Design and data collection
A cross-sectional study was conducted, evaluating MS in women after childbirth recruited to the study from public health centers in Zanjan, a city in the northwest of Iran. Surveys, providing the study data, were returned between 5 January and 1 April 2019.
The inclusion criteria included mothers who had a singleton, healthy babies, livening with a partner, pregnancy without complications, no history of surgery in the past 3 months, absence of the history of chronic disease includes diabetes, hypertension, thyroid, and cardiovascular diseases, not using psychiatric medications, willingness to participate in the study.
In this study, a total of 447 women were enrolled who were in a six-month childbirth period. Seventeen questionnaires have not been analyzed due to incomplete data and having exclusion criteria.
This study was approved by the Ethical Committee of Zanjan University of Medical Sciences (IR.ZUMS.REC.1398.112). After explaining the study's purposes, written consent and verbal assent was collected from all participants and women were informed that their participation was voluntary, confidential, and anonymous
Data Collection Instruments
Data collection instruments were a questionnaire including demographic and obstetric characteristics, Beck`s anxiety inventory, female SF index( FSFI), Body Self-Relation Questionnaire (BSRQ), the Enrich Marital Satisfaction and the NEO Personality Inventory (NEO PI-R).
Demographic And Obstetric Data
Demographic and obstetric data included age, partner age, married age, educational level, job, type of delivery, family income, the number of times breastfeeding per day, and planned pregnancy.
Beck`s Anxiety Inventory
we used the Iranian version of Beck`s anxiety inventory for assessing anxiety disorder. This questionnaire contains 21 questions, each item was scored on a 4-point Likert-type scale of 0 (not at all) to 3 (severely). Higher total scores indicate more severe anxiety symptoms. The standardized cutoffs are 0–9 normal to minimal anxiety, 10–18 mild to moderate anxiety, 19–29 moderate to severe anxiety, 30–63 severe anxiety. The validity and reliability of the Iranian version of the questionnaire are well documented (7, 8).
Female Sexual Function Index (fsfi)
This scale was composed of six subscales with 19 items that assess a woman’s sexual function during the previous four-week period. This questionnaire includes six main aspects of sexual functions consisting of sexual desire (two items), arousal (four items), lubrication (four items), orgasm (three items), satisfaction (three items) and pain (three items). The score ranges for all items are 0–5 except for items 1, 2, 15, and 16 (the range is 1–5). The sum score of each domain was multiplied in its certain factor. This factor for desire was 0.6, 0.3 for arousal and lubrication, and 0.4 for orgasm, satisfaction, and pain. The overall scale score ranged from 2 to 36, which higher scores meaning better SF. The overall scale score was obtained by adding the mean scores of all six domains, with ranged from 2 to 36. Higher scores represent the better SF. The psychometric properties of this questionnaire have been verified in the Iranian population (9).
Body Self-relation Questionnaire (bsrq)
For evaluating women`s attitude toward multiple aspects of body image structure, the Body Self-Relation Questionnaire (69 items) was used (10). This includes 10 subscales: appearance evaluation, appearance orientation, fitness evaluation, fitness orientation, health evaluation, health orientation, illness orientation, body areas satisfaction, overweight preoccupation, self- classified weight. The Iranian version of the BSRQ showed good validity and reliability (11).
Enrich Marital Satisfaction
This questionnaire has 35 items on a Likert scale from 4 (very much) to 0 (very little) used for assessing MS. The validity and reliability of the Iranian version of Enrich Marital Satisfaction have previously been confirmed (12). For the aim of the comparability of the scales, the scores of this questionnaire were transformed so that the maximum score was set to be 100. This tool had a 5-point Likert-type scale with the following cut-off point: scores between 10–22 (5–15%) and 23–28 (20–35%) represented the strong low satisfaction and the low satisfaction dissatisfaction of marital partners, respectively. Moreover, scores between 29–35 (40–60%) and 36–40 (65–80%) demonstrated moderate satisfaction and high satisfaction, respectively. Eventually, scores between 41 and 50 (85–100%) indicated a high level of satisfaction.
We used the NEO questionnaire in our study that is a 240-item self-report instrument to assess five personality domains: neuroticism, extraversion, agreeableness, conscientiousness, and openness to experience. Determining extraversion trait, 48 items are proposed in a 5-option Likert scale (completely disagree, disagree, no idea, agree, and strongly agree) and are scored by 0–4, respectively. The validity and reliability of the Iranian version of the questionnaire are well documented (13).
Bivariate correlations were used to analyze the degree of association between postnatal MS with SF, body image, personality, anxiety, income, level of education, and the number of times breastfeeding per day. Baseline data analyzed using descriptive statistics. Analyses were performed with the SPSS, version 21. P-values less than 0.05 were considered statistically significant. A path model was used to evaluate the cause-effect relationship between some variables. Direct, indirect, and total effects of causal relations between variables were found by path analysis. Path model is an extension of different regression, and allowed evaluation of more than one dependent variable at a time whereas allowing for variables to be dependent with respect to some of the variables and independent with respect to the others. LISREL software version 8.5 was used.
RMSEA (Root mean square error of approximation), AGFI (adjusted goodness of fit index), CFI (Confirmatory Factor Analytic), and Chi-square/df were used for evaluation of the model fitness. RMSEA values less than 0.07, Chi-square/df lower than 3, AGFI more than 0.9, and CFI more than 0.95 are indicative of a good fitting model.