nursing

A Case Study of Postpartum Stress, Coping, and Health

Among Native American Mothers and Application of the

Nursing as Caring Theory

Melessa Kelley, PhD, RN Lorraine O. Walker, EdD, MPH

School of Nursing, The University of Texas at Austin, Austin, TX, USA

Abstract: The purpose of this article is to highlight postpartum stress and coping among Native American women and its impact on overall health and well-being. Exploring these provides a foundation for providing culturally relevant nursing from a caring framework. In this case study and secondary analysis, 17 women who identified as Native American were included and compared with 17 White women. Respondents were at least 18 years of age, were English speaking, resided in the United States, had Internet access, and had a child they had given birth to who was between 2 and 22 months of age. Five measures were analyzed and included the Perceived Stress Scale, Sources of Stress-Revised, Postpartum Coping Scale, Patient-Reported Outcomes Measurement Information System, and Global Health survey. The findings of this case study and secondary analysis among Native American women can serve as the foun‐ dation for further exploratory studies that elucidate how women manage stress and cope during the postpartum period. There is a need for culturally tailored resources for Native American women during postpartum, such as community-engaged activities and classes. Finally, there is an increased need to continue contributing to the body of knowledge regarding how Native American women find meaningful support during postpartum that is reflective of the Native American worldviews and grounded in culturally relevant care.

Keywords: postpartum stress; coping; health and healing; traditional birthing practices; Native American women/mothers; nursing as caring theory

International Journal for Human Caring, Volume 30, Number 1, 2026 © 2026 International Association for Human Caring http://dx.doi.org/10.20467/IJHC-2025-0032

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Introduction

Pregnancy and the postpartum period can be an extremely stressful time for many women. Currently, one in eight women in the United States reports postpartum depression or symp‐ toms of stress (Bauman et al., 2020). Compa‐ ratively, one in five Native American women experiences postpartum stress or depression (Krehbiel-Burton, 2018). Postpartum stress is a broad term encompassing a range of emotional, mental, and various psychological challenges, including postpartum depression, anxiety, and posttraumatic stress disorder (Maxwell et al., 2022). Postpartum stress is often underdiagnosed and/or undertreated due to stigma, lack of culturally relevant screening tools, and inad‐ equate resources and access to care among Native American women (Ward et al., 2022). Contributing factors leading to the higher rates of postpartum stress among Native American women include chronic stressors, such as poverty, historical trauma, and underfunded health care systems (O’Keefe et al., 2020; Ward et al., 2022). Native American women are frequently impac‐ ted by limited or lack of access to proper and quality prenatal and postpartum care, especially in rural or reservation areas (Reyes, 2025). Higher rates of poverty and unemployment contribute to food insecurity, housing instability, and lack of adequate transportation, which are also common stressors impacting Native American women (Kozhimannil et al., 2019, 2020).

Additionally, cultural disconnection and health disparities, such as higher rates of mater‐ nal morbidity, gestational diabetes, hypertension, and mental health conditions, such as depres‐ sion, increased stress, and anxiety, were higher among Native American women compared with White women (Kozhimannil, 2020; O’Keefe et al., 2020). The loss of traditional practices in Native American culture surrounding childbirth and postpartum care can potentially lead to feelings of isolation. Often, Native American women may lack adequate access to culturally competent and appropriate care that respects and incorporates traditional healing and birthing practices (Austin et al., 2020; Kozhimannil, 2020; O’Keefe et al., 2020; Ward et al., 2022). Many Native American women often struggle with a lack of consistent and supportive networks during the postpartum period, especially for those women who live away from their tribal communities (Reyes, 2025). However, having strong family ties and social

support systems serves as a protective factor and buffer against stress (Liddell et al., 2021; Ward et al., 2022). Overall, however, Native American women’s coping patterns with postpartum stress have received limited attention in a scant num‐ ber of studies (Maxwell et al., 2022). The pur‐ pose of this article is to highlight the impact of postpartum stress and coping among Native American women on overall health and well- being. Exploring these provides a foundation for delivering culturally relevant nursing from a caring framework.

Theoretical Framework

Guided by the nursing as caring theoretical framework (Boykin & Schoenhofer, 2001), this article aims to understand and highlight the impact of postpartum stress and coping on the overall health and well-being of Native Ameri‐ can women. The theoretical framework enabled understanding and viewing from the perspec‐ tive of Native American women postpartum. The overarching central and core concepts that served as a guide for this article include car‐ ing persons, personhood, and nursing situations among Native American women and mothers. The results highlighted in this article are a secondary analysis from a larger study and a national internet survey in the United States. We are highlighting the results of postpartum stress and coping captured from Native Ameri‐ can women. The primary research question that guided this secondary analysis is the following: What is the impact of postpartum stress and coping on overall health and well-being among a small group of Native American women?

Native American Women as Caring Persons

Within many Native American worldviews, motherhood and caring are seen as sacred responsibilities. Typically, Native American women’s and mothers’ roles extend beyond providing physical care; they also encompass emotional, social, and mental support, moral guidance, and the preservation of tradition and culture of the family unit (Liddell et al., 2021). Native American women and mothers are often recognized as nurturing and caring individuals within their families and tribal communities and are the center or “glue” for the family, personify‐ ing both deeply rooted cultural and family roles that closely align with the core concepts in the

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nurses as caring theory (Boykin & Schoenhofer, 2001; Liddell et al., 2021; Rickert, 2025).

Respect for Personhood and Caring Nursing Situations

Within many Native American worldviews, every person is valued and seen as equal, which closely aligns with the core concept of respect for personhood in the nurses’ caring theory. Every person is valued and seen as an equal and a caring human being. Therefore, to be a caring person is to live one’s humanness to the fullest extent. For Native American mothers, caring is seen as both a sacred duty and communal act— an expression of identity, culture, and connection to all living things (Boykin & Schoenhofer, 2001). Nursing as caring views every person as a whole, including body, mind, and spirit. This closely aligns with many Native American worldviews and cultural beliefs. In regard to postpartum nursing situations, nurses can honor the role of the caring mother by recognizing their cultural values and beliefs. The nurses can also provide supportive and meaningful postpartum care and traditional parenting practices.

Methods

Design

This case study is a secondary analysis of data taken from two surveys completed in 2022 and 2024 (combined sample N = 800). Both surveys focused on stress, coping, and health during the period of 2–22 months postpartum (Walker et al., 2025a,b). Survey data were collected through the survey platform Qualtrics XM and were fur‐ ther checked for credibility and quality. For this case study, data from all women identifying as Native American and a subset of White non-His‐ panic postpartum women who matched them were compared. Respondents were recruited by various means that included emails, flyers, postings on mothers’ groups, and recruitment through CloudResearch (https://www.cloudre‐ search.com).

Participants and Selection

The participants in the two surveys combined in this study are described in Walker et al. (2025a,b). Briefly, the inclusion criteria for the surveys were that respondents were at least 18 years of age, were conversant in English, resi‐ ded in the United States, had Internet access,

and had a child they had given birth to who was between 2 and 22 months of age. In the final combined survey samples, a Native Amer‐ ican subsample (n = 17) was identified by respondents who selected “Native American” as their only or one of several racial or ethnic identities. The White subsample (n = 534) was identified by respondents who selected “White (non-Hispanic)” as their only identity. From the White sample, a subsample (n = 17) was selec‐ ted to match the following demographics of the Native American subsample: age (within ±3 years), marital/partner status, number of children (within ±1 child), and insurance type for care during pregnancy (Medicaid/self-pay or private insurance). Because Medicaid is means-tested, it is also considered to be a proxy measure of income level in this study.

Ethical Considerations

Both surveys were reviewed by the Institutional Review Board of the University of Texas at Austin and classified as exempt. Both surveys included a research information sheet explaining the study and their rights. Consent was given by clicking on a box indicating their agreement to participate.

Instrumentation

Survey items included demographic variables, functional limitations related to mobility or use of fingers, and four scales that measured perceived stress, stress from postpartum-specific factors, coping strategies to manage postpartum stressors, and ratings for physical and mental health.

Perceived stress was measured by the Perceived Stress Scale (PSS; Cohen & William‐ son, 1988). The PSS has been extensively used to measure stress-related perceptions, such as having limited control over happenings in one’s life and being overwhelmed, for example, “In the last month, how often have you felt difficul‐ ties were piling up so high that you could not overcome them?” In a postpartum population, the 10-item version of the PSS had a Cronbach’s alpha of .88 (Walker et al., 2025a). Higher scores represent more frequent experiences and percep‐ tions of stress.

Stress from postpartum-specific factors was measured by the Sources of Stress-Revised (SoS-R; Walker et al., 2023). The 32-item SoS-R comprised six subscales: Overload, Changes After Pregnancy, Baby-Related Concerns, Working

Postpartum Stress in Native American Mothers 5

Mother Concerns, Low Support Resources, and Isolated Motherhood, with Cronbach’s alpha of .88, .77, .78, .72, .84, and .77, respectively. Items address concerns of postpartum persons that were derived from mothers’ and postpar‐ tum persons’ reported stressors. We computed item-averaged scores for all subscales so that all ranged along a common metric of 0 (never) to 4 (very often) in regard to how frequently stressors were experienced.

Coping strategies to manage postpartum stressors were measured by the Postpartum Coping Scale (PCS; Walker et al., 2023). Like the SoS-R, the PCS is derived from coping strategies reported by mothers and postpartum persons. The 32-item PCS has six subscales, which are not combined into a total coping index, includ‐ ing self-regulation, spiritual care, self-care, use and seek support, internal and external resources, and health promotion. Cronbach’s alphas for the six subscales are .80, .84, .77, .72, .66, and .69, respectively. Similarly to our treatment of SoS- R subscales, we computed item-averaged scores for all PCS subscales so that all ranged along a common metric of 0 (never) to 4 (very often), so that higher scores indicated more frequent use of a coping strategy.

Ratings for physical and mental health were assessed by the Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health (Hays et al., 2009). Scales in the PROMIS library are designed to be state-of- the-art measures of patient outcomes (National Institutes of Health, n.d.). We used eight items loading on either physical or mental health subscales in a postpartum sample (Walker et al., 2024). The Cronbach’s alpha for the postpartum physical and mental health subscales is .85 and .83, respectively. For both PROMIS health scores, we item-aged scores so that each subscale ranged along a common metric of 1 (equivalent to a rating of poor health) to 5 (equivalent to a rating of excellent health).

Data Analysis Methods

All continuous variables were inspected using histograms. Because a number departed from normal distributions, we used medians to report central tendencies except for age variables. Native American and White subsamples were compared using bar charts and not statistical analyses because of the small sample size and low power. Demographic variables were reported as

frequencies or medians. Analyses were based on use of SPSS version 29 (IBM, Armonk, NY).

Results

Subsample Characteristics

Table 1 presents the matching and other demo‐ graphic characteristics of the two subsamples in this case study. In both, 14 of 17 were living with a spouse or partner, and 13 of 17 were covered by Medicaid for their prenatal and postpartum health care. More White women reported having higher education, and more Native American women reported having more physical disabilities.

Stress, Coping, and Health

Native American women reported more fre‐ quent experiences of postpartum-specific stress than White women, but frequency of perceived stress—a measure of general perceived stress— was similar for both groups (Figure 1). Further‐ more, Native American women reported more frequently experiencing all specific sources of stress measured on the SoS-R except overload compared with White women (Figure 2).

With regard to coping, Native American women reported using self-regulation, self-care, and health promotion strategies more often than White women. In contrast, White women more often reported using and seeking support and spiritual care (Figure 3). Seeking and using resources were equal and low in both groups.

With regard to health ratings, Native American women rated their physical and mental health as less positive than White women. Notably, both groups rated their physical health more positively than their mental health (Figure 4).

Discussion

In this case study and secondary analysis, Native American women reported more fre‐ quently experiencing postpartum-specific stress than White women, especially related to isola‐ tion, working mother concerns, and baby-rela‐ ted concerns. They responded to those stressors by engaging more regularly in caring-orien‐ ted coping practices, including self-regulation, self-care, and health promotion, which are generally viewed as positive. Despite these efforts, Native American women, compared with White women, rated their physical and men‐ tal health less positively. This gap in health is supported by other studies that have included

6 Kelley and Walker

Native American women (Bauman et al., 2020). We discuss these findings in the context of Native American women’s postpartum stress and coping and the nursing as caring theory.

Many Native American women and com‐ munities experience mistrust of Western health systems due to colonization, forced assimilation, and ongoing health disparities, such as limited access to culturally safe postpartum caring and

intergenerational trauma (Gone, 2023; Maxwell et al., 2022; O’Keefe et al., 2020). Therefore, caring nursing practices based on presence, empathy, and partnership can foster and rebuild trust, improving access to care and reducing stress related to medical encounters (Boykin & Schoenhofer, 2001). By reducing health care mistrust, it also promotes a sense of positive health promotion and improved quality of care.

TABLE 1. Characteristics of American Indian and White non-Hispanic Postpartum Persons (N = 17)

Characteristic Native American White non-Hispanic Mean (SD) Mean (SD)

Age (years) 31.9 (6.5) 32.0 (6.1)

Baby age (months) 13.9 (9.7) 11.8 (6.8)

n n

Marital/partner or co-parent

Single, living apart 3 3

Single, living together 7 6

Married, living together 7 8

Number of children living at home

1 child 2 2

2 children 7 8

3 children 5 3

4 children 0 3

5 or more children 3 1

Income level

Lower (Medicaid/self-pay) 13 13

Higher (private/other insurance) 4 4

Education

High school graduate/GED or less 8 3

Some college 6 6

College graduate or higher degree 3 8

Employment status

Not employed 8 8

Part-time employed 3 6

Full-time employed 6 3

Physical disability

No 13 16

Yes 4 1

Speak a language besides English at home

Never 14 15

Sometimes 2 1

More than half of the time 1 1

GED = General Educational Development; SD = standard deviation.

Postpartum Stress in Native American Mothers 7

Figure 1. Medians of general perceived stress and postpartum-specific stress by group.

Note. Gen. Stress = general perceived stress; NH = non-Hispanic. Post. Stress = postpartum-specific stress (total). Higher scores indicate more frequent stress.

Figure 2. Medians of postpartum-specific sources of stress by group.

Note. NH = non-Hispanic. Higher scores indicate more frequent stress.

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Positive Self-Regulation and Self-Care

Studies by Kavanaugh and Moro (2006) demon‐ strate that positive self-regulation refers to the ability of the mothers to manage their emotions,

thoughts, and behaviors in healthy ways while adjusting to the challenges of motherhood. The results from this secondary analysis of Native American mothers demonstrated positive self- regulation during the postpartum period. For

Figure 3. Medians of postpartum-specific coping strategies by group.

Note. Health.Promo. = health promotion; NH = non-Hispanic; Self.Reg. = self-regulation; Use.Resources = seek and use resources. Higher scores indicate more frequent use of a coping strategy.

Figure 4. Medians of physical and mental health by group.

Note. NH = non-Hispanic. Higher scores indicate better health ratings.

Postpartum Stress in Native American Mothers 9

many Native American women and mothers, conceptions of health include balance among body, mind, spirit, and community, a view consistent with caring-based nursing models, such as Boykin and Schoenhofer’s (2001) nurs‐ ing as caring theory and Watson’s (2012) theory of human caring. Nursing as caring emphasi‐ zes authentic presence, respect, and relational practice, which aligns with many Native Amer‐ ican worldviews that value connection, listen‐ ing, and trust-building (Boykin & Schoenhofer, 2001). A caring nurse who takes time to under‐ stand cultural traditions and avoid stereotypes can reduce patients’ stress related to cultural misunderstanding or discrimination. Integral to postpartum healing includes the incorporation and support of traditional healing and birthing practices, such as sacred rest periods, herbal remedies, smudging, sweat lodges, or healing ceremonies (Dennis et al., 2007). By providing this type of care, nurses can foster a sense of cultural safety and reduce spiritual and emotional stress and enhance emotional well-being and resilience among these Native American women.

Limitations

Due to the nature and characteristics of this secondary analysis, the sample size, making generalizations of the findings to all Native American women and mothers, must be cau‐ tioned. Participants in the study were part of a national internet survey conducted in the United States. Limitations include lack of information about the resources these women used to seek and receive care. Geographical location was also not captured in this study; therefore, a determi‐ nation of where these women lived, such as urban or rural areas and/or reservation areas, was undetermined.

Future studies are needed to explore the experiences of Native American women who are from various settings and locations dur‐ ing stressful situations, such as the postpartum period. Additionally, future research should also explore healthy ways of coping and relieving stress among Native American women, espe‐ cially during the postpartum period, to improve mental health. Using research methodologies that will discover the different pathways of relation‐ ships and the connectedness to protective factors, risk factors, recovery, and resiliency can provide valuable information.

Conclusion

The findings of this case study and secondary analysis among Native American women and mothers can serve as the foundation for fur‐ ther exploratory studies that elucidate how these women manage stress and cope during the postpartum period. Many Native American cultures are very community-oriented; therefore, there is a need for culturally tailored resour‐ ces for Native American women during post‐ partum, such as community-engaged activities and classes. There is a need to continue con‐ tributing to the body of knowledge regarding how Native American women find meaningful support during the postpartum period that is reflective of the Native American worldview and grounded in the nursing as caring theoretical framework. However, by fostering trust, cultural humility, and deep relational care, a healing environment can be created that provides a counterbalance to postpartum stress and offers a path toward more effective, healing-centered care for Native American women and communities.

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Author Contribution. M.K.: conceptualization, writing, original draft preparation, and editing. L.O.W.: conceptualization, methods, writing, and editing.

Disclosure. The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.

Acknowledgment. The authors wish to thank our research participants for participating in this study. This work was supported by the University of Texas at Austin, School of Nursing.

Funding. The authors received no specific grant or financial support for the research, authorship, and/or publication of this article.

Correspondence regarding this article should be directed to Melessa Kelley, PhD, RN, School of Nursing, The University of Texas at Austin, 1710 Red River Street, Austin, TX 78701, USA. E-mail: melessa.kelley@aus‐ tin.utexas.edu

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