Factors Related to Sexual Satisfaction in Women with Gestational Diabetes in the Third Trimester CURRENT STATUS: POSTED

Background: Sexual satisfaction is important for maintaining pregnant women’s self-esteem and interpersonal relationships, and serves as a major indicator of health. Affecting a woman's sexual issues will indirectly affect her quality of life. The present study aimed to examine the factors related to sexual satisfaction in women with gestational diabetes in the third trimester. Method: This cross-sectional descriptive-analytic study was conducted in 2019 on 120 women with gestational diabetes visiting the clinics affiliated with Mazandaran University of Medical Sciences. Multistage random cluster sampling was performed, and the sample was selected in a non-probability and convenience manner. The data collection instruments included 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 Parental Distress Questionnaire, and the Depression, Anxiety, and Stress Scale. Data were analyzed in SPSS 23 by using descriptive statistics, chi-squared test, t-test, ANOVA, Pearson’s correlation coefficient, Kruskal-Wallis test, Mann-Whitney U test, and Spearman correlation coefficient. Results: Results showed that about 50% of women with gestational diabetes had low and moderate sexual satisfaction. In women with gestational diabetes, sexual satisfaction was positively correlated with sexual function (β = 0.215, p = 0.02) and marital satisfaction (β = 0.298, p = 0.003), and negatively correlated with depression (β = -0.269, p = 0.05). Conclusion: Half of the women with gestational diabetes had low and moderate sexual satisfaction. Marital satisfaction, sexual function, and depression significantly predicted sexual satisfaction in women with gestational diabetes. Examination of sexual function, marital satisfaction, and depression must be part of the routine evaluation for women with gestational diabetes. To increase the sexual satisfaction of these women, it is essential to offer interventions for reducing depression and improving sexual function, marital satisfaction and, thus, their quality of life. 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).

sense of emotional and sexual intimacy. During pregnancy, sexual satisfaction may remain unchanged, increase, or decrease. Any of these changes may lead to long-term negative effects on sexual relations and mental health (12).
Sexual satisfaction is important for maintaining pregnant women's self-esteem and interpersonal relationships, and serves as a major indicator of health. Affecting a woman's sexual issues will indirectly affect her quality of life (19). Still, limited studies have focused on the sexual satisfaction of women with gestational diabetes, necessitating the performance of more studies. Results of such a study will introduce factors related to sexual satisfaction of women with gestational diabetes and lead to the discovery of new strategies for elimination or reduction of these factors, thus playing a major role in improving the quality of life of women with gestational diabetes during pregnancy. Thus, the present study aimed to examine factors related to sexual satisfaction in women with gestational diabetes visiting the clinics of obstetrics/gynecology affiliated with Mazandaran University of Medical Sciences.

Method
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.
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.  orgasm (items 11-13), satisfaction (items [14][15][16], and pain (items [17][18][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: The scores of all the above-mentioned questionnaires were calculated using the following formula,

Results
In this study, 120 women with gestational diabetes, with the mean age of 31.21 ± 0.52 years, and gestational age of 34.24 ± 0.2 weeks participated. The demographic and midwifery information of the participants is given in Table 1.   Table 3. health, and quality of life (Table 4).

Discussion
The present study was the first study to examine the factors related to sexual satisfaction in women with gestational diabetes in the third trimester.
Based on the findings, about 50% of the women with gestational diabetes had low and moderate sexual satisfaction. Jamali et al. (2018) reported that about 56% of women in the reproductive age have low and moderate sexual satisfaction (37). The level of disorder in sexual satisfaction during pregnancy is 48% (38). Memarian et al. (2015) reported that 50% of women in the third trimester have low and moderate sexual satisfaction (16). Evidently, about half of the women, whether pregnant or not, have low and moderate sexual satisfaction, and this demonstrates the importance of this study.
In the present study, the score of sexual satisfaction had a significantly positive correlation with the score of sexual function in women with gestational diabetes. Research shows that a significant positive correlation exists between sexual function and sexual satisfaction in women. Inadequate attention to sexual problems can lead to sexual dissatisfaction, and may even affect marital and family relationships over time (39). In the present study, the score of sexual satisfaction had a significantly negative correlation with the score of depression in women with gestational diabetes. Findings reveal that gestational diabetes is accompanied by psychological problems such as depression, anxiety, and stress during pregnancy (41). Moreover, depression is the most important predicting factor of sexual satisfaction and sexual desire (42).
In the present study, the score of sexual satisfaction had a significantly positive correlation with the score of marital satisfaction in women with gestational diabetes. Previous studies report a direct correlation between sexual satisfaction and marital satisfaction, with a higher sexual satisfaction accompanied by a higher marital satisfaction (43). In fact, sexual satisfaction is strongly related to marital satisfaction (40). Relationship satisfaction is the main predictor of sexual satisfaction in pregnant women in the third trimester. Sexual satisfaction has a moderate positive correlation with other dimensions of relationship, such as intimacy, commitment, and marital satisfaction (44). There is a significant negative correlation between sexual satisfaction and problems in marital problems; that is, those with a lower sexual satisfaction suffer from more marital problems (45). Satisfaction with sexual relations is a major factor contributing to marital satisfaction, and affects the health and quality of life of the couples. In fact, a mutual relationship exists between sexual satisfaction and marital satisfaction (43).
Diagnosis of gestational diabetes considerably modifies daily lifestyle, and these modifications potentially affect sexual function (41). Inadequate attention to sexual problems can lead to sexual dissatisfaction, and may affect marital and family relationships over time (43).
Based on the cultural context of Iran, a sense of shame and embarrassment in women and refraining from talking about sexual issues were the limitations of this study; by having the questionnaires completed in a self-report manner, and ensuring the participants of the confidentiality of their data, attemps were made to ameliorate this limitation.

Conclusion
Half of the women with gestational diabetes had low and moderate sexual satisfaction. Marital satisfaction, sexual function, and depression significantly predicted sexual satisfaction in women with gestational diabetes. Examination of sexual function, marital satisfaction, and depression must be part of the routine evaluation for women with gestational diabetes. To increase the sexual satisfaction of these women, it is essential to offer interventions for reducing depression and improving sexual function, marital satisfaction and, thus, their quality of life.

Competing interests
The authors declare that they have no competing interests.

Funding
This study was not funded by any funding bodies.