Symptoms of postnatal depression are the main mental health problem following childbirth and are characterised by serious mood changes, sadness, hopelessness, feeling of worthlessness, fatigue, insomnia, suicidal thoughts and other psychological symptoms. The Pregnancy Risk Assessment Monitoring System (PRAMS) has identified symptoms of postnatal depression as the fourth most common health issue that requires rapid and careful attention during the first year after childbirth (Kanotra et al, 2007). A range of 5.6–29.2% of women are reported to experience symptoms of depression during the early postnatal period (Buist and Bilszta, 2006; Buist et al, 2008; Austin et al, 2010; Xie et al, 2011) and almost one third reportedly experience symptoms of postnatal depression at 5 months and 9 months postpartum (Gress-Smith et al, 2012).
Various factors have been reported to affect postnatal mental health and cause symptoms of depression, including: illnesses, previous history of mood disorder, negative childhood experiences or abuse, stressful life events, insufficient family or social supports, pregnancy loss, childbirth-related distress, having a baby that is restless, difficult to settle or unwell, intrapersonal issues and interpersonal problems (Cunningham et al, 2010; Nunes et al, 2010; Khajehei and Hadzic, 2012; Khajehei et al, 2012a; 2012b; Zadeh et al, 2012). Another risk factor is sexual dysfunction. Women who have sexual problems after childbirth may experience higher rates of postnatal depression symptoms and mental health problems. This association has been reported to be mutual (Azar et al, 2007; Shifren et al, 2008; Khajehei et al, 2015a; 2015b). In addition to other risk factors, relationship dissatisfaction has been suggested to be associated with symptoms of postnatal depression. Women with lower levels of relationships satisfaction may be at greater risk of depressive symptoms in the postnatal period (Pruchno et al, 2009).
Evidence from the literature shows that the association between symptoms of depression, sexual dysfunction and relationship dissatisfaction is under-studied and the research has been inconclusive (Frohlich and Meston, 2002; Vulink et al, 2006). In addition, there have been inconsistent reports on the issue and controversial findings, such as no association between sexual dysfunction and women's mental health status, have been reported (Cyranowski et al, 2004; Song et al, 2008). Further to these shortcomings, previous research has failed to conclusively evaluate the role of various factors in the development of depressive symptoms after childbirth.
Symptoms of postnatal depression can have a negative effect on women's quality of life, the mental health of their partners and the intellectual and physical development of their children (Mercer et al, 2005; Gress-Smith et al, 2011). Depression can also impose economic pressure on the entire family. Health service expen di tures have been shown to be 90% higher among depressed mothers and their families in the US (Dagher et al, 2012). Considering its negative consequences, and because there is of a dearth of up-to-date comprehensive research among Australian postpartum women, this study was con ducted to investigate the association between sexual dys function, relationship dissatisfaction and symptoms of post natal depression in Australian women with children aged 0–12 months. The study also aimed to explore risk factors that could predict the likelihood of postnatal depression symptoms.
Methods
Study design
This cross-sectional study was part of a larger mixed-methods research in which sexual function, mental health and relationship satisfaction of postpartum Australian women were investigated.
Ethical considerations
The Human Research Ethics Committee at Curtin University, Perth, approved the study protocol. Women provided passive consent by completing and submitting the online questionnaire.
Participants
From a power calculation, a total of 295 postpartum women were needed to participate in the study. Postnatal women were invited to participate if they met the following inclusion criteria:
Exclusion criteria were being clinically diagnosed with any kind of psychiatric illness, such as obsessive compulsive disorders, anorexia nervosa, post-traumatic stress disorder or phobia.
The inclusion and exclusion criteria for this study were based on the objectives of the study and the literature review. The National Health and Medical Research Council (NHMRC, 2015: 16) guidelines affirm that ‘consent should be a voluntary choice’; because the legal age of consent in Australia is 16 years (Child Family Community Australia, 2016), women who were ≥ 16 years old were invited to voluntarily participate in the study. Women who were > 40 years old were excluded from the study because they were more likely to experience premenopausal and perimenopausal changes, which have been shown to affect sexual life and mental health—specifically evidence of depression—in women in this age group (Avis et al, 2009; Hess et al, 2009; Hess et al, 2012).
Recruitment process
Women were invited to complete the online questionnaires through flyers, emails sent to managers of childcare centres to distribute, invitation letters on Facebook pages, community papers and snowball sampling. A link to the study website was available through search engines, tagged with the terms ‘sexual health’, ‘sexual function’, ‘depression’, ‘relationship’, ‘childbirth’ and ‘after birth’; this meant women searching for these terms could self-direct to the study website and be offered the chance to participate.
Participation in this study was voluntary and anonymous. The first two pages of the study website provided information about the study, including anonymity and confidentiality of the responses. All information collected was anonymous. No identification information was requested; thus, the confidentiality of the responses was protected. The data were collectively analysed and the results of the research presented using aggregated data, such as numbers and percentages or means in groups, rather than individual information.
Participants were informed that they provided their consent by completing and submitting the online questionnaire, and were then directed to the multisection questionnaire. The study website was launched in May 2012 and was active until August 2012.
Variables
Guided by the researchers' literature review, a multisection questionnaire was designed. The first section contained questions on a range of topics:
To investigate the face and content validity of the designed questionnaire, 15 researchers who had previously conducted online studies reviewed the questionnaire and provided comments and feedback.
Patient Health Questionnaire
The Patient Health Questionnaire (PHQ-8) was used to investigate symptoms of depression in the participants (Gjerdingen et al, 2009). The original questionnaire consisted of nine questions (PHQ-9), which were developed based on the criteria of depression in the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition (DSM-III) and have been updated according to the 4th edition (DSM-IV) (American Psychiatric Association, 1994). This questionnaire is a validated tool that has been used to investigate depression in many studies. Its reliability has been reported to be from 0.78 to 0.89 (Kroenke et al, 2001; Monahan et al, 2009). The instrument has been reported to be more accurate, reliable (Weobong et al, 2009) and specific (Gjerdingen et al, 2009) than other tools to identify postnatal depression. The ninth question in the original PHQ-9, which asks about different symptoms of depression within the past 2 weeks (Gjerdingen et al, 2009), focuses on ‘thoughts of suicide or self-harming’. Because asking this question could induce distress for some individuals, it was removed to create the PHQ-8. This version has been widely used in several studies and has shown high levels of reliability (Coefficient alpha: 0.90) (Kroenke et al, 2009; Smith et al, 2010; Skopp et al, 2011). For the present study, the PHQ-8 was used to collect data on symptoms of depression among the participants.
Female Sexual Function Index
The Female Sexual Function Index (FSFI) was used to assess sexual function of the participants. The FSFI contains 19 multiple-choice questions that capture information about sexual function in the past 4 weeks and evaluate six main domains of female sexual function: desire, arousal, lubrication, orgasm, satisfaction and pain. The items were scored using a Likert scale: questions 1, 2, 15 and 16 were scored from 1–5; the other questions were scored from 0–5. A total score of ≤ 26 identified women with a sexual dysfunction. This measure has been used in many studies and its validity and reliability have been documented (Burri et al, 2010; Chang et al, 2010; Rivalta et al, 2010). The FSFI has also been validated and used in many studies in Australia (Nijland et al, 2008; Conaglen et al, 2010; Watson and Halford, 2010).
Relationship Assessment Scale
The participants' level of relationship satisfaction was explored using the Relationship Assessment Scale (RAS). The RAS was developed primarily for married couples; however, after being revised, this scale is now applicable for use in other types of relationships including couples who are engaged, dating and cohabiting (Vaughn and Baier, 1999). The reliability of this tool has been shown to vary between 0.86–0.91 (Hendrick, 1988; Vaughn and Baier, 1999). RAS includes seven multiple-choice questions to assess the level of relationship satisfaction; a 5-point Likert scale is used to score the items. Because the RAS is ‘not limited to marriage relationships’ (Vaughn and Baier, 1999: 145), it can be used to evaluate relationship satisfaction in any type of commitment including either heterosexual or homosexual couples who may be married, cohabiting or dating (Hendrick, 1988; Hendrick et al, 1998).
The three standardised questionnaires (PHQ-8, FSFI and RAS) had already been used in previous studies across Australia, with reasonable response rates. As the demographics of the participants in this study were comparable with those of other studies conducted in Australia, the three questionnaires were assessed as being appropriate to be used in the present study.
Data analysis
Statistical Package for the Social Sciences, Advanced Statistics, Release 18.0 was used to analyse the data. Distribution of all variables among women with and without symptoms of postnatal depression was calculated by using chi-squared (χ2) test. The independent samples t test was used to assess mean scores on the PHQ-8 among women with and without symptoms of postnatal depression. Multiple logistic regression analysis (backward Wald) identified the factors that were significantly associated with symptoms of post natal depression. In this analysis, the dependent variable was depression and was measured on a dichotomous scale with mutually exclusive categories (women with symptoms of post natal depression and women without symptoms of post natal depression).
The independent categorical variables were also dichotomous, such as sexual function (women with sexual dysfunction and women without sexual dysfunction) and relation ship satisfaction (women with relationship satisfaction and women without relationship satisfaction). Differences were considered significant when the P-value was < 0.05.
Results
A total of 489 responses were received. Of these, 164 responses were excluded; 48 women did not answer all questions and 116 did not comply with the inclusion criteria. Reasons for non-compliance were:
Therefore, responses from 325 participants were considered for analysis. Preliminary analysis showed no significant difference in the demographics of those who were excluded and those whose data were analysed. Table 1 shows the demographic characteristics of the participants whose responses were analysed. Seventy-eight women (24%) experienced symptoms of depression after childbirth. There was no significant difference in age group, educational level, occupation or annual income between women with and without depression (P > 0.05).
| Criteria | Frequency (n = 325) | Percentage * |
|---|---|---|
| Age | ||
| 18–20 years | 13 | 4.0 |
| 21–30 years | 170 | 52.3 |
| 31–40 years | 142 | 43.7 |
| Education | ||
| High school or lower | 2 | 0.6 |
| Diploma degree | 113 | 34.8 |
| University degree | 210 | 64.6 |
| Origin | ||
| Australian | 138 | 42.5 |
| European | 58 | 17.8 |
| American | 72 | 22.2 |
| Asian | 15 | 4.6 |
| New Zealander | 11 | 3.4 |
| Other | 31 | 9.5 |
| Employment | ||
| No formal career | 164 | 50.5 |
| Casual job | 25 | 7.7 |
| Part-time job | 76 | 23.4 |
| Full-time job | 60 | 18.5 |
| Income | ||
| < $50 000 | 110 | 33.8 |
| ≥ $50 000 | 215 | 66.2 |
Table 2 reveals that symptoms of postnatal depression were not significantly associated with the following factors: parity, number of children at home, history of miscarriage or abortion, having regular menstrual bleeding, method of delivery, place of birth, gender of the baby and birth weight of the baby. However, women with symptoms of postnatal depression were more likely not to breastfeed their babies than were those without symptoms of postnatal depression (P = 0.026).
| Factor | With symptoms of depression (n = 78) | Without symptoms of depression (n = 247) | P-value | |||
|---|---|---|---|---|---|---|
| n | % | n | % | |||
| Parity | Primparous | 16 | 20.5 | 71 | 28.7 | 0.098 |
| Multiparous | 62 | 79.4 | 176 | 71.2 | ||
| Number of children at home | 1 child | 26 | 33.3 | 101 | 40.8 | 0.145 |
| ≥ 2 children | 52 | 66.6 | 146 | 59.1 | ||
| Miscarriage or abortion1 | None | 43 | 55.1 | 142 | 57.4 | 0.406 |
| One or more | 35 | 44.8 | 105 | 42.5 | ||
| Method of delivery | Normal vaginal delivery without tears or episiotomy | 32 | 41 | 98 | 39.6 | 0.331 |
| Normal vaginal delivery with tears or episiotomy | 21 | 26.9 | 86 | 34.8 | ||
| Instrumental delivery2 | 3 | 3.8 | 14 | 5.6 | ||
| Caesarean section | 22 | 28.2 | 49 | 19.8 | ||
| Birth place | Public hospital | 44 | 56.4 | 142 | 57.4 | 0.693 |
| Private hospital | 14 | 17.9 | 46 | 18.6 | ||
| Home | 16 | 20.5 | 53 | 21.4 | ||
| Birth centre | 4 | 5.1 | 6 | 2.4 | ||
| Gender of the baby | Boy | 34 | 43.5 | 120 | 48.5 | 0.555 |
| Girl | 43 | 55.1 | 120 | 48.5 | ||
| Twin boys | 1 | 1.2 | 3 | 1.2 | ||
| Twin girls | 0 | 0 | 4 | 1.6 | ||
| Baby's birth weight | < 2500 g | 19 | 24.3 | 33 | 13.3 | 0.141 |
| 2500–4000 g | 49 | 62.8 | 179 | 72.4 | ||
| > 4000 g | 10 | 12.8 | 35 | 14.1 | ||
| Breastfeeding | No breastfeeding | 25 | 32 | 65 | 26.3 | 0.026* |
| Exclusive breastfeeding | 36 | 46.1 | 86 | 34.8 | ||
| Partial breastfeeding | 17 | 21.7 | 96 | 38.8 | ||
| Regular menstrual bleeding after childbirth | Yes | 33 | 42.3 | 122 | 49.3 | 0.3 |
| No | 45 | 57.6 | 125 | 50.6 | ||
Table 3 shows that the following factors were not significantly associated with sexual dysfunction after childbirth: use of hormonal medicines, use of particular medicines, pelvic operations, sleep hours in a 24-hour period, cigarette smoking, alcohol consumption and illness during pregnancy. However, women who were clinically diagnosed with depression were at greater risk of developing symptoms of postnatal depression than women who did not have a history of depression and the difference between the two groups was statistically significant (P = 0.003).
| Factor | With symptoms of depression (n = 78) | Without symptoms of depression (n = 247) | P-value | |||
|---|---|---|---|---|---|---|
| n | % | n | % | |||
| Use of hormonal medicines | No | 75 | 96.2 | 223 | 90.3 | 0.074 |
| Yes | 3 | 3.8 | 24 | 9.7 | ||
| Use of any type of medication | Yes | 6 | 7.7 | 15 | 6.1 | 0.39 |
| No | 72 | 92.3 | 232 | 93.9 | ||
| Pelvic operations | Female tubal legation | 5 | 6.4 | 7 | 2.8 | 0.318 |
| Bladder prolapse repair | 1 | 1.3 | 1 | 0.4 | ||
| Laparoscopy | 0 | 0.0 | 5 | 2.0 | ||
| Ovariectomy | 0 | 0.0 | 1 | 0.4 | ||
| None | 72 | 92.3 | 233 | 94.3 | ||
| Sleep hours in a 24-hour period | 4–6 hours | 43 | 55.1 | 102 | 41.3 | 0.059 |
| 7–9 hours | 32 | 41.0 | 139 | 56.3 | ||
| 10–11 hours | 3 | 3.8 | 6 | 2.4 | ||
| Cigarette smoking | No smoking | 70 | 89.7 | 224 | 90.7 | 0.818 |
| Occasional smoking1 | 1 | 1.3 | 5 | 2.0 | ||
| Regular smoking2 | 7 | 9.0 | 18 | 7.3 | ||
| Alcohol consumption | No alcohol consumption | 46 | 59.0 | 141 | 57.1 | 0.909 |
| Light drinking3 | 29 | 37.2 | 94 | 38.1 | ||
| Moderate drinking4 | 2 | 2.6 | 10 | 4.0 | ||
| Heavy drinking5 | 1 | 1.3 | 2 | 0.8 | ||
| Illness during pregnancy | Yes | 17 | 21.8 | 50 | 20.2 | 0.44 |
| No | 61 | 78.2 | 197 | 79.8 | ||
| Being clinically diagnosed with depression | Yes | 60 | 76.9 | 223 | 90.3 | 0.003* |
| No | 18 | 23.1 | 24 | 9.7 | ||
There was no significant association between symptoms of postnatal depression and usual sexual activity, frequency of sex, resumption of sex after childbirth or sexual orientation (Table 4). Women with symptoms of postnatal depression were less likely than women without symptoms of postnatal depression to be the initiator of sex during partnered sexual activity. In addition, the risk of sexual dysfunction and relationship dissatisfaction was greater among women with symptoms of postnatal depression, compared with women without symptoms of postnatal depression.
| Factor | With symptoms of depression (n = 78) | Without symptoms of depression (n = 247) | P-value | |||
|---|---|---|---|---|---|---|
| n | % | n | % | |||
| Usual sexual activity | No sexual activity | 9 | 11.5 | 23 | 9.3 | 0.324 |
| Single method: vaginal sex | 35 | 44.9 | 82 | 33.2 | ||
| Single method: masturbation | 0 | 0 | 4 | 1.6 | ||
| Single method: anal sex | 0 | 0 | 1 | 0.4 | ||
| Mixed method: oral and vaginal sex | 12 | 15.4 | 41 | 16.6 | ||
| Mixed method: masturbation and vaginal sex | 8 | 10.3 | 23 | 9.3 | ||
| Mixed method: masturbation, oral and vaginal sex | 7 | 9.0 | 52 | 21.1 | ||
| Mixed method: oral, vaginal and anal sex | 3 | 3.8 | 7 | 2.8 | ||
| Mixed method: masturbation, oral, vaginal and anal sex | 4 | 5.1 | 14 | 5.7 | ||
| Frequency of sex | No sexual activity | 9 | 11.5 | 23 | 9.3 | 0.782 |
| Daily | 2 | 2.6 | 4 | 1.6 | ||
| Every second day | 11 | 14.1 | 48 | 19.4 | ||
| Once a week or less often | 56 | 71.8 | 172 | 69.6 | ||
| Resumption of sex after childbirth | No sexual activity | 9 | 11.5 | 23 | 9.3 | 0.396 |
| 0–4 weeks | 15 | 19.2 | 74 | 30.0 | ||
| > 4 weeks | 54 | 69.2 | 150 | 60.7 | ||
| Person who usually iniated sex | The woman | 12 | 15.4 | 27 | 10.9 | 0.012* |
| Her partner | 40 | 51.3 | 95 | 38.5 | ||
| The woman and her partner equally | 17 | 21.8 | 102 | 41.3 | ||
| No sexual activity | 9 | 11.5 | 23 | 9.3 | ||
| Sexual orientation | Heterosexual relationship | 73 | 93.6 | 236 | 95.5 | 0.332 |
| Same-sex relationship | 5 | 6.4 | 11 | 4.5 | ||
| FSFI score | ≤ 26 (with sexual dysfunction) | 64 | 82.1 | 145 | 58.7 | < 0.001* |
| > 26 (without sexual dysfunction) | 14 | 17.9 | 102 | 41.3 | ||
| RAS score | < 4 (lower relationship satisfaction) | 51 | 65.4 | 70 | 28.3 | < 0.001* |
| ≥ 4 (higher relationship satisfaction) | 27 | 34.6 | 177 | 71.7 | ||
FSFI Female Sexual Function Index RAS Relationship Assessment Scale
More women with symptoms of postnatal depression than those without experienced a higher rate of sexual dysfunction (82% vs 58.7%, respectively) and relationship dissatisfaction (65.3% vs 28.3%, respectively) (P < 0.001). These findings were supported by the independent samples t test results. The mean scores on the RAS and the FSFI showed that women with symptoms of postnatal depression were at a greater risk of relationship dissatisfaction (3.4 ± 0.9 vs 4.1 ± 0.8) and sexual dysfunction (17.6 ± 8.5 vs 22.8 ± 8.9) than women without symptoms of postnatal depression (P < 0.001).
After conducting a multiple logistic regression analysis, it was revealed that women who had a diploma or a lower level of education were more likely than women who had a university degree to experience symptoms of depression (odds ratio (OR) = 2.256, 95% conficence interval (CI) = 1.239–3.848). The risk of postnatal depression symptoms was also shown to be higher among women who had sexual dysfunction (OR = 2.516, 95% CI = 1.279–4.95) and relationship dissatisfaction (OR = 3.752, 95% CI = 2.116–6.654) (Table 5).
| Variable | Crude odds ratio | Adjusted odds ratio | 95% confidence interval for odds ratio | P-value | |
|---|---|---|---|---|---|
| Sleep hours | ≥ 7 hours | 1 | 1 | 0.918–2.827 | 0.097 |
| 4–6 hours | 1.746 | 1.611 | |||
| Education | University degree | 1 | 1 | 1.273–3.998 | 0.005* |
| Diploma or lower | 1.955 | 2.256 | |||
| Sexual dysfunction | No | 1 | 1 | 1.279–4.95 | 0.008* |
| Yes | 3.216 | 2.516 | |||
| Relationship dissatisfaction | No | 1 | 1 | 2.116–6.654 | <0.001* |
| Yes | 4.776 | 3.752 |
Discussion
In this study, 24% of the respondents had symptoms of postnatal depression, and women who had a diploma or a lower level of education, sexual dysfunction and relationship dissatisfaction were at greater risk of symptoms of postnatal depression. The researchers believe that this may be caused by two factors:
To the authors' knowledge, this was the first study of its kind to com prehensively focus on symptoms of postnatal depression among Australian postpartum women and investigate association between symptoms of postnatal depression, sexual dysfunction and relationship dissatisfaction, while considering the role of other potential factors including demographics, reproductive and medical factors, sexual life and infant characteristics.
The findings show a statistically significant association between symptoms of postnatal depression and low level of education, which corroborates the results of earlier research. A study by Figueira et al (2010) reported that the risk of symptoms of postnatal depression increased with a decrease in the level of education. In addition, lower educational level was reported to be a risk factor for symptoms of depression after childbirth among Canadian women (Davey et al, 2011). The association between lower educational level and symptoms of postnatal depression may be because women with a low level of education may know less about various ways of adjusting to a maternal role and, therefore, feel less capable of dealing with a newborn's needs as well as the expectations of a partner and other family members (Britton, 2008). In addition, women with low education have been shown to have low socioeconomic status, which is a risk factor for symptoms of postnatal depression in itself. Therefore, these women may be more vulnerable to psychological changes during the perinatal period and at greater risk of symptoms of postnatal depression (Goyal et al, 2010).
This study also showed a statistically significant association between symptoms of postnatal depression, sexual dysfunction and relationship dissatisfaction. This association has been addressed in the literature, indicating that women's mental health can be affected by the quality of their intimate relationships. The study by Perlman et al (2007) showed a significant association between depressive symptoms and sexual dysfunction, while Goyal et al (2009) reported that relationship satisfaction was the only significant predictor for symptoms of postnatal depression among the participants in their study. Although the present study did not investigate the cause-and-effect association between symptoms of postnatal depression and sexual dysfunction, their mutual association has previously been reported (Davison et al, 2009; Chivers et al, 2011). This association may be partly due to the use of antidepressants resulting in sexual difficulties, as well as intrapersonal and interpersonal difficulties among depressed women (Clayton et al, 2002).
The association between symptoms of postnatal depression and difficulties in intimate relationships is so important that the American Psychiatric Association (2003) has recommended that individuals' psychological status must be assessed when making an effort to diagnose sexual difficulties. In 2008, the Australian government launched the National Perinatal Depression Initiative (NPDI) (Australian Health Ministers' Advisory Council, 2008), recommending the routine screening for antenatal and postnatal depression symptoms. This initiative aimed to improve prevention and early detection of antenatal and postnatal depression symptoms. However, according to Fisher et al (2012: 559):
‘The implementation of the NPDI is uneven among Australian maternity hospitals. Little is known about perinatal mental health screening practices in the private sector and hospitals with < 1000 births annually.’
Mental health is important for maintaining quality of life for women, their families and society. It is important to include mental health assessment as a discussion topic during postnatal visits. Although women's mental health can be dramatically disturbed during the perinatal period, research has shown that only a small proportion of women seek help, advice and treatment from health professionals (Dennis and Chung-Lee, 2006; Gjerdingen et al, 2009). This may be due to lack of knowledge on the issue, cultural beliefs and myths or the stigma of having a mental illness (Dennis and Chung-Lee, 2006; Gjerdingen et al, 2009). Other potential barriers to meaningful discussion of postnatal mental health could be women's inability to disclose their feelings, limited time dedicated to each health care contact, and judgemental attitudes of some practitioners (Dennis and Chung-Lee, 2006).
Considering the effects of depressive symptoms on women's quality of life, their families and wider society (Glavin and Leahy-Warren, 2013), it is important to assess women's mental health status during the perinatal period and refer them to specialist mental health professionals when required. Women who are at risk of symptoms of postnatal depression may benefit from early post natal screening.
Postpartum women and health care providers should be encouraged to pay attention to this sensitive issue. Health professionals should discuss not only mental health issues but also any difficulties with women's intimate relationships. Such discussions should not be limited to postnatal visits, but should also be addressed during antenatal care, with anticipatory guidance provided; this may serve to enhance continued discussions postnatally. Efforts should be made to engage with women and their partners, and referrals for multidisciplinary support (i.e. counselling, cognitive behavioural therapy, family therapy, psychosexual therapy etc) during the first 12 months postpartum should be made if deemed necessary.
Limitations and recommendations
Similar to other research, the present study has some limitations. Firstly, this was a cross-sectional study that recruited a non-randomised sample of postnatal women across Australia. Therefore, the sample may not be representative for the total birth population in Australia, and the findings may not be generalisable to the entire population of Australian postpartum women. However, the findings may operate as an informative element within the greater body of knowledge. Secondly, participants completed an online questionnaire, meaning those without access to a computer or who were computer-illiterate were excluded. Thirdly, the study collected self-reported data, which possess inherent limitations. However, as the study was anonymous with no face-to-face contact, it is reasonable to conclude that participants were likely to provide honest, trustworthy responses (Bjerke et al, 2008; Lindstrom et al, 2010). Finally, this was an online study and women voluntarily answered the questions, so there may be an assumption that women with symptoms of depression were over-represented in this study, as they may have been more interested in sharing their experience in the hope of finding a solution. However, the authors concluded that there was minimal risk of overrepresenting of women with depressive symptoms, because the prevalence of symptoms of postnatal depression in this study (24%) was in accordance with the reports from previous Australian research (Buist and Bilszta, 2006; Buist et al, 2008; Austin et al, 2010).
Future studies considering these shortcomings with a random sampling approach may allow generalisation to the population of postnatal women in Australia. In addition, further research is needed in the form of a longitudinal study to evaluate women's mental health during pregnancy and follow them up until after childbirth to compare the changes and possibly uncover a cause-and-effect relationship.
Despite its limitations, the findings of the present study have considerable value and may have significant implications for health professionals who provide care for perinatal women. These findings can be used to support the implementation of routine screening of postnatal women for symptoms of depression, sexual problems and relationship dissatisfaction.
Conclusion
This study found that lower level of education, sexual dysfunction and relationship dissatisfaction are more likely than other factors to cause symptoms of depression in postnatal women. To prevent and minimise symptoms of postnatal depression, it is vital to improve training for health professionals and information provided to women. It is recommended that midwives and other health professionals in contact with pregnant and postnatal women be educated about these associated factors and trained in how to address sexual and relationship problems in perinatal women. In addition, perinatal women may benefit from attending educational classes that explain potential changes in various aspects of their lives, encouraging them to talk openly about their problems and seek help and support when required. By addressing the issues identified in this study, it may be possible to reduce or eliminate symptoms of postnatal depression in some women.