Design and setting
A descriptive cross-sectional study was conducted at the outpatient department of the largest women’s and children’s hospital in Western China (located in Cheng Du, the capital city of Sichuan province).
Participants recruitment
We prospectively recruited 660 postpartum women who were waiting for postpartum check from November 2022 to January 2023. Convenience sampling was adopted to register delivery women who have been given birth in this hospital. The inclusion criteria were as follows: ①participating this research voluntarily; ②competence for completing this research independently; ③ having a fixed partner; and④age 18years or older. The following were established as exclusion criteria: ①severe medical, obstetric or psychiatric diseases; ②without written informed consent.
This study was conducted in accordance with the Declaration of Helsinki, and the protocol (No. 2019 (002)) was reviewed and approved by the ethics committee of West China Second University Hospital of Sichuan University. Besides, written informed consent forms was obtained from all participants before involved.
Measurement
Basic characteristics
A self-developed questionnaire was used to investigate basic characteristics involved age, educational level, family income per month, and residence. Obstetric information included gravity (primipara or multipara), delivery mode (vaginal delivery or cesarean), and complications. Finally, infant contents contained neonate gender satisfaction, condition of neonate, relationship with caregiver and feeding situation.
Dyadic Adjustment
Dyadic adjustment scale was used to assess the quality and adjustment status of marriage[16, 27], which was developed by Spanier[28] and revised by Shek[29]. It has 32-item that assess four dimensions embraced affectional expression, dyadic consensus, dyadic cohesion and dyadic satisfaction, each item was ranging from "always consistent" to "always inconsistent", the total score range is 0 to 151, high total and subscale scores indicate a high positive appraisal of the marriage, and the subscale can be used individually without losing their reliability or validity. The good psychometric properties of this scale have been confirmed in Chinese populations[26, 30]. the Cronbach’s alpha coefficient for the DAS was 0.85 and the re-retest reliability was 0.88, which has good internal consistency[30].
Coping styles
The Simplified Coping Style Questionnaire (SCSQ) was used to assess coping style, which was revised by Xie[31] on the basis of coping Questionnaire designed by Folkman and Lazarus[32]. The questionnaire consists of 20 items that are divided into two dimensions, positive coping styles and negative coping styles. Use of active thinking, seeing the trouble from a better perspective, and positive transaction of problems were regarded as positive coping styles. But, intense negative emotion like irritability or depression or grief, evading reality, rumination, incapable of working out problems separately were recognized negative coping styles[33, 34]. Each item is ranked on 4-point scale ranging from “never=0” to “always=3”, a higher score considers a more continual use of this coping style. The Cronbach’s alpha coefficient for the SCSQ was 0.90 and the test-retest reliability was 0.89, previous study[35] in China has reported satisfied reliability of Chinese version of the SCSQ among pregnant women.
PPD
The Edinburgh Postnatal Depression Scale (EPDS) developed by Cox, Which is considered the common standard for measuring the PPD in postpartum women as individuals[36]. The psychometric evaluation of the Mainland Chinese version of this scale was validated by Wang[37], which consists of 10 items, each item is rated on 4-point scale ranging from 0 to 3 for a total score of 0 to 30. The higher score means the higher probability of depression[38]. The Cronbach’s alpha for the EPDS was 0.79 and the test-retest reliability was 0.85, it has been widely used among prenatal and postpartum women in China[39-42]. A cutoff of 10 has been confirmed to be valid on the Chinese version of this scale[43].
Data collection
The target population was women who were approximately 6 weeks postpartum and waiting for postpartum check in the outpatient department. We collected data from November 2022 to January 2023 at the obstetric care archive room of the outpatient department. All eligible participants were given an ample explanation of this research, and signed written informed consent, then completed the questionnaire approximately 10-15 minutes instructed by uniformly trained staff.
Statistical analysis
Statistical analysis was performed by SPSS 25.0. Descriptive statistics were used to summarize the basic characteristics of the participants and the average scores of DAS, SCSQ and EPDS. Pearson correlation analysis was adopted to diagnose the correlations among dyadic adjustment, coping styles and depression. Structural equation modeling (SEM) was performed with the Analysis of Moment Structures (AMOS 21.0) software to analyze the path relationships among measured variables. SEM can handle measurement models (the relationship between latent variables and observed variables) and structural models (the relationship between latent variables)[44]. Simultaneously, therefore, it was considered the preferred analytic strategy for analyzing the path relationship among the constructs (dyadic adjustment, coping styles, and postpartum depression) in the hypothetical model[45].
When testing whether the structural equation model is tenable, some fitting indicator are predominantly measured. Results illustrated that the fit indices of Model of this study were good. X²/df =2.124, RMSEA = 0.042, GFI=0.998, AGFI=0.973, NFI=0.998, IFI=0.999, CFI=0.997, TLI=0.985, all goodness of fit indicators amount to common criteria, being seen as available model with matching degree of fortune. Thus, standardized path coefficients were administrated to test the direct effects of dyadic adjustment and coping styles on PPD, the bootstrapping method was employed to examine the significance of both positive coping style and negative coping style mediated the links between dyadic adjustment and postpartum depression. P<0.05 indicated statistically significant (two-tailed test).