“Well, they are deeply rooted customs”: a qualitative study on nutritional practices among postpartum mothers in Oaxaca, Mexico

“Well, they are deeply rooted customs”: a qualitative study on nutritional practices among postpartum mothers in Oaxaca, Mexico | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article “Well, they are deeply rooted customs”: a qualitative study on nutritional practices among postpartum mothers in Oaxaca, Mexico Marian Marian, Ramona L. Pérez This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9610340/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 12 You are reading this latest preprint version Abstract Background Maternal nutrition during the postpartum period is a critical time for mothers as they recover from pregnancy and delivery and continue to support their infant through breastfeeding. As Mexico goes through a nutrition transition away from traditional, home-prepared meals to more processed foods, it is unknown what the current dietary choices of women are after pregnancy. This study aimed to explore the nutritional practices of women in Southern Mexico during the postpartum period. Methods A qualitative study, guided by the Ecological Systems Theory and the Intersectionality Framework, was conducted involving 25 low-income women with children under the age of five in the cities of Oaxaca and Puerto Escondido, Oaxaca, Mexico. Data were collected through in-depth interviews between June and December 2023. Interviews were audio-recorded, transcribed verbatim in Spanish, coded, and analyzed using NVivo R1 following a grounded theory approach. Results Three main themes emerged: (i) maternal diet after a C-section, (ii) food practices during the breastfeeding period, and (iii) supplement consumption after the delivery. These findings reveal that, compared to women who deliver vaginally and are not advised on a specific diet during the postnatal recovery, women who deliver via C-section usually have a selective diet, based on recommendations from health providers and family members, that consists mainly of fruits, vegetables, and broths and restricts them from consuming mainly seafood and pork. Atole , a traditional hot beverage, was frequently consumed by postnatal women to increase their milk supply. Iron and folic acid were nutritional supplements mostly consumed during the postnatal period by women with a greater need to replenish nutrients lost during childbirth or the postnatal period. Conclusion This study highlighted the significance of understanding the nutritional habits that postnatal women in Puerto Escondido and Oaxaca City practice, as they are driven by customs and focus on the recovery of the mother and the development of the baby. These findings could be used to inform culturally relevant policies. Still, as postnatal care continues to be understudied in Mexico, future research is needed to identify any gaps in the nutrition of the mothers during puerperium. postpartum period nutrition practices breastfeeding postnatal women Mexico 1. Background The puerperium, better known as the postpartum or postnatal period, is a six-week period immediately following childbirth that is critical for the health of both the mother and baby. Healthy eating for the mother is prioritized and recommended as the body recovers and returns to its pre-pregnant state as well as the physiological demands of breastfeeding.( 1 , 2 ) Micronutrient excess or deficiency during the postnatal period can affect the quality and quantity of breast milk as well as short- and long-term maternal and child health.( 3 ) In Mexico, women currently face healthcare and nutritional challenges during the pregnancy and postpartum periods. While the levels of breastfeeding in this country have increased, its prevalence continues to be close to 35%, which lower is than the 50% established by the World Health Organization (WHO) and lower compared to other countries in the Latin American region.( 4 , 5 ) Micronutrient deficiency is very common among pregnant women in this country.( 6 ) The prevalence of anemia among Mexican pregnant women is 35%; however, these levels are greater among women living in rural areas (42%) and adolescent girls (46%).( 7 ) Nevertheless, according to the National Survey of Health and Nutrition, more than 80% of women receive adequate prenatal care, more than 70% get iron and vitamin supplementation, and more than 90% get folic acid supplementation.( 6 ) It is important to state that there are no current statistics on the anemia prevalence of postpartum women in Mexico, and data and research on postnatal care in this country are very limited.( 8 ) In a country where 55% of the deliveries occur via Cesarean section (C-section), which when improperly followed up can lead to short-and long-term complications for the mother and baby ( 9 , 10 ), it is imperative to document and monitor postnatal care data to identify and prevent any gaps in care in this neglected period, which globally has the highest risk of mortality for both the mother and the baby.( 11 ) Mexico used to follow the dieta de la milpa , which provided enough macro- and micronutrients through meals based on corn, beans, squash, leafy greens, fruits, chilies, chocolate, and small amounts of protein.( 12 ) However, for the last 30 years, Mexico has been undergoing a demographic, epidemiologic, and nutrition transition, including an increase in the non-communicable disease burden from high to low socioeconomic groups.( 13 – 15 ) This transition has increased the levels of diseases related to malnutrition in all life stages, including pregnancy and postnatal periods.( 16 ) Low-income women are a particular risk during the postnatal period, as socioeconomic status may influence food access, intake, and quality.( 17 ) The postpartum period is marked by different cultural beliefs and practices.( 18 ) Cultural practices and dietary restrictions during the postnatal period are common around the world, including Mexico.( 18 ) While there is a vast literature base on nutrition among postpartum women in Mexico, almost all is exclusive to breastfeeding practices and their impact or association on different outcomes for the mother and baby in Mexico.( 4 , 5 , 19 – 22 ) To our knowledge, there is no recent literature that exclusively examines the dietary practices of Mexican mothers during the postpartum period to better understand the maternal diet of women in this country. The primary aim of the study documented the nutritional practices and knowledge that women in the Southern state of Oaxaca received and employed during their pregnancy and in the postpartum period.( 23 ) The present study builds upon these findings to elaborate on the nutritional postpartum practices of low-income women and their families in Southern Mexico. 2. Methods 2.1 Study design A qualitative study guided by the Ecological Systems Theory ( 24 ) and the Intersectionality Framework ( 25 ) was conducted among low-income women with at least one child under the age of five residing in the cities of Oaxaca City and Puerto Escondido, Oaxaca, Mexico, to gain a more detailed understanding of the nutritional practices of low-income postnatal women in Southern Mexico. 2.2 Study setting This study was conducted in the cities of Oaxaca and Puerto Escondido in Southwestern Mexico. Both cities are located in the state of Oaxaca, which has some of the highest levels of poverty and food insecurity in the country, as over 25% of the population in this southern state lives in extreme poverty ( 13 , 26 – 28 ), with 23% of the population currently experiencing moderate or severe food insecurity, and close to 30% lacking access to nutritious and quality food.( 28 ) Puerto Escondido is located on the Pacific Coast and is in a tropical, high humidity ecological zone whereas Oaxaca City is in a subtropical highland to semi-arid ecological zone.( 29 ) Oaxaca is home to a rich agricultural base and culinary heritage shaped by both ecological and cultural diversity, Indigenous cultures, and a post-colonial history that make up this southern state.( 30 – 33 ) 2.3 Study participants The inclusion criteria comprised women aged 18 years or older who had at least one full-term pregnancy in the last five years and had lived in the state of Oaxaca full-time during the last five years. Participants in the city of Puerto Escondido were recruited through opportunistic sampling at a health center. While in the city of Oaxaca, snowball and opportunistic sampling were used to recruit participants through word of mouth, in-person solicitation at health centers, hospitals, and markets; flyers posted at hospitals and health center; and phone calls to patients from a health center. Participant recruitment lasted until thematic saturation was reached (n = 25). 2.4 Data collection Twenty-five semi-structured in-depth interviews were conducted between June and December 2023. The interviews were conducted in Spanish, the native language of the authors and participants, and lasted approximately between 30 and 45 minutes. The interviews in the city of Puerto Escondido (n = 16) were at the Lázaro Cárdenas Health Center, while in the city of Oaxaca, six interviews were conducted at the San Diego State University Oaxaca Center for Mesoamerican Studies and three at markets or local events, locations where participants were recruited. All interviews were conducted, audio-recorded and transcribed by the primary investigator (MM). Prior to the interview, participants completed a short socio-demographic survey as well as the 8-item adult version of the Latin American and Caribbean Scale of Food Security (ELCSA is the Spanish acronym).( 34 ) An interview guide, informed by investigators’ prior formative research along with the Ecological Systems Theory and the Intersectionality Framework, was developed and used broad open-ended questions to foster a discussion on women’s nutritional practices during pregnancy and the postpartum periods, including food acquisition, consumption of nutritional supplements, and nutritional education to guide the interviewing process. The interview guide can be accessed on a previously published manuscript that used data from the same study. ( 23 ) 2.5 Data analysis All interviews were audio recorded and transcribed verbatim and kept in the original language for analysis in order to preserve participants’ meanings and nuance ( 35 ). In order to tailor the interview guide and develop the codebook, the first author completed data collection and analysis concurrently. Two coders (MM and LC) independently read and coded all interviews using NVivo R1. A grounded theory approach ( 36 , 37 ) as well as the Ecological Systems Theory and the Intersectionality Framework were used for the analysis of data and dissemination of results. Coding consistency meetings were conducted between the coders to create new codes, discuss code definitions, and draw consensus on any discrepancies during the coding and analytic processes. 2.6 Ethical considerations This study was granted ethical approval by San Diego State University Institutional Review Board (Record Number HS-2023-0108). All women in this study provided written informed consent prior to participation. All identifiable participant information was anonymized, securely coded, and stored. 3. Results 3. 1 Sample characteristics Participants had an average age of 29y (range: 20–42). Most were born in the state of Oaxaca (n = 23), were currently living with a partner or married (n = 22), had less than a high school educational attainment (n = 19), were stay-at-home mothers (n = 17), considered themselves of indigenous belonging (n = 14), reported having had an average of 2 pregnancies (range: 1–7), and were currently low food insecure (n = 15). 3.2 Emergent themes We identified three emergent themes driven by the Intersectionality Framework and the Ecological Systems Theory to understand women’s multiple individual characteristics and social and ecological factors that influence women’s nutrition decisions and practices during the postnatal period: 1) maternal diet after a C-section; 2) food practices during the breastfeeding period; and 3) supplement consumption after the delivery. Each theme is described in detail below. Theme 1. Maternal diet after a C-section The most common theme on postpartum nutritional practices among participants was the diet followed by women who gave birth to their child via C-section, compared to a few participants who delivered vaginally and specified that they were not given specialized nutritional instructions or diets. Some participants who delivered via C-section remembered having what they considered very restrictive diets after childbirth. “Eating salads, vegetables, and meat—but without salt or sugar—I wasn't eating anything at all.” (Participant #23, age 41, Puerto Escondido) According to participants who had a C-section, the most common foods recommended to eat during the recovery period included vegetables, fruits, soups (such as vegetable or chicken soup), rice, eggs, and cheese. Related to what to drink during this period, water is mentioned as the beverage to drink. A participant mentioned that sodas and other forms of carbonated drinks were prohibited during this period. “(doctors told me to eat) what are broths, vegetables, but without tortillas and without bread” (Participant #15, age 38, Puerto Escondido) “Just broth, just vegetables, just fruit. No fat at all. Well, that was because of the C-section.” (Participant #18, age 22, Puerto Escondido) Consumption of pork, seafood, or foods with a high content of fat were the foods more frequently mentioned by participants as being restricted from their diets after the C-section. Bread, tortillas, and spicy foods were also prohibited for a few participants. Participants also mentioned that to prevent high content of fat or the use of oil, some foods such as eggs, cheese, or meat could only be eaten if they were grilled or boiled and not cooked some other form. “Because of the C-section, pork is bad for you” (Participant #6, age 24, Oaxaca City) “It was pure nourishment—but completely natural; there was no oil involved, because I had a C-section.” (Participant #10, age 20, Puerto Escondido) The time that these diets were followed by women after their C-section delivery varied from one week to one year; however, two months was the most frequent period mentioned among participants. “For nearly two and a half months, I was careful not to eat all those things—because, supposedly, it was bad for my C-section recovery. And yes, I really did watch what I ate for two months. I continued to be careful for a little while longer—specifically regarding those foods—for two and a half months in total; and at that point, I started eating the same things I used to eat before.” (Participant #20, age 21, Puerto Escondido) Some participants mentioned these dietary practices were recommended by health professionals right after the delivery of the child. However, others did mention the food to eat and amount of time to follow these practices were taught by older family members, such as mothers, grandmothers and mothers-in-law. Some of the participants mentioned that this specific diet, particularly avoiding seafood or pork, was to prevent constipation or to prevent the C-section wound from opening or getting infected. “Parents get you used to other things, like you can't eat pork, or you can't eat fish because it will infect your (C-section) wound, so they stop giving us certain foods that we don't consume during that two-month period.” (Participant #23, age 41, Puerto Escondido) “She (grandmother) told me (I) couldn't eat fish because something happened to a colleague of hers—it (wound) opened up a little because she ate shrimp.“ (Participant #10, age 20, Puerto Escondido) Theme 2. Food practices during the breastfeeding period Another common theme among participants were the food practices that postpartum women followed while breastfeeding. Similar to some participants who delivered via C-section, a few women mentioned having restrictive diets during their postpartum period because they were breastfeeding their child. “Yes, I changed my diet a lot. The first month was quite strict at home because we (participant and her natal family) believed that you only take care of yourself for a month. So, I followed a very strict diet because of breastfeeding.” (Participant #18, age 34, Puerto Escondido) Atole , a traditional hot beverage made from ground corn dough, was commonly mentioned by some participants as a food they consumed during the postpartum period in order to increase the milk supply for breastfeeding. This was mentioned to be consumed a few times a week or weekly and was suggested for consumption by health care professionals, such as nurses, after the delivery or during follow-up appointments as well as family members, specifically participants’ mothers and mothers-in-law. “Atole, to help the milk come in. To help the milk come in and have enough for the baby to drink.” (Participant #12, age 31, Puerto Escondido) Besides consuming atole , a few women who gave birth vaginally described having the same diet as what they ate before becoming pregnant while breastfeeding; however, some did have a more restrictive diet while breastfeeding that included broths, vegetables, fruits, and juices. A few women also mentioned some foods that were recommended not to be consumed during the postpartum period while breastfeeding, such as beans and corn, as they would lead to minor health issues for the baby. “(I eat) the same (food). Fish, same thing. I mean, beef. Whatever.” (Participant #14, age 34, Puerto Escondido) “They say not to eat certain foods, like beans, because that's what gives the girl gas. That's what they say. And in fact, well, my mother-in-law has also told me that corn tamales also cause gas; she says that's what triggers it too.” (Participant #16, age 22, Puerto Escondido) “It (diet) was very paltry. At home, my mom only gave me broths, soups, egg broth, chicken soup, chicken with vegetables, and more broths and more broths. And no tortillas, just toast. My delivery was natural, but my mom still took great care of me for about 40 days.” (Participant #18, age 34, Puerto Escondido) While many participants mentioned they breastfed for six months, the time that they mentioned they started introducing mashed vegetables to their child’s diet, women mentioned consuming atole for up to three months. “I consumed it (atole) for about two or three months, I think. I gradually stopped taking it, but I did take it. That's why they told me to drink a lot so my (breast) milk would come in, and then to take care of myself, to avoid the cold, and to bathe at a reasonable hour so the (breast) milk wouldn't get cold and harm the baby.” (Participant #12, age 31, Puerto Escondido) Theme 3. Supplement consumption after the delivery Consumption of postpartum nutrition supplements in the form of vitamins, folic acid, and iron in tablets or injections was mentioned by participants. These were always suggested by health care professionals. The reason why some of the participants continued consuming postpartum included replacing blood lost during delivery and replenishing nutrients depleted during pregnancy. “ The thing is, I lost a lot of blood (during delivery) .” (Participant #8, age 42, Oaxaca City) “Throughout my entire pregnancy—before and even afterwards—they kept sending me for (iron and folic acid) because I had lost so much weight.” (Participant #18, age 34, Puerto Escondido) For participants who used supplements during the postpartum period, the length of time these supplements used varied by participants from a month to up to six months, with three months being the most frequent time provided by participants. One participant was still taking iron supplements at the time of the interview. Reasons for stopping consuming supplements during the postpartum period included no longer needing to consume supplements, already consuming enough supplements, and economic issues where the participant was no longer able to afford buying supplements. “Consequently, I only took those medications for three months, even though I still needed another three months' supply; this was because his father also underwent surgery shortly thereafter—creating yet another expense—on top of the costs for his food, my food, the baby's food, and all the baby's other needs. So, that is why I tell you: there were indeed times when we found ourselves facing such hardship.” (Participant #23, age 41, Puerto Escondido) 4. Discussion This qualitative study explored the nutritional practices of women during the postnatal period in two cities of the Southwestern state of Oaxaca, Mexico, one on the coast and the other in a major urban space in the valley. Our results highlight the lived experience of 25 women in the cities of Puerto Escondido and Oaxaca City. Our findings suggest that the nutritional practices during the postnatal period are driven by three health outcomes of the perinatal period: delivering via a C-section, practicing breastfeeding, and requiring additional nutrients after delivery. Our results found that women in Oaxaca City and Puerto Escondido who deliver via a C-section have a more restrictive diet during the postpartum period than women who deliver vaginally; however, a variety of nutritious foods, such as vegetables and fruits, are the main source of nourishment for these women during the postnatal period. As dietary patterns are associated with sociodemographic characteristics, such as socioeconomic status and area of residence ( 38 , 39 ), our findings align with results from the National Health and Nutrition Surveys that found that women and people of lower socioeconomic status, mainly from Southern Mexico, have a higher quality of diet.( 38 ) As Oaxaca is one of the states with higher levels of food insecurity in the country ( 28 ), future research could evaluate the coping mechanisms low-income women in this state use to have a high quality of food during the postnatal period. Also related to the restrictive diets for postnatal women who delivered via C-section were the foods that were avoided to prevent C-section stitches from opening or getting infected, such as seafood, pork, foods with a high fat content, and spicy food. While the practice of avoiding fish and oil was also found in other studies done in a semi-urban community from the central state of Estado de México and a rural area of the central state of Hidalgo, respectively, the reason for this was different, as it was specific for pregnant and breastfeeding women in the first study, and it was not specified for the type of postnatal women that practiced this in the second study. ( 22 , 40 ) However, the practice of avoiding these foods to prevent a C-section infection has been found in postpartum women in other countries such as India, Bangladesh, and several countries in Africa.( 41 – 43 ) Breastfeeding women in Puerto Escondido and Oaxaca City also described restrictive diets during the postnatal period, which match results from other studies done in different regions of Mexico. For example, similar to our results, studies in rural areas of Hidalgo and Estado de Mexico also mentioned atole as something to drink to increase the milk supply among women who breastfeed, as well as restricted some foods and vegetables during this period.( 22 , 40 ) However, some of the restrictions in food that our participants mentioned are not practiced in other regions. For example, a study in Guadalajara, Jalisco, one of the biggest cities in the country, found that corn-based foods, particularly tortillas, were the most consumed items during the breastfeeding period ( 44 ), while some of our participants stayed away from foods made of corn, such as tamales (which are typical made with pork fat), to prevent health issues in their babies; however, it is important to state that atole , a main food consumed by participants when breastfeeding, is a corn-based beverage. As many of our participants stated consuming broths and juices as their main diet during breastfeeding, it is possible that our participants focused on consuming corn as part of a “hot” drink, while excluding consuming corn in a solid form that could be cooked with foods, such as pork fat, that were restricted from their diets during the postnatal period, as consuming hot drinks is typically done in rural and urban regions ( 22 , 40 ) around the country to promote the production of breastmilk. Given the breastfeeding rates across Mexico are lower than the recommendation from the WHO, particularly after the first 6 months ( 45 ), it is imperative to further understand the reasons why women decided to breastfeed or not breastfeed their infant, including the nutritional practices around this activity to best help mothers continue this practice for the recommended time. Several participants followed a strict diet, either because of the C-section or because they were breastfeeding, for 30 to 60 days after the delivery. This is typical of “ la cuarentena” (also known in English as postpartum confinement or quarantine), which is the immediate period after delivery that lasts for 40 days, traditionally common in Mexico, that involves a period of rest for the mother as well as the household support (such as cooking and cleaning) of mainly female family relatives. ( 46 , 47 ) In our study, these customs continued to be practiced among our participants nutrition-wise, and these practices came mainly from participants’ mothers and mothers-in-law, as they were the main sources of nutritional information and at times were in charge of the participant’s diet during the postnatal period, even when the term cuarentena was not used frequently. Describing nutritional customs during the postnatal period without including the term cuarentena or excluding nutrition customs when discussing the cuarentena is not uncommon among recent Mexican literature. A study in the southeastern state of Veracruz on cuarentena showed that women continue to observe these culturally prescribed practices; however, no information was provided on the nutritional practices that were followed during the cuarentena .( 48 ) While a study on puerperium that briefly used the term cuarentena interchangeably found that close to 65% of Purépecha Indigenous women in the state of Michoacan continue to follow nutritional customs and practices during puerperium, while they follow fewer of these customs for physical and general care.( 49 ) Since cultural nutritional practices continued to be followed in urban and rural Mexico during the postnatal period, it is crucial to further understand what the cuarentena currently stands for as well as the different traditional practices, particularly nutrition-wise, for integrating a culturally sensitive approach to health care policies at the local, state, and national level. Related to the use of nutritional supplements during the postpartum period, the WHO recommends postpartum oral iron and folate supplementation for 6 to 12 weeks for some women with risk of anemia.( 50 ) The only participants in our study who used nutritional supplements, mainly iron and folic acid, during the postnatal period were the ones who were prescribed them by a professional health provider to replenish depleted nutrients and for recovery after delivery. These results argue that postnatal women in Oaxaca and Puerto Escondido only use nutritional supplements when necessary. However, while not common among participants, it was mentioned in our study that postnatal supplement consumption was stopped due to financial issues. There is limited literature on postnatal care in Mexico; however, another study in Oaxaca and five other Mexican states found that maternal nutritional care compliance during the postpartum period is very low (from 5.7% to 17%).( 51 ) The fact that postpartum care is frequently underemphasized compared to antenatal care around the world, including Mexico, as recent literature found that as high as 30% of women do not have postnatal care visits within 6 weeks after their discharge from delivering the baby ( 8 , 52 ), along with our findings, suggests more research on maternal adherence to nutrition supplements in Mexico, particularly iron and folic acid, to better understand the prevalence of this behavior along with the reasons behind it when adherence is not followed. While most of the information provided by participants was on the foods they consumed during their postnatal period, several provided the source of where the information from those practices came from. While the nutrition supplements were exclusively recommended by health professionals, the nutritional practices information from women recovering from C-sections, as well as for breastfeeding women, came from family members, more commonly mothers, grandmothers, and mothers-in-law. While there are qualitative studies in Mexico that describe the role of mothers, sisters, and grandmothers in postnatal women’s nutrition practices, particularly while breastfeeding ( 53 , 54 ), quantitative studies should also be completed around the country to better understand the knowledge and practices these women share with postnatal women and learn if there are any gaps in nutrition that are left from what family members know and what healthcare providers do and do not provide after delivery. Strengths and limitations This study provides rich information regarding nutritional practices and lived experiences of women during the postpartum period. This is one of the few studies that examines nutritional practices of postpartum women ( 55 ), and to our knowledge, the first one that uses the Ecological Systems Theory and the Intersectionality Framework in postnatal nutrition in Mexico. This study is not without limitations. Given the small sample size (n = 9) in the city of Oaxaca, this study may not capture the complete range of different dietary behaviors practiced by women during the postnatal period in the capital of the state of Oaxaca; however, by using qualitative methods for this study, our goal was not to achieve generalizability. Also, this study focused on women from a lower socioeconomic level in urban areas. Future work that focuses on different populations would help to elucidate differences in nutritional practices and patterns by sociodemographic characteristics, such as socioeconomic characteristics and geographical location. Another possible limitation is potential recall bias, as we interviewed women with children up to the age of five, and for some women, their postpartum experiences had already passed for several years. Conclusions This study provides an in-depth understanding of the food practices among women in Puerto Escondido and Oaxaca during the postnatal period, driven by customs and focusing on the recovery of the mother and the development of the infant. Still, restrictions in women’s food choices could impact the quality of diet as well as outcomes for both mother and baby, so future research is required to identify any potential gaps in nutrition for these women during puerperium. Until recently, Mexico did not have an official feeding guide for pregnant and lactating women.( 56 ) In 2025 the Mexican government published the Healthy and Sustainable Dietary Guidelines for the Mexican Population 2025–2030, which included specific guidelines for pregnant and lactating women.( 57 ) Our study adds culturally relevant information for future versions of this guide, as well as for any future regional guidelines, if this guide is adapted to the diets and cultures of the 32 federal entities that make up Mexico. Given the limited data of postnatal care in this country, our research provides new evidence for targeted interventions, policy changes, and any broader initiatives that focus on the health and nutrition of postnatal women in the state of Oaxaca. Abbreviations C-section Cesarean section WHO World Health Organization Declarations Ethics approval and consent to participate This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. The San Diego State University Institutional Review Board has provided ethics approval for this study (Record Number HS-2023-0108). All participants provided informed consent in Spanish prior to data collection, and their confidentiality and autonomy were respected throughout the research process. Consent for publication Not applicable Availability of data and materials Excerpts of the data are in this publication. Participants’ transcripts are not available to share as they contain confidential information. For more information, please reach the corresponding author. Competing interests The authors declare no competing interests. Funding Research reported in this publication was partially supported by the San Diego State University Graduate Student Travel Fund. The first author (MM) also received support from the Tinker Field Research Grant for preliminary research for this project. Authors' contributions MM and RLP conceptualized the study. MM conducted the interviews and collected data from participants. MM conducted data analysis and interpretation, supported by RLP. MM prepared the manuscript with support from RLP. All authors read and approved the final manuscript. Acknowledgements We are grateful to all the women who participated in this study and took time to share their experiences. We would also like to thank Lucia Canul, Corina Rendón, Dr. Melissa Smith, the Colonia Estrella Health Center staff, Dr. Isabel Saucedo, the Colonia Lázaro Cárdenas Health Center staff, GES Mujer, Dr. Lina Rosa Berrio and Dr. Laura Montesi Altamirano, who supported this project in numerous ways. 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Intersectionality and health-related stigma: insights from experiences of people living with stigmatized health conditions in Indonesia. Int J Equity Health. 2020;19(1):206. 10.1186/s12939-020-01318-w . CONEVAL, Medición CONEVAL. 2023 Aug [cited 2024 Feb 26]. Available from: https://www.coneval.org.mx/Medicion/MP/Documents/MMP_2022/Pobreza_multidimensional_2022.pdf Pobreza en 2022. menor que previa a la pandemia, pese a caída en acceso a servicios de salud [Internet]. México cómo vamos; 2023 Aug [cited 2024 Jan 26]. Available from: https://mexicocomovamos.mx/wp-content/uploads/2023/08/20230810_PublicacionMCV_Pobreza2022.pdf Robledo Muñoz EC, Iturria Almazan A, Martin Molina JF, Leal González AJ, Ovando Galdamez JR. Policy Brief para Fortalecer la Seguridad Alimentaria en Oaxaca, México [Internet]. 2025 Oct. Available from: https://cgspace.cgiar.org/server/api/core/bitstreams/66c3c05c-0843-4074-9e56-e67efe7260f1/content INEGI. 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De las leguminosas, todas las que se pueda. Available from: https://idp.cimmyt.org/de-las-leguminosas-todas-las-que-se-pueda/ Comité Científico de la ELCSA. Escala Latinoamericana y Caribeña de Seguridad Alimentaria (ELCSA) - Manual de uso y aplicación. May: FAO; 2012. van Nes F, Abma T, Jonsson H, Deeg D. Language differences in qualitative research: is meaning lost in translation? Eur J Ageing. 2010;7(4):313–6. 10.1007/s10433-010-0168-y . PubMed PMID: 21212820; PubMed Central PMCID: PMC2995873. Charmaz K. Constructing Grounded Theory [Internet]. 2nd ed. Sonoma State Univesity: SAGE Publications; 2014 [cited 2022 Aug 31]. Available from: https://uk.sagepub.com/en-gb/eur/constructing-grounded-theory/book235960 Strauss AL. Qualitative Analysis for Social Scientists [Internet]. Cambridge: Cambridge University Press; 1987 [cited 2022 Aug 31]. 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Rev Mex Trastor Aliment. 2023;13(1):17–29. 10.22201/fesi.20071523e.2023.1.744 . Bathula SS, Helena K, Avvaru K. Nutritional experiences of postpartum mothers - A qualitative study. J Fam Med Prim Care. 2024;13(4):1243–8. doi:10.4103/jfmpc.jfmpc_904_23 PubMed PMID: 38827687; PubMed Central PMCID: PMC11141956. Jahan N, Islam MS. Cultural Practices of Mothers and Babies during the Postnatal Period: A Qualitative Study in Rural Bangladesh. Int J Environ Res Public Health. 2024;21(10):1344. 10.3390/ijerph21101344 . Olajide BR, van der Pligt P, Vasilevski V, McKay FH. Cultural Food Practices During Pregnancy and the Postpartum Period Among African Migrant Women Living in Australia: A Qualitative Study. J Racial Ethn Health Disparities. 2025 Oct;8. 10.1007/s40615-025-02690-5 . Amezcua López JA, Solís Pacheco JR, García Morales E, Gutiérrez Padilla JA, Zepeda Morales ASM, Angulo Castellanos E, et al. Influencia de la dieta de mujeres mexicanas sobre la calidad nutricional y la presencia de microorganismos benéficos en la leche humana. Nutr Hosp. 2019;36(5):1139–49. 10.20960/nh.02477 . Bigman G, Wilkinson AV, Homedes N, Pérez A. The Associations Between Breastfeeding Duration and Body Dissatisfaction, Ethnicity, and Obesity Among Mexican Women, a Cross-Sectional Study, ENSANUT 2012. Breastfeed Med. 2020;15(3):147–54. 10.1089/bfm.2019.0180 . Romo SPG, Gracia-Arnaiz M. Mujeres (in)visibles: Género, alimentación y salud en comunidades rurales de Oaxaca. PUBLICACIONS UNIVERSITAT ROVIRA i VIRGILI; 2014. p. 176. Jewell SL, Letham-Hamlett K, Ibrahim MH, Luecken LJ, MacKinnon DP. Family support and family negativity as mediators of the relation between acculturation and postpartum weight in low-income Mexican-origin women. Ann Behav Med Publ Soc Behav Med. 2017;51(6):856–67. 10.1007/s12160-017-9909-x . PubMed PMID: 28470505; PubMed Central PMCID: PMC5670022. Wolfe-Sherrie EJ, Perroni-Marañón AG, Núñez-de la Mora A, Piperata BA. Hey child, why were you born when the world is almost over? An analysis of first-time mothers’ postpartum experiences during the early stages of the COVID-19 pandemic in Coatepec, Veracruz, Mexico. Matern Child Health J. 2022;26(8):1732–40. 10.1007/s10995-022-03405-6 . PubMed PMID: 35731361; PubMed Central PMCID: PMC9213642. Silva SMM, Ramos EC, Carranza ARP, Villegas GG, de Ruiz-Recéndiz M. Costumbres y Prácticas de las Mujeres Purépechas durante el Puerperio. Estud Perspect Rev Científica Académica. 2024;4(3):3216–32. 10.61384/r.c.a.v4i3.610 . WHO recommendations on maternal and newborn care for a positive postnatal experience: executive summary [Internet], WHO. 2022 [cited 2026 Mar 31]. Available from: https://www.who.int/publications/i/item/9789240044074 Ruiz OA, Ancira-Moreno M, Omaña-Guzmán I, Cordero SH, Morales ACB, Navarro CP, et al. Low quality of maternal and child nutritional care at the primary care in Mexico: an urgent call to action for policymakers and stakeholders. Int J Equity Health. 2024;23:35. 10.1186/s12939-024-02129- . z PubMed PMID: 38388936; PubMed Central PMCID: PMC10885649. Neef V, Choorapoikayil S, Hof L, Meybohm P, Zacharowski K. Current concepts in postpartum anemia management. Curr Opin Anaesthesiol. 2024;37(3):234–8. doi:10.1097/ACO.0000000000001338 PubMed PMID: 38390913; PubMed Central PMCID: PMC11062600. Banda-Pérez A, de Álvarez-Aguirre J, Diaz-Manchay A, Banda-Pérez RJ, de J A, Álvarez-Aguirre A, Diaz-Manchay RJ. Creencias y costumbres en la alimentación durante el puerperio mediato de las mujeres nahuas e implicaciones para Enfermería. Rev Cuba Enferm [Internet]. 2022 Dec [cited 2026 Apr 16];38(4). Available from: http://scielo.sld.cu/scielo.php?script=sci_abstract&pid=S0864-03192022000400004&lng=es&nrm=iso&tlng=es Vázquez-Vázquez A, del Fewtrell P, Chan‐García MS, Batún‐Marrufo H, Dickinson C, Wells F. Do maternal grandmothers influence breastfeeding duration and infant nutrition? Evidence from Merida, Mexico. Am J Biol Anthropol. 2022;179(3):444–59. 10.1002/ajpa.24623 . PubMed PMID: 36790606; PubMed Central PMCID: PMC9826188. Aparicio E, Jardí C, Bedmar C, Pallejà M, Basora J, Arija V. Nutrient Intake during Pregnancy and Post-Partum: ECLIPSES Study. Nutrients. 2020;12(5):1325. doi:10.3390/nu12051325 PubMed PMID: 32392706; PubMed Central PMCID: PMC7285175. INSP [Internet]. 2025 [cited 2026 Apr 1]. Cerrando la brecha en salud materna: guías de alimentación saludable y sostenible - Portal INSP. Available from: https://insp.mx/ultimas-noticias/cerrando-la-brecha-en-salud-materna-guias-de-alimentacion-saludable-y-sostenible SSA INSP, UNICEF. Guías Alimentarias Saludables y Sostenibles para la Poblacion Mexicana 2025–2030 [Internet]. México; 2025. Available from: https://www.gob.mx/cms/uploads/attachment/file/1029510/Guias_Alimentarias_Mexico_2025.pdf Additional Declarations No competing interests reported. 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Pérez","email":"","orcid":"","institution":"San Diego State University","correspondingAuthor":false,"prefix":"","firstName":"Ramona","middleName":"L.","lastName":"Pérez","suffix":""}],"badges":[],"createdAt":"2026-05-04 16:10:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9610340/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9610340/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109452296,"identity":"9ad9020a-4c2f-43ea-b3c0-d18ccb63ac64","added_by":"auto","created_at":"2026-05-18 09:12:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":222392,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9610340/v1/3ea19211-b5b1-4df1-a896-2cc052e9890c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"“Well, they are deeply rooted customs”: a qualitative study on nutritional practices among postpartum mothers in Oaxaca, Mexico","fulltext":[{"header":"1. Background","content":"\u003cp\u003eThe puerperium, better known as the postpartum or postnatal period, is a six-week period immediately following childbirth that is critical for the health of both the mother and baby. Healthy eating for the mother is prioritized and recommended as the body recovers and returns to its pre-pregnant state as well as the physiological demands of breastfeeding.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Micronutrient excess or deficiency during the postnatal period can affect the quality and quantity of breast milk as well as short- and long-term maternal and child health.(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn Mexico, women currently face healthcare and nutritional challenges during the pregnancy and postpartum periods. While the levels of breastfeeding in this country have increased, its prevalence continues to be close to 35%, which lower is than the 50% established by the World Health Organization (WHO) and lower compared to other countries in the Latin American region.(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Micronutrient deficiency is very common among pregnant women in this country.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) The prevalence of anemia among Mexican pregnant women is 35%; however, these levels are greater among women living in rural areas (42%) and adolescent girls (46%).(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) Nevertheless, according to the National Survey of Health and Nutrition, more than 80% of women receive adequate prenatal care, more than 70% get iron and vitamin supplementation, and more than 90% get folic acid supplementation.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) It is important to state that there are no current statistics on the anemia prevalence of postpartum women in Mexico, and data and research on postnatal care in this country are very limited.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) In a country where 55% of the deliveries occur via Cesarean section (C-section), which when improperly followed up can lead to short-and long-term complications for the mother and baby (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), it is imperative to document and monitor postnatal care data to identify and prevent any gaps in care in this neglected period, which globally has the highest risk of mortality for both the mother and the baby.(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eMexico used to follow the \u003cem\u003edieta de la milpa\u003c/em\u003e, which provided enough macro- and micronutrients through meals based on corn, beans, squash, leafy greens, fruits, chilies, chocolate, and small amounts of protein.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) However, for the last 30 years, Mexico has been undergoing a demographic, epidemiologic, and nutrition transition, including an increase in the non-communicable disease burden from high to low socioeconomic groups.(\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) This transition has increased the levels of diseases related to malnutrition in all life stages, including pregnancy and postnatal periods.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) Low-income women are a particular risk during the postnatal period, as socioeconomic status may influence food access, intake, and quality.(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) The postpartum period is marked by different cultural beliefs and practices.(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) Cultural practices and dietary restrictions during the postnatal period are common around the world, including Mexico.(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) While there is a vast literature base on nutrition among postpartum women in Mexico, almost all is exclusive to breastfeeding practices and their impact or association on different outcomes for the mother and baby in Mexico.(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) To our knowledge, there is no recent literature that exclusively examines the dietary practices of Mexican mothers during the postpartum period to better understand the maternal diet of women in this country. The primary aim of the study documented the nutritional practices and knowledge that women in the Southern state of Oaxaca received and employed during their pregnancy and in the postpartum period.(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) The present study builds upon these findings to elaborate on the nutritional postpartum practices of low-income women and their families in Southern Mexico.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study design\u003c/h2\u003e \u003cp\u003eA qualitative study guided by the Ecological Systems Theory (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) and the Intersectionality Framework (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) was conducted among low-income women with at least one child under the age of five residing in the cities of Oaxaca City and Puerto Escondido, Oaxaca, Mexico, to gain a more detailed understanding of the nutritional practices of low-income postnatal women in Southern Mexico.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Study setting\u003c/h2\u003e \u003cp\u003eThis study was conducted in the cities of Oaxaca and Puerto Escondido in Southwestern Mexico. Both cities are located in the state of Oaxaca, which has some of the highest levels of poverty and food insecurity in the country, as over 25% of the population in this southern state lives in extreme poverty (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), with 23% of the population currently experiencing moderate or severe food insecurity, and close to 30% lacking access to nutritious and quality food.(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) Puerto Escondido is located on the Pacific Coast and is in a tropical, high humidity ecological zone whereas Oaxaca City is in a subtropical highland to semi-arid ecological zone.(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) Oaxaca is home to a rich agricultural base and culinary heritage shaped by both ecological and cultural diversity, Indigenous cultures, and a post-colonial history that make up this southern state.(\u003cspan additionalcitationids=\"CR31 CR32\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Study participants\u003c/h2\u003e \u003cp\u003eThe inclusion criteria comprised women aged 18 years or older who had at least one full-term pregnancy in the last five years and had lived in the state of Oaxaca full-time during the last five years. Participants in the city of Puerto Escondido were recruited through opportunistic sampling at a health center. While in the city of Oaxaca, snowball and opportunistic sampling were used to recruit participants through word of mouth, in-person solicitation at health centers, hospitals, and markets; flyers posted at hospitals and health center; and phone calls to patients from a health center. Participant recruitment lasted until thematic saturation was reached (n\u0026thinsp;=\u0026thinsp;25).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data collection\u003c/h2\u003e \u003cp\u003eTwenty-five semi-structured in-depth interviews were conducted between June and December 2023. The interviews were conducted in Spanish, the native language of the authors and participants, and lasted approximately between 30 and 45 minutes. The interviews in the city of Puerto Escondido (n\u0026thinsp;=\u0026thinsp;16) were at the L\u0026aacute;zaro C\u0026aacute;rdenas Health Center, while in the city of Oaxaca, six interviews were conducted at the San Diego State University Oaxaca Center for Mesoamerican Studies and three at markets or local events, locations where participants were recruited. All interviews were conducted, audio-recorded and transcribed by the primary investigator (MM).\u003c/p\u003e \u003cp\u003ePrior to the interview, participants completed a short socio-demographic survey as well as the 8-item adult version of the Latin American and Caribbean Scale of Food Security (ELCSA is the Spanish acronym).(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) An interview guide, informed by investigators\u0026rsquo; prior formative research along with the Ecological Systems Theory and the Intersectionality Framework, was developed and used broad open-ended questions to foster a discussion on women\u0026rsquo;s nutritional practices during pregnancy and the postpartum periods, including food acquisition, consumption of nutritional supplements, and nutritional education to guide the interviewing process. The interview guide can be accessed on a previously published manuscript that used data from the same study. (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Data analysis\u003c/h2\u003e \u003cp\u003eAll interviews were audio recorded and transcribed verbatim and kept in the original language for analysis in order to preserve participants\u0026rsquo; meanings and nuance (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). In order to tailor the interview guide and develop the codebook, the first author completed data collection and analysis concurrently. Two coders (MM and LC) independently read and coded all interviews using NVivo R1. A grounded theory approach (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) as well as the Ecological Systems Theory and the Intersectionality Framework were used for the analysis of data and dissemination of results. Coding consistency meetings were conducted between the coders to create new codes, discuss code definitions, and draw consensus on any discrepancies during the coding and analytic processes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Ethical considerations\u003c/h2\u003e \u003cp\u003e This study was granted ethical approval by San Diego State University Institutional Review Board (Record Number HS-2023-0108). All women in this study provided written informed consent prior to participation. All identifiable participant information was anonymized, securely coded, and stored.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003e3. 1 Sample characteristics\u003c/p\u003e \u003cp\u003eParticipants had an average age of 29y (range: 20\u0026ndash;42). Most were born in the state of Oaxaca (n\u0026thinsp;=\u0026thinsp;23), were currently living with a partner or married (n\u0026thinsp;=\u0026thinsp;22), had less than a high school educational attainment (n\u0026thinsp;=\u0026thinsp;19), were stay-at-home mothers (n\u0026thinsp;=\u0026thinsp;17), considered themselves of indigenous belonging (n\u0026thinsp;=\u0026thinsp;14), reported having had an average of 2 pregnancies (range: 1\u0026ndash;7), and were currently low food insecure (n\u0026thinsp;=\u0026thinsp;15).\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Emergent themes\u003c/h2\u003e \u003cp\u003eWe identified three emergent themes driven by the Intersectionality Framework and the Ecological Systems Theory to understand women\u0026rsquo;s multiple individual characteristics and social and ecological factors that influence women\u0026rsquo;s nutrition decisions and practices during the postnatal period: 1) maternal diet after a C-section; 2) food practices during the breastfeeding period; and 3) supplement consumption after the delivery. Each theme is described in detail below.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 1. Maternal diet after a C-section\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe most common theme on postpartum nutritional practices among participants was the diet followed by women who gave birth to their child via C-section, compared to a few participants who delivered vaginally and specified that they were not given specialized nutritional instructions or diets. Some participants who delivered via C-section remembered having what they considered very restrictive diets after childbirth.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Eating salads, vegetables, and meat\u0026mdash;but without salt or sugar\u0026mdash;I wasn't eating anything at all.\u0026rdquo;\u003c/em\u003e (Participant #23, age 41, Puerto Escondido)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAccording to participants who had a C-section, the most common foods recommended to eat during the recovery period included vegetables, fruits, soups (such as vegetable or chicken soup), rice, eggs, and cheese. Related to what to drink during this period, water is mentioned as the beverage to drink. A participant mentioned that sodas and other forms of carbonated drinks were prohibited during this period.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;(doctors told me to eat) what are broths, vegetables, but without tortillas and without bread\u0026rdquo;\u003c/em\u003e (Participant #15, age 38, Puerto Escondido)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Just broth, just vegetables, just fruit. No fat at all. Well, that was because of the C-section.\u0026rdquo;\u003c/em\u003e (Participant #18, age 22, Puerto Escondido)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eConsumption of pork, seafood, or foods with a high content of fat were the foods more frequently mentioned by participants as being restricted from their diets after the C-section. Bread, tortillas, and spicy foods were also prohibited for a few participants. Participants also mentioned that to prevent high content of fat or the use of oil, some foods such as eggs, cheese, or meat could only be eaten if they were grilled or boiled and not cooked some other form.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Because of the C-section, pork is bad for you\u0026rdquo;\u003c/em\u003e (Participant #6, age 24, Oaxaca City)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It was pure nourishment\u0026mdash;but completely natural; there was no oil involved, because I had a C-section.\u0026rdquo;\u003c/em\u003e (Participant #10, age 20, Puerto Escondido)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe time that these diets were followed by women after their C-section delivery varied from one week to one year; however, two months was the most frequent period mentioned among participants.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;For nearly two and a half months, I was careful not to eat all those things\u0026mdash;because, supposedly, it was bad for my C-section recovery. And yes, I really did watch what I ate for two months. I continued to be careful for a little while longer\u0026mdash;specifically regarding those foods\u0026mdash;for two and a half months in total; and at that point, I started eating the same things I used to eat before.\u0026rdquo;\u003c/em\u003e (Participant #20, age 21, Puerto Escondido)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome participants mentioned these dietary practices were recommended by health professionals right after the delivery of the child. However, others did mention the food to eat and amount of time to follow these practices were taught by older family members, such as mothers, grandmothers and mothers-in-law. Some of the participants mentioned that this specific diet, particularly avoiding seafood or pork, was to prevent constipation or to prevent the C-section wound from opening or getting infected.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Parents get you used to other things, like you can't eat pork, or you can't eat fish because it will infect your (C-section) wound, so they stop giving us certain foods that we don't consume during that two-month period.\u0026rdquo;\u003c/em\u003e (Participant #23, age 41, Puerto Escondido)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;She (grandmother) told me (I) couldn't eat fish because something happened to a colleague of hers\u0026mdash;it (wound) opened up a little because she ate shrimp.\u0026ldquo;\u003c/em\u003e (Participant #10, age 20, Puerto Escondido)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 2. Food practices during the breastfeeding period\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAnother common theme among participants were the food practices that postpartum women followed while breastfeeding. Similar to some participants who delivered via C-section, a few women mentioned having restrictive diets during their postpartum period because they were breastfeeding their child.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Yes, I changed my diet a lot. The first month was quite strict at home because we (participant and her natal family) believed that you only take care of yourself for a month. So, I followed a very strict diet because of breastfeeding.\u0026rdquo;\u003c/em\u003e (Participant #18, age 34, Puerto Escondido)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003eAtole\u003c/em\u003e, a traditional hot beverage made from ground corn dough, was commonly mentioned by some participants as a food they consumed during the postpartum period in order to increase the milk supply for breastfeeding. This was mentioned to be consumed a few times a week or weekly and was suggested for consumption by health care professionals, such as nurses, after the delivery or during follow-up appointments as well as family members, specifically participants\u0026rsquo; mothers and mothers-in-law.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Atole, to help the milk come in. To help the milk come in and have enough for the baby to drink.\u0026rdquo;\u003c/em\u003e (Participant #12, age 31, Puerto Escondido)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eBesides consuming \u003cem\u003eatole\u003c/em\u003e, a few women who gave birth vaginally described having the same diet as what they ate before becoming pregnant while breastfeeding; however, some did have a more restrictive diet while breastfeeding that included broths, vegetables, fruits, and juices. A few women also mentioned some foods that were recommended not to be consumed during the postpartum period while breastfeeding, such as beans and corn, as they would lead to minor health issues for the baby.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;(I eat) the same (food). Fish, same thing. I mean, beef. Whatever.\u0026rdquo;\u003c/em\u003e (Participant #14, age 34, Puerto Escondido)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;They say not to eat certain foods, like beans, because that's what gives the girl gas. That's what they say. And in fact, well, my mother-in-law has also told me that corn tamales also cause gas; she says that's what triggers it too.\u0026rdquo;\u003c/em\u003e (Participant #16, age 22, Puerto Escondido)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It (diet) was very paltry. At home, my mom only gave me broths, soups, egg broth, chicken soup, chicken with vegetables, and more broths and more broths. And no tortillas, just toast. My delivery was natural, but my mom still took great care of me for about 40 days.\u0026rdquo;\u003c/em\u003e (Participant #18, age 34, Puerto Escondido)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhile many participants mentioned they breastfed for six months, the time that they mentioned they started introducing mashed vegetables to their child\u0026rsquo;s diet, women mentioned consuming \u003cem\u003eatole\u003c/em\u003e for up to three months.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I consumed it (atole) for about two or three months, I think. I gradually stopped taking it, but I did take it. That's why they told me to drink a lot so my (breast) milk would come in, and then to take care of myself, to avoid the cold, and to bathe at a reasonable hour so the (breast) milk wouldn't get cold and harm the baby.\u0026rdquo;\u003c/em\u003e (Participant #12, age 31, Puerto Escondido)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 3. Supplement consumption after the delivery\u003c/b\u003e \u003c/p\u003e \u003cp\u003eConsumption of postpartum nutrition supplements in the form of vitamins, folic acid, and iron in tablets or injections was mentioned by participants. These were always suggested by health care professionals. The reason why some of the participants continued consuming postpartum included replacing blood lost during delivery and replenishing nutrients depleted during pregnancy.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThe thing is, I lost a lot of blood (during delivery)\u003c/em\u003e.\u0026rdquo; (Participant #8, age 42, Oaxaca City)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Throughout my entire pregnancy\u0026mdash;before and even afterwards\u0026mdash;they kept sending me for (iron and folic acid) because I had lost so much weight.\u0026rdquo;\u003c/em\u003e (Participant #18, age 34, Puerto Escondido)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFor participants who used supplements during the postpartum period, the length of time these supplements used varied by participants from a month to up to six months, with three months being the most frequent time provided by participants. One participant was still taking iron supplements at the time of the interview. Reasons for stopping consuming supplements during the postpartum period included no longer needing to consume supplements, already consuming enough supplements, and economic issues where the participant was no longer able to afford buying supplements.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Consequently, I only took those medications for three months, even though I still needed another three months' supply; this was because his father also underwent surgery shortly thereafter\u0026mdash;creating yet another expense\u0026mdash;on top of the costs for his food, my food, the baby's food, and all the baby's other needs. So, that is why I tell you: there were indeed times when we found ourselves facing such hardship.\u0026rdquo;\u003c/em\u003e (Participant #23, age 41, Puerto Escondido)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis qualitative study explored the nutritional practices of women during the postnatal period in two cities of the Southwestern state of Oaxaca, Mexico, one on the coast and the other in a major urban space in the valley. Our results highlight the lived experience of 25 women in the cities of Puerto Escondido and Oaxaca City. Our findings suggest that the nutritional practices during the postnatal period are driven by three health outcomes of the perinatal period: delivering via a C-section, practicing breastfeeding, and requiring additional nutrients after delivery.\u003c/p\u003e \u003cp\u003eOur results found that women in Oaxaca City and Puerto Escondido who deliver via a C-section have a more restrictive diet during the postpartum period than women who deliver vaginally; however, a variety of nutritious foods, such as vegetables and fruits, are the main source of nourishment for these women during the postnatal period. As dietary patterns are associated with sociodemographic characteristics, such as socioeconomic status and area of residence (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e), our findings align with results from the National Health and Nutrition Surveys that found that women and people of lower socioeconomic status, mainly from Southern Mexico, have a higher quality of diet.(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e) As Oaxaca is one of the states with higher levels of food insecurity in the country (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), future research could evaluate the coping mechanisms low-income women in this state use to have a high quality of food during the postnatal period.\u003c/p\u003e \u003cp\u003eAlso related to the restrictive diets for postnatal women who delivered via C-section were the foods that were avoided to prevent C-section stitches from opening or getting infected, such as seafood, pork, foods with a high fat content, and spicy food. While the practice of avoiding fish and oil was also found in other studies done in a semi-urban community from the central state of Estado de M\u0026eacute;xico and a rural area of the central state of Hidalgo, respectively, the reason for this was different, as it was specific for pregnant and breastfeeding women in the first study, and it was not specified for the type of postnatal women that practiced this in the second study. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) However, the practice of avoiding these foods to prevent a C-section infection has been found in postpartum women in other countries such as India, Bangladesh, and several countries in Africa.(\u003cspan additionalcitationids=\"CR42\" citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eBreastfeeding women in Puerto Escondido and Oaxaca City also described restrictive diets during the postnatal period, which match results from other studies done in different regions of Mexico. For example, similar to our results, studies in rural areas of Hidalgo and Estado de Mexico also mentioned \u003cem\u003eatole\u003c/em\u003e as something to drink to increase the milk supply among women who breastfeed, as well as restricted some foods and vegetables during this period.(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) However, some of the restrictions in food that our participants mentioned are not practiced in other regions. For example, a study in Guadalajara, Jalisco, one of the biggest cities in the country, found that corn-based foods, particularly tortillas, were the most consumed items during the breastfeeding period (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e), while some of our participants stayed away from foods made of corn, such as \u003cem\u003etamales\u003c/em\u003e (which are typical made with pork fat), to prevent health issues in their babies; however, it is important to state that \u003cem\u003eatole\u003c/em\u003e, a main food consumed by participants when breastfeeding, is a corn-based beverage. As many of our participants stated consuming broths and juices as their main diet during breastfeeding, it is possible that our participants focused on consuming corn as part of a \u0026ldquo;hot\u0026rdquo; drink, while excluding consuming corn in a solid form that could be cooked with foods, such as pork fat, that were restricted from their diets during the postnatal period, as consuming hot drinks is typically done in rural and urban regions (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) around the country to promote the production of breastmilk. Given the breastfeeding rates across Mexico are lower than the recommendation from the WHO, particularly after the first 6 months (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e), it is imperative to further understand the reasons why women decided to breastfeed or not breastfeed their infant, including the nutritional practices around this activity to best help mothers continue this practice for the recommended time.\u003c/p\u003e \u003cp\u003eSeveral participants followed a strict diet, either because of the C-section or because they were breastfeeding, for 30 to 60 days after the delivery. This is typical of \u003cem\u003e\u0026ldquo; la cuarentena\u0026rdquo;\u003c/em\u003e (also known in English as postpartum confinement or quarantine), which is the immediate period after delivery that lasts for 40 days, traditionally common in Mexico, that involves a period of rest for the mother as well as the household support (such as cooking and cleaning) of mainly female family relatives. (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e) In our study, these customs continued to be practiced among our participants nutrition-wise, and these practices came mainly from participants\u0026rsquo; mothers and mothers-in-law, as they were the main sources of nutritional information and at times were in charge of the participant\u0026rsquo;s diet during the postnatal period, even when the term \u003cem\u003ecuarentena\u003c/em\u003e was not used frequently. Describing nutritional customs during the postnatal period without including the term \u003cem\u003ecuarentena\u003c/em\u003e or excluding nutrition customs when discussing the \u003cem\u003ecuarentena\u003c/em\u003e is not uncommon among recent Mexican literature. A study in the southeastern state of Veracruz on \u003cem\u003ecuarentena\u003c/em\u003e showed that women continue to observe these culturally prescribed practices; however, no information was provided on the nutritional practices that were followed during the \u003cem\u003ecuarentena\u003c/em\u003e.(\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e) While a study on puerperium that briefly used the term \u003cem\u003ecuarentena\u003c/em\u003e interchangeably found that close to 65% of Pur\u0026eacute;pecha Indigenous women in the state of Michoacan continue to follow nutritional customs and practices during puerperium, while they follow fewer of these customs for physical and general care.(\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e) Since cultural nutritional practices continued to be followed in urban and rural Mexico during the postnatal period, it is crucial to further understand what the \u003cem\u003ecuarentena\u003c/em\u003e currently stands for as well as the different traditional practices, particularly nutrition-wise, for integrating a culturally sensitive approach to health care policies at the local, state, and national level.\u003c/p\u003e \u003cp\u003eRelated to the use of nutritional supplements during the postpartum period, the WHO recommends postpartum oral iron and folate supplementation for 6 to 12 weeks for some women with risk of anemia.(\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e) The only participants in our study who used nutritional supplements, mainly iron and folic acid, during the postnatal period were the ones who were prescribed them by a professional health provider to replenish depleted nutrients and for recovery after delivery. These results argue that postnatal women in Oaxaca and Puerto Escondido only use nutritional supplements when necessary. However, while not common among participants, it was mentioned in our study that postnatal supplement consumption was stopped due to financial issues. There is limited literature on postnatal care in Mexico; however, another study in Oaxaca and five other Mexican states found that maternal nutritional care compliance during the postpartum period is very low (from 5.7% to 17%).(\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e) The fact that postpartum care is frequently underemphasized compared to antenatal care around the world, including Mexico, as recent literature found that as high as 30% of women do not have postnatal care visits within 6 weeks after their discharge from delivering the baby (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e), along with our findings, suggests more research on maternal adherence to nutrition supplements in Mexico, particularly iron and folic acid, to better understand the prevalence of this behavior along with the reasons behind it when adherence is not followed.\u003c/p\u003e \u003cp\u003e While most of the information provided by participants was on the foods they consumed during their postnatal period, several provided the source of where the information from those practices came from. While the nutrition supplements were exclusively recommended by health professionals, the nutritional practices information from women recovering from C-sections, as well as for breastfeeding women, came from family members, more commonly mothers, grandmothers, and mothers-in-law. While there are qualitative studies in Mexico that describe the role of mothers, sisters, and grandmothers in postnatal women\u0026rsquo;s nutrition practices, particularly while breastfeeding (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e), quantitative studies should also be completed around the country to better understand the knowledge and practices these women share with postnatal women and learn if there are any gaps in nutrition that are left from what family members know and what healthcare providers do and do not provide after delivery.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStrengths and limitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study provides rich information regarding nutritional practices and lived experiences of women during the postpartum period. This is one of the few studies that examines nutritional practices of postpartum women (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e), and to our knowledge, the first one that uses the Ecological Systems Theory and the Intersectionality Framework in postnatal nutrition in Mexico. This study is not without limitations. Given the small sample size (n\u0026thinsp;=\u0026thinsp;9) in the city of Oaxaca, this study may not capture the complete range of different dietary behaviors practiced by women during the postnatal period in the capital of the state of Oaxaca; however, by using qualitative methods for this study, our goal was not to achieve generalizability. Also, this study focused on women from a lower socioeconomic level in urban areas. Future work that focuses on different populations would help to elucidate differences in nutritional practices and patterns by sociodemographic characteristics, such as socioeconomic characteristics and geographical location. Another possible limitation is potential recall bias, as we interviewed women with children up to the age of five, and for some women, their postpartum experiences had already passed for several years.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study provides an in-depth understanding of the food practices among women in Puerto Escondido and Oaxaca during the postnatal period, driven by customs and focusing on the recovery of the mother and the development of the infant. Still, restrictions in women\u0026rsquo;s food choices could impact the quality of diet as well as outcomes for both mother and baby, so future research is required to identify any potential gaps in nutrition for these women during puerperium. Until recently, Mexico did not have an official feeding guide for pregnant and lactating women.(\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e) In 2025 the Mexican government published the Healthy and Sustainable Dietary Guidelines for the Mexican Population 2025\u0026ndash;2030, which included specific guidelines for pregnant and lactating women.(\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e) Our study adds culturally relevant information for future versions of this guide, as well as for any future regional guidelines, if this guide is adapted to the diets and cultures of the 32 federal entities that make up Mexico. Given the limited data of postnatal care in this country, our research provides new evidence for targeted interventions, policy changes, and any broader initiatives that focus on the health and nutrition of postnatal women in the state of Oaxaca.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eC-section\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCesarean section\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. The San Diego State University Institutional Review Board has provided ethics approval for this study (Record Number HS-2023-0108). All participants provided informed consent in Spanish prior to data collection, and their confidentiality and autonomy were respected throughout the research process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eExcerpts of the data are in this publication. Participants\u0026rsquo; transcripts are not available to share as they contain confidential information. For more information, please reach the corresponding author. \u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearch reported in this publication was partially supported by the San Diego State University Graduate Student Travel Fund. The first author (MM) also received support from the Tinker Field Research Grant for preliminary research for this project.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMM and RLP conceptualized the study. MM conducted the interviews and collected data from participants. MM conducted data analysis and interpretation, supported by RLP. MM prepared the manuscript with support from RLP. All authors read and approved the final manuscript.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful to all the women who participated in this study and took time to share their experiences. We would also like to thank Lucia Canul, Corina Rend\u0026oacute;n, Dr. Melissa Smith, the Colonia Estrella Health Center staff, Dr. Isabel Saucedo, the Colonia L\u0026aacute;zaro C\u0026aacute;rdenas Health Center staff, GES Mujer, Dr. Lina Rosa Berrio and Dr. Laura Montesi Altamirano, who supported this project in numerous ways. \u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAparicio E, Jard\u0026iacute; C, Bedmar C, Pallej\u0026agrave; M, Basora J, Arija V. Nutrient Intake during Pregnancy and Post-Partum: ECLIPSES Study. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.gob.mx/cms/uploads/attachment/file/1029510/Guias_Alimentarias_Mexico_2025.pdf\u003c/span\u003e\u003cspan address=\"https://www.gob.mx/cms/uploads/attachment/file/1029510/Guias_Alimentarias_Mexico_2025.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nutrition","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nutn","sideBox":"Learn more about [BMC Nutrition](http://bmcnutr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nutn/default.aspx","title":"BMC Nutrition","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"postpartum period, nutrition practices, breastfeeding, postnatal women, Mexico","lastPublishedDoi":"10.21203/rs.3.rs-9610340/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9610340/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMaternal nutrition during the postpartum period is a critical time for mothers as they recover from pregnancy and delivery and continue to support their infant through breastfeeding. As Mexico goes through a nutrition transition away from traditional, home-prepared meals to more processed foods, it is unknown what the current dietary choices of women are after pregnancy. This study aimed to explore the nutritional practices of women in Southern Mexico during the postpartum period.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e A qualitative study, guided by the Ecological Systems Theory and the Intersectionality Framework, was conducted involving 25 low-income women with children under the age of five in the cities of Oaxaca and Puerto Escondido, Oaxaca, Mexico. Data were collected through in-depth interviews between June and December 2023. Interviews were audio-recorded, transcribed verbatim in Spanish, coded, and analyzed using NVivo R1 following a grounded theory approach.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThree main themes emerged: (i) maternal diet after a C-section, (ii) food practices during the breastfeeding period, and (iii) supplement consumption after the delivery. These findings reveal that, compared to women who deliver vaginally and are not advised on a specific diet during the postnatal recovery, women who deliver via C-section usually have a selective diet, based on recommendations from health providers and family members, that consists mainly of fruits, vegetables, and broths and restricts them from consuming mainly seafood and pork. \u003cem\u003eAtole\u003c/em\u003e, a traditional hot beverage, was frequently consumed by postnatal women to increase their milk supply. Iron and folic acid were nutritional supplements mostly consumed during the postnatal period by women with a greater need to replenish nutrients lost during childbirth or the postnatal period.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study highlighted the significance of understanding the nutritional habits that postnatal women in Puerto Escondido and Oaxaca City practice, as they are driven by customs and focus on the recovery of the mother and the development of the baby. These findings could be used to inform culturally relevant policies. Still, as postnatal care continues to be understudied in Mexico, future research is needed to identify any gaps in the nutrition of the mothers during puerperium.\u003c/p\u003e","manuscriptTitle":"“Well, they are deeply rooted customs”: a qualitative study on nutritional practices among postpartum mothers in Oaxaca, Mexico","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-18 09:12:10","doi":"10.21203/rs.3.rs-9610340/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-21T10:07:13+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-20T23:14:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"310819297208205901498767198865243521150","date":"2026-05-13T15:37:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-11T17:30:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"130480462779777302864228794977966116931","date":"2026-05-11T15:36:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"290661735621801203306376547107639331844","date":"2026-05-08T17:44:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"257353275253663299985175251479747404688","date":"2026-05-08T14:08:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-05-08T13:18:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-05-08T13:13:44+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-05-08T06:20:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-05-07T20:36:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nutrition","date":"2026-05-07T17:04:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nutrition","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nutn","sideBox":"Learn more about [BMC Nutrition](http://bmcnutr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nutn/default.aspx","title":"BMC Nutrition","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"93eb955f-5b2f-4af3-8eab-c258c12211ed","owner":[],"postedDate":"May 18th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-21T10:07:13+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-20T23:14:09+00:00","index":57,"fulltext":""},{"type":"reviewerAgreed","content":"310819297208205901498767198865243521150","date":"2026-05-13T15:37:28+00:00","index":55,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-11T17:30:10+00:00","index":54,"fulltext":""},{"type":"reviewerAgreed","content":"130480462779777302864228794977966116931","date":"2026-05-11T15:36:06+00:00","index":53,"fulltext":""},{"type":"reviewerAgreed","content":"290661735621801203306376547107639331844","date":"2026-05-08T17:44:51+00:00","index":49,"fulltext":""},{"type":"reviewerAgreed","content":"257353275253663299985175251479747404688","date":"2026-05-08T14:08:49+00:00","index":47,"fulltext":""},{"type":"reviewersInvited","content":"32","date":"2026-05-08T13:18:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-05-08T13:13:44+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-05-08T06:20:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-05-07T20:36:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nutrition","date":"2026-05-07T17:04:15+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-21T10:23:07+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-18 09:12:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9610340","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9610340","identity":"rs-9610340","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}