Introduction

Child delivery and giving birth is considered the most significant event of a woman’s life. In fact, no other life events have such physical, emotional, and social effects on the life of a woman and her relatives (1).

Marital satisfaction refers to the couples’ feelings of content and happiness resulting from marriage and partnership (3); in fact, it is considered a key factor in strengthening and preserving marriage (4). During pregnancy and after delivery, a considerable decrease is often observed in couples’ emotional intimacy; also, transition to parenthood is often associated with a reduction in marital satisfaction (2).

According to the data presented by The Statistical Center of Iran, divorce rate has increased in recent years (5). Divorce rate, which is one of the most important indicators of marital distress, suggests that marital satisfaction cannot be simply achieved (6). In fact, divorce is a major social issue, which causes many negative consequences and problems, both at social and personal levels. These consequences affect husbands, wives, and even children (7).

Marital satisfaction is a complex process which is achieved during the couple’s life, and affects the health of couple and their families, life satisfaction, income level, educational success, and the couple’s job satisfaction. Couples who have a desirable marital communication and understanding enjoy a better health status.

The life quality of couples is affected by the birth of a child (3, 8-10). Pregnancy-related issues, child delivery and birth, and infant care negatively affect marital satisfaction. Moreover, pregnancy and delivery weaken the relationship between the couples (11). Twenge (2003) in a meta-analysis showed that childbirth and parenthood leave a negative impact on marital satisfaction, and lead to increased conflicts between the married couple (12).

The strength of marriage is influenced by several contributing factors. In other words, the married couple cannot experience great satisfaction in their marital life if these factors are ignored (13). Studies have indicated that diverse factors such as emotional, physical, and sexual aspects along with mutual religious beliefs contribute to the duration, stability, and satisfaction of marital life (14-16). Moreover, marital satisfaction is associated with various other factors such as friendship, companionship, affection, personal characteristics, parenting styles, and sexual relationship (17).

Individual and family-related factors (demographic characteristics) are among the predicting and most significant factors, which contribute to marital satisfaction (3, 11). Numerous studies have mentioned the contradictory effects of individual factors on marital satisfaction. In studies by Golmakani (2013), Yousefi (1995) and Rahmani (2009), it was shown that no significant relationship can be found between marital satisfaction, maternal age, and educational level (18-20); however, in the study by Ghafourvand and Maghsoudi, the educational level was a predicting factor for marital satisfaction (21, 22).

According to Atari’s study (1997), there was a significant relationship between economic status, marriage duration, and marital satisfaction; though in the study of Rahmani (2009), no significant association was reported between the income level, marriage duration, and marital satisfaction (11, 20).

On the other hand, there is evidence regarding the high risk of psychological change in women during the first year after childbirth (23). Fear of childbirth, infant care, and the feeling of being unattractive to the husband lead to anxiety in mothers, and change the postpartum period to a vulnerable stage for mental disorders (10). In the studies of Shirjang (2012) and Gotlib et al. (2004), marital satisfaction was significantly associated with postpartum depression, while in the studies of Anton et al. (1989) and Bergant et al. (1999), marital satisfaction was not significantly associated with postpartum depression (10, 24, 25).

The importance of marital satisfaction in the physical and mental health of couples, their families, and community in general, cannot be doubted. The findings of different reports with regard to factors contributing to marital satisfaction are numerous and sometimes inconsistent. Given the fact that the relationship between psychological factors and marital satisfaction has been less considered in Iran, this study was performed with the aim to evaluate the factors associated with marital satisfaction in primiparous women during the postpartum period.

Materials and Methods

This correlational study was performed in 2013, on 104 primiparous women, who met the inclusion criteria, and referred to the health and medical centers under the coverage of Mashhad Health Center No.1. In this study, multi-stage sampling was conducted, and among five health centers in Mashhad, Health Center No.1 was randomly selected. Afterwards, 9 affiliated centers were chosen, based on the number of referrals for postpartum care and infant vaccination.

Using convenient sampling method, the subjects were selected from primiparous women, who had referred to the health centers for infant vaccination and other services. The sample size was determined using mean comparison.

The subjects who met the following criteria were included in the study: 1) primiparity, 2) Iranian nationality, 3) resident of Mashhad, 4) literacy (the minimum), 5) having a healthy infant, 6) referral after 8 weeks of vaginal delivery, 7) living in monogamy, and 8) living with the spouse. The exclusion criteria were postpartum complications and specific mental and physical disorders.

The sample size was determined using Cochran’s formula. The women who were eligible to participate in the study and referred to the health centers, were asked to participate in the study. After obtaining the written consents, they were transferred to a quiet and empty room in the health center, and were given instructions on how to answer each questionnaire; afterwards, they completed the survey forms.

Data collection tools included Azarin Nathan H. marital satisfaction questionnaire, stress, anxiety, and depression scales (DASS-21), and demographic and fertility questionnaire, consisting of four sections of individual/family characteristics, sexual relationship, pregnancy, and infant.

DASS-21 consisted of 21 items measuring stress, depression, and anxiety (7 items for each scale); each item was given a score from zero to three. Scores 0 (minimum) and 3 (maximum) were allocated to the item if it “did not apply” and “often applied” to the person, respectively. The scores 1 and 2 were given to the items which “sometimes” and “relatively many times” applied to the person, respectively; the highest score in each of the subgroups was 21. Regarding the aspect of stress, a score between 0-14 was normal, 15-18 was mild, and 19-21 was considered moderate to severe. Considering the aspect of anxiety, a score of 0-7 was normal, 8-9 was mild, and 10-21 was considered moderate to severe. With regard to depression, a score of 0-9 was normal, 10-13 was mild, and 14-21 was considered moderate to severe.

The validity of the demographic form was confirmed using the method of “content validity”, and the reliability was confirmed by assessors’ agreement, with a correlation coefficient of r=0.83. The questionnaire of marital satisfaction was a revision of Azarin Nathan H. questionnaire, rating from 1 (completely dissatisfied) to 10 (completely satisfied).

In this questionnaire, the minimum and maximum obtained scores were 8 and 80, respectively. A score of 8-57 indicated poor marital satisfaction, 58-69 showed average marital satisfaction, and 70-80 was an indicator of good satisfaction. The scientific validity of the simultaneous measurement of stress, anxiety, and depression scales was confirmed by Sahebi (1987); also, the reliability of this form was confirmed by Sahebi in Mashhad, Iran (with r=0.9) (32).

The modified marital satisfaction questionnaire of Azarin Nathan H. was designed by Azarin, Naster, and Jenz (1973), and revised by Bernstein Wilson et al. (1935). In Iran, the reliability and validity of this form was confirmed by Heidari (1991) in Mashhad School of Nursing and Midwifery, using the method of equivalent reliability (r=0.71); P

In the current study, the statistical descriptive tests of Kruskal-Wallis and Pearson correlation were performed using SPSS v16. P-value less than 0.01 was considered statistically significant. This study was approved by the Ethics Committee of Mashhad University of Medical Sciences. Additionally, ethical considerations such as the confidentiality of the data were considered during data collection.

Results

Demographic data showed that the mean age of women and their spouses was 25.88±3.9 and 30.33±4.8 years, respectively. Of all participants, 48.1% had high school diploma, and 79.8% were housewives. The mean duration of their marriage was 3.88±1.9 years, and 70.2% of the subjects had sufficient income; also, 50% of the participants were tenants.

In 77 cases (74%), pregnancy was planned and contraceptive methods were ceased in 38 subjects (36.5%). The frequency of postpartum intercourse was less than once per week in 49 participants (47.1%), and the mean time for starting sexual relationship after delivery was 42.2±9.2 days. In 91 subjects (87.5%), their infants were breastfed.

The mean scores of depression, anxiety, and stress were 6.14±2.97, 6.30±2.82, and 8.64±3.24, respectively (within the range of 0-21). The study results showed that 90 (86.5%), 81 (77.8%), and 78 (75%) women were in the normal range, regarding depression, anxiety, and stress scales, respectively(Table 1).

A significant inverse relationship was observed between marital satisfaction and the couple’s age (P=0.03, r=-0.203 for women and P=0.02, r=-0.219 for husbands, respectively). Other individual/family factors were not significantly associated with marital satisfaction (Table 2).

An inverse significant correlation was observed between marriage duration and marital satisfaction (P=0.03, r=0.203). Also, a significant direct relationship was observed between marital satisfaction, the onset of sexual intercourse after delivery (P=0.006, r=-0.268), and the frequency of intercourse per week (P=0.001) (Table 3).

The results of this study showed no significant association between planned pregnancy (P=0.13), pregnancy duration (P=0.79), and type of infant feeding (P=0.17). However, the neonate’s birth weight was significantly associated with the total score of marital satisfaction (P=0.03).

Also, the findings showed a significant inverse correlation between marital satisfaction and depression, anxiety, and stress. There was also an inverse and significant relationship between all aspects of marital satisfaction and depression, anxiety, and stress, except for financial issues and husband’s independence (r=-0.1 to -0.41). The lowest and highest scores of marital satisfaction were obtained in terms of sexual satisfaction and affection, respectively (Table 4).

Discussion

The present study aimed to investigate the factors contributing to marital satisfaction in primiparous women during the postpartum period.

In this study, there was a significant inverse relationship between marital satisfaction and stress, anxiety, and depression; postpartum marital satisfaction was lower in women with higher levels of depression, anxiety, and stress. The obtained results are consistent with the findings of Beck (2001), Gotlib (2004), Abedini (1996) and Shirjang (2012) (10, 24, 26, 27).

Beck et al. (2001) in their study reported that marital satisfaction is among the predicting factors for postpartum depression. Salehi Fardi (1996) also states that marital and family satisfaction affects the stress level of an individual (28); though, the results are inconsistent with the studies of Anton et al. (1989) and Bergant et al. (1999). It seems that the variation in the results may be due to cultural, ethnical, attitudinal, and lifestyle differences in the studied populations.

 In this study, there was no significant relationship between education level and marital satisfaction; this is consistent with the results of Atari (2007), Yousefi (2005), Rahmani (2009), Afkhami (2013), Bakhshayesh (2009) (11, 19, 20, 29, 30), and inconsistent with the studies of Agha Mohammadian (2006), Maghsoudi (2011), (2005), and Mirghafourvand (2013) (13, 22, 21).

Several studies indicated that education plays an important role in marital life. Lack of education leads to disagreement or even divorce among couples (3). Mirahmadizade and colleagues reported that educational level was significantly lower in divorced couples (32).

Lack of association between education and marital satisfaction in this study could be due to the high educational level of most of the participants (about 90% were educated individuals with high school diploma and higher educational degrees). In fact, the number of subjects with low educational level was very low in the current study, and lack of educational disparity led to the similarity in the educational level of the participants. Therefore, the higher level of education caused no change in the mean score of marital satisfaction.

In this study, there was an inverse relationship between marriage duration and marital satisfaction. In other words, marital satisfaction decreased with increasing marriage duration; this result is consistent with the findings of Jadiry (2009), Atari (2007) and Banifatemeh (2009) (3, 11, 33), and inconsistent with the results of Bakhshayesh (2009) and Yousefi (2005) (30, 19).

It can be concluded that couples who are in the first stages of their marriage have high satisfaction rates, due to factors such as affection, and lack of problems. With increased duration of marriage, the couples deal with different problems including economic issues and new challenges; eventually, these issues negatively affect the couple’s marital satisfaction.

According to the results, there was a direct correlation between the onset of sexual intercourse after delivery, the frequency of intercourse, and marital satisfaction. However, in the study of Golmakani (2013), no relationship was found between the onset of sexual intercourse after delivery, the frequency of intercourse per week, and marital satisfaction (18). This variation in the results could be due to the differences in the type of sampling and the target population.

 Many studies have indicated the positive effect of sexual intercourse on marital satisfaction (18-20, 30, 35). The joy and satisfaction of sexual desires is one of the most important pleasures a person can experience during his/her life. In fact, sexual pleasure can decrease many everyday life issues and marital disputes (4).

After child delivery, the quality of a couple’s life is affected by childbirth, since marital satisfaction is related to anxiety, stress, and depression; therefore, more empathy, respect, and support should be provided by the husband for his partner.

One of the limitations of the present study was the inclusion of women who had referred to medical health centers to receive services, without considering other populations; therefore, this factor can limit the generalizability of the study. The strength of this study was the use of valid and reliable instruments, which have been validated in many studies, particularly in Iran.

Conclusion

This study showed that the age of women and their spouses, marriage duration, time and frequency of sexual intercourse after delivery, stress, depression, and anxiety are among factors contributing to marital satisfaction. Since marital satisfaction affects the health of couples and their families, women's marital satisfaction can be increased during the postpartum period by recognizing the related factors and proper planning.

Given that this study was conducted only on primiparous women with vaginal delivery, it is recommended that further studies be performed on multiparous mothers, and women with cesarean section deliveries. In addition, the questionnaires should be filled by the couples to compare marital satisfaction and the contributing factors for women and their husbands.

Acknowledgment

This study was funded by the Research Council of Mashhad University of Medical Sciences. The authors would like to thank the Research Council, all the personnel of health centers in Mashhad, and the participants of this study.

Conflict of Interest

No conflict of interest exists.