Partner's Support During Pregnancy As the Mediator of Women's Sexual Satisfaction After Childbirth

Sexual and Relationship Therapy

ISSN: 1468-1994 (Print) 1468-1749 (Online) Journal homepage: https://www.tandfonline.com/loi/csmt20

Partner's support during pregnancy as the mediator of women's sexual satisfaction after childbirth

Mariusz Jaworski, Mariusz Panczyk, Iga Królewicz, Jarosława Belowska, Tomasz Krasuski & Joanna Gotlib

To cite this article: Mariusz Jaworski, Mariusz Panczyk, Iga Królewicz, Jarosława Belowska, Tomasz Krasuski & Joanna Gotlib (2019): Partner's support during pregnancy as the mediator of women's sexual satisfaction after childbirth, Sexual and Relationship Therapy, DOI: 10.1080/14681994.2019.1575507 To link to this article: https://doi.org/10.1080/14681994.2019.1575507

Published online: 14 Feb 2019.

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ORIGINAL ARTICLE Partner’s support during pregnancy as the mediator of women’s sexual satisfaction after childbirth

Mariusz Jaworski a, Mariusz Panczyk a, Iga Krolewicz b, Jarosława Belowskaa, Tomasz Krasuskic and Joanna Gotlib a aDivision of Teaching and Outcomes of Education, Faculty of Health Science, Medical University of Warsaw, Warsaw, Poland; bFaculty of Health Science, Medical University of Warsaw, Warsaw, Poland; cDepartment of Psychology and Medical Communication, Second Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland

ABSTRACT ARTICLE HISTORY The aim of the study was an empirical verification of a model Received 5 April 2018 assuming the influence of subjectively perceived sexual attractive- Accepted 23 January 2019 ness and positive childbirth experience (PCE) (independent varia- KEYWORDS bles) on the level of women’s sexual satisfaction after home birth Sexual behaviour; sexuality; or hospital birth (dependent variable) with the mediating involve- ’ pregnancy; sexual ment of subjectively perceived partner s support during pregnancy. satisfaction; childbirth The study was conducted with a group of 253 women after childbirth. Three standardised research tools were used in the study: the PCE Questionnaire, Sexual Satisfaction Questionnaire and Body Esteem Scale as well as original tools for the evaluation of subjectively perceived partner’s support during pregnancy and childbirth. The empirical verification of the theoretical model was performed with the use of multiple regression methods. The level of subjectively perceived partner’s support during pregnancy, level of attractiveness and PCE had influence on the level of women’s sexual satisfaction. Such an influence was, however, not noticed in relation to the partner’s presence during childbirth, level of partner’s support during childbirth or role of the place of childbirth. Subjectively perceived partner’s support during pregnancy is of key importance, mediating between PCE and the level of women’ssex- ual satisfaction after childbirth.

Introduction

Childbirth is an experience that may significantly influence the perception of women’s own sexual attractiveness and the possibility to gain sexual satisfaction (Bancroft, 2009; Beveridge, Vannier, & Rosen, 2018; Staruch, Kucharczyk, Zawadzka, Wielgos, & Szymusik, 2016; Vannier & Rosen, 2017). It may also be connected with physical changes (e.g. weight gain) and physiological changes (e.g. hormonal fluctuations) that took place during pregnancy and that contributed to reducing sexual activity as the pregnancy progressed (Bancroft, 2009;Gała˛zka, Drosdzol-Cop, Naworska, Czajkowska,

CONTACT Dr. Mariusz Panczyk [email protected] Division of Teaching and Outcomes of Education, Faculty of Health Science, Medical University of Warsaw, Warsaw, Poland ß 2019 College of Sexual and Relationship Therapists 2 M. JAWORSKI ET AL.

& Skrzypulec-Plinta, 2015). In literature, changes have been observed in the domains of arousal, lubrication and orgasm that were particularly notable in primaparae in the third trimester of pregnancy (Gała˛zka et al., 2015). Additionally, childbirth is recog- nised as one of the major stressors, and, in some cases, may even be perceived as a traumatic experience (Dunkel Schetter & Tanner, 2012). Negative experiences connected with childbirth may lead to total denial of women’s own sexual needs, and even sexual aversion or low sexual desire (Brotto, 2010). The emergence of negative childbirth experience may also bear negative influence on the quality of partnership (Bancroft, 2009). Therefore, determining perinatal factors bearing influence on the reduction of libido after childbirth may be of high clinical and therapeutic importance. The attempt to determine such a correlation may be of particular significance in the context of sex therapy in women, where a significant reduction of libido after childbirth occurs. In the literature, more attention is being paid to the role of psychosocial factors in the context of women’s sexual satisfaction during pregnancy (Beveridge et al., 2018; Staruch et al., 2016; Vannier & Rosen, 2017). However, smaller numbers of papers definitely discuss the topic of the sense of sexual attractiveness and sexual satisfaction after childbirth (Amiri Omidvar, Bakhtiari, & Hajiahmadi, 2017; Barbara et al., 2016; McDonald, Woolhouse, & Brown, 2017) or the relation of perinatal experiences on the quality of partnership (Negron, Martin, Almog, Balbierz, & Howell, 2013). For example, there was a strong association between emotional satisfaction and the degree to which women experienced physical pleasure in their sexual relationship. Women who were happy with their partner’s contribution to household tasks were markedly more likely to report high emotional satisfaction and somewhat more likely to report greater physical pleasure in their sexual relationship (McDonald et al., 2017). Many papers discussing women’s sexual activity after childbirth focus on diagnos- ing sexual dysfunction, such as sexual desire disorder, postpartum dyspareunia and others (Lagaert et al., 2017; Wallwiener et al., 2017). There is still too small a number of papers regarding the role of psychosocial and relational factors in the context of initiating and drawing satisfaction from sexual contacts after childbirth (Amiri et al., 2017; Barbara et al., 2016; McDonald et al., 2017). The findings suggest that intimate relationships are significantly strained in the years following childbirth, and women want more information from primary health care professionals regarding changes to intimate and sexual relationships after childbirth (Woolhouse, McDonald, & Brown, 2014). Undoubtedly not only physical factors (e.g. those connected with physical changes in the area of genital organs) but also the psychological context and the context of partnership are all of major importance here (McDonald et al., 2017; Woolhouse et al., 2014). The quest for psychosocial and relational correlates of women’s sexual satisfaction after childbirth is justified by The Circle of Female Sexual Response (Basson, 2000). The model discussed assumes psychological and relational factors play a key role in women undertaking sexual activity (Bancroft, 2009). Additionally, the sense of women’s own sexual attractiveness is not a constant feature. It may undergo changes depending on various psychosocial factors (e.g. social approval or the perception of women’s appearance as attractive to others) (Bancroft, 2009). Childbirth undoubtedly influences the perception of women’s own body, SEXUAL AND RELATIONSHIP THERAPY 3 including its attractiveness. It should be emphasised that desired weight loss, depres- sive symptoms and body surveillance were indirectly associated with higher levels of body dissatisfaction and appearance-related barriers to breastfeeding (Rodgers, O’Flynn, Bourdeau, & Zimmerman 2018). The literature review shows that the response to visual sexual stimuli may, to a varying degree, influence the level of sexual excitement in men and women, and thus the level of motivation to initiate sexual contacts (Rupp & Wallen, 2008). What is more, research shows that there are differences between the genders regarding preferences of partner’s physical attractiveness and its influence on long-term relationship outcomes. Partner physical attractiveness played a larger role in predicting husbands’ satisfaction than predicting wives’ satisfaction. Hence, women’s self-perception as less attractive after childbirth may bear influence on the quality of partnership (Meltzer, McNulty, Jackson, & Karney, 2014) and negatively affect their sexual/body esteem (Zielinski, Kane Low, Smith, & Miller, 2017). In this regard, identification of perinatal factors that have a relational context with the partner on one hand, and on the other influence the perception of women’sown sexual attractiveness and the level of sexual satisfaction is of vital importance. The subjectively perceived partner’s support both during pregnancy and childbirth may be one of those factors (Beveridge et al., 2018; McDonald et al., 2017), probably because low partnership quality was revealed as a significant risk factor for sexually dysfunc- tional problems in the postpartum period (Wallwiener et al., 2017). In line with health psychology research, stress aggravation may be reduced by providing adequate levels of social support, which is known as the buffering model of social support (Cohen & Wills, 1985). There is still not enough research that would analyse the role of subjectively perceived partner’s support on women’s sexual satisfaction after childbirth. Much more attention is devoted to the association between modes of delivery and postpartum female sexual functioning (Amiri et al., 2017; Barbara et al., 2016). However, McDonald et al. (2017) stressed that women experience profound changes in their sexual and intimate relationships in the first 18 months postpartum. While sex appears to improve over time, emotional satisfaction appears to decline. What is more, McDonald et al. (2017) emphasised that pregnant women and their partners may benefit from information and discussion about the likelihood of changes to their emotional and sexual relationships after childbirth. In regard to these studies, we carried out the research which analyses the role of subjectively perceived increase in partner’s support on the quality of women’s own perception of sexual attractiveness and sexual satisfaction after childbirth, as well as positive childbirth experience (PCE) in these women.

Material and methods

Material The research was conducted with 253 women after childbirth. The criteria for inclu- sion were the following: (a) informed consent, (b) age over 18 and before 50 (the age of menopause), (c) a minimum of one childbirth and (d) women who were up to 4 M. JAWORSKI ET AL.

6 weeks postpartum and those who attended the obligatory 6-week postpartum care at the clinic. Midwife care is provided up to 6 weeks after childbirth and has a medical and educational character. The course of the care depends on the current health and developmental needs of the baby and its family as well as the partners’ adapta- tions to their parental roles. The discussed care comprises a minimum of four midwife visits (Iwanowicz-Palus, Krysa, & Bien, 2013). After attending the obligatory 6- week postpartum care at the clinic, women completed the survey. During this obligatory 6-week postpartum care, midwife assessed the psychological patients’ functioning (e.g. if there is postpartum depression (PPD) after childbirth). If there was a risk of PPD, the patient was excluded from the study and asked to consult a doctor. The exclusion criteria were: (a) the absence of consent to visit a gynaecologist after childbirth, (b) age under 18, (c) women during menopause (over the age of 50), (d) no experience of childbirth and (e) women who not were between 6 and 12 postpartum and those who did not attend the obligatory 6-week postpartum care at the clinic.

Methods Theoretical assumptions of the mediation model On the basis of literature review, the theoretical model of the role of perceived partner’s support on the quality of women’s sexual satisfaction after childbirth was developed (Figure 1). The model developed assumes the influence of subjectively perceived women’s own sexual attractiveness and PCE (independent variables) on the level of their sexual satisfaction after home birth or hospital birth (dependent variable) with the mediating involvement of subjectively perceived partner’s support during pregnancy.

Study procedure The study was conducted in the period from November 2017 to January 2018 with the use of the paper-and-pencil interviewing (PAPI) method in five antenatal clinics in the Mazowieckie Province (Poland). PAPI is known as a method where all survey data collection done by an interviewer is done via PAPI. The interviewer explain the purpose of the questionnaire and to explain any questions or concepts that the

Figure 1. Theoretical model of mediation. SEXUAL AND RELATIONSHIP THERAPY 5 respondent requires clarifying. The interviewer was specially trained by the authors of this study. All clinics were public. The consent for conducting research in the clinics was obtained. The data were gathered among women waiting for a 6-week postnatal check. All women were informed about the aim of the study and their voluntary participation in the study. No register of women who did not give their consent to participate in the project was kept. Women were asked to fill out questionnaires by themselves. The time of completing the questionnaire was not limited.

Ethical assessment The authors sought approval from the Ethics Committee of the Medical University of Warsaw to conduct the present study. In response of the Ethics Committee, “non- interventional studies do not require the opinion of the Ethics Committee in accord- ance with Art. 37al of the Pharmaceutical Law Act (Journal of Laws of 2001, No. 126, item 1381)”. All patients provided informed consent to participate in this research. The participants were also informed that the study was a research study only and that the findings were to be limited to research purposes only. Information about the details of the study, data collection and analysis and names of the researchers and their contact information were also presented.

Research tools PCE questionnaire, a questionnaire made up of nine questions, devised especially for the purpose, was used in order to measure PCE. An approach integrating the sciences of obstetrics, psychology and sexology was used in order to devise the questionnaire. Questions that on the one hand may serve as evidence of PCE and on the other indirectly impact the positive image of oneself as a woman were excluded from the survey. A pilot study was conducted with a group of 50 women who verified the lin- guistic correctness of this scale. In the pilot study, the validity of the PCE questionnaire was assessed by the method of competent judges, specifically a midwife, psychologist and sexologist. Exemplary item: Childbirth helped me accept my own body. The reliability of the questionnaire for the analysed group of women was satis- factory (Cronbach’s alpha = 0.874, the first main compound of the scale, explained 52.4% of the total variance. The reported Cronbach’s alpha is from the current research. The respondents answered each item on a 5-degree Likert scale (1 ¼ strongly disagree, 5 ¼ strongly agree). The PCE questionnaire does not have a cut-off score, and the result is assessed based on the total score. The higher the score, the higher the PCEs are. In other words, a lower score is indicative of a negative childbirth experience and vice versa. A standardised Sexual Satisfaction Questionnaire (SSQ) by Nomejko and Dolinska- Zygmunt was used to measure the level of sexual satisfaction (Nomejko & Dolinska- Zygmunt, 2014). The author’s consent to use the SSQ in the study was obtained. The SSQ consists of 10 items, which make up one dimension. The respondents answered each item on a 4-degree Likert scale (1 ¼ definitely not, 5 ¼ definitely yes). The Cronbach’s alpha coefficient for the original SSQ version was 0.890 (Nomejko & 6 M. JAWORSKI ET AL.

Dolinska-Zygmunt, 2014). In the studied group of women, the coefficient was 0.913. The first main component accounted for 56.9% of the total variance. For the evaluation of the level of own sexual attractiveness, the subscale “Sexual attractiveness”, which forms a part of the standardised Body Esteem Scale (BES) devised by Franzoi and Shields in the Polish adaptation by Lipowska and Lipowski (Lipowska & Lipowski, 2013), was employed. The Polish BES version may be down- loaded for free from the webpage of Pracownia Testow Psychologicznych i Pedagogicznych [Psychological and Pedagogical Test Laboratory]. The BES scale is made up of 35 items in three subscales, separate for women and men. Each of the BES items may be answered on a 5-degree Likert scale, where 1 stands for strongly negative feelings, 5 for strongly positive feelings and 3 for neutral. In the presented paper, only one BES subscale was used. For maintaining methodological soundness and disguising the main aim of the study, all items incorporated in the BES were asked to be answered. The subscale “Sexual attractiveness” is made up of 13 items and pertains to the evaluation of these parts of a woman’s body, the appearance of which cannot be changed through physical exercise (e.g. the evaluation of satisfaction with women’s lips or breasts). The attitude towards these parts of the body is also connected with highlighting elements of the appearance connected with sexuality, and their modelling is possible only through the application of cosmetic procedures (e.g. makeup). In order to evaluate subjectively perceived partner’s support, two items were used. The first pertained to subjectively perceived partner’s support during: (a) pregnancy (item phrasing: Please determine the degree of mental support that you received from your partner during pregnancy.) and (b) childbirth (item phrasing: Please determine the degree of mental support that you received from your partner during childbirth.) In both items, the respondents could voice their subjectively perceived degree of partner’s support on an 8-degree Likert scale (0 ¼ total lack of support, 7 ¼ large support). In the proposed study, it was decided to directly ask the question pertaining to the level of partner’s support, as obtaining the actual first impression of women after childbirth was of key importance. Additionally, in the study, the following variables were monitored: age, place of residence (village, town below 100,000 inhabitants, city above 100,000 inhabitants), marital status (single, in a relationship, divorcee), education (basic, vocational, secondary, higher), number of deliveries, date of last delivery, place of last delivery (hospital/home), number and type of complications during delivery and partner‘s presence during childbirth.

Statistical analysis In the first stage, the influence of the selected factors on the level of sexual satisfaction of the examined group of women was studied with the use of multiple regression techniques. Among the examined factors, there were: variables connected with childbirth (place of childbirth (hospital/home), PCE and partner’s presence during childbirth) and psychological variables (the level of woman’s own sexual attractiveness and subjective sense of partner’s support during pregnancy and childbirth). The regression analysis was performed in line with Hayes’ guidelines (Hayes, 2017). The regression SEXUAL AND RELATIONSHIP THERAPY 7 model was fitted to the empirical data by the ordinary least squares method. The vec- tor and intensity of significant correlations were interpreted by determining b standardised regression coefficients. Qualitative variables of a dichotomous character were coded in a binary system. In the second stage, a three-phase evaluation of partial mediation was performed according to the assumptions of Cohen et al. (2013). In the first stage, the influence of the level of women’s own sexual attractiveness and PCE (independent variables) on the level of sexual satisfaction (dependent variable) were evaluated independently. In the second stage, it was independently evaluated whether independent variables remain in a prominent relationship with the potential mediator that is the subjective sense of partner’s support during pregnancy. In the third and last stage of the analysis, it was evaluated whether the independent variables and the mediator influence the level of sexual satisfaction. It was assumed that the mediation was significant when indirect relations of the independent variable and mediator and the mediator and dependent variable were statistically significant. In such cases, the existence of mediations was determined by the result of the Sobel mediation test, which evaluates whether the number of unstandardised regression coefficients of both relations was significantly different from zero (Cohen et al., 2013). All of the statistical analyses were performed using STATISTICA 13.1 TIBCO Software Inc. (Palo Alto, California, United States) under the Medical University of Warsaw licence. P-values <.05 were considered to be statistically significant.

Results

Demographics data of the research participants Average age of women in the study was 29.2 years (the standard deviation (SD)= 4.54). Detailed figures about demographic variables connected with childbirth are presented in Table 1.

Table 1. Sociomedical data of the research participants. N (%) Place of residence Village 49 (19.4) Town 69 (27.3) City 135 (53.3) Education Basic 3 (1.2) Vocational 2 (0.8) Secondary 72 (28.5) Higher 176 (69.5) Marital status Single 62 (24.5) In a relationship 184 (72.7) Divorcee 7 (2.8) Number of births 1 159 (62.8) 2 65 (25.7) 3 26 (10.3) 4 3 (1.2) 8 M. JAWORSKI ET AL.

The influence of factors on the level of women’s sexual satisfaction The first of the tested linear regression models describing the influence of chosen factors on the level of sexual satisfaction was statistically significant (F ¼ 35.21, ¼ 2 p .001, Standard Error of the Estimate (SEE) = 5.75, R adjusted =0.35). Regression analysis results showed that neither the place of childbirth nor the presence of the partner/father of the baby during delivery had a significant influence on the level of women’s sexual satisfaction after delivery (Table 2). However, b ¼ b ¼ both sexual attractiveness ( std =0.498,p .001) and PCE ( std =0.208,p .001) were factors that positively influenced the sense of sexual satisfaction in the studied women. The second of the discussed linear regression models describing the influence of selected factors on the level of sexual satisfaction was also statistically significant ¼ ¼ 2 (F 25.20, p .001, SEE = 5.69, R adjusted = 0.37). Results of the regression analysis b showed that next to sexual attractiveness ( std = 0.472, p ¼ .000) and PCE (bstd = ¼ ’ b ¼ 0.152, p .011), partner s support during pregnancy ( std = 0.137, p .033) also positively influenced the sense of sexual satisfaction in the studied women (Table 3). However, the degree of stress suffered during delivery (p ¼ .697) and trauma (p ¼ .194) did not significantly influence sexual satisfaction, similarly to partner’s support during delivery (p ¼ .116).

Table 2. The influence of selected factors on the level of sexual satisfaction. Confidence interval

Independent variables B bstd 0.95 þ0.95 t p-value Intercept 4.635 –––1.940 .053 Place of childbirth 0.017 0.001 0.109 0.107 0.016 .987 0 ¼ hospital 1 ¼ home Was the partner/father of the baby 0.964 0.059 0.163 0.045 1.119 .264 present during delivery? 0 ¼ No 1 ¼ Yes The level of sexual attractiveness 0.423 0.498 0.391 0.605 9.148 .001 Positive Childbirth Experience (PCE) 0.167 0.208 0.097 0.319 3.692 .001 b: Unstandardised regression coefficient; bstd: Standardised regression coefficient.

Table 3. The influence of selected factors on the level of sexual satisfaction. Confidence interval

Independent variables B bstd 0.95 þ0.95 t p-value Intercept 6.336 - - - 2.293 .023 The degree of stress suffered during childbirth 0.097 0.026 0.158 0.106 0.390 .697 The degree of traumatisation during childbirth 0.288 0.087 0.219 0.045 1.303 .194 Subjectively perceived level of support from 0.545 0.137 0.011 0.262 2.147 .033 the partner during pregnancy Subjectively perceived level of support from 0.322 0.098 0.220 0.024 1.577 .116 the partner during childbirth The level of sexual attractiveness 0.401 0.472 0.365 0.580 8.636 .001 Positive Childbirth Experience (PCE) 0.122 0.152 0.035 0.268 2.567 .011 b: Unstandardised regression coefficient; bstd: Standardised regression coefficient. SEXUAL AND RELATIONSHIP THERAPY 9

Mediation analysis The first stage of mediation analysis showed that both sexual attractiveness and PCE independently influenced the level of sexual satisfaction in the studied women (Table 4). It was observed that women with a greater level of sexual attractiveness b also had higher sexual satisfaction after childbirth ( std = 0.569, p ¼ .000). Similarly, women who experienced their delivery positively also experienced higher sexual satis- b faction than women with worse observations in this regard ( std = 0.379, p ¼ .000). The results of the second stage of mediation showed that both tested factors remain in a statistically significant correlation with the potential mediator, which is a subjective sense of partner’s support during pregnancy (Table 5). The relation above b was of a positive nature, which is the level of sexual attractiveness ( std = 0.247, ¼ b ¼ p .001) and PCE ( std = 0.283, p .001) remain in a positive relationship with the evaluation of partner’s support during pregnancy. In the third and last stage, the simultaneous influence of the studied factors and the mediator on the degree of women’s sexual satisfaction after childbirth was studied

Table 4. The influence of sexual attractiveness and positive childbirth experience on the level of sexual satisfaction. Confidence interval

Independent variables B bstd 0.95 þ0.95 t p-value Intercept 7.148 - - - 3.245 .001 The level of sexual attractiveness 0.484 0.569 0.467 0.671 10.964 .001 Intercept 19.653 - - - 10.960 .001 Positive childbirth experience (PCE) 0.304 0.379 0.264 0.494 6.481 .001 b: Unstandardised regression coefficient; bstd: Standardised regression coefficient.

Table 5. Correlation analysis between sexual attractiveness and positive childbirth experience and subjective evaluation of partner’s support during pregnancy. Confidence interval

Independent variables B bstd 0.95 þ0.95 t p-value Intercept 2.910 - - - 4.471 .000 The level of sexual attractiveness 0.053 0.247 0.127 0.368 4.046 .000 Intercept 3.385 - - - 7.266 .000 Positive Childbirth Experience (PCE) 0.057 0.283 0.164 0.402 4.680 .000 b: Unstandardised regression coefficient; bstd: Standardised regression coefficient.

Table 6. The influence of partner’s support during pregnancy and sexual attractiveness and positive childbirth experience on the level of sexual satisfaction after childbirth. Confidence interval

Independent variables B bstd 0.95 þ0.95 t p-value Intercept 5.723 - - - 2.522 .012 Subjectively perceived level of support from 0.490 0.123 0.018 0.227 2.313 .022 the partner during pregnancy The level of sexual attractiveness 0.458 0.539 0.434 0.643 10.143 .001 Intercept 17.468 - - - 8.964 .001 Subjectively perceived level of support from 0.645 0.162 0.043 0.280 2.690 .008 the partner during pregnancy Positive Childbirth Experience (PCE) 0.268 0.333 0.214 0.451 5.531 .001 b: Unstandardised regression coefficient; bstd: Standardised regression coefficient. 10 M. JAWORSKI ET AL.

(Table 6). It was observed that partner’s support during pregnancy is a partial mediator of relations between PCE and sexual satisfaction after childbirth (Sobel mediation test, Z ¼ 4.207, p ¼ .001). Also, mediation was not noted in the case of sexual attractiveness.

Discussion

The conducted study showed that only the level of subjectively assessed partner’s support during pregnancy, the level of sexual attractiveness and PCE had positive influence on the level of sexual satisfaction. However, no such influence was noted in relation to the partner’s presence at childbirth, the level of partner’s support during childbirth or the role of the place of childbirth (hospital vs. home). The obtained results indicate that support received from the partner in the course of pregnancy had a greater role in the context of women’s sexual satisfaction after childbirth in comparison to the support during childbirth. The support that a woman receives in the course of her pregnancy is not only aimed at reducing stress connected with psychosocial factors (e.g. new social role of “being a mother” or the change of the current lifestyle) but also specific physical and physiological changes during pregnancy. Additionally, fears connected with the health of the baby, appropriate nutrition, etc. may also be important stressors (Negron, Martin, Almog, Balbierz, & Howell, 2013; Redshaw & Henderson, 2013). High and chronic stress has a negative impact on human functioning, including immunosuppression and constant fatigue. In a situation when stress intensity is too high, it may reduce the adaptability of an individual. As a consequence, it may lead to the conviction that the current situation is too difficult in order to be able to cope with it (Buckner et al., 2017). The findings of the current meta-synthesis carried out by Lunda, Minnie, and Benade (2018) demonstrated that women appreciated continuous support during childbirth. The influences were multidimensional and the benefits of continuous childbirth support were reaffirmed leading to the conclusion that continuous support during childbirth is an essential aspect of childbirth. However, women’s preference for specific support persons vary depending on interpersonal relationships, culture, values or birth environment. What is more, it is suggested that fathers’ attitudes to the pregnancy, fathers’ behaviours across the perinatal period and the relationship between them and the mother are significant in relation to adverse birth outcomes (Jomeen, 2017). In this regard, receiving adequate partner support during pregnancy may be of key importance not only for a healthy relationship between a mother and her baby but also, as was shown in the study, may have important implications in the context of the sexual relationship with her partner after childbirth. The described correlation could conform to the research in the field of women’s sexuality, which suggests the tremendous role of psychological and relational factors in the context of finding pleasure in sexual contacts (Bancroft, 2009). In this case, appropriate emotional bond- ing between a mother and her partner could have a positive influence on their relationship after childbirth (Jomeen, 2017; Lunda et al., 2018), but it requires further research. SEXUAL AND RELATIONSHIP THERAPY 11

A related point to consider is that the very presence of the partner and the support that he demonstrates during childbirth did not influence the level of women’s sexual satisfaction after delivery. It is an interesting observation, which suggests the need to conduct further research in this respect. Perhaps, it is not so much the partner’s presence at childbirth and his demonstrated support that has key significance in stress reduction at delivery (Salehi, Fahami, & Beigi, 2016), as it is the support demonstrated throughout the duration of pregnancy. It should be noted that Salehi et al. (2016) suggested that trained husbands beside their wives during delivery decreased mother’s anxiety. This means that the husband should be properly prepared on how to support his wife during delivery. Therefore, partners support could not be aimed at immediate stress reduction but support throughout the period of pregnancy. It would partially explain the obtained original results, which stress the mediating role of the intensity of subjectively perceived partner’s support during pregnancy between the PCE and level of women’s sexual satisfaction after childbirth. Iravani, Zarean, Janghorbani, and Bahrami (2015) stress that the partner’s support during childbirth is very important, but not for all women. It is stressed that women’s perceptions about continuous support during childbirth were influenced by the characteristics and attributes of the support person as well as the types of supportive care rendered. Women preferred someone with whom they were familiar and comfortable. The pro- viders of supportive care comprised midwives, female relatives, friends or husbands. It was not always the partner (Lunda et al., 2018). This problem requires further research. It is worth mentioning that creating proper emotional bonds in a relationship, and thus deeper commitment in a relationship, is a long-lasting process (Bancroft, 2009). In the triangular theory of love devised by Sternberg (1986), commitment in a relationship is one of the components of love which appears latest. It depends, among others, on this variable (in an appropriate combination with intimacy and passion) whether the relationship will be sustained (Sternberg, 1986). The obtained results, indicating a greater role of support provided by the partner in the period of pregnancy, rather than during childbirth, can also be explained, appealing to this concept, in the context of women’s sexual satisfaction after childbirth. The more support a partner provides during pregnancy (including pro-relationship behaviour), the stron- ger his relationship may be with his partner and the greater commitment in the relationship. It is going to translate into the quality of sexual life after childbirth. Recording the lack of a mediating role of partner’s support during pregnancy on the correlation between the perceived sense of own sexual attractiveness and the level of sexual satisfaction was also an interesting observation. The result determines the lack of correlation between support and sexual attractiveness. It should be, however, noted that the present study has showed that the two variables have key importance in the context of women’s sexual satisfaction after childbirth. As a result, they are in mutual cooperation with each other. It is an important result stressing the need of conducting further research aiming at the identification of factors connected with the self-perception of a sexually attractive woman. The observations made may also be significant during therapy of patients in which reduced libido after childbirth and a negative evaluation of their own sexual attractiveness was observed. 12 M. JAWORSKI ET AL.

An interesting observation gained on the basis of received results was the lack of influence of the place of childbirth (hospital vs. home) on the quality of women’s sexual satisfaction after childbirth. Despite the fact that home birth has its unique character (Comeau et al., 2018; Rossi & Prefumo, 2018; Zielinski, Ackerson, & Kane Low, 2015), it did not have a significant influence on the level of women’s sexual satisfaction after childbirth. In the context of home birth, special attention is paid to the hol- istic care over the mother and the baby in a safe environment (Comeau et al., 2018; Rossi & Prefumo, 2018). It is, therefore, an environment where childbirth takes place in a peaceful, intimate atmosphere. It is the woman who decides what to do in a given moment in time, and no one imposes their opinion on her or silences her when she wants to scream (Comeau et al., 2018; Rossi & Prefumo, 2018). Despite the fact that the presented results did not demonstrate that the place of childbirth had influence on women’s sexual satisfaction, conducting further research analysing the role of home birth in the shaping of the sense of sexual satisfaction is suggested. The results obtained may have significance in the context of prevention and therapy. The demonstrated significance of support provided by the partner during pregnancy suggests that already in the early stage of pregnancy the couple needs to be encouraged (e.g. joint medical checks). Providing knowledge and tools that will let the partner deal with the possible helplessness in a new situation may be necessary. Specialist measures (e.g. a doctor, psychologist or midwife) may include motivating a couple to a constructive mutual voicing of their needs and expectations. Birth schools may turn out to be places exceptionally susceptible to such environmental impacts. In terms of therapy, the study indicates how significant and manifold consequences may stem from the conflict of relationship, crisis, insufficient partner’s support or lack of such a person whatsoever. It seems that in such a situation providing support for the pregnant woman in another way should be promoted. The present study also indicates the significance of mothers’ sense of attractiveness. It is a multidimensional aspect, often connected with self-esteem. In the context of pregnancy, attention needs to be drawn to changes taking place in the body and their subjective reception by the pregnant woman. The obtained results encourage develop- ing the thread in further research, which would focus on an analysis of influence of therapeutic interactions on the evaluation of women’s own attractiveness in the course of the pregnancy. Therapeutic actions may focus also on the evaluation of their attractiveness after childbirth. They could be directed at the acceptance of their own body, as well as work on their own appearance.

Limitations and strengths of the present study One of the strengths of the current study is the use of cognitive values to analyse the role of subjectively perceived partner’s support on women’s sexual satisfaction after childbirth. Our findings may be of practical use through their application in midwifery and psychosexual counselling. Another strength of this study is the multidisciplin- ary approach that integrates obstetrics, psychology and sexology. In addition, research methodology (the use of three standardized research tools) increases the cognitive and practical values of the obtained results. SEXUAL AND RELATIONSHIP THERAPY 13

The present study is not devoid of limitations. One of them is an unrepresentative group of respondents and small sample size. It should be noted that in the present study had 208 women declaring hospital birth and only 45 women declaring home birth. The group of women deciding to give birth to their baby at home is smaller than women delivering their baby in a hospital, which stems from quite rigorous and numerous criteria that each woman should meet in order to deliver a baby at home in the absence of any indication to the contrary (Comeau et al., 2018). Additionally, reaching women that decide on a home birth is difficult methodologically. Additionally, taking into account voluntary participation in the study, it needs to be borne in mind that women who negatively evaluated the quality of their sexual life had the possibility to not take part in the study. An important limitation is the lack of assessment of the severity of PPD. The assessment of the patients’ mental functioning was assessed during consultations with midwife on the basis of conversation and observation. This consultation took place during this obligatory 6-week postpartum care. During this obligatory 6-week postpartum care, midwife assessed the psychological patients’ functioning (e.g. if there is PPD after childbirth). If there was a risk of PPD, the patient was excluded from the study and asked to consult a doctor. Another important limitation of the present study is the application of one of the questions directly to the measurement of support of perceived partner’s support. However, it should be noted that social support is a very subjective variable, and it is difficult to perform an objective measurement of the parameter. Additionally, in the present study, the evaluation of partner’s support during both pregnancy and delivery, as perceived by the women, was a key feature. However, objective statements whether the support took place was not the aim of the study. What is more, there was no measurement of partner support in the postnatal period. Without these data, it is difficult to know if support during pregnancy is a stand-alone factor or a proxy for continued support postnatally. There are limitations in these data of retrospective recall (6–12 months after birth is a long time to recall how one felt during pregnancy or childbirth). It should be noted that only mental support was analyzed. Other types of support such as physical or emotional were not included. Overlooking those types of support would seem a huge oversight.

Conclusions

The levels of subjectively assessed partner’s support during pregnancy, level of attractiveness and PCE have positive influence on the level of sexual satisfaction. At the same time, subjectively perceived partner’s support during pregnancy is of key mediating importance between PCE and the level of women’s sexual satisfaction after delivery. The obtained results may be of practical use through their application in midwifery and psychosexual counselling. Additionally, they may serve in order to conduct further research in the area of women sexuality after childbirth and to search for potential causes of sexual aversion in women after birth. However, it requires further research. 14 M. JAWORSKI ET AL.

Disclosure statement

No potential conflict of interests was reported by the author(s).

ORCID

Mariusz Jaworski http://orcid.org/0000-0002-5207-8323 Mariusz Panczyk http://orcid.org/0000-0003-1830-2114 Joanna Gotlib http://orcid.org/0000-0002-2717-7741

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