Intersections: Postpartum Sexual Quality of Life in Two Cultures: A Qualitative Study

Intersections: Gender and Sexuality in Asia and the Pacific
Issue 45, April 2021

Postpartum Sexual Quality of Life in Two Cultures:
A Qualitative Study

Azam Rahmani

Arezoo Fallahi

Leila Allahqoli

Susanne Grylka-Baeschlin

Introduction

Sexuality is a key aspect of human life and has a fundamental role in quality of life and general well-being. Postpartum quality of life comprises health- and non-health-related factors that need to be considered within the cultural context in which the individual lives.[1] Many couples experience childbirth and the transition into parenthood as a stressful time with consequences for both health and quality of life.[2] Sexual activity has been found to be an important factor for postpartum quality of life, which is often negatively affected after a woman has given birth.[3] In this paper we focus on the sexual quality of life experienced after childbirth in Iran and Switzerland.

Health-related quality of life is a multidimensional construct including physical, social, emotional and psychological dimensions.[4] Sexual quality of life is essential for general wellbeing but is usually ignored and treated as a taboo topic.[5] However, the World Health Organization (WHO) emphasises sexual health and especially focuses on the importance of sexual activity in the context of women’s and reproductive health.[6] According to WHO, sexual health is defined as 'a state of physical, emotional, mental, and social well-being in relation to sexuality'. After childbirth, more than half of the mothers experience sexual dysfunction.[7] Therefore, sexual problems and dysfunction are important aspects of women’s lives and can not only affect wellbeing and health but also place burdens on marriages and partnerships.[8]

In Iran, although several studies have been conducted regarding postpartum sexuality, most of them have focused on the prevalence of sexual dysfunction after childbirth.[9] A systematic review showed that 46 per cent of mothers in Tehran experienced at least one type of sexual dysfunction during the postpartum period; this prevalence is even higher (50 per cent) in other cities of Iran.[10] In Europe, only a few scientific articles have been published about sexuality after having given birth,[11] and none of them has been published in Switzerland. Previous studies recognised some factors associated with sexual dysfunction such as primiparity, exclusive breastfeeding, age, type of delivery, education, time since delivery, mode of birth, family income and partnership problems.[12] However, no study focusing on postpartum sexual quality of life has been found in Iran and Switzerland.

Sexual activity is a culturally based topic and Iranian culture is completely different from Swiss culture in terms of sexual beliefs, sex education, laws about sexual activity, and sexual health services. It is anticipated that these factors could affect the sexual quality of life of postpartum women at one of the critical stages of their life.[13] In Iran, there is no formal education for couples especially in the postpartum period [14] although there are some cultural codes that have been attributed to religion such as the sexual obedience of a wife to her husband.[15] In addition, there are some patriarchal beliefs regarding marital and sexual relationships in the Iranian context.[16] Even though in Switzerland, the attitude towards sexuality is more open and the majority of women have postpartum care until 56 days after childbirth, sexuality is a topic that is often not talked about. This study with a qualitative approach helps us to understand the effect of these two different cultures on the sexual quality of life of mothers in one of the critical stages of their lives.

Since sexual activity plays a critical role in women’s quality of life, there is no study focusing on postpartum sexual quality of life in Iran and Switzerland, and there is no study on the effect of cultural difference on postpartum sexual quality of life, this study was conducted to explore the most important differences in postpartum sexual quality of life among Iranian and Swiss mothers.

Method Design

The present study was a joint research project between Switzerland and Iran in the framework of a Seed Money Grant in 2018. We employed a qualitative approach, using conventional content analysis techniques because there were few data and no preconceived hypotheses in the field of the sexual quality of life in the postpartum period.[17] The study was conducted from December 2018 to March 2019 and its protocol was approved by the Review Boards of the National Institute for Medical Research Development: 976748 (NIMAD) in Iran, and the cantonal Ethics Committee of Zurich (BASEC-Nr. Req-2018-00984) in Switzerland.

Participants

Participants were recruited through health-care centres affiliated to the Tehran University of Medical Sciences in Iran, and through independent midwives providing postpartum care in Switzerland. Inclusion criteria were: primiparous mothers, older than 18 years; being married or living with the partner as cohabitants; Iranian nationality or fluent oral German knowledge; experiencing a healthy pregnancy; and vaginal birth or caesarean section without complication during the last three months. To minimise the effect of confounding variables on sexual quality of life, we excluded mothers who had had a negative experience such as the death of a close relative or friend during the last six months, who reported a history of psychological disease or sexual dysfunctions before pregnancy, and who felt uncomfortable talking about sex. Since focus groups have been recognised as useful techniques for data gathering in research into the topic of sexuality, [18] we asked mothers to indicate their interest in participating in an individual interview or focus group discussion (FGD).

After enrolling Iranian participants, ten mothers stated that they would prefer to participate in the FGDs, and we, therefore, designed two FGDs with five mothers each; but, in the end, only three mothers participated in each FGD. In total, we conducted two FGDs (six participants altogether) and 17 individual interviews in Iran. In Switzerland, 13 mothers fulfilled eligibility criteria and were interested in participating in an individual interview.

Procedures

Before starting the interviews and FGDs, all participants in both countries completed a baseline survey about demographic characteristics (age, level of education, economic status, occupational status, and mode of delivery).

FGDs and interviews were conducted in a private room by a female PhD graduate with a background in nursing and midwifery in Iran and by a female PhD graduate and a midwifery master’s student in Switzerland. Interviews were conducted in private rooms or at the participant’s home. We obtained informed written consent from all participants; after which the interviewer used a semi-structured guide of open-ended questions. The interview guide contained the following topics relating to four dimensions (physical, social, emotional and psychological):

We applied some strategies to overcome the language of silence and privacy concerns. These strategies were:

We conducted maximum variation sampling to yield greater transferability and data saturation. Therefore, participants were selected from different age groups, various educational levels, and different socioeconomic statuses. Data saturation was achieved after two focus group discussions and 15 individual interviews in Iran and after 13 individual interviews in Switzerland; in fact, no additional information was found in the last individual interviews, meaning that data saturation was reached.

Data analysis

Ulla Graneheim and Berit Lundman's approach to qualitative content analysis was employed for analysing the data.[19] Data analysis started during the time that data was being collected in Iran. Each FGD and the individual interviews were transcribed verbatim and analysed before the next FGD or interview. Reading and re-reading the transcripts were applied to achieve a deep comprehension of data. In the next step, units of meaning were extracted from the statements. Data analysis was performed using line-by-line coding, and codes were created during repeated discussions between the researchers. Non-verbal expressions were coded and included in the data analysis. Themes emerged based on the codes with similar meanings. Since Iranian interviews were conducted first and the aim of the study was to explore differences in postpartum sexual quality of life between two cultures. The Iranian coding scheme was then translated into English and consequently into German and applied to the Swiss data. In this stage of the analyses, we focused on similarities and differences between countries and we also created new sub-categories. Repeated in-depth discussions between the researchers of both countries were held in order to identify cultural differences. The analysis was done in the original languages. Quotations were translated from Farsi and German into English and were checked by native Farsi and German speakers as well as by a native English-speaking person. We used MAX-QDA 10 software in Iran and Atlas.ti 8 in Switzerland for analysing the data.

Rigour

An expert in qualitative methods (AF) was involved in the study as a second coder. The Iranian coder (AR) also exchanged with the Swiss coder (SG-B) and advised on the analyses of Swiss data. We asked five of our participants to review the summary of the interviews and the findings to confirm that the results were consistent with their beliefs and experiences. For confirmability of the findings, we conducted peer check; as the substantive codes and themes were checked by four individuals who were familiar with qualitative methods of content analysis and were experts in sexuality issues.[20] Maximum variation sampling enhanced the transferability of data.[21]

Results

A total of 36 (23 Iranian and 13 Swiss) mothers participated in FGDs and individual interviews. The age of the Iranian participants ranged from 19 to 35 years and all were married. Thirteen mothers had caesarean sections, 14 were housewives, and the economic status of 16 mothers was moderate. The majority of participants (n = 9) held bachelor degrees. Swiss mothers were between 25 and 35 years of age. Three mothers had caesarean sections, four instrument vaginal births, and six spontaneous vaginal births. A good half of the mothers were married (n=7) and six lived with their partner in stable relationships. Seven mothers had bachelor degree or higher and one was an undergraduate. The interviews were conducted from 32 to 104 days after birth in both countries. The characteristics of participants have been shown in Table 1.

Table 1. Sample characteristics of participants

		Switzerland (n=13) N %	Iran (n=23) N %
Age	< 20	0 (0)	1 (4.3)
	21–30	6 (46.2)	10 (43.5)
	>30	7 (53.8)	12 (52.2)
Mode of Delivery	Natural delivery	10 (76.9)	10 (43.5)
Mode of Delivery	Caesarian section	3 (23.1)	13 (56.5)
Occupational status	Housewife	0 (0)	14 (60.9)
Occupational status	Employed	13 (100)	9 (39.1)
Educational level	Under diploma	0 (0)	0 (0)
	Diploma	6 (46.2)	8 (34.8)
	University	7 (53.8)	15 (56.2)

We categorised the results according to similarities and differences between the two cultures. Themes which were associated with differences included individual factors (fear of having a child and negative feelings about being a woman), interpersonal relationships (husband’s/partner’s negative behaviour, expectations of the spouse/partner, management of marital life, and managing conflicts in marital/partnership life), and sexual life (sexual interests, negative sexual behaviours of husbands and partners, positive sexual behaviour of mothers, and comparison to first intercourse in life). More details of categories have been summarised in Table 2.

Table 2. Extracted themes based on differences between two cultures

Themes	Category	Switzerland	Iran
Individual factors	Fear of having a child	Preoccupation about ability to manage baby care due to: * inexperience * unstable psychological state	Instability in the country, changes in marital life
Individual factors	Negative feelings about being a woman	Only in the context of motherhood	Because they experienced: * gender discrimination * multiple responsibilities
Interpersonal relationships	Husband's/partner's negative behaviour	Overwhelmed caring for baby	Harsh behaviour, disregard for their material needs, lack of emotion towards them, failure to meet their expectations in daily life
	Expectations of spouse/partner	Accept that husbands/partners are a second priority	Males should make an effort to: * seek the new mother’s opinions in life's decisions, * contribute to home affairs
	Management of martital life	Not only becoming parents but remaining a couple	Making joint decisions, husbands help wives
	Managing conflicts in marital/partnership life	* Speak about strategies to manage marital life * baby as an additional issue of conflict	* Being completely silence during discussions and for several days later * huffing (sulking)
Sex life	Sexual interests	Having fun using sex toys	Suggesting anal sex
	Negative sexual behaviours of husbands or partners	No related quotations	* Neglecting the woman's sexual needs * ignoring the woman's readiness to instigate sex
	Sexual behaviour of new mothers	Accepting the husband’s or partner’s request despite the lack of willingness is seen as a culturally unexpected behaviour	Accepting the husband’s or partner’s request despite the lack of willingness is seen as a positive behaviour
	Comparison to first intercourse in life	Similarity between first intercourse and first intercourse after childbirth	No related quotations

Individual factors

Fear of having a child

Whereas Iranian mothers mentioned reasons such as instability in the country and changes in marital life, mothers living in Switzerland were preoccupied with their ability to manage baby care due to inexperience or an unstable psychological state.

Apart from the fact that our country is not in a good condition, I always thought that it would be a betrayal if I intend to bring a living creature into this world; that is why I am depressed. (Iranian mother, 35 years old, caesarean, 65 days after birth, an employee)

Sometimes I panic a lot … What will it be like with a child? … Will I worry too much about myself and the baby? Is it even a good idea to have children?' (Mother in Switzerland, 34 years old, 94 days after spontaneous birth, an employee in administration)

Negative feelings about being a woman

Some Iranian mothers had negative feelings about being a woman because they experienced gender discrimination or faced multiple responsibilities, especially after giving birth. There were no quotations about discriminatory attitudes towards women in Switzerland. Instead Swiss women mentioned negative feelings about being a woman only in the context of motherhood. Some of the quotes from mothers are listed below:

The prevailing belief in society is that whenever a woman is a housewife or an employee, she must do all the housework. And it takes lots of energy from me and this overload of responsibilities makes of me an exhausted person who is not interested in a sexual relationship. (Iranian mother, 35 years old, 65 days after caesarean section, employee)

When you can't participate in decisions, but men have their ideas and decisions; in such a situation, I wish I was a man and everything, sexual and non-sexual things, was in my hands. (Iranian mother, 31 years old, normal delivery, 71 days after birth, housewife) At the moment I feel more like a mother than a woman … because I’m completely functional and … it is not really what it was before. (Mother in Switzerland, 29 years old, 97 days after spontaneous birth, architect)

Swiss mothers were worried about caring for the baby while Iranian mothers were anxious in relation to the socioeconomic status of the country. This difference could be attributed to the different economic situations of the two countries; Switzerland is stable in terms of the economic situation while Iran faces an economic crisis and sanctions. Individual factors reflect the stress and anxiety of mothers in the postpartum period which could indirectly affect their sexual quality of life. Mothers who experienced fear about having a child and negative feelings regarding being a woman reported depression and loss of self-confidence in their marital and sexual relationships. In addition, the gender discrimination that was reported among Iranian mothers could also affect sexual self-confidence and sexual quality of life.

Interpersonal relationships

We categorised this theme into four categories including:

Husband’s/partner’s negative behaviour

Although negative behaviour of the husband or partner was reported in both countries, the quotations of Iranian mothers were much stronger in this regard. Some Iranian mothers stated that their husbands' behaviour caused them to feel psychologically abused. They complained that they experienced harsh behaviour, disregard for their material needs, lack of emotion towards them, and failure to meet their expectations in daily life. No mothers in Switzerland mentioned abusive behaviour. However, a few mothers felt overwhelmed by the burden of caring for both the baby and the husband.

He is unresponsive to my financial needs including buying something for me or giving me a gift or something else. (Iranian mother, 33 years old, 58 days after caesarean birth, employee)

Some days, I get so involved with the kid that I don't have time to do anything. Then he comes home and says: then, where's the food? This makes me angry. (Iranian mother, 32 years old, 53 days after caesarean birth, employee)

And then, in the evening, the husband comes at home, and he also needs attention. (Mother in Switzerland, 29 years old, 97 days after spontaneous birth, architect)

Expectations of the spouse/partner

Participants reflected on the ideals and expectations in relation to their husbands/partners. Most participants expected their husbands/partners to understand that their situation had changed after childbirth, and to care of their emotional needs. Iranian mothers mentioned that they expected their husbands to make an effort in seeking their opinions in life's decisions and to contribute when it came to home affairs such as cooking and cleaning. Some mothers in Switzerland, however, expected that their husbands and partners would accept the priority needs of a new baby and that they were a second priority.

There were sometimes when he could do something to help me, but he didn't. I wonder why I have to sacrifice so much, but he can easily say I can't (Iranian mother, 31 years old, , 81 days after normal delivery, employee)

My husband used to decide with his mother, but I fought so much and I was able to convince him that I should participate in decision making and that we have to make decisions together. (Iranian mother, 31 years old, 71 days after normal delivery, housewife)

But at the beginning of a partnership, a couple is always together and suddenly the baby is here and he (the husband) is the second priority. He feels neglected but he must bear this. (Mother in Switzerland, 33 years old, 80 days after caesarean section, scientific assistant)

Management of marital life

For Iranian mothers, the management of marital life related to how daily life planning was done and how decisions were made in the family. Most participants stated that they made decisions jointly with their husbands, but there were a few mothers who stated that the final decision was made by their husbands. Most participants also stated that they were trying to help each other and meet each other's needs, but in contrast, there were examples of husbands who refused to help their wives. In Switzerland, helping each other and mutual respect were both very important. In the context of parenthood, some mothers mentioned the importance of not only becoming parents but remaining a couple.

My husband tries to please me in everything; when we want to buy something or we want to go somewhere, he always asks my opinion. (Iranian mother, 27 years old, 75 days after caesarean birth, housewife)

In any situation, my husband decides by himself; in fact, he asks my opinion, but he finally makes his own decision. (Iranian mother, 31 years old, 78 days after caesarean birth, housewife)

It's mutual respect and I think that's the reason why it works so well. (Mother in Switzerland, 34 years old, 94 days after spontaneous birth, administration assistant)

We are not only parents, but we still are a couple. And we must take ourselves in hand. (Mother in Switzerland, 35 years old, 97 days after spontaneous birth, lawyer)

Managing conflicts in marital/partnership life

Beside positive behaviour—such as solving problems by talking—Iranian mothers also mentioned negative behaviours that they engaged in, such as being completely silence during heated discussions and for several days later and huffing around the house. Mothers in Switzerland spoke about the strategies they used to manage marital or couples’ life but also mentioned that the baby was an additional issue of conflict.

If we fight, we usually stay silent and also we hardly talk to each other for a few days. (Iranian mother, 31 years old, normal delivery, 71 days after birth, housewife).

We both try to skip from little conflicts to avoid any disagreements because we don't like to make each other upset. (Iranian mother, 34 years old, 81 days after caesarean birth, employee)

I need to tell him more actively again what bothers me. (Mother in Switzerland, 29 years old, 97 days after spontaneous birth, architect)

And we also argue about her (the baby), so sometimes and that's why it happens … but yes. So now there is another point of contention. (Mother in Switzerland, 33 years old, 80 days after caesarean section, scientific assistant)

Some of the interpersonal conflicts that mothers had experienced existed from earlier stages in their marital or couples' life while some others were related to the changes that had happened postpartum. For example, some reported that the baby had become a new source for conflict. In terms of marital life, Swiss mothers reported more mutual respect in their personal relationship and more husbands/partners’ help with the housework than Iranian mothers. In addition, the importance of remaining a couple after childbirth was clearer in quotations provided by Swiss mothers.

Sex life

This theme was formed based on four categories:

Sexual interests

Although in both countries, participants spoke about what they liked about their sexual behaviours in the postpartum period, there were some differences between cultures. Some Iranian mothers stated that because of dyspareunia, their husband suggested having anal sex. They reported that they did not enjoy non-vaginal sex, especially anal sex, because it was also painful. In Switzerland, some mothers mentioned having fun using sex toys.

I do not allow anal sex because not only is it painful but also it is harmful. (Iranian mother, 33 years old, 58 days after caesarean birth, employee)

We also experimented and have some toys at home so as it is still the same as it used to be. This hasn't changed. It was and still is important for us to have fun. (Mother in Switzerland, 34 years old, 94 days after spontaneous birth, administration assistant)

Perceived negative sexual behaviours of husbands/partners

Some Iranian mothers stated that they experienced negative sexual behaviours from their husbands, including neglecting the woman's sexual needs and ignoring the woman's readiness to instigate a sexual relationship. In Switzerland, no mother complained of being obliged to have sex against her will. A big difference was observed in new mothers feeling obliged to accede to their husbands’/partners’ sexual suggestions despite their own unwillingness. This behaviour was more common in the Iranian context.

Unfortunately, my husband disregards my desire, and it bothers me. For example, when I suggest a sexual relationship, he usually delays it until the weekend. (Iranian mother, 19 years old, 51 days after caesarean birth, housewife)

If I reject my husband's sexual suggestions, he will become upset and huff. (Iranian mother, 31 years old, 71 days after normal delivery, housewife)

Perceived positive sexual behaviour of mothers

For Iranian mothers, several topics recurred in the interviews that reflected what they called "positive" sexual behaviour. These included: asking their husbands for sex, attempting to know their husbands’ sexual interests, using different methods of sexual activity depending on the situation, and accepting their husbands' requests for sex even if they were not willing. In Switzerland, accepting the husband’s or partner’s request despite the lack of willingness would not be called a positive behaviour and is not expected culturally. Very few Swiss mothers agreed to have sex without desire. Neither did they fake an orgasm.

The doctor said to us that we must not have a sexual relationship, but I did something to satisfy my husband. I applied other methods than vaginal sex for him. (Iranian mother, 31 years old, 84 days after caesarean birth, housewife)

My husband always tries to make fun of me during sex, how could I reject him? It's more because of love that I don't want to reject him. (Iranian mother, 32 years old, 53 days after caesarean birth, employee)

Yes, before giving birth I often agreed to have sex, simply because I thought I need to satisfy him as a man. Not because he would be unfaithful but because he deserves it somehow. He is so nice and kind. (Mother in Switzerland, 91 days after spontaneous birth, beautician)

Comparison to first intercourse in life

In Switzerland, some mothers compared the first sexual encounter after childbirth to their first experience of intercourse. There was no related sentiment in Iranian culture.

It is comparable to the first sexual intercourse in life. For me, it was definitely like this. The first time, I also had the feeling that something happened … It is comparable. The tissue was stretched, and it was not used to it because of the scar. (Mother in Switzerland, 35 years old, 90 days after instrument birth, physiotherapist)

Afterwards, we both said that it was like the first time (in life). (Mother in Switzerland, 28 years old, 98 days after vaginal instrument birth, social education worker)

Discussion

The present study is the first to identify differences in the sexual quality of life after childbirth in two cultures (Iranian and Swiss). The study showed the most significant differences Between the two countries were themes associated with individual factors (fear of having a child and negative feelings about being a woman), interpersonal relationships (husband’s/partner’s negative behaviour, expectations of the spouse/partner, management of marital life, and managing conflicts in marital/partnership life), and sexual life (sexual interests, negative sexual behaviours of husbands and partners, positive sexual behaviour of mothers, and comparison to first intercourse in life).

In the Iranian culture, fear of having a child was expressed for a variety of reasons. Although some Swiss mothers were concerned about the prospect of regaining their freedom in the postpartum period, Iranian mothers put more emphasis on this fear and expressed it differently. The socioeconomic and cultural conditions of the two countries appear to be responsible for the differences. Because of the economic problems associated with Iran, some Iranian mothers regarded childbearing as a betrayal. The results of a national study in Iran showed that the rate of unwillingness to have children was 68.2 per cent. The most important reasons for this unwillingness were uncertainty about the future life of the children (76.1 per cent) and concern about the increasing economic problems of having another child (71 per cent).[22] In addition, the results of a systematic review demonstrate that economic problems were repeatedly mentioned as a concern about whether or not to have more children.[23]

One of the major differences between the Iranian and Swiss cultures was the experience of and feelings associated with gender discrimination that forced mothers to undertake more responsibilities than they felt they could handle. One aspect of gender discrimination described in the Iranian culture included the area of responsibility. Another aspect was related to how decisions were made at home; many mothers reported that their husbands were more likely to assert their opinions, especially in relation to big decisions, and that wives were less likely to be involved in decision making.

Swiss mothers did not report any discriminatory attitudes towards women even though there is still a wage gap between women and men in the employment arena.[24] Although researchers are working on gender discrimination in the Iranian context in different aspects such as entrepreneurship [25] and wages,[26] it seems that gender discrimination has an ancient history in the Iranian culture. Unlike Swiss mothers, some Iranian mothers stated that their husbands’ behaviour, for example, neglect of the material needs of their wives and failure to show emotion, made them feel psychologically abused. An interpretation for this difference is that mutual responsibility and understanding of the requirements in a relationship are less accepted in the Iranian culture. According to the theory of gender-role socialisation, gender inequality is institutionalised from early childhood through the process of gender socialisation in boys and girls, and each individual, regardless of his or her personality trait, is given direction based on his or her gender towards role selection.[27]

Differences between Swiss and Iranian mothers was also evident in mothers' social self-perceptions. Although both Iranian and Swiss mothers talked about limiting their social lives after childbirth, Swiss mothers were especially concerned about returning to work. There were few quotations from Iranian mothers about returning to work. One of the reasons may be related to the smaller number of employed mothers in Iran (14 of 23) compared to the participants in Switzerland, who all worked in the paid workforce. Another reason was that there is a much longer period of maternity and paternity leave in Iran—nine and a half months.[28] In comparison, maternity leave is only 14 weeks in Switzerland.[29] One Swiss mother stated her concern about the social acceptance of not being married before the birth of her child. Even though more than a quarter of first time Swiss mothers are not married,[30] they do not feel fully accepted. In Iran, all mothers were married.

One of the concepts that was more discussed among Iranian mothers was their expectations regarding marital life and their husbands. Several Iranian mothers stated that their husbands would make decisions with their own mothers (the wife's mother-in-law). The absence of such reports in the Swiss context could be that young Swiss people usually leave home several years before starting a family. Therefore, they experience independence at an earlier stage in life and are less affected by their parents' opinions and decisions. However, people in Iran remain with their parents until marriage, and they are influenced by this family oversight in relation to their behaviour, habits, and decisions. After marriage, it takes several years for husbands to relinquish their reliance on their mothers’ opinions and for couples to make their own decisions independently. Even so, the results of a study examining the social factors affecting decision-making power in Iranian families concluded that women's decision-making in the family can be a source of power, especially when women have education, a job, and personal income.[31]

A further difference observed in the two cultures was the management of marital life as well as conflicts in this area. A significant number of Iranian mothers reported that their husbands refused to help them with housework. In contrast, reports on this issue rarely existed in the Swiss context. The difference between the two cultures could be because in Switzerland it is expected that men will do housework. Even so, there is still inequality in the distribution of domestic tasks.[32] However, in Iran, marriage is regarded as a mutual contract. Under this agreement, women are required to do housework and childcare, and men are required to manage and finance marital life.

In the Iranian culture, acceding to the husband's sexual request even if his wife (a new mother) was unwilling to have sexual intercourse, was considered positive. For some Iranian mothers, the reason they gave for compliance was love for their husband. However, accepting sexual requests without readiness was very rarely the case in the Swiss context. One member of a couple, mostly, would not initiate sexual intercourse without the desire of both partners. Rejection of the sexual demands of a male spouse in the Iranian culture is unacceptable and the new mothers prefer to always, or in most cases, give a positive response to their husband's sexual request. This difference is largely due to the cultural differences as well as the style of marriage and expectations that couples have of each other in the framework of Islamic marriage where husband and wife are supposed to provide sexual fulfilment to each other.[33] The researcher observed in the interviews that many Iranian women viewed sex as their duty—not a sexual right that should be met. In Switzerland, only one woman stated that her partner deserved sex and she agreed sometimes without her desire. Most women expect their husband or partner to wait after childbirth until they are ready. In addition, legal aspects could be another reason for this difference. In Iran, the law considers that sex occurs only within marriage and, therefore, does not address spousal rape, including in cases of forced marriage. While, in Switzerland, rape, including spousal rape, are statutory offenses for which penalties range from one to ten years in prison.

Sexual interests were another difference between the two cultures. Iranian mothers did not like non-vaginal sex, especially anal sex. Using sex toys was mentioned by some Swiss mothers, but none of the Iranian mothers mentioned using sex toys because it is not acceptable in Iranian culture. Although sex-toy use has become increasingly common in other cultures,[34] it is unacceptable in Iranian. Studies have demonstrated that sex-toy use is more prevalent among women who have diverse sexual orientations (e.g., lesbians and bisexual women)[35] while diverse sexual orientations are forbidden in the Iranian culture. Another reason for not using sex toys in Iran is the prevailing belief that sex toys are used for masturbation, which is also religiously forbidden.

A strength of our study was that we conducted interviews addressing similar topics in two countries with completely different cultures. Additionally, data analysis was accompanied by a close exchange between the researchers to find and interpret differences and explanations. Based on the nature of qualitative studies, the sample size was relatively small. However, the aim of qualitative studies is not the compilation of generalisable data but to provide an in-depth understanding of experiences and concepts.[36] Translation of interviews and data was a limitation of the study. Using three different interviewers also provided a potential limitation due to different interviewing styles and techniques.

Conclusion

Many aspects of postpartum sexual quality of life were more general than just sexual intercourse and were not limited to the bedroom. The main differences between the Swiss and Iranian postpartum sexual quality of life were related to culture. In both countries, breaking the taboo and speaking about sexuality as well as counselling after having given birth might help mothers to better adapt to their new situation. On a political level, strengthening women’s sexual and reproductive rights could improve the postpartum sexual quality of life. Further, research in different populations is needed to fully understand cultural differences in women's postpartum sexual quality of life.

Acknowledgements

We would like to thank the participating women for their time and trust in sharing their experiences with the researchers. This study was financed by Seed Money Grant from Leading House South Asia (Staatssekretariat für Bildung, Forschung und Innovation) and Iran and NIMAD (National Institute for Medical Research Development). No potential conflict of interest was reported by the authors. The study was approved by Review Boards of NIMAD (National Institute for Medical Research Development: 976748) in Iran, and the cantonal Ethics Committee of Zurich (BASEC-Nr. Req-2018-00984) in Switzerland. Interviewees received oral and written study information and gave written consent for participating in the study. German and Farsi transcripts of interviews contain sensitive data and are available on request from the authors.

Notes

[1] Mulubrhan F. Mogos, Euna M. August, Abraham A. Salinas-Miranda, Dawood H. Sultan, Hamisu M. Salihu, 'A systematic review of quality of life measures in pregnant and postpartum mothers,' Applied Research in Quality of Life 8(2) (2013): 219–50, doi: https://doi.org/10.1007/s11482-012-9188-4; Susanne Grylka-Baeschlin, Edwin Van Teijlingen, Mechthild M. Gross, 'Cultural differences in postnatal quality of life among German-speaking women—a prospective survey in two countries,' BMC pregnancy and childbirth 14(277) (2014), doi: 10.1186/1471-2393-14-277; Shahrum Vahedi, 'World Health Organization Quality-of-Life Scale (WHOQOL-BREF): Analyses of their item response theory properties based on the graded responses model,' Iranian Journal of Psychiatry 5(4) (2010): 140–53.

[2] Susanne Grylka-Baeschlin, Thorsten Meyer, Luise Lengler, Edwin Van Teijlingen, Jessica Pehlke-Milde and Mechthild M. Gross, 'Postnatal quality of life—A content analysis of qualitative results to the Mother-Generated Index,' Women and Birth 32(2) (2019): e229–37, doi: 10.1016/j.wombi.2018.06.003; Marjan Khajehei, 'Sexuality after childbirth: Gaps and needs,' World Journal of Obstetrics and Gynecology 1(2) (2012):14–16, doi: 10.5317/wjog.v1.i2.14.

[3] Susanne Grylka-Baeschlin, Azam Rahmani, Arezoo Fallahi, 'Development of a sexual quality of life scale for the postpartum period and assessment of its psychometric properties,' Research Square (forthcoming 2021): 1–16, doi: 10.21203/rs.3.rs-72226/v1.

[4] Milad Karimi and John Brazier, 'Health, health-related quality of life, and quality of life: What is the difference?' Pharmacoeconomics 34(7) (2016): 645–49, doi: 10.1007/s40273-016-0389-9.

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Published with the support of Gender and Cultural Studies, School of Culture, History and Language, College of Asia and the Pacific, The Australian National University.
URL: http://intersections.anu.edu.au/issue45/rahman_etal.html
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