How Do Pregnant Women Conceptualize Their Sexual Relationships: A Qualitative Study

Introduction

Pregnancy is a unique physiological and psychological experience that might affect couple relationship and challenge marital and sexual bonds (1-3). As such, pregnancy could influence sexual relationship between couples to a large extent. It is believed that several factors including sexual value systems, social, cultural and religious beliefs may influence the sexuality of couples in pregnancy (4, 5).

There is evidence that pregnancy could create a situation that either might be positive or negative. For instance, studies have shown that sexual relationship during pregnancy was improved and couples showed more commitment and intimacy, while some studies reported that sexual relationship between couples during pregnancy was declined dramatically that can potentially be harmful to intimate relationship (2). Also the sexual behaviors of men in pregnancy can be severely affected and led to intensifying male sexual disorder (6, 7). Even, sexual and relationship difficulties in pregnancy can set the platform for the postpartum problems and ongoing relationship problems can have critical consequences for the preparations for motherhood, parent-child relationship and later child development (4, 6, 8-12).

In Iran, expressions of sexuality are primarily dictated by Muslim values and by sociocultural norms. Islam allows people to have sex in pregnancy and considers sexual pleasure to be the right of every human being (13). Tugut et al. (2016) showed that the majority of the women stopped engaging in coital activities during pregnancy (8). Kazemi et al. (2017) showed that different factors can affect pregnant women’s quality of life which are classified in three categories, namely, the effects of pregnancy on different aspects of health, pregnancy-related concerns and coping with pregnancy (11). Babazadeh et al. (2013) study the pregnant women perception of sexual activity and showed that excessive anxiety and insufficient information is the major reason why sexual intercourse is often considered dangerous, and sometimes avoided, during pregnancy in Iran (14). Considering the studies in Iran, there is no qualitative study about this subject and most of the current quantitative studies have assessed the sexual function. Unfortunately, data on sexual relationship during pregnancy among couples who are Muslim and usually consider certain values are limited. Thus this study aimed to explore the topic and contribute to the literature. In particular, the specific objective of this study was to respond to the following question: what is the feeling of pregnant women about sexual relationship in pregnancy? The woman’s responses to relationship shared with her husband during pregnancy may offer a framework for understanding the future marital relationship or even childbearing outcomes. However, since most studies about sexuality during pregnancy are quantitative, the views and experiences of pregnant women needed to be assessed qualitatively (14). Therefore, an attempt has been made to explore the meaning of sexuality from a pregnant woman’s perspectives. It was hoped that the findings could help women to adapt their sexual roles during pregnancy.

Materials and Methods

This was a qualitative study with interpretive approach that was approved by the ethics committee of the Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran (No. IR.TMU.REC.1396.702). All methods were performed in accordance with Declaration of Helsinki (15) and was conducted following the Consolidated Criteria for Reporting Qualitative Research (COREQ) (16).

A purposeful sample of pregnant women attending the community health centers affiliated to Kashan University of Medical Sciences, Kashan, Iran was recruited when they came to receive routine pregnancy services. All participants lived in Kashan and they were ordinary women who had normal expectations about marital life. All participants were informed about the objectives of the study. Additionally, confidentiality and anonymity of the data were guaranteed, and participants were assured that all recorded files would be deleted after completion of the study. Written informed consent was obtained from all participants. All interviews were voice-recorded with permission. The recruitment continued until the data saturation achieved.

Data were collected through semi-structured and in-depth individual interviews, all of which took place between June and January 2018. Each interview lasted for 20-45 minutes, and a follow-up interview was scheduled if needed. The interviews were started by asking an open question, followed by more in-depth questions. All interviews were performed face to face and individually in a private room and all were audio recorded. Women were asked to express their feelings and understanding of the way pregnancy influences their marital life. The interviews included questions such as ‘How do you feel pregnancy change your sexual life’? and ‘Would you please express how your sexual relationship is’? Or ‘Could you tell me your thoughts about marital relationships in pregnancy’. The intention was to understand how the participants perceived the meaning of marital and sexual life in pregnancy. Further probing questions were asked to clarify explanations, including: Could you give me an example? May you explain more? The policy for data collection was to expose the questions implicitly, never directing them to address our concerns, directly. All interviews were conducted by the main investigator (MRB) in community health care centers and were recorded for later transcription.

Conventional content analysis, in the form of a systematic classification process, was used to extract meaningful codes and to identify themes and patterns (17). Interviews and analysis of texts began simultaneously, and each analysis was continuously compared with prior ones (18). Data were analyzed manually. Initially, each interview was transcribed verbatim and each transcript was read several times to attain an overall sense of the data. According to qualitative content analysis, as suggested by Graneheim and Lundman (19), each individual interview was considered a separate unit of analysis, since it was large enough to be kept in mind as context for the meaning unit during the analysis process. We defined a unit of meaning as words, sentences, or paragraphs containing aspects related to each other in content and context. In the next step (condensation), we reduced the size of the unit of meaning while preserving the core meaning and attempted to indicate both manifest and latent content with a description close to the text. A further step involved abstracting and labeling the condensed units of meaning with codes. After the coding process, all codes were compared with each other and were classified into subcategories and categories based on similarities and differences. Eventually, theme was developed after rereading and the analysis process described above.

Credibility, dependability, conformability, transferability, and authenticity were considered for the trustworthiness of the results. The credibility of the data strengthened through spending enough time on data collection was established through prolonged engagement, immersion in the data, writing of field notes and member checking. For member checking, the primary results of the qualitative analysis were given back to four of the participants to confirm that the researchers had correctly interpreted their perceptions and to ask whether the analysis made sense to them. Dependability was checked through external checking by four experts outside the research team. For peer checking, three sexual and reproductive health care professionals specializing in qualitative methodology supervised the process of coding and the extraction of subcategories and categories. Confirmability was established by reviewing the analyses with two participants who confirmed the findings (20).

Results

Participants

The mean age of participants was 27.8 years. The majority were in the third trimester of pregnancy. Most had their first pregnancy. More than two thirds of the participants had higher education and were housewife. The characteristics of participants are detailed in Table1.

The main theme

Priority to fulfill husband’s sexual need

Using the transcripts provided from interviews, unit of meanings, and condense unit of meanings or primary codes were extracted for further analysis (Table 2). Then, codes were classified into sub-sub-categories, sub-categories, categories and the main theme. In all there were 748 codes tapping into 15 sub-sub-categories, five sub-categories, two categories and the main theme (Table 3). The main theme was named as ‘priority to fulfill husband’s sexual need’ comprising of two categories including: (1) more male-centered sexual relationship in pregnancy and unmet emotional-sexual expectations of pregnant women.

1. More male-centered sexual relationship in pregnancy

Becoming more impressive of male-centered sexual relationship in pregnancy demonstrate the behaviors that occur in androcentric context in Iranian society. This main category was extracted from three subcategories and nine sub-sub-categories:

Passive sexual role

Passive sexual role was inclusive of intensification of passive sexual behavior during pregnancy, not priority of sex for pregnant women, having sex despite pregnancy restrictions just for marital duties, stepping forward in sexual relationship to consideration husband’s sexual satisfaction and suggesting sex despite pregnancy problems to remove husband's annoyance due to reduction of intercourse.

In terms of passive sexual role that was existed in expression of pregnant women, we can mention some concepts. The feeling intensification of passive sexual behavior during pregnancy is evidently obvious when analyzing the expressions. Some pregnant women stated that:

“I am inevitable to accept him when requested for sex. p7.”

Meanwhile, most of participants expressed that sex have not priority for them in pregnancy.

"For a pregnant woman sex is in next priorities. P8".

"I don't think about it (intercourse) at all. I mean, I do not have time to think about these things at all. My only thought and mention is what will occur about my pregnancy and my baby. Sex is not important for me and has been one of my lower priorities. P1"

There are some reasons to avoidance of women from initiating the sexual action. For example, embarrassment, indifference to sexual activity and sense of shamefacedness.

 “I never request my husband because I’m embarrassed especially in pregnancy. p7”.

Some pregnant woman mentions that they having sex despite pregnancy restrictions just for marital duties. These behaviors culturally and socially have socialized in Iranian women.

"I do not upset my husband in pregnancy, for example, if I am tired or something else. I accept his request for asexual relationship. P12".

Stepping forward in sexual relationship to consideration husband’s sexual satisfaction was another impression of our participants; preference of husband’s sexual satisfaction over self was mentioned frequently. This construction concerning women’s sexuality and must consider the notion that some Muslim women may have internalized and accepted the centrality of men’s sexual interests and that is an indicator of modesty and of being an ideal wife. Women stated that they are knowing of men's high sexual desire and tried to satisfy them. On the other hand, pregnant women perceive a mind calming sensation due to meet the men’s sexual requests. Participants stated:

"During the intercourse, I just wanted my have be satisfied. I want he don't be upset from my pregnancy because I just want him to be satisfied. P11"

"It is important for me that my partner was happy in sex. I am always like that and in my pregnancy it intensified. I want my husband to enjoy it (sex) more than I do". P15.

Suggesting sex despite pregnancy problems to remove husband's annoyance due to reduction of intercourse was another statement of our participants. In this regard, some pregnant women stated that:

 “When I saw that the sexual abstinence has taken a long time and he was under a lot of pressure emotionally, I have offered him a sexual relationship. P22.”

"For example, when I saw that it had lasted a week that we haven’t any sex, I would say to him "Let's have a sex", because I was sure that he wanted to have, but he doesn’t state this. P21"

Give in to sex for fear of infidelity concerns

Give in to sex for fear of infidelity concerns about spouse infidelity during pregnancy and trying to improve sex after presentiment of possible infidelity by husband. In terms of give in to sex for fear of infidelity during the pregnancy, some participants expressed concerns which were emerged in their current pregnancy and pushed them to trying to improve sex after presentiment of possible infidelity by husband. They said:

“I am afraid of this issue that pregnancy cause to infidelity, always. Before pregnancy, I was worried that if I getting pregnant and could not have a good sexual relationship with my partner, there would be a disloyalty in our relationship.” (p.2)

Self-blame for not providing the optimal sex to the partner

 Self-blame for not providing the optimal sex to the partner (guilty feeling after refusing a spouse's request for sex and pangs of conscience for not providing good sex). Another concept that derived from experiences of our pregnant women was the self-blame sensation for not providing the optimal sex to the partner. This claim reveals the extent to which the women are taught to behave like a nurturer women and had been constructed as the providers of male sexual gratification throughout their marital relationships.

So guilty feeling after refusing a spouse's request for sex is not unexpected and the pangs of conscience for not having enough good sex is thoughts of Iranian women that to be inspired with cultural heritage from a generation to new generation. They said:

“When I would negative answer to him at night because of pregnancy difficulties, I feeling so bad in the morning and became upset. P11.”

“My sensation is that I am shirking in marital relationship a bit. P18”

Among the other personal understanding which has been mentioned by the participants, the pangs of conscience for not having enough good sex could be observed. A pregnant woman said:

“Well, because my abdomen is coming forward and became bigger, I can’t struggle so much to satisfy him and I feel that he no longer enjoys in sex.” (p15).

2. Unmet emotional-sexual expectations of pregnant women

This category is consisted of 2 sub-categories; needing to more husband's empathetic behaviors and dissatisfaction from mutual companionship of spouse in sexual relationship.  Interpersonal behavior interaction includes comportments that present an emotional manner of pregnant women which make a spectrum appearance from an inappropriate marital relationship to a relative satisfaction from husband’s actions. This main category is extracted 6 sub-sub category:

Needing to more husband's empathetic behaviors

Needing to more husband's empathetic behaviors expresses some demand that appears on the bed of past needs extracted from expectation for more attention from the spouse than before pregnancy.

In this regard need to spouse's affection as an alternative for sexual activity concern of our participants. For example, pregnant women stated that:

 “I would like my husband to approach to me more and I was to be valued in pregnancy. P21.”

"In my pregnancy, I became more sensitive to his relationship with his family. I had his hug but I just wanted him to pay more attention to me, only me. P18"

In the context of perception of care and understanding by spouse the majority of participants expressed about appearance a good sensation in their bilateral marital relationship after their gestation.

“I have felt more passionate in my marital life with my husband after to be conceived. P23.”

“He got better; we got closer to each other while not so close and dependent before pregnancy. P2.”

"Our relationship with my spouse has become more intimate than before pregnancy. P10"

"After pregnancy, I was in a very bad situation; I felt that the person (her husband) had a great impact on our relationship. Anyway, I saw he accompanying me, did not leave me alone for a second, was by my side and helped me in everything and any situation. It completely changed my mind about my partner. Pregnancy changed my outlook on life. P4"

 “I love to be hugged, touched and feel warmth of his hand on my abdomen. This is usually occurred before bedtime, even if it is not a sexual relationship. p15.”

Dissatisfaction from mutual companionship of spouse in sexual relationship

Another sub category that emerged from participant's declaration was dissatisfaction from mutual companionship of spouse in sexual relationship; annoyance of spouse's disregard to the pregnant woman's sexual demands, decreased agreement with the spouse to have sex compared to before pregnancy and relative understanding the spouse of the pregnant woman's readiness to have sex.

From the participants’ point of view, annoyance of spouse's disregard to the pregnant woman's sexual demands can be neglected emotional-sexual expectations and for most of them a partner’s indifference behavior is very important factor for disturbance physically and psychologically. One of the respondents stated:

 “Before I got pregnant, I tried to reach orgasm and he knew the sexual position that I like more, but he didn't care much in current sexual relationship! p11”.

He wants every day to have sex if possible but I don’t like this. This issue makes me crazy. I want he do sex gently because of pregnancy but he doesn't care. P7”.

From what pregnant said, it is understood that mutual agreement is good but a decreased agreement with the spouse to have sex compared to before pregnancy is obvious. Some participants stated that:

 “I am so comfortable with my husband that I can easily tell him how and when I want to sex.

On the other hand, he is waiting to an appropriate time to sex. P15.”

“I can’t speak with him because he is responsible for this unwanted pregnancy. I’m very upset about this.  I blame him for my current misfortunes.” P7.

 “I mostly excused the fetus health to refuse a sexual intercourse or sometimes I pretended to falling asleep. Although this fear or stress was very low but I rolled play to him”. P23.”

The sub-sub category is relative understanding the spouse of the pregnant woman's readiness to have sex. It presented a mutual agreement to have sex and spouse' acceptable understanding of the pregnant woman's special physical and psychological situation.

 “My husband is one of those men who talk to me about sexual issues. This manner helps a lot to me for a comfortable sense in decision making about having sex or not especially in pregnancy. P3.”

Some misunderstanding and lack of communication skills, for example making excuses have led to an undesirable mutual conversation about sexual issues in pregnancy. Some of them were unable to communicate effective verbally and emotionally with the spouse about sexual intercourse due to some reasons such as blaming the spouse for the occurrence of unwanted pregnancy or feeling ashamed of speaking about sex.

Discussion

The current qualitative study found that ‘priority to fulfill husband's sexual need’ was a dominant factor that contributed to meaning of mutual sexual relationship of pregnant women. The majority of participants indicated that their experiences of sexual relationship during pregnancy were associated with sacrifice toward sexual demands of their husbands and thus women expressed that they were emotionally dissatisfied. Perhaps such experiences might be observed in those societies that are male-centered.

One concept that emerged from our participants’ experiences was the issue of male-centered sexual relationship in pregnancy. In fact, we found that passive sexual behavior during pregnancy was intensified implying that Iranian pregnant women experience extra manner of androcentric behaviors. One might argue that since all participant were Muslim, the experience of intensified male-centered sexual relationship might be explained by the fact that participants may have internalized and accepted the centrality of men’s sexual preferences and see this as indication of modesty and of being a perfect wife (21). Similarly a study found that in a Muslim society the main sexual motivation was to satisfy men and inference that kept husbands sexually satisfied reinforced a successful relationship and was the main responsibility of a powerful woman (22). However, Lamiyan et al, pointed out that although the sexual relationship of Muslim women at reproductive age in Iran has changed greatly in a way that they play more active role in this respect, still feeling of power, independence and self-confidence are hidden inside this relationship (23).

The finding showed that participants played a passive sexual role. As such it is argued that this passive role is an indication of several facts. For instance, it is argued that women believe that sexual obedience and sex offer are essential to the consolidation of marriage (21); or most women feel moral obligations to respond to their husbands’ sexual needs as a cultural and religious belief. In fact they perceive sexual submission (Feminin Tamkin) as evidence of performing religious duties and being a devoted Muslim woman(24, 25).

The findings indicated that the most frequent reason for sexual relationship during pregnancy was to satisfy their husbands. Nonetheless similar observation was reported from Iran and elsewhere (21, 26). It is argued that having sex despite pregnancy restrictions just for marital duties might be due to the culture of shyness imposed on women through a series of normative values and thus they are unable to discuss their sexual needs and preferences with their husbands making them remain silent and give in to sex to maintain the honesty of their marriage (27).

The majority of women in the current study felt that they had sex only to keep their partners happy and pleased. The motivation for such doing perhaps may include obtaining positive outcomes, such as the spouse’s well-being and long-term intimacy (28). However, in some occasions it has been reported that a number of couples set a verbal arguments for restriction of sexual activity during pregnancy (5, 12).

This is some study in agreement with our subcategory that named give in to sex for fear of infidelity. Some researcher show that the pregnant women sustain the vaginal intercourse as pre pregnancy for prevention of infidelity in Nigeria and Pakistan (29, 30). This investigation takes placed in societies that are as the same as society of Iran in the term of religion and culture, partly. Shirpak et al. showed that a serious sexual concern of  Iranian women is fear of infidelity of their partners, because they believed that if they could not satisfy their husbands' sexual preferences, they would exercise their legal right to have additional wives (27). Also sexual dysfunction can cause serious partnership problems and lead to infidelity and divorce (14).

In present study pregnant women expressed their feelings that made another main category namely unmet emotional-sexual expectations of women by their husband consisting of two sub-categories, needing more husband's empathy and dissatisfaction from mutual companionship of spouse in sexual relationship. This finding is similar to the findings where it was reported that pregnant woman may have a strong need for affection. In fact they are looking for a sense of security and understanding through physical contact such as being held and kissed or having sex (6). Every woman needs more attention during pregnancy and greater levels of affection from her husband than before. Therefore the relationship should be more enthusiastic and deep (12). This demand was very obvious in our study. Sexual satisfaction enables them to cope with stress and tolerate coming unknown physical conditions. In addition, satisfying experience during pregnancy was found to strengthen the marital bond by increasing the emotional ties between couples and ease the uncertainty and loneliness brought on by pregnancy in some women (6).

Needing to more husband's empathetic behaviors during pregnancy and ignored emotional-sexual expectations were very obvious in our study. Based on above findings  and because  most of pregnant woman are commonly distressed by changes in their sexuality such as reduced frequency and sexual distress is correlated with decreased relationship satisfaction (7), need of our participant for more attention is explainable.

Although changes in sexual interest and activity during pregnancy may have an adverse effect on couples' relationships, in some studies the younger participants believed that their first pregnancy affected the nonsexual aspect of their relationship with their husbands in a positive way. This finding supported by our results that constructed subcategories named needing to more husband's empathetic behaviors during pregnancy and dissatisfaction from mutual companionship of spouse in sexual relationship. In the present study, as in others, pregnant women feel deeply to attention of their partners and this make them developed from partners to parents, is a healthy sexual relationship during pregnancy.

Moreover, whereas some women worried about their husbands' displeasure or felt pressured into intercourse, others felt that their husbands neglected their sexual needs (14). In our study majority husbands refuses to closeness and make an intimacy for many reasons and this disturbed the pregnant women.

Another our participant conception in their pregnancy was couples' dysfunctional verbal communication about sexual issues. Due to various cultural and religious factors, the Iranian society gives men greater sexual rights, respects their sexual desires. Despite  the suggestion of researcher that communication about sexual preferences can build the intimacy and mutual understanding in sexual relationship (6), but our participants say that they didn’t effective conversation with their husbands about sex in pregnancy.

This study had some limitations. Similar to other qualitative studies the results cannot be generalized. In addition, this study was conducted in an urban area and may not be representative of the general population. In this study, we used the views of pregnant women who were willing to participate in the study that may be different from the views of those who did not wish to participate. Finally, we interviewed pregnant women at any trimester and thus might influenced the results. Perhaps for the future studies is better to include and a more homogenous sample of participants.

Conclusion

The findings suggest that pregnancy can have unpleasant effects on pregnant women's life emotionally and lead to a decreased quality of sexual life. Sexual health consultation must be embedded in prenatal care in order to increase marital satisfaction, keep and enrich sexual health of couples, increasing quality of life in pregnant women, and finally strengthening family bonds. As well as, there is a need for many studies in a range of various settings. Also conduction a study on the pregnant women with their partners which focus on the marital and sexual interactions could be very useful.

Acknowledgements

The present study was originated from Ph.D. thesis of the first author at Department of Reproductive Health, Tarbiat Modares University, Tehran, Iran. The authors would like to thank women who participated in the study.

Conflicts of interest

Authors declared no conflicts of interest.