Women & Health

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Maternal self-efficacy, postpartum depression,

and their relationship with functional status in
Iranian mothers

Fahimeh Fathi, Sakineh Mohammad-Alizadeh-Charandabi & Mojgan

Mirghafourvand

To cite this article: Fahimeh Fathi, Sakineh Mohammad-Alizadeh-Charandabi &

Mojgan Mirghafourvand (2018) Maternal self-efficacy, postpartum depression, and their
relationship with functional status in Iranian mothers, Women & Health, 58:2, 188-203, DOI:
10.1080/03630242.2017.1292340

To link to this article: https://doi.org/10.1080/03630242.2017.1292340

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WOMEN & HEALTH
2018, VOL. 58, NO. 2, 188–203
http://dx.doi.org/10.1080/03630242.2017.1292340

Maternal self-efficacy, postpartum depression, and their

relationship with functional status in Iranian mothers
Fahimeh Fathi, MCsa, Sakineh Mohammad-Alizadeh-Charandabi, PhDb,
and Mojgan Mirghafourvand, PhDc
a
Nursing and Midwifery Faculty, Tabriz University of Medical Sciences, Tabriz, Iran; bSocial
Determinants of Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran; cMidwifery
Department, Tabriz University of Medical Sciences, Tabriz, Iran

ABSTRACT ARTICLE HISTORY

Readiness to care for family, infant, and self are important during Received 3 November 2015
the postpartum period. The objective of this study was to deter- Revised 12 December 2016
mine the relationships of self-efficacy and postpartum depressive Accepted 16 January 2017
symptoms with functional status in randomly sampled Iranian KEYWORDS
mothers (n = 437). The study was cross-sectional and conducted Depressive symptoms;
in 2015. The mean (SD) of the total functional status score was 2.3 functional status;
(0.2) out of a possible score of 1–4. The maximum and minimum postpartum; self-efficacy
scores in infant care were 4.0 and 2.2 and, in social and commu-
nity activity, levels were 3.5 and 1.0, respectively. Significant
inverse correlations were observed between postpartum depres-
sive symptoms and total scores for functional status, self-care,
and levels of social and community activity. A significant positive
relationship was observed between self-efficacy and functional
status and all of its subscales. In the multivariate linear regression
model, postpartum depressive symptoms, nulliparity, and low
income were significantly negatively related with functional sta-
tus; maternal self-efficacy, having a spouse aged 26–35 years,
high school diploma, lower educational level, and the spouse’s
job (shopkeeper) were significantly positively correlated with
functional status. Early diagnosis and treatment of depressive
symptoms and promotion of maternal self-efficacy may improve
overall functional status of mothers in the postpartum.

Introduction
The postpartum is a transition period for mothers in accepting a new infant
into one’s family, and the mother has an adjustment period to accommodate
these changes (Mortazavi et al. 2014). A new mother must prepare to care for
herself, the newborn infant, other children, and manage daily tasks, and first-
time parents face role changes and lifestyle adjustments (Solmeyer and
Feinberg 2011).
Postpartum functional status has been defined as a multi-dimensional
concept that includes self-care, neonatal care, family care, and social and
occupational activities (MacDonald 2011). However, according to the Barkin

CONTACT Mojgan Mirghafourvand, PhD mirghafourvandm@tbzmed.ac.ir Nursing and Midwifery Faculty,

Midwifery Department, Tabriz University of Medical Sciences, South Shariati Street, Tabriz, Iran.
© 2018 Taylor & Francis
 WOMEN & HEALTH 189

index of maternal functioning, postpartum functional status covers a broad

range of functional areas, including self-care, infant care, mother–child
interaction, psychological well-being of mother, social support, management,
and adjustment (Barkin et al. 2010a). Women assume many roles in their
lifetime, with motherhood being among the most difficult and time-consum-
ing (Noor et al. 2015). The maternal role may require the mother to reorga-
nize her life and reassign priorities to handle these responsibilities (McVeigh
2000). During the postpartum period, the mother has to deal with the
complex task of taking care of herself while caring for her newborn(s), and
deal with resource constraints such as money, a lack of social support, and
difficulty accepting help (Barkin and Wisner 2013). An inability to fulfill
one’s social and occupational obligations, while performing self-care activ-
ities and obligations at home, are among the changes that may occur in
adaptation to new motherhood (Aktan 2007).
Personal factors, such as exhaustion, depressive symptoms, and self-effi-
cacy, can affect the functional status of mothers (Barkin et al. 2010b; Webb
et al. 2008). Postpartum depression is the most prevalent psycho-behavioral
disorder in women occurring after childbirth (Pearlstein et al. 2009). It is a
socially disabling disorder with adverse effects on the mother, child, and
family (Patel et al. 2012). Women with postpartum depression may have
difficulty with their housekeeping and social responsibilities; they may find
themselves unable to shower, pay bills, and ask for help for their depressive
symptoms and other health-related issues (Olson et al. 2002).
Self-efficacy refers to one’s individual perceptions of their capabilities in
performing certain tasks (Bandura 1998). Self-efficacy is an important moti-
vational factor for successful social and everyday living skills (French et al.
2014). In addition, self-efficacy affects one’s healthful behaviors and manage-
ment of chronic diseases (Jackson et al. 2014). Maternal self-efficacy refers to
the mother’s perception of her effectiveness as a mother. It is strongly related
to maternal feelings, the extent of one’s self-confidence, and perception of
one’s competence (Teti and Gelfand 1991). Self-efficacy is an important
index for the successful transition to becoming a mother and acquiring the
maternal role and is an important factor related to positive maternal behavior
(Eaton 2007). Maternal self-efficacy and maternal functioning overlap little.
Self-efficacy refers to beliefs and judgments individuals have in their abilities
to perform their duties and responsibilities (Duprez et al. 2016), while
functional status is the readiness to assume necessary responsibilities
(Aktan 2007).
Parental self-efficacy plays an important role in increasing self-confidence
among parents and promoting the abilities of parents to perform parenting
tasks (Abarashi et al. 2014). However, in a study conducted by Cranley
(1981), no significant relationship between self-efficacy and the acceptance
of an infant into the family was observed. Impaired functioning in mothers
190 F. FATHI ET AL.

with postpartum depressive symptoms has been associated with a failure of

the infant to thrive and decreased lactation (Stewart 2007). Some findings
have suggested that mothers can properly care for their infants despite
suffering from postpartum depression (McLearn et al. 2006). Nevertheless,
in a study conducted by Koenigseder (1991), functional status was negatively
correlated with temperament, lasting for 3 days after delivery. Postpartum
depressive symptoms have been shown to be inversely related to maternal
functional status in terms of personal, social, and familial duties; however, no
relationship between postpartum depressive symptoms and infant care has
been observed (Posmontier 2008).
The goal of this study was to determine the relationships between self-
efficacy and postpartum depressive symptoms with functional status. We
conducted this study because: (1) maternal functional status in the postpar-
tum period is important (Aktan 2007); (2) results from prior studies have
been inconsistent (Fawcett, Tulman, and Myers 1988); (3) studies of maternal
functional status during the postpartum period have been lacking in Iranian
samples of women; (4) the high importance of this concept in nursing,
suggesting further inquiry is needed to guide nursing practice (Aktan
2007); and (5) maternal functional status has been related to self-efficacy
and postpartum depressive symptoms.

Materials and methods

Participants
A total of 437 new mothers admitted to various health-care centers in Bonab,
Iran, between February and June 2015 participated in this cross-sectional
study. Bonab is a county in East Azerbaijan province in Iran. At the 2011
census, the county’s population was 129,795 with 37,380 families. The main
language spoken is Azerbaijani.
To participate in this study, participants were required to: (1) be an
Iranian national, (2) be 8 weeks since childbirth, (3) have a neonate with
no abnormalities, (4) not have had a stillbirth, and (5) be willing to partici-
pate in the study. Participants were excluded if they had: (1) a history of
psychological disorders (e.g., anxiety and stress, obsessive-compulsive disor-
ders, and schizophrenia), (2) depressive symptoms pre-pregnancy and during
pregnancy, or (3) an experience of stressful events during pregnancy and
after childbirth, including infant loss, divorce, and pre-term childbirth.
The total sample size needed was estimated to be 437, based on
Khorramirad, Mousavi Lotfi, and Shoori Bidgoli (2010). The desired preci-
sion (d) was 0.05. The mean score was 10.2 ± 3.82 on the Edinburg
Postpartum Depression Scale (overall score ranges between 0 and 30; scores
≥12 indicate the presence of postpartum depressive symptoms) (Kheirabadi
 WOMEN & HEALTH 191

et al. 2012; Kozinszky and Dudas 2015) using a two-sided α = 0.05

and β = 0.1.

Sampling
Random sampling was performed after gaining approval for the study pro-
tocol and the ethics code (5/4/9929) from the Ethics Committee at the Tabriz
University of Medical Sciences. Bonab is a city in the East Azerbaijan
Province of Iran and has three health centers and three health posts. In the
urban areas of Iran, health care is provided by health centers and health
posts. The first line of health-care provision in urban areas is health posts
that are also staffed by three health technicians (usually family health tech-
nician, environmental health technician, and midwife) who are trained at the
university level. The health post is under supervision of an urban health
center. Health centers usually cover two health posts, and typically one health
center is available for every 60,000 people. At health centers, a family health
technician, an environmental health technician, a midwife, a doctor, and a
dentist provide health services. For this study, the sampling was established
based on the proportion of the population served by each health center and
post.
Mothers under the care of the centers or posts and in the first 8–10 weeks
after childbirth were identified from health records. Those with no health
record were identified through the vaccination schedule card of their infants.
Infants were sorted by health record number. The samples were selected
randomly at each location based on the total quota for each center, using
computer-generated random numbers (www.random.org). Selected mothers
were then called and provided with an explanation of the study and invited
to participate. Each woman who was willing to participate was asked to
report to their health center at a specific date and time. Those interested in
the study but not eager to attend the centers were met in person at their
homes by the researcher and provided with information about the study,
methodology, and confidentiality matters. Participants were included in the
study after their signed and written informed consent was obtained.
Interviews were used to collect all data.
The total number of women selected for the sample was 560 and the total
number of those that participated in screening for eligibility when called was
501; of these, 52 women were excluded due to the lack of inclusion or
exclusion criteria, and 12 mothers did not participate in the study due to
lack of time or transportation. A total of 489 mothers were assessed for
eligibility. Of these, 52 women were excluded: 38 due to hospitalization of the
baby, 6 due to having a history of depression and taking antidepressant
drugs, 4 due to premature labor, 2 due to death of close relatives, one due
to congenital deformities of the newborn, and one due to divorce.
192 F. FATHI ET AL.

Instruments and data collection

Sociodemographic information and other data were collected using a ques-
tionnaire developed for this study, the Edinburgh Postpartum Depression
Scale (EPDS) (Montazeri, Torkan, and Omidvari 2007), the Maternal Self-
Efficacy Questionnaire (MSQ) (Teti and Gelfand 1991), and the Inventory of
Functional Status after Childbirth (IFSAC) (Fawcett, Tulman, and Myers
1988).
The sociodemographic questionnaire developed for this study comprised
questions about the woman’s age, educational level, jobs of her parents,
economic status, number of pregnancies, place of residence, whether the
pregnancy was intentional, sex preference for infant, whether the mother
had access to a helper, whether the birth was of a single or multiple infants,
whether postpartum care was received, and where postpartum care, if any,
was obtained. The questionnaire was reviewed and approved by ten faculty
members from the Tabriz University of Medical Sciences.
The MSQ measures the amount of maternal self-efficacy with a concen-
tration on neonatal care responsibilities. It has ten items, including nine
pertaining to maternal activities and one general item, which are scored on
a four-point Likert scale, ranging from 1 (much worse) to 4 (better than
others). A higher score indicates higher levels of maternal self-efficacy. Its
validity was α = 0.79 in the preliminary review and α = 0.86 in the main
study (Teti and Gelfand 1991). The psychometric properties of this scale were
determined in Iran with a Cronbach’s alpha (α) of 0.89 and intraclass
correlation coefficient (ICC) of 0.98, content validity index (CVI) of 0.92,
and content validity ratio (CVR) of 0.94 (Mirghafourvand et al. 2016b).
The EPDS consists of ten items with the overall score ranging from 0 to
30. Scores ≥12 indicate the presence of postpartum depressive symptoms
(Kheirabadi et al. 2012). In a study in Iran, its reliability was confirmed using
Cronbach’s α (0.77) and ICC (0.8) (Montazeri, Torkan, and Omidvari 2007).
In the present study, mothers with scores ≥12 were referred to a psychiatrist.
IFSAC is a specialized instrument for assessing the postpartum functional
status of mothers (Fawcett, Tulman, and Myers 1988). It consists of 36 self-
report items that assess a mother’s ability to take on new responsibilities and
resume old ones across five fields: infant care, self-care activities, house-
keeping activities, social and community activities, and professional activities.
In the subscales of personal care and occupational activities, scores ranged
from 1 = never to 4 = always. A mother was regarded as regaining her
normal functional status if her mean functional status was 3.5 or higher
(Fawcett, Tulman, and Myers 1988). Because new mothers are entitled to 6
months of maternity leave in Iran, the professional activities of study parti-
cipants were not addressed. The psychometric assessment of the
 WOMEN & HEALTH 193

questionnaire was performed by Mirghafourvand et al. (2016a) in Iran with a

Cronbach’s α of 0.73 and ICC of 0.96.
The language of the study population was Azerbaijani. However, the
national language of Iran is Persian, and all the instruments were in
Persian. All participants were fluent in Persian.

Statistical analysis
Data were analyzed using SPSS, version 21. Descriptive statistics, including
frequency, percentage, mean, and standard deviation, were used to describe
all demographic characteristics, self-efficacy, postpartum depressive symp-
toms, and functional status of mothers. Bivariate tests, including Pearson’s
correlation, independent t-tests, and one-way ANOVAs were used to deter-
mine the relationships between functional status and levels of self-efficacy,
postpartum depressive symptoms, and sociodemographic characteristics.
To estimate the relationship of independent variables (self-efficacy, post-
partum depressive symptoms, and sociodemographic characteristics) to the
dependent variable (functional status) and to explain any variance in the
results, those independent variables with p-values lower than .2 in bivariate
tests (Jewell 2003) were introduced into multivariate linear regressions and
were retained using a backward stepwise approach. This approach started
with all of the independent variables in the model. The variable that was least
significant (largest p-value) was removed, and the model was refitted. Each
subsequent step removed the least significant variable in the model until all
remaining variables had individual p-values smaller than .2.
Assumptions for multiple linear regression (e.g., normality of the residuals,
homoscedasticity, independence of observations, linearity of variables, no mul-
ticollinearity, and no outliers) were assessed by examining histograms and
normal probability plots of the studentized residuals, scatter plots of standar-
dized predicted values versus standardized residual values, and scatter plots of
the dependent variable versus the standardized residuals. Multicollinearity was
assessed by examining the variance inflation factor (VIF) and tolerance index.
The model fit was assessed according to values of the multiple correlation
coefficient (R), the coefficient of determination (R2), adjusted R2, and standard
error of the estimate. The F (ANOVA) test was used to test the hypothesis. In
this study, p < .05 was set as the significance level.

Results
The mean ages (SD) of the studied mothers and their spouses were 28.9 (5.8)
and 33.4 (5.7) years, respectively (Table 1). About one-third of mothers and
spouses (29.7 percent and 30.2 percent, respectively) had a high school
diploma, and 56.1 percent of mothers were multiparous. About half of the
194 F. FATHI ET AL.

Table 1. Functional status and its sub-domains, and their correlations with postpartum depres-
sive symptoms and maternal self-efficacy in newly delivered mothers (n = 437).
Correlation with
depressive Correlation with
symptoms self-efficacy
Variable Mean (SD) Obtainable range Observed range r (p) r (p)
Total IFSAC score 2.3 (0.2) 1–4 1.6–3.3 −0.14 (.003) 0.33 (<.001)
Household 2.4 (0.4) 1–4 1–3.7 −0.07 (.146) 0.23 (<.001)
Social\community 1.4 (0.4) 1–4 1–3.5 −0.16 (<.001) 0.20 (<.001)
Infant care 3.6 (0.3) 1–4 2.3–4 −0.05 (.236) 0.22 (<.001)
Self-care 1.9 (0.3) 1–4 1–3.2 −0.09 (.046) 0.12 (<.001)
Postpartum 8.3 (5.3) 0–30 0–26 – –
depressive
symptoms
Maternal 32.1 (4.1) 10–40 20–40 – –
self-efficacy

mothers (51 percent) had had a Cesarean section. More than three-fourths of
them (83.3 percent) were housekeepers, and about half of spouses (53.8
percent) were self-employed. According to 53.5 percent of the mothers,
their household income almost compensated for the household expenditures.
In addition, the majority of mothers (89.7 percent) and spouses (92 percent)
were pleased with their infant’s sex, and 21.5 percent of pregnancies were
unwanted. Half of the studied families (50.8 percent) lived in their own
house, and about half of mothers (51.3 percent) had help at home. The
majority of infants (97.3 percent) were singleton, and more than three-
fourths of mothers (79.3 percent) had received postpartum care. About half
of the latter group (46.7 percent) had been referred to public centers to
receive postpartum care.
The mean (SD) of the total functional status score of mothers was 2.3 (0.2)
(range: 1 to 4) (Table 1). The maximum and minimum scores of mothers for
infant care were 3.6 and 0.3, and for social and community engagement were
1.4 and 0.4, respectively. The mean (SD) postpartum depressive symptom
score was 8.3 (5.3) (range: 0 to 30). Postpartum depressive symptom score
was negatively correlated (p < .05) with the total functional status score,
social and community activities, and self-care subscales; whereas, no correla-
tion between housekeeping responsibilities and infant-care subscales was
observed. The mean (SD) score of maternal self-efficacy was 32.1 (4.1)
(range: 10 to 40). Maternal self-efficacy was positively correlated (p < .05)
with the total functional status score and all of its subscales (Table 1).
Results obtained from the one-way ANOVA and independent t-tests
suggested a significant positive relationship between the overall functional
status score and high economic status, job of spouse (shopkeeper), having a
spouse between 26 and 35 years of age, multiparity, having a helper at home,
and high school diploma and lower educational level (p < .05) (Table 2.).
These variables, along with depressive symptoms and self-efficacy variables,
 WOMEN & HEALTH 195

Table 2. Relationships between sociodemographic characteristics and functional status in newly

delivered mothers (n = 437).
Variable Number Mean (SD) p-Value Variable Number Mean (SD) p-Value
Mother’s age (years) Spouse’s age (years)
≤25 130 2.35 (0.26) .166 ≤25 33 2.31 (0.28) .025
26–35 240 2.41 (0.26) 26–35 249 2.42 (0.26)
≥36 67 2.38 (0.27) ≥36 155 2.39 (0.26)
Type of delivery Parity
Vaginal 211 2.38 (0.23) .606 Nulliparous 192 2.32 (0.25) <.001
Caesarean 226 2.39 (0.29) Multipara 254 2.44 (0.27)
Occupation Education
Housewife 336 2.39 (0.25) 0.435 Elementary school 76 2.41 (0.21) .043
Employee 71 2.36 (0.32) Secondary school 65 2.34 (0.27)
Spouse’s occupation High school 39 2.41 (0.29)
Worker† 68 2.41 (0.23) .038 Diploma 130 2.43 (0.27)
Employee 109 2.38 (0.27) University 127 2.24 (0.27)
Shopkeeper 24 2.53 (0.24) Spouse’s education
Private sector 235 2.37 (0.27) Elementary school 74 2.41 (0.28) 0.890
Sufficiency of income for expenses Secondary school 70 2.40 (0.26)
Completely 125 2.44 (0.27) .020 High school 40 2.41 (0.21)
To some extent 234 2.37 (0.27) Diploma 132 2.38 (0.26)
Absolutely not 78 2.34 (0.22) University 121 2.37 (0.28)
Lodging Wanted pregnancy
Private house 222 2.40 (0.27) 0.750 Yes 343 2.38 (0.26) .366
Rental home 135 2.38 (0.25) NO 94 2.41 (0.26)
Parents home‡ 80 2.38 (0.28) Father’s interest in fetal sex
Mother’s interest in fetal sex Yes 402 2.38 (0.26) .081
Yes 392 2.38 (0.26) .379 No 35 2.46 (0.32)
No 45 2.42 (0.27) Number of newborn
Having help for childcare Single 425 2.39 (0.26) .211
Yes 224 2.42 (0.25) .012 Twins 12 2.26 (0.36)
No 213 2.36 (0.27) Postpartum care center
Receiving of postpartum care Public sector 240 2.40 (0.25) .407
Yes 348 2.39 (0.26) .258 Private sector 60 2.40 (0.25)
No 89 2.36 (0.28) Both sectors 84 2.36 (0.27)
†
Three people were unemployed.
‡
Two cases lived in her parents’ house and one case lived in home-governmental organization.
§
Forty-five mothers were visited by obstetricians, 10 mothers were visited by midwife, and 5 mothers were
visited by general physician.

were introduced to a multivariate linear regression model with a backward

stepwise strategy. Some variables, including having a helper, mother’s age,
and spouse’s sex preference were excluded from the model. Postpartum
depressive symptoms, nulliparity, and low income were associated (p < .05)
with poorer functional status, and maternal self-efficacy, having a spouse
between 26 and 35 years of age, high school diploma and lower educational
level, and the job of the spouse (shopkeeper) were related (p < .05) to greater
functional status, which explained 47.6 percent of the variance in the func-
tional status score (Table 3).
The values of R, R2, and adjusted R2 were 0.476, 0.226, and 0.201,
respectively. The independent variables explained 20.1 percent of the
 196
F. FATHI ET AL.

Table 3. Factors related to functional status according to multivariate linear regression model (n = 437).
Variable B (95 percent CI) p-Value Variable B (95 percent CI) p-Value
Maternal self-efficacy 0.02 (0.02 to 0.01) <.001 Postpartum depressive symptoms −0.01 (−0.01 to −0.001) .014
Parity Spouse’s occupation
Multiparous (Ref) 0 Private sector (reference) 0
Nulliparous −0.15 (−0.21 to −0.10) <.001 Worker 0.01 (0.09 to −0.06) .779
Sufficiency of income for expenses Employee 0.002 (0.06 to −0.05) .949
Completely (reference) 0 Shopkeeper 0.14 (0.24 to 0.03) .009
To some extent −0.70 (−0.12 to −0.01) .015 Educational level
Absolutely not −0.10(−0.18 to −0.02) .010 University (reference) 0
Spouse’s age Elementary school 0.05 (0.13 to 0.02) .163
36 and higher (reference) 0 Secondary school 0.01 (0.09 to −0.06) .696
25 and lower 0.06 (0.17 to −0.04) .232 High school 0.07 (0.16 to −0.02) .158
26–35 0.12 (0.18 to 0.07) <.001 Diploma 0.08 (0.14 to 0.01) .031
 WOMEN & HEALTH 197

variation in the dependent variable. The standard error of the estimate was
0.24. The p-value for the F statistic was <.001. All assumptions of multiple
linear regression were confirmed. No evidence of multicollinearity was
apparent in our data, based on tolerance values from 0.6 to 1 and a VIF
between 1 and 2.

Discussion
The mean functional status score in our study was moderate. Among all sub-
domains of functional status, mothers scored highest in the infant-care
domain and the lowest in social and community engagement. Higher levels
of postpartum depressive symptoms, nulliparity, and low income were asso-
ciated with diminished functional status; and higher maternal self-efficacy,
having a spouse between 26 and 35 years of age, high school diploma and
lower educational level, and the job of the spouse (shopkeeper) were asso-
ciated with greater functional status. A moderate maternal functional status
is consistent with another study conducted in South Korea (Yoo 1999) but
inconsistent with studies conducted in Canada (MacDonald 2011), Turkey
(Şanlı and Öncel 2014), and the United States (Posmontier 2008) in which
higher levels of functional status have been reported. These differences may
be a result of differences among the study populations, sampling time during
the postpartum period, and the study environment. MacDonald and collea-
gues (2011) conducted their study 12 weeks after delivery, whereas the
Posmontier (2008) collected data between 6 and 26 weeks after delivery.
Meanwhile, Gjerdingen and Center (2003) indicated that maternal functional
status improves with time.
In this study, among all sub-domains of functional status, mothers scored
highest in the infant-care domain and the lowest in social and community
engagement. These results are consistent with studies in Turkey (Şanlı and
Öncel 2014) and the United States (Posmontier 2008). Probably, during in
the postpartum, mothers reduced their social activities to spend more time
caring for their babies, which resulted in these findings.
In this study, maternal self-efficacy was significantly and positively related
with the total score for maternal functional status and all its subscales. These
results are consistent with the results of McVeigh (1995). Self-efficacy is a
main factor associated with an individual’s behavior and is significantly
related to one’s expectations, aspirations, resilience, and vulnerability
(Duprez et al. 2016). Therefore, mothers with higher amounts of self-efficacy
tend to adjust better to postpartum changes and have better functional status.
Postpartum depressive symptoms were significantly related to a poorer
overall maternal functional status score, social and community engagement,
and self-care. Posmontier (2008) also found a similar relationship between
depressive symptoms and functional status. Additionally, the study of Barkin
198 F. FATHI ET AL.

et al. (2016) indicated associations of bipolar status, atypical depression,

higher depressive symptom score, and private insurance type with poorer
postpartum maternal functioning. A depressive state can lead to a person’s
lack of interest in everyday activities, a lack of energy to conduct routine
activities and manage tasks, and general discomfort. In addition, individuals
with depression or other mental illness may fail to maintain strong relation-
ships with family members, friends, and even their children (Santini et al.
2015). Therefore, depressive symptoms can lead to a decrease in maternal
functional status.
We did not find a significant relationship between postpartum depressive
symptoms and quality of infant care. This is consistent with the findings of
McLearn et al. (2006), in which no difference was found in the level of infant
care between depressed and non-depressed mothers. However, several car-
egiving activities appeared to be compromised by postpartum depressive
symptoms, including feeding practices, particularly breastfeeding, sleep rou-
tines, wellness visits, vaccinations, and safety practices (Field 2010). Although
a functional spectrum is seen in depressed mothers in caring for their
neonates, to our knowledge no study has explained why postpartum
depressed mothers could properly care for their infants despite decreased
functional status in other activities.
Additionally, we did not find a significant relationship between house-
keeping responsibilities and postpartum depressive symptoms. Our findings
are inconsistent with the results of other studies potentially due to differences
in the research environment (MacDonald 2011; Posmontier 2008), Iranian
culture, and religious instructions. In Iranian culture, family forms the
foundation of society. Therefore, the Iranian community views the family
as a holy unit and tries to strengthen and maintain it continuously. In Iran,
mothers thus strive to continue their housework and strengthen family
relations despite their postpartum depressive symptoms. In Iran, most
mothers are responsible for housekeeping. In this study, most mothers
(83.3 percent) were housekeepers.
In this study, multiparous mothers had better functional status than
nulliparous mothers. Şanlı and Öncel (2014) also found similar results and
attributed it to the increased experience of multiparous mothers as compared
with nulliparous mothers. The present study also showed greater maternal
functional status with increasing age of the partner. Coventry et al. (2004)
suggested that social support from husbands increases with age. Aktan (2010)
showed that maternal postpartum functional status improves with increasing
social support, helping mothers to regain their pre-pregnancy status.
High family income and the job of the spouse (shopkeeper) was positively
correlated with functional status. This is consistent with the results of Yoo
(1999) in South Korea but inconsistent with the results of MacDonald (2011)
in Canada. The differences in results may be a product of the importance of
 WOMEN & HEALTH 199

economic status as a higher income generally results in access to a high

standard of living and better access to quality levels of exercise, nutrition,
health care, etc. A steady income may mitigate one’s stress and tension to
some degree and eventually improve the functional status of all family
members, particularly the mother.
A mother’s high level of education was associated with greater functional
status, consistent with the results of Şanlı and Öncel (2014) in Turkey but
inconsistent with those of Posmontier (2008) in the United States and
MacDonald (2011) in Canada. In the latter two studies, most mothers had
completed at least a secondary education or higher. A higher level of educa-
tion and awareness level was significantly related to their levels of social and
family communications as well as their self-care capability and improved
postpartum functional status.
Due to the intrinsic limitation of cross-sectional studies, the relationships
shown between functional status, self-efficacy, postpartum depressive symptoms,
and sociodemographic characteristics in the present study do not necessarily
imply a causal relationship, because the temporal relations of these variables
could not be determined in this cross-sectional design. One other limitation of
this study stemmed from limitations of the IFSAC. The premise on which optimal
maternal functioning is based represents a limitation of the IFSAC. To achieve full
functional status, a woman must resume the majority of the roles she possessed
before giving birth. Because of the reprioritization that often occurs in the life of a
new mother, a return to full functional status (as measured by the IFSAC) can be
difficult for many women. Additionally, the IFSAC does not account for women’s
feelings or levels of satisfaction with the changes in their lives since childbirth.
Additionally, at the time of data collection, employee mothers were on leave after
childbirth (Aktan 2007; Barkin et al 2010a). Thus, we were unable to assess the
occupational subdomain of the functional status questionnaire.
Although some studies have been conducted regarding factors associated with
postpartum maternal functioning in women with postpartum depressive symp-
toms (Barkin et al. 2016; Posmontier 2008), considering the importance of the
postpartum period, conducting further qualitative and quantitative studies on
the inhibitors and facilitators of maternal functional status in all women,
including women with and without postpartum depressive symptoms, is recom-
mended to provide mothers with proper solutions. Additionally, conducting
more studies is necessary to unveil why mothers can properly care for their
infants despite suffering from postpartum depressive symptoms and decreased
functional status in terms of self-care and social and community activities.

Conclusion
In this study, we found a positive relationship between functional status and
maternal self-efficacy, and also as depressive symptoms increased,
200 F. FATHI ET AL.

functioning scores decreased. Some sociodemographic components, includ-

ing number of pregnancies, the job status and age of one’s spouse, the
educational level of the mother, and economic status were associated with
functional status. Because of the importance of functional status and the
relationship of maternal self-efficacy, postpartum depressive symptoms, and
living conditions with functional status, maternal health-care providers
should be well-versed in these subject areas to improve maternal functional
status through encouraging mothers to care for themselves and teaching
mothers proper care for their infants. Also, they should improve postpartum
adjustment in mothers through early diagnosis and treatment of postpartum
depressive symptoms and also through promoting maternal self-efficacy by
using health education strategies because the effect of education has been
shown in a number of prior studies (Bagherinia, Mirghafourvand, and
Shafaie 2016; Sercekus and Baskale 2016; Dodt et al. 2015).

Acknowledgments
We are thankful to the health deputy of the university, all employees of medical health-care
centers in Bonab, and all mothers who participated in this study.

Funding
This study was approved and financed by Tabriz University of Medical Sciences.

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