Ann M DiGirolamo, MPH, PhD,(1) V Nelly Salgado de Snyder, PhD.(2)
(1) Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA. (2) Centro de Investigación en Sistemas de Salud, Instituto Nacional de Salud Pública, México
El propósito de esta contribución fue revisar la literatura publicada en los últimos 20 años con respecto al papel que tienen las mujeres mexicanas en el ámbito familiar y describir los retos psicosociales y de salud que cotidianamente enfrentan. Se analizan los problemas actuales y las mejoras que han ocurrido en tres áreas: salud reproductiva, nutrición y salud mental; se discute cómo el papel de cuidadora de otros influye o es influido por estos temas de salud. Se enfatiza el entorno cultural, su rol como cuidadoras, los retos que enfrentan y la fortaleza y resistencia que demuestran. Se concluye que es imperativo modificar la manera en que las necesidades de la mujer mexicana están siendo evaluadas, interpretadas y confrontadas, junto con una necesidad impostergable de concretar propuestas que tomen en cuenta retos y fortalezas, así como el contexto cultural y la realidad nacional.
The purpose of this contribution is to review the peer reviewed literature from the last 20 years regarding the role of Mexican women in the family, and to describe the psychosocial and health challenges they face. We analyze the current problems and recent improvements in three areas: reproductive health, nutrition, and mental health, and we discuss how the role of caregiver may influence or be influenced by these health issues. We emphasize the cultural context, women’s role as caregivers, the challenges they face, and the strength and resilience these women exhibit. We conclude that it is imperative that we modify the way in which Mexican women’s needs are assessed, interpreted, and confronted, along with a definite need for concrete proposals that take into account both women’s challenges and strengths, and the cultural context and national reality.
Address reprint requests to: Dra. V. Nelly Salgado de Snyder. Instituto Nacional de Salud Pública Av. Universidad 655 Cuernavaca, Mor. 62508 Mexico. E-mail: email@example.com
To better understand the challenges to the health and well-being of women in Mexico, it is important to acknowledge that the family is considered the most important value in Mexican culture, and that the woman is the essential unifying element within the family. The conformation of families brings generations together, transmits identity to their members and articulates lines of family relationships (parentesco) through a complex net of social interactions. Families give a unifying meaning to the world, nurturing the life and actions of their members.1,2 Within the family, women play the most significant role as socialization agent and caregiver. The objective of this contribution is to review women’s pivotal role within the family and to analyze the social and health challenges they face. First, we describe the cultural context for women living in Mexico, with a particular focus on their role as caregivers, the social challenges they face, and the strength and resilience that they exhibit. Drawing from the peer reviewed literature from the last 20 years (1988-present), we then analyze the current problems and recent improvements in the area of women’s health in light of this context, discussing how the role of caregiver may influence or be influenced by these particular health issues.
Socialization process of Mexican women as caregivers
Gender bias in Mexico has fostered an ideology that magnifies women’s role in childbearing as the one determinant aspect of the female identity.3,4 As a consequence, research and health care services for women in Mexico have been addressed primarily insofar as they affect reproduction, reflecting a one-dimensional view of their roles and needs and often characterizing women as passive.2 Gender roles assigned to women remain traditional. Passivity, dependence, submissiveness and self-sacrifice characterize the socially assigned role for women,2,5 but in reality, they continue to exhibit a resilience and strength in their role as caregiver, as illustrated by the following quote:
“Being a mom, yes, above all else, is the main foundation, the main foundation of the children, the home, the husband, of everything; because one is not only a guide to the children, but also to the husband, because, how should I say it… They (men) feel that their only responsibility is to bring in the money; once they bring in the money, they say, ‘I am done, I have given to you, that was my obligation,’ (and) they forget about everything else, and we do not.”6,*
* “Ser mamá, pues sí, sobre todo es la base principal, la base principal de los hijos, del hogar, del marido, de todo; porque uno no nada más es guía para los hijos, sino también para el marido, porque, como le dijera…Ellos sienten nomás en traer por decir “yo ya cumplí, yo ya te di, ésa fue mi obligación’, (y) se olvidan de todo lo demás, y uno no.” (Original Spanish version, Ojeda, 1999:230).
Motherhood is highly valued in Mexican culture, particularly in rural areas where traditional gender roles are accentuated and motherhood is considered a sign of femininity. The influence of catholicism on family size and traditional gender roles has idealized the role of women to the point of considering motherhood as the most important function of women.5,7
The universal role of woman as primary caregiver and reproductive agent establishes that she becomes the support and guide of the family. In Mexican society, a woman is her husband’s sexual and social partner, the mother or grandmother who cares and nurtures her children and grandchildren, socialization agent, educator, and main person responsible for transmitting the cultural and social values with which she was raised. She is responsible for the reproduction of the species, the social family system and the family’s property, as well as the health and well-being of her husband and family.8 Many of the health care programs, especially for children, require the involvement of women in order to access the children and be successful. For example, programs in child nutrition, immunization, and management of diarrheal or respiratory illnesses in children require that the mother or primary caregiver bring the child to a health facility for medical attention. Thus, society and the current health care system also reinforce the role of the woman as primary caregiver, providing her with additional responsibilities, and may even blame the woman if the husband or children are not receiving adequate medical care. This multiplicity of roles limits the woman considerably in her own personal development and in taking care of her own health and well-being. Gender socialization within this culture encourages women to be supportive of their children and husbands, and to silently sacrifice themselves in order to do so. Taking care of their children, husbands, and families is the main priority; taking care of their own physical and mental health needs comes later, if at all.8,9 The demands and expectations placed on Mexican women strongly influence their emotional well-being. For instance, the lower position that women have in society, the demands of motherhood, and the demands of being a wife, daughter, and a working person have been associated with depression, anxiety, guilt, repressed hostility and psychosomatic disorders.5
However, despite, or perhaps as a result of the many social challenges faced daily, Mexican women appear to demonstrate personal strength and resilience. Resilience has been defined as a characteristic developed by those who, in spite of living under high risk situations, develop healthy and successful ways of coping.10 Resilience among Mexican women seems to be formed through the interaction of introspection, self-demands, goal setting, and testing one’s capabilities and creativity. Also, women seem to gain strength from their own conditions and values that they have built up, and they further develop inner strengths which allow them to recreate themselves as agents of health promotion for their family.11 Similarly, some have suggested that personal strength in Mexican women, defined as “the potential people have for self-modification, and to endure and resist life’s challenges,” is particularly important in allowing them to carry out their function as caregiver.12 In addition, women seem to draw strength from their role as mother and caregiver. The strong sense of collectivism and family, having extended family participate in the caregiving process, and the respect given to the role of mother are all aspects of the Mexican culture which may be helpful in dealing with some of the stressors women experience. Furthermore, women have described a deep belief in God and faith as a means to deal with everyday stressors, and an acceptance of their surroundings and circumstances.13,14
Challenges and recent improvements in women’s health relevant to the caregiving role
In the following section, we focus on three dimensions of women’s health that are related to and can influence their ability to successfully carry out their role as caregiver. These include reproductive health, nutrition, and mental health.
Reproductive health and well-being
In addition to some of the familial and social challenges, women in Mexico must also deal with the physical and psychosocial challenges in the area of reproductive health. These challenges take on special significance within the cultural context of a woman’s identity primarily being defined by her roles of reproduction, mother, and caregiver. Challenges in reproductive health include access to health care; breast, uterine, and cervical cancer; and family planning and use of contraceptives. In recent years, the Mexican government has developed an official norm for reproductive health services which involves a comprehensive and proactive approach to women’s health care, focusing on the three areas of breast and cervical cancer prevention, family planning, and prenatal care.15,16,17 However, medical personnel are not fully trained in or providing the new standard of care and relying on their previous standards of practice. Data from a recent study suggested that within the last several years, a large percentage of medical professionals (e.g., nurses, physicians) reported conducting activities aimed at prevention of cervical/uterine cancer and breast cancer, addressing prenatal care, and family planning.18,19 However, this same survey suggested that within the last year, only about half of the medical professionals reported receiving training in these areas. Both survey data and clinic visits indicated that in practice, many medical professionals are only superficially addressing these areas and may require more technical training in order for these norms to be fully effective.
Mortality from breast cancer among women in Mexico has continued to steadily rise, with an increment of 74% from 1992 to 1997.20 Deaths due to breast cancer for every 100 000 women in Mexico were 15.1 in 1998 and 18.5 in 2000, with approximately 30 new cases diagnosed each day.21,22 In Mexico, breast cancer tends to be diagnosed fairly late, with 90% of new cases detected in stages with metastasis and only 2% identified in stage 1 or in which the cancer is localized.20,22,23 In 2000, breast cancer was estimated to contribute to 31 821 Disability Adjusted Life Years (DALYs)24,* lost nationally among women ages 15 to 44 years.25 This greatly impacts both the woman and her family –her own health, well-being, and identity as a woman and mother, and her ability to care for her family. In addition, death due to breast cancer has contributed to a large number of orphans in Mexico.26 Although early prevention of breast cancer is possible and important for breast cancer survival, several factors in Mexico have been identified which may influence the late diagnosis and high mortality due to this disease. These include: differential access to health care for men and women; women underestimating their physical discomfort and postponing seeking medical care because of priorities in taking care of their family’s needs; men in this culture being opposed to the women in their family seeking medical attention for problems related to their genital organs or breasts, especially from male health care providers; and fear preventing one from taking an active role in prevention and detection.25,27,28 Cancer of the breast also has a specific emotional burden attached to it because of the significance of the breast in nurturing and motherhood.25
* DALYs are the “sum of years of life lost because of premature mortality and years of life lived with disability, adjusted for the severity of disability.” (Murray & Lopez, 1996:740)24
In 1973-1974, more emphasis and acceptance were given to family planning in Mexico, including the legalization of the sale of contraceptives.29 Following this emphasis on family planning, a decrease in the number of births occurred,30,31 and in 1995, the National Survey of Demographic Dynamics noted that general fertility in Mexico had fallen 51% in the last 20 years.32 Increased access to family planning services produced a direct positive effect on women’s reproductive health through the decrease in number of births and increase in spacing between pregnancies, which in turn, decreased the health risks associated with reproduction.6 This effect was especially important because many women in Mexico tend not to receive any prenatal care.33,34 In addition, an increasing percentage of women finishing primary school was associated with a decrease in fertility, which in turn led to some cultural changes and an explosion of alternatives for women beyond the traditional role of “wife and mother”.30 At the macro level of society, these educational advances and the ability to control reproduction have led to increasing numbers of younger women being part of the educational system, and along with this, receiving training for work, having more social opportunities, having more information about their health, and in turn, having better health conditions.6 However, these changes were not experienced universally or in the same way by women of different social and ethnic groups.6 Among poorer women in some regions in Mexico, lack of education independently predicted non-use of contraceptives, with illiterate women 1.6 times more likely to have never used contraception than those who had attended secondary school; most illiteracy among women occurs in the southern rural regions in Mexico.35,36 Additional socioeconomic variables associated with nonuse of contraceptives include having given birth at home, having experienced the death of at least two children, and not having a paid job.35 Thus for many women in Mexico, advances in family planning have served to strengthen their role in Mexican society, expanding their abilities, and enabling them to better care for themselves and for others. But for a group of women already at risk due to stressors of poverty, malnutrition, and illness —the poorer in rural regions of Mexico— these opportunities and positive changes have not occurred.
Malnutrition among adult women in Mexico has been a common phenomenon, which has also affected their children. For example, children born to women with short stature due to nutritional stunting have a greater probability of being low birth-weight, which in turn is associated with higher risk for infant mortality and morbidity.36,37 A recent survey, however, has suggested that malnutrition among Mexican women, as measured by body mass index, has currently disappeared, with prevalence lower than one would expect in a healthy population.36 Despite this decrease in protein-energy malnutrition, women in Mexico still suffer from deficiencies of various micronutrients, which have many functional consequences, including impaired ability to adequately care for one’s children. In 1999, the national prevalence of anemia (based on hemoglobin adjusted for altitude) was 20% among women of reproductive age (12 to 49 years), and 26% among pregnant women, with the highest prevalence occurring in the southern part of the country and in the rural areas. This constitutes a substantial increase in anemia from 1988 when the prevalence was 15% among women of reproductive age and 18% among pregnant women.36 Anemia is associated with increased susceptibility to infections, fatigue and lethargy, less capacity for physical work, and pregnancy complications such as preterm delivery, low birth weight, and fetal death.38
Although the prevalence of folic acid depletion among pregnant women is moderate (10.6%),36 this is still of public health concern due to its association with an increased risk of neural tube defects (NTD) in the offspring.39,40 The incidence of NTDs in Mexico is one of the highest in the world, with multiple factors involved.36 Factors shown to contribute to NTDs have included a common genetic condition putting a woman more at risk for having a child with NTDs, folic acid deficiency among women of reproductive age, and other environmental factors.39 Along with substantial folic acid depletion among pregnant women, Mexico has been shown to have a high prevalence of women with the genetic condition associated with risk for NTDs, both of which may explain the high prevalence of NTDs in Mexico.36,41
A growing epidemic among women in Mexico is overweight and obesity, with 71.6% falling in either category according to the National Nutrition and Health Survey (ENSANUT, per its abbreviation in Spanish) of 2006.42 This is a definite increase from 1988 when the First National Nutrition Survey showed that 35% of women were considered overweight or obese.43 The high prevalence of overweight and obesity is especially concerning in light of their association with illnesses such as hypertension, hypercholesterolemia, and diabetes, 44-47 all of which are on the increase among Mexican women.42
In Mexico, the prevalence of mental disorders and the differences between males and females have not been studied until recently. The many socio-cultural contexts in which Mexican society has evolved have made it difficult to accept a single indicator of mental health problems, thereby making the study of mental health more difficult. De la Fuente and colleagues48 reported that women have a consistently higher prevalence than men of several mental disorders such as depression, anxiety disorders (obsessive disorder), and depressive symptomatology, based on several epidemiological studies in Mexico conducted among urban adult populations. Results of a recent stu dy conducted with rural Mexican women suggested that nervios (folk illness with similar symptoms to depression and anxiety disorders) is a prevalent syndrome among the adult inhabitants of rural Mexico, and that women have a significantly higher prevalence of nervios and associated physiological and psychological symptomatology than men.49 Almost three-fourths of the women with nervios reported feeling sad, depressed or down which confirms that nervios is often expressed with negative effect.50 Similar findings have been reported in past literature that further suggest that the higher prevalence of this condition among women has been related to the multiple responsibilities and obligations assigned to them in traditional societies.51,52
Women in rural communities have to face everyday situations that produce great levels of stress. Such conflicts are related to the context of poverty in which they live, their large family size, and their limited resources.53,54 Thus, it is not surprising that the rural women with the highest prevalence of nervios were married, had a low level of education, were home makers, and had more than four children under their care. It has been suggested that the demands many rural women in Mexico face seem to be chronic in nature and the possibility of change is remote due to traditional gender roles and the context of scarcity in which they live.49,54 Findings have also revealed that more women than men self-reported having poor physical and mental health. This difference may be related to the greater levels of stress women face because of the unequal distribution of labor and responsibilities between the sexes in rural settings.Women’s involvement with familial, household, labor, and even financial responsibilities is a 24-hour job. In a context of poverty, such responsibilities can at times become unbearable. Poverty was singled out as the most important predictor of poor health and mental health status among women.49,54
Another issue that has influenced women’s mental health is alcohol and illegal drug consumption by the husband and children or other family members living in the same household.55 Mexican women tend not to consume alcohol or use drugs or tobacco. Data from the most recent National Survey of the Addictions (2002)56 revealed that the highest consumption of alcohol is found among urban men between 30 and 39 years old. Dependence was higher among rural men (10.5%), followed by urban men (9.3%). Women had a considerably lower dependency index (0.7% urban and 0.4% rural). In Mexico, according to data from the ENSANUT,42 consumption of tobacco and alcohol is about three times higher among men than women. Women living with an alcoholic husband or children are forced to take responsibility as head of households and are accountable for the wrongdoing of intoxicated family members. These women are frequently victims of psychological, physical and sexual abuse from their partners and male offspring while under the influence.57,58
From a traditional perspective, women are seen as weak and vulnerable, and their psychopathology is usually reduced to problems associated with their reproductive functions, such as premenstrual syndrome, postpartum depression, menopause, or infertility.59 This old-fashioned vision has minimized the importance of women’s mental health problems; thus, their psychosocial problems are treated as if they were problems of a physiological etiology. These problems tend to be treated with medication and little importance is given to the socio-cultural factors that are often responsible for the origination of such problems.60
This contribution is a review of the current social and health challenges experienced by Mexican women in the context of their primary role as caregiver, and discusses that despite such challenges, these women develop strength and resilience and play an active role in the lives of their families. Throughout history and in the literature, Mexican women have often been portrayed as weak, dependent, and passive, with a focus on their role in reproduction and caregiving. Within this context, women in Mexico face several health challenges, particularly in the areas of reproductive health, nutrition, and mental/emotional health.
This review is not exhaustive and does not summarize all the literature on gender roles, health, and the well-being of Mexican women. Rather, we have provided a brief account of what we consider three important themes that seem to challenge and strengthen the role of Mexican women as caregivers and the impact of such challenges on their well-being. Although this could be considered a potential limitation, we believe that the information provided is sufficient to gain a clearer understanding of the roles and challenges of women in Mexico, further analyzing the same old issues: gender and well-being.
As we make progress and gain experience in new methodological approaches such as life histories, participatory methodologies, and other qualitative methods that allow us to gather more information on the “why” and “how,” we reaffirm the need to understand the experiences of Mexican women and to examine the implications of what being a woman means in different socio-cultural contexts within the country. As researchers, we have started to question the ways in which, traditionally, women’s health and mental health problems have been studied and confronted; we have begun to re-examine women’s experiences and well-being from a standpoint that acknowledges the socio-cultural contexts in which women live and the simple fact that in some cultures, being a woman itself constitutes a risk factor.
Future research and programs should continue to explore ways to effectively address the problems described in this article and the lack of emphasis on women seeking care for themselves, perhaps by attempting to reframe women’s health care in the context of caring for oneself in order to better care for one’s children and family. With the rise of problems such as breast cancer and obesity, and continued problems in reproductive health, finding ways to emphasize the importance of women’s health and well-being that facilitate appropriate care and prevention is critical. In addition, it is necessary to further explore the relationships between physical and emotional well-being to better understand the emotional and socio-cultural significance of some of the physical challenges these women experience. Research and programs must tap into the resources and protective factors available to these women and to investigate the mechanisms by which these factors can be helpful in improving the emotional and physical well-being of women in this country. In conclusion, we see an imminent need to modify the way in which women’s needs are assessed, interpreted, and confronted, along with a definite need for concrete proposals and recommendations that take into account both women’s challenges and strengths, and adequately incorporate the cultural context and national reality of women in Mexico.
1. Macías R. La familia. Saber Ver. Número especial: La Nación Mexicana, Retrato de Familia 1994:13-15. 2. Tuirán R. Familia y sociedad en el México contemporáneo. Saber Ver. Número especial: La Nación Mexicana, Retrato de Familia 1994:33-55. 3. Amuchástegui A. El significado de la virginidad y la iniciación sexual. Un relato de investigación. In: Szasz I, Lerner S, ed. Para comprender la subjetividad. Investigación cualitativa en salud reproductiva y sexualidad. México: El Colegio de México, 1996:137-172. 4. Del Río-Zolezzi A, Liguori AL, Magis-Rodríguez C, Valdespino JL, García ML, Sepúlveda J. La epidemia de VIH/SIDA y la mujer en México. Salud Publica Mex 1995;37:581-591. 5. Lara, MA. Inventario de masculinidad y feminidad (IMAFE). México: El Manual Moderno, 1993. 6. Ojeda N. Curso de vida femenino y conceptualización social de la salud reproductiva. In: Ojeda N, editor. Género, familia y conceptualización de la salud reproductiva en México. Tijuana, BC: El Colegio de la Frontera Norte, Departamento de Estudios de Población, Programa de Salud Reproductiva y Población; 1999:203-274. 7. Salgado-de Snyder VN, Acevedo A, Díaz-Pérez MJ, Saldívar-Garduño A. Understanding the sexuality of Mexican-born women and their risk for HIV/AIDS. Psychol Women Q 2000;24:100-109. 8. Camps V. Virtudes publicas. Madrid:Espasa-Calpe, 1990. 9. Falicov CJ. Family organization: The safety net of close and extended kin. In: Latino families in therapy: A guide to multicultural practice. New York; The Guilford Press, 1998:161-186. 10. Rutter M. Psychosocial resilience and protective mechanisms. Am J Orthopsychiatry 1987;57:316-331. 11. Ospina DE, Jaramillo DE, Uribe TM. La resiliencia en la promoción de la salud de las mujeres. Invest Educ Enferm 2005; 23(1): 78-89. 12. Díaz-Guerrero, Melgoza-Enríquez. Fuerza personal. Medida breve de fibra emocional. Aletheia 1994;13(1):21-24. 13. Salgado-de Snyder VN. Envejecimiento, género y pobreza en México rural. In: Salgado de Snyder VN, Wong R, editors. Envejeciendo en la pobreza: género, salud y calidad de vida. México; Instituto Nacional de Salud Pública, 2003:37-56. 14. Zack R. Achicopalada: A Manifestation of Depression in a Semi-Rural Mexican Community [unpublished master’s thesis]. Atlanta, Georgia: Rollins School of Public Health of Emory University, 2002. 15. Secretaría de Salud. Norma Oficial Mexicana NOM-014-SSA2-1994, Para la Prevención, Tratamiento y Control de Cáncer del Cuello del Útero y de la Mama en la Atención Primaria. NOM-014-SSA2-1994. México: Secretaría de Salud, 1994. 16. Secretaría de Salud. Norma Oficial Mexicana de los Servicios de Planificación Familiar Mayo 1994. NOM-005 SSA 2-1993. México: Secretaría de Salud, 1994. 17. Secretaría de Salud. Norma Oficial Mexicana para la Atención de la Mujer Durante el Embarazo, Parto y Puerperio y del Recién Nacido. NOM-007 SSA 2-1993. México: Secretaría de Salud, 1995. 18. Arenas LM, Hernández I, Ortega D, Mota B. Cliente simulada: análisis de la salud reproductiva en Guerrero, Morelos y Oaxaca. In: Quintanilla L, Pedroza L, del Río Solezzi A, ed. El género y la salud: resultados de investigación. México: Secretaría de Salud, 2006. 19. Hernández I, Ortega-Altamirano D, Arenas LM. Los significados socioculturales de los prestadores de servicio y su influencia en el programa de salud reproductiva de los estados de Morelos, Guerrero y Oaxaca, México. In: González N, Ángeles MI, ed. Investigación cualitativa como estrategia de conocimiento, intervención y trabajo de las políticas de salud: Una aproximación desde México y Cuba. México: Universidad Autónoma del Estado de México, 2006. 20. Ortega-Altamirano D, López-Carrillo L, López-Cervantes M. Estrategias para la enseñanza del auto examen del seno a mujeres en edad reproductiva. Salud Publica Mex 2000;42(1):17-25. 21. Dirección General de Epidemiología, Secretaría de Salud. Registro histopatológico de neoplasias en México. México, DF: SSA, 1997:1993-1996. 22. López-Carrillo L, Torres-Sánchez L, López-Cervantes M, Rueda-Neria C. Identificación de lesiones mamarias malignas en México. Salud Publica Mex 2001;43:19-202. 23. Olaiz G, Hernández M. Cáncer: Un encuentro con el futuro epidemiológico. In: Sepúlveda J, editor. Los retos de la Transición. Cuadernos de Salud Núm. I. México, DF: SSA, 1994:81. 24. Murray CJL, Lopez AD. Evidence-based health policy—Lessons from the Global Burden of Disease study. Science 1996;274:740-743. 25. Ortega-Altamirano D. Diagnósticos tardíos de cáncer mamario en México: Desencuentros entre los servicios de salud y las mujeres. In: Bronfman M, Denman C, Langer A, ed. Servicios de salud reproductiva y género. México DF: Fundación Ford, 2003:157-180. 26. Cisneros-Cárdenas MT. Mortalidad por cáncer en la edad reproductiva. In: Elú MC, Langer A, editors. Maternidad sin riesgos. Comité promotor de la iniciativa por una maternidad sin riesgos en México. México DF: Instituto Mexicano de Estudios Sociales AC. (Imes) & Family Care International, 1994:98-105. 27. Szasz I. Género y salud. Propuesta para el análisis de una relación compleja. In: Bronfman M, Castro R, ed. Salud, cambio social y política. Perspectivas desde América Latina. Mexico: EdaMex, 1999:109-121. 28. Tezoquipa H. El proceso salud enfermedad en mujeres de mediana edad [unpublished doctoral dissertation]. España: Universidad de Barcelona, 2001. 29. Martinez CS. Planificación familiar: Un programa con larga historia. In: Bronfman MN, Langer A, Trostle J, editors. De la investigación en salud a la política: La difícil traducción. México, DF: Editorial El Manual Moderno, 2000:51-89. 30. Esquivel-Hernandez MT, Trujano-Ruiz MM. The politics of fecundity and cultural change: Some reflections. Sociologica 1991;6(17):129-154. 31. Gallegos A, Pena JG, Solis JA, Keller A. Recent trends in contraceptive use in Mexico. Stud Fam Plann 1977;8(8):197-204. 32. Welti C. Adolescent fertility: Implications of early initiation of maternity. Demos 1995;9-10. 33. Alcalay R, Ghee A, Scrimshaw S. Designing prenatal care messages for low-income Mexican women. Public Health Rep 1993;108(3):354-362. 34. Martinez-Gonzalez L, Reyes-Frausto S, Garcia-Pena MD. Adequate utilization of prenatal care at the Mexican Institute of Social Security. Salud Publica Mex 1996;38(5):341-351. 35. Nazar-Beutelspacher A, Molina-Rosales D, Salvatierra-Izaba B, Zapata-Martelo E, Halperin D. Education and nonuse of contraceptives among poor women in Chiapas, Mexico. Int Fam Plann Persp 1999;25(3):132-138. 36. Rivera-Dommarco J, Shamah-Levy T, Villalpando-Hernández S, González-Cossio T, Hernández-Prado B, Sepúlveda J. Encuesta Nacional de Nutrición 1999. Estado nutricio de niños y mujeres en México. Cuernavaca, Morelos, México: Instituto Nacional de Salud Pública, 2001. 37. Ashworth A. Effects of intrauterine growth retardation on mortality and morbidity in infants and young children. Eur J Clin Nutr 1998;52(1):34-42. 38. Yip R. Iron. In: Bowman BA, Russell RM, editors. Present Knowledge in Nutrition, 8th ed. Washington DC: ILSI PRESS, 2001:311-328. 39. Botto LD, Moore CA, Khoury MJ, Erickson JD. Neural-tube defects. N Engl J M 1999;341:1509-1519. 40. Czeizel AE. Primary prevention of neural-tube defects and some other major congenital abnormalities: Recommendations for the appropriate use of folic acid during pregnancy. Paediatric Drugs 2000;2(6):437-449. 41. Mutchinick OM, Lopez MA, Luna L, Waxman J, Babinsky, VE. High prevalence of the thermolabile methylenetetrahydrofolate reductase variant in Mexico: A country with very high prevalence of neural tube defects. Mol Genet Metab 1999;68:461-467. 42. Olaiz-Fernández G, Rivera-Dommarco J, Shamah-Levy T, Rojas R, Villalpando-Hernández S, Hernández-Avila M, et al. Encuesta Nacional de Salud y Nutrición 2006. Cuernavaca, México: Instituto Nacional de Salud Pública, 2006. 43. Secretaría de Salud. Encuesta Nacional de Nutrición. México: Dirección General de Epidemiología, 1988. 44. Chan JM, Rimm EB, Colditz GA, Stampfer MJ, Willett, WC. Obesity, fat distribution, and weight gain as risk factors for clinical diabetes in men. Diabetes Care 1994;17:961-969. 45. Colditz GA, Willett WC, Stampfer MJ, Manson JE, Hennekens CH, Arky RA, et al. Weight as a risk factor for clinical diabetes in women. Am J Epidemiol 1990; 132(3):501-513. 46. Dwyer JT. Medical evaluation and classification of obesity. In: Blackburn GL, Kanders BS, editors. Obesity. Pathophysiology, Psychology, and Treatment. Chapman & Hall Series in Clinical Nutrition. New York: Chapman & Hall, 1994:2-38. 47. World Health Organization. WHO MONICA Project: Risk Factors. Int J Epidemiol 1989;18(Supl I):S46-S55. 48. De la Fuente R, Medina-Mora ME, Caraveo J. Salud mental en México. México: Fondo de Cultura Económica-Instituto Mexicano de Psiquiatría, 1997. 49. Salgado-de Snyder VN, Diaz-Pérez MJ, Ojeda V. The prevalence of nervios and associated symptomatology among inhabitants of Mexican rural communities. Cult Med Psychiatry 2000;24:453-470. 50. Salgado de Snyder VN, Maldonado M. Características psicométricas de la Escala de Depresión del Centro de Estudios Epidemiológicos (CESD) en mujeres mexicanas adultas de áreas rurales. Salud Publica Mex 1994;36:200-209. 51. Finnerman R. The burden of responsibility: Duty, depression, and nervios in Andean Ecuador. In: Davis DL, Low SM, editors. Gender, Health and Illness: The Case of Nerves. New York: Hemisphere, 1989:49-65. 52. Guarnaccia PJ, Farias P. The social meanings of Nervios: A case study of a Central American Woman. Soc Sci Med 1988;26:1223-1231. 53. González-de la Rocha M. De por qué las mujeres aguantan golpes y cuernos: un análisis de hogares sin varón en Guadalajara. In: Gaballet L, El Colegio de Jalisco/CIESAS, ed. Mujeres y sociedad, salarios, hogar y acción social en el occidente de México. Guadalajara: El Colegio de Jalisco/CIESAS, 1988:129-142. 54. Salgado-de Snyder VN, Díaz-Pérez MJ. La salud mental de las mujeres rurales: Problemas, necesidades y alternativas. In: Lara-Cantu MA, Salgado de Snyder VN, ed. Cálmese, son sus nervios, tómese un tecito. Mexico: PAX, 2002:151-172. 55. Natera G, Mora J. Atribuciones del género femenino en la prevención de las adicciones. In: Perez-Gil Romo, editor. Género y Salud Femenina. México: Centro de Investigaciones y Estudios Superiores en Antropología Social/Universidad de Guadalajara/ Instituto Nacional de la Nutrición, 1995:109-126. 56. INEGI / SSA. Encuesta Nacional de Adicciones, 2002. Mexico: INEGI, 2002. 57. Natera G, Tiburcio M, Villatoro J. Marital violence and its relationship to excessive drinking in Mexico. Contemporary Drug Problems 1997;24:787-804. 58. Natera G, Mora J, Tiburcio M. Experiencia de las mujeres frente al abuso de alcohol y drogas de sus familiares. In: Lara-Cantu MA, Salgado de Snyder VN, ed. Cálmese, son sus nervios, tómese un tecito. Mexico: PAX, 2002:105-130. 59. Lara MA. Introducción. In: Lara-Cantu MA, Salgado de Snyder VN, ed. Cálmese, son sus nervios, tómese un tecito. Mexico: PAX; 2002:7-20. 60. Burin M, Moncarz E, Velásquez F. El malestar de las mujeres. La tranquilidad recetada. Barcelona: Paidós, 1990.