This descriptive-analytical study was conducted in 2019 on women with gestational diabetes for whom diabetes was diagnosed based on gestational diabetes screening in week 24–28 of pregnancy by the two-hour oral glucose tolerance test (OGTT), which involved taking 75 g of glucose (20), in the past month. These women, who visited the clinics affiliated with Mazandaran University of Medical Sciences, lived with their husbands; were literate; sexual activity during pregnancy was not prohibited for them (due to spotting, risk of miscarriage, etc.); their husbands did not have erectile dysfunction or premature ejaculation (as declared by the wife); the couple did not have a mental or physical disease, and were not addicted to narcotics or stimulants. The exclusion criteria were unwillingness to participate and withdrawal from completing the questionnaire.
In this study, multistage sampling was performed. First, random cluster sampling was performed; every city in Mazandaran Province was viewed as a cluster, and in addition to the center of the province, three other cities were randomly selected with a probability proportionate to their population. In the first stage, four cities were regarded as the selected clusters. Then, quota sampling was performed; the sample size was distributed among these four cities proportionate to the statistics on the prevalence of gestational diabetes in the selected cities. To reach the determined sample size in each city, some healthcare centers were randomly selected. Then, in the selected centers, a sample of women with gestational diabetes was selected by using non-probability and convenience sampling.
Sample size was calculated to be 120 based on formula , α = 0.05, 1-β = 0.80, K = 1, and effect size (θ) = 0.4.
Eligible women with gestational diabetes who were willing to participate completed the informed consent form, and then completed the questionnaires in a self-report manner.
Data collection instruments: The data collection instrument included eight questionnaires: a demographic and midwifery-related information questionnaire, Hudson’s Index of Sexual Satisfaction, the Female Sexual Function Index, ENRICH Marital Satisfaction Scale (short version), the Female Sexual Distress Scale, The World Health Organization Quality of Life questionnaire, the Pregnancy-Related Anxiety Scale, and the Depression, Anxiety, and Stress Scale.
The demographic and midwifery information questionnaire: This was an instrument with seven questions, examining the couples’ age, level of education, length of marriage, number of pregnancies, and gestational age.
Hudson’s Index of Sexual Satisfaction: This questionnaire included 25 questions scored on a five-point Likert scale. In questions 1, 2, 3, 10, 12, 13, 16, 17, 19, 21, 22, and 23, “none of the time” receives the score of 1, and “all of the time” receives the score of 5, while the rest of the questions are reverse-scored. The minimum score is 25, and the maximum score is 125. Scores 25–50 indicate lack of sexual satisfaction, 51–75 low sexual satisfaction, 71–100 moderate sexual satisfaction, and 101–125 high sexual satisfaction (21). In Iran, Bahrami et al. (2016) reported the Cronbach's alpha of 0.80 for positive questions, and 0.77 for negative questions. The intracluster correlation coefficient was 0.80. The construct validity of the questionnaire was examined by exploratory factor analysis, and showed three factors (sexual attitude, quality of sexual life, and sexual adjustment) with an eigenvalue > 1. In total, the three extracted factors explained 42.73% of the total variance of the variables of this instrument (22).
The Female Sexual Function Index: This index contains 19 questions and assesses sexual function in three dimensions of sexual desire (items 1–2), sexual arousal (items 3–6), lubrication (items 7–10), orgasm (items 11–13), satisfaction (items 14–16), and pain (items 17–19). Each item is scored from 0 (no sexual activity in the past 4 weeks) to 5 (a better function). The total score in each dimension is multiplied by a specified coefficient (desire: 0.6, arousal and lubrication: 0.3, orgasm, satisfaction, and pain: 0.4), and the total score is calculated by summing these scores. The minimum and maximum total score is 2 and 26, respectively (23). Scores higher than the cut-off score (total score: 28, desire: 3.3, arousal: 3.4, lubrication: 3.4, orgasm: 3.4, satisfaction: 3.8, and pain: 3.8) indicate optimal sexual function. The Persian version of this instrument has a high reliability and construct validity, and the Cronbach’s alpha for each dimension and the entire instrument is 0.7 or above (24).
The ENRICH Marital Satisfaction Scale (short form): This questionnaire was used to assess marital satisfaction (25). The short form of this questionnaire has 10 questions, scored on a 5-point Likert scale, from “strongly agree” (5) to “strongly disagree” (1). Items 1, 3, 5, 8, and 9 should be reverse-scored. Higher scores show higher satisfaction with marital life (26). The Persian version of this questionnaire has optimal reliability and validity, with a Cronbach’s alpha of 0.74 (27).
The Female Sexual Distress Scale: This 13-item scale was used for evaluation of female sexual distress. The scores on a five-point Likert scale vary from 0 to 4 (never: 0, always: 4). The total score is the sum of the scores of 13 statements, and varies from 0 to 52, with higher scores indicating higher sexual distress (28). The internal consistency of this scale (Cronbach's alpha) falls in the 0.86–0.93 range. Moreover, its diagnostic validity is optimal by differentiating normal women from women with sexual dysfunction, and its divergent validity with the Female Sexual Function Index has been reported to be optimal (29).
The World Health Organization Quality of Life Questionnaire (WHOQOL- BREF) This questionnaire has 26 items, and the first two items are separately analyzed. The first item examines one’s perception of the general quality of life, and the second item evaluates one’s perception of total health. The items are scored on a Likert scale (1–5), and items 3, 4, and 26 are reverse-scored. The domains include physical health, psychological health, social relationships, and the environment. The score of each domain varied from 4 to 20, with 4 showing the poorest and 20 showing the best status of quality of life in that domain (30). The psychometric properties of this questionnaire have been examined in several studies. The Cronbach's alpha for all the dimensions, except for social relationships, was > 0.70 and acceptable (31).
The Parental Distress Questionnaire This questionnaire has 12 statements scored on a five-point Likert scare (never = 0, and always = 4). Total scores vary from 0 to 48, and higher scores show higher worries during pregnancy (32). Based on several studies, this short and useful questionnaire enjoys the necessary psychometric properties. In the Persian version, the test-retest reliability of the entire questionnaire was 0.74 and its Cronbach's alpha was 0.78. Moreover, its criterion validity has been confirmed upon simultaneous administration and assessment of the correlation between its score with those of the Cambridge Worry Scale (0.75) and the State-TraitAnxiety Inventory (0.53) (33).
The Depression Anxiety Stress Scales (DASS): This 42-item questionnaire has been developed to assess depression, anxiety, and stress. Its short form has 21 items, with 7 items assessing depression, 7 assessing anxiety, and 7 stress. The items are scored on a four-point Likert scale from 0 to 3. The items for each topic are: Stress: Items 16-14-12-11-8-6-1, depression: Items 21-17-16-13-10-5-3, anxiety: Items 20-19-15-9-7-4-2. The scores fall from 0 to 21 for each domain (34). The factor structure of the short form of the questionnaire (DASS21) has been examined and confirmed (35). The internal consistency of the Persian version of the instrument was examined by calculating Cronbach’s alpha, and the following results were obtained: Depression scale 0.77, stress scale 0.78, and anxiety scale 0.79. The validity of the instrument was investigated by exploratory factor analysis, its criterion validity was evaluated by simultaneous administration and calculating the correlation between its scores with those of Beck's Depression Inventory (0.70), Zung Self-Rating Anxiety Scale (0.67), and Perceived Stress Inventory (0.49) (36).
The scores of all the above-mentioned questionnaires were calculated using the following formula, and reported: (Score-Minimum) /(Maximum-Minimum) × 100.
Statistical analysis: SPSS 23 (Version 23, IBM Corporation, Armonk, NY) was used to analyze the data. To check the normality of data distribution, Kolmogorov-Smirnov test was run. To describe quantitative variables, mean (SD), and to describe qualitative variables, number (percentage) were used. Moreover, to examine factors related to sexual satisfaction, the multivariate linear regression was used. P-value < 0.05 was set as the significance level.
Ethical considerations: This study was approved in the Ethics Committee of Shahid Beheshti University of Medical Sciences (IR.SBMU.PHARMACY.REC.1397.263). Written informed consent was obtained from all the participants.