ABSTRACT
Objective
This descriptive cross-sectional study aimed to assess pregnant women’s attitudes toward sexuality and their perceptions of sexual health-related risks.
Methods
The study sample consisted of 255 pregnant women who presented to the obstetrics and gynecology outpatient clinic of a public hospital. Data were obtained through the administration of “the Descriptive Information Form”, “the Attitudes Toward Sexuality in Pregnancy Scale”, and “the Risk Perception in Pregnancy Scale”. Statistical analyses included descriptive statistics (frequency, percentage, and mean), the Mann-Whitney U test, the Kruskal-Wallis H test, the Shapiro-Wilk test, and Spearman’s correlation analysis.
Results
The results demonstrated that participants had a moderate level of attitudes toward sexuality during pregnancy, as indicated by a mean total scale score of 116.07±21.26. The mean total score obtained from the Risk Perception in Pregnancy Scale was 34.02±22.05, corresponding to a moderate level. In addition, pregnant women who did not perceive sexual intercourse during pregnancy as a risky condition had higher levels of risk perception, with this difference reaching statistical significance (p<0.05). No statistically significant relationship was observed between pregnant women’s attitudes toward sexuality and their risk perceptions (p>0.05).
Conclusion
It is recommended that healthcare professionals provide structured counseling and educational programs aimed at improving pregnant women’s risk perceptions and attitudes toward sexuality during pregnancy.
INTRODUCTION
Sexuality is an individual as well as a social construct, usually associated with one or more partners experienced and defined by the individual. A range of physiological processes, such as hormonal changes, menstruation, pregnancy, childbirth, breastfeeding, and menopause, may influence it (1). Pregnancy involves emotional and physiologic changes affecting the woman, her partner, and their relationships (2, 3). Therefore, sexuality in pregnancy is very important.
In the absence of pregnancy-related complications, sexual activity is considered a natural process that may contribute positively to the sexual and psychological well-being of both partners. Healthy sexual practices during pregnancy can support the quality of the couple’s relationship and may have positive effects on the pregnant woman’s self-esteem and psychological well-being. A variety of factors can shape sexual attitudes and behaviors during pregnancy, including maternal age, previous adverse pregnancy experiences, concerns regarding motherhood, culturally embedded myths about pregnancy, changes in body image associated with physiological alterations, perceptions that sexual activity is incompatible with the sacred role of motherhood, and the misconception that sexual intercourse may pose risks to fetal and maternal health (4, 5).
Pregnancy represents a multifaceted period marked by substantial physiological, psychological, and social transformations. These changes may influence pregnant women’s sexual lives and subsequently shape their attitudes toward pregnancy and sexuality during this period. Anxiety, personal beliefs and values concerning sexuality, as well as attitudes toward the acceptability of sexual activity during pregnancy, have been reported to be associated with sexual functioning. Furthermore, pregnancy-related physical discomfort, restricted mobility resulting from bodily changes, concerns about potential harm to the fetus, and cultural factors may contribute to alterations in sexual life during pregnancy. Dyadic adjustment is a factor that influences pregnancy both positively and negatively. Pregnant individuals who experience a supportive and harmonious relationship with their partners may adapt to the pregnancy process more effectively. In contrast, insufficient partner harmony and support may contribute to difficulties during pregnancy. Greater relationship satisfaction and mutual adjustment, which are considered important factors influencing perceptions of motherhood and dyadic adaptation during pregnancy, may foster more positive attitudes toward sexuality. The perception of motherhood begins to develop during pregnancy. At the same time, pregnancy is accompanied by substantial changes in women’s physical appearance and body image. The process of preparing for parenthood may also influence the quality of the couple’s dyadic adjustment. Collectively, the physical, psychological, and relational experiences associated with pregnancy can shape attitudes toward sexuality. Furthermore, perceiving sexual activity during pregnancy as taboo and having limited access to sexual counseling may adversely affect women’s attitudes toward sexuality (6, 7). Risk perception during pregnancy lies based on the negative impact on women’s sexual lives. Many studies suggest that many couples do not find sexual intercourse safe during pregnancy and are afraid of sexual intercourse (8, 9). Risk perception is delineated as the subjective assessment individuals make regarding the likelihood and origin of a given risk. This cognitive process holds pivotal importance in how individuals assess and respond to information pertaining to their health status. Central to the concept of risk perception is the recognition that risk is essentially a cognitive construct shaped by one’s perceptions, past experiences, and anticipations (10, 11). Risk perception in pregnancy is defined as the likelihood of unexpected but foreseeable conditions in routine pregnancy follow-up or conditions involving life risk in the antenatal period (12). Changes occurring during pregnancy pose a potential risk for every pregnant woman and her developing baby. These risks may occur in different ways in every pregnancy period. When the entire pregnancy process is evaluated worldwide, a risky situation that negatively affects maternal/fetal health is encountered in 5-20% (13). In Türkiye, 35.2% of pregnancies are in the risk category (14). The high perception of risk prepares the ground for people to stay away from the behaviors they will exhibit in the relevant subject (15).
Risk perception is an emotional process that results in emotions, attitudes, and behavioral parameters. High-risk perception towards pregnancy makes it difficult for women to adapt to pregnancy and negatively affects many processes, such as sexuality during pregnancy (10-12). Negative effects on sexuality during pregnancy negatively affect women’s physical and psychological health and change their quality of life (8, 9). Determining the levels of risk perception of pregnant women towards their babies and themselves will contribute to the determination of the training and counseling services to be provided to health professionals and pregnant women, to a smooth process for maternal and infant health, and thus to a positive effect on the sexual attitudes of pregnant women. Considering these findings collectively, this study aimed to examine the relationship between risk perception during pregnancy and attitudes toward sexuality.
Research Questions
The study sought to address the following research questions:
1. What is the level of women’s attitudes toward sexuality during pregnancy?
2. What is the level of women’s risk perceptions during pregnancy?
3. Do women’s attitudes toward sexuality and risk perceptions during pregnancy vary significantly according to their sociodemographic characteristics?
4. Is there a significant association between women’s attitudes toward sexuality and their risk perceptions during pregnancy?
MATERIAL AND METHOD
Study Design and Participants
This study employed a descriptive cross-sectional design and included 255 pregnant women who attended the obstetrics and gynecology outpatient clinic of a state hospital. The target population comprised 1.200 pregnant women who visited the same outpatient clinic in 2020. The study sample consisted of pregnant women aged 18 years or older who had no communication difficulties or psychiatric disorders and voluntarily agreed to participate in the study between September 13, 2021, and October 31, 2022. Using research data obtained with the post-hoc G*Power program, the sample size was determined to be 255 based on 95% confidence and 95% test power.
Measurements
Data collection was conducted using “the Descriptive Information Form” developed by the researchers following a comprehensive review of the relevant literature, “the Risk Perception Scale in Pregnancy”, and “the Attitudes Toward Sexuality in Pregnancy Scale (ATSPS)”.
Descriptive Information Form: The form consists of a total of 27 items, including sociodemographic (age, education, etc.), obstetric (number of pregnancies, number of children, mode of conception, etc.), and sexual characteristics (satisfaction with the marital relationship, sexual life before pregnancy, etc.) of the participants (16-18).
ATSPS: The scale was developed by Sezer and Şentürk Erenel (16) in 2018 to assess the attitudes of pregnant women and men whose partners are pregnant toward sexuality. The ATSPS consists of 34 items and three subscales. In the ATSPS, negative items (3-4-7-8-9-10-12-13-15-16-17-18-19-22-25-26-27-29-30) are coded in reverse.
ATSPS yields a total score ranging from 34 to 170. Higher scores on the ATSPS indicate more positive attitudes toward sexuality during pregnancy. The Cronbach’s alpha coefficients were 0.85 for the “Anxiety Toward Sexual Intercourse During Pregnancy” subscale, 0.86 for the “Beliefs and Values Toward Sexuality During Pregnancy” subscale, and 0.81 for the “Approval of Sexuality During Pregnancy” subscale, while the coefficient for the overall scale was 0.90 (16). In the present study, Cronbach’s alpha coefficients were 0.86 for the “Anxiety Toward Sexual Intercourse During Pregnancy” subscale, 0.91 for the “Beliefs and Values Toward Sexuality During Pregnancy” subscale, and 0.78 for the “Approval of Sexuality During Pregnancy” subscale, with a coefficient of 0.92 for the overall scale.
Risk Perception in Pregnancy Scale: The scale was originally developed by Heaman and Gupton (19) in 2009, and its validity and reliability in Turkish were subsequently established by Evcili and Dağlar (12) in 2019. This visual analog scale consists of nine items grouped into two factors. The first factor, “pregnant women’s risk perception toward the baby” includes five items (items 2, 6, 7, 8, and 9), whereas the second factor, “pregnant women’s risk perception toward themselves” comprises four items (items 1, 3, 4, and 5). Each item is accompanied by a 0-100 mm linear visual analog scale anchored by the statements “no risk at all” and “extremely high risk”. The overall scale score is calculated by summing the scores obtained from the nine items and dividing the total by nine. The scale does not have an established cut-off value; therefore, higher scores indicate greater perceptions of risk concerning the pregnant woman and her baby (12). The internal consistency of the scale, as assessed by Cronbach’s alpha, was reported as 0.87 in the original study (19), 0.84 in the Turkish adaptation study (12), and 0.91 in the current study.
Data Collection
Face-to-face interviews were conducted with eligible pregnant women attending the obstetrics and gynecology outpatient clinic. The duration of each interview was approximately 15-20 minutes.
Ethical Considerations
The study received ethical clearance from the Çankırı Karatekin University Ethics Committee (approval no: 20, date: 03.06.2021) and institutional approval from the relevant institution (09.08.2021/E-53449070-779-88). Before enrollment, the pregnant women were informed about the study’s purpose and procedures. Written and verbal informed consent was obtained from all participants who agreed to take part in the study. The research was conducted in accordance with the principles of the Declaration of Helsinki.
Statistical Analysis
The SPSS (Statistical Package for the Social Sciences) 25.0 program was used for statistical data analysis in this study. Shapiro-Wilk analysis was performed to evaluate the normal distribution of the data. In this context, the mean and frequency values of the data were calculated. Mann-Whitney U analysis and Krustal-Wallis H analysis were applied. Correlation was performed to evaluate the relationship between the scales. Mann-Whitney U analysis was used to compare scale scores according to variables with two subcategories, while Kruskal-Wallis H analysis was used to compare variables with three or more subcategories. Spearman’s correlation analysis was used in the relationship between scale scores. The significance level was accepted as p<0.05.
RESULTS
Among the pregnant women, 31.8% were in the 23-27 age group, 47.1% were university graduates, and 67.1% were employed. It was found that 56.5% of the pregnant women had income equal to expenses, 48.6% of their husbands were university graduates, and 96.9% were employed. It was determined that most pregnant women (87.8%) lived in the city, 82% lived with their spouse and child, and 98% had their own bedroom. It was determined that 47.5% of the pregnant women were in the second trimester, 46.7% had their first pregnancy, approximately half had no living children, 82.4% had planned pregnancies, and 91.8% had a positive pregnancy evaluation (Table 1).
The findings indicated that 51.4% of the pregnant women had received information about sexual life during pregnancy, with 58.8% reporting midwives or nurses as their primary source of information. Additionally, 52.9% of the participants demonstrated a moderate level of knowledge regarding sexuality during pregnancy. A perceived risk associated with restricting sexual intercourse during pregnancy was reported by 86.3% of the pregnant women. Among those who reported restrictions on sexual intercourse, 44.0% identified the risk of miscarriage as the reason for the restriction. Physicians were reported as the source of restriction by 15.7% of the participants, and among these women, 52.9% stated that the restriction was due to the risk of miscarriage (Table 2).
The findings showed that 67.8% of the pregnant women were satisfied with their marital relationship, while 69.0% reported satisfaction with their sexual relationship with their spouses before pregnancy. During the current pregnancy, 63.5% indicated that they were satisfied with their sexual life with their spouses. Furthermore, 54.1% reported no change in sexual life satisfaction compared with the pre-pregnancy period. Sexual intercourse during pregnancy was reported by 67.8% of the participants, whereas 30.1% indicated that they abstained from sexual intercourse due to a physician’s recommendation or restriction (Table 2).
The mean scores of pregnant women were 31.55±6.90 for anxiety regarding sexual intercourse during pregnancy, 37.90±8.63 for beliefs and values concerning sexuality, and 46.62±8.86 for approval of sexuality during pregnancy. The mean total attitude score toward sexuality during pregnancy was 116.07±21.26, indicating a level above moderate. Regarding risk perception during pregnancy, the mean scores were 33.67±24.33 for perceived risk to the fetus, 34.44±23.64 for perceived risk to themselves, and 34.02±22.05 for overall risk perception (Table 3).
Pregnant women aged 18-22, 23-27, and 28-32 years had significantly higher scores for beliefs and values regarding sexuality during pregnancy compared with those aged 37 years and older (p<0.05). Women in the first trimester demonstrated significantly higher total attitude scores toward sexuality during pregnancy than those in the second trimester (p<0.05). Furthermore, the level of approval of sexual intercourse during pregnancy was significantly higher among women experiencing their second pregnancy than among those with three or more pregnancies (p<0.05). In addition, pregnant women who perceived sexual intercourse during pregnancy as a risky situation had significantly higher scores for beliefs and values concerning sexuality during pregnancy (p<0.05; Table 4).
No statistically significant differences were observed in pregnant women’s risk perception toward the fetus, risk perception toward themselves, or overall risk perception according to age group, gestational week, number of pregnancies, or emotional assessment of pregnancy (p>0.05). However, pregnant women who did not consider sexual intercourse during pregnancy to be a risky situation had significantly higher total risk perception scores (p<0.05; Table 5).
No statistically significant association was identified between pregnant women’s overall risk perception during pregnancy and their total attitudes toward sexuality (r=0.005; p>0.05; Table 6).
DISCUSSION
Pregnancy includes emotional and physiologic changes that affect the woman, her partner, and all her relationships, especially sexuality (2). Pregnancy involves various potential maternal and fetal risks, which may influence and increase pregnant women’s perceptions of risk (12). A heightened perception of risk may predispose individuals to avoid engaging in behaviors associated with the relevant situation (15). All these affect the perspectives and attitudes of women and their spouses towards sexuality during pregnancy (16). As research investigating pregnant women’s attitudes and risk perceptions regarding sexuality remains limited, the findings of this study were interpreted and discussed in relation to the available literature.
In this study, the mean total attitude score of pregnant women towards sexuality was 116.07±21.26, which was above the moderate level. In the literature, it was found that the attitudes of pregnant women (5, 20) and spouses (5) towards sexuality were more positive than moderate. In contrast to our study results, Moyano et al. (21) found that non-pregnant women had higher self-esteem and sexual assertiveness than pregnant women. In our study, the fact that almost all pregnant women (91.8%) had positive feelings about the current pregnancy and 82.4% had a planned pregnancy may have positively affected the attitudes of pregnant women towards sexuality.
In this study, it was determined that pregnant women aged below 31 years were positively affected by beliefs and values toward sexuality. In a previous study, it was found that beliefs and values towards sexuality were positively affected positively in pregnant women under the age of 29 who found it safe to have sexual intercourse during pregnancy (20). Another study found that gestational age was parallel with libido; the younger the age, the more positive the sexual attitude (22). As a remarkable result, our study determined that beliefs and values towards sexuality were positively affected by pregnant women who perceived sexual intercourse during pregnancy as risky. The study by Kahveci and Cirban Ekrem (6) found that pregnant women have a negative attitude towards sexuality. These findings differ from those of previous studies, which have documented positive attitudes toward sexuality during pregnancy (20, 23).
In the present study, pregnant women aged 36-48 years demonstrated more favorable attitudes toward sexuality compared with those in other age groups. Previous studies have yielded inconsistent findings regarding the association between age and sexual attitudes during pregnancy, with some reporting an increase in positive attitudes with advancing age (23), whereas others have indicated a decline (20). It was reported that 87.9% of Nigerian pregnant women did not find sexual intercourse during pregnancy objectionable, and 61.1% of them engaged in sexual activity during pregnancy (24), whereas 78% of Turkish pregnant women and 52.5% of their partners found sexual intercourse safe during pregnancy (25). Although our results are similar to the literature, it is thought that the attitude of pregnant women towards sexuality is shaped within the framework of demographic, obstetric, and cultural factors (20, 23). In addition, more than half of the pregnant women (63.5%) in our study were satisfied with their sexual life during pregnancy and had received information about sexual life, and awareness (51.4%) may have positively affected our findings.
Although the frequency of sexual intercourse during pregnancy decreases significantly, it has been reported that many people worldwide have positive attitudes towards sexuality during this period (26). This study determined that the attitudes of pregnant women in the first trimester were highly positive toward sexuality during pregnancy. In the study by Şolt Kırca and Dagli (7), it was found that the attitude towards sexuality of pregnant women up to the third trimester was highly positive. In another study, contrary to our findings, the attitudes of pregnant women towards sexuality in the third trimester were reported to be highly positive (27). Another study found that most pregnant women (66.7%) had a positive attitude towards sexuality during pregnancy, and the percentages of pregnant women with a positive attitude varied by trimester: 57.1% (first trimester), 82.1% (second trimester), and 62.1% (third trimester) (23). Previous studies have indicated that pregnant women and their partners may refrain from sexual intercourse during pregnancy due to negative perceptions of pregnancy-related physical changes, such as weight gain and alterations in skin color, as well as psychological changes, including anxiety and depression, and concerns about potentially harming the fetus (23, 28). Another qualitative study reported that fatigue, breast tenderness, numbness, and increased abdominal size were associated with a reduced frequency of sexual intercourse, while pregnancy-related physical changes adversely affected women’s sexual experiences. However, some pregnant women reported an increased desire for sexual activity during pregnancy (28). Physical and psychological difficulties that become more pronounced as pregnancy progresses, concerns about potential harm to the fetus, fears that sexual intercourse may result in miscarriage or preterm birth, and beliefs that sexual activity during pregnancy is sinful or unsafe may contribute to sexual dysfunction among pregnant women (6, 7, 28). In our study, the high level of education of pregnant women and their spouses and their high level of awareness since the majority lived in urban areas may have positively affected their attitudes towards sexuality. It was determined that women with second pregnancy approved sexuality during pregnancy at a higher level than women with three or more pregnancies. In Aksoy et al.’s (18) study, it was reported that couples’ attitudes toward sexuality and marital adjustment were negatively affected as the number of pregnancies increased. The findings indicated that gestational duration, parity, limitations on sexual activity, and changes in the partner’s sexual attitudes were predictive factors associated with sexual functioning during pregnancy. Prenatal care should incorporate a comprehensive needs assessment that addresses the physical, emotional, and psychological well-being of pregnant women while also taking their partners’ participation into account. Pregnant women should be provided with comprehensive information on the physiological and psychological aspects of sexuality during pregnancy, safe sexual practices and relevant precautions, common sexual dysfunctions and potential management strategies, emotional intimacy and alternative forms of sexual closeness, as well as sexual health during the postpartum period. Considering the uniqueness of each couple’s experiences, individualized needs should be prioritized throughout the counseling process (23). It is thought that these results may be due to the decrease in the time allocated to each other by the spouses with the increase in responsibilities due to the increase in the number of children.
In our study, the mean total risk perception score of pregnant women during pregnancy was 34.02±22.05, which was at a moderate level. In our study, it is a remarkable result that pregnant women’s risk perceptions towards themselves were higher than their risk perceptions towards their babies. In the literature, risk perceptions of pregnant women were found to be low (10, 29, 30). The difference in the study results may be because risk perception in pregnancy is a multidimensional concept affected by various personal (age, education, etc.), psychological (perception, learning, beliefs and attitudes, etc.), and social factors (family, role and status in society, time and available resources, relationship with spouse, etc.) (23).
In the present study, higher risk perception scores were observed among pregnant women who did not perceive sexual intercourse during pregnancy as a potential risk. This finding is another remarkable result of our study. In a study similar to our findings, it was found that more than half of the pregnant women perceived sexual intercourse during pregnancy as safe, but their anxiety was high (20). Sexuality constitutes an integral aspect of human life and is influenced by a range of factors, including individual attitudes and values, behavioral patterns, personality traits, physical appearance, beliefs, emotions, and the social environment (16). The fact that 84.3% of the pregnant women did not perceive sexual intercourse during pregnancy as risky may have been influenced by the fact that 84.3% of them were not restricted from sexual intercourse by a doctor with any diagnosis. In addition, the fact that 46.7% had their first pregnancy may have affected the risk perceptions of these pregnant women.
No statistically significant relationship was observed between pregnant women’s risk perceptions and their attitudes toward sexuality during pregnancy. No study examines the relationship between risk perception and attitude towards sexuality in pregnant women. In this context, our findings in this study are unique and are thought to make an important contribution to the literature. The literature has reported that risk perception is associated with health status, health decisions, and behaviors (30-32). It has been reported that individuals with a high perception of disease risk are associated with worse health status in future disease diagnoses (31). Pregnant women have different risk perceptions and interpretations. Pregnancy risk perception depends on medical diagnoses and individual factors (30, 33). Our study result may have been influenced by the fact that almost all of the pregnant women did not perceive sexual intercourse during pregnancy as a risk, their pregnancy was planned, they had positive feelings about the current pregnancy, more than half of them received information about sexual life from health professionals, and 84.3% of them were not restricted from sexual intercourse by a doctor with any diagnosis.
Study Limitations
The study has several limitations. First, its single-center, cross-sectional, and descriptive design limits the extent to which the findings can be generalized. Secondly, the sample was limited to pregnant women who presented to the obstetrics and gynecology outpatient clinic at the institution where the study was conducted and who voluntarily agreed to participate. Therefore, the findings may not be generalizable to the broader population of pregnant women.
CONCLUSION
In the present study, pregnant women demonstrated an overall positive attitude toward sexuality, with the mean total score being above the moderate level. Pregnant women aged below 31 years exhibited more favorable beliefs and values concerning sexuality. Highly positive attitudes toward sexuality during pregnancy were observed among women in the first trimester, while women in their second pregnancy reported greater approval of sexual activity.
Our study determined that pregnant women’s mean total risk perception score during pregnancy was moderate, and that pregnant women who viewed and experienced sexual intercourse as normal during pregnancy had a high risk perception. No statistically significant relationship was identified between pregnant women’s risk perceptions and their attitudes toward sexuality during pregnancy.
In light of the study findings, healthcare professionals should assess pregnant women’s perceptions of sexuality and pregnancy-related risks and provide pregnant women and their partners with comprehensive education and counseling regarding these issues.
