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\begin{document}

\title{Obstetric Outcome and Emotional Adjustment to Childbirth in Women with
Dyspareunia: A Cross-sectional Study}



\author[1]{Anna Padoa}%
\author[2]{Roni Tomashev}%
\author[3]{Inbal Brenner}%
\author[2]{Ayelet Golan}%
\author[4]{May Igawa}%
\author[5]{Ido Lurie}%
\author[6]{Yael Reicher}%
\author[7]{Anat Talmon}%
\author[8]{Karni Ginzburg}%
\affil[1]{Assaf Harofeh Medical Center}%
\affil[2]{Shamir Medical Center Assaf Harofeh}%
\affil[3]{Lev Hasharon Mental Health Center}%
\affil[4]{Tel Aviv University Sackler Faculty of Medicine}%
\affil[5]{Shalvata Mental Health Center}%
\affil[6]{Soroka Medical Center}%
\affil[7]{Paul Baerwald School of Social Work and Social Welfare}%
\affil[8]{Tel Aviv University the Bob Shapell School of Social Work}%


\vspace{-1em}



  
  \date{May 07, 2024}


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\selectlanguage{english}
\begin{abstract}
Objective: To assess obstetrical outcomes, perceptions of childbirth
experience and emotional adjustment in women with dyspareunia. Design:
Cross-sectional study. Setting: The maternity ward of a single medical
center. Population: Four-hundred forty women, recruited within two days
postpartum. Methods: We administered self-report questionnaires
addressing demographic and reproductive background, dyspareunia, pain
and perceived threat during delivery, sense of control during labour,
perceived professional support, and maternal adjustment (i.e., perinatal
dissociation, acute stress disorder (ASD), bonding, anticipated maternal
self-efficacy depression and positive and negative affect). Obstetrical
information was retrieved from clinical files. Main outcomes measures:
Obstetrical outcomes and emotional adjustment to childbirth in women
with dyspareunia versus comparisons. Results: Three-hundred eighty-eight
women filled the dyspareunia questionnaire. The dyspareunia group
included 71 women (18.3\%) and the comparison group 317 (81.7\%).
Demographic data were similar between groups. No difference was observed
in labour onset, analgesia, route of delivery and perineal tears. More
participants with dyspareunia had premature delivery versus comparisons
(14.1\% vs 5.6\%, p=0.02). Women with dyspareunia reported lower sense
of control (p=0.01), lower perceived support (p\textless{}0.001), more
perinatal dissociation (p\textless{}0.001), ASD symptoms
(p\textless{}0.001), depression (p=0.02), negative affect
(p\textless{}0.001), lower maternal bonding (p\textless{}0.001) and
anticipated maternal self-efficacy (p=0.01). Women who experienced pain
during pelvic exams were less likely to have spontaneous labor onset,
more likely to need cervical ripening (p=0.02), and reported higher
levels of negative affect (p=0.03). Conclusion: Dyspareunia was
associated with more premature deliveries, more emotional distress and
poorer maternal adjustment. Perinatal caregivers should be cognizant of
such emotional reactions during prenatal care.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Dyspareunia, a common complaint, reported by 7.5\% of sexually active
women (1), is a multifactorial bio-psychosocial phenomenon and carries
extensive physical, mental and social implications. Causes include
bio-medical factors such as vulvovaginal skin conditions, iatrogenic
factors, and hormonal changes (2). The most common aetiologies of
long-standing dyspareunia are provoked vestibulodynia (PVD), a chronic
vulvar pain condition, with prevalence ranges of 10\%-28\% in women of
reproductive age (3,4), and vaginismus, a reflexive, involuntary pelvic
muscle tightening with prevalence ranges of 5\%-17\% (5).

Despite the high prevalence of dyspareunia, surprisingly few studies
have addressed reproductive function in women with this condition, with
inconsistent results. Some studies have shown dyspareunia to be related
to a higher need for assisted reproductive techniques (ART) (7,8), while
others have not identified such an association (9). Studies in women
with dyspareunia have observed a higher risk for cesarean section,
instrumental delivery (8) and perineal lacerations (10,11). Women with
dyspareunia were also found to experience postpartum perineal pain
longer than comparisons (9).

So far, studies on reproductive outcomes in women with dyspareunia have
focused mainly on obstetrical parameters. There are indications that
women with dyspareunia express fear of delivery (12), yet reports on
their actual experience of labor are restricted to pain and anxiety
levels and largely based on midwives' impressions (11). Excluding a
single study which used a qualitative methodology (13), no research has
focused on emotional and cognitive parameters or on maternal adjustment
after childbirth in women with dyspareunia. The aim of this study was to
assess obstetrical outcomes, perceptions of childbirth experience and
emotional adjustment following childbirth, among women with a history of
dyspareunia.

\textbf{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.

\textbf{Statistical analysis}

The statistical software package~SPSS 27 was used to analyze the data.
Missing data analysis indicated that, across variables measured by the
self-report questionnaires, 0-10.3\% of values were missing. Missing
data were replaced with expectation maximization algorithm, based on all
variables in the model.

A serial of Chi square and t tests analyses were used to examine
differences between the dyspareunia group and the comparison group in
demographic data, obstetric outcomes, perceptions of birth, and
adjustment following the childbirth.

Finally, to explore the specificity of the effects of dyspareunia on
study variables, Chi square analyses and univariate analyses of variance
(ANOVAs), examined the associations between pain experienced during
pelvic examinations, and obstetric outcomes, perceptions of birth, and
adjustment following the childbirth.

\textbf{Results}

One hundred and fourteen (29.3\%) participants reported having
experienced some extent of pain during intercourse. Of them, 69 (60.5\%)
women reported superficial dyspareunia and 16 (14\%) reported deep
dyspareunia. Eighteen participants (15.8\%) reported primary
dyspareunia, eight (7.0\%) secondary dyspareunia, and 88 participants
(77.2\%) did not recall the timing of pain onset, or did not respond.
Only 24 participants (17.4\%) had consulted with a practitioner
regarding dyspareunia. Eleven women (8.0\%) had received a diagnosis,
including yeast infection, vulvovaginitis, vaginal dryness, PVD,
vaginismus, pelvic floor overactivity, retroverted uterus, uterine
leiomyoma. Ten women (7.2\%) had received treatment, including pelvic
floor physiotherapy, local creams, psychosexual treatment or vulvar
vestibulectomy. Seventy-one women (18.3\%) reported dyspareunia in at
least one-third of intercourse episodes. According to this cutoff,
participants were classified into the dyspareunia group (n=71,18.3\%) or
the comparison group (n=317, 81.7\%).

More women in the dyspareunia group suffered pain during transvaginal
ultrasound and pelvic exam, as compared to comparisons (34.3\% vs
14.6\%, p\textless{}0.001; 39.4\% vs 13.6\%, p\textless{}0.001,
respectively). In addition, more women in the dyspareunia group reported
experiencing pain while performing internal checks and inserting
tampons, as compared to comparisons (8.6\% vs 1\%, p\textless{}0.001;
8.5\% vs 3.2\%, p\textless{}0.001, respectively).

The participants' demographic data and obstetric outcomes are shown in
Table 1 and Table 2. The two groups did not differ in demographic and
clinical characteristics. History of ART was similar between groups
{[}13 (18.3\%) vs. 34 (10.9\%), p=0.09{]}. As for obstetric outcomes,
more participants from the dyspareunia group had premature delivery
versus comparisons (14.1\% vs 5.6\%, p=0.02, respectively), and in
accordance, the mean birthweight was lower in the former group
(BW=3100.76\selectlanguage{ngerman}±550.73 vs. 3253.95±482.45, p=0.01, respectively).

No difference between groups was found in prevalence of high-risk
pregnancies {[}18 (26.5\%) vs. 70 (23.6), p=0.61{]} and labour induction
(Table 2). Type of analgesia used during labour, rate of cesarean
sections, operative vaginal deliveries and perineal tears were similar
between groups (Table 2).

Participants' perceptions of childbirth experience are presented in
Table 3. Although the two groups did not differ in their reports on pain
and perceived threat to their lives or that of the baby during delivery,
participants in the dyspareunia group reported lower levels of sense of
control (p=0.01) and perceived support (p\textless{}0.001), as compared
to comparisons.

Table 4 presents the participants' emotional reactions and adjustment
during and following childbirth. Participants in the dyspareunia group
reported higher levels of perinatal dissociation (p\textless{}0.001),
ASD symptoms (p\textless{}0.001), depression (p=0.02), negative affect
(p\textless{}0.001), lower levels of bonding with the baby
(p\textless{}0.001), and anticipated maternal self-efficacy (p=0.01).
The two groups did not differ in their reported levels of positive
affect.

Further analyses examined the associations between participants' reports
on pain during pelvic exams and obstetrical characteristics, birth
perceptions, and adjustment following childbirth. Pain during pelvic
exam was not related to preterm delivery (p = 0.68), birthweight (p =
0.74), route of delivery (p = 0.86), type of analgesia (p = 0.47), and
perineal tears (p = 0.68). Pain during pelvic exams was associated, with
nature of labour onset: more participants who did not experience pain
had spontaneous labour onset (n=90, 53.9\%) as compared to those who
reported always (n=21, 31.8\%) or occasionally (n=59, 44.1\%)
experiencing pain during pelvic exams. Fewer participants who did not
report pain on pelvic exams had cervical ripening (n=11, 6.6\%) as
compared to those who reported always (n=9, 13.6\%), or occasionally
(n=18, 15.3\%) experiencing pain during pelvic exams (p=0.02).

Pain experienced during pelvic exams was not related to participants'
reports regarding pain during delivery (p = 0.66), perceived threat for
their life (p = 0.75), or that of the baby during delivery (p = 0.41),
sense of control during delivery (p = 0.28), perceived support from the
staff (p = 0.17), ASD symptoms (p = 0.67), dissociation (p = 0.18),
depression symptoms (p = 0.07), positive affect (p = 0.66), bonding to
the baby (p = 0.92), and maternal self-efficacy (p = 0.39). Participants
reporting pain during examinations had higher levels of negative affect,
as compared to those who do not experience pain (1.81 ± 0.86 vs. 1.55 ±
0.63, p=0.03).

\textbf{Discussion}

\textbf{Main Findings}

In our cohort, 18.3\% reported significant dyspareunia. We observed more
preterm deliveries in the dyspareunia group and no difference between
groups in other obstetrical outcomes. Women with dyspareunia reported
lower sense of control and perceived staff support, despite similar pain
levels and perceived threat for their or the baby's lives. Women with
dyspareunia reported higher dissociation, ASD-related symptoms,
depression, negative affect, lower bonding and maternal self-efficacy.
Women with pain during pelvic exams had less spontaneous labor onset,
more cervical ripening, and higher levels of negative affect.

\textbf{Strengths and limitations}

Despite our study's cross-sectional design, which does not allow us to
determine causality but only a relationship between variables, we have
gathered important data on obstetrical outcomes, childbirth experiences
and emotional adjustment in women with dyspareunia. The lack of effect
of pain during pelvic exams on the study variables, further validates
our findings, by demonstrating the specific effect of dyspareunia on
women's experiences. To our knowledge, the latter topics have not been
addressed in the medical or psychosocial literature so far.

There are several limitations to this study. Firstly, we used a
non-validated screening tool for dyspareunia assessment. The cohort
included women in the immediate post-partum period, therefore we
considered available validated tools unsuitable, as they are designed
for non-pregnant women and inquire on sexual activity during the last
few weeks. We therefore selected a questionnaire (11) specifically
developed and utilized for post-partum women. Some questionnaire items
indicate a possible aetiology for dyspareunia, nevertheless the
condition was established according to self-report, which by itself does
not allow a precise medical diagnosis. Potential recall bias is a major
limitation, given the lack of pre-delivery comparative data. As for
obstetrical parameters, selection bias of participants is plausible: for
ethical reasons, we excluded women in critical conditions or with
negative outcomes. Therefore, our cohort included mostly uncomplicated
deliveries. Lastly, this is a convenience sample in a single study
center, with understandable threat to external validity.

\textbf{Interpretation}

The observed prevalence of dyspareunia in this study is similar to
established epidemiological data (3). In obstetrical cohorts, the
prevalence of dyspareunia has varied from 0.06\% (8) to more than 40\%
(11). An explanation for this discrepancy may be different study
populations and methodologies: some studies identified subjects
according to a specific diagnosis in the medical records, such as
``vaginismus'' or ``provoked vestibulodynia (PVD)'' (8,10), while others
have relied on self-report by patients (11).

Our study indicates similar mode of delivery in women with and without
dyspareunia, confirming previous findings (11) and conflicting with
studies showing a higher likelihood of cesarean deliveries in women with
dyspareunia (8). We observed no difference between groups in rate or
severity of perineal lacerations. This contrasts with previous data
indicating increased risk for perineal tears in women with dyspareunia
(10) and showing a correlation between perineal lacerations and
dyspareunia severity (11). This discrepancy may be attributed to a
selection bias, as there were no perineal tears grade 3-4 in our cohort.

We found no difference in rate of ART between groups. Likewise, Nguyen
et al. (9) reported similar rates of conception in women with PVD versus
comparisons. Conversely, studies focusing on women with vaginismus (7,8)
have reported a high rate of ART. This discrepancy may stem from
different coping strategies in vaginismus versus PVD. Women with
vaginismus tend to be ``fear-avoidant'' and refrain from intercourse,
hindering their ability to conceive, while women with PVD are
``task-persistent'' and continue to have intercourse despite pain (26).

The relationship between dyspareunia and pre-term labour has not been
previously described, however studies have pointed out a connection
between chronic pelvic pain conditions and pre-term labour. A systematic
review (27) has suggested a relationship between endometriosis (28) and
preterm delivery, through hyper-expression of pro-inflammatory mediators
involving changes in gene expression, oxidative stress, local estrogen
production and progesterone resistance. When such changes occur earlier
than at pregnancy term, the contractile activity of the myometrium is
triggered, leading to preterm labour (29). Some studies have shown a
heightened systemic inflammatory response in PVD (3,30) and we suggest
that an inflammatory mechanism may be plausible in women with
dyspareunia.

The literature regarding emotional strategies for approaching
reproductive events in women with dyspareunia is scarce. A study (13) on
the impact of vulvodynia on thoughts and feelings on reproduction
identified some central themes: efforts to reach acceptable pain levels
before pregnancy; disconnect between dyspareunia treatment and obstetric
care, anxiety and hopefulness regarding pregnancy. Rather than on
conception and pregnancy, in our study we focused on women's perception
and emotional adjustment to childbirth.

We observed that women with dyspareunia are discontent with obstetric
care, confirming previous data showing greater negative affect, more
interpersonal and social discomfort (31) and mistrustful attitudes of
women with dyspareunia toward health care providers (13). A study (32)
exploring personality traits of women with PVD found evidence of
cautiousness, insecurity, pessimism, shyness in social situations, along
with a tendency to be intolerant, impatient and critical of others.
Another recent study (33) observed social anxiety and paranoid ideation
in women with dyspareunia. The low level of sense of control experienced
by our dyspareunia patients is aligned with previous data (32)
indicating reports by women with dyspareunia that their attitudes,
behaviours and choices were determined by influences outside their
control or against their own will. Expert opinion on management of women
with dyspareunia during labour and delivery has indeed emphasized the
importance of practices that increase women's sense of control (34).

We observed more perinatal dissociation in women with dyspareunia. A
relationship between dissociative symptoms and chronic pelvic pain
states has been previously suggested (35). Recently, Farina et al. (36)
conceptualized dyspareunia as a somatoform dissociative symptom and
found an odds ratio of 6.15 of psychoform dissociation in women with
dyspareunia. Similarly, Özen et al. (37) found high rates of somatoform
dissociation in dyspareunia patients. Our study corroborates these data
and is, to our knowledge, the first study specifically assessing
perinatal dissociation in women with dyspareunia.

Women with dyspareunia reported more ASD-related symptoms, depression,
negative affect, lower maternal bonding and self-efficacy. Previous
research has indicated depression (3,38--40), anxiety (31,38,40--42),
obsessive-compulsive and phobic symptoms (42) are common co-morbidities
in dyspareunia. Regardless whether these affective states represent a
personality style predating pain onset, or are a product of the
prolonged pain experience, they constitute potential risk factors for
negative affective reactions to childbirth.

We observed less spontaneous labour onset, more cervical ripening, and
higher negative affect in women experiencing pain during pelvic exams.
The presence of high anxiety levels, known to be related to increased
need for induction of labour (43,44), may explain this relationship.
Pain during pelvic exams is often related to anxiety, which results in
phasic activation of the perineal muscles as part of a guarding response
(45).

\textbf{Conclusion}

Our findings point on comparable obstetric outcomes in women with and
without dyspareunia, except for more preterm deliveries in the former
group. Women with dyspareunia scored worse on parameters of emotional
distress during childbirth and maternal adjustment following childbirth.
Women with dyspareunia are reluctant to disclose their history to
medical professionals, however they do not feel at ease with the
disconnect between dyspareunia treatment and perinatal concerns. In
light of the complexity of such experiences, future studies should
assess whether screening for dyspareunia and validating its broad impact
during prenatal care may improve emotional outcomes.

\textbf{Disclosure of interest}

Anna Padoa Receives annual royalties from Springer as co-editor of the
book ``The Overactive Pelvic Floor'' and is Board member of the
International Society for the Study of IC/BPS (ESSIC).

Authors have no additional disclosures.

\textbf{Contribution to authorship}

Study conception: AP, IB, IL, AT, KG

Study planning: AP, IB, IL, AT, KG

Conduction of study: AP, RT, AG, MSI, YR, AT, KG

Analysis of data: AP, IB, IL, AT, KG

Writing and Editing: AP, IB, IL, AT, KG

\textbf{Ethics approval:}

The study has been approved by the ``Shamir-Assaf Harofeh IRB'' and by
the Ethics Committee at Tel Aviv University.

Date of approval: November 2\textsuperscript{nd}, 2017

Study reference number: 0232-17-ASF

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3. Pukall CF, Goldstein AT, Bergeron S, Foster D, Stein A, Kellogg-Spadt
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