Introduction

It is considered as the biggest period of compatibility in parent's life especially the mother, and it is associated with psychological and physical stress as the result of neonate's birth, responsibility after delivery, some issues related to caring, and mother and newborn attachment (3). However, most of pregnant women do not attempt for any treatment or may have delay in their decision for treatment because they consider that the psychological issues of this period are merely hormonal changes (1).

In fact, psychopathology in pregnancy and postpartum period is a common event (4). Therefore, psychiatric disorders related to this period, such as psychos and postpartum depression are known phenomena (5). Furthermore, obsessive-compulsive disorder in mothers often occurs after delivery and as the result of facing with health needs of newborn (6, 7). It is a common disorder among women than men and mostly starts in childbearing age due to pregnancy and childbearing, and most of the time it is simultaneously observed, along with depression disorder (1).

According to the diagnostic criteria of fifth version of Diagnostic and Statistical Manual
of Mental Disorders, obsessive-compulsive disorder is recognized by repetitive and permanent thoughts and imaginations, as well as repetitive behaviors in order to respond to these thoughts (7). This disorder is often observed in mothers by the fear of intentional or accidental harming and constantly checking neonate in terms of infection, and frequent washing of hands and preventive behaviors (6). The reason for this disorder is not completely obvious; however, there are some evidences that show some factors, such as genetic and environmental effects, as well as functional abnormalities in neurotransmitters of the brain, which may lead to this kind of disorder (8).

On the other hand, some researchers believe that generally serotonin system disorders are involved in having obsessive thoughts and behaviors. In this regard, it seems that fast fluctuation of estrogen and progesterone levels during pregnancy and postpartum period change the serotonin transmission, reabsorption, as well as connection, and it is associated with intensification of obsessive-compulsive symptoms (9). Consequently, the lifetime prevalence of this disorder in general population is stable and is estimated about two to three percentage, as well as the fact that some environmental stressful factors especially stress of pregnancy, childbearing, or caring of children can accelerate and intensify Obsessive-Compulsive disorder in parents (10).

Therefore, the results of a meta-analysis study showed that prevalence rates of obsessive-compulsive disorder in pregnancy (2.07%) and postpartum period (2.43%) are higher than that in general population (1.08%) (11). Furthermore, the findings revealed the high risk of Obsessive-Compulsive disorder
in pregnancy (12). Meanwhile, postpartum
period is also the time of high risk for
the intensification of obsessive-compulsive symptoms and at least lasts for six months (5); moreover, in chronic conditions, it can affect maternal life and viewpoint toward life (13) and may lead to aggressive behaviors toward neonate (14).

After active brain patterns in response to social and psychological stresses, women with Obsessive-Compulsive disorder may have more stressful and automatic responses toward postpartum issues than their peers (6). On the other side, the results of studies showed that the frequency of abortion in mothers with obsessive-compulsive symptoms is less than that in women without the symptoms of such disorder, and there is no relationship between the severity of obsessive-compulsive symptoms and special complications of midwifery in pregnancy and postpartum period (4).

Consequently, obsessive-compulsive sym-ptoms are accompanied with chronic complications and disabilities, as well as the reduction of life quality in pregnancy and postpartum periods. Given the differentiation of obsessive-compulsive disorder prevalence across different cultures, psychologists believe that the findings of one country regarding this disorder cannot be utilized as scientific, fundamental, and functional principles in other cultures (10, 15). Regarding this, it seems that the early diagnosis of obsessive-compulsive disorder in pregnancy and postpartum period can help the clinicians to outline a general treatment plan to solve maternal problems regarding stressful conditions faced during pregnancy and childbearing and the associated complications by the adoption of early measures and treatments (10).

Meanwhile, due to obsessive-compulsive symptoms the prevalence of women in childbearing ages screened in terms of having such symptoms by psychological counseling before marriage can prevent from the recurrence of these symptoms and cause that disorder and complications with no medical required treatment. Therefore, in order to perform screening, along with associated required costs in three periods of pre-marriage, pregnancy, and postpartum, the efficiency and effectiveness of health centers can be promoted in this regard (1). Consequently, the present study aimed to compare the severity of obsessive-compulsive symptoms in pre-marriage, pregnancy, and postpartum period among women referred to health centers of Mashhad in 2011. 

Materials and Methods

It is a descriptive cross-sectional study carried out comparatively on 900 women (500 women before marriage, 200 pregnant women, and 200 women in postpartum period) referred to health centers of Mashhad, Iran, from May 2011 to February 2012. The subjects were selected by cluster and quota sampling methods. Firstly, three health centers of Mashhad were chosen by convenience sampling method among all health centers of Mashhad and called health center number 1, 2, and 3.

Then, a list of health centers of Mashhad covered by health centers number 1, 2, and 3 was separately provided. The health centers with pre-marriage counseling were selected through the list and the other centers were eliminated. Afterwards, two health centers were chosen from each of the health centers number 1, 2, and 3 through the list using quota sampling and based on the number of their clients for pre-marriage counseling (totally six health centers).

In order to perform sampling from the groups of pre-marriage, pregnancy, and postpartum period, the researcher referred to each of the above-mentioned centers. In pre-marriage group, the selection was from people referred to the centers weekly on even days to receive pre-marriage counseling; in pregnancy group, the selection was conducted from women referred to the centers weekly in a certain day and participated in pregnancy classes, at the end of classes with the permission of trainer and participants.

In order to perform sampling for postpartum group, a list of people covered by each center and passed two to six weeks after delivery was supplied and their phone numbers were randomly taken; then, they were invited to that health center to participate in the study. The sample size consisted of 153 individuals for each group and was calculated based on Abramowitz et al. study (2010) (16), Cochran's formula (unknown sample size) (n=[(t^2 pq).d^2 ].(1+1.N) [(t^2 pq).d^2 -1] ), with a 95% confidence level (α=0.05) and 80% test power (β=0.2). Due to the sample drop and global prevalence of intellectual-practical obsession that is about 2 to 3 percentage, 500, 200, and 200 cases were placed in pre-marriage,  pregnancy, and postpartum groups, respectively.

The inclusion criteria of the present study were the tendency of participants based
on their consent form, reading and
writing literacy, first-time marriage, Iranian nationality, the lack of any kind of psychiatric disorder or drugs consumption associated with psychology, and lack of major stress during the last six months (that was mentioned in the case of that client). The data were obtained using participants' profiles, Madezly obsessive-compulsive questionnaire, and Yale Brown bsessive-compulsive severity scale.

Madezly obsessive-compulsive questionnaire is a standard tool to examine the type and area of obsessive disorders, including 30 items with correct answer=1 and wrong answer=0. The test score is within the range of 0-30 and the higher scores show more obsessive-compulsive symptoms. The cut-off point of the questionnaire is 15 years. The reliability of the questionnaire was confirmed through internal consistency rendering a Cranach's alpha coefficient of 0.86.

Yale Brown obsessive-compulsive severity scale is a standardized tool to evaluate the severity of obsessive symptoms (17). This scale includes 10 components that five of them evaluate obsessive thoughts and the other five items assess obsessive actions. Each component is graded from zero (with no symptom) to four (very intensive symptoms). The subscale score and the total score ranges of obsessive-compulsive severity are from 0-20 and 0-40, respectively.

New studies determine the cut-off point of 17 as the least severity of disorder that requires treatment. The reported scores between 8 to 16 displays mild obsession, between 17 to 23 presents average obsession, between 24 to 31 shows intensive obsession, and between 32 to 40 suggests very intensive obsession. The reliability was confirmed by internal consistency rendering a Cranach's alpha coefficient of 0.79.

After the study was approved by the Ethics Committee of Mashhad University of Medical Sciences, the researcher referred to the selected health centers to obtain data and to verify eligible individuals. The participants should have written consent and then complete demographic characteristic questionnaire and Madezly obsessive-compulsive questionnaire.

Then, the subjects who obtained Madezly obsessive-compulsive questionnaire score of 15 and higher than that were entered to the study to examine their severity of obsessive-compulsive intensity; as well as those that completed Yale Brown obsessive-compulsive scale. The data were analyzed using descriptive statistics, Fisher's exact test, Kruskal–Wallis one-way analysis of variance, and Mann-Whitney U test in SPSS software (version 11).

Results

A total of 900 individuals entered the study, including 500, 200 and 200 individuals in pre-marriage, pregnancy, and postpartum groups, respectively. According to table 1, the most frequent demographic information in pre-marriage group was: 208 students (41.6%), 216 individuals with diploma degree (43.2%), 361 cases with non-family marriage (72.2%), 496 subjects with no physical illnesses background (99.2%), 500 participants with no psychological disorders background (100%), and 497 individuals with no obsessive-compulsive background (99.4%) with thee mean age of 20.9±4.3 years.

The most frequent demographic information of pregnancy group was: 181 housewives (90.5%), 100 cases with diploma degree (50%), 141 individuals with non-family marriage (70.5%), 197 subjects with no physical illnesses background (98.5%), 199 participants with no psychological disorders background (99.5%), 194 individuals with no obsessive-compulsive background (97%), 197 cases with no multiple-birth background (98.5%), 180 subjects with no abortion background (90%), 194 participants with no stillbirth background (97%), 181 cases with no infertility background (90.5%), 193 individuals with no bleeding background (96.5%), 192 subjects with preterm delivery (96%), 191 cases with low-weight neonate (95.5%), 194 participants with no high blood pressure during pregnancy (97%), and 198 individuals with diabetic during pregnancy (99%) with the mean age of 24.8±4.2 years.

The most frequent demographic information for postpartum group was: 185 housewives (92.5%), 101 individuals with diploma degree (50.5%), 135 cases with non-family marriage (67.5%), 197 subjects with no physical illness background (98.5%), 200 participants with no psychological disorder background (100%), 195 individuals with no obsessive-compulsive background (97.5%), 191 cases with no multiple-birth background (95.5%), 174 subjects with no abortion background (87%), 196 participants with no stillbirth background (98%), 181 individuals with no infertility background (90.5%), 199 cases with no bleeding background (99.5%), 179 subjects with no preterm delivery background (89.5%), 180 participants with no low-weight newborn (90%), 180 individuals with no high blood pressure during pregnancy (90%), and 190 cases with no diabetic background during pregnancy with the mean age of 26.1±4.5 years.

According to Table 2, due to the abnormal distribution of obsessive-compulsive severity data, the Kruskal-Wallis test was used to compare pre-marriage, pregnancy, and postpartum groups and the obtained results showed that there was a statistically significant difference between the mentioned groups regarding the mean score of obsessive-compulsive severity (P=0.007). The obtained results of Mann-Whitney U test in two by two comparison of obsessive-compulsive severity showed that there was a statistically significant difference between pre-marriage and postpartum groups (P=0.003) and between per-marriage and pregnancy groups (P=0.007) in terms of the mean score of obsessive-compulsive intensity. However, there was no statistically significant difference between

pregnancy and postpartum groups considering the mean value of obsessive-compulsive severity (P=0.674).

According to Table 2, in order to compare pre-marriage, pregnancy, and post-partum groups, one-way analysis of variance was used due to the abnormal data distribution of thought obsessive severity and the findings revealed that there was a statistically significant difference between the three mentioned groups (P=0.019). The results of Tukey test indicated that there was a statistically significant difference between pre-marriage and pregnancy groups (P=0.013), as well as between pre-marriage and postpartum groups (P=0.017) in terms of the mean score of thought obsessive severity.

However, there was no statistically significant difference between the pregnancy

Table 2. Comparison of mean scores of obsessive-compulsive disorder in pre-marriage, pregnancy, and postpartum groups

Table 3. Frequency of obsessive-compulsive disorder in pre-marriage, pregnancy, and postpartum groups

■ Chi-square test

■■ Fisher's exact test

■■■ Kruskal-Wallis test

■■■■ Analysis of variance test