Research in Nursing & Health, 2009, 32, 582591

Effects of Stress and Social Support on Postpartum Health of Chinese Mothers in the United States
Ching-Yu Cheng,1* Rita H. Pickler2**

1 Taipei Medical University, Taipei, Taiwan Virginia Commonwealth University, Richmond, VA Accepted 22 September 2009

Abstract: Postpartum maternal well being across cultures has received limited research attention. We examined relationships among stress, social support, and health in 152 Chinese mothers < 1 year postpartum in the United States. These mothers did not perceive high levels of stress, although they did not receive as much support as they indicated they needed; 23.7% of mothers scored high for depressive symptoms. About half of the mothers experienced interrupted sleep, decrease in memory, and lack of sexual desire. All health measures were inter-correlated. Social support moderated the effects of stress on depressive symptoms. Culturally relevant care that is perceived as supportive may promote postpartum maternal health. 2009 Wiley Periodicals,
Inc. Res Nurs Health 32:582591, 2009

Keywords: stress; social support; maternal competence; postnatal physical condition; postnatal depression

Becoming a mother is an important developmental task and may be perceived as a personal achievement, yet new mothers often experience psychological distress (Z. J. Huang, Wong, Ronzio, & Yu, 2007; McGovern et al., 2006) and physical discomforts (Cheng & Li, 2008). In addition, new mothers may not be satised with their maternal role performance (Knauth, 2000; Mercer, 1985). Stress may worsen a new mothers health and has been associated, not only with less parenting condence and satisfaction with the infant (Reece & Harkless, 1998) but also with postpartum depression (Beck, 2001). According to Lazarus and Folkman (1984), during stress the demands in the environment exceed the ability to manage or cope with them. Social support may buffer the

negative effects of stress on an individuals health by inuencing modulations to the hypothalamic pituitaryadrenal axis (DeVries, Glasper, & Detillion, 2003), which is a complex set of interactions between the brain and other organs in the body that controls reactions to stress and affects numerous body processes. Indeed, ndings from recent studies of new mothers conrm that social support has positive effects on postpartum mood (Surkan, Peterson, Hughes, & Gottlieb, 2006). The number of women of Chinese descent giving birth in the US has steadily increased since 1970 (National Center for Health Statistics, 2007). Like other immigrants, new mothers of Chinese descent may experience higher levels of stress.

The authors gratefully appreciate Dr. Lorraine O. Walker for her support and insightful guidance in conducting the study. Correspondence to Ching-Yu Cheng. *Assistant Professor. **Professor. Published online 29 October 2009 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/nur.20356

2009 Wiley Periodicals, Inc.

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Yet, Chinese-born mothers may have fewer available social supports than non-Chinese mothers born in the US (Cuellar, Bastida, & Braccio, 2004; Patel, 1992). They may also perceive stress, support, and health differently from non-Chinese born women owing to cultural differences. Research on Chinese mothers has not been focused on U.S. residents (Chan, Levy, Chung, & Lee, 2002; To & Wong, 2003) and has not addressed some important topics related to these mothers health needs and postpartum experiences. The purpose of our study was to examine relationships among stress, social support, and maternal health in postpartum mothers of Chinese-descent living in the US. We examined: (a) levels of stress, social support, and health status; (b) relationships among stress, social support, and health status; and (c) moderating effects of social support on the relationship between stress and health status.

Taiwan also described emotional challenges related to pressure from their in-laws, disappointment in not being able to give birth to a boy, and dissatisfaction with marital life and with their husbands (Chan et al., 2002; Chen, Wu, Tseng, Chou, & Wang, 1999). Stress, Social Support, and Postpartum Maternal Health New mothers often experience increased levels of stress, which, in turn, may negatively affect maternal health. Few investigators have examined the effect of stress on new mothers physical health. The ndings of these studies suggest that stress is strongly related to mothers healthpromoting lifestyle (Walker, 1989a,b). Hung and Chung (2001), who focused on Chinese mothers, reported that new mothers who are stressed have a greater chance of experiencing psychiatric morbidity during the early postpartum period. New Chinese mothers usually benet from receiving positive support from family members, friends, and care providers who can help alleviate the stress and challenges of motherhood. The majority of Chinese new mothers are supported and taken care of by their female relatives, especially their mother or mother-in-law, for about 30 40 days postpartum, which is known as doing-the-month. The new mothers follow cultural practices related to activity and foodand herb-intake in order to prevent diseases and promote health. These new mothers caregivers take over house responsibilities and prepare foods for them (Holroyd, Katie, Chun, & Ha, 1997; Lai, 1998; Weng, 1994). Chinese new mothers with a high level of depressive symptoms often receive limited family support; those who receive the most support experience lower mental distress (Heh, Coombes, & Bartlett, 2004; Hung & Chung, 2001). Yet, because of the detrimental inuence of some cultural attitudes toward new mothers responsibilities and position at home, which places them in a subservient position to their own mothers or mothers-in-law, Chinese new mothers may not always perceive family members involvement during the postpartum period as a positive source of support. For example, in the Chan et al. (2002) study, Chinese mothers with postpartum depression described their controlling and powerful in-laws as the major cause of their depression. Similarly, Heh et al. (2004) reported that, among their sample of Taiwanese new mothers, the women had a high level of depression when their mother-in-law was their key helper during the postpartum period.

BACKGROUND Postpartum Maternal Health Status Postpartum mothers generally perceive their health as good. Yet, compared to women in the general community, postpartum women experience more pain, worse physical health and functioning, less vitality, and more physical limitations (McGovern et al., 2006; Otchet, Carey, & Adam, 1999). Physical health problems are highly prevalent among postpartum mothers worldwide. For example, mothers at 2 months postpartum have a high rate of physical exhaustion, sore nipples or breast tenderness, backaches, and pain at the cesarean incision or perineum (Cheng & Li, 2008). Depression is common among postpartum mothers. In a metanalysis on studies conducted in developed countries and published in English by Gaynes et al. (2005), the point prevalence for major and minor depression among mothers in developed countries within 1 year postpartum was 6.5 12.9%, depending on the screening tool used and the measurement period. Researchers who investigated Chinese mothers in Hong Kong and in Taiwan found that the prevalence of postpartum depression ranged from 12.0% to 50.3%, depending on measuring scales, cut-off points, and measurement periods (Huang, Carter, & Guo, 2004; Lee, Yip, Chiu, Leung, & Chung, 2001). In addition to depressive symptoms among new mothers worldwide, postpartum Chinese mothers in Hong Kong and in
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Maternal Contextual Factors and Maternal Health Whether the health status of mothers differs by demographic factors is controversial. For example, although Hungs study (2004) showed older mothers had a lower level of depression, other studies did not (Heh et al., 2004; Honey, Morgan, & Bennett, 2003; Horowitz, Damato, Duffy, & Solon, 2005). The McCormick, Brooks-Gunn, Holmes, Wallace, & Heagarty study (1992) showed that unemployed mothers more often reported fair or poor health than did employed mothers. Although employed Italian mothers did not have physical symptoms that were different from non-employed mothers, employed French mothers experienced more constipation, lack of sexual desire, and extreme tiredness than did unemployed mothers (Saurel-Cubizolles, Romito, Lelong, & Ancel, 2000). Employment did not affect postpartum depressive symptoms among Chinese mothers in the Heh et al. study, but was negatively correlated with depressive symptoms in Hungs (2004) study of Chinese mothers. Maternal health status changes over time. For physical health, the percentage of mothers who self-rated their health as good or very good decreased from 2 months to 12 18 months m, postpartum (Schytt, Lindmark, & Waldenstro 2005). In addition, the prevalence of physical conditions, such as tiredness/fatigue, backache, and lack of sexual desire increased over time (Saurel-Cubizolles et al., 2000; Schytt et al.; Thompson, Roberts, Currie, & Ellwood, 2002). Other conditions, such as hemorrhoids and perineal pain, decreased (Brown & Lumley, 2000; Thompson et al.). In addition, most depressed mothers become depressed by the third postpartum month (Loh & Vostanis, 2004) and depressive symptoms peaked at 6 weeks postpartum, declining thereafter until 6 months postpartum (Gjerdingen, Froberg, & Kochevar, 1991). Although some researchers have shown that the longer immigrants lived in the US, the poorer their health (Lara, Gamboa, Kahramanian, Morales, & Bautista, 2005; Uretsky & Mathiesen, 2007), still not addressed is how immigrant mothers length of stay in the US affects their postpartum health status. METHODS Conceptual Framework The Lazarus and Folkman theory of stress was used to guide the study. The theory includes three
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components: causal antecedents, mediating processes, and health outcomes (Lazarus & Folkman, 1986). The antecedents are personal and environmental factors that may result in stress. Mediating processes involve how individuals appraise and cope with stress. Health outcomes result from how an individual manages stress. In this study, the antecedents were identied as maternal contextual factors, such as the mothers age, parity, employment status, length of stay in the US, and babys age. Stress was also viewed as an antecedent within the framework. Social support was identied as the moderating element because, as previous studies have found, social support is the moderator of stress and health. The outcomes of the framework included general health, physical health, and depressive symptoms. Design and Procedure We used a cross-sectional correlational design. The Institutional Review Board of the sponsoring university approved the study protocol. Eligible participants were mothers who had children under 1 year old, had given birth to a healthy child, identied themselves as being of Chinese or Taiwanese descent including US-born and nonUS-born Chinese mothers, were older than 17 years, and lived with their newborn in the US. Participants were recruited through professional referrals, distribution of paper yers, and electronic announcements on Web sites. The investigation included a pilot study, which tested reliability and validity of all translated instruments, and a main study. Only results of the main study are reported here. Data were collected from paper and electronic questionnaires that were sent and returned via postal mail and e-mail. Instruments in both English and Chinese languages were available for participants to choose. Sample Of 162 Chinese mothers who responded to invitations or advertisements for the main study, 10 mothers were excluded because their youngest child was older than 13 months or they did not complete the questionnaires. The majority of participants (94.2%) was born outside the US and had lived an average of 8.66 (SD 8.29, range .08 41.08) years in the U.S. Their mean age was 33.42 (SD 3.75) years. Most participants (55.9%) had an educational level higher than a bachelors degree, 87.1% spoke languages other

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than English, 45.4% were homemakers, 32.9% worked full time, and 13.2% were in the Women, Infants, and Children Program. Most (60.5%) of the participants were primiparas, 71.1% had delivered vaginally, 90.7% received the Chinese traditional cultural postpartum care (i.e., doingthe-month), and 5.3% experienced postpartum complications including breast lump, carpal tunnel problems, itch, spinal headache, urinary and bowel incontinence, infection (unspecied), and delayed incision wound healing. Most infants (55.3%) were males and were breastfed (96.0%). The mean infant age at the time of data collection was 6.00 (SD 3.46) months.

Measures Five instruments were used to measure the ve study concepts: general health, physical health, mental health, stress, and social support. Before the main study began, all instruments were translated into Chinese following a series of procedures: translation, back-translation, and comparison of the original and back-translated versions of the instruments, as recommended by Bracken and Barona (1991). Four Chinese nurses who were also mothers reviewed the Chinese versions of the instruments to conrm their readability and content validity. The reliability and validity of all translated instruments were tested in a pilot study with 30 Chinese postpartum mothers in the US. General health. The Self-Rated Health Subindex (SHS) is a four-item instrument measuring the general health of an individual (Lawton, Moss, Fulcomer, & Kleban, 1982). The total score of the SHS ranges from 4 to 13, with higher scores indicating higher levels of general health. A sample question from the SHS is How would you rate your overall heath at the present time? with options of excellent, good, fair, and poor (scores 4 1). The other two questions ask the participants to compare their current health with their health 3 years ago and with the health of most people their age (scores 3 1). The last question asks participants whether their health problems prevent them from doing things they want to do (scores 3 1). In the original developmental study, Cronbachs a for the SHS was .76. The validity was evidenced by internal validity (multiple correlation R .47 between the SRHS and physical health domain index; Lawton et al.). Cronbachs a for the SHS in the current study was .75.
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Physical health. The Physical Health Condition Checklist (PHCC) presents a list of physical health conditions that may occur after childbirth, such as headache, sore nipples, and physical exhaustion. Respondents are asked to mark the conditions they are experiencing at the moment and also what they experienced at 2 months postpartum. For the current study, the PHCC was modied from the original tool (Declercq, Sakala, Corry, Applebaum, & Risher, 2002). In addition to the 15 physical health conditions listed in the original checklist, seven conditions that had a high incidence rate, had an impact on postpartum mortality, or were recommended by the participants in the pilot study were included: sleep disturbance, hemorrhoids, eating disorder, retained body weight, excessive vaginal bleeding, interrupted sleep, and decreased memory. The total number of physical conditions (0 22) mothers experienced was used for data analysis. In the current study, the KR-20 for the PHCC was .72. Mental health. The Center for Epidemiologic Studies Depression (CES-D) scale is a 20-item, four-point (item score ranges 0 3, total score ranges 0 60) response, self-report measures of depressive symptoms (Radloff, 1977). Higher scores indicate the respondent is experiencing more depressive symptoms. A score of 16 or higher indicates a high degree of depressive symptomatology. The Cronbachs a of the CESD was .76 when tested on Chinese postpartum mothers in Taiwan (Chien, Tai, Ko, Huang, & Sheu, 2006). The convergent validity was established by CES-Ds positive correlation with other scales that measured depression or psychopathology (r ranged .43 .74). The discriminant validity was evidenced by negative or low positive correlation between CES-D and other scales for positive affects or different concepts (r ranged from .55 to .32; Radloff). In the current study, the Cronbachs a of the CES-D was .89. Stress. The 10-item Perceived Stress Scale (PSS-10) measures the degree to which an individual appraises situations as stressful (S. Cohen & Williamson, 1988). The PSS-10 is a 5-point scale (item score ranges 0 4, total score ranges 0 40). Higher scores indicate higher levels of perceived stress. The scale has been translated into Chinese and used in research involving Chinese new mothers. The reliability of the Chinese PSS-10 was satisfactory (Cronbachs a .85); a factor analysis derived one factor that explained 77.5% of the total variance of stress (Chen, 1994). In the current study, the Cronbachs a for the PSS-10 was .88.

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Social support. The Postpartum Support Questionnaire (PSQ) is a 34-item, 5-point (item score ranges from 0 to 4, total score ranges from 0 to 136) scale. The scale results in two scores derived from the same set of items. The rst score reects the respondents perception of the importance of particular supportive behaviors and the second score reects the amount of help the respondent reports receiving. Higher scores indicate higher levels of the perceived importance of support or the amount of support received (Logsdon, Usui, Birkimer, & McBride, 1996). In a study conducted by Leung (2002), the PSQ was translated into Cantonese. The Cronbachs a for the Cantonese PSQ was .94; a factor analysis derived four factors that explained 58.07% of the variance in support. In the current study, the Cronbachs alphas for the PSQ-importance and PSQ-received scales were .94 and .96, respectively. Data Analysis All data were tested for normality before conducting inferential statistics. Linearity and equal variance were conrmed by examining scatter plots of the data. Descriptive statistics were used to analyze demographic information and the participants level of health status. Pearsons correlation and hierarchical regression with a two-tailed test and a level of .05 were used to analyze relationships among variables and moderating effects of social support. Assumptions of independence, homoscedasticity, linearity, and normality were tested. In regression analysis for moderating effects, stress and social support were centered to avoid multicollinearity (J. Cohen, Cohen, West, & Aiken, 2003). Maternal contextual variables, including babys age, length of stay in the US, employment, and parity were entered in the rst set of regression terms, stress- and support-related variables were entered in the second set, and interaction terms were entered in the third set. Because maternal age was not correlated with any health variables, it was not included in the regression analyses. Employment status was coded as 0 for employed while not-employed was coded as 1 in the regression analyses. RESULTS Levels of Tested Variables Participants had a mean score of 18.39 (SD 5.34, range 0 32) on the SHS, and 65.1% of mothers
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self-rated their health as good or excellent on the question asking about overall health. Mothers had a mean score of 11.00 (SD 8.84) on the CES-D; 23.7% of mothers had scores over the 16 cut-off for high depressive symptoms. The participants experienced a mean of 3.77 (SD 2.63, range 0 11) physical conditions at the time of data collection. More mothers within 6 months postpartum experienced sore nipple/breast tenderness and painful intercourse than mothers over 6 months postpartum (see Table 1). Those mothers who experienced postpartum complications did not differ in general health, number of physical conditions, or depressive symptoms from mothers without postpartum complications (Mann Whitney Z .58, .19, and 1.09; p .56, .85, and .27, respectively). Participants had a mean score of 18.39 (SD 5.34, range 0 32) on the PSS-10. Mothers had signicantly higher scores on the PSQimportance (M 95.10, SD 23.64, range 27 136) than the PSQ-received (M 75.70, SD 28.17, range 10 132; t[151] 8.00, p < .001, d .53). Relationships Among Tested Variables As shown in Table 2, general health was negatively correlated with number of physical conditions, depressive symptoms, and stress, and positively correlated with support received. The number of physical conditions experienced was positively correlated with both depressive symptoms and stress. Depressive symptoms were negatively correlated with support received but were positively correlated with stress. Mothers age was not related to any health variables but was related to support received, whereas mothers length of stay in the US was positively related to general health and inversely related to depressive symptoms, perceived stress, and the importance of support. The babys age was inversely related to general health and number of physical health conditions. Effects of Stress and Social Support on Health-Related Variables General health. Results of hierarchical regression showed that the maternal contextual variables of babys age, stress, and support received accounted for 41.2% of the variance in general health (F 34.4, p < .001). Babys age (B .11, t 2.98, p .003) and stress (B .15,

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Table 1. Comparisons of Physical Health Conditions by Babys Age Groups Current Point in Time (N 152) Interrupted sleep Decrease in memory Lack of sexual desire Backache Retained body weight Physical exhaustion Sleep disturbance Hemorrhoids Frequent headaches Sore nipples/breast tenderness Painful intercourse Bowel problems Eating disorder/GI upsetsa Urinary problems Breast infection CS wound painb,c Perineal pain Excessive vaginal bleeding Urinary tract infection Episiotomy wound infection CS wound infection Uterine infection Without above conditions 87 (62.6%) 70 (50.4%) 69 (49.6%) 63 (45.3%) 57 (41.0%) 53 (38.1%) 47 (33.8%) 31 (22.3%) 26 (18.7%) 25 (18.0%) 23 (16.5%) 12 (8.6%) 10 (7.2%) 8 (5.8%) 6 (4.3%) 6 (13.6%) 4 (2.9%) 3 (2.2%) 2 (1.4%) 0 (.0%) 0 (.0%) 0 (.0%) 13 (8.6%) Within 6 Months Postpartum (n 72) 45 (62.5%) 38 (52.8%) 37 (51.4%) 33 (45.8%) 32 (44.4%) 24 (33.3%) 22 (30.6%) 13 (18.1%) 10 (13.9%) 19 (26.4%) 18 (25.0%) 8 (11.1%) 7 (9.7%) 6 (8.3%) 5 (6.9%) 4 (19.0%) 3 (4.2%) 0 (.0%) 2 (2.8%) 0 (.0%) 0 (.0%) 0 (.0%) 0 (.0%) 6 12 Months Postpartum (n 80) 42 (62.7%) 32 (47.8%) 32 (47.8%) 30 (44.8%) 25 (37.3%) 29 (43.3%) 25 (37.3%) 18 (26.9%) 16 (23.9%) 6 (9.0%) 5 (7.5%) 4 (6.0%) 3 (4.5%) 2 (3.0%) 1 (1.5%) 2 (8.7%) 1 (1.5%) 3 (4.5%) 0 (.0%) 0 (.0%) 0 (.0%) 0 (.0%) 13 (16.3%)

p
.25 .14 .19 .33 .10 .74 1.00 .55 .39 .002 .003 .23 .19 .15 .10 .40 .35

Fishers Exact Test was used to compare occurrence rate of physical health conditions between mothers who were within 6 months and mothers at 6 12 months postpartum. a GI, gastrointestinal. b CS, cesarean section. c Only those who had cesarean section were compared.

t 5.75, p < .001) had negative effects on maternal general health while support received (B .03, t 5.43, p < .001) showed positive effects. The interaction term of stress and social support added only another 2% of variance to the level of general health. Thus, social support did not moderate the relationship between stress and general health (F change 1.97, p .14). Physical health conditions. Results of hierarchical regression showed that the maternal contextual variables of mothers length of stay in the US, babys age, stress, and social support accounted for 16.8% of the variance in the number of reported physical conditions (F 9.90, p < .001). Mothers length of stay in the US (B .06, t 2.43, p .02) and stress (B .18, t 4.81, p < .001) had positive effects while babys age (B .15, t 2.65, p .01) had a negative effect on physical health conditions. The interaction term of stress and social support accounted for less than 1% of variance in the number of physical conditions reported (F change .97, p .38). Thus, social support did not moderate the relationship between stress and reported physical conditions.
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Depressive symptoms. Results of hierarchical regression showed that the maternal contextual variables of parity, stress, and social support accounted for 65.6% of the variance in depressive symptoms (F 69.95, p < .001). Parity (B 1.68, t 2.51, p .01) and support received (B .13, t 7.06, p < .001) showed negative effects, while stress (B .92, t 9.81, p < .001) and importance of support (B .05, t 2.39, p .02) had positive effects on depression. The interaction between stress and the social support and support received accounted for an additional 7% of variance in depressive symptoms (F change 18.42, p < .001). Thus, the relationship between perceived stress and depressive symptoms was moderated by support received (B .01, t 5.44, p < .001) and importance of support (B .01, t 2.17, p .03).

DISCUSSION This study was one of the rst to examine USliving Chinese postpartum mothers health status

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Table 2. Pearson Correlations Between Maternal Stress, Support, and Health-Related Variables 1 1. SHS 2. PHCC 3. CES-D 4. PSS 5. PSQ-importance 6. PSQ-received 7. Mother age 8. Employmenta 9. Parity 10. Baby age 11. Years lived in the US 1 .36 .58 .50 .06 .47 .04 .16 .06 .25 .20 2 3 4 5 6 7 8 9 10

1 .44 .31 .14 .22 .06 .13 .07 .16 .11

1 .73 .22 .50 .11 .11 .16 .11 .16

1 .32 .29 .05 .01 .14 .10 .23

1 .27 .13 .04 .17 .05 .34

1 .21 .28 .17 .05 .00

1 .14 1 .48 .24 .07 .02 .18 .13

1 .09 .21

1 .01

SHS, Self-Rated Health Subindex for general health; PHCC, Physical Health Condition Checklist for physical health conditions; CES-D, Center for Epidemiologic Studies Depression scale for depressive symptoms; PSS, Perceived Stress Scale for perceived global stress; PSQ, Postpartum Support Questionnaire for social support. a Employed was coded as 0 whereas unemployed was coded as 1. p < .05. p < .01.

via the Lazarus and Folkman theory of stress. Dimensions of healthgeneral, physical, and mentalwere correlated with each other. These results are similar to ndings from other studies in the US (Fowles, 1998; Gjerdingen & Chaloner, 1994; Howell, Mora, Horowitz, & Leventhal, 2005). Second, stress and support received inuenced all dimensions of health. Similar to ndings from previous studieseither in western countries or with Chinese mothersstress, particularly childcare stress, and life stress, was a predictor of postpartum depressive symptomatology (Hung, 2004; S. S. Leung, Arthur, & ikko nen, StrandMartinson, 2005; Pesonen, Ra rvenpa a , 2005). In addition, mothers berg, & Ja who perceived having inadequate social support tended to report their general health as poor or fair (Haas et al., 2004) and to report a higher level of depressive symptoms (E. Leung, 1985). Third, social supporteither support mothers received or the importance of supportmoderated only the relationship between stress and depression. The moderating effect of support on stress and depression was similar to the results of Collins, Dunkel-Schetter, Lobel, and Scrimshaw (1993), who found that overall social support during pregnancy had a buffering effect on postpartum depression. Support did not moderate the relationship between stress and general health or stress and physical health. This nding is similar to that of Lenz, Parks, Jenkins, and Jarrett (1986), who found that support did not moderate the relationship between life change and illness. In the current study, 65.1% of Chinese mothers self-rated their current overall health as good
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or excellent, which was much lower than the percentage (88%) reported in an earlier study of American mothers that used questions similar to those on the SHS (McCormick et al., 1992). In addition, in this current study, mothers stress scores were signicantly higher than the general population norm for females in the US or ethnic minorities in the US (S. Cohen & Williamson, 1988). We found also that the mothers length of time living in the US was related to general health and that both perceived stress and support received accounted for a large portion of the variance in both general and physical health. These ndings suggest that Chinese postpartum mothers who have not been in the US long may have higher levels of stress and feel less supported during the postpartum period. In general, Chinese mothers in our study did not have a high level of depressive symptoms, although almost a quarter of them scored above the cut-off. Yet, this percentage was lower than the rate (35.6%) of Chinese mothers in a national study of the 2001 birth cohort in the US (Z. J. Huang et al., 2007). The small sample size in our study and the fact that Z. J. Huang et al. did not use a Chinese version of the CES-D in their investigation may explain the difference in percentages. Regardless of the difference in the rate of depressive experiences, however, in our study, stress was strongly correlated with depression, and the support mothers received moderated the effects of stress on depression. Culturally appropriate supportive interventions may help new mothers manage their depressive symptoms as well as manage their stress.

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Implications Further studies are needed to examine postpartum mothers general physical health and also the morbidities of ongoing health conditions over time during the postpartum period. As we found in our study, numerous postpartum health conditions have a high rate of prevalence among Chinese mothers and are associated with their overall physical health status, particularly sleep concerns, decreased memory, lack of sexual desire, backache, retained body weight, and physical exhaustion. For many mothers of all ethnicities, postpartum health conditions may persist over a long period of time. Thus, developing an instrument to measure long-term postpartum maternal morbidities may help identify those physical conditions new mothers experience most often and about which they are most concerned. Additional studies are also needed to focus on intervention strategies that prevent or moderate the occurrence of prevalent postpartum health conditions and improve maternal physical health status. Research is needed also that addresses the long-term effects of particular intervention strategies on postpartum physical health conditions. More research also is needed to examine the positive effects of culturally based care on the overall maternal health of foreign-born new mothers living in the US, in particular among the growing population of postpartum mothers of Chinese descent. According to Chien et al. (2006), Chinese new mothers who adhere to their cultures traditional postpartum care practices experience less severe rates of physical symptoms. Yet, their study was not conducted in the US; whether the care received by Chinese mothers in China is the same, or has the same effect, as the care received by Chinese mothers in the US is not known. Studies focused on the effects of traditional cultural approaches to postpartum healthcare with mothers of various ethnicities are recommended. To examine maternal stress among Chinese postpartum mothers living in the US, we measured only participants general perceived stress. We recommend further research using scales to identify and measure specic stressful events, not only for Chinese postpartum mothers but for all new mothers. Such focused scales may help identify and enhance understanding of prevalent events that most often increase new mothers level of stress. Interventions that reduce particular inuences on maternal stress can then be developed and tested and, if successful, applied in healthcare practices to improve maternal health.
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