G Model
NS-2563; No. of Pages 12 International Journal of Nursing Studies xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
Depressive symptoms, pain, and sexual dysfunction over the first year following vaginal or cesarean delivery: A prospective longitudinal study Shiow-Ru Chang a,*, Kuang-Ho Chen b, Hong-Nerng Ho c, Yeur-Hur Lai a, Ming-I Lin d, Chien-Nan Lee c, Wei-An Lin e a
School of Nursing, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan Central Taiwan University of Science and Technology, Taichung, Taiwan Department of Obstetrics and Gynecology, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan d Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan e Department of Environmental and Occupational Medicine, National Taiwan University Hospital, Taipei, Taiwan b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 1 October 2014 Received in revised form 13 April 2015 Accepted 28 April 2015
Background: Childbirth has a significant impact on maternal health, and the high rate of cesarean delivery is a global health concern. Few studies have used validated measures to explore depression, pain, and sexual dysfunction following vaginal or cesarean delivery over a prolonged time period. Objective: We examined the associations between vaginal and cesarean delivery and depressive symptoms, pain, and sexual function during the 1-year postpartum period. Design: A prospective, five-time-point longitudinal study. Setting: Maternity unit at a medical center. Participants: A total of 351 of 736 women completed a questionnaire that described demographic characteristics, depressive symptoms, and pain levels at 3–5 days postpartum, and updated personal data, depressive symptoms, pain levels, and sexual function at 4–6 weeks and at 3, 6, and 12 months after delivery. Methods: Differences between the vaginal and cesarean groups in depressive symptoms, pain, and sexual function and trends of changes in these factors over the first postpartum year were examined. Results: Compared with the vaginal birth group, the cesarean birth group had a significantly higher prevalence of depressive symptoms at 3 months (p = 0.03); higher scores for non-localized pain at 3–5 days (p < 0.001), 4–6 weeks (p = 0.03), and 3 months (p = 0.046); higher scores for abdominal pain at 3–5 days (p < 0.001), 4–6 weeks (p < 0.001), and 6 months (p = 0.01); lower perineal pain scores at 3–5 days (p 0.85 and high sensitivity and specificity (McDowell and Newell, 2006; Roberts and Vernon, 1983). Cronbach’s alpha coefficient estimates of the CES-D in this study were 0.82–0.93. Participants were grouped by their CES-D scores; women in the low-scoring group had scores 26.55 (Wiegel et al., 2005). Participants with low scores were viewed as possibly experiencing sexual dysfunction (Wiegel et al., 2005). Assessment of sexual function in the present study included the frequency of high FSFI values (FSFI score >26.55), and both total FSFI scores and scores on the six domains of the FSFI (desire, arousal, lubrication, orgasm, satisfaction, and pain). 2.3. Statistical analyses Statistical analyses were performed using SAS version 9.3 (SAS Institute, Inc., Cary, NC). Differences in the prevalence of depressive symptoms, the pain score, and the sexual function score between those who completed questionnaires at five visits (351 subjects) and those who did not were tested using multivariate analysis of variance (MANOVA). Descriptive analyses were used to identify the demographic characteristics of participants and the prevalence of depressive symptoms, pain scores, high FSFI frequencies, total FSFI scores and scores on the six domains of the FSFI. Differences in demographic characteristics between the two groups were explored via MANOVA to identify significant covariates that differ between the groups. Comparisons of depressive symptoms, pain, and sexual function in the two groups were assessed using multivariate analysis of covariance (MANCOVA), adjusting for significant differences in demographic covariates. The least squares means (LS Means) represented the means that have been adjusted for multivariate analysis (Nash and Sofer, 1996; Wolf and Ghilani, 1997). Between-group comparisons of the trends in depressive symptoms, sexual function, and pain from 3–5 days to 4–6 weeks, from 4–6 weeks to 3 months, from 3 to 6 months, and from 6 to 12 months postpartum were explored via regression analysis using a generalized estimating equation (GEE) model. A GEE is appropriate for longitudinal analyses as it accounts for the correlation between repeated measures in an individual (Liang and Zeger, 1986) regardless of whether the measures are discrete or continuous outcomes and have normal or non-normal distributions (Zeger and Liang, 1986). Despite non-normality, it is still appropriate to use MANOVA/MANCOVA with a symmetric multivariate distribution (Timm, 2002). These multiple comparisons were tested independently. All outliers and missing data were excluded before performing any test. A p-value 0.05) or the PRI score for non-localized pain (all p > 0.05) at 3–5 days, 4–6 weeks, and 3 and 6 months between those who did and did not participate at all time points. We also found no difference in the total sexual function score (all p > 0.05) at 4–6 weeks and at 3
and 6 months between these groups. Such similar findings validated our choice of a longitudinal within-subjects design to study the 351 participants constituting our final sample. Table 1 shows the characteristics of 200 (57.0%) and 151 (43.0%) participants at 3–5 days after vaginal and cesarean delivery, respectively. Significant differences were evident between the two groups in age, current body mass index (BMI), personal income, feeding type, gestational age of the baby, and neonatal care unit attended (all p < 0.05). These significant variables served as covariates. Time-dependent covariates included age, BMI, and feeding type. Fixed covariates included gestational age, neonatal care unit attended, and personal income.
Table 1 Characteristics of study participants on days 3–5 after delivery.
Age (years) Body mass index Gestational age of the baby (weeks) Newborn birth weight (g) Apgar score 1 min Apgar score 5 min Parity 1 2 3–4 Gravidity 1 2 3 4–9 Medical history (or condition) No Yes Highest education level Elementary school Junior high school High school University Graduate and above Employment Full-time Part-time Unemployed Homemaker Other Personal income (US$/year) 33,333 Feeding type Completely or mostly breast fed Other feeding types Pregnancy expected No Yes Depression history No Yes Neonatal care unit attended Baby room or room in Neonatal observation room Neonatal intensive care unit
Vaginal delivery (n = 200)
Cesarean delivery (n = 151)
P
32.1 0.3 24.7 0.2 38.6 0.1 3068.8 28.9 8.8 0.1 9.1 0.0
33.9 0.3 25.6 0.3 37.7 0.2 2994.8 45.5 8.6 0.1 8.9 0.0
NS-2563; No. of Pages 12 International Journal of Nursing Studies xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
Depressive symptoms, pain, and sexual dysfunction over the first year following vaginal or cesarean delivery: A prospective longitudinal study Shiow-Ru Chang a,*, Kuang-Ho Chen b, Hong-Nerng Ho c, Yeur-Hur Lai a, Ming-I Lin d, Chien-Nan Lee c, Wei-An Lin e a
School of Nursing, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan Central Taiwan University of Science and Technology, Taichung, Taiwan Department of Obstetrics and Gynecology, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan d Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan e Department of Environmental and Occupational Medicine, National Taiwan University Hospital, Taipei, Taiwan b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 1 October 2014 Received in revised form 13 April 2015 Accepted 28 April 2015
Background: Childbirth has a significant impact on maternal health, and the high rate of cesarean delivery is a global health concern. Few studies have used validated measures to explore depression, pain, and sexual dysfunction following vaginal or cesarean delivery over a prolonged time period. Objective: We examined the associations between vaginal and cesarean delivery and depressive symptoms, pain, and sexual function during the 1-year postpartum period. Design: A prospective, five-time-point longitudinal study. Setting: Maternity unit at a medical center. Participants: A total of 351 of 736 women completed a questionnaire that described demographic characteristics, depressive symptoms, and pain levels at 3–5 days postpartum, and updated personal data, depressive symptoms, pain levels, and sexual function at 4–6 weeks and at 3, 6, and 12 months after delivery. Methods: Differences between the vaginal and cesarean groups in depressive symptoms, pain, and sexual function and trends of changes in these factors over the first postpartum year were examined. Results: Compared with the vaginal birth group, the cesarean birth group had a significantly higher prevalence of depressive symptoms at 3 months (p = 0.03); higher scores for non-localized pain at 3–5 days (p < 0.001), 4–6 weeks (p = 0.03), and 3 months (p = 0.046); higher scores for abdominal pain at 3–5 days (p < 0.001), 4–6 weeks (p < 0.001), and 6 months (p = 0.01); lower perineal pain scores at 3–5 days (p 0.85 and high sensitivity and specificity (McDowell and Newell, 2006; Roberts and Vernon, 1983). Cronbach’s alpha coefficient estimates of the CES-D in this study were 0.82–0.93. Participants were grouped by their CES-D scores; women in the low-scoring group had scores 26.55 (Wiegel et al., 2005). Participants with low scores were viewed as possibly experiencing sexual dysfunction (Wiegel et al., 2005). Assessment of sexual function in the present study included the frequency of high FSFI values (FSFI score >26.55), and both total FSFI scores and scores on the six domains of the FSFI (desire, arousal, lubrication, orgasm, satisfaction, and pain). 2.3. Statistical analyses Statistical analyses were performed using SAS version 9.3 (SAS Institute, Inc., Cary, NC). Differences in the prevalence of depressive symptoms, the pain score, and the sexual function score between those who completed questionnaires at five visits (351 subjects) and those who did not were tested using multivariate analysis of variance (MANOVA). Descriptive analyses were used to identify the demographic characteristics of participants and the prevalence of depressive symptoms, pain scores, high FSFI frequencies, total FSFI scores and scores on the six domains of the FSFI. Differences in demographic characteristics between the two groups were explored via MANOVA to identify significant covariates that differ between the groups. Comparisons of depressive symptoms, pain, and sexual function in the two groups were assessed using multivariate analysis of covariance (MANCOVA), adjusting for significant differences in demographic covariates. The least squares means (LS Means) represented the means that have been adjusted for multivariate analysis (Nash and Sofer, 1996; Wolf and Ghilani, 1997). Between-group comparisons of the trends in depressive symptoms, sexual function, and pain from 3–5 days to 4–6 weeks, from 4–6 weeks to 3 months, from 3 to 6 months, and from 6 to 12 months postpartum were explored via regression analysis using a generalized estimating equation (GEE) model. A GEE is appropriate for longitudinal analyses as it accounts for the correlation between repeated measures in an individual (Liang and Zeger, 1986) regardless of whether the measures are discrete or continuous outcomes and have normal or non-normal distributions (Zeger and Liang, 1986). Despite non-normality, it is still appropriate to use MANOVA/MANCOVA with a symmetric multivariate distribution (Timm, 2002). These multiple comparisons were tested independently. All outliers and missing data were excluded before performing any test. A p-value 0.05) or the PRI score for non-localized pain (all p > 0.05) at 3–5 days, 4–6 weeks, and 3 and 6 months between those who did and did not participate at all time points. We also found no difference in the total sexual function score (all p > 0.05) at 4–6 weeks and at 3
and 6 months between these groups. Such similar findings validated our choice of a longitudinal within-subjects design to study the 351 participants constituting our final sample. Table 1 shows the characteristics of 200 (57.0%) and 151 (43.0%) participants at 3–5 days after vaginal and cesarean delivery, respectively. Significant differences were evident between the two groups in age, current body mass index (BMI), personal income, feeding type, gestational age of the baby, and neonatal care unit attended (all p < 0.05). These significant variables served as covariates. Time-dependent covariates included age, BMI, and feeding type. Fixed covariates included gestational age, neonatal care unit attended, and personal income.
Table 1 Characteristics of study participants on days 3–5 after delivery.
Age (years) Body mass index Gestational age of the baby (weeks) Newborn birth weight (g) Apgar score 1 min Apgar score 5 min Parity 1 2 3–4 Gravidity 1 2 3 4–9 Medical history (or condition) No Yes Highest education level Elementary school Junior high school High school University Graduate and above Employment Full-time Part-time Unemployed Homemaker Other Personal income (US$/year) 33,333 Feeding type Completely or mostly breast fed Other feeding types Pregnancy expected No Yes Depression history No Yes Neonatal care unit attended Baby room or room in Neonatal observation room Neonatal intensive care unit
Vaginal delivery (n = 200)
Cesarean delivery (n = 151)
P
32.1 0.3 24.7 0.2 38.6 0.1 3068.8 28.9 8.8 0.1 9.1 0.0
33.9 0.3 25.6 0.3 37.7 0.2 2994.8 45.5 8.6 0.1 8.9 0.0
