Sexual self-care, quality of sexual life and fertility desire in women attending comprehensive health centers in Urmia, Iran

Abstract

Background

Sexual self-care and quality of sexual life are critical factors in women’s health. These factors can also influence women’s fertility desire. This study aims to examine sexual self-care, quality of sexual life, and their relationship with fertility desire in women attending comprehensive health centers in Urmia.

Methods

This descriptive-analytical study was conducted on 384 women which were randomly selected using a multistage sampling method. Data were collected using standard validity and reliability questionnaires of sexual self-care, quality of sexual life and fertility desire. Data were analyzed using one-way ANOVA, independent t-test, and multiple regression.

Results

The average age of the participants was 32.92 ± 8.03 years. Women’s education level and economic status were significantly associated with fertility desire (P < 0.05). Additionally, sexual self-care (B = 0.490,p < 0.001) and the quality of sexual life (B = 0.232,p < 0.001) were strong predictors of fertility desire. Together, they accounted for 92.8% of the variance in total fertility desire scores.

Conclusion

Sexual self-care and the quality of women’s sexual life are directly related to the fertility desire. Therefore, Participating in training workshops on body anatomy, menstrual cycle and sexual self-care techniques, providing private counseling sessions to investigate sexual concerns and problems, and providing suitable solutions will help women’s fertility desire.

Background

Sexual self-care is a comprehensive approach to maintaining and improving an individual’s sexual health and refers to an individual’s ability and responsibility to manage and enhance various aspects of their sexual health [1]. It includes various concepts such as sexual awareness, sexual communication skills, sexual health management, prevention of sexually transmitted diseases (STDs), and sexual well-being [2]. Sexual self-care empowers individuals to identify their sexual needs and concerns with awareness and responsibility, enabling them to take proactive steps toward maintaining and improving their sexual health. Individuals with higher sexual self-care skills are generally more aware of their sexual health and better at identifying and managing their sexual needs and issues [1]. Effective sexual self-care helps individuals prevent sexual dysfunctions and address these issues if they arise [3]. Among issues related to sexual health, sexual dysfunction is the most common, affecting approximately 10–40% of the global population [4]. Studies conducted in Iran indicate a 27.3% prevalence of sexual dysfunction among women, with the highest prevalence observed in the domain of sexual desire, affecting approximately 35% [5]. Additionally, orgasmic dysfunction and pain during intercourse were reported at rates of 35.5% and 20.1%, respectively [5]. This issue not only directly impacts the quality of sexual life but also affects interpersonal relationships, mental health, and even fertility [6]. Changes in women’s fertility desire have been significant over the past three decades, and can greatly influence personal aspects of life, including sexual relationships, emotional well-being, marriage, and family dynamics [7]. The reduction in population growth in the coming years can pose threats such as a decrease in the active and productive population, which is essential for economic growth and social development [8]. Fertility desire is a key component of women’s health and quality of life, referring to the willingness and readiness to have children [9]. Factors influencing fertility desire include sexual health and quality of sexual life. Studies have shown that sexual dysfunction and dissatisfaction with sexual life can negatively affect fertility desire [10, 11].

Sexual quality of life is a key aspect of sexual and reproductive health and refers to an individual’s satisfaction and positive experience with various dimensions of their sexual life, encompassing physical, psychological, emotional, and social well-being. This quality is influenced by multiple factors, including communication with a sexual partner, sexual health awareness, and the ability to express needs and desires. Overall, sexual quality of life can have a significant impact on an individual’s overall health and life satisfaction [12, 13]. There is a consensus that the quality of sexual life is closely intertwined with overall life satisfaction and quality. A low quality of sexual life can be indicative of an individual’s poor general health and life quality [14]. Enhancing sexual health and quality of life in women can positively impact their fertility desire, and women with moderate to high quality of sexual life are more likely to have children [15]. It is essential to explore the specific challenges and concerns women encounter regarding sexual and reproductive health, including issues like menstruation, pregnancy, childbirth, and hormonal changes, as these can have a profound effect on their quality of life. Additionally, social and cultural changes in contemporary societies influence women’s perspectives and decisions regarding fertility. Investigating these topics can help identify and analyze patterns of sexual self-care among women, increase sexual health awareness, empower women to manage sexual issues, and enable informed decision-making, allowing women to feel more in control of their sexual and reproductive lives. Furthermore, focusing on this group can lead to the development of effective educational and counseling programs to assist women in better managing their sexual and reproductive health. In particular, the city of Urmia, with its cultural and ethnic diversity and unique social and cultural challenges, underscores the importance of studying sexual self-care patterns and the quality of life among women. Therefore, this study aimed to examine sexual self-care, sexual quality of life, and their relationship with fertility desire among women attending comprehensive health centers in Urmia.

Methods

Study design and setting

This study is a cross-sectional study, with data collected from October to December 2023. The study population includes all women registered in the integrated health system (SIB) in Urmia. To protect participants’ rights, the researcher adhered to ethical considerations, including approval from the university’s ethics committee (Ethics code: IR.UMSU.REC.1402.248), introducing health workers as data collectors, and explaining the study objectives to participants. Participants were fully informed about the voluntary nature of their participation and the confidentiality of their information. Consent forms were obtained before completing the questionnaires.

Study population

Due to a lack of sufficient data on fertility desire in Urmia households, a proportion (P) of 0.5 was assumed, resulting in the largest sample size. With a margin of error (d) of 0.05 and an alpha (α) of 0.05, the sample size was calculated to be 384 using the following formula:

$$\:{n}^{{\prime\:}}=\frac{{Z}_{1-\alpha\:}^{2}\times\:P(1-P)}{{d}^{2}}=\:\frac{{1.96}^{2}\times\:0.5\times\:0.5}{{0.05}^{2}}=384$$

Data collection method

This study utilized a multi-stage sampling method, with data collected from 79 comprehensive health centers in Urmia. Urban health centers were used as the primary sampling units, from which 8 centers were randomly selected. Subsequently, approximately 47–48 samples were selected from each center through convenience sampling. For systematic selection of health centers, they were listed based on the socio-economic status of women, and centers were chosen at appropriate intervals.

Inclusion & exclusion criteria

Women who met the following criteria were included: generally healthy, no contraindications for pregnancy, literacy, in the reproductive age range (18–49 years), non-pregnant, registered in the health center and household system, living with a spouse, and not taking specific medications. Individuals who did not consent to participate and questionnaires with more than 50% of the questions unanswered or with responses limited to a single option were excluded from the study.

Data collection tools

Data were collected using questionnaires covering demographic characteristics (age, education, occupation, history of abortion/stillbirth, previous delivery method, number of children, economic status), sexual self-care, sexual quality of life, and fertility desire. The sexual self-care questionnaire, was developed by Yazdani et al. [16]. The questionnaire consists of 40 items across four domains: prevention of sexually transmitted diseases (14 questions) (e.g., “If my partner has genital sores like warts, herpes, or any skin lesion, we use a condom during sexual intercourse”), prevention of women’s cancers (7 questions) (e.g., “I perform screening for human papillomavirus or genital warts infections”), prevention of unwanted pregnancies (6 questions) (e.g., “I encourage my partner to use a safe method of contraception for healthy fertility”), and promotion of sexual health (13 questions) (e.g., “If I or my partner encounter issues with sexual activity, we seek advice from a counselor”). The scoring system uses a 5-point Likert scale (1 = Never, 5 = Always). The minimum score is 40 and the maximum score is 120, with higher scores indicating better sexual self-care. The validity and reliability of the questionnaire were assessed by Yazdani et al. [16] showing a content validity index of 0.93 and an overall validity ratio of 0.96. The tool’s internal consistency was demonstrated with a Cronbach’s alpha of 0.94, and its stability was confirmed by an intra-cluster correlation coefficient of 0.97 (with a confidence interval ranging from 0.94 to 0.98). In the current study, the Cronbach’s alpha for the sexual self-care questionnaire was 0.95.

The Women’s Sexual Quality of Life Questionnaire was designed and developed by Simonds et al. to assess sexual quality of life. This questionnaire contains 18 questions, measured on a six-point Likert scale: Strongly Agree, Agree, Somewhat Agree, Somewhat Disagree, Disagree, and Strongly Disagree (e.g., “When I think about my sexual life, I find that it is generally an enjoyable part of my life,” “I do not enjoy sexual activity”). In the study by Roshan Chesli et al. [17] the validity of this questionnaire was considered suitable for evaluation. To validate it, three datasets from studies related to women’s health in the United Kingdom and the United States were used. The internal consistency of the questionnaire was demonstrated through a Cronbach’s alpha coefficient of 0.89. In the current study, the Cronbach’s alpha for the Sexual Quality of Life Questionnaire was found to be 0.83.

Fertility Desire of women was assessed using the questionnaire by Kaveh Firooz et al. [18]. This questionnaire consists of 21 items, rated on a five-point Likert scale ranging from Strongly Agree to Strongly Disagree. The minimum and maximum scores range from 21 to 105, with higher scores indicating a more positive attitude toward childbirth and lower scores indicating a more negative attitude (e.g., “Having children contributes to the stability and cohesion of the family”). This questionnaire was used in a study by Kaveh Firooz et al. in Iran, where the content validity index of the tool was reported as 0.91, the overall validity ratio as 0.94, and the Cronbach’s alpha coefficient as 0.77, confirming its validity and reliability [18]. In the current study, the Cronbach’s alpha for the Childbirth Attitude Questionnaire was found to be 0.68.

Data analysis

Data were entered into SPSS 20 software by a statistical expert. For comparing the means of quantitative variables between two groups, an independent t-test was used. For comparisons among more than two groups, one-way ANOVA was employed, and multiple regression analysis was used to examine the influence of predictor variables on the outcome variable. Results were considered statistically significant at p < 0.05.

Results

The mean age of the participants was 32.92 ± 8.03 years, and the mean age of their spouses was 37.66 ± 8.43 years. Most participants had university education (47.7%), were homemakers (70.1%), and their spouses were mainly self-employed (70.3%). Additionally, it is noted that 21.1% of the women surveyed had a history of abortion or stillbirth. In terms of delivery methods, 55.2% underwent cesarean section, while 39.1% experienced vaginal delivery. Additionally, the distribution of the number of children among participants was as follows: 38.3% had one child, 3% had two children, 13.8% had three children, 6% had no children, and 3.9% had more than four children.

One-way analysis of variance and independent t-tests were used to examine the relationship between demographic variables and fertility desire, and the results showed that the Women’s level of education and economic status had a significant relationship with fertility desire (P < 0.05). Lower education levels and better economic status were associated with lower fertility desire. (Table 1).

Table 1 Frequency distribution and relationship with the fertility desire

Table 2 Mean and standard deviation of the studied variables

According to Table 3, the quality of sexual life and sexual self-care and its dimensions were observed to have a positive and significant correlation with fertility desire, that is, the higher the score of the quality of life and sexual self-care increases, the more fertility desire increases in women (Table 3).

Table 3 Correlation test between sexual self-care and quality of sexual life with fertility desire

Based on the adjusted R-squared value (Table 4), the variables of sexual self-care and quality of sexual life account for 92.8% of the variance in the overall score of fertility desire. Notably, the P-values for both sexual self-care and quality of sexual life indicated that these variables significantly predict the score of fertility desire (P < 0.001). Also, with an increase of one standard deviation in the score of the quality of sexual life, the overall score of the fertility desire will increase by 0.509 standard deviations.

Table 4 The results of multiple regression analysis on the fertility desire among the participants

In addition, quality of sexual life and different aspects of sexual self-care (prevention of sexually transmitted diseases, prevention of cancer, prevention of unwanted pregnancies and sexual health) predict 94.7% of the variance of the overall score of fertility desire.

The variables of quality of sexual life, prevention of sexually transmitted diseases, prevention of cancer and prevention of unwanted pregnancies significantly predict the overall score of fertility desire (P < 0.001).

There is an inverse relationship between cancer prevention and fertility desire. Additionally, it is suggested that with an increase of one standard deviation in the quality of sexual life, prevention of sexually transmitted diseases, and prevention of unwanted pregnancies score, the fertility desire score will increase by 0.267, 0.146, and 0.787 standard deviations, respectively (Table 4).

Discussion

The concept of sexual self-care is important from various aspects, including sexual health and fertility desires. The present study revealed that sexual self-care significantly predicts overall fertility desires. Kandi et al. showed that sexual self-care plays a significant role in people’s experiences of sexual intimacy and positive sexual self-perception and sexual experiences are linked to positive pregnancy experiences [19]. Enhancing sexual self-care skills through education reduces cognitive distortions and improves sexual performance [20]. In women of reproductive age, sexual self-care is crucial in preventing unwanted pregnancies and promoting reproductive health [1, 21]. Therefore, sexual awareness and self-care help women make deliberate decisions about the number of children and time gap between pregnancies, improving family life quality and sexual health. This matter could, in turn, have an impact on demographics and the sustained development of communities.

Dunn et al. showed a positive correlation between sexual satisfaction and increased fertility desires in women [15]. This is consistent with the present study, where sexual quality of life predicts fertility desires. Research also indicated that stress, anxiety, and depression can reduce sexual quality of life and ultimately lower fertility desires in women [22]. The quality of sexual life in women is influenced by various factors, such as the quality of the relationship with their partner, sexual attitudes, knowledge, personality traits, and fertility desires. The quality of the relationship between partners directly affects women’s fertility desires [10, 11]. Factors such as sexual performance and depression also influence sexual quality of life and can affect attitudes toward pregnancy [23]. Therefore, it seems that providing appropriate education on sexual health, intimate relationships, and expanding family and social support by strengthening emotional life and intimacy between couples can help improve sexual satisfaction and quality of life for women, indirectly increasing their fertility desires.

In the present study, prevention of sexually transmitted diseases (STDs) showed a significant positive correlation with fertility desires. Magadi et al. found that women infected with STDs often have a more negative attitude towards pregnancy [24]. This may be due to concern about the transmission of these diseases to their children or their adverse effects on pregnancy [25]. Additionally, Dyer has found that STDs can have a detrimental effect on the quality of women’s sexual life [26] which negatively affects their fertility desires. Therefore, prevention of STDs through practicing safe sex, regular testing, and open communication with sexual partners can help increase women’s positive attitude towards pregnancy.

Similarly, Crist et al. reported that women diagnosed with cancer often have a more negative attitude towards having children because of the possibility of passing the disease to their children and the effects of cancer treatment on their fertility or pregnancy [27]. Jeronimo et al. found that cancer and its treatments can lead to a decrease in the quality of women’s sexual life, which negatively affects the desire to have children [28]. Early screening and diagnosis of prevalent cancers in women, such as breast and cervical cancer, can hinder the progression of these diseases and help maintain a positive attitude towards fertility [3]. In the present study, an inverse relationship was found between cancer prevention and fertility desires, which aligns with previous research. The inverse relationship between cancer prevention and fertility desires may be attributed to several factors. Individuals focused on cancer prevention are typically in older age groups, who generally have lower fertility desires. Additionally, lifestyle changes, such as a focus on education and career, could delay childbearing. Furthermore, some cancer prevention treatments, such as hormone therapy, may negatively affect fertility. Finally, increasing awareness about cancer and prevention methods could lead to changes in individuals’ life priorities, moving them away from childbearing. This issue could be addressed in future studies.

Based on the results of the current study, sexual self-care also plays a crucial role in preventing unwanted pregnancies, which in turn affects women’s attitudes toward pregnancy. Frost et al. found that promoting sexual self-care, such as the correct use of contraception, is effective in reducing unwanted pregnancies [29]. Ochako et al. also discovered that unwanted pregnancies are often associated with negative attitudes toward continuing pregnancy and childbearing, and preventing such cases can help maintain a positive attitude [30]. Therefore, sexual self-care, by preventing unwanted pregnancies and improving women’s sexual quality of life, can play an important role in preserving positive attitudes and increasing fertility desires.

Fort et al. have shown that women with higher education express less desire to have children [31], which is consistent with the results of the present study. Women with higher education levels express less desire to have children. This may be due to various reasons: educated women often pursue career and professional goals, delaying childbearing [32]; Additionally, women with higher education are more aware of contraceptive methods and have better fertility control [33].

However, the results of this study show that higher economic status correlates with higher fertility desire, which is in line with the findings of other studies [34,35,36]. Studies by Kreyenfeld and Sobotka suggest that families with better economic status are more capable of providing the costs of having children and have access to superior reproductive health services, which creates more motivation to have children. On the other hand, financial concerns in families with a lower economic status can reduce fertility desire. Nevertheless, social factors and national supportive policies may as well affect fertility desire. Furthermore, better access to education and contraceptive services in families with higher economic status can positively influence fertility desire. Therefore, better economic status is associated with higher fertility desire. However, this relationship may vary in different societies and can be influenced by social factors and supportive policies.

Conclusion

There is a direct relationship between sexual self-care, sexual quality of life, and women’s fertility desires. Women with a high level of sexual self-care tend to experience better sexual quality of life and exhibit a greater inclination toward childbearing. This highlights the importance of educating and empowering women in sexual health to enhance their sexual functioning and satisfaction. To improve women’s sexual self-care and quality of sexual life, organizing educational workshops and developing resources on topics such as sexual hygiene, STD prevention, and the significance of regular check-ups can play a crucial role. Additionally, individual and group counseling provided by health professionals and psychologists, as well as encouraging open discussions about sexual issues within families and communities, can help reduce taboos and increase awareness about sexual health.

For future research, it is recommended to conduct experimental studies on the impact of sexual self-care education and quality of sexual life on fertility desires. Furthermore, the influence of cultural and social factors on these aspects should be thoroughly examined.

Limitations & strengths

This study has some limitations, particularly concerning cultural and religious beliefs surrounding sexual matters, which are often considered taboo in Muslim countries. Such sensitivities may have caused some women to feel resistant when addressing sexual health topics, potentially introducing bias in questionnaire responses. Nevertheless, these challenges were accounted for during the study’s implementation, with efforts such as education and counseling aimed at reducing resistance. On the other hand, the study’s strengths include raising women’s awareness of sexual health, equipping them with essential skills to manage sexual issues, and challenging societal taboos.