 1.12� 0.07 0.13� 0.05b

Child’s health coverage 0.91� 0.22 �0.14� 0.17Child/adult ratio 0.83� 0.04a �0.09� 0.04b

Full-time maternal employment 0.86� 0.08 0.05� 0.05Part-time maternal employment 0.85� 0.08 0.06� 0.07WIC benefits 0.86� 0.09 0.24� 0.07c

Predictor block 5: ethnic group membership F� 3.76c F� 6.36a

Hispanic, Mexican heritage 0.98� 0.20 0.15� 0.13Hispanic, other heritage 1.28� 0.20 �0.06� 0.11Black 0.96� 0.11 0.09� 0.10Asian/Pacific Islander 0.65� 0.13b �0.41� 0.12c

Predictor block 6: acculturation status F� 8.00a F� 3.12b

Spanish as home language 0.62� 0.14b 0.21� 0.16Other non-English language as home language 1.11� 0.27 0.13� 0.12Foreign-born 1.35� 0.24 0.21� 0.14Years resident in United States 1.03� 0.01a 0.00� 0.01Constant 7.16� 0.66a

No. of cases (nearest 50) 5750 5600F for complete model 8.74a 22.31a

Total with sufficient dataStrata 88 88Primary sampling units 177 177R2 0.21

WIC indicates Supplemental Nutrition Program for Women, Infants, and Children.a P� .001.b P� .05.c P� .01.

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Accounting for Variation in InfantHealth and Cognitive Proficiency

To examine whether the early protec-tive factors manifested in robustbirths also advanced developmentduring infancy, we regressed the like-lihood that infant health was rated asexcellent and we estimated the child’sweight at 9 months of age (Table 4).Infants of older gestational age at birthand LGA infants were significantly morelikely to be rated as being in excellenthealth. Mothers with higher levels of de-pression, lower efficacy in raising the in-fant, and poorer relationships with theirownmother were less likely to rate theirinfants’ health as excellent. With all co-variates included, Hispanic mothers inSpanish-speaking homes were still 38%less likely to rate their infants as being inexcellent health.

Infants of older gestational age andthose LGA at birth weighed more at 9months of age, whereas SGA newbornsweighed less than the reference group(appropriate for gestational age).Breastfed infants weighed less thannonbreastfed infants. Infants withmothers who scored higher on thema-ternal depression scale also weighedless, as did infants in families withmore resident children per residentadult. Infants whose mothers partici-pated in the Supplemental NutritionProgram for Women, Infants, and Chil-dren weighed more.

Risk factors became more prevalentfor Hispanic infants when Bayley scalecognitive scores at 9 months were es-timated (Table 5). Maternal practices,including the consistency of praise,warm affect, and cognitive facilitationduring the interactive tasks, were sig-nificantly related to cognitive scores(Mexican mothers fell below whitemothers) (Table 2). When estimatingtask engagement, we saw that mater-nal praise and encouragement, alongwith warm affect, were associatedwith higher cognitive scores. Infants in

TABLE 5 Estimation of Children’s Cognitive Proficiency at 9 Months of Age From Birth Status,Maternal Practices, Social Status and Support, Ethnic Group Membership, andAcculturation Status

Weighted Least-Squares Estimate� SE

Child’s Bayley ScaleCognitive Score

Child’s TaskEngagement Score

Predictor block A: basic child attributes F� 449.47a F� 19.86a

Female child 0.68� 0.17a 0.13� 0.05b

Child’s age of 9–10 mo 4.26� 0.19a 0.23� 0.08c

Child’s age of 11–12 mo 10.57� 0.31a 0.58� 0.12a



Predictor block B: child’s birth status F� 57.37a F� 21.11a

Gestational age 0.33� 0.04a 0.04� 0.01a

SGA �0.74� 0.28b �0.18� 0.08b

LGA 0.60� 0.24b 0.11� 0.09Multiple birth �0.97� 0.24a �0.38� 0.09a

Fertility intervention �1.00� 0.41b 0.06� 0.14Predictor block 2: early parenting practices andsocial interaction

F� 6.65a F� 3.05c

NCATS-1 (praises effort and encourages child) 0.16� 0.06c 0.04� 0.02c

NCATS-2 (responds to child distress) 0.08� 0.04 0.01� 0.01NCATS-3 (warm affect and emotional support) 0.30� 0.08a 0.08� 0.02a

NCATS-4 (cognitive fostering and verbalspecificity)

0.29� 0.13b 0.05� 0.04

NCATS-5 (avoids negative sanctions) 0.77� 0.47 0.02� 0.18Breast feeding in previous 7 d �0.22� 0.26 0.01� 0.09Formula in previous 7 d �0.69� 0.23c 0.06� 0.10Milk in previous 7 d 0.77� 0.26c 0.11� 0.10Ability to provide balanced meals to child 0.60� 0.55 0.12� 0.16Physician visit �1.35� 0.93 �0.33� 0.24Knowledge of development �0.01� 0.06 0.01� 0.02Predictor block 4: maternal support, social class,and relationships

F� 4.08a F� 3.15c

Child of average difficulty to raise 0.20� 0.19 �0.05� 0.07Child very difficult to raise �0.24� 0.35 �0.17� 0.11Fairly close relationship with own mother �0.21� 0.18 0.02� 0.05Not close relationship with own mother 0.01� 0.35 �0.02� 0.09Maternal depression �0.02� 0.02 0.00� 0.00Father at home 0.16� 0.24 0.06� 0.09Social class index 0.10� 0.14 �0.09� 0.05Child’s health coverage �0.78� 0.55 0.21� 0.15Child/adult ratio �0.46� 0.12a �0.13� 0.04c

Full-time maternal employment 0.33� 0.18 0.05� 0.06Part-time maternal employment 0.45� 0.18b 0.15� 0.06b

WIC benefits 0.58� 0.24b 0.14� 0.09Predictor block 5: ethnic group membership F� 2.26 F� 3.03b

Hispanic, Mexican heritage �0.02� 0.41 �0.42� 0.20b

Hispanic, other heritage �0.43� 0.37 �0.28� 0.14b

Black �0.54� 0.30 �0.14� 0.09Asian/Pacific Islander �0.63� 0.40 �0.22� 0.12Predictor block 6: acculturation status F� 1.56 F� 0.61Spanish as home language �0.68� 0.47 0.18� 0.20Other non-English language as home language 0.12� 0.47 �0.11� 0.16Foreign-born �0.51� 0.43 0.05� 0.13Years resident in United States �0.01� 0.01 0.00� 0.00Constant 58.12� 1.99a �2.27� 0.53a

No. of cases (nearest 50) 5600 5600F for complete model 156.60a 6.70a

Total with sufficient dataStrata 88 88Primary sampling units 177 177R2 0.63 0.07

WIC indicates Supplemental Nutrition Program for Women, Infants, and Children.a P� .001.b P� .05.c P� .01.

e330 FULLER et al



families with greater child/adult ratiosdemonstrated lower Bayley scalescores and task engagement, whichfurther disadvantaged Mexican chil-dren. Infants of Mexican mothersscored lower on task engagementeven with all covariates in the model,which suggests additional negative ef-fects resulting from unobserved riskfactors.

DISCUSSION

This study corroborates earlier find-ings showing that Hispanic mothersdisplay healthy prenatal and early nu-trition practices, on average, althoughwe show how these protective factorsoperate mainly among Mexican andless-acculturated Hispanic women.2,6

These factors contribute to robustbirths and normal levels of physicalgrowth, despite the fact that Hispanicinfants often are raised in poor house-holds. Less-acculturated Hispanic andMexican-heritage mothers generallyavoid tobacco and alcohol use duringpregnancy, with levels far below thoseof white mothers. Healthy birth out-comes contribute to the early healthand cognitive growth of Hispanicinfants.

These early protective factors tend tobe eclipsed by maternal practices andhome dynamics during the infancy pe-riod, disadvantaging infants of Mexi-can and less-acculturated mothers.Robust newborns, including Hispanicinfants, display stronger cognitiveskills at 9 months. However, cognitivegrowth is then suppressed by low ma-ternal education, weaker cognitive fa-

cilitation, and the presence of morechildren per resident adult. Hispanicmothers displayed less praise and en-couragement during interaction taskswith their infants.

These social dynamics resemble thehome environments of other low-income populations, along with thesubsequent slowing of children’s cog-nitive growth and deterioration ofhealth indicators.11,15,23 However, manyHispanic mothers seem to sustainwarm and supportive environmentsfor their infants and toddlers, even aslocal exigencies and certain practicesslow their children’s development incognitive domains.10,11

Future work should address thepresent study’s limitations. Childhealth data for undocumented immi-grant families are sorely needed. Legalstatus likely limits access to healthcare and parents’ ability to sustain thebenefits initiated by robust births.Cultural groups also vary in theirsometimes-naive diagnoses of child ill-nesses, which may bias responses tostandard interview questions. Wemust learn more about the conditionsthat constrain maternal practices re-lated to young children’s cognitivegrowth. Why the epidemiologicalparadox benefits birth outcomes ofMexican-heritage newborns but failsto carry over to cognitive developmentis a pressing topic for investigation.How the weight of Hispanic infants sur-passes the weight of white infants by 9months (although Hispanic infants areborn lighter) also invites future work.

CONCLUSIONS

Health care providers should recog-nize that many Hispanic women ap-proach pregnancy with strong prena-tal practices. Rather than womenbeing at risk across domains, protec-tive factors predominate initially, es-pecially for less-acculturated Hispanicwomen and those of Mexican descent.However, these same subgroups areless knowledgeable regarding childdevelopment, on average. The often-robust physical health of Hispanic in-fants does not necessarily imply thatcognitive growth is keeping pace withthe growth trajectories of white in-fants. Child health providers should besensitive to the impact of lower levelsof maternal education, weaker cogni-tive facilitation, and larger family size,factors that seem to override the ben-efits of prenatal factors in shaping in-fants’ cognitive proficiencies. The epi-demiological paradox represents ahead start for newborns of certain His-panic subgroups, but maternal prac-tices and home dynamics often thenconstrain cognitive growth during theinfancy period.

ACKNOWLEDGMENTSThis article stems from the Latino ChildDevelopment Project, funded by theSpencer Foundation and the Universityof California, Los Angeles, Centerfor Healthier Children, Families, andCommunities.

Special thanks go to Jim Griffin, GailMulligan, and Jennifer Park for over-seeing data collection and for steadyadvice.

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DOI: 10.1542/peds.2009-0496 2010;125;e324-e332; originally published online Jan 25, 2010; Pediatrics

Rabe-Hesketh and Alice Kuo Bruce Fuller, Edward Bein, Margaret Bridges, Neal Halfon, Sunyoung Jung, Sophia

Maternal Practices That Influence Hispanic Infants' Health and Cognitive Growth

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