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.