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Sexual Dysfunction in Postpartum Turkish Women: It's Relationship with Depression and Some Risk Factors.

Introduction

Pregnancy and delivery are one of the most significant periods of a women's life (1,) (2). Postpartum period is the time when spouses adapt to their parenting roles, resume their sexual activities, but have problems specific to this period. The physiological, psychological, socio-cultural changes that occur during this period affect women's sexual health and behaviors (1,) (3-5). Reports show that during the postpartum period, women experience problems such as less frequent sexual intercourse, decreased sexual desire, difficulty having orgasm, vaginal dryness, perineal pain, dyspareunia, decreased sexual satisfaction and sexual dysfunction (2,6-8).

Sexual dysfunction is characterized by disturbance in sexual desire and in the psychophysiological changes that characterize the sexual response cycle and cause marked distress and interpersonal difficulty (9). Female sexual dysfunction is a multidimensional disorder with a prominent impact on overall general well-being (10,11). In several studies, it has been indicated that the prevalence of sexual dysfunction in the postpartum period varies between 20% and 76% (8,12-15). Postpartum sexual function is affected by changes in anatomy, hormonal milieu, family structure, and husband relationships that accompany childbirth (4,6,14). Breastfeeding, vaginal bleeding, caesarean section, perineal trauma and episiotomy can cause sexual dysfunction in women (1-3,5,7). In addition, prenatal sexual problems, adaptation to the new role, marital conflicts, sleep disorders, and fatigue negatively affect the sexual life of women and thus lay the groundwork for sexual dysfunction (2,12,16).

One of the variables affecting sexual life in the postnatal period is postnatal depression (14,17,18). Symptoms of postnatal depression are the most common health issues that require rapid and careful attention during the first year after childbirth. A range of 6-33% of women is reported to experience symptoms of depression during the postnatal period. Several demographic and obstetric factors (maternal age, twin birth, type of delivery, breastfeeding, unintended pregnancy, perinatal complications, etc.) associated with depression in the postpartum period have been identified (17-19). In addition, it has been reported that there is a strong mutual relationship between depression and sexual dysfunction, and that sexual dysfunction is more frequent in women with postnatal depression (8,20).

Postpartum sexual dysfunction is the serious morbidity and may lead to a variety of physical, mental, social adverse effects on the woman. However, this problem has received little consideration from both healthcare providers and researchers (24). There is a gap in the literature related to studies investigating sexual dysfunction and depression among postpartum women (14,18), and there is no study on this issue in Turkey. However, the World Health Organization (11) highlights that sexual health is an important aspect to be taken into consideration for the improvement of well-being and health of women and should be integrated into primary healthcare services. Therefore, the present study aimed to determine the prevalence of sexual dysfunction in postpartum women, and the relationship between sexual dysfunction, depression and some risk factors.

Methods

Design

This cross-sectional study was conducted between March 2017 and December 2017 in Kocaeli, a province in Turkey.

Sample

The study population comprised postpartum women who had given birth during the previous 2-12 months in Kocaeli University Faculty of Medicine Department of Obstetrics and Gynecology.

The minimum sample size was calculated with the PASS (Power Analysis and Sample Size) 11 Statistical Software (NCSS LLC, Kaysville, Utah, USA). The single report by Acele and Karacam (21) showed that 91.3% of postpartum women in Turkey reported sexual dysfunction. On the other hand, in studies carried out worldwide, the rate of sexual dysfunction in the postpartum women ranged from 20% to 76% (8,12,13,15). Therefore, the minimum sample size was calculated using the following formula.

n= [([z.sub.[alpha]/2]).sup.2] P(1-P) / [d.sup.2]

Based on this formula (22), the minimum sample size was calculated as n= 384 by using p= 0.5, 1-P= 0.5, [z.sub.[alpha]/2]= 1.96, d= 0.05, and [beta]= 0.80 for the prevalence of sexual dysfunction. To achieve the minimum sample size, the gynecology and obstetrics clinic register was examined, and the data on how to contact the women who gave birth 2-12 months were obtained. According to the birth records of this hospital, the number of the women in the 2-12 months postpartum period was 1080, and all women were invited to complete the online questionnaire, if they met the following inclusion criteria. The inclusion and exclusion criteria for this study were based on the objectives of the study and the literature review. The inclusion criteria were as follows: aged [greater than or equal to]18 years old (the legal age of consent is 18 years in Turkey), aged [less than or equal to]40 years old (as they are more likely to experience premenopausal and perimenopausal changes, and their sexual function decreases with age), giving birth 2-12 months ago to a live baby, delivery at week [greater than or equal to]37, having a regular sexual partner, not currently pregnant, not having any obstetric/neonatal complications related to the current birth. The exclusion criteria were as follows: being clinically diagnosed with a physical or psychiatric illness, taking antipsychotic medicine.

A total of 622 responses were received. Of these, 92 responses were excluded; 53 women did not answer all the questions, and 39 did not comply with the inclusion criteria. Reasons for non-compliance were: 8 were pregnant, 14 were >40 years old, 12 had given birth in week 36 or earlier, 5 used antipsychotic medication. Therefore, responses from 530 women were considered for analysis.

Instruments

Data were collected with the Personal Information Form, Index of Female Sexual Function and Edinburgh Postnatal Depression Scale.

Personal Information Form: The form consists of 22 questions on socio-demographic characteristics such as age, partner's age, education level, employment status, economic status, length of marriage, and on the obstetric and clinical characteristics such as the history of a physical-psychiatric disease, the presence of obstetric/neonatal complications, high risk pregnancy or not, the type of delivery, breastfeeding status, return of menstruation, presence of dyspareunia, and family planning method used.

Index of Female Sexual Function (IFSF): The IFSF was developed by Kaplan et al. (23) to determine the women's sexual functions in the last 4 weeks. The Turkish validity and reliability study of the scale was conducted by Yilmaz and Eryilmaz and its Cronbach's alpha value was reported as 0.82 (24). The five-point Likert-type scale consisted of 9 items and the following 6 subscales: quality of sexual intercourse, lubrication, sexual desire, sexual satisfaction, orgasmic function, and clitoral sensitivity. The responses were rated between 1 (almost never or never) and 5 (almost always or always). Zero points are given to those who had not had sexual intercourse in the last month. The total score was calculated by summing the scores for each subscale. The minimum and maximum possible scores to be obtained from the scale were 5 and 45 respectively. Women with a score of [less than or equal to]30 are considered to suffer sexual dysfunction (24).

The Cronbach alpha reliability coefficient of the scale was calculated as 0.89 in this present study.

Edinburgh Postnatal Depression Scale (EPDS): The scale was developed by Cox and Holden (25) to determine the risk of developing postpartum depression in women. The four-point Likert type scale is a self-assessment scale and consists of 10 items. The lowest and highest possible scores to be obtained from the scale were 0 and 30 respectively. The Turkish validity and reliability study of the scale was performed by Engindeniz et al. The cut-off score of the scale was calculated as 12. Individuals with a score of [greater than or equal to]13 were considered at risk for depression (26). In this present study, Cronbach alpha reliability coefficient of the scale was calculated as 0.93.

Application

Participation in this anonymous study was voluntary. Women were phoned and invited to complete the online questionnaires. Then, the link to the study web site was sent via a message to the women who were called. The first pages of the study website provided information about the study, including anonymity and confidentiality of the responses. No credentials were requested; thus, the confidentiality of the responses was protected. Participants were informed that they provided their consent by completing and submitting the online questionnaire and were then directed to the multisession questionnaire. The questionnaire was designed to take approximately 20 minutes to complete. The study website was active between March 2017 and December 2017.

Data analysis

To analyze the data, the SPSS 16.0 software (SPSS, Inc., Chicago, IL, USA) was used. For the analysis of the data, descriptive statistics and the Chi-square test were used. Pearson correlation analysis was used to determine the relationship between sexual dysfunction and postnatal depression because the data showed a normal distribution according to the Kolmogorov--Smirnov test (27). The results were assessed at the significance level of p<0.05.

Results

Of the participants, 54.2% were in the 25-34 age group, 42.5% were primary school graduates, 63.4% were unemployed, 58.3% reported their economic status as middle class, and 94.9% were married for 1-5 years. Of the participants' spouses, 68.1% were in the age group of 25-34, 43.8% were university graduates and all were employed at a paid job.

The distribution of some variables affecting the sexual life of the participating postpartum women is given in Table 1. Of them, 20.0% had high risk pregnancy, 61.7% underwent caesarean section, and 94.3% breastfed their babies. Sexual life of 80.6% of the participants were adversely affected in the postpartum period, and among the causes were fatigue (65.5%), vaginal dryness (58.5%), insomnia and lack of time (54.5%), not being able to be alone with the husband (49.4%), breast problems (44.2%), and perineal pain (30.6%). Of the participants, 86.4% shared the same bed with their husbands, 82.3% slept in the same room with the baby, 50.2% had dyspareunia, 73.2% used a family planning method and 54.3% used a condom as the family planning method. In 52.3% of them, menstrual periods returned.

In the study, the mean scores the participants obtained from the Index of Female Sexual Function was 23.89[+ or -]9.16, and 74.3% of the participants suffered sexual dysfunction. In addition, the mean score they obtained from the Edinburgh Postnatal Depression Scale was 11.23[+ or -]2.30, and 24.7% of them were at risk for postnatal depression (Table 2).

The distribution of sexual dysfunction in the participants according to some characteristics is shown in Table 3. As is seen in the table, the prevalence of sexual dysfunction was found to be statistically significant in women who were high school graduates, who reported their economic status as middle class, who had a history of high risk pregnancy, whose menstruation did not return, who had dyspareunia, who did not use a family planning method, who used withdrawal as a family planning method and who were at-risk for postnatal depression (p<0.05).

Pearson's correlation analysis revealed a moderate negative correlation between Index of Female Sexual Function and Edinburgh Postnatal Depression Scale ([r.sup.2]: -0.601, p<0.01).

Discussion

Although sexual dysfunction and depression are among the main problems experienced in the postpartum period, they are often overlooked by healthcare professionals (2,4). In the present study aimed at determining sexual dysfunction and factors affecting sexual dysfunction in postpartum period, 74.3% of the participating women experienced sexual dysfunction. This result shows that the prevalence of sexual dysfunction in postpartum women cannot be neglected. In the present study, most of the women stated that their sexual lives were adversely affected due to fatigue, vaginal dryness, insomnia and perineal pain they experienced. Although the interest in the evaluation of sexual life during the postpartum period has increased in recent years, sexuality, which is considered as a private matter and thus hidden by most women, is neglected in clinical practices (4,8). However, healthcare professionals play a key role in the prevention, evaluation, and treatment of postpartum sexual concerns during the postpartum period. So, postpartum sexual counseling should be the part of the prenatal and postnatal follow-up to improve women sexual health and quality of life (4,28,29).

The analysis of the factors related to sexual dysfunction, the other dimension of the study, revealed that education level affected the prevalence of sexual dysfunction and that sexual dysfunction was more prevalent in high school graduate women. In the literature, there is no consensus on the effect of education level on female sexual dysfunction. While the prevalence of sexual dysfunction decreased as the education level increased in some studies (3,30,31), in some studies, the prevalence of sexual dysfunction increased as the education level increased (14,32), and in some other studies, no relationship was determined between the education level and sexual dysfunction (8,12,13). This may have resulted from the difference in research designs, age groups, social, cultural and economic factors, partners' tendency, inadequate or incorrect sex-related knowledge. Thus, more studies should be conducted to explain what this difference stems from.

In the present study, sexual dysfunction was more prevalent in the participants who reported their economic status as middle class. In the literature, findings about the effect of economic status on sexual life vary from one study to another. While some studies indicate that there is no relationship between the economic status and sexual dysfunction (13,33), some studies report that low income level is a variable that increases sexual dysfunction (3,30,31). Financial difficulties affect the relationship between spouses and thus can cause sexual dysfunction (31).

One of the most important variables affecting the prevalence of sexual dysfunction is the history of high-risk pregnancy. Obstetrics complications (antepartum bleeding, fetal conditions, etc.), medication use, limited mobility, fear of harming to the baby, fear of premature birth, psychological burden of having a high risk pregnancy, social myths and lack of knowledge related to high risk pregnancy negatively affect the sexual life of women (34,35). Consistent with the literature, sexual dysfunction was more prevalent among women with the history of high risk pregnancy (34,36,37). This result suggests that the sexual problems experienced during pregnancy continue after pregnancy. Therefore, evaluation of women in terms of sexual function both during pregnancy and during the postpartum period gains importance.

In the present study, sexual dysfunction was more prevalent in women whose menstruation did not recommence and who did not use a family planning method. Similarly, Khajehei et al. (8) reported that women who did not have regular menstrual periods after birth suffered sexual dysfunction more. This result can be explained by the fact that women whose menstrual periods do not return lack sexual desire and experience sexual dysfunction due to their high prolactin level and their concerns that they can become pregnant again. On the other hand, the family planning method used can affect the sexual life of spouses and if the woman trusts the family planning method they use, then their satisfaction of sexual intercourse increases (38). In the present study, it was determined that sexual dysfunction was more common in women using the withdrawal method. The withdrawal method which the most widely used traditional contraceptive method in Turkey is not a medical method and as the partner has to withdraw at the peak point of the sexual intercourse it prevents reaching sexual satisfaction and causes post intercourse tension and for that reason has negative effects on sex life (39).

Pregnancy, labor and birth are risk factors for the development of postpartum dyspareunia (34). Demage to pelvic muscles during birth, tear and episiotomy, instrumental birth, hormonal changes, vaginal dryness and relationship issues causes dyspareunia and thus sexual dysfunction (1,2,4,14). In the present study, sexual dysfunction was more prevalent in women with dyspareunia, which is consistent with the results in the literature (3,5,7). Early diagnosis of dyspareunia in the postpartum period may contribute to the improvement of sexual function in women.

Postnatal depression is a non-psychotic depressive disorder that occurs after childbirth and is characterized by serious mood changes, sadness, hopelessness, feeling of worthlessness, fatigue, and insomnia (17,18). Nearly one out of every four women in the postpartum period experiences depressive symptoms (8,18,19). In the present study, 25% of the women were at risk for postnatal depression. Postnatal depression is another risk factor for sexual dysfunction. In the literature, it is stated that symptoms of postnatal depression affect women's sexual functioning negatively and that there is a mutual association between postnatal depression and sexual dysfunction (8,14,18,20). In the current study, the sexual dysfunction rate was higher in the participants with postnatal depression, and there was a moderate relation between them, which is consistent with the results in the literature. Mental health is important for maintaining quality of life for women, their families and society (18). Therefore, health professionals should routinely screen for signs of antenatal and postnatal depression and assess women' sexual function to increase their quality of life.

Study Limitations

The study was conducted in a single department of obstetrics and gynecology in Kocaeli, and the findings may not be generalizable to the entire population of Turkish postpartum women. The participants completed an online questionnaire, therefore, women without access to the computer were not included in the study, which was another limitation of the study. Also, the study was based on self-reported measures with no structured interview. However, as the study was anonymous with no face-to-face contact, the participants were thought to give more honest and reliable answers in cases where sexuality was perceived as taboo and women experienced problems such as mental illnesses, myths or stigma. The other limitation of the study is that factors such as medical condition, mediation use, marital adjustment, domestic violence, cultural factors that may be related to sexual dysfunction were not investigated. Due to its cross-sectional nature, the present study was inadequate to explain the causal relationship between the variables affecting sexual dysfunction, which was another limitation of the study. Longitudinal studies could provide more insight into the underlying mechanism of the relationships found in this study.

Ethical Approval

The study protocol was designed in compliance with the principles of the Declaration of Helsinki. Prior to data collection, necessary approvals and permissions were obtained from the Kocaeli University Clinical Research Ethics Committee (Decision date and no. 2017/36) and General Secretariat of the Public Hospitals Union, respectively. Women provided consent by completing and submitting the online questionnaire.

Conclusion

In the current study, 75% of the participants suffered sexual dysfunction in the postpartum period and 25% of them were at risk for postnatal depression. The risk factors identified in the present study indicate that the female sexual dysfunction is a multidimensional problem with physical, emotional and social aspects. In the light of these results, it was concluded that health professionals should holistically evaluate all women in the postpartum period and give training and counseling services to them. Healthcare professionals can assess the sexual and mental problems of women, especially the high-risk groups indicated also in this study, via short screening scales during routine postpartum follow-ups, and they can refer women for early diagnosis and treatment. In addition, to better explain the causal relationship between female sexual dysfunction and affecting factors in the postpartum period and to generalize the results to the community, it is recommended that longitudinal studies with larger samples should be performed.

Conflict of Interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Contribution of Authors

Study conception/design: FAY, DA, YAA, RO, ND; Data collection/analysis: RO, ND, DA; Drafting of manuscript: FAY, DA; Critical revisions for important intellectual content: FAY, DA, YAA; Supervision: DA, FAY.

Funding

This study was supported by Scientific Research Projects Coordination Unit of Bandirma Onyedi Eylul University (Project number: BAP-18-SBF-1009-019).

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Figen Alp Yilmaz (1), Dilek Avci (2*), Yilda Arzu Aba (2), Resmiye Ozdilek (3) and Nafiye Dutucu (3)

Bozok University, Faculty of Health Sciences, Department of Nursing, Yozgat, Turkey (1); Bandirma Onyedi Eylul University, Faculty of Health Sciences, Department of Nursing, Balikesir, Turkey (2); Kocaeli University, Faculty of Health Sciences, Department of Midwifery, Kocaeli, Turkey (3)

(*)For Correspondence: Email: daydinenator@gmail.com; Phone: +90 0266 718 64 00

DOI: 10.29063/ajrh2018/v22i4.6
Table 1: Some variables affecting women's postpartum sexual life in
Kocaeli, Turkey

Variables                                    n    %

History of pregnancy
High risk pregnancy                          106  20.0
Low risk pregnancy                           424  80.0
Type of delivery
Vaginal delivery                             203  38.3
Caesarean section                            327  61.7
Breastfeeding
Yes                                          500  94.3
No                                            30  5.7
Whether the sexual life was affected during
the postpartum period
Yes                                          427  80.6
No                                           103  19.4
Factors affecting sexual life during
the postpartum period (*)
Fatigue                                      347  65.5
Vaginal dryness                              310  58.5
Insomnia                                     289  54.5
Lack of time                                 289  54.5
Not being able to be alone with the husband  262  49.4
Breast problems                              234  44.2
Perineal pain                                162  30.6
Sharing the same bed with the husband
Yes                                          458  86.4
No                                            72  13.6
Sharing the same room with the baby
Yes                                          436  82.3
No                                            94  17.7
Return of menstrual periods
Yes                                          277  52.3
No                                           253  47.7
Dyspareunia
Yes                                          266  50.2
No                                           264  49.8
Using a family planning method
Yes                                          388  73.2
No                                           142  26.8
The family planning method used (n=388)
Condom                                       207  53.4
Withdrawal                                   132  34.0
Intra uterine device                          49  12.6

(*) More than one option was marked.

Table 2: Means and standard deviations for the IFSF, and EPDS

Scales                        Mean [+ or -] SD   Min-Max  n (%)

IFSF                          23.89[+ or -]9.16  5-39
IFSF Grouping
[less than or equal to]30
There are sexual dysfunction                              394 (74.3)
>30 No sexual dysfunction                                 136 (25.7)
EPDS                          11.23[+ or -]2.30  0-21
EPDS Grouping
[less than or equal to]12 No postnatal depression         399 (75.3)
[greater than or equal to]13 There are postnatal
depression                                                131 (24.7)
IFSF: Index of Female Sexual Function; EPDS: Edinburgh Postnatal
Depression Scale.

Table 3: Distribution of sexual dysfunction according to some
characteristics in postpartum women in Kocaeli, Turkey

Variables                           Sexual   dysfunction  Sexual
                                    present               present
                                    n        %            n

Age
18-24 years                         148      37.6          54
25-34 years                         213      54.1          74
35-40 years                          33       8.4           8
Education level
Primary school                      162      41.1          63
High school                         117      29.7          18
University                          115      29.2          55
Economic status
High class                           58      14.7          31
Middle class                        243      61.7          66
Low class                            93      23.6          39
Length of marriage
1-5 years                           376      95.4         127
[greater than or equal to] 6 years   18       4.6           9
History of pregnancy
High risk pregnancy                  86      21.8          20
Low risk pregnancy                  308      78.2         116
Type of delivery
Vaginal delivery                    148      37.6          55
Caesarean section                   246      62.4          81
Breastfeeding
Yes                                 371      94.2         129
No                                   23       5.8           7
Sharing the bed with husband
Yes                                 340      86.3         118
No                                   54      13.7          18
Sharing the room with baby
Yes                                 324      82.2         112
No                                   70      17.8          24
Return of menstrual periods
Yes                                 156      39.6         121
No                                  238      60.4          15
Dyspareunia
Yes                                 212      53.8          54
No                                  182      46.2          82
Using a family planning method
Yes                                 271      68.8         117
No                                  123      31.2          19
Used family planning method
Condom                              133      49.1          74
Withdrawal                          108      39.8          24
Intra uterine device                 30      11.1          19
Postnatal depression
Yes                                 113      28.7          18
No                                  281      71.3         118

Variables                           dysfunction not   [chi square]
                                    %

Age
18-24 years                         39.7              0.937
25-34 years                         54.4
35-40 years                          5.9
Education level
Primary school                      46.3
High school                         13.2             15.391
University                          40.4
Economic status
High class                          22.8              7.965
Middle class                        48.5
Low class                           28.7
Length of marriage
1-5 years                           93.4              0.878
[greater than or equal to] 6 years   6.6
History of pregnancy
High risk pregnancy                 14.7              3.205
Low risk pregnancy                  85.3
Type of delivery
Vaginal delivery                    40.4              0.354
Caesarean section                   59.6
Breastfeeding
Yes                                 94.9              0.090
No                                   5.1
Sharing the bed with husband
Yes                                 86.8
No                                  13.2              0.019
Sharing the room with baby
Yes                                 82.4
No                                  17.6              0.001
Return of menstrual periods
Yes                                 89.0             98.798
No                                  11.0
Dyspareunia
Yes                                 39.7             16.391
No                                  60.3
Using a family planning method
Yes                                 86.0              5.136
No                                  14.0
Used family planning method
Condom                              63.2
Withdrawal                          20.5             13.789
Intra uterine device                16.3
Postnatal depression
Yes                                 13.2             12.961
No                                  86.8

Variables                            p

Age
18-24 years                          0.626
25-34 years
35-40 years
Education level
Primary school
High school                         <0.001
University
Economic status
High class                           0.019
Middle class
Low class
Length of marriage
1-5 years                            0.234
[greater than or equal to] 6 years
History of pregnancy
High risk pregnancy                  0.045
Low risk pregnancy
Type of delivery
Vaginal delivery                     0.310
Caesarean section
Breastfeeding
Yes                                  0.479
No
Sharing the bed with husband
Yes
No                                   0.510
Sharing the room with baby
Yes
No                                   0.545
Return of menstrual periods
Yes                                 <0.001
No
Dyspareunia
Yes                                  0.003
No
Using a family planning method
Yes                                 <0.001
No
Used family planning method
Condom
Withdrawal                           0.001
Intra uterine device
Postnatal depression
Yes                                 <0.001
No
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Article Details
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Title Annotation:ORIGINAL RESEARCH ARTICLE
Author:Yilmaz, Figen Alp; Avci, Dilek; Aba, Yilda Arzu; Ozdilek, Resmiye; Dutucu, Nafiye
Publication:African Journal of Reproductive Health
Article Type:Report
Geographic Code:7TURK
Date:Dec 1, 2018
Words:5278
Previous Article:Fertility, Family Size Preference and Contraceptive Use in Sub-Saharan Africa: 1990-2014.
Next Article:The Impact of Healthcare spending on Life Expectancy: Evidence from Selected West African Countries.
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