effect of online problem solving counseling on the sexual anxiety and intimacy of women with recurrent pregnancy loss: A Clinical Trial

doi:10.21203/rs.3.rs-3584682/v1

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effect of online problem solving counseling on the sexual anxiety and intimacy of women with recurrent pregnancy loss: A Clinical Trial

https://doi.org/10.21203/rs.3.rs-3584682/v1

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Background: Recurrent pregnancy loss creates complex reproductive conditions among women globally and in Iran affects many psychological consequences on all aspects of women's lives. Short-term problem solving therapy is one of the sexual health approaches.

Objective: This study was designed to investigate the effect of online problem solving counseling on the sexual anxiety and intimacy of women with RPL.

Materials & Methods:In this Parallel clinical trial, with the control group, the research population consists of women with recurrent pregnancy loss with a recorded file in abortion Center in Yazd. The eligible participants were assigned into two groups including control and intervention, using random allocation software. Participants in the intervention group were given online counseling through a social network with a problem solving approach. Eight weekly sessions were held each lasting 90 min. The control group received an educational file to improve sexual anxiety and intimacy. All participants in two groups completed the questionnaires before, after, and 1 month after the study. Data were analyzed with SPSS16 using descriptive and inferential statistics(P<0.05).

Results: The mean score of sexual anxiety at baseline was 62.8±10.71 in the online group and 62.00±6.43 in the control group (P=0.706). The mean score of sexual anxiety in the eighth and twelfth weeks was significantly less than the online group (53.17±7.13 in the online group and 61.34±6.13 in the control group), (49.74±7.09 in the online group and 61.25±5.96 in the control group). The mean score of sexual intimacy in the baseline was 28.68 ± 2.75 in the online group and 28.31 ± 2.77 in the control group (P=0.576). The mean score of sexual intimacy in the eighth and twelfth weeks was significantly higher in the online group (32.05±2.22 in the online group and 28.31±2.6 in the control group), (32.25±2.35 in the online group and 29.31±2.59 in the control group), (p<0.001).

conclusion: Counseling with problem solving approach in women with RPL improved sexual anxiety and intimacy. hence, this method is recommended as a non-drug and cost-effective method in the form of community-based care.

Trial Registration: This research has been registered in Iran's clinical trial center with code IRCT20220620055229N1 in 14/02/2023.

Habitual Abortion

online counseling

problem solving

Sexual counseling

Sexual intimacy

sexual anxiety

Recurrent pregnancy loss (RPL) is defined as the failure of at least two clinically recognized pregnancies before 20–24 weeks gestation. The American Association of Obstetricians and Gynecologists (ACOG) reports that approximately 65% of women with recurrent unexplained pregnancy loss subsequently conceive. The majority of recurrent pregnancy losses (approximately 60%) occur in random outbreaks, and the prevalence of recurrent pregnancy loss among couples is approximately one percent (1, 2, 3). RPL can be primary or secondary, but the prevalence of primary RPL is higher, and the main cause is endocrine disorders with a rate of 39%. Other causes include uterine abnormalities (5.7%), vitamin D3 deficiency (3.5%), mental disorders (3.2%), infections (3.6%), and autoimmune disorders (1.8%). Various diagnostic procedures are performed in abortion centers, including requesting parents' karyotypes, analyzing semen and female hormones, two- and three-dimensional ultrasound, hysterosonography, etc. (4). However, the cause remains unknown in the majority of cases and can lead to a frustrating reproductive experience. Factors that are predictive of subsequent successful fertility in the mother include the age of the mother and the number of previous abortions (1). According to one study, the probability of live birth within two years of abortion is 75% for women under age 30 compared to 40% for women in their 40s. In addition, the probability of a live birth within the next two years decreases with the number of abortions: after 3 abortions, the probability of a live birth within the next two years is 70%, but after 6 abortions, the probability drops to 45% (2), and the overall birth rate after recurrent primary abortions (73.7%) is lower than after secondary abortions (81.6%) (5).

Abortion has been described as a severe sexual crisis for couples (6, 7). Sexual anxiety is a concern about sex that leads to various sexual disorders. Sexual performance anxiety affects 9–25% of men, leading to premature ejaculation and erectile dysfunction. It also affects 6–16% of women, inhibiting their libido. Studies have shown that women with anxiety disorders report poorer sexual performance and more sexual inhibition than women without anxiety disorders (8, 9). One of the things that is effective in improving the sexual performance of people is sexual intimacy. Sexual intimacy occurs when spouses can easily share feelings and desire emotionally, intellectually, spiritually, sexually, physically, aesthetically, and socially (10, 11). Studies have shown that decreased sexual performance, lack of sexual satisfaction, reduction in sexual relations, common misconceptions, and lack of correct knowledge are common in couples with RPL. They lead to differences between couples and a decrease in mental health, sexual performance, and marital satisfaction (12, 13, 14). The rate of divorce and marital dissolution was significantly higher in the group of women with recurrent abortions than in the group of women without recurrent abortion in the study by Sugira-Ogasawara et al.(12). Due to the lack of sufficient and comprehensive studies in the area of sexual health interventions for couples with recurrent pregnancy losses, this study aimed to investigate the effect of online problem solving counseling on sexual anxiety and intimacy in women with recurrent pregnancy loss.

Design and Setting

This interventional parallel clinical trial was conducted between March 2023 and August 2023 using a before-after design with an active control group and a 1-month follow-up. The statistical population of this research is all women with recurrent pregnancy loss who were referred to the Yazd Abortion Center for treatment. In order to conduct the research, written informed consent was obtained from all participants. Eligible participants were contacted based on center's list according to inclusion criteria. Sampling was done on the basis of the inclusion criteria by examining the available documentation. Among the participants who had been referred to Yazd Abortion Center, the information of 200 patients with recurrent pregnancy loss was reviewed and of these, 90 participants were invited to participate in the study through telephone calls. Finally, 70 participants who met the inclusion criteria were included in the study. The required sample was determined in each group using the following formula.

$$\varvec{n}=\frac{2{{\varvec{S}}_{\varvec{p}}}^{2}{\left[{\varvec{Z}}_{1-\varvec{\alpha }/2}+{\varvec{Z}}_{1-\varvec{\beta }}\right]}^{2}}{{{\varvec{\mu }}_{\varvec{d}}}^{2}}$$

According to Elsharkawy et ai.’s paper(15). Confidence level was 95%, test power of 80% and subject attrition rate of 10%, 35 samples were considered in each group.

Eligibility Criteria

Inclusion criteria are: history of at least two repeated abortions, age between 18 and 45 years, no history of major stress such as death of relatives in the last 3 months, access to the internet and a smart phone, and being Iranian. Exclusion criteria are: patient’s or her spouse’s affliction with serious psychological disorders such as severe depression and psychosis, consumption of any drug affecting sexual relations by the patient or her spouse (self-reported), history of participating in sexual health education and counseling sessions, and being pregnancy.

The first-generation random allocation method was used to assign the eligible participants into two intervention and active control groups, each participant was given a number from 1 to 70.

Then, using the website http://www.randomization.com. participants were randomly assigned into two blocks of 35, C and D. A person external to the study used a random lottery method to select each block as an intervention or active control group.

Instruments

The demographic information form and the Farsi version of the women’s sexual anxiety and intimacy questionnaire were developed electronically and it was provided to the participants.

Demographic Information form: This included the patient’s age, spouse's age, patient’s employment status, spouse's employment status, patient’s education, spouse's education, and information on recurrent pregnancy loss including the number of abortions and the duration of the last abortion.

Sexual Anxiety Questionnaire: This questionnaire was developed in 2006 by Davis et al.(16) It consists of 18 items with a 5-point Likert scale. The minimum score obtained from this tool is 18 and the maximum score is 90. A higher score is indicative of a greater degree of sexual anxiety. Besides, the validity and reliability of the Farsi version of this questionnaire were first confirmed by Gheisari et al.(17) (2013) with Cronbach's α of 0.75 in Iran.

Sexual Intimacy Questionnaire: This questionnaire was developed in 2001 by Bagarozi et al.(18) It consists of 5 items with a 10-point Likert scale. The minimum score obtained from this tool is 5 and the maximum score is 50. A higher score indicates a better level of sexual intimacy. Besides, the validity and reliability of the Farsi version of this questionnaire were first confirmed by Etemadi et al. (2006) in Iran(19).

Intervention

To conduct the research, informed consent was obtained from participants by creating an online consent form. After obtaining consent and explaining the research objectives, all participants were provided demographic, sexual anxiety, and intimacy questionnaires online. Following completion of the questionnaires, participants in the intervention group were placed in a social networking group where they received information and advice about the intervention process and attended consultations. In the course of the implementation of the intervention sessions, the participants in the intervention group were divided into two blocks of 17 and 18 participants, respectively, in order to facilitate interaction and the opportunity for questions and answers between the participants and the counselor. The sessions in each block were held at two different times of day on every other day of the week. The intervention consisted of eight 90-minute counseling sessions that used a problem solving approach and were delivered online once a week. The sessions were conducted online using the social network. During each session, the researcher presented solutions to problems based on the approach's problem solving protocol using the approach's common tools (20). Participants were given assignments to present at the start of the next session at the end of each session. Questions and answers and clarification of participants' doubts took up the last 15 minutes of each session. In between sessions, participants could ask questions and receive responses as a group. If an individual missed a meeting, the content of that meeting was made available to that individual. Missing more than two sessions or completing at least 30% of homework was considered a refusal to continue (for session content, see Table 1). In addition, each member of the active control group was sent an educational pamphlet on sexual issues via social networking sites to be read every two weeks. Directly after the end of the intervention period and one month after the end of the intervention period (flow-up), participants in both the intervention and control groups completed the Sexual Anxiety and Intimacy Questionnaire.

Ethical considerations

This study was conducted based on the declaration of Helsinki and the approval of the Ethics committee of the Research Vice-Chancellor of shahid sadoughi university of medical sciences with code: IR. SSU.REC.1401.078. Additionally, after explaining the objectives of the study to the participants, informed written consent was obtained from all the participants to take part in the study and they were assured of the confidentiality of the study results. This clinical trial has been registered in the Iranian registry of Clinical Trials (IRCT) with the code: IRCT20220620055229N1 in 14/02/2023.

Table 1

Details of the content presented in the sessions with a problem solving approach
Session	Session content	Home practice
First	Introduce with group members. Explaining the goals and vision of the group. Distribute questionnaires. Description of sexual terms such as sexual anxiety, sexual intimacy and recurrent pregnancy loss.	Making the list of sexual anxieties to work on. recording these problems.
Second	Review the assignment of the previous session. Talk about the clients' experiences of the recurrent pregnancy loss. defining the problem solving approach.	Understanding and evaluating the causes of sexual anxiety. prioritizing these subjects.
Third	How did you improve your sexual performance after recurrent pregnancy loss? breaking the main goal into smaller goals. strengthening self-control	Prepare a list of your negative thoughts related to their sexual anxiety.
Fourth	Review the assignment of the third session, teaching and implementing snowball, emotion-oriented and problem-oriented techniques.	Practicing the snowball technique and discovering emotion-oriented and problem-oriented techniques.
Fifth	Review the assignment of the Fourth Session. teaching creative visualization techniques and finding thoughts and beliefs related to problems.	challenging beliefs of their post-sexual anxiety and practicing creative visualization techniques.
Sixth	Feedback and discussion about the problem solving technique as a combination of the techniques of the previous sessions and examining positive and negative solutions.	Examining positive and negative solutions in solving problems.
Seventh	Examining the task of the sixth session. implementing the best solution chosen by the members	Implementing the best solution.
Eighth	Reviewing the development and setting the follow-up meeting. Completion of questionnaires.	Preparation the development until the follow-up period.

Data analysis

Statistical analysis of the data extracted from the questionnaires was done using SPSS version 16 software. Descriptive statistics were used to describe data, draw tables, and calculate percentages, averages, and standard deviations, and inferential statistics were used to compare the average of variables in each group. The chi-square test was used to compare the qualitative variable. One sample Kolmogorov-Smirnov test was used to check the normality of the distribution of the study data.

Due to the normality of the distribution of the quantitative variables related to the demographic questionnaire, the parametric Independent sample t-test was used to compare the variables in the two groups. Also, due to the normality of the data distribution, Repeated Measures was used to compare within the group the mean score of sexual anxiety and intimacy three time for each group. (p < 0.05).

The data of 70 people ( 35 people in the intervention group and 35 people in the control group) were statistically analyzed. For each group, the losses and exclusions after randomization with reasons are shown in detail in Fig. 1. The mean age of participants was 29.04 ± 5 and 29.82 ± 5.31 in the intervention and the control group respectively. Results showed the normality of demographic characteristics in the two groups. There were no significant differences in terms of women’s age (P = 0.730), Spouse’s age (P = 1.00), women’s education (P = 0.940), Spouse’s Education (P = 0.720), women’s job (P = 0.330), spouse’s Job (P = 0.770), number of abortion (P = 0.770), duration of last abortion (P = 0.730) (Table 2,3).

Also, the score of sexual anxiety three times was significantly different between the control and the intervention groups. Sexual anxiety in the intervention group was obtained at 62.8 ± 10.71, 53.17 ± 7.13, and 49.74 ± 7.09, and in the control group 62.00 ± 6.43, 61.34 ± 6.13 and 61.25 ± 5.96 before, after, and one month after the intervention respectively (Table 4). The statistical test shows the difference in means of sexual anxiety in the two groups. Sexual anxiety before and immediately after the intervention was significantly different (P < 0.001), before and one month after the intervention was significantly different (P < 0.001), and also immediately after the intervention and one month later was significantly different (P < 0.001). There was no significant difference in the control group at any time. the score of sexual anxiety three times was significantly different between the control and the intervention groups. Sexual intimacy was not significantly different before the intervention (P = 0.576), but immediately after the intervention (P < 0.001) and one month after the intervention (P < 0.001) was significantly different (Table 5). Sexual intimacy in the intervention group before and immediately after the intervention was significantly different (P < 0.001), before and one month after the intervention was significantly different (P < 0.001), also immediately after the intervention and one month later was significantly different (P < 0.001) (Table 5).

Table 2-Demoghraphic characteristics of the studied samples in two groups.

* Chi-Square

Table3-Demoghraphic characteristics of the studied samples in two groups.

*Independent Sample T-test

Table 4

Comparison of mean and standard deviation of sexual anxiety variable in three times in two groups.
P value	P value	group		variable
P value	P value	control	intervention	variable
**<0.001				Sexual anxiety
	*0.706	62.00 ± 6.43	62.8 ± 10.71	Before intervention
	*<0.001	61.34 ± 6.13	53.17 ± 7.13	Immediately after the intervention
	*<0.001	61.25 ± 5.96	49.74 ± 7.09	One month after the intervention
		**0.314	**<0.001	Time 0–8
		**0.766	**<0.001	Time 8–12
		**0.322	**<0.001	Time 0–12
		*<0.001		*P value between group time**
* (Independent Sample) T-test
** Repeated Measure

Table 5

Comparison of mean and standard deviation of sexual intimacy variable in three times in two groups.
P value	P value	group		variable
P value	P value	control	intervention	variable
< 0.001**				Sexual intimacy
	*0.576	28.31 ± 2.77	28.68 ± 2.75	Before intervention
	*<0.001	28.31 ± 2.60	32.05 ± 2.22	Immediately after the intervention
	*<0.001	29.31 ± 2.59	33.25 ± 2.35	One month after the intervention
		**1	**<0.001	Time 0–8
		**<0.001	**<0.001	Time 8–12
		**0.021	**<0.001	Time 0–12
		**<0.001		*P value between group time**
* (Independent Sample) T-test
** Repeated Measure

The main goal of this study was to investigate the effectiveness of online counseling with a problem solving approach in the sexual anxiety and intimacy of women with recurrent pregnancy loss.

The results showed that the average score of sexual anxiety and intimacy in the intervention group had a statistically significant difference before the intervention, immediately after, and one month after, and the use of online counseling with a problem solving approach led to improvement. The score of anxiety and sexual intimacy in the participants of the intervention group was so that in the period immediately after the intervention and one month after that, the sexual anxiety and intimacy score of none of the participants of this group was not in the poor range and most of them were in the range of the desired score.

The results of the active control group showed that the average score of sexual anxiety and intimacy in this group did not have a statistically significant difference compared to before the intervention, but one month after the intervention, the average score of sexual intimacy of the participants compared to immediately after There is a significant difference. Therefore, it seems that providing problem solving content in a longer period of time may improve sexual anxiety and intimacy in women with recurrent pregnancy loss.

According to the results of the study, the mean score of sexual anxiety and intimacy before the intervention in both groups was not statistically significantly different from each other. After the intervention, the average score of sexual anxiety and intimacy differented in both groups, but in the intervention group, the difference in the mean score was higher than the active control group, and this difference is statistically significant.

The results showed that online counseling with a problem solving approach improves the sexual anxiety and intimacy of women with recurrent pregnancy loss. The findings are similar to the results of Hassanzadeh, Zulfaghari, and Elsharkawy’s research (15, 21, 22). It is known that the quality of sexual life decreases after recurrent pregnancy loss (7). Also, Some studies have linked recurrent pregnancy loss to sexual anxiety in men (23). One study found that recurrent pregnancy loss may increase the risk of posttraumatic stress disorder in both spouses (24). Infertility and abortion may have a negative impact on mental health, according to research on women with recurrent pregnancy loss (25, 26). In his study(2021) entitled "Effect of happiness counseling on depression, anxiety and stress in women with recurrent miscarriage", Elsharkawy showed that the intervention caused a significant difference in the improvement of depression, anxiety, and stress (15). However, this research was not the same as the present study in terms of the type and method of education. The fact is that psychological support for women with abortion improves their quality of life, and holding counseling programs is an effective and low-cost strategy to improve the overall well-being of these couples.

Nazaralivand et al. (2021) in a study of 46 women who had a spontaneous abortion in their first pregnancy found that 8 sessions of 90-minute problem solving group counseling can be effective in improving mental health after a spontaneous abortion (27). The present study was consistent with this study and similar in terms of time to complete the questionnaires and type and number of intervention sessions. In fact, the problem solving approach with a positive orientation leads couples to find effective solutions to the problems and issues in their lives and to enjoy their married life more.

A study (2017) showed that positive orientation is one of the problem solving patterns associated with improving people's abilities (28). Studies have shown the effectiveness of the problem solving approach in improving people's sexual performance (29). Online group counseling with the possibility of private chat (30) may be a better answer to improve sexual performance in a safe, accessible, and effective way. Ozaki et al (2015) showed that online sexual health counseling is also very effective in Japan (31). Carlbring (2007) also showed in his research that online cognitive-behavioral interventions are effective for general and social anxiety, reducing depression and retention in treatment (32). One study showed that both in-person and telephone sexual health counseling improved sexual functioning in Breastfeeding women (33). Thompson et al. (2020) in their clinical study with a remote emotional therapy approach and through online tools stated that online training is an excellent way to provide psychological services (34). Our study was consistent with these studies and showed that remote and online counseling is an effective and feasible approach.

Farajkhoda et al. (2021) in their study entitled " Online Compared to Face-to-Face Sexual Intimacy Enhancement Training Program Counseling with Cognitive-Behavioral Approach on Sexual Intimacy in Pregnant Women" showed that the satisfaction of pregnant women was higher with the online method (35). The present study differed from their study in the type and duration of the counseling approach.

Explaining the concept of intimacy involves discussing its common definition as the level of closeness between partners, sharing values and ideas, participating in activities together, engaging in sexual relations, getting to know each other, and engaging in emotional behaviors such as caressing. Research suggests that intimate couples experience higher levels of marital satisfaction (36). Michelson et al. (2020) demonstrated that a counselor's problem solving intervention had a moderate effect on improving psychosocial outcomes among adolescents, compared to using problem solving booklets alone (37). Additionally, the current study found online counseling to be more effective and long-lasting than training booklets.

One strength of this study was the comparison of women experiencing recurrent pregnancy loss from a single treatment center. Another strength was the clients' willingness to participate in counseling sessions and communicate with their counselors over time if they had medical questions. Given the geographical dispersion of study participants across multiple provinces and the limitations on holding in-person meetings, this method proved to be a cost-effective solution for non-native people.

Clients in this method are trained to effectively identify and solve everyday problems, which can be of great value when couples experience emotional reactions and seek to reduce pressure and stress, resulting in improved overall health.

Study limitations

One of the limitations of this study is the presence of cultural issues such as shying away from expressing sexual problems, stress, and concerns related to the process of diagnosis and treatment, which could affect people's responses. In order to solve this problem of ensuring the confidentiality of information, not needing to mention names made them satisfied to continue participating in the study. Also, the sample size in the study is small and its results cannot be generalized to the whole society.

Sexual health counseling with a problem solving approach caused a significant decrease in sexual anxiety and a significant increase in sexual intimacy in women with recurrent pregnancy loss. As a result, it can be said that problem solving counseling as one of the new therapeutic approaches deals with the positive adaptation of people against negative life events. Therefore, considering the many sexual problems of women suffering from recurrent abortions, it is suggested that counselors and therapists use this short-term, non-pharmacological, and effective approach in recurrent abortion centers.

RPl

Recurrent Pregnancy loss

Acknowledgements:

This paper was extracted from a Master’s thesis in counseling in midwifery approved by the Shahid Sadoughi University of Medical Sciences. We would like to express our appreciation to Dr. Nasrin Ghasemi all, the personnel of the Yazd Abortion Center for their cooperation in the execution of this research and the personnel of the Shahid Sadoughi University of Medical Sciences.

Authors’ contributions:

Mahshid Bokaie and Shahla Mohammadkhani wrote the main manuscript text, Nasrin Ghasemi prepared table 1 and Tayebeh Mokhtari Sorkhani Provided advice on project implementation steps and editing of the manuscript . All authors reviewed the manuscript.

Funding:

Not applicable.

Availability of data and materials

The datasets used and analyzed during the present study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

The study was approved by the Ethics Committee of the Research Deputy of the Shahid Sadoughi University of Medical Sciences (code: IR.SSU.REC.1401.078). Based on the list available at the institute, first, the research objectives and the reason for conducting the research were explained to the participants via text messages or phone calls. After calling the participants and obtaining more information, they announced their consent or dissatisfaction to enter the study. It was emphasized that refusing to participate in the study would not interfere with providing regular care for the patients. After explaining the study’s aims to the participants, written informed consent was obtained from them, and their confidentiality was ensured.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Author details

1. Research Center for Nursing and Midwifery Care, Non-communicable Diseases Research Institute, Department of Midwifery/Nursing, School of Nursing and Midwifery, Shahid Sadoughi University of Medical Sciences, Yazd, Iran. 2. MSc. Student in Midwifery counseling, Research Center for Nursing and Midwifery Care, Shahid Sadoughi University of Medical Sciences, Yazd, Iran. 3. abortion research Center, reproductive sciences institute yazd Shahid Sadoughi University of Medical Sciences and health services, Yazd, Iran. 4.Department of Health Education and Health Promotion,Social Determinant of Health Research Center, School of Public Health,Shahid Sadoughi University of Medical Sciences, Yazd, Iran.

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No competing interests reported.

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effect of online problem solving counseling on the sexual anxiety and intimacy of women with recurrent pregnancy loss: A Clinical Trial

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Introduction

Methodology

Design and Setting

Eligibility Criteria

Instruments

Intervention

Ethical considerations

Data analysis

Results

Discussion

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conclusion

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