Introduction: The first sexual intercourse after childbirth is an important step for couple to create intimate relationships. This study was conducted to determine the impact of counseling based on PLISSIT model on sexual intimacy of breastfeeding women during 6 months after childbirth. Materials and Methods: This study is based on randomized clinical trial. The samples of study consisted of 82 nulliparous and breastfeeding women during the first 6 months after childbirth. Samples were assigned randomly in intervention group and control group. To collect data, demographic and midwifery characteristics questionnaire and intimacy questionnaire were used. Sexual intimacy of person was measured in three phases: before intervention, 1 month, and 3 months after intervention. Results: Three months after intervention, the mean of sexual satisfaction and sexual intimacy scores increased significantly in intervention group (P > 0.001). There was a significant difference between sexual intimacy and sexual satisfaction scores in the experimental and control groups, 1 month (P > 0.001) and 3 months (P > 0.001) after the intervention by doing Mann–Whitney test. Conclusion: Based on the results of this study, sexual counseling increased sexual intimacy of breastfeeding women, and the impact of the counseling was still stable 1 and 3 months after the intervention.
Keywords: Breastfeeding women, counseling, PLISSIT model, sexual intimacy
|How to cite this article:
Banaei M, Safarzadeh S, Shahrahmani H. Impact of counseling on sexual intimacy of lactating women. Ann Trop Med Public Health 2017;10:1763-9
|How to cite this URL:
Banaei M, Safarzadeh S, Shahrahmani H. Impact of counseling on sexual intimacy of lactating women. Ann Trop Med Public Health [serial online] 2017 [cited 2020 Aug 14];10:1763-9. Available from: https://www.atmph.org/text.asp?2017/10/6/1763/222717
Sexuality is a part of human life. Healthy sexual function plays an important role to improve the health and quality of life for individuals and families. These emotional tendencies are expressed in various ways in individuals’ language, beliefs, behaviors, and relationships. In general, the sexual instinct is one of the strongest human instincts effective in individual behavior, and according to the World Association of Sexology, it is an essential part of every person’s character.
In Iran, 88% of divorces are said to be due to sexual matters. In addition, in another study, among applicants of divorce, 66.7% of men and 68.4% of women were not satisfied with their sex life so that the dissatisfaction was effective in their sexual activity. One of the important processes that affects marital satisfaction is intimacy. Several factors such as age, depression, stress, socioreligious beliefs, way of life, marriage characteristics, chronic disease, infertility, pregnancy and childbirth, menopause, or lack of proper relationship with spouse can be effective in sexual satisfaction and subsequently in sexual intimacy.
Pregnancy and childbirth is a specified period in a woman’s life that makes physical and hormonal changes and has considerable effects on mothers’ health and the quality of their lives. The postpartum period is known as a vulnerable and stressful period for women by different cultures that mothers in this period are faced with many new concerns and issues. In general, during pregnancy, women tend to receive frequent visits for birth control, preparation for childbirth, and breastfeeding. Moreover, usually after 6-week postpartum, they refer to health centers for physical examination of the genital area and refer to doctor or midwife to consult for choosing an appropriate contraceptive method, but little attention is paid to sexual life of women in this period.
Sexual activity in the postpartum period is an important issue for couples so that the first sexual intercourse after childbirth is an important step for couples to create intimate relationships. Sexual intimacy involves sharing romantic experiences with each other, the need for physical contact, sexual intercourse, and relationships that are designed to motivate, stimulate, and sexual satisfaction. Intimacy is considered as a key feature of marital relations and important feature of a successful marriage. This feature refers to the interaction between spouses. The absence or lack of it is an indicator of the turmoil in the marital relationship. Sociocultural issues and improper functioning of the Units of Health Services in the field of sexual health education and unwillingness of health-care workers to discuss sexual activity are some of the important reasons of sexual dysfunction and sexual dissatisfaction, followed by the lack of sexual intimacy in this period.,
Health-care workers can play an important role to aid couples to match with the postpartum period due to changes that occur during this period. Thus, intimacy, sexual satisfaction, and performance of mothers will improve. Ignoring the sexual instinct in humans leaves irreparable effects, and in most cases, sexual dysfunction and sexual dissatisfaction lead to the collapse of family foundations. Physical and psychological pressures arising from adverse sexual satisfaction will pervert the person and disturb his/her health. Nowadays, lack of proper sex education for couples is felt in our society more than ever, while, in health centers, no effective training is provided in this regard. Teaching sex can lead to more satisfaction between couples and ultimately leads to higher life satisfaction. Consequently, divorces due to sexual problems and dissatisfaction will decrease.
One of the approaches used to investigate the sexuality is the PLISSIT advising model. This model was developed in 1970 by Annon, and it discusses sexual issues individually. In the model, people are permitted to discuss and talk about their sex problems, limited information about sexuality is provided for them, and specific suggestions are represented to solve their sexual problems. Finally, in the last level, intensive therapy is provided for those who need more intervention. In a study, Torkzahrani et al. used the model for postpartum advice during breastfeeding on sexual function of lactating women that the average score of sexual function at 4-week postpartum between the two groups was significant. In addition, postpartum counseling led to improvement in sexual function of lactating women.
Therefore, evaluation of health and quality of women sexual life during both reproductive, especially pregnancy periods and breastfeeding is very important. Proper and satisfactory sex relations of couples will be followed by higher marital satisfaction for them. On the other hand, the ignorance of sexual and nonsexual satisfaction not only is associated with symptoms for both the individual such as depression, anxiety, low self-esteem, and isolation but also creates problem in the field of sexual and family relations resulting in emotional or legal divorce. As a result, the researcher will use the model that is applicable in various studies and its effects have been examined. In addition, the researcher conducted a study to determine the effect of counseling on sexual intimacy of lactating women referred to health centers affiliated to University of Medical Sciences of Bandar Abbas in 2015.
|Materials and Methods|
The present study was conducted in a randomized controlled clinical trial in 2015 in Niyayesh health center in Bandar Abbas on 82 lactating women (41 in experimental and 41 in control groups) who were referred to the center to receive health services, from September to December of 2015. The required sample size was calculated by taking 12.5% loss.
The criteria to enter into the study included primiparous and lactating women after giving birth to a singleton, within the first 6-month period after delivery, lack of exposure to stressful events during pregnancy and after childbirth, lack of postpartum depression, lack of complications in pregnancy and after childbirth, no history of chronic physical and mental illness, having at least moderate sexual satisfaction (score above 76), and being accessible during the study. The criteria to leave the study included become pregnant during the study, loss of baby, being away from spouse, severe marital conflicts, and the occurrence of adverse events (death of loved ones, accidents, etc.). The present study was conducted by confirmation of Ethics Committee of Shahid Beheshti University of Medical Sciences (IR.SBMU.PH.NM.1395.516). Data collection tools included demographic and midwifery specification questionnaire, the Edinburgh’s postnatal depression questionnaire, a questionnaire of sexual intimacy and sexual satisfaction of Larson.
Demographic and midwifery specification questionnaire included 32 questions related to demographic information, pregnancy and childbirth status, baby’s gender in the view of the woman and her husband, contraception, breastfeeding condition, average intercourse in the week before pregnancy and after delivery, and the onset time of intercourse 1 week after childbirth. Sexual intimacy questionnaire has 30 questions that examine the needs for intimacy of couples and emotional, psychological, intellectual, sexual, physical, spiritual, esthetic, and social entertainment dimensions. Each question has a four-option response (always, sometimes, rarely, or never) with a score of 1–4. The maximum score is 120 and the minimum is 30. The higher score is indicative of higher sexual intimacy. In the study of Shakarami et al., the reliability of sexual intimacy was equal to 78.0 using Cronbach’s alpha. In the present study, the Cronbach’s alpha is obtained as 82.0.
Edinburgh’s postnatal depression questionnaire is a tool developed to screen for postpartum depression, and a valid tool for screening for depressive symptoms during 7 days past the postpartum period. With respect to postpartum depression being an intervening variable in this study, it was used for the assessment of the participants in the two groups regarding postpartum depression and its comparison in both groups. Sexual satisfaction questionnaire of Larson included 25 questions, and the responses were scored on a 5-Likert scale, that due to sexual satisfaction being an intervening variable in the present study, the questionnaire was used to examine the conditions of samples in two groups regarding sexual satisfaction and its comparison in two groups.
After reading numerous books and papers and passing sex therapy workshop to enhance skills in this field, the researcher referred to the health center affiliated to University of Medical Sciences of Bandar Abbas, and while introducing himself and mentioning the objectives of the study, he received written consent of the qualified individuals. Lactating women who referred to Niyayesh health center during the first 6 months and had the specifications of the study were invited to take part in the study. Before beginning the study, the valid telephone number would be obtained from the women.
At the first level, women filled in demographic and midwifery specification questionnaire, the Edinburgh’s postnatal depression questionnaire, a questionnaire of sexual intimacy and sexual satisfaction of Larson. If having the criteria for entering into the study, they were passed to the second level of study. Two groups were statistically similar regarding the average score of sexual intimacy. In the next stage, in the experimental group, sex counseling was done based on components of PLISSIT model in two 60–90 min sessions once a week.
At the end of each session, the women’s questions were fully answered. Follow-up phone calls were provided to check sexual relationship of these people with their husbands and respond to questions of women by the researcher.
In control group, routine training was given by the midwife of the clinic. Both intervention and control groups in the first and third month after the counseling were reviewed and evaluated regarding their sexual intimacy. Individuals of intervention and control groups referred to the clinic in different days in order not to communicate with each other.
Finally, by analyzing data by SPSS (version 22) software (Armonk, NY: IBM Corp.) with significant level <5.0, they were evaluated, and the effect of training and sex advice of PLISSIT on sexual intimacy of lactating women in both experience and control groups during 1 month and 3 months after intervention was investigated and compared.
According to the findings of the present study, the studied units based on [Table 1] did not have any significant difference regarding demographic and midwifery features. The average of gestational age was 38.97 ± 1.01 weeks. Among the samples, the mean number of intercourse before pregnancy was 45.2 ± 30.1 times a week, and the mean number of intercourse after childbirth was 32.1 ± 88.1 times a week. In addition, beginning time of intercourse was 79.6 ± 88.1 weeks after childbirth. Not all the above-mentioned cases had any significant difference in both control and experimental groups.
|Table 1: Demographic and midwifery features of the study units in both test and control groups
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The average score of sexual intimacy for experimental group was 19.81 before the intervention, 29.99 a month after the intervention, and 02.112 3 months after the intervention that by conducting the test, the difference was significant (P < 024.0 and P < 001.0, respectively). In control group, the average score of sexual intimacy was 02.82 before the intervention, 85.85 a month after the intervention, and 02.90 3 months after the intervention that by conducting the test, the difference was not significant [Table 2].
|Table 2: Comparing the mean and standard deviation of sexual intimacy before and 1 month and 3 months after intervention in both groups
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There was not any significant statistical relation between score of sexual intimacy in control and experimental groups before the intervention (P = 480.0). However, a significant difference was observed between mean scores of sexual intimacy of both groups with Mann–Whitney test one month (P < 001.0) and three months (P < 001.0) after the intervention [Figure 1].
|Figure 1: Sexual intimacy mean scores changes in the intervention and control groups
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The effect of sexual counseling on sexual intimacy of lactating women was examined. Findings showed that there was a significant statistical difference between the mean scores of female sexual intimacy of intervention and control groups in posttest and follow-up. The results showed that sexual counseling has increased sexual intimacy of lactating women and the effect of counseling has been still s[Table 1] and 3 months after intervention.
The results obtained from the present study were aligned with the findings of the study of Khanjani et al. that examined the effect of sexual training on improvement of quality of marital relationships. Their results indicated that sexual education has had a significant and positive impact on improving the marital quality components such as sexual satisfaction, marital satisfaction, and sexual intimacy and reduction of couple’s conflict.
Shahsiah et al. investigated the effect of sexual training on improving marital satisfaction of couples in Isfahan and concluded that sexual education has been effective in marital satisfaction and subscales of satisfaction with spouse’s personality, improving communication, sex intimacy, and reduction of conflicts of couples. In addition, in the study of Karimi et al., sexual satisfaction of couples had a significant increase in the intervention group rather than the control group after intervention indicating the effect of sexual health education on sexual satisfaction of couples in the intervention group.
In his study, Bazmi concluded that training sexual skills among discordant couples led to an increased coordination and sexual and marital satisfaction. In the study of Shakarami et al., it was shown that sexual training has been effective in increasing women’s sexual intimacy, and the effect of sexual training has been stable after 2 months after the completion of training sessions. In the study of Botlani et al., attachment-based couple therapy increased sexual satisfaction of couples. Sexual satisfaction is an important predictor of marital satisfaction of couples. In their study, Nathan et al. concluded that in the experimental group compared with the control group, there was an improvement in sexual relationships, self-acceptance, or self-esteem, acceptance of the spouse, and joy of sex.
To explain the obtained results, it can be stated that in training sessions when participants could have emotional and nonsexual contacts at the first stage, and sexual and emotional contact with their husbands, and could keep the contacts continuously, this allowed couples to feel closer to each other. One other issue that made sexual intimacy of participants with their husbands increase was training how to talk about sexual issues with husband. Participants learnt that they must speak explicitly with their husbands about needs, interests, preferences, and their sexual desires, especially in breastfeeding. When women could have their emotional and sexual issues in a context of marital intimacy transferred to their husbands, and got familiar with the husband’s ideas about their sexual relations, this negotiation caused individuals to make a new view of their sexual relationships, and do behaviors causing more sexual intimacy and satisfaction. As the result of trainings, participants concluded that they should plan for sexual relationship with their husbands, have a more intimate and joyful sexual relation with better programming. In addition, when the participants got familiar with the skills of bedroom, and learnt new methods of having sex, the more various and more joyful experience of these relations helps them to experience more sexual intimacy with their husbands.
Lorenso concluded in his study that for many couples, sex happens when they are able to establish more delicate and more subtle relation with each other and respond to their attachment needs. Sexual relations are a part of romantic relation among couples, and the bonds of love and intimacy and satisfaction from sex are key factors in attachment of spouses. Dissatisfaction with sex can cause immense problems in the relations between husbands and wives and can create hate, annoyance, jealousy, competition, sense of revenge, feeling of humiliation, and lack of confidence, and so on. These issues are strengthened by tensions and disputes, or manifested and expressed in their frame, and gradually deepen the gap between couples. The results of Hosseini Zand et al. showed that couple therapy training in an Islamic way could increase sexual intimacy between couples with 99% confidence, and the increase continued to the follow-up phase (P < 001.0). Lack of adequate knowledge or having misinformation and contradictory information can lead to vulnerability and lack of intimacy of couples; however, when the information is delivered correctly and in accordance with religion and culture of Iran, sexual knowledge will be increased and will provide more sexual intimacy.
In line with the results of this study, it seems that with the passage of time due to their greater compatibility with postpartum conditions, problems of these people would be less, and as a result, their sexual satisfaction and intimacy would be improved. In the study conducted by Mohamadi Mohamadi Almoti et al. aimed at influencing sexual counseling in groups on sexual function during breastfeeding, it was shown that there was a significant relation between individuals of control group during the time regarding sexual satisfaction. In total, education sessions helped participants find a positive view of sexuality, shape realistic expectations, positive and healthy about sex in their relationship with their spouse, and have more sexual self-expression. As a result, they could experience more intimacy and satisfaction in their sexual relations with their spouses by having more sexual knowledge and awareness.
One of the limitations of the present study is justification of people to attend in sessions to continue sessions due to the sexuality being a taboo in society, and the lack of consultation with partners. Consequently, the researcher has considered measures such as attracting the trust of participants, providing a private and intimate environment, and following the principles of consultation.
According to the findings of the present study, it can be deduced that sexual training and counseling help people to improve more enjoyable intercourse. In addition, representing such trainings to couples especially in the damaging periods of life such as pregnancy and breastfeeding, many marital problems, and conflict can be avoided. According to the undeniable impact of sexuality in marriage, it is recommended to hold some workshops enriching sexual relations with an emphasis on improving the quality of sex and the prevention of sexual problems during pregnancy and breastfeeding in health centers so that the trainings can be used to increase more sexual intimacy and promote marital satisfaction.
We appreciate the department head and the deputy manager of the research department and all the women who had cooperation with the researchers of the study and all staff of Niyayesh health center, Bandar Abbas, Iran for facilitating the recruitment of patients and the use of clinical data.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Nusbaum MR, Gamble G, Skinner B, Heiman J. The high prevalence of sexual concerns among women seeking routine gynecological care. J Fam Pract 2000;49:229-32.
Bernhard LA. Sexuality and sexual health care for women. Clin Obstet Gynecol 2002;45:1089-98.
Liu HL, Hsu P, Chen KH. Sexual activity during pregnancy in Taiwan: A Qualitative study. Sex Med 2013;1:54-61.
World Association Of Sexology. Declaration Of Sexual Rights. 2005. Available from: http://www. Worldsexology. Org/About_Sexualrights. Asp. [Last accessed on 2005 Jan 23].
Bolhari J, Ramezanzadeh F, Abedinia N, Naghizadeh M, Pahlavani H, Saberi S. To explore identifying the influencing factors of divorce in Tehran. Iran J Epidemiol 2012;8:83-93.
Eid MA, Sayed A, Abdel-Rehim R, Mostafa T. Impact of the mode of delivery on female sexual function after childbirth. Int J Impot Res 2015;27:118-20.
Metz ME, Mccarthy BW. The “Good-Enough Sex” model for couple sexual satisfaction. Sex Relatsh Ther 2007;22:351-62.
Nappi RE, Albani F, Vaccaro P, Gardella B, Salonia A, Chiovato L, et al. Use of the Italian translation of the Female Sexual Function Index (FSFI) in routine gynecological practice. Gynecol Endocrinol 2008;24:214-9.
Nasiri M. Mental health of prenatal and delivery period. Tehran: Boshra Publisher; 2000. p. 4-5
Olsson A, Lundqvist M, Faxelid E, Nissen E. Women’s thoughts about sexual life after childbirth: Focus group discussions with women after childbirth. Scand J Caring Sci 2005;19:381-7.
Chang SR, Chen KH, Lin HH, Chao YM, Lai YH. Comparison of the effects of episiotomy and no episiotomy on pain, urinary incontinence, and sexual function 3 months postpartum: A prospective follow-up study. Int J Nurs Stud 2011;48:409-18.
Bagarozzi DA. Enhancing Intimacy in Marriage: A Clinician’s Guide. NY: Routledge; 2001.
Tork Zahrani S, Banaei M, Ozgoli G, Azad M. Investigation of the postpartum female sexual dysfunction in breastfeeding women referring to healthcare centers of Bandar Abbas. The Iranian Journal of Obstetrics, Gynecology and Infertility. 2016;19:1-2.
Dolgun A, Asma S, Yıldız M, Aydın ÖS, Yıldız F, Düldül M, et al. Barriers to talking about sexual health issues with physicians. Provider 2014;4:5.
Nezhad MZ, Goodarzi AM. Sexuality, intimacy, and marital satisfaction in Iranian first-time parents. J Sex Marital Ther 2011;37:77-88.
Boyd MA. Psychiatric Nursing Contemporary Practice. Philadelphia: Lippincott Williams & Wilkins; 2002.
Shahsiah M, Bahrami F, Etemadi O, Mohebi S. Effect of sex education on improving couples marital satisfaction in Isfaha. J Health Syst Res 2010;6:690-7.
Taylor B, Davis S. The extended PLISSIT model for addressing the sexual wellbeing of individuals with an acquired disability or chronic illness. Sex Disabil2007;25:135-9.
Banaei M, Zahrani ST, Pormehr-Yabandeh A, Ozgoli G, Azad M. Investigating the impact of counseling based on PLISSIT model on sexual intimacy and satisfaction of breastfeeding women. International Journal of Pharmaceutical Research and Allied Sciences. 2016;5:489-99.
Botlani S, Ahmadi SA, Bahrami F, Shahsiah M, Mohebbi S. Effect of attachmentbased couple therapy on sexual satisfaction and intimacy. J Fundament Ment Health 2010;2:496-505.
Shakarami M, Davarniya R, Zahrakar K, Gohari S. The effect of sex education on sexual intimacy of married women. J Nurs Educ 2014;2:34-42.
Cox JL, Chapman G, Murray D, Jones P. Validation of the Edinburgh Postnatal Depression Scale (EPDS) in non-postnatal women. J Affect Disord 1996;39:185-9.
Larson JH, Anderson SM, Holman TB, Niemann BK. A longitudinal study of the effects of premarital communication, relationship stability, and self-esteem on sexual satisfaction in the first year of marriage. J Sex Marital Ther 1998;24:193-206.
Khanjani veshki S, Botlani S, Shahsiah M, Sharifi E. The effect of sex education on marital quality improvement in couples of Qom. Interdiscip J Contemp Res Bus 2012;4:134-47.
Karimi A, Dadgar S, Afiat M, Rahimi N. The effect of sexual health education on sexual satisfaction in couples. Iran J Obstet Gynecol Infertil 2013;15:22-30.
Bazmi N. The effect of cognitive-behavioral group therapy in problem-solving skills education and sexual skills education on in adjusted couples’ marital satisfaction increase. The Second Congress of Family Pathologies in Iran. Shahid Beheshti University. Tehran: Family Research Center; 2006.
Nathan EP, Joanning HH. Enhancing marital sexuality: An evaluation of a program for the sexual enrichment of normal couples. J Sex Marital Ther 1985;11:157-64.
Laurenceau JP, Barrett LF, Rovine MJ. The interpersonal process model of intimacy in marriage: A daily-diary and multilevel modeling approach. J Fam Psychol 2005;19:314-23.
Hosseini Zand M, Shafiabadi A, Sodani M. The effectiveness of couple therapy based on Islamic teachings on sexual intimacy couples who referred to clinics in Tehran righteous. Soc Psychol 2012;25:27-39.
Mohamadi Almoti M. Impact of Group’s Consultation on Sexual Function in Lactating Women. Thesis of Master. Tehran university of medical sciences: Faculty of nursing and midwifery: 2010.
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2]