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Beliefs Associated with Mexican Immigrant Families’ Practice of La Cuarentena during Postpartum Recovery
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Beliefs Associated with Mexican Immigrant Families’ Practice of La Cuarentena during Postpartum Recovery Lisa Johnson Waugh
Correspondence Lisa Johnson Waugh, RN, PhD Department of Health Care Policy and Financing 1570 Grant Street Denver, CO 80203 [email protected] Keywords postpartum recovery Mexican immigrants perinatal care la cuarentena
ABSTRACT Objective: To examine underlying beliefs that motivate the observed behaviors of la cuarentena, which refers to the 40 days (6 weeks) of postpartum recovery observed by Mexican immigrant women in the United States. Design: Qualitative/descriptive. Participants/ Setting: Forty Spanish speaking individuals from 19 different Mexican immigrant families in Colorado were visited in their homes during pregnancy and the postpartum period. Methods: Ethnographic methods for this study focused on participant observation and interviews during traditional observance of la cuarentena. Mothers, their partners, and caregivers were interviewed in their homes in a series of four visits. Results: Families described perceptions of the body as “open” and vulnerable to drafts or aire. Women reported that the cultural traditions of la cuarentena will “close” the body, and this was seen as the central purpose of postpartum recovery. Immigrant women reported that they hide their traditions in health care settings, recognizing that many providers don’t understand or trivialize their beliefs and customs. A lack of awareness of la cuarentena among health care providers is a barrier to many women seeking professional care. Conclusions: Understanding the underlying fears associated with la cuarentena will assist nurses and clinicians in supporting immigrant families during postpartum recovery. Support from health care providers is particularly important given the occasional lack of family social support for immigrant women after they give birth.
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ies in California and Texas have estimated that approximately 80% of immigrant families practice traditional customs in the postpartum period (Niska, 1998; Zepeda). Without the support of extended family, Mexican women in the United States can find it difficult to observe traditions such as la cuarentena. Social isolation during the postpartum period can leave immigrant women vulnerable to exaggerated fears, mood disorders, and complications during recovery (Clark; MartinezSchallmoser).
The author reports no conflict of interest or relevant financial relationships.
a cuarentena (cuarenta d´ıas or quarantine) is a term commonly understood by Mexican American and Mexican immigrant families to refer to 40 days of postpartum recovery. The term references traditional behaviors regarding diet, clothing, bathing, and sexual abstinence as well as specific beliefs/fears about health and expectations of social support. Studies in the public health literature document that nutrition, infant-feeding practices, maternal depression, the acquisition of parental role responsibilities and sexual behavior in Mexican American and immigrant families are influenced by traditional customs during the 6 weeks of postpartum recovery (Clark, 2001; Kay, 1982; Kieffer & Willis, 2002; Martinez-Schallmoser & Tellen, 2003; Niska, 2001; Zepeda, 1982). There are few estimates of the prevalence of the practices of la cuarentena in the literature, though stud-
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C 2011 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
Lisa Johnson Waugh, RN, PhD is a health policy specialist for the Department of Health Care Policy and Financing, State of Colorado. This research was conducted at the University of Colorado, Department of Health and Behavioral Sciences, Denver, CO.
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Given that Mexican immigrant families are a growing ethnic group in many parts of the United States, it is essential that health care providers understand not only the expressions of cultural behaviors, but also the culturally influenced fears and understandings of the body that motivate
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those behaviors. Using ethnographic methods I explored how observance of la cuarentena shapes families’ beliefs and perceptions during the postpartum period. My research addresses those beliefs related to diet, clothing, bathing, and sexual practices. Underlying fears of illness and perceptions of the body’s vulnerability influence postpartum health behaviors, and cultural traditions emphasize informal, family-centered systems of care during the 6 weeks of postpartum recovery.
Background There is extensive scholarly literature on postpartum practices in a variety of cultural contexts. Research literature outlines the commonalities and differences among cultural expectations for seclusion and recovery postpartum, in contexts as different as Guatemala, China, Jordan, Lebanon, Egypt, Palestine, and India (Callister & Vega, 1998; Galanti, 1997; Holroyd & Katie, 1997; Jordan, 1983; Kim-Godwin, 2003; Lang & Elkin, 1997; Spector, 2000). Most references in the ethnographic literature of Latin America, whether referring to Mexican Americans (Kay, 1982; Melville, 1980), Hispanics (Zepeda, 1982), Mexican immigrants (Niska, 1998), families in Mexico (Bortin, 1993; Resau, 2002), immigrants from Puerto Rico (Padilla, 1958; Zentella, 1997), or generally Latin American postpartum practices (Argote & Vasquez, 2005), suggest that whether a particular family chooses to comply with some or many of the customs of la cuarentena, these traditional practices are familiar and well known, influencing and informing families’ postpartum beliefs, behaviors, social roles, and expectations. Although there are references to la cuarentena in the research literature, few studies focus specifically on revealing the underlying cultural beliefs that shape women’s understandings of the body during recovery. Studies are outlined below that address la cuarentena from a variety of perspectives, such as cataloging observed behaviors (Kay, 1982; Melville, 1980), addressing la cuarentena in the framework of family systems theory (Niska, 2001), assessing types of social support (Clark, 2001), assessing the protective features of la cuarentena in terms of decreasing postpartum depression (MartinezSchallmoser, 2005; Stern & Kruckman, 1985), documenting dietary restrictions (Clark, 2001; Niska, 2001; Zepeda, 1982), and la cuarentena as support for success in breastfeeding (Higgins, 2000; Moreland & Lloyd, 2000; Skeel & Good, 1988). The existing literature in both English and Spanish lan-
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The primary meaning of the word cuarentena is quarantine, and women are traditionally considered to be in quarantine and protected in the home.
guage scholarly journals verifies the centrality of these practices in Latin American culture. Crosscultural studies include the practices of la cuarentena as examples of postpartum cultural practices and draw parallels to cultural expectations in other contexts (Kim-Godwin, 2003). Melville (1980) and Kay (1982) were among the first to publish descriptions of la cuarentena as a significant cultural tradition for postpartum recovery. In Melville’s work, the observed behaviors of the 40 days were described and referred to as la dieta (a phrase that is often used interchangeably with la cuarentena but tends to emphasize the dietary restrictions postpartum). Melville (1980) mentioned the concept of aire, which addressed women’s perceptions of vulnerability during recovery: Currents of air are always thought to be dangerous but especially so after delivery. Air can harm the eyes causing punzadas, which may lead to blindness. It may harm the ears as well. If it is necessary for the mother to leave the house before the prescribed time is over, she must be very careful to cover her head with a cloth that conforms to the shape of the head and thus completely protects it. She must always keep her feet covered, for air can enter through the feet. The shoulders must be covered or a breast infection may develop. (p. 60) Niska (1998, 1999, 2001) used an ethnographic approach to understand the perspective of Mexican American parents regarding family health. Her study emphasized a family systems approach, stating that “a thorough understanding of la cuarentena will assist nurses to enhance adaptation to parenthood for Mexican American parents” (1998, p. 329). In a comprehensive study of social support during la cuarentena, Clark (2001) revealed the complexity behind a cultural value placed on la familia and “social support which includes instrumental help, emotional support, and the perception that others can be counted on to ‘be there’ for them” (p. 1313). In her analysis Clark recognized
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“disconnections in social support for immigrant women with the lowest levels of acculturation and poorest English language skills, and failed support for women who encountered aggravation and antagonism from family and friends who they believed should have offered support instead” (p. 1313). Clark provided a nuanced account of how social support during la cuarentena varied among families, not always adhering to the cultural ideal. Martinez-Schallmoser (2005) referred to la cuarentena as providing valuable social support to Latina women during a time of vulnerability to postpartum depression. In her study she stated that “extraordinary care, thoughtfulness, assistance with housework and childcare, and individual attention are traditionally provided to postpartum Mexican American women during the cuarentena” (p. 331), and she cited findings showing that women without social support were at increased risk for experiencing postpartum depression. In an earlier study Stern (1985) revealed findings which showed that “observance of the cuarentena correlated significantly with having a positive emotional response to the pregnancy and to having less postpartum depression or blues” (p. 237). Several studies outline dietary restrictions during la cuarentena that include observance of a liquid or soft diet. Women customarily avoid foods associated with heat, cold, acidity, gas, heaviness, spicyness, or greasiness. Interview data in a number of studies show that women tend to favor nutritious drinks, including atoles (cornmeal or oatmeal-based drinks) as well as soups and broths. These are documented as being traditionally associated with increased milk production, but there is little in the literature that demonstrates that variable milk production is also related to the underlying perceptions of the body as vulnerable to illness in the postpartum period (Clark, 2001; Niska, 2001; Zepeda, 1982). In a study of feeding practices among Puerto Rican families in New York, Higgins (2000) observed that la cuarentena positively influenced breastfeeding practices among women who observe the traditional 40 days of postpartum recovery. There have also been recent studies in the Journal of Human Lactation that mention la cuarentena as a significant factor in the establishment of successful breastfeeding practices due to the positive social support from experienced female relatives (Moreland, 2000; Skeel, 1988).
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Although providing valuable descriptive information about the objectively observed behaviors of this time, the literature has lacked ethnographic documentation of the belief systems which guide recovery during la cuarentena. The perception of the body as vulnerable during la cuarentena has been largely unexplored; the findings and conclusions of this study address this deficit.
Methods Design The research question guiding the study was as follows: How does observance of la cuarentena shape families’ beliefs and perceptions during the postpartum period? Aims of the study focused on exploring the underlying beliefs and values that motivated the behaviors of la cuarentena, specifically those beliefs related to diet, clothing, bathing, and sexual practices. Ethnographic methods were based in the methodological expectations for anthropological research (Agar, 1996; Bernard, 1998; DeWalt & DeWalt, 2002; LeCompte & Schensul, 1999). Ethnographic methods for the study focused on participant observation and in-depth interviews with mothers and their caregivers during la cuarentena. Key informant interviews focused on verifying findings with bicultural and bilingual health care providers, who discussed their personal and professional experiences with la cuarentena and the practices, beliefs, and knowledge associated with postpartum recovery among Mexican immigrant families. Participant observation in this study was enhanced by the researcher’s 7 years of experience with Spanish speaking immigrant families in their homes during the perinatal period.
Sample and Setting The 40 participants in this study were pregnant women and their family members who were recruited by prenatal care providers in a community health center in Colorado. The researcher contacted participants at home for informed consent and interviews. Participants included the pregnant woman, her partner, and her caregiver (often her mother). Informed consent was obtained from all family members who participated in the study. Transcripts and notes included communications with all participants/ members of the family. Women were recruited who reported Mexican ethnicity and were pregnant at first interview. The inclusion criteria specified Spanish speaking women age 18 to 40, primiparous and multiparous
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women were included. Women were excluded who were English speaking, had no knowledge of or interest in la cuarentena, or had infants in critical care. The demographic characteristics of the participants are outlined in Table 1. Only women who defined themselves as “traditional” or invested in the traditional customs of la cuarentena were included in the study; if they did not express an interest in la cuarentena they were excluded from participation. This was an intentional study of traditional beliefs and practices, and though the prenatal clinic setting included many acculturated women who did not choose to engage in these practices, there were also numerous immigrant women of any age, parity, socioeconomic level, and level of education who reported that they continue to embrace the cultural perspectives of their families of origin. The study did include a clear predominance of women who came from rural areas; almost 80% of the participants came to the United States from rural parts of Mexico.
Table 1: Demographic Characteristics of Study Participants Sample description: Demographic Indicators
N = 40
New mothers
23
Female caregivers
5
Male partners
7
Bicultural expert key informants
5
Maternal characteristics First-time mothers
5
Previous births
18
Mean maternal age
28 years
Mean maternal years of education
9 years (9th grade)
In United States fewer than 2 years
5
In United States more than 2 years
18
Household characteristics Mean at 200% of 2008 poverty
100%
threshold Family characteristics Spanish speaking only
100%
From urban area in Mexico
22%
From rural area in Mexico
78%
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Sexual abstinence during the 6 weeks of recovery remains the primary meaning of la cuarentena for many men and for many families in general.
Data Collection With the consent of participants, all interviews were digitally recorded and transcribed verbatim. All interviews were conducted in Spanish. Families were interviewed in their homes or in the home in which they stayed for la cuarentena (sometimes this was the home of the maternal caregiver). Details of the home environment were documented in field notes as they were relevant to understanding the social and cultural context of family life. Extensive field notes recorded impressions and observations of family dynamics, emotions, descriptions of the homes and underlying social cues. The interviews and participant observation began during the prenatal period and continued through the customary 40 days of recovery. Information was collected during three to four visits to the home. The first visit was usually in the last trimester of pregnancy and was very informal, though sometimes the introductory visit and the first interview were combined. The following visit was soon after delivery, and visits were timed to be approximately every 2 weeks during the 6 weeks of recovery. All interviews were recorded, and usually audio taping was left on even when formal interviewing had ended. Information was documented in field notes before and after the visits, and the visits that focused on formal interviews also involved time before and after the interview for informal interaction with the family. Ultimately it was very important to be flexible about the sequence, content, and structure of the interviews, as it was necessary to time the interviews when family members were available, and accommodate their individual circumstances and priorities.
Data Analysis All field notes and interviews were subject to thematic coding, labeling, and analysis, according to standards of practice in qualitative research (Creswell, 2007; Patton, 2002). Specific quoted phrases from the interview transcripts were coded, grouped, and labeled; these were then categorized by commonalities and differences. Patterns were highlighted through the use of alternate groupings. Main ideas were synthesized into themes and central concepts. Several primary
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themes emerged from the coding processes that were then identified as key findings. As much as possible, the phrases were kept verbatim to accurately reflect the women’s voices as they described their experience; they have been translated for the purposes of publication. Several of the key informants reviewed the coding process and the identification of themes and ideas helping to check and verify linguistic and cross-cultural understandings.
Findings The study explored the underlying perception of the body as “open,” which was reported to motivate the behaviors of la cuarentena. There were three primary themes that emerged from the interview data: “The body is so open after delivery, you must protect it from aire (drafts),” “La cuarentena, it’s about closing the body,” and “I was going to wrap up, but they wouldn’t let me.”
“The body is so open after delivery, you must protect it from aire (drafts).” It is clear from the literature that historically the primary meaning of the word cuarentena has been quarantine, and women were traditionally considered to be in seclusion, at risk for serious illness, and separated/isolated from the community and social responsibilities. The quarantine was also associated with isolation from sexual activity, and that remains the primary meaning of la cuarentena for many men and for many families in general. Interviews revealed that many of the typical behavioral expectations of la cuarentena follow a consistent pattern of protecting the body, reflecting apprehension and fear about the mother’s health during the period of postpartum recovery. Although there were many different fears and beliefs expressed in the interviews, there were relatively few differences related to age, parity, or time in the United States. The primary feature that most of the women held in common was that they reported that they were “close to their family” and engaged with their families of origin. This was clearly a more significant influence than any other, including socioeconomic status or whether they came from rural or urban settings in Mexico. Several themes emerged as central in explaining the need for extra caution and care during this vulnerable time, and extensive quotes reveal how women expressed those fears. One category was aire (drafts), which was connected to a second concept of the body as “open” or abierto. Another category related to concerns about frio,
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or cold, damp air (which was not connected to seasonal temperatures), and calor, which referred to the mother’s heat/energy/life-force, which was considered to be passed to the baby during la cuarentena. Finally, there was a category of concerns or apprehensions about “changes in personal/interpersonal boundaries,” when boundaries between mother and child and between father and mother were loose, and serious lifethreatening illness could be passed from one to the other if the custom of abstinence during la cuarentena was not honored.
Aire A central concept of la cuarentena was that the body is at risk for aire, which can enter through any unprotected area. The word aire was repeated many times to explain the dangers of being vulnerable, exposed, or weakened; for example, “if the body is not strong, the aire could enter.” It has been translated as a draft but also refers to something that is part physical and part spiritual essence. Some women said that the aire was not just wind or air currents but also an essence, humor, or spirit that could enter the body if it is unprotected. Although many found it difficult to describe the aire itself, they could all provide detail about how, why, and in what ways the aire could enter the body and what would happen if “te toca el aire,” if “the aire touches you.” When and if the aire entered the body, women referred to general symptoms of headaches, joint pain, colds/flu, body aches, back pain, general aches and pains. But they also referred to specific types of headaches (punzadas), and specific effects of the aire, for example, if aire got into the back, it was believed that the breast milk would dry up; if aire got in the ears, the ears could feel as if they were “bursting.”
Abierto The body was imagined to be open in several different ways: some women described how the pelvic bones were stretched and widened during delivery, others focused on the Cesarean incision or the episiotomy, others addressed a broader, vague perception of the body as “opened.” For example, the skin was described as losing its integrity, and the pores become open and exposed allowing illness to enter. The back was seen as particularly vulnerable, and the feet were a focal point for concern. Walking on cold floors was referred to as causing more than discomfort or chills; several women referred to walking on cold hospital floors as being responsible for later inflammation of the
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feet and other joints. Many of the participants put cotton in their ears because the ears were perceived to be an important and particularly open entry point for aire. Many women in the study felt that wrapping the abdomen tightly would help the extended belly contract and regain its shape and strength. This tightening of cloths around the lower belly was referred to as fajarse (to bind oneself) and most commonly involves the use of a commercial girdle. But there are various types of fajas, for example, traditional vendas are homemade and vary from being soft, stretchy fabric to strips of bed sheets used to wrap the torso from under the breasts to just above the pubic bone. Several women explained that it is typical to use girdles, elastic or spandex girdles that are designed to pull in the abdomen and are sold as women’s underwear. But the concept of the faja is more than just a form-fitting girdle because it needs to hold together an abdomen that is “open” or abierto. Many of the women wrapped first with the vendas (long cloths) then put the faja (girdle) on top to ensure that the abdomen was secure and tightly held. The internal organs were referred to as “floating,” and the faja was seen as a way of “closing” the abdomen so that the organs could regain their alignment. Several women expressed fears of their internal organs “falling out” if the faja were not there to bind the abdomen together. This understanding of the body as loose, exposed, and vulnerable postpartum explains the need for wrapping the head, back, feet, and abdomen.
El Frio Sometimes the aire would be referred to as el frio, or “the cold,” but the protections from aire continued through the summer months. In the heat of August, in many families the new mother was expected to be in the home with all the windows closed and the newborn baby wrapped up. Often the new mother still wore a lightweight sweatshirt with a hood. Women explained that even a cool summer’s breeze could be interpreted as frio because it touches the new mother’s open body and can weaken her defenses. This frio was understood to cause long term health problems: You have to take good care when you go out and cover up as much as possible. More than anything, you have to cover the back because that’s for the breast milk. If you go out without a wrap, in a few days your milk will dry up. You won’t have any milk. Cov-
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ering up – that’s for the entire 40 days. It’s partly for the baby and partly for yourself. You cover your ears, or put cotton in your ears so that the drafts can’t get in because of the headaches and so that you don’t get the aches and pains in your bones and all that. Also the feet – without socks, on the cold floor – it gives you aches and pains like reumos, achy bones/ joints, and you get varicose veins. It’s called like phlebitis. That’s el frio, or el aire.
El Calor There was a less common but still frequent reference in the interviews to the heat (el calor) of the new mother. This was explained as a spiritual essence that the new mother would pass to the newborn when they had skin-to-skin contact immediately after delivery. It was described as a physical warmth that the mother could pass on (the warmth of physical contact) but also the heat or life force that she held in her body and that could be given to the newborn. Several of the families expressed fears that the hospital rooms were so cold, and the gowns were so flimsy, that the mother’s calor would be lost and she would be unable to provide the baby with the warmth he or she needed. After delivery in Mexico, families reported that it was imperative that the new mother have a chance to wrap up after delivery: wrap her body with warm blankets, wrap her abdomen with the faja, and wrap the baby inside the blankets with her. In the cold sterility of the hospital, families reported that the spiritual process of giving life, or dando la luz (literally, giving light or giving heat) was inhibited when the new mother’s body was exposed in a hospital gown. In the home and for the entire period of la cuarentena women referred to the need to keep the calor (or body heat) “stoked.” The baths were often referred to as ways of “cooking” the body because they would help the mother’s body to close and build the internal heat that would help her heal and feed the baby.
Changes in Personal/Interpersonal Boundaries Abstinence was consistently referred to as the essential and defining characteristic of la cuarentena by men and women. Older caregivers most specifically emphasized its centrality as the primary reason for the quarantine. The consequences of breaking these rules were among the most serious of any in la cuarentena and most seriously
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Many of the behaviors of la cuarentena are rooted in beliefs about how to protect the “open” body from drafts or aire during postpartum recovery.
affected the newborn. Women reported that if the parents were to have intercourse during la cuarentena, damage to the mother included hemorrhage, debilitating illness, another pregnancy, various forms of cancer, and possibly death could occur. However, the most horrifying consequence was that because everything from the mother is passed to the child, the child could ultimately die. Reports of consequences for the father were also serious: anything from empacho or an upset stomach to other forms of illness, cancer, or death. These fears were seen in terms of changes in personal/interpersonal boundaries, because during la cuarentena the boundaries between family members changed. Rules for isolation and abstinence during la cuarentena were seen to maintain boundaries and personal space and give the new mother a socially acceptable mechanism for maintaining personal boundaries. However, it also appeared that the need for this distance was based in a belief that the integrity of the usual boundaries between individuals became more vulnerable during la cuarentena. Just as the new mother needed to be protected from aire, so too she needed to be protected from the forces of other types of strong/sexual energy that would be passed on to the baby through her body.
body heals and is closed, women reported confusion and frustration when health care providers recommended things that were inconsistent with these priorities. Women referred to the burden of arguing with health care providers about the importance of these customs, many of them simply hiding their beliefs and customs when they entered health care settings. One woman reported a struggle with nurses in the hospital over her need to wrap the abdomen tightly with the faja or girdle: La cuarentena, it’s about taking good care of yourself and also dedicating yourself to caring for your baby. And well, it’s about wrapping the abdomen right after you deliver, whether it’s a normal delivery, or csection, wrapping the abdomen with the venda, the kind that is wide . . . you have to wrap up for the full 40 days. And if it’s not a c-section, you put the venda on just the same at first, and then later a girdle, the kind they sell in the store with elastic. And to be wrapped up like that, as tight as possible, it helps you a lot so that you can move better, and you can reach more things. It helps by giving you support because without the faja – no! It’s more difficult, and I would walk more slowly. It holds you in tightly, and the faja helps out. She felt that it was very important to have the faja on from the moment of delivery, but she was told not to put it over her incision. She argued with the nurses:
“La cuarentena, it’s about closing the body.” Women reported that many of the behaviors of la cuarentena are rooted in beliefs about how to protect the body postpartum. Women emphasized that staying in the home (sometimes in bed) protects the new mother from the risk of illness and exhaustion, the soft diet protects her from indigestion or symptoms associated with “harsh” foods, wrapping the body holds warmth in and keeps drafts out, and special baths help to “close” or “cook” the body. They reported confidence that the cultural traditions of la cuarentena would effectively close the body and help the mothers regain their health. This was stated as the essential task of postpartum recovery: the body needs to successfully close, to regain its physical integrity, and no longer to be open or vulnerable to aire. Given this assumption that the body is open and that the traditional practices will ensure that the
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I was going to wrap up [from the beginning] at the hospital but they wouldn’t let me. They said the faja wasn’t recommended because of my wound. The doctor told me that, and I said “ok,” and I took it off . . . “that’s what we do in Mexico,” I said. But ok, I took it off. Then what I did was when the doctor left and they weren’t paying attention, I put it back on. Then the nurse came in and told me again that it wasn’t recommended to wear it, and again I said “ok, that’s fine.” I just told her that, but at any rate I wrapped up with the faja. When she left I said to Luis, “Help me quickly, put the faja on” because if not, they wouldn’t let me. And there was no way I was going to walk downstairs, walk outside, and get up in the truck without the faja – it would have been really bad for me with my wound. So yes, I wore my faja.
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“I was going to wrap up . . . but they wouldn’t let me.” Many women reported that they relied on traditional knowledge to understand their health during recovery and to cope with the transition of the postpartum period, and they “just don’t mention” their postpartum customs when they enter the clinic setting. Of the women who participated in this study, not one was comfortable discussing her postpartum practices with her health care providers. At prenatal appointments, during labor and delivery, and in the immediate postpartum period in the hospital, it was reported consistently that it was important to be guarded about the expectations of la cuarentena. Women reported encounters with providers who discouraged them from using herbs, taking sweat baths, and particularly discouraged use of the faja to wrap the belly. Without these tools for closing and healing the body, they felt they weren’t addressing the primary task of recovery, which was to ensure that aire didn’t enter the body and cause serious health problems. Although they relied on the clinic as the ultimate authority for their child’s health, the clinic was often referred to as irrelevant for maternal care in the postpartum period. Women expressed sympathy and genuine pity for the inherent knowledge limitations in the understanding of clinicians: “they just don’t understand,” “they don’t know,” “they think they’re right, but they’re not,” and “they don’t know la cuarentena.” Ultimately it was implied that the clinicians’ limited perspective prevented them from being of much help during postpartum recovery.
Discussion As providers become more familiar with the beliefs and practices associated with la cuarentena, responses to families can be more informed and can more appropriately address their needs and concerns. First and foremost, it is important to ask about traditional family practices. This gives women an opportunity to describe their mother’s experiences and make choices about which customs are meaningful to her. Health care providers need to specifically ask about fears associated with the body being open and vulnerable to illness. Many of the culturally defined beliefs and practices of la cuarentena would be seen as promoting health from a biomedical perspective, and it is only when taken to extremes that they could lead to medical issues. For example, in the early postpartum period some women observe a very
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restricted diet of vegetable broth, tea, and atoles (warm drinks made of cornstarch and flavoring). Providers can emphasize the need for a balanced diet and high nutritional content of foods without suggesting that the special diet be broken. Traditional soups or caldos can be made from chicken and can include a broader range of ingredients to increase the caloric content and protein level in the soup. Very few women who observe la dieta during la cuarentena are willing to eat the food provided in the hospital setting. It is important for prenatal providers to suggest that women prepare traditional soups and bring them to the hospital, so that they have something they can eat during the 24 to 48 hours postpartum. Women in this study reported being hungry and thirsty in the hospital because the food provided was inappropriate for them during la cuarentena, and the water was too cold. All of the women in the study reported that ice water is considered to put one at risk for aire. Although wrapping the abdomen tightly in the immediate postpartum period is not recommended by many clinicians because of risks of blood clots, occlusions, and other consequences, providers could suggest that a loose faja is preferable to tight binding. This would help mothers to understand an appropriate level tension for wrapping the abdomen. Discouraging use of the faja altogether might alienate the new mother, who then might hide and continue with her traditional practices without medical guidance. Women in this study expressed feelings of being confused about conflicting advice from family and health care providers; when in doubt many said that it was easier to ignore advice from clinicians and go along with the expectations of their families. It is also important to allow women to make choices about whether to bathe in the hospital setting. Steam baths and cooking the body are understood to be healthy; showers are often perceived to unnecessarily expose the already open body and increase the risk of aire. Many women would rather wait several days for traditional baths in the home, rather than risking the loss of heat or calor that would put them and their babies at risk. Several women reported that they were pressured to bathe/shower in the hospital and later felt that this was why they had gotten sick or been slow to recover. Providers can more meaningfully address concerns and apprehensions if they understand that immigrant women approach the postpartum period with a perception that the body is open
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and exposed to illness and vulnerable to longterm health consequences. For many immigrant women, the goal of recovery in the postpartum period is to close and protect the body, and they need their health care providers to understand that priority. The cultural expectations of la cuarentena are unfamiliar to many health care providers in the United States; further understanding of the implications of this cultural perspective can improve the quality of care provided to immigrant families.
Clark, L. (2001). La familia: Methodological issues in the assessment of perinatal social support for Mexicanas living in the US. Social Science & Medicine, 53, 1303–1320. Creswell, J. (2007). Qualitative inquiry & research design. Thousand Oaks, CA: Sage. DeWalt, K., & DeWalt, B. (2002). Participant observation. Walnut Creek, CA: Alta Mira Press. Galanti, A. (1997). Caring for patients from different cultures: Case studies from American hospitals (2nd ed.). Philadelphia, PA: University of Pennsylvania Press. Higgins, B. (2000). Puerto Rican cultural beliefs: Influence on infant feeding practices in western New York. Journal of Transcultural Nursing, 11 (1), 19–30. Holroyd, E., & Katie, F. (1997). “Doing the month”: An exploration of postpartum practices in Chinese women. Health Care for Women
Limitations This study focuses on a small, relatively homogenous sample of Mexican immigrants within a confined community in the southwestern United States. The personal stories of particular women are highlighted, and though their stories are individual and unique, they are assumed to be typical of immigrant experience in other areas. A more comprehensive review could include a variety of immigrant ethnicities (including indigenous families) and a broader variety of socioeconomic backgrounds. The study also did not focus on the prevalence of observance of la cuarentena; there are many women who do not find the traditional practices meaningful and who do not identify with their mothers’ and grandmothers’ experiences of the postpartum period. This study focuses less on whether/how/why women lose their traditional understandings during acculturation and more on how and why la cuarentena still matters to many immigrant women who continue to engage in traditional understandings. Methodological limitations include a relatively small sample size, ethnically and socioeconomically homogenous participants, and exclusion of very young women.
International, 18, 301–313. Jordan, B. (1983). Birth in four cultures: A crosscultural investigation of childbirth in Yucatan, Holland, Sweden and the US. London, UK: Eden Press. Kay, M. (1982). Anthropology of human birth. Philadelphia, PA: Davis Company. Kieffer, E., & Willis, S. (2002). Perspectives of pregnant and postpartum Latino women on diabetes, physical activity, and health. Health Education & Behavior, 29 (5), 542–556. Kim-Godwin, Y. (2003). Postpartum beliefs and practices among nonwestern cultures. American Journal of Maternal/Child Nursing, 28 (2), 74–78. Lang, J. B., & Elkin, E. D. (1997). A study of the beliefs and birthing practices of traditional midwives in rural Guatemala. Journal of Nurse-Midwifery, 42 (1), 25–31. LeCompte, M., & Schensul, J. (1999). Ethnographer’s toolkit: Designing and conducting ethnographic research. Walnut Creek, CA: Alta Mira Press. Martinez-Schallmoser L., & Tellen, S. (2003). The effect of social support and acculturation on postpartum depression in Mexican American women. Journal of Transcultural Nursing, 14 (4), 329– 338. Martinez-Schallmoser, L., & MacMullen, N. (2005). Social support in Mexican American childbearing women. Journal of Obstetric, Gynecologic & Neonatal Nursing, 34, 755– 760. Melville, M. (1980). Twice a minority: Mexican American women. St. Louis, MO: Mosby. Moreland, J., & Lloyd, L. (2000). A new teaching model to prolong breastfeeding among Latinos. Journal of Human Lactation, 16 (4), 337–341.
Acknowledgment Funded by an NRSA Fellowship award from the National Institutes of Nursing Research.
Niska, K., & Snyder, M. (1998). Family ritual facilitates adaptation to parenthood. Public Health Nursing, 15 (5), 329–337. Niska, K. (1999). Family nursing interventions: Mexican American early family formation. Nursing Science Quarterly, 12 (4), 335– 340. Niska, K. (2001). Mexican American family survival, continuity, and
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Spector, R. (2000). Cultural diversity in health and illness (5th ed). Upper Saddle River, NJ: Prentice Hall Health.
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Beliefs Associated with Mexican Immigrant Families’ Practice of La Cuarentena during Postpartum Recovery Lisa Johnson Waugh
Correspondence Lisa Johnson Waugh, RN, PhD Department of Health Care Policy and Financing 1570 Grant Street Denver, CO 80203 [email protected] Keywords postpartum recovery Mexican immigrants perinatal care la cuarentena
ABSTRACT Objective: To examine underlying beliefs that motivate the observed behaviors of la cuarentena, which refers to the 40 days (6 weeks) of postpartum recovery observed by Mexican immigrant women in the United States. Design: Qualitative/descriptive. Participants/ Setting: Forty Spanish speaking individuals from 19 different Mexican immigrant families in Colorado were visited in their homes during pregnancy and the postpartum period. Methods: Ethnographic methods for this study focused on participant observation and interviews during traditional observance of la cuarentena. Mothers, their partners, and caregivers were interviewed in their homes in a series of four visits. Results: Families described perceptions of the body as “open” and vulnerable to drafts or aire. Women reported that the cultural traditions of la cuarentena will “close” the body, and this was seen as the central purpose of postpartum recovery. Immigrant women reported that they hide their traditions in health care settings, recognizing that many providers don’t understand or trivialize their beliefs and customs. A lack of awareness of la cuarentena among health care providers is a barrier to many women seeking professional care. Conclusions: Understanding the underlying fears associated with la cuarentena will assist nurses and clinicians in supporting immigrant families during postpartum recovery. Support from health care providers is particularly important given the occasional lack of family social support for immigrant women after they give birth.
JOGNN, 40, 732-741; 2011. DOI: 10.1111/j.1552-6909.2011.01298.x Accepted June 2011
ies in California and Texas have estimated that approximately 80% of immigrant families practice traditional customs in the postpartum period (Niska, 1998; Zepeda). Without the support of extended family, Mexican women in the United States can find it difficult to observe traditions such as la cuarentena. Social isolation during the postpartum period can leave immigrant women vulnerable to exaggerated fears, mood disorders, and complications during recovery (Clark; MartinezSchallmoser).
The author reports no conflict of interest or relevant financial relationships.
a cuarentena (cuarenta d´ıas or quarantine) is a term commonly understood by Mexican American and Mexican immigrant families to refer to 40 days of postpartum recovery. The term references traditional behaviors regarding diet, clothing, bathing, and sexual abstinence as well as specific beliefs/fears about health and expectations of social support. Studies in the public health literature document that nutrition, infant-feeding practices, maternal depression, the acquisition of parental role responsibilities and sexual behavior in Mexican American and immigrant families are influenced by traditional customs during the 6 weeks of postpartum recovery (Clark, 2001; Kay, 1982; Kieffer & Willis, 2002; Martinez-Schallmoser & Tellen, 2003; Niska, 2001; Zepeda, 1982). There are few estimates of the prevalence of the practices of la cuarentena in the literature, though stud-
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C 2011 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
Lisa Johnson Waugh, RN, PhD is a health policy specialist for the Department of Health Care Policy and Financing, State of Colorado. This research was conducted at the University of Colorado, Department of Health and Behavioral Sciences, Denver, CO.
L
Given that Mexican immigrant families are a growing ethnic group in many parts of the United States, it is essential that health care providers understand not only the expressions of cultural behaviors, but also the culturally influenced fears and understandings of the body that motivate
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those behaviors. Using ethnographic methods I explored how observance of la cuarentena shapes families’ beliefs and perceptions during the postpartum period. My research addresses those beliefs related to diet, clothing, bathing, and sexual practices. Underlying fears of illness and perceptions of the body’s vulnerability influence postpartum health behaviors, and cultural traditions emphasize informal, family-centered systems of care during the 6 weeks of postpartum recovery.
Background There is extensive scholarly literature on postpartum practices in a variety of cultural contexts. Research literature outlines the commonalities and differences among cultural expectations for seclusion and recovery postpartum, in contexts as different as Guatemala, China, Jordan, Lebanon, Egypt, Palestine, and India (Callister & Vega, 1998; Galanti, 1997; Holroyd & Katie, 1997; Jordan, 1983; Kim-Godwin, 2003; Lang & Elkin, 1997; Spector, 2000). Most references in the ethnographic literature of Latin America, whether referring to Mexican Americans (Kay, 1982; Melville, 1980), Hispanics (Zepeda, 1982), Mexican immigrants (Niska, 1998), families in Mexico (Bortin, 1993; Resau, 2002), immigrants from Puerto Rico (Padilla, 1958; Zentella, 1997), or generally Latin American postpartum practices (Argote & Vasquez, 2005), suggest that whether a particular family chooses to comply with some or many of the customs of la cuarentena, these traditional practices are familiar and well known, influencing and informing families’ postpartum beliefs, behaviors, social roles, and expectations. Although there are references to la cuarentena in the research literature, few studies focus specifically on revealing the underlying cultural beliefs that shape women’s understandings of the body during recovery. Studies are outlined below that address la cuarentena from a variety of perspectives, such as cataloging observed behaviors (Kay, 1982; Melville, 1980), addressing la cuarentena in the framework of family systems theory (Niska, 2001), assessing types of social support (Clark, 2001), assessing the protective features of la cuarentena in terms of decreasing postpartum depression (MartinezSchallmoser, 2005; Stern & Kruckman, 1985), documenting dietary restrictions (Clark, 2001; Niska, 2001; Zepeda, 1982), and la cuarentena as support for success in breastfeeding (Higgins, 2000; Moreland & Lloyd, 2000; Skeel & Good, 1988). The existing literature in both English and Spanish lan-
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The primary meaning of the word cuarentena is quarantine, and women are traditionally considered to be in quarantine and protected in the home.
guage scholarly journals verifies the centrality of these practices in Latin American culture. Crosscultural studies include the practices of la cuarentena as examples of postpartum cultural practices and draw parallels to cultural expectations in other contexts (Kim-Godwin, 2003). Melville (1980) and Kay (1982) were among the first to publish descriptions of la cuarentena as a significant cultural tradition for postpartum recovery. In Melville’s work, the observed behaviors of the 40 days were described and referred to as la dieta (a phrase that is often used interchangeably with la cuarentena but tends to emphasize the dietary restrictions postpartum). Melville (1980) mentioned the concept of aire, which addressed women’s perceptions of vulnerability during recovery: Currents of air are always thought to be dangerous but especially so after delivery. Air can harm the eyes causing punzadas, which may lead to blindness. It may harm the ears as well. If it is necessary for the mother to leave the house before the prescribed time is over, she must be very careful to cover her head with a cloth that conforms to the shape of the head and thus completely protects it. She must always keep her feet covered, for air can enter through the feet. The shoulders must be covered or a breast infection may develop. (p. 60) Niska (1998, 1999, 2001) used an ethnographic approach to understand the perspective of Mexican American parents regarding family health. Her study emphasized a family systems approach, stating that “a thorough understanding of la cuarentena will assist nurses to enhance adaptation to parenthood for Mexican American parents” (1998, p. 329). In a comprehensive study of social support during la cuarentena, Clark (2001) revealed the complexity behind a cultural value placed on la familia and “social support which includes instrumental help, emotional support, and the perception that others can be counted on to ‘be there’ for them” (p. 1313). In her analysis Clark recognized
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“disconnections in social support for immigrant women with the lowest levels of acculturation and poorest English language skills, and failed support for women who encountered aggravation and antagonism from family and friends who they believed should have offered support instead” (p. 1313). Clark provided a nuanced account of how social support during la cuarentena varied among families, not always adhering to the cultural ideal. Martinez-Schallmoser (2005) referred to la cuarentena as providing valuable social support to Latina women during a time of vulnerability to postpartum depression. In her study she stated that “extraordinary care, thoughtfulness, assistance with housework and childcare, and individual attention are traditionally provided to postpartum Mexican American women during the cuarentena” (p. 331), and she cited findings showing that women without social support were at increased risk for experiencing postpartum depression. In an earlier study Stern (1985) revealed findings which showed that “observance of the cuarentena correlated significantly with having a positive emotional response to the pregnancy and to having less postpartum depression or blues” (p. 237). Several studies outline dietary restrictions during la cuarentena that include observance of a liquid or soft diet. Women customarily avoid foods associated with heat, cold, acidity, gas, heaviness, spicyness, or greasiness. Interview data in a number of studies show that women tend to favor nutritious drinks, including atoles (cornmeal or oatmeal-based drinks) as well as soups and broths. These are documented as being traditionally associated with increased milk production, but there is little in the literature that demonstrates that variable milk production is also related to the underlying perceptions of the body as vulnerable to illness in the postpartum period (Clark, 2001; Niska, 2001; Zepeda, 1982). In a study of feeding practices among Puerto Rican families in New York, Higgins (2000) observed that la cuarentena positively influenced breastfeeding practices among women who observe the traditional 40 days of postpartum recovery. There have also been recent studies in the Journal of Human Lactation that mention la cuarentena as a significant factor in the establishment of successful breastfeeding practices due to the positive social support from experienced female relatives (Moreland, 2000; Skeel, 1988).
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Although providing valuable descriptive information about the objectively observed behaviors of this time, the literature has lacked ethnographic documentation of the belief systems which guide recovery during la cuarentena. The perception of the body as vulnerable during la cuarentena has been largely unexplored; the findings and conclusions of this study address this deficit.
Methods Design The research question guiding the study was as follows: How does observance of la cuarentena shape families’ beliefs and perceptions during the postpartum period? Aims of the study focused on exploring the underlying beliefs and values that motivated the behaviors of la cuarentena, specifically those beliefs related to diet, clothing, bathing, and sexual practices. Ethnographic methods were based in the methodological expectations for anthropological research (Agar, 1996; Bernard, 1998; DeWalt & DeWalt, 2002; LeCompte & Schensul, 1999). Ethnographic methods for the study focused on participant observation and in-depth interviews with mothers and their caregivers during la cuarentena. Key informant interviews focused on verifying findings with bicultural and bilingual health care providers, who discussed their personal and professional experiences with la cuarentena and the practices, beliefs, and knowledge associated with postpartum recovery among Mexican immigrant families. Participant observation in this study was enhanced by the researcher’s 7 years of experience with Spanish speaking immigrant families in their homes during the perinatal period.
Sample and Setting The 40 participants in this study were pregnant women and their family members who were recruited by prenatal care providers in a community health center in Colorado. The researcher contacted participants at home for informed consent and interviews. Participants included the pregnant woman, her partner, and her caregiver (often her mother). Informed consent was obtained from all family members who participated in the study. Transcripts and notes included communications with all participants/ members of the family. Women were recruited who reported Mexican ethnicity and were pregnant at first interview. The inclusion criteria specified Spanish speaking women age 18 to 40, primiparous and multiparous
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women were included. Women were excluded who were English speaking, had no knowledge of or interest in la cuarentena, or had infants in critical care. The demographic characteristics of the participants are outlined in Table 1. Only women who defined themselves as “traditional” or invested in the traditional customs of la cuarentena were included in the study; if they did not express an interest in la cuarentena they were excluded from participation. This was an intentional study of traditional beliefs and practices, and though the prenatal clinic setting included many acculturated women who did not choose to engage in these practices, there were also numerous immigrant women of any age, parity, socioeconomic level, and level of education who reported that they continue to embrace the cultural perspectives of their families of origin. The study did include a clear predominance of women who came from rural areas; almost 80% of the participants came to the United States from rural parts of Mexico.
Table 1: Demographic Characteristics of Study Participants Sample description: Demographic Indicators
N = 40
New mothers
23
Female caregivers
5
Male partners
7
Bicultural expert key informants
5
Maternal characteristics First-time mothers
5
Previous births
18
Mean maternal age
28 years
Mean maternal years of education
9 years (9th grade)
In United States fewer than 2 years
5
In United States more than 2 years
18
Household characteristics Mean at 200% of 2008 poverty
100%
threshold Family characteristics Spanish speaking only
100%
From urban area in Mexico
22%
From rural area in Mexico
78%
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Sexual abstinence during the 6 weeks of recovery remains the primary meaning of la cuarentena for many men and for many families in general.
Data Collection With the consent of participants, all interviews were digitally recorded and transcribed verbatim. All interviews were conducted in Spanish. Families were interviewed in their homes or in the home in which they stayed for la cuarentena (sometimes this was the home of the maternal caregiver). Details of the home environment were documented in field notes as they were relevant to understanding the social and cultural context of family life. Extensive field notes recorded impressions and observations of family dynamics, emotions, descriptions of the homes and underlying social cues. The interviews and participant observation began during the prenatal period and continued through the customary 40 days of recovery. Information was collected during three to four visits to the home. The first visit was usually in the last trimester of pregnancy and was very informal, though sometimes the introductory visit and the first interview were combined. The following visit was soon after delivery, and visits were timed to be approximately every 2 weeks during the 6 weeks of recovery. All interviews were recorded, and usually audio taping was left on even when formal interviewing had ended. Information was documented in field notes before and after the visits, and the visits that focused on formal interviews also involved time before and after the interview for informal interaction with the family. Ultimately it was very important to be flexible about the sequence, content, and structure of the interviews, as it was necessary to time the interviews when family members were available, and accommodate their individual circumstances and priorities.
Data Analysis All field notes and interviews were subject to thematic coding, labeling, and analysis, according to standards of practice in qualitative research (Creswell, 2007; Patton, 2002). Specific quoted phrases from the interview transcripts were coded, grouped, and labeled; these were then categorized by commonalities and differences. Patterns were highlighted through the use of alternate groupings. Main ideas were synthesized into themes and central concepts. Several primary
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themes emerged from the coding processes that were then identified as key findings. As much as possible, the phrases were kept verbatim to accurately reflect the women’s voices as they described their experience; they have been translated for the purposes of publication. Several of the key informants reviewed the coding process and the identification of themes and ideas helping to check and verify linguistic and cross-cultural understandings.
Findings The study explored the underlying perception of the body as “open,” which was reported to motivate the behaviors of la cuarentena. There were three primary themes that emerged from the interview data: “The body is so open after delivery, you must protect it from aire (drafts),” “La cuarentena, it’s about closing the body,” and “I was going to wrap up, but they wouldn’t let me.”
“The body is so open after delivery, you must protect it from aire (drafts).” It is clear from the literature that historically the primary meaning of the word cuarentena has been quarantine, and women were traditionally considered to be in seclusion, at risk for serious illness, and separated/isolated from the community and social responsibilities. The quarantine was also associated with isolation from sexual activity, and that remains the primary meaning of la cuarentena for many men and for many families in general. Interviews revealed that many of the typical behavioral expectations of la cuarentena follow a consistent pattern of protecting the body, reflecting apprehension and fear about the mother’s health during the period of postpartum recovery. Although there were many different fears and beliefs expressed in the interviews, there were relatively few differences related to age, parity, or time in the United States. The primary feature that most of the women held in common was that they reported that they were “close to their family” and engaged with their families of origin. This was clearly a more significant influence than any other, including socioeconomic status or whether they came from rural or urban settings in Mexico. Several themes emerged as central in explaining the need for extra caution and care during this vulnerable time, and extensive quotes reveal how women expressed those fears. One category was aire (drafts), which was connected to a second concept of the body as “open” or abierto. Another category related to concerns about frio,
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or cold, damp air (which was not connected to seasonal temperatures), and calor, which referred to the mother’s heat/energy/life-force, which was considered to be passed to the baby during la cuarentena. Finally, there was a category of concerns or apprehensions about “changes in personal/interpersonal boundaries,” when boundaries between mother and child and between father and mother were loose, and serious lifethreatening illness could be passed from one to the other if the custom of abstinence during la cuarentena was not honored.
Aire A central concept of la cuarentena was that the body is at risk for aire, which can enter through any unprotected area. The word aire was repeated many times to explain the dangers of being vulnerable, exposed, or weakened; for example, “if the body is not strong, the aire could enter.” It has been translated as a draft but also refers to something that is part physical and part spiritual essence. Some women said that the aire was not just wind or air currents but also an essence, humor, or spirit that could enter the body if it is unprotected. Although many found it difficult to describe the aire itself, they could all provide detail about how, why, and in what ways the aire could enter the body and what would happen if “te toca el aire,” if “the aire touches you.” When and if the aire entered the body, women referred to general symptoms of headaches, joint pain, colds/flu, body aches, back pain, general aches and pains. But they also referred to specific types of headaches (punzadas), and specific effects of the aire, for example, if aire got into the back, it was believed that the breast milk would dry up; if aire got in the ears, the ears could feel as if they were “bursting.”
Abierto The body was imagined to be open in several different ways: some women described how the pelvic bones were stretched and widened during delivery, others focused on the Cesarean incision or the episiotomy, others addressed a broader, vague perception of the body as “opened.” For example, the skin was described as losing its integrity, and the pores become open and exposed allowing illness to enter. The back was seen as particularly vulnerable, and the feet were a focal point for concern. Walking on cold floors was referred to as causing more than discomfort or chills; several women referred to walking on cold hospital floors as being responsible for later inflammation of the
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feet and other joints. Many of the participants put cotton in their ears because the ears were perceived to be an important and particularly open entry point for aire. Many women in the study felt that wrapping the abdomen tightly would help the extended belly contract and regain its shape and strength. This tightening of cloths around the lower belly was referred to as fajarse (to bind oneself) and most commonly involves the use of a commercial girdle. But there are various types of fajas, for example, traditional vendas are homemade and vary from being soft, stretchy fabric to strips of bed sheets used to wrap the torso from under the breasts to just above the pubic bone. Several women explained that it is typical to use girdles, elastic or spandex girdles that are designed to pull in the abdomen and are sold as women’s underwear. But the concept of the faja is more than just a form-fitting girdle because it needs to hold together an abdomen that is “open” or abierto. Many of the women wrapped first with the vendas (long cloths) then put the faja (girdle) on top to ensure that the abdomen was secure and tightly held. The internal organs were referred to as “floating,” and the faja was seen as a way of “closing” the abdomen so that the organs could regain their alignment. Several women expressed fears of their internal organs “falling out” if the faja were not there to bind the abdomen together. This understanding of the body as loose, exposed, and vulnerable postpartum explains the need for wrapping the head, back, feet, and abdomen.
El Frio Sometimes the aire would be referred to as el frio, or “the cold,” but the protections from aire continued through the summer months. In the heat of August, in many families the new mother was expected to be in the home with all the windows closed and the newborn baby wrapped up. Often the new mother still wore a lightweight sweatshirt with a hood. Women explained that even a cool summer’s breeze could be interpreted as frio because it touches the new mother’s open body and can weaken her defenses. This frio was understood to cause long term health problems: You have to take good care when you go out and cover up as much as possible. More than anything, you have to cover the back because that’s for the breast milk. If you go out without a wrap, in a few days your milk will dry up. You won’t have any milk. Cov-
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ering up – that’s for the entire 40 days. It’s partly for the baby and partly for yourself. You cover your ears, or put cotton in your ears so that the drafts can’t get in because of the headaches and so that you don’t get the aches and pains in your bones and all that. Also the feet – without socks, on the cold floor – it gives you aches and pains like reumos, achy bones/ joints, and you get varicose veins. It’s called like phlebitis. That’s el frio, or el aire.
El Calor There was a less common but still frequent reference in the interviews to the heat (el calor) of the new mother. This was explained as a spiritual essence that the new mother would pass to the newborn when they had skin-to-skin contact immediately after delivery. It was described as a physical warmth that the mother could pass on (the warmth of physical contact) but also the heat or life force that she held in her body and that could be given to the newborn. Several of the families expressed fears that the hospital rooms were so cold, and the gowns were so flimsy, that the mother’s calor would be lost and she would be unable to provide the baby with the warmth he or she needed. After delivery in Mexico, families reported that it was imperative that the new mother have a chance to wrap up after delivery: wrap her body with warm blankets, wrap her abdomen with the faja, and wrap the baby inside the blankets with her. In the cold sterility of the hospital, families reported that the spiritual process of giving life, or dando la luz (literally, giving light or giving heat) was inhibited when the new mother’s body was exposed in a hospital gown. In the home and for the entire period of la cuarentena women referred to the need to keep the calor (or body heat) “stoked.” The baths were often referred to as ways of “cooking” the body because they would help the mother’s body to close and build the internal heat that would help her heal and feed the baby.
Changes in Personal/Interpersonal Boundaries Abstinence was consistently referred to as the essential and defining characteristic of la cuarentena by men and women. Older caregivers most specifically emphasized its centrality as the primary reason for the quarantine. The consequences of breaking these rules were among the most serious of any in la cuarentena and most seriously
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Many of the behaviors of la cuarentena are rooted in beliefs about how to protect the “open” body from drafts or aire during postpartum recovery.
affected the newborn. Women reported that if the parents were to have intercourse during la cuarentena, damage to the mother included hemorrhage, debilitating illness, another pregnancy, various forms of cancer, and possibly death could occur. However, the most horrifying consequence was that because everything from the mother is passed to the child, the child could ultimately die. Reports of consequences for the father were also serious: anything from empacho or an upset stomach to other forms of illness, cancer, or death. These fears were seen in terms of changes in personal/interpersonal boundaries, because during la cuarentena the boundaries between family members changed. Rules for isolation and abstinence during la cuarentena were seen to maintain boundaries and personal space and give the new mother a socially acceptable mechanism for maintaining personal boundaries. However, it also appeared that the need for this distance was based in a belief that the integrity of the usual boundaries between individuals became more vulnerable during la cuarentena. Just as the new mother needed to be protected from aire, so too she needed to be protected from the forces of other types of strong/sexual energy that would be passed on to the baby through her body.
body heals and is closed, women reported confusion and frustration when health care providers recommended things that were inconsistent with these priorities. Women referred to the burden of arguing with health care providers about the importance of these customs, many of them simply hiding their beliefs and customs when they entered health care settings. One woman reported a struggle with nurses in the hospital over her need to wrap the abdomen tightly with the faja or girdle: La cuarentena, it’s about taking good care of yourself and also dedicating yourself to caring for your baby. And well, it’s about wrapping the abdomen right after you deliver, whether it’s a normal delivery, or csection, wrapping the abdomen with the venda, the kind that is wide . . . you have to wrap up for the full 40 days. And if it’s not a c-section, you put the venda on just the same at first, and then later a girdle, the kind they sell in the store with elastic. And to be wrapped up like that, as tight as possible, it helps you a lot so that you can move better, and you can reach more things. It helps by giving you support because without the faja – no! It’s more difficult, and I would walk more slowly. It holds you in tightly, and the faja helps out. She felt that it was very important to have the faja on from the moment of delivery, but she was told not to put it over her incision. She argued with the nurses:
“La cuarentena, it’s about closing the body.” Women reported that many of the behaviors of la cuarentena are rooted in beliefs about how to protect the body postpartum. Women emphasized that staying in the home (sometimes in bed) protects the new mother from the risk of illness and exhaustion, the soft diet protects her from indigestion or symptoms associated with “harsh” foods, wrapping the body holds warmth in and keeps drafts out, and special baths help to “close” or “cook” the body. They reported confidence that the cultural traditions of la cuarentena would effectively close the body and help the mothers regain their health. This was stated as the essential task of postpartum recovery: the body needs to successfully close, to regain its physical integrity, and no longer to be open or vulnerable to aire. Given this assumption that the body is open and that the traditional practices will ensure that the
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I was going to wrap up [from the beginning] at the hospital but they wouldn’t let me. They said the faja wasn’t recommended because of my wound. The doctor told me that, and I said “ok,” and I took it off . . . “that’s what we do in Mexico,” I said. But ok, I took it off. Then what I did was when the doctor left and they weren’t paying attention, I put it back on. Then the nurse came in and told me again that it wasn’t recommended to wear it, and again I said “ok, that’s fine.” I just told her that, but at any rate I wrapped up with the faja. When she left I said to Luis, “Help me quickly, put the faja on” because if not, they wouldn’t let me. And there was no way I was going to walk downstairs, walk outside, and get up in the truck without the faja – it would have been really bad for me with my wound. So yes, I wore my faja.
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“I was going to wrap up . . . but they wouldn’t let me.” Many women reported that they relied on traditional knowledge to understand their health during recovery and to cope with the transition of the postpartum period, and they “just don’t mention” their postpartum customs when they enter the clinic setting. Of the women who participated in this study, not one was comfortable discussing her postpartum practices with her health care providers. At prenatal appointments, during labor and delivery, and in the immediate postpartum period in the hospital, it was reported consistently that it was important to be guarded about the expectations of la cuarentena. Women reported encounters with providers who discouraged them from using herbs, taking sweat baths, and particularly discouraged use of the faja to wrap the belly. Without these tools for closing and healing the body, they felt they weren’t addressing the primary task of recovery, which was to ensure that aire didn’t enter the body and cause serious health problems. Although they relied on the clinic as the ultimate authority for their child’s health, the clinic was often referred to as irrelevant for maternal care in the postpartum period. Women expressed sympathy and genuine pity for the inherent knowledge limitations in the understanding of clinicians: “they just don’t understand,” “they don’t know,” “they think they’re right, but they’re not,” and “they don’t know la cuarentena.” Ultimately it was implied that the clinicians’ limited perspective prevented them from being of much help during postpartum recovery.
Discussion As providers become more familiar with the beliefs and practices associated with la cuarentena, responses to families can be more informed and can more appropriately address their needs and concerns. First and foremost, it is important to ask about traditional family practices. This gives women an opportunity to describe their mother’s experiences and make choices about which customs are meaningful to her. Health care providers need to specifically ask about fears associated with the body being open and vulnerable to illness. Many of the culturally defined beliefs and practices of la cuarentena would be seen as promoting health from a biomedical perspective, and it is only when taken to extremes that they could lead to medical issues. For example, in the early postpartum period some women observe a very
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restricted diet of vegetable broth, tea, and atoles (warm drinks made of cornstarch and flavoring). Providers can emphasize the need for a balanced diet and high nutritional content of foods without suggesting that the special diet be broken. Traditional soups or caldos can be made from chicken and can include a broader range of ingredients to increase the caloric content and protein level in the soup. Very few women who observe la dieta during la cuarentena are willing to eat the food provided in the hospital setting. It is important for prenatal providers to suggest that women prepare traditional soups and bring them to the hospital, so that they have something they can eat during the 24 to 48 hours postpartum. Women in this study reported being hungry and thirsty in the hospital because the food provided was inappropriate for them during la cuarentena, and the water was too cold. All of the women in the study reported that ice water is considered to put one at risk for aire. Although wrapping the abdomen tightly in the immediate postpartum period is not recommended by many clinicians because of risks of blood clots, occlusions, and other consequences, providers could suggest that a loose faja is preferable to tight binding. This would help mothers to understand an appropriate level tension for wrapping the abdomen. Discouraging use of the faja altogether might alienate the new mother, who then might hide and continue with her traditional practices without medical guidance. Women in this study expressed feelings of being confused about conflicting advice from family and health care providers; when in doubt many said that it was easier to ignore advice from clinicians and go along with the expectations of their families. It is also important to allow women to make choices about whether to bathe in the hospital setting. Steam baths and cooking the body are understood to be healthy; showers are often perceived to unnecessarily expose the already open body and increase the risk of aire. Many women would rather wait several days for traditional baths in the home, rather than risking the loss of heat or calor that would put them and their babies at risk. Several women reported that they were pressured to bathe/shower in the hospital and later felt that this was why they had gotten sick or been slow to recover. Providers can more meaningfully address concerns and apprehensions if they understand that immigrant women approach the postpartum period with a perception that the body is open
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and exposed to illness and vulnerable to longterm health consequences. For many immigrant women, the goal of recovery in the postpartum period is to close and protect the body, and they need their health care providers to understand that priority. The cultural expectations of la cuarentena are unfamiliar to many health care providers in the United States; further understanding of the implications of this cultural perspective can improve the quality of care provided to immigrant families.
Clark, L. (2001). La familia: Methodological issues in the assessment of perinatal social support for Mexicanas living in the US. Social Science & Medicine, 53, 1303–1320. Creswell, J. (2007). Qualitative inquiry & research design. Thousand Oaks, CA: Sage. DeWalt, K., & DeWalt, B. (2002). Participant observation. Walnut Creek, CA: Alta Mira Press. Galanti, A. (1997). Caring for patients from different cultures: Case studies from American hospitals (2nd ed.). Philadelphia, PA: University of Pennsylvania Press. Higgins, B. (2000). Puerto Rican cultural beliefs: Influence on infant feeding practices in western New York. Journal of Transcultural Nursing, 11 (1), 19–30. Holroyd, E., & Katie, F. (1997). “Doing the month”: An exploration of postpartum practices in Chinese women. Health Care for Women
Limitations This study focuses on a small, relatively homogenous sample of Mexican immigrants within a confined community in the southwestern United States. The personal stories of particular women are highlighted, and though their stories are individual and unique, they are assumed to be typical of immigrant experience in other areas. A more comprehensive review could include a variety of immigrant ethnicities (including indigenous families) and a broader variety of socioeconomic backgrounds. The study also did not focus on the prevalence of observance of la cuarentena; there are many women who do not find the traditional practices meaningful and who do not identify with their mothers’ and grandmothers’ experiences of the postpartum period. This study focuses less on whether/how/why women lose their traditional understandings during acculturation and more on how and why la cuarentena still matters to many immigrant women who continue to engage in traditional understandings. Methodological limitations include a relatively small sample size, ethnically and socioeconomically homogenous participants, and exclusion of very young women.
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Acknowledgment Funded by an NRSA Fellowship award from the National Institutes of Nursing Research.
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