Depression and sexual dysfunction are major postpartum health concerns. The prevalence of postpartum depression has been reported from 0-60% in many Eastern and Western countries  (1). Childbirth is a known risk factor for increasing depression risk in women. In total, 35% to 40% of women experience depressive symptoms after childbirth (2). The prevalence rate of postpartum depression in Iran is reported as 25% (3).

The prevalence rate of anxiety after childbirth has been reported to be 25-45%. Anxiety is a common problem during the postpartum period. Stress after childbirth is a distinct negative emotional condition. Many women experience postpartum anxiety, which is associated with a high prevalence of depression. (4). Difficulty in the relationship between the spouses is a risk factor for postnatal depression (PND). Loss of sexual desire after childbirth and a decrease in intercourse at 3 months postpartum are reported in women with PND. According to Elliott and Watson (1985), a relationship was detected between PND and women's decreased sexual interest, enjoyment, frequency, and satisfaction during 6 months after childbirth, which reached significantly by 9 and 12 months after delivery (5).

Tiredness and weakness are among the reasons for the loss of sexual desire during late pregnancy and after the childbirth (2). Sexual dysfunction is a risk factor for depression during the first 24 months after childbirth. During the entire 24 months after childbirth, sexual dysfunction is reported by 14.9-66.7% of women. Sexual dysfunction causes the risk of postpartum depression. The prevalence rate of sexual dysfunction in women has been also globally estimated at 30-50%, and this value is reported as 31.5% in Iran (6, 7). The women with reported sexual dysfunction and decreased sexual satisfaction have an elevated risk of depression during the entire 24 months after childbirth (1). Depression, anxiety, and sexual dysfunction constitute a continuous cycle in which sexual dysfunction can lead to anxiety and ultimately depression and vice versa (8).

Despite the prevalence of sexual dysfunction, both physicians and women may delay talking about sexual concerns after pregnancy that is due to having a sense of discomfort in terms of starting conversations about sex or absence of appropriate training by healthcare providers to provide a proper sexual history from clients. In this regard, according to the literature, only 19% of 67 women with postpartum sexual dysfunction shared their sexual problems with healthcare providers (9).

Numerous approaches have been proposed for sexual counseling, including PLISSIT, known as one of the most commonly used models (10). The PLISSIT model comprises 4 levels, namely 1-Permission, 2-Limited Information, 3-Specific Suggestions, and 4-Intensive Therapy (11). It should be noted that ruling religious and cultural values in Iran make women not share their sexual dysfunction with counselors. Furthermore, considering the fact that the results of studies in this domain have suggested the use of different counseling approaches to reduce women’s postpartum sexual dysfunction (11-13) and due to lack of investigations conducted  on comparing counseling approaches for the reduction of female postpartum sexual dysfunction up to now, the present study aimed to assess the effectiveness of the PLISSIT model on depression, anxiety, and stress in women with sexual dysfunction after childbirth.

Materials and Methods

This two-group randomized clinical trial was conducted on 80 women referring to eight selected healthcare centers with a sexual complaint within 4 weeks to 6 months after childbirth in Mashhad, Iran, from August to March 2017. The eight health centers were selected by the simple random lottery method. There was no similar study in this regard; accordingly, the sample size was calculated at 38 individuals with 80% test power and 95% confidence interval to produce an effect size equal to 65%; however, the sample size was determined as 45 patients in each group due to 20% sample loss.

The inclusion criteria in this study were being married within the age range of 18-45 years, obtaining a score equal to or lower than 28 based on the female sexual function index  (FSFI), being able to speak, read, and understand the Persian language, giving birth to a healthy term neonate in recent pregnancy, in the 4^th weeks to the 6^th months of the postpartum period, starting to have sexual intercourse after childbirth, having a stable relationship with husband, with no infection, chronic diseases, or epilepsy, no alcohol abuse and addiction to opioids and other psychoactive substances, no infliction with chronic psychological illnesses, such as anxiety, and no sexual dysfunction before and during pregnancy.

The Depression, Anxiety, and Stress Scale-21 (DASS-21) was completed by eligible candidates to rule out the women affected with severe-to-moderate depression, anxiety, and stress to refer to a psychologist. The exclusion criteria were attending courses on sexuality training during this study, alcohol or drug abuse, and consumption of medications affecting their sexual functioning or that of their husband, prostate problems, schizophrenia, and sexual disorders in their spouse.

At the baseline, a total of 90 women were eligible for the participation, and 10 women were excluded from the study (Figure 1). Written informed consent was obtained prior to randomization, and the demographic and sexual characteristics questionnaire and FSFI were completed by the subjects. The participants were randomized into one of the two study groups, namely PLISSIT or control. According to a preexisting list produced by a computer program, 80 women were assigned randomly to each group. The first author enrolled participants and consulted with the women, and the second author assigned the cases to the intervention or control group.

The subjects in the PLISSIT group attended two sessions and received one-on-one weekly consultation for 2 weeks in the counseling room of the centers (each session lasted 60-90 min). The consultation time was equal for all women. The subjects in the control group received routine care in health centers.

The data collection instruments included a demographic and sexual characteristics questionnaire, FSFI, and DASS-21. The demographic and sexual characteristics questionnaire contained 30 items developed after reviewing the latest international books and articles on the topic of study validity of which was also determined by content validity. Therefore, after the preparation of the questionnaire, it was submitted to seven faculty members and professors of Mashhad University of Medical Sciences for validity. The FSFI included 19 items evaluating female sexual functioning in six domains of sexual desire, sexual arousal, vaginal lubrication, orgasm, sexual satisfaction, and pain during intercourse (14).

The reliability of the index has also been confirmed in Iran by Mohammadi et al. (2008), and its subscales were confirmed rendering a Cronbach’s alpha coefficient of 0.7 (15). In the present study, the reliability of the given questionnaire calculated by Cronbach’s alpha coefficient was determined as 0.82. The DASS-21 items are scored based on a 4-point Likert scale from 0 (not applied to me at all) to 3 (applied to me very much or most of the time). Higher scores indicate morefrequent symptomatology. Seven items comprise each of the three scales, including depression, anxiety, and stress (16).

 In another study, Antony et al. (1998) analyzed the scale. The results of the aforementioned study showed that 68% of the total scale variance was assessed by these three factors. The special value of the stressors, depression, and anxiety factors in this study were equal to 9.07, 89.2, and 23.1, and Cronbach’s alpha coefficients for these three factors were 0.97, 0.92, and 0.95, respectively (17).

In a study conducted by Sahebi et al. (2005), the internal consistency of DASS-21 was calculated using Cronbach's alpha coefficient obtained at 0.77, 0.79, and 0.7 for depression, anxiety, and stress scales, respectively. The validity of this form has been confirmed according to a structural narrative study conducted by Sahebi et al. in Iran in 2005 (18). In the aforementioned study, the reliability of the DASS-21 questionnaire was determined using a Cronbach's alpha coefficient of 0.80 for the whole questionnaire.

It should be noted that the researcher (first author) had obtained the certificates of participation in a sex therapy training course, dyspareunia and vaginismus workshops, as well as medication therapy in sexual disorders, and a course of sexual counseling with a psychologist. The PLISSIT counseling model included a 4-level process in which the first and the second levels could be conducted within the first counseling session and the third and fourth levels could be performed in the second session.

First session: The purpose was to create a sense of security and relaxation for the patient and allow the individual to speak about her sexual function, which may sometimes be contrary to the counselor's beliefs (i.e., Permission). The counselor began by asking a few open questions about sexual issues and while respecting values, beliefs, feelings, and attitudes, the researcher allowed the subject to talk about sexual problem. Then the counselor provided the client who was directly concerned with her problem with limited information (i.e., Limited Information). Information was also provided for the client about the genital anatomy and physiology, and the changes that were made after the delivery, and sexual function. In addition, sexual concerns in the postpartum period were answered.

Second session: The purpose of this session was to increase the subject’s ability to handle her sexual problems. Firstly, the subject was asked to express the result of the action taken on the solutions presented in the previous session and to express her sexual problems again. Then the counselor offers specific suggestions to enable the woman to manage her sexual problems, such as the emphasis on increasing the time for more vaginal lubrication, developing sexual imagination in case of decreased libido, setting the baby's sleeping hours to spend more time with the spouse (i.e., Specific Suggestions). Furthermore, Intensive Therapy is performed for women who still needed more intervention (11).

In order to prevent sample attrition, the researcher contacted the participants to remind them of counseling sessions. Finally, in the PLISSIT (4 weeks after the last session) and control (4 weeks after receiving routine care) groups, the FSFI and DASS-21 were completed by another person blinded to study. After data collection and coding, data analysis was conducted using SPSS software (version 24) by the Kolmogorov-Smirnov test, Mann-Whitney U test, independent t-test, Chi-square test, analysis of covariance (ANCOVA), and Fisher’s exact test. P-value less than 0.05 was considered statistically significant in these tests.

Demographic and sexual characteristics examined and compared before the intervention between the two study groups were observed to be homogenous in all cases (Tables 1, 2, 3).

  The educational levels of the women were reported as 10% (n=4), 5% (n=2), 3% (n=12), and 50.5% (n=7) in the control group and 2.5% (n=1), 7.5% (n=3), 35% (n=14), and 55% (n=22) in the PLISSIT group for elementary, middle school, high school, and university education, respectively. Moreover, 87.5% and 75% of the cases were housewives in the control and PLISSIT groups, respectively.

As shown in Table 4, the P-value of DASS-21 total

score and domain of ​​anxiety were significant before and after the intervention in the control and PLISSIT groups, respectively (P=0.026, P=0.030).