An Account of Iranian Pregnant Women’ Experiences of Spousal Role: An Ethnophenomenological Exploration

Document Type: Original Research Article

Authors

1 Assistant Professor, Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

2 Professor, Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

3 Associate Professor, Department of Social Sciences, Faculty of Literature and Humanity, Ferdowsi University of Mashhad, Mashhad, Iran

4 a. Professor, Department of Midwifery, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran b. Professor, Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

10.22038/jmrh.2020.49044.1606

Abstract

Background & aim: Women experience many physical and emotional changes during pregnancy. Simultaneously, they experience dramatic alterations in their family structure and function including changes in the spousal role of couple. Due to the scarcity of studies in this regard, the present study aimed to provide an account of women's experiences of spousal role during pregnancy.
Methods: In this ethnophenomenological exploration, 25 pregnant women referred to health centers, prenatal clinics of hospitals, and private offices of obstetricians, were included in the study. Participants were selected using purposive sampling with a maximum variation strategy between October 2016 and March 2017. Data were collected using semi-structured in-depth individual interviews, vignette interviews, and participant observations. The data were analyzed adopting Van Manen's descriptive-interpretive phenomenological approach (1997) using MAXQDA software (version 10).
Results: The main theme of "attempt to preserve spousal role" was emerged. This theme was derived from four themes of "mother's effort to manage marital issues", "couples' interactions", "husband physical and mental care of wife" and "mother's conflicts with the rights and duties attached to the spousal role".
Conclusion: Pregnant women consider the spousal role to be one of their main duties and regarded it as their central responsibility. Therefore, they meticulously play their spousal role to provide constructive interactions with their spouses. The inclusion of gender-sensitive programs and services, including providing prenatal care, is of utmost importance to pregnant women in order to meet their needs to play their spousal role, appropriately.

Keywords


Introduction

 

Pregnancy is a unique experience that occurs in a woman's life (1). This period brings about major changes to various physical and psychological dimensions of women (2, 3) and creates new needs for them (4). Moreover, the effects of this period are beyond these dimensions and include changes in the structure and communication within and between families (5). During pregnancy, mothers' relationships with their husbands, families, and their roles in society change (1). In this regard, new roles need to be acquired in the family system, new relationships need to be developed, and existing relationships need to be rebuilt to prevent the negative consequences of pregnancy (6).

    Different studies have demonstrated that the emotional bond between mother and child is directly related to the degree of communication, intimacy, and conflict between mothers and their husbands (7, 8). In addition, men's participation in pregnancy has positive effects, such as the reduction of negative health behaviors, premature birth and low birth weight, and even infant mortality (9-11). Therefore, couples' dissatisfaction with each other during pregnancy is an important factor related to low birth weight (12).

    During pregnancy, women who have better communication with their husbands and benefit from their support experience more physical and mental health during this period (13, 14). One study pointed to the importance of spousal support during pregnancy on the enjoyment of this period, increased maternal mental health, and even maternal-fetal attachment (15). It has been even asserted that the consequences of communication between couples can affect the postpartum period (14). However, the stress and multidimensional changes of pregnancy exert profound impacts on the relationship between couples (12, 14, 16).

    It affects all aspects of marriage and creates the basis for disruption of marital relationships and the spousal role of pregnant women (17). Therefore, pregnancy is considered a crisis in the life of couples (13). Furthermore, the results of some studies are indicative of a marked decrease in marital satisfaction during pregnancy (14, 16). In this period, fetus and woman's health are often the focus of the attention of pregnant women. Therefore, husbands may receive less attention resulting in the aforementioned changes (16).

    Therefore, pregnancy and the birth of a neonate brings about a fundamental change to family organization, which requires a change in the patterns of communication between husband and wife and drive parents to modify their patterns of behavior (12). In this regard, studies show that women are looking for marital satisfaction more than men are. They are also less likely to talk to a counselor about issues, such as their interactions with their spouses (14, 18).

    Therefore, the study of couples during pregnancy is very important since many of them are not ready to face the post-childbirth changes in their relationship with their spouses. On the other hand, today, prenatal care has a biological perspective, and the communication and roles of pregnant women in life, including the spousal role, are not considered despite their impact on women's experience of pregnancy (19-21) (13). Nonetheless, this period requires special attention in terms of non-medical dimensions due to physiological changes and psychological adaptations (4). There is a paucity of studies on pregnant women's experience of spousal role during pregnancy; moreover, to the best of our knowledge, no study has been conducted in this regard in Iran.

    In other words, little information exists regarding women's lived experiences of changing roles and responsibilities, including pregnant women's spousal role (22). With this background in mind, it seems necessary to perform an in-depth study of pregnant women's experiences of this role with an emphasis on Iranian culture. To this end, the qualitative research method was used since quantitative studies do not allow for unraveling all aspects of the phenomenon under study.

    In addition, there is no prior written knowledge in this regard and qualitative research is able to explain this issue by a deep and comprehensive account of the spousal role of pregnant mothers. Consequently, the current study was conducted to explain women's experience of spousal role of during pregnancy (23).

Materials and Methods

    In this study, the integrated approach of Van Mann's interpretive phenomenology and ethnography called ethno-phenomenology was used. These two approaches are comparable and integratable due to their exploratory nature, the use of researcher as a data collection tool, interviews and a combination of open and structured questions, and the search for meaning in participants' statements.

    By the integration of these two methods in one study, the phenomenological perspective enables the researcher to focus on the phenomenon under study and to gain pregnant women's experience of the phenomenon under study. At the same time, the ethnographic perspective allows the cultural beliefs and behaviors involved in the formation of this experience to be revealed to individuals in the cultural group and the cultural context associated with it (24).

    In the present study, 33 interviews were conducted with 25 pregnant women to collect data. In-depth semi-structured interviews using open-ended questions, Vignette interview (19 interviews), observation (10 observations), field notes, and post-interview notes from participants' homes were used to collect data. The interviews lasted between 110-45 min. The purposive sampling was performed within 2016-2017. The study environment was health centers, hospitals, private offices of obstetricians and gynecologists in Mashhad. The participants included Iranian pregnant women who were able to speak and communicate in Persian, willing to participate in the study and express their experiences, and not affected by medical problems or life-threatening symptoms.

It is worth noting that in order to achieve maximum diversity of participants' experiences, criteria such as age, education, employment, social class, gravida, childbirth, gestational age, and even religion were considered among the eligible women. Interviews started with general questions, such as how did you feel when you found out you were pregnant? How has your experience been since you were pregnant?

    Thereafter, based on the answers and information provided by the participants, the researcher gradually entered into the depths of their experiences of the spousal role, as well as the cultural beliefs and behaviors in this area. Clarifying questions were also used if it was necessary to explore women's experiences in more depth. At the end of the interview, participants were asked to make a point if they had any. Finally, they were thanked and appreciated pointing to the possibility of future interviews.

    For Vignette's interview, the researcher also showed the participants several photos which were the result of extensive research related to the roles of men and women in life. They were asked to recall a similar experience if they had a similar experience and explain their understanding and feelings about the photos and discuss them with the researcher. The researcher tried to prepare different pictures about the different roles that are attributed to men and women in life (the traditional roles of women performing household chores and the man in charge of work outside, as well as women working in society and the man doing household chores and taking care of children).

    Moreover, in order to gain an in-depth understanding of the phenomenon under study, if participants were willing, the researcher would attend their homes and collect information and notes through interviews and observations. These notes were then read and the findings were reviewed. After interviewing each participant, the interviews were recorded and rewritten and coded as soon as possible. The interviews continued until data saturation (non-reception of new data from participants).

    The present study used the interpretive phenomenological approach of Van Manen’s six stages, including 1- Turning to a phenomenon which seriously interests you and you want to study, 2. Investigating experience as it is lived rather than as it is conceptualized, 3. Reflecting on the essential themes which characterize the phenomenon, 4. Describing the phenomenon through the art of writing and re-writing, 5. Maintaining a strong orientation to the original question, 6. Balancing the research question by identifying parts and the whole.

    In the first stage, the development of the phenomenological question, the clarification of the researcher's previous assumptions and perceptions of men's exposure to pregnancy, and the second stage, the accuracy and sensitivity of data collection were considered. In order to obtain the real meaning of the phenomenon and discover the main theme of thematic analysis, the main themes of the phenomenon were determined and the main meaning of the phenomenon was obtained using three holistic, selective, and discrete approaches.

    It should be noted that the shift between the text of the interviews and the extracted themes was continuously performed to ensure that themes are realistic. In order to differentiate between the main and sub-themes, an attempt was made to separate the main and exclusive concepts of the phenomenon from unnecessary meanings. The last three steps were used to analyze the data (25).

    MAXQDA software (version 10) was used to manage and process the data. It is noteworthy that throughout the study, the researcher's involvement with the research question, which is one of the necessities of phenomenological studies and considering the research question in the researcher's mind helped to extract the study themes (25).

Necessary ethical considerations, including obtaining written consent from the participants, the purpose of using audio recording, as well as the ethical approval of the ethics committee of Mashhad University of Medical Sciences, were observed in the current study. In order to validate the data, Lincoln & Guba's (1985) trustworthiness criteria, including credibility, dependability, confirmability, and transferability, were used.

    The careful selection of participants with different characteristics, long interaction with them, use of different methods to collect data, returning coded interviews to participants, obtaining their opinions based on approval or change of data, utilization of guidance and supervision of qualitative research professors, and finally providing the possibility of examining the research stages by others by clarifying the study stages all helped to achieve the study goals (26).

Results

    A total of 25 pregnant women with a mean age of 30.36 ±6.55 years participated in this study. They had different occupations from freelancer to university senior, and their educational level ranged from elementary school to PhD (Table 1).

Data analysis led to the emergence of the main theme of "attempt to maintain the spousal role." This theme was derived from the four themes of "mother's effort in marriage management", "couple interactions", " Spouse’s physical and psychological care of women during pregnancy" and "mothers’ conflicts in the face of the rights and duties of the spousal role" and 10 sub-themes (Table 2).

Attempt to maintain spousal role

The spousal role had a unique place for some mothers, and it was the top priority for women in some cases. In the performance of this role, women not only did their best to perform their duties with great sensitivity but were also engaged in mutual interactions with their husbands. From mothers 'point of view, husbands' responsibility toward them was also involved in their experience of the spousal role. In addition, conflicts caused by mothers' interactions with their spouses about their spousal role also provided mothers with special experiences. This theme includes the following subthemes: "Mother's effort in marriage management", "Couples' interactions", ”spouses’ physical and mental care of women" and "Mother's conflicts in the face of the rights and duties of spousal role" which are elaborated below.

Mother's effort in marriage management

    Pregnant women, according to their femininity and gender, considered marriage management to be one of their most important duties and were especially sensitive to the perfect fulfillment of this responsibility. Almost all mothers devoted special attention to the performance of marital duties in different forms and degrees. Some other women attempted to provide a congenial and warm atmosphere for their husbands. Mothers' experiences demonstrated that the spousal role never diminished in their minds and they performed this role with great sensitivity. In order to fulfill this role, some mothers were concerned about the interference of pregnancy with marriage management, especially in early pregnancy. They were worried that the burden of pregnancy would impede marriage management and result in their husbands' dissatisfaction.

    "I had a lot of stress in early pregnancy. For example, in the first few months I was worried that I could not perform my feminine roles. What's going on now, don't let your husband be unhappy with you". (Participant No. 11).

    Therefore, due to the sensitivity of mothers to this issue, they paid more attention to their abilities and strengthened their marriage management and attention to their husbands by restoring their power and ability. Most of them, in different ways, tried to fill the gap in the performance of this role and pay special attention to this dimension of life.

"Then I remind myself that I can, I must do my duties, my husband should not get annoyed with me, or emotionally separated ". (Participant No. 3)

    The vast majority of mothers tried to prove that they did not forget about their husbands' position and the performance of their spousal role, rather they showed more determination to do so. They took different approaches to their marital responsibilities. Some mothers respected their spouses and even maintained their personality, especially among families and relatives.

    "No, thank God I respect my husband. For example, I'm not like that. I don't disrespect him. Even when he comes home, I get up even if I'm lying down. "He comes quickly and says, "Sit down, you're embarrassing me". (Participant N0.8)

    Another participant stated that she tried to pay more attention to her husband's sensitivities to compensate for pregnancy-related physical problems that she was unable to solve. She asserted that she tried to take effective measures to provide her husband with a high standard of comfort and devote assiduous attention to his needs.

    ”Yeah, I'll make up for all my pain, as much as I can. Well, for example, my husband would love to be respected, he's very sensitive to that. I welcome him when he comes home from work. If I’m upset, I forget about it to make him refresh and relaxed. I treat him well, and then I tell him what happened. I will make up for it in these things". (Participant No. 12).

    This indicates the strong belief of this group of mothers in a feminine role. Some other participants even asserted that they did not neglect their spouses and accompany them in all situations. Participant No. 6 stated that she did not want her husband to think that pregnancy hampers them from accompanying each other in life. She stated that she even tried to perform her spousal role in having fun with her husband. In their efforts to perform their spousal role, the majority of mothers paid attention to their husbands' peace of mind. In so doing, apart from maintaining an emotional connection with their spouses, they tried to ensure their mental security during pregnancy.

    To this end, they sought to provide psychological and emotional support to their spouses and to provide them with peace and comfort, especially when they were concerned about doing so. I think my husband needs mental support since it's so important to him, and he's much more emotional than his family, and then they don't do it at all.

"My emotional support means a lot to him". (Participant N0.5)

    Some mothers even decided to change their personal characteristics, such as introversion, to have more verbal communication with their spouses so that they attain more intimacy through negotiation and interaction with each other.

   "For example, my husband comes, he asks a lot, 'what's wrong, madam?' I had already decided to tell him if I had a problem. I'm trying my best. But it's a little hard, especially since I've grown up in a way to have self-control. Then it is very difficult to change this characteristic. But I try very hard to change it because that's how we can talk more". (Participant No. 12)

    For most mothers, the maintenance of intimacy and emotional connection with their spouses after getting pregnant was of paramount importance. In other words, since this aspect of life mattered a lot to them, they may have thought long and hard about the performance of this role since the onset of pregnancy.  They tried different ways to fulfill these roles and maintain their unique position among their spouse.

    "The new baby must bring him happiness instead of the feeling that he/she is the reason that his wife is no longer what he wants. Someone I loved and married is no longer my ideal. You should do what your husband likes, his expectations must be met. Husbands should not emotionally detach from their wives after childbirth ". (Participant No. 25)

    Some of them even remained sober in dealing with their husbands' anger since they considered the protection of marital peace to be their prime duty and tried to give priority to this issue.

    "I've got to figure out how to deal with him. When he’s angry and shouts, I keep calm and silent since I know my anger at that moment results in nothing but something worse ". (Participant No.22)

    In the current study, a very limited number of mothers had a verbal argument with their spouses during pregnancy due to hormonal changes and their increased sensitivity.

    ” I'm tired of my behavior, my words have negative effects. I'm saying it with a bad expression. I talk violently, and he tries to get rid of that argument". (Participant No.10)

Couples interactions

    Almost all mothers regarded their interactions and mutual communications as another aspect of marriage and the spousal role and believed that all efforts should be made to stabilize and strengthen these interactions. The emotional connection of women with their spouses and their romantic endeavors had led to the development of their emotional interactions. Another dimension of maternal interactions was related to their sexual relationships which did not pose a serious challenge to many mothers despite the problems of pregnancy. This relationship was looked upon as a foundation for a successful marriage and a successful pregnancy. Another dimension which was confirmed by the experiences of all mothers in the current study was about their common decisions.

    The experiences of many mothers in the present study were indicative of emotional dependency on their spouses, mutual understanding, intimate two-way communication, the desire to be together, and the inability to continue life even for a moment. In other words, some of them talked so enthusiastically about being together and maintaining the sanctity of marriage that they shed tears with all their being.

    "There is an emotional connection between me and my wife that connects us and always is, even now that we don't have sex. We have security and trust that protects the sanctity of the family. We are not satisfied with the absence of each other, no matter how angry we are or how busy our lives are. My husband is always eager to come home at night". (Participant No. 16)

    They stated that in this verbal caress with their spouses, they took refuge in each other, and pregnancy did not hamper these dependencies.

"   "My husband is a shelter to me, without whom I cannot live for a moment (Participant No. 20)

Another dimension of pregnant women's relationships with their husbands was related to their sexual relationships. In the present study, for most mothers, the performance of sexual duties was one of their major concerns of women. Many of them considered this dimension of marriage an integral part of marriage, even though they had problems due to pregnancy. This suggests the beliefs and behaviors of their gender role encouraging them to devote special attention to the sexual needs of men and considered this to be one of their spousal duties.

    "The woman must also observe these things. This is one of the normal things in life. Because the man has his needs, it doesn't matter you are not in the mood or your body is tired now. He has his own expectations and wives should observe them to some extent". (Participant No. 1)

However, for a few mothers, the provision of this dimension of marriage ended in forced sexual relationships.

   ”Although it is still less than before, I sometimes have to give in." (Participant No. 23)

Few other women regarded this as a fulfillment of their religious duty and performed it despite their inner desires. This was derived from the religious beliefs and culture of this group of pregnant women.

    "I told my husband has his own needs. He sometimes asks for sex and I'm not in the mood but I don’t let him down. One reason is that it has religious rewards and God's command, and the other is that I will finally meet his needs". (Participant No. 8)

Moreover, many spouses had good cooperation in understanding the sexual problems arising from pregnancy and even tried to increase their knowledge and information in this field.

"Or, for example, in sexual relationships, my husband says, 'I don't insist, now baby's health is more important to me. I don’t want you to get in trouble because of me. Especially now that the last sonography showed marginal placenta. Doctor asked me to be careful. For example, my health is very important to me, baby" (Participant No. 22).

    A few mothers also complained about their husbands’ disregard for their sexual needs. They complained that their needs were not met by their spouses, and even this negligence sometimes soured their relationships.

"Well, maybe one day he did it for two days, he noticed me in bed, he put it all aside again. But deep inside I wanted more attention. But I didn't tell him anymore ". (Participant No. 7)

    A large number of women met their husbands 'sexual needs. On the other hand, a few women were asked to increase their sexual desire, and they also complained about their husbands' high sexual drive.

    "I would like my husband to have less sexual desire. Her request should be less. I mean, I'm tired of his demands in this case. Especially my situation, which is like this, and I'm pregnant. He complains and says:  what should I do with postpartum depression?" That's all my concern about my husband". (Participant No. 17)

    A number of mothers pointed to their reluctance to have sex and a marked decrease in their interest to have sex with their spouses, especially as the pregnancy progresses. A few mothers asserted that although they acknowledged that as a wife they needed to pay attention to their husband's needs, it was painful for them and they did not give in to it.

    "My sexual relationship with Mehdi is awful, awful. I hate it when he approaches me. I don't enjoy it at all. I suffer more. He understands himself. One day he was very upset and asked: Don’t you like it or you are afraid? I answered the second one. If I say the first one, it will be very annoying. He is my husband and after all, he is a man, I'm scared". (Participant No.14)

    Only one mother with extreme sadness or shame in her voice stated that her husband holds an instrumental view on women and regard them as the providers of husband's sexual needs and they are obliged to do so. This mother believed that her husband thinks of women as a subordinate or a creature created to provide services. This is suggestive of the completely traditional gender role of women, and this mother was reluctant to accept these highly traditional beliefs.

She stated:

    "My husband considers wife's responsibilities to be childcare and the fulfillment of man's sexual needs. It revolves mostly around this. Most of what I learned is to have children, take care of them, and meet his sexual needs". (Participant 10)

Spouse’s physical and psychological care of women during pregnancy

    Mothers' experiences indicated that a large number of spouses attempted to be sensitive to physical or mental care and the provision of psychological motivations during pregnancy. This had given mothers more satisfaction than ever before and strengthened their motivation to have a better pregnancy. Many mothers reported that their husbands took great and full-time care of them during pregnancy. This tender care was very satisfying and enjoyable for women and they talk about these concerns very enthusiastically.

    "Ongoing and full-time support. Like a bell tied to your feet that accompanies you everywhere you go. Sometimes I tell him lots of women get pregnant and nothing happens to them or their babies. I think that his sensitivities have made him take care of me a lot". (Participant N0. 21) 

For some mothers, this care and concern increased after the physical development of the fetus and the sense and. In this regard, fathers became more concerned about helping and caring for mothers after feeling a new life developing inside her body. 

"   Until the baby was physically developed, he couldn't believe there was a real pregnancy. But after that, his cooperation and understanding of my need for care increased." (Participant No. 22)

Most spouses were very sensitive to the physical pressure on women when shopping or doing housework.

    "That day I wanted to move the pot. My husband said: 'Let Mahdieh do this, don't bend over". (Participant No. 14)

Many spouses accompanied their wives in the nutrition of pregnant women, shopping, medical affairs, and even following up on medical results, and women were satisfied with this cooperation.

    "I tell him, for example, there is nothing wrong if there is no milk. I will drink it tomorrow morning, but he himself insisted and said, if you get reflux, what we can do".(participant number 11)

    "But he accompanies me as far as he can. So far, we've visited a lot of doctors together. I referred to some of them with my mother ".

    Nearly just a few women have experienced differently from the aforementioned ones. According to most women, spouses were almost more aware of their physical needs than their psychological needs. Some spouses have even tried to provide insight and information about pregnancy to better care for their wives. Consequently, they obtained appropriate and acceptable information about the physiological changes of pregnancy and, if necessary, provided their wives with the necessary advice on reducing the severity of pregnancy complications.

    "I noticed that he was searching the internet. For example, he said you should eat this. For example, your morning sickness is normal. I understood that he had read the articles on the net ". (Participant N0.5)

     This situation, in which the spouses actively and seriously strived to support and care for women, increased mothers' self-confidence in enduring the hardships they pointed out.

    "If I have pain at night, my husband asks if I want to give you a massage, and most of the time he massages my back. Well, that makes me more tolerant of the pain and suffering of pregnancy ". (Participant No. 14)

    A limited number of mothers were dissatisfied with their spouse's lack of understanding of their physical condition or pregnancy-related problems. These issues posed pregnant women serious problems and consequences. Accordingly, they complained that they had to deal with the burden of pregnancy and its related problems alone and their husbands could not understand them. It is as if some mothers have to end this journey in the face of difficulties and without the possibility of getting the help and guidance of their spouses.

    "I am also a woman. Ladies like to be understood. Who doesn't like it? But my husband doesn't understand. You have to talk to him very directly. I don't understand, I just have to tell him directly ". (Participant number 12)

    Some mothers attributed their husbands' lack of understanding of the different natures of men and women. Some others believed that although men expressed sympathy and support their wives, they were not inherently able to do so.

    "Because I will be alone by myself. In the end, these situations and the problems you have are only tolerated by the mother herself. Now the man may say emotionally, 'I understand, he really can't. I must tolerate the difficulties ". (Participant No.3)

    The spouses of a small number of participants in this study did not care about their women's medical issues. Therefore, they did not accompany them in these situations. Consequently, when women were not accompanied, they asked others for help.

    "He makes excuses for accompanying me in visiting doctor. He says, 'Now, wait, go with someone now. It doesn't matter much now. Then I have to go with someone like my mother". (Participant No. 10)

    Some women were even upset by their husbands' concerns about their finances and medical expenses and were held accountable if they paid a lot.

    "When I came, I told her, 'Today I paid doctor about 200000 tomans and he said: you did a wrong thing ".(participant No.23)

    However, another aspect of women's experiences in this study was related to their spouses' attention to their non-physical dimensions. Spouses ' fulfillment of their wives' psychological needs and the provision of psychological motivations seemingly bring them deeper experiences that were well understood in their statements. Some women spoke so enthusiastically about their spouses' psychological support and motivation during pregnancy that tears welled up in their eyes. For them, their spouse's support was a factor in the acceptance of pregnancy-related problems and the reduction of anxiety caused by possible shortcomings in doing housework after pregnancy.

    ”Then my husband came home and said, 'Who cries over cooking? Don't cry. You're having a baby. It's okay". (Participant No.11) '

Encouragement offered by some spouses provided a positive incentive for women to do the housework and persist in it. Encouragement from some other spouses regarding wives’ innovation in doing housework was an effective factor in strengthening their innovation. In other words, the psychological motivations offered by spouses gave women a persistent good feeling and helped them to overcome problems.

    ”He encouraged me to do my homework, and that gave me the incentive to be more responsible. For example, when I went out, I tried to prepare the meals." (Participant No.25)

    In the present study, most women benefited from the increased understanding and cooperation of their spouses during pregnancy compared to before and drew great comfort from this issue.

   "But he's really changed since the baby was born. I mean, I really feel this change. His collaboration, cooperation." (Participant No. 22)

The proper psychological communication with husbands during pregnancy, the companionship and coordination of men in different dimensions, and husbands' involvement in comprehensive and full-time care gave women tranquility and reassurance, and they could rely on their husbands with peace of mind.

    "Look, my husband really helps me. I think if he's not, my life will be paralyzed. Ever since he found out that I am pregnant, he has helped me a lot. Because of his working conditions, he had to go out of Mashhad for a while. I said, "If you want to go, my life will be completely paralyzed." He helps me a lot now and calms me down." (Participant No. 13)

    The reduction of conflict and provision of peace at home, an increase of attention to mothers' sensitivities, and not upset women were other examples of spouses' efforts to provide comfort to some other mothers.

    "Again, my husband is more careful. He is cautious not to annoy me since I am pregnant (participant No.10).

    These mothers were pleased with the support provided by their husbands, their companionship, and their understanding. They calmly recounted their experiences of their spouses' positive behaviors. Nonetheless, for a small number of mothers, their spouses' understanding and companionship were greatly diminished, and their spouses did not try to understand and bring them comfort. Some mothers were deeply saddened by the way their spouse understood and ignored them. It is as if they have to shoulder the burden of pregnancy problems without any support from their spouses.

    "Recently, when we were talking, I said, 'No, you don't care about a lot of things. You don't pay attention to me as you should". (Participant No. 23)

    A few mothers said that they like to be noticed by their husbands as all women do. Nevertheless, their husbands do not have the necessary insight to pay attention to their psychological needs. In other words, they do not feel obligated to meet the psychological needs of their wives.

    "Yeah, for example, ladies like men to understand them. That's not just my opinion, everyone likes it. But my husband doesn't understand, I have to talk to him very directly, he doesn't understand indirectly. I have to tell him I'm upset about it now. He doesn't believe I should be in a situation where I feel comfortable ". (Participant No. 12)

Mothers’ conflicts in the face of the rights and duties of spousal role

    Mothers' experiences in this study revealed two opposing spectrums of what they and their spouses consider to be true or obligatory. Accordingly, the women had two different approaches to the spousal role. Nearly half of them shared these rights and responsibilities with their spouses, and they sympathized with the delegated responsibilities of life to men and women and did not conflict with this issue. Marital life was important to them; therefore, in accordance with the conditions of life, they delegated the responsibilities of life with empathy and without any problems. In other words, the couple had an egalitarian gender role.

    "Now, apart from the children's education, as you defined, you are in charge of most of your daughter's responsibilities and your husband is responsible for your son? Yes. But did you take care of the children's education? Yes, he wanted so and said you are more qualified and you are responsible for children's education". (Participant No. 13)

    Several mothers believed in, accepted, and strived for their feminine role; therefore, the fulfillment of this role was of paramount importance to them. They were not dissatisfied with the duties that were allocated to them due to their femininity and tried to fulfill them. This satisfaction is derived from their cultural beliefs about accepting their feminine duties, and they had somehow accepted the gender division of household chores.

    "It's usually important to them. I try to make a delicious meal appealing to his taste. Then tidiness is important to men when they enter the house. Then I say these are what I care about.  I feel like I'm performing my duties to some extent anyway". (Participant No.10).

    However, some other mothers did not agree with their husbands about the duties assigned to men and women in life and were very dissatisfied with issues, such as considering some activities to be merely feminine duties. This showed their disagreement with the gender division of household affairs and traditional cultural beliefs on the subject. Participant No. 16 stated that she cared about household duties and did her best to perform them. Nonetheless, she expressed his dissatisfaction with the fact that he was doomed to do certain things absolutely and unavoidably under any circumstances. She said:

    "It's my duty whether I feel well or no. But he does his duties whenever he is in the mood". (Participant N0.16)

Their views differed greatly from those of their husbands on issues, such as giving importance to the life partner, paying attention to women, and their right to be understood by husbands.

    “My husband said that if I didn't care about you, I wouldn't have gone to buy so much last week. I said: If you don't do this, I'm sorry, you're too careless. I can even complain, for example, that this man neglects about food and housing. But he says no, I did so here, I did it so here". (Participant No. 10)

    In general, some women disagreed with their husbands about their rights and responsibilities in life. They had a hard time remembering this situation and had no way out. For some women, even their husbands' ways of understanding and expressing love were not satisfactory. On the other hand, from men's point of view, the way they adopted seemed quite logical. In general, this group of couples disagreed about their duties and responsibilities.

    "For example, he said: 'Get pregnant. I'll take care of you beyond your imagination. When I got pregnant, he bought meat soon after. I told him it's your responsibility, you must do it. It's not related to loving me. Loving me means doing me what I want very quickly. But he says that what he buys for the house means love, but my view is different, I say that it is part of their duties". (Participant No. 23)

    These two different approaches provided mothers with an experience of complete satisfaction and pleasure in doing things, a cordial life, and the performance of a spousal role.

Discussion

    The present study aimed to determine the knowledge and attitude of women referring
to Mashhad comprehensive health centers regarding preconception care based on the health belief model. According to the results, the mean score of women's knowledge was 11.0±2.3 from 19, and women's knowledge of preconception care was weak and moderate in 36.4% and 63.6% of women, respectively, and not good in any participants. In a study conducted by Ayalew (2017), the knowledge level of women in Ethiopia about preconception care was relatively low and there was no good knowledge (10), which is in line with the findings of the current study. The similarities that make the results consistent can be the type of study, the method of implementation, scope of the questions related to the measurement of knowledge, and subjects of the study regarding the reproductive age.

In another study, Firouzi and Ebrahimi (2017) assessed the knowledge and attitude of 384 married women aged 15-49 years in Natanz, Iran. The knowledge score of women was 8.13±1.5 from 10, showing a favorable knowledge of women in this regard (16). These results are inconsistent with our findings, which might be due to the use of the health belief model in the present study and differences in the method and population of the study. In the current research, 19 items were designed for knowledge with regard to all preconception care components. However, Firouzi and Ebrahimi (2017) assessed their subjects with six items on knowledge. In addition, subjects in the mentioned study were married women aged 15-49 years with tubectomy or vasectomy. In the present study, willingness to become pregnant and the lack of health-related education or occupation were considered.

    In the present study, "attempts to maintain the spousal role" emerged as the main theme of the in-depth account of pregnant women's experience of the spousal role. In this regard, the women were particularly sensitive to this role and regarded it as both a religious and feminine duty. Mother's effort in marriage management manifested itself in the form of mothers' confrontation with spousal duties and the provision of an atmosphere of peace, tranquility, and stability for husbands. Moreover, spouse's involvement in the maintenance of mother's physical health, provision of psychological motivations to pregnant mothers, and an understanding of mothers' psychological condition, which ranged from complete understanding to total neglect, and generally speaking, physical and mental care of women, formed another aspect of the spousal role.

    Couple's emotional interactions in dimensions, such as sexual, emotional, and life decision-making, were among the most effective and powerful aspects of this dimension. As the study became more in-depth, women's experiences of their disagreement with their allocated rights and responsibilities became more evident. Men cared more seriously for their wives' physical dimension, compared to their mental dimension, especially after the onset of symptoms of fetal growth. In this regard, they undertook activities, such as shopping, accompanying women in medical affairs, and being sensitive to not putting pressure on them while doing housework.

    Women's support and psychological motivation by their spouses, as well as the increase in the understanding and cooperation of the spouses during the pregnancy, were some of the issues that brought great happiness and peace to pregnant women. Men strived to create a good environment for mothers by taking measures, such as the provision of an atmosphere of peace, tranquility, and stability at home. However, in the current study, a few mothers did not receive the required support and understanding, and their spouses had an evident lack of attention to the provision of comfort to their wives.

    In a study conducted by Joy et al. (2012), the theme of relationship with the spouse in physical and psychological dimensions is in line with the meaning that emerged in the current study. In the mentioned study, participants asserted that their love and affection for their spouses increased after pregnancy and they became more emotionally dependent on each other. They noted the need for greater support for spouses who participated in such issues as buying spouse's favorite foods and household activities (27). In agreement with the results of the present study, in the study performed by Kav et al. (2004), men referred to supporting their wives as their main role in pregnancy (28). In a similar vein, a study carried out by Sayakhot et al. (2016) pointed to the importance of psychological care for mothers and the fact that spouses are the best caregivers and suppliers of this type of women's needs (29).

    The theme of the emotional interactions of the present study confirmed the theme of "from relaxation to anxiety” emerged in a study conducted by Tehran (2015). In the mentioned study, spouses also spoke of their great empathy for their wives, expressing a range of emotions from anxiety to happiness out of empathy toward mothers and the fetus in their bodies (30).

    Along the same lines, in a study performed by Firoozan (2018), the physical care of mothers, caring for their nutrition, empathy, providing them peace of mind, and appreciating them were some of the obtained themes. They confirmed the emerged themes of the present study, including spouses' provision of emotional and psychological care, as well as psychological motivations, and emotional interaction (31).

    In a study performed by Borghei (2017), women mentioned their husbands' appreciation in family gatherings, which made them happy and warm-hearted (32). In the present study, these motivations act as a great amoral booster and an incentive for women to maintain that behavior, even at a higher level and strengthened their morale.

    In general, reinforcement or reward is one of the basic concepts of behavioral sociology, they can be positive or negative. Positive reinforcements work when environmental changes are rewarded, which increases the likelihood that the same behavior will occur in the future. Baldoniha stated that humans are usually educated through positive reinforcement since it enhances pleasant outcomes and experiences in people's lives (33). Another point worth noting is the importance of pregnant women's psychological support and their need for love and affection. It is recognized as the most important aspect of fathers' participation in pregnancy care in various studies (36-34). However, it is noteworthy that in the above-mentioned study, apart from men's measures and behaviors, expectations or tasks that were regarded as the responsibility of men from women's point of view were included in the mentioned concepts. Nevertheless, in the present study, these expectations of rights and responsibilities were placed under the heading of "Maternal conflicts in the face of the rights and duties of the spousal role". In other words, in our study, compared to previous studies, the themes that were extracted based on the ethnographic perspective added to the richness of information and concepts.

    In this way, the mothers stated that in maintaining their spousal role, they pay great attention to performing the duties assigned to them as women. On the other hand, they expected that men fulfill the duties imposed on them regarding women's rights and they would oblige themselves to implement them. In fact, whenever women were dissatisfied with the provision of these rights, conflicts arose for them. In other words, women felt tense when they found themselves alone in fulfilling women's duties or requirements, or when they feel they are obliged to perform such duties due to their gender.

    Researchers believe that gender division of labor increases role conflict. Accordingly, families should seriously reconsider their responsibilities regarding the gender division of labor between men and women in the family environment, rather they should adopt participatory work-sharing instead of gender segregation (37). For this purpose, using pregnant women’ experiences of the spousal role, which is among the strengths of the present study, can be considered one of the strategies that have been implemented in this regard. The use of Vigant is the strength of the present study.

    The impossibility of living with pregnant women in their homes is one of the limitations of the current study. However, the researchers tried to cooperate with those participants who were both willing and able to be interviewed at home. Following this study, it is recommended that studies be performed with the participation of men and in the postpartum period.

Conclusion

    In the present study, the pregnant women considered marriage management and being a good wife one of their main responsibilities and they fulfilled their role in the provision of effective interactions with their husband. They experienced well that pregnancy affects different aspects of relationship and marriage. Pregnant mothers gave importance to duties and behavioral requirements of this role and considered them as their duty. Moreover, if it is not possible to provide it, they insisted that the husband and wife persuade each other to achieve this goal so that the importance of doing so is not neglected.

     With their feminine concerns, pregnant women tried not to neglect their spousal responsibilities. In fact, they tried to demonstrate their skill in planning and coordinating the spousal role in another dimension of life.

Acknowledgements

The current study was extracted from a PhD dissertation in Reproductive Health approved by the Ethics Committee of Mashhad University of Medical Sciences. Our deepest appreciation goes to the Research Vice-Chancellor of Mashhad University of Medical Sciences for cooperation in different stages of the current study. Special gratitude is also extended to all the participants who sincerely expressed their experiences.

Conflicts of interest

Authors declared no conflicts of interest.

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