Methods
Participants and procedure
Following IRB approval, a convenience sample of adult postpartum women
(N=440) were recruited in the maternity ward of the “Shamir-Assaf
Harofeh Medical Center”, between April 2018 and August 2020. Assuming
medium-sized effects, with 0.80 power and 0.05 probability of Type I
error, the minimum group size for t test is 64 participants. Considering
an estimated prevalence of dyspareunia in women of reproductive age as
16% (1,3,4), and taking into account 10% missing values, resulted in
440 participants. Exclusion criteria included: lack of knowledge of the
local language and physical, emotional or psychiatric conditions not
allowing to fill self-report questionnaires, including women in critical
medical conditions or with negative maternal or neonatal outcomes. On
recruitment days, the researches approached women at the maternity ward,
within 48 hours postpartum. After individual explanation on the aim and
importance of the study, women were invited to go through the
questionnaire before they consented to participate and were alerted that
some questions may be of a sensitive, private, or triggering nature.
Participants were encouraged to contact the researchers if they needed
counselling after reading the questionnaire, and were provided with the
principal investigator’s (AP) contact details. We reached out to 636
women and 440 agreed to participate, resulting in a response rate of
69%. Due to the nature of the enlisting procedure, we don’t have
details characterizing the non-respondent women. After informed consent,
participants filled out self-report questionnaires. Women who returned
the questionnaire were offered to be sent a copy of study results.
Three-hundred eighty-eight women (88.2%) who filled out the dyspareunia
questionnaire were included in the analyses. Demographic data, medical
background and obstetrical information were retrieved from clinical
files. Obstetrical data included details on pregnancy complications,
week and mode of delivery, nature of labour onset, analgesia method,
birthweight, and perineal tears.
Measures
Dyspareunia was assessed based on a questionnaire
developed by Alon et al. (11). Patients were asked the following
screening question: “Do you experience pain during sexual
intercourse?”. Patients who answered “yes” or “sometimes” were asked
to complete an additional questionnaire on dyspareunia severity (i.e.,
how many times out of 10 episodes of intercourse they experience pain),
onset (primary or secondary), patient’s experience regarding
localization of pain and its cause (introital, deep, muscular or
experiencing fear with penetration), duration of symptoms, previous
medical evaluation, diagnoses, and treatment. As suggested by Alon et
al.(11), a cutoff of 3 (out of 10 episodes) was used as an indication
for the presence of moderate to severe dyspareunia.
In addition, patients were queried about pain experienced during routine
pelvic exams, transvaginal sonography, “internal checks” (a Jewish
orthodox ritual, performed following menstruation), and use of menstrual
tampons.
Participants’ perceptions of birth were assessed by
three single-item indicators, assessing participants’ sense of pain,
perceived threat for themselves and perceived threat for the baby.
Participants were asked to rate, on a scale ranging between 0-10, the
level of pain during delivery, perceived threat of death for them and
for the baby. The assessment of pain by the single-item indicator is
widely used following birth (14). The items for perceived threat for the
mother and the baby are elaborations of items used to assess perceived
threat following medical procedures (15). For the benefits of using
single-item indicators in medical setting, see Youngblut & Casper (16).
Sense of control during birth was assessed by the
10-item version of the Labor Agentry Scale (LAS) (17). The scale
includes six positive and four negative descriptions of the extent to
which women feel in control during childbirth. Participants were asked
to rate their experiences on a 7- point scale from (1) ‘almost all of
the time’ to (7) ‘never, or almost never’. Mean scores were used, with
higher scores representing greater levels of sense of control.
Cronbach’s alpha for the current sample was 0.76.
Perceived professional support was assessed by the
Intrapartum Care Scale (18). The scale includes 13 statements regarding
birth attendants such as “Members of the team calmed me down” and “I
felt abandoned by members of the team” (reverse scored). Participants
were asked to rate their level of agreement with each statement ranging
from 1 (completely disagree) to 5 (completely agree). Mean scores were
used, with higher scores representing greater levels of perceived staff
support. Cronbach’s alpha for the current sample was 0.77.
Perinatal dissociation was assessed by the Peritraumatic
Dissociative Experiences Questionnaire (PEDQ) (19,20), a widely used
scale that assesses dissociative experiences during and shortly after
traumatic events. Participants were asked to rate the extent to which
each item describes their reactions during labour or immediately after
labour, on a 5-point scale ranging from 1 (not at all true) to 5
(extremely true). One item, referring to pain experienced during labour
was reduced, due to a possible effect of analgesia. Mean scores were
used, with higher scores representing greater levels of perinatal
dissociation. Cronbach’s alpha for the current sample was 0.83.
Birth-induced acute stress disorder (ASD) symptoms were
assessed by the Stanford Acute Stress Reaction Questionnaire (SASRQ)
(21), a 28-item scale describing ASD symptoms. Participants were asked
to rate, on a six-point scale, the extent to which they suffer from each
of the symptoms ranging from 1 (not at all) to 6 (very often). Mean
scores were used, with higher scores representing greater levels of ASD.
Cronbach’s alpha for the current sample was 0.93.
Depression was assessed by the Edinburgh Postnatal
Depression Scale (EPDS) (22), a commonly-used measurement consisting of
10 items relating to postnatal depression. Participants were asked to
rate the extent to which each item characterizes their overall emotional
state since labour, with four response options each rated 0–3. Sum
scores were used, with higher scores representing greater levels of
depression. Cronbach’s alpha for the current sample was 0.85.
Positive and negative affect was assessed by the short
form of the Positive and Negative Affect Schedule (PANAS) (23), and is
comprised of 10 items evaluating various positive (5 items) and negative
(5 items) emotions. Respondents are asked to rate the extent to which
they feel each emotion on a 5-item scale ranging from 1 (not at all) to
5 (very often). Mean scores were used, with higher scores representing
greater levels of positive and negative emotions. Cronbach’s alpha for
the current sample was 0.78 and 0.79, for positive and negative
emotions, respectively.
Maternal bonding was assessed by the Mother-to-Infant
Bonding Scale (MIBS) (24). This 8-item scale assesses mothers’ feelings
towards their infant. Participants were asked to rate the extent each
item describes their feelings, on a 4-point scale ranging from 1 (not at
all) to 4 (very much). Mean scores were used, with higher scores
representing greater levels of maternal bonding. Cronbach’s alpha for
the current sample was 0.75.
Anticipated maternal self-efficacy was assessed by the
Maternal Self-Efficacy Scale (25). This 18-item scale, refers to women’s
expectations regarding the degree of their competence as mothers (e.g.,
”I think I will be able to relax my baby when he/she is crying”; ”Being
a mother will cause me stress and anxiety”). Participants were asked to
indicate the degree to which they agreed with the statements on a
four-point scale ranging from 1 (not at all) to 4 (very much). Mean
scores were used, with higher scores representing greater levels of
anticipated self-efficacy. Cronbach’s alpha for the current sample was
0.85.