Biological Forum – An International Journal 7(2): 289-295(2015)

ISSN No. (Print): 0975-1130

ISSN No. (Online): 2249-3239

The Effects of Reproductive Health Education on Girls' Premarital and

Post-Marital Needs
Bahareh Kamranpour
Ph.D. student of Reproductive Health, Faculty of Nursing and Midwifery,
Isfahan University of Medical Sciences, Isfahan, Iran.
Lecturer of Department of midwifery, Rasht Branch, Islamic Azad University, Rasht, Iran
(Corresponding author: Bahareh Kamranpour)
(Received 29 May, 2015, Accepted 15 July, 2015)
(Published by Research Trend, Website: www.researchtrend.net)
ABSTRACT: Marriage changes the nature of sexual and reproductive health needs. The lack of attention to
the varied nature of sexual and reproductive health needs in different situations would reduce the
effectiveness of educational programs. The purpose of this study is to report educational needs of young
people in the field of sexual and reproductive health and compare premarital and post-marital educational
needs.
In a cohort study in 2014, we selected 280 marriage candidates in Tehran by random stratified sampling
method. Using a researcher-made questionnaire, we investigated premarital and post-martial educational
needs in various aspects of sexual and reproductive health with Likert five-point scale. Then we analyzed the
data using SPSS v.16, t-test and paired t-test.
The mean scores of premarital and post-marital educational need were 3.56±0.95 and 3.72±0.82 respectively.
Post-martial educational need was more than pre-martial educational need, but the increase was not
statistically significant (P value = 0.096). The most important educational topic before marriage was "sexual
relation health" and after marriage was "the best physical, mental and social conditions of woman for
pregnancy".
The findings of this study suggest that appropriate educational contents should be designed and implemented
based on sexual and reproductive health needs of the young people with consideration to their cultural and
social status.
Keywords: Educational need, sexual health, reproductive health, marriage
INTRODUCTION This can be accompanied by the experiences and
opinions of other sources being aware of their health
Nowadays, one fifth of the world's population is
needs (World Health Organization 2001). Families,
between 10-19 years old, with 85% of them living in
particularly parents, can help the health team and
developing countries (Tegegn et al., 2008). Over 500
contribute to effective implementation of health
million adolescent girls live in developing countries.
promotion programs by giving their views and opinions
This part of the population plays a significant role both
(Ford et al., 2009). Health care providers are another
in the health of society and in the health of future
source whose views are of great importance in the
generations, so investment for their health is vital to the
exploration of adolescents' health needs (Mngadi et al.,
fulfillment of long-term goals (United Nations
2008, Warenius et al., 2006, Saewyc et al., 2006).
Population Fund 2009).
One of the most important needs of adolescent girls is
Iran, with 15 million adolescents, is one of the youngest
educational need on reproductive health as distinct from
countries in the world (Statistics Center of Iran 2005).
that of adults. Adolescents have difficulty obtaining
The promotion of adolescents' health calls for
reproductive health services as their attempts might be
understanding their needs, their awareness about the
prevented by adults. Compared with adults, this age
available self-care services, and their use of available
group has less information, experience and facilities for
services. Understanding the health needs of adolescents
the protection of their reproductive health (Shaw,
is crucial to the development of efficient solutions for
2009). Therefore, they are exposed to risky behaviors
prevention of risky behaviors among adolescents,
which may affect their health in adulthood. Annually,
provision of self-care services to them, and promotion
2.5 million unsafe abortions occur among adolescents,
of their health which in turn promotes the health of
which is one of the major causes of death among them.
society. The first step in investigating the health needs
Also, the age group of 15-19 constitutes the most
of adolescents is to explore their health priorities from
prevalent sexually-transmitted diseases such as HIV
their own viewpoints.
(World Health Organization 2006, 2009).
 Kamranpour 290
Despite the emphasis of World Health Organization on reliability of the questionnaire, we used reference
the provision of reproductive health services needed by books, questionnaires used in similar studies, and views
adolescents and promotion of adolescent friendly of experts, specialists and faculty members. To assess
services, such needs have not been satisfied in many the validity, we delivered the questionnaire to four
points of the world (International Conference on midwifery experts with at least three years of
Population and Development 1994). experience in family health affairs asking them to
Investigation of Iranian centers providing reproductive determine the validity of form and content. Content
health services to adolescents indicates that these validity index was 0.79 (CVI). To assess the reliability,
centers are in medium-to-low level in terms of we delivered the questionnaire to 20 females and 20
standards and instructions of World Health males and investigated internal consistency of the
Organization (Ramezanzadeh et al 2010). questionnaire by two methods of Cronbach's Alpha and
Reproductive health services needed by adolescents in splitting the questions. In Cronbach's Alpha method, an
various cultural, social and economic contexts of the alpha coefficient of 0.97 was obtained. In the method of
societies may be defined and prioritized in different splitting, the questions were divided into even and odd
ways (Asadi-Lari et al., 2003, Bennett and Tonkin questions and Spearman correlation coefficient of 0.96
2003). The existing information suggests that there has was obtained.
not been a deep and comprehensive understanding of We analyzed the data using SPSS v.16. In order to
reproductive health services needed by adolescent girls determine the amount of educational need, we
in Iran. Therefore, it is necessary to make a deeper computed mean scores of need feeling for each topic
investigation about what Iranian adolescents conceive and compared the means in each topic before and after
as the needed reproductive health services. The existing marriage. To determine and compare the amount of
gap in this connection and the big share of adolescents educational need for sexual and reproductive health
in Iran's population make it essential to conduct such before and after marriage, we added up need feeling
studies. In this study, we explore the structure of scores in each topic and then computed the mean score.
reproductive health services needed by adolescent girls We compared the means between two sexual groups
using qualitative research method, which gives a rich using independent t-test and compared the means
description and deep understanding of human between two time periods using paired t-test. P-value
phenomena and experiences (Burns et al., 2003). The was set on less than 0.05. From the whole samples, 61
purpose of this study was to determine the concept and people (52.1%) were single and 56 people (47%) were
mental structure of reproductive health services from married. The mean and standard deviation of age in
the viewpoint of Iranian adolescent girls. males was 3.00±27.70 and in females was 3.82±23.96.
57.4% of singles and 82.1% of married participants had
RESEARCH METHOD
academic degrees. Singles had a monthly income
After obtaining scientific and ethical confirmation from between 500,000-1,000,000 Toman, but most of
Tehran University of Medical Sciences, we conducted married participants had no income.
this cohort study in 2014 on the participants in pre-
FINDINGS
marriage counseling program before and after marriage.
Using randomized stratified sampling method, we The young women believed that the ideal number of
selected the samples in different days in pre-marriage children was 2, and there was no significant difference
and post-marriage groups from among single people between pre-marriage and post-marriage attitudes in
with the ability of reading and writing. 280 people were this respect (p=0.948). Most of the participants believed
selected before participation in pre-marriage counseling that the decision for having a child rests with both
program and were given the questionnaire. 200 people husband and wife, and there was no significant
in pre-marriage group and 200 people in post-marriage difference between pre-marriage and post-marriage
group agreed to be followed up six months later. attitudes in this connection (p=0.150). Most of the
Generally, questionnaires were completed via telephone participants believed that the decision for using
by a questioner of the same sex for 190 people before contraception methods rests with both husband and
marriage and 90 people after marriage and finally 280 wife, and there was no significant difference between
questionnaires were analyzed. pre-marriage and post-marriage attitudes (p=0.149).
We collected the data using a researcher-made Table 1 contains the amount of educational need to
questionnaire consisting of two parts: the first part each educational heading.
contained questions about social and individual Pre-marriage and post-marriage attitudes regarding the
characteristics and the second part embraced 11 most appropriate educational method shows a
educational topics concerning sexual and reproductive significant difference (p = 0.000) (Figure 1). But pre-
health. The samples were asked to express to what marriage and post-marriage attitudes regarding
extent they needed education in each topic based on educational courses which are being held in the
Likert five-point scale (ranging from 1, i.e. very low, to province does not show a significant difference (p =
5, i.e. very high). To determine the validity and 0.799).
 Kamranpour 291
Table 1: Relative frequency distribution of educational need scores of young women with respect to
reproductive health and sexual problems.
Question Unaware Average Aware
Reproductive system 33.9 45.0 21
Menstruation and intercourse health 28.4 37.7 33.9
Pregnancy and development of fetus 21.4 34.8 43.8
Emergency contraception method 42.1 26.9 31.1
Contraception methods 35.2 35.6 29.2
Contraception tools 38.7 31.3 30.0
Sexually-transmitted diseases and prevention methods 22.7 28.3 49.0
Risky and unwanted pregnancies and their consequences 19.8 25.0 55.3
Congenital diseases and prevention methods 16.7 25.0 58.9
Prevalent cancers prevention methods before and after marriage 18.4 22.9 58.7
Prevalent disorders in sexual relations 17.9 31.3 50.9
Necessary preparedness before sexual, psychological and 34.4 28.8 36.9
environmental relations
Sexual arousal methods 37.9 28.1 34.0
Sexual relation and intercourse 37.5 29.0 33.5
Sexual satisfaction 39 26.3 34.8

70
60
50
40
Before marriage 30
After marriage 20
10
0
internet multimedia journal Educational
class

Fig. 1. The most effective educational method from the viewpoint of young women.
54

52

50

48

46

44

42

40
Primary school middle school secondary school university
schoo completion
diploma

Fig. 2. Educational need and educational level.

There was a significant difference between pre- that educational packages were more appropriate. The
marriage and post-marriage attitudes regarding mean scores of educational need indicated there was no
educational packages distributed in pre-marriage significant difference between educational need before
counseling classes (P-0.000). The participants believed and after marriage (P-0.075).
 Kamranpour 292
There was a significant difference between educational We also investigated other educational needs of young
need of the people with different occupations (P-0.000). women. 65% of women believed that educational
Those who worked in home and unskilled workers materials were sufficient and 10% requested for more
needed more education. The results suggested that the materials about sexual relations. There was a significant
lower the age of marriage, the more education is difference between the amount of other educational
needed. However, the difference was not statistically needs among young women before and after marriage
significant (P-0.318). Rural women needed more (P-0.000).
education than urban women did and the difference was
statistically significant (P-0.000).

40

35

30

25

20

15

10

0
Metropolis center of city rural area district
province

Fig. 3. Educational need and residence place.

Table 2: Comparison of means of sexual and reproductive health educational need before and after marriage.
Before marriage P value (Independent t- After marriage P value (Independent t-

test) test)

3.50±1.03 0.266 3.66±0.87 0.490

DISCUSSION AND CONCLUSION

health is lower than this research. As regards the
In this study, we investigated educational need among pregnancy and development of fetus, 43.8% of young
the young women in various topics. The results women chose "high" and "very high". This indicates
indicated that most of young women needed education that there is more educational need on this topic. The
on reproductive system before and after marriage. 66% occurrence of pregnancy when a woman is not
of the participants stated that they needed such physically, mentally, socially and even financially
educations at medium, high and very high level. In the ready to become pregnant can cause many problems for
study of Aghdak and coworkers, educational need on both woman and her child. Education of girls,
reproductive system before and after marriage is lower particularly pre-marriage education, is one of the ways
than this research and is among the last priorities for preventing such problems (Moodi and Sharifzadeh
(Aghdak et al., 2009). With regard to educational need 2008).
on menstruation and intercourse health, 28.4% of the Educational need on contraception methods was in a
participants chose "law" and "very low" and 33.9% low level. In the question regarding emergency
chose "high" and "very high". In the study of Davoud contraception method, 42.1% of the participants chose
Pourmarzi and coworkers, educational need on this "low" and "very low". Also, educational need on
topic has been reported to be in medium level various contraception methods was in a low level. In
(Pourmarzi, Rimaz et al. 2013). In the study of Aghdak this question, only 29.2% of the participants chose
and coworkers, educational need on menstruation "high" and "very high".
 Kamranpour 293
Educational need on appropriate contraception tools at of prevalent cancers showed that there was no
the beginning of marriage was also in low level, significant difference between two groups before and
because only 30% of participants chose "high" and after marriage (Davazdahemami et al., 2004).
"very high". This indicates that pre-marriage Educational need on prevalent disorders in sexual
educational classes might have dealt with this issue relations was in a high level as 17.9% of the
more than other topics. In the question regarding participants chose "low" and "very low", while 50.9%
educational need on sexually-transmitted diseases and chose "high" and "very high". This item is the fourth
prevention methods, 22.7% of the participants chose priority of educational needs. In the study of Davoud
"low" and "very low", while 49% chose "high" and Pourmarzi, the item of "prevalent disorders in sexual
"very high". This indicates that young women need relations and their treatment" was the fourth priority in
more education on this subject. Annually, over 8 billion post-marriage period. In the study of Aghdak, this item
dollars is spent for diagnosis and treatment of sexually- was the seventh priority between 21 topics. In the
transmitted diseases (Eng and Butler 1997). It seems section of necessary preparedness before sexual
that young couples are the best target population for relations (mental and environmental preparedness),
beginning the activities regarding prevention of 36.9% of the participants chose "high" and "very high".
sexually-transmitted diseases, because, considering the Therefore, education need on this topic is in medium
culture of our society, most of young people do not level.
receive proper and comprehensive education on disease With regard to sexual arousal, 37.9% of the participants
prevention methods from parents and schools until the chose "low" and "very low", while 34.0% chose "high"
age of marriage (Mir et al. 2006). and "very high". In the question on sexual relations and
The results indicate that educational need on risky and intercourse, 5.37% of the participants chose "low" and
unwanted pregnancies and their consequences is in very "very low", while 33.5% chose "high" and "very high".
high level. In the question concerning this issue, 19.8% In a study conducted in Egypt, sexual relations was the
of the participants chose "low" and "very low", while most important subject to newly-married young people
55.3% chose "high" and "very high. Therefore, this (Tahseen Project 2004). With regard to educational
item is the third priority of educational needs. In the need on sexual satisfaction, 39% of the participants
study of Davoud Pourmarzi and coworkers, educational chose "low" and "very low" and 34.8% chose "high"
need on "risky and unwanted pregnancies" is the second and "very high". Since sexual satisfaction is one of the
priority in post-marriage period. This indicates that this main goals of marriage, education on sexual relation
item should be paid special attention in educational and promotion of people's knowledge at the beginning
courses. The results indicated that educational need on of marital life will enhance the happiness of young
congenital diseases and prevention ways was in a very people (Pakgohar et al. 2005, Farnam et al., 2011).
high level. In the question on this topic, 16.1% of the Regarding the most appropriate educational package,
participants chose "low" and "very low", while 58.9% the participants gave different answers and there was a
chose "high" and "very high". This indicates that this significant difference between the groups before and
item should be the first priority in educational after marriage (p-0.000). Compared with males,
programs. Unfortunately, this topic is not sufficiently females were more willing to participate in educational
dealt with in pre-marriage counseling programs. In the classes. Also, females mostly preferred educational
study of Davoud Pourmarzi, "congenital diseases and books while men preferred educational CDs. In the
prevention ways" is the third priority in post-marriage investigation about appropriateness of information
period. At present, congenital diseases is the third cause provided in pre-marriage counseling centers, 40.2% of
of mortality and disability of children in developed the participants believed the classes were appropriate.
countries. The major congenital malformations exist in Also, there was no significant difference between the
2-3% of infants. This rate increases by about 3% until attitudes before and after marriage (p-0.799). In the
the age of five and reaches 8% in the age of 18. Minor study of Pakgohar, the women in control group who
congenital disorders exist in about 15% of infants. In had received ordinary consultation of health centers
general, congenital malformations cause one firth of evaluated the quality of classes to be in medium level.
mortalities among infant (Dastgerdi S. Congenital In the study of Shahin Salarvand, 59% of females and
malformations. Hatami et al., 2006). 55.8% of males evaluated the educational contents to be
Educational need on prevention of prevalent cancers in good level (Salarvand and Bahri 2012). There was a
before and after marriage was in a very high level. significant difference between pre-marriage and post-
18.4% of the participants chose "low" and "very low", marriage attitudes concerning educational packages
while 58.7% chose "high" and "very high". This item is distributed in counseling centers (p-0.000). Compared
the second priority in our study and needs to be paid with males, females were more willing to receive
more attention. educational packages.
In the study of Sharareh Davazdah Emami and As regards the educational level, the mean scores
coworkers under title of "comparison of educational indicated that people with lower educational level
needs before and after marriage" which was conducted needed more education. There was a significant
in Mollahadi pre-marriage counseling center of Esfahan difference between groups with different educational
in 2004, mean scores of educational need on prevention levels (p-0.000).
 Kamranpour 294
In the study of Aghdak and coworkers, the more sexually-transmitted diseases and prevention ways, and
educated men needed more education, while educated pregnancy and development of fetus. It is recommended
women needed less education. With regard sex, the that females be provided with educational books and
mean score of educational need indicated that there was males be provided with educational CDs. Premarital
no significant difference between educational need and post-marital educational packages should be
before and after marriage (p-0.075). In the study of prepared and distributed separately. People with lower
Davoud Pourmarzi, females needed more education educational level need more education, so post-
than males did, but the difference was not statistically marriage complementary classes should be held for
significant. In other study, there was a significant such people. Rural people also need more education, so
difference between educational need before and after complementary classes should also be held for them.
marriage. Pre-marriage counselors should be aware of these needs
With regard to occupation, the mean score of and prepare appropriate educational programs and
educational need indicated that those who worked in equipment accordingly. One of the limitations is this
home needed more education. Unskilled workers, study was the inaccessibility of some participants due to
housewives and self-employed people were in the next change of their residence place and telephone number.
position. There was a significant difference between In such cases we used replacement method to complete
educational needs among people with different the sample size.
occupations (p-0.000). In the study of Aghdak and
REFERENCE
coworkers, there is a significant relationship between
educational need and occupation of women (p<0.001) Aghdak P, Majlessi F, Zeraati H, et al. Reproductive health
and men (p<0.05). The mean score of educational need and educational needs among pre-marriage couples.
indicated that people who marry in lower age needed Payesh 2009; 8(4): 379-85.[Persian]
more education, but the difference was not significant Asadi-Lari M, Packham C, Gray D. Need for redefining
needs. Health and Quality of Life Outcomes 2003; 1:
(p-0.318). In the study of Khousheh Khaleghinejad
34-8
under title of "pre-marital educational needs from the Bennett DL ,Tonkin RS. International developments in
viewpoint of women referring to health centers of adolescent's health care: a study of advocacy and
Mashhad", educational need in all aspects in both males achievement. Journal of Adolescent Health 2003; 33:
and females is above medium level and there is no 240-251
significant difference between pre-marital and post- Burns N, Grove SK. The practice of nursing research
martial educational need. Relation with spouse and conduct: critique and utilization. W.B. Saunders:
mental health were most needed educational topics in Philadelphi, 2002.
both groups. Also, both groups were willing to Dastgerdi S. Congenital malformations. Hatami H, Razavi
SM, Eftekhar Ardabili H, Majlesi F, Seyed nozadi M,
participate in educational sessions (Khaleghinejad et
Parizadeh SM, edirors. Textbook of Public Health.
al., 2008). As regards residence place, mean score of Vol. 3. 1st, Tehran: Arjmand Publication; 2006.
educational need indicated that rural women needed 1223-31. [Persian].
more education than urban women did. This difference Davazdahemami Sh, Ghasemi S, Ehsanpour S. Comparison
was statistically significant (p-0.000). In the study of of premarital educational needs among would be
Aghdak and coworkers, there is no significant spouses in Molahady center. Iranian Journal of
difference between educational needs among urban and Nursing and Midwifery Research 2004; 29: 33-
rural people. 41.[Persian]
According to the results of this study, young women Eng TR, Butler WT. The Hidden Epidemic: Confronting
Sexually Transmitted Diseases 1st ed. The Institute of
believed that the educational classes are useful to some
Medicine Washington DC: National Academies
extent. But certain topics have not been sufficiently Press; 1997.
dealt with in such classes. To solve this problem, Farnam F, Pakgohar M, Mir-mohammadali M. Effect of pre-
appropriate educational texts should be prepared and marital counseling on marital satisfaction of Iranian
provided in complementary classes. For example, newlywed couples, a randomized controlled trial.
counseling classes have been successful in the Sexuality & Culture 2011; 15: 141-52.
education of contraception methods, but have not Ford CA, Davenport AF, Miere A, McRee AL. Parents and
managed to meet the needs of participants in other health care professionals working together to improve
subjects. Therefore, designing educational contents adolescent health: The perspectives of parents.
Journal of Adolescent Health 2009; 442: 191-94.
based on educational needs may be an effective step in
International Conference on Population and Development.
line with meeting educational needs of young women in Programme of Action of the International Conference
the field of sexual and reproductive health. According on Population and Development. 1994. UNFPA, New
to our results, educational priorities are: congenital York. www.unfpa.org/public/publications/pid/1973,
diseases and prevention ways, premarital and post- Accessed 20 March 2009.
martial prevalent cancers, risky and unwanted
pregnancies, prevalent disorders in sexual relations,
 Kamranpour 295
Khaleghinejad K, Abbaspour Z, Afshari P, Attari Y, Rasekh Simbar M, Rmezaani Tehrani F, Hashemi Z. Sexual-
A. Educational needs in premarital counseling: reproductive health belief model of college students
viewpoints of couples referring to health care centers 2004. Iranian South Medical Journal; 4: 70-8
in Mashhad. Iranian J Med Educat 2008; 8(2): 247- (Persian)
52.[Persian] Statistics Center of Iran. 2005; Annual book of statistics.
Mngadi PT, Faxelied E, Zwane IT, Hojer B, Ransjo Arvidson Tehran, Iran(Persian). Available from:URL:
AB. Health providers' perceptions of adolescent http://amar.sci.org.ir/index_e.aspx , Accessed 16 June
sexual and reproductive health care in Swaziland. 2009
International Nursing Review 2008; 55:148-55 Streubert HJ, Carpenter DR. Qualitative research in nursing
Moodi M, Sharifzadeh GHR. The effect of instruction on advancing the Humanistic Imperative. 3st Edition,
knowledge and attitude of couples attending Lippincott Williams& Wilkins: Philadelphia, 2003
premarriage consolation classes. J Birjand Univ Med Tahseen Project. Reproductive health services for young
Sci 2008; 15(3): 32-40.[Persian] engaged and newly married couples. United States
Pakgohar M, Mirmohammadalaei M, Mahmodi M, et al. Agency for International Development; 2004.
Assessing effect consulting before marrige on sexual Tegegn A, Yazachew M, Gelaw Y. Reproductive health
health of couple's reffering to Tehran University of knowledge and attitude among adolescents: a
Medical Sciences. Hayat 2005; 11(3-4):39- community based study in Jimma Town, Southwest
46.[Persian] Ethiopia. Ethiopian Journal of Health Development
Pourmarzi D, Rimaz Sh, Al-sadat Merghati Khoii E, et al. 2008; 223: 243-51
Comparative survey of youth's sexual and United Nations Population Fund .2009; Available from:
reproductive health educational needs in two stages URL: http :// www .unfpa . org
before and after marriage, Tehran 2011.Razi J /adolescents/girls.htm, Accessed 20 March 2009
MedSci 2013; 20(106):30-9. Warenius LU, Faxelied EA, Chishimba PN, Musandu JO,
Ramezanzadeh F, Haghollahi F, Shariat M, Mahmood Arabi Ongany AA, Nissen EBM. Nurse-midwives' attitudes
M, Hosseini H, Jaafar Abadi M and et al. towards adolescent sexual and reproductive health
Reproductive health services centers for youth in needs in Kenya and Zambia. Reproductive Health
Iran. Journal of School of Public Health and Matters 2006; 427:119-28
Reasearchs 2010; 7: 1-10 (Persian) World Health Organization 2006. Pregnant adolescents:
Saewyc E M, Bearinger LH, McMahon G, Evans T.A delivering on global promises of hope. Geneva:
national needs assessment of nurses providing health WHO. Available at:http :// whqlibdoc .Who.int/
care to adolescents. Journal of Professional Nusring publication. Accessed November 4, 2008
2006; 225: 304-13 World Health Organization 2009. http: //www .who.int/child
Salarvand SH, Bahri NA, Pournia YA.Young client _adolescent
satisfaction with the quality of premarital family _health/topics/prevention_care/adolescent/en/index.ht
planning counseling services. Middle East Journal of m, Accessed 20 March 2009
Nursing 2012; 6(4): 13-18. World Health Organization. Giving adolescents a voice:
Shaw D. Access to sexual and reproductive health for young conducting a rapid assessment of adolescents health
people:bridging the disconnect between rights and needs. WHO:Geneva,2001.
reality. International Journal of Gynecology and
Obstetrics 2009;106: 132-36.