Sexuality in Pregnancy: New Approaches to Effective Patient Education

Pregnancy is a complex period of changing self-image and body transformation. These profound emotional, psychological, and emotional changes can greatly affect the sexual health of pregnant women and their partners. Despite these profound changes, many women do not mention or receive any counseling from their obstetric care providers on this topic. This lack of discussion is due to identified patient, provider and system barriers that include time constraints, embarrassment, shame, and lack of knowledge. The lack of communication leaves women turning to non-evidence based forms of anecdotal or online education that can serve to perpetuate incorrect information, fears, and myths on sexual activity in pregnancy. Current research suggests that a majority of Americans go to the internet as a primary source of health information, and innovative patient education tools should see this as an opportunity to increase health promotion and literacy. The use of new and widely accessible forms of online patient education should be created to provide information that is not only evidence-based, but free of cost, easily accessible, and can serve as a starting point for patients and providers to open the conversation on sexuality in pregnancy. The goal of this scholarly project was to address the lack of communication about sexuality in pregnancy between patients and providers by developing comprehensive, standardized patient education tools that are available online. Initially, a thorough literature review was completed to determine the current standards of practice and identify current gaps in research and patient education on sexuality and sexual health in pregnancy. To increase patient education, a podcast was recorded on sexuality in pregnancy in collaboration with a local mental health treatment center. This podcast is available free of cost through multiple platforms online. In addition, a patient education handout was drafted for future submission to the American College of Nurse Midwives (ACNM) "Share with Women" patient education series. This aligns with the 2008 U.S. Department of Health and Human Services suggestion that health care provider organizations should step up in distributing understandable materials for their members to use with their patients and families to promote universal access to health information. To evaluate the effectiveness of the developed patient education tools, a recorded focus group discussion with pregnant and postpartum women took place. The tools were modified based on participant feedback. The patient education handout was then submitted for publication and national dissemination within the Journal of Midwifery and Women's Health (JMWH). After publishing, this patient handout will be available online and free of cost to allow providers and patients to view, print, and disseminate. The knowledge gained through this project will then be further disseminated at a local ACNM chapter meeting. In summary, although providers are aware of changes to sexuality in pregnancy and have an understanding of possible counseling points, we are not communicating this to women to normalize and assuage fears. Allowing this deficiency to persist would effectively be neglecting to address an entire aspect on the health continuum.

Running Head: SEXUALITY IN PREGNANCY Sexuality in Pregnancy: New Approaches to Effective Patient Education Paige Miller, RN, BSN, SNM/SWHNP University of Utah In partial fulfillment of the requirements for the Doctor of Nursing Practice 1 SEXUALITY IN PREGNANCY 2 Executive Summary Pregnancy is a complex period of changing self-image and body transformation. These profound emotional, psychological, and emotional changes can greatly affect the sexual health of pregnant women and their partners. Despite these profound changes, many women do not mention or receive any counseling from their obstetric care providers on this topic. This lack of discussion is due to identified patient, provider and system barriers that include time constraints, embarrassment, shame, and lack of knowledge. The lack of communication leaves women turning to non-evidence based forms of anecdotal or online education that can serve to perpetuate incorrect information, fears, and myths on sexual activity in pregnancy. Current research suggests that a majority of Americans go to the internet as a primary source of health information, and innovative patient education tools should see this as an opportunity to increase health promotion and literacy. The use of new and widely accessible forms of online patient education should be created to provide information that is not only evidence-based, but free of cost, easily accessible, and can serve as a starting point for patients and providers to open the conversation on sexuality in pregnancy. The goal of this scholarly project was to address the lack of communication about sexuality in pregnancy between patients and providers by developing comprehensive, standardized patient education tools that are available online. Initially, a thorough literature review was completed to determine the current standards of practice and identify current gaps in research and patient education on sexuality and sexual health in pregnancy. To increase patient education, a podcast was recorded on sexuality in pregnancy in collaboration with a local mental health treatment center. This podcast is available free of cost through multiple platforms online. In addition, a patient education handout was drafted for future submission to the American College of Nurse Midwives (ACNM) "Share with Women" patient education series. This aligns with the 2008 U.S. Department of Health and Human Services suggestion that health care provider organizations should step up in distributing understandable materials for their members to use with their patients and families to promote universal access to health information. To evaluate the effectiveness of the developed patient education tools, a recorded focus group discussion with pregnant and postpartum women took place. The tools were modified based on participant feedback. The patient education handout was then submitted for publication and national dissemination within the Journal of Midwifery and Women's Health (JMWH). After publishing, this patient handout will be available online and free of cost to allow providers and patients to view, print, and disseminate. The knowledge gained through this project will then be further disseminated at a local ACNM chapter meeting. In summary, although providers are aware of changes to sexuality in pregnancy and have an understanding of possible counseling points, we are not communicating this to women to normalize and assuage fears. Allowing this deficiency to persist would effectively be neglecting to address an entire aspect on the health continuum. This project was overseen by project chairs Amanda Al-Khudairi, DNP, WHNP-C, and Diane Chapman, DNP, FNP-C; specialty track director Gwen Latendresse, PhD, CNM, FACNM, and assistant dean of MS and DNP programs, Pam Hardin, PhD, RN. Additional assistance was provided by content experts Andrew Black, PhD, MBA, MSHI, and Julie Jones, CNM, and licensed medical sex counselor. Braxton Duxton, CSW, with The Healing Group, and Frances E. Likis, DrPH, NP, CNM, FACNM, FAAN, with JMWH also helped collaborate on this project. SEXUALITY IN PREGNANCY 3 Table of Contents Executive Summary ........................................................................................................................ 2 Table of Contents ............................................................................................................................ 3 Acknowledgements .........................................................................................................................4 Problem Statement .......................................................................................................................... 5 Clinical Significance ....................................................................................................................... 6 Objectives ....................................................................................................................................... 8 Literature Review............................................................................................................................ 9 Female Sexual Dysfunction ................................................................................................ 9 Female Sexual Dysfunction Disorders.............................................................................. 10 Sexual Function in Pregnancy .......................................................................................... 11 Physical and Hormonal Changes ...................................................................................... 12 Psychological and Emotional Changes ............................................................................. 13 Absolute and Relative Contraindications ......................................................................... 15 Barriers in Current Practice .............................................................................................. 15 Strategies for Communication .......................................................................................... 16 Implementation to Practice ............................................................................................... 16 Patient Education .............................................................................................................. 17 Andragogy and Adult Learning Theory............................................................................ 20 Share with Women............................................................................................................ 21 Podcasting ......................................................................................................................... 22 Selected Theoretical Framework .................................................................................................. 23 Implementation and Evaluation Plan ............................................................................................ 24 Results ............................................................................................................................................27 Future Recommendations ............................................................................................................ 29 DNP Essentials ..............................................................................................................................30 Conclusions ....................................................................................................................................31 References ..................................................................................................................................... 33 Appendices .....................................................................................................................................37 SEXUALITY IN PREGNANCY 4 Acknowledgements I would like to thank my husband, Ty, who has supported me through this long journey from Cameroon all the way to my doctorate. I would never have been able to accomplish my dreams without your support, love, patience, and guidance through every step. I would like to thank my family, who have also been my greatest cheerleaders. Next, I would like to thank my project chairs, Amanda Al-Khudari and Diane Chapman, for their guidance and help along the way. A big shout out to my content experts, Julie Jones and Andrew Black, who met with me to contribute their expertise on relevant topics. Lastly, thanks to Braxton Duston, for making my podcast possible and Frances Likis, for agreeing that sexuality in pregnancy belongs in "Share with Women." SEXUALITY IN PREGNANCY 5 Problem Statement Sexual health is not defined as merely the absence of sexual dysfunction or disease. According to the current World Health Organization (2016) definition, sexual health is: a state of physical, emotional, mental and social well-being in relation to sexuality…Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled (para 3). Current research has demonstrated a 60% prevalence of reduced sexual interest and enjoyment during pregnancy (Zaksek, 2016). Similarly, qualitative reports show a decrease in sexual frequency during pregnancy in 71% of surveyed women (Murtagh, 2010). This shift in sexual health can present a crisis to the individual and can affect future sexual and marital bonds within the partnership. Healthy sexual functioning in pregnancy can ease the transition to parenthood (Zaksek, 2016). While these sexual health changes in pregnancy are not pathological, they do warrant anticipatory guidance and provider counseling to promote overall sexual health. Sexual health and sexuality are difficult topics for patients to discuss with providers due to feelings of embarrassment and insecurity. Many women fear that sexual activity could cause adverse pregnancy outcomes. Despite profound changes to sexual wellness in this transitional life stage, less than 30% women report having received information about sexual function in pregnancy from their providers (Johnson, 2011). The deficiency in conversation between providers and patients on this topic leaves women turning to the internet, friends, or the media SEXUALITY IN PREGNANCY 6 for information. The information gained from these varied resources can serve to perpetuate myths and potentially have an adverse effect on the sexual health of women. Personal clinical rotations within a local midwifery practice group have demonstrated a clear lack of sexual health education in pregnancy. Possible identified barriers include provider comfort, provider experience, and time constraints. In an aim to improve patient knowledge and open the conversation about sexuality in pregnancy, novel approaches to patient education should be utilized. This project aims to use widely available, free of cost platforms to develop patient education on sexuality in pregnancy that can be disseminated to a wide audience both online and in the clinic setting. The use of online technologies helps ensure patient access to evidence-based health information, regardless of whether their provider is involved or not. Clinical Significance The significance of this problem is broad-reaching and improvement in patient education on this topic has the potential to reach a large audience. The availability of a printable handout could provide a useful tool to encourage providers to bring the topic of sexuality in pregnancy up during regular prenatal care visits. Improving sexual health and well-being during the pregnancy has the potential to translate to long-lasting stability in the sexual health relationship. Current research supports the high prevalence of sexual changes in pregnancy and the surprising lack of information women receive on this topic. In one study, only 35.7% of women received any information on sex in pregnancy, with only 23.5% of the information coming from a healthcare provider (Erenel, Eroglu, Vural, & Dilbaz, 2011). Although we are aware of changes in sexual desire and frequency in each trimester, nurse midwives are not communicating this to women to normalize and assuage fears. The availability of a printable handout could provide a useful tool SEXUALITY IN PREGNANCY 7 to encourage providers to bring the topic of sexuality in pregnancy up during regular prenatal care visits. As providers, allowing this deficiency to persist would effectively be neglecting to address an entire aspect on the health continuum. Not addressing sexual health and relationships can affect not only the individual, but the partnership both during and after the pregnancy. As Foux (2008) states, "women who were more satisfied with their relationship reported higher sexual satisfaction, were more positive about their anticipated mother role and experienced fewer fatigue and depressive symptoms" (p. 275). The clinical implications for addressing sexual health in this transitional life period can extend and promote physical, emotional and mental health throughout the lifespan. The "Share with Women" series is an educational series published through ACNM's professional journal, the Journal of Midwifery and Women's Health (JMWH). These articles are intended for consumers with the intent that they can be copied, distributed, and shared without permission. They are available online and can be found through a topic-based internet search. Although there is currently an article titled "Sexual Health and Sexual Dysfunction", the article does not address specific changes, suggestions, and precautions in pregnancy. We are currently in the midst of what some call a "podcast revolution" (Shapiro & Dean, 2014). We have already seen the advent of health and medicine podcasting with participation from venerable institutions such as Johns Hopkins and Harvard Medical school. This novel form of communication is primed to be a platform to increase patient education. There are currently three podcasts on sexuality in pregnancy, ranging from discussions by holistic healers to ACOGcertified obstetricians. Although podcasting has the potential to become a major form of online SEXUALITY IN PREGNANCY 8 patient education, care needs to be provided in recommending only evidence-based information to patients. This project has the potential to impact a large population of women's health care providers and their patients through collaboration with the national professional organization, The American College of Nurse-Midwives (ACNM). Identified stakeholders within the proposed project include: − The ACNM as an organization − The JMWH as a publication − Certified nurse-midwives − Patients who see midwives during pregnancy (and by extension, their partners) − Individuals who seek information about sexual health in pregnancy online. Objectives The primary goal of this scholarly project is to develop comprehensive, standardized, evidence-based patient education tools using emerging technologies on the topic of sexuality in pregnancy to address the lack of communication between patient and providers in the antepartum period. The following five objectives serve to meet this goal: 1. Determine the current standards of practice by conducting a thorough literature review to identify gaps in research and patient education on sexuality and sexual health in pregnancy. 2. Develop a patient education handout on sexuality and sexual health in pregnancy in collaboration with The Journal of Midwifery and Women's Health. 3. Develop and record a podcast on sexuality in pregnancy in collaboration with local mental health clinic. SEXUALITY IN PREGNANCY 9 4. Evaluate the effectiveness of the developed patient education tools through a recorded focus group discussion with 6-10 pregnant or postpartum women. 5. Disseminate patient information on sexuality in pregnancy through publication and a poster presentation. Literature Review A literature review on sexuality and pregnancy was conducted through the PubMed and CINAHL databases. The search terms of "sexuality IN pregnancy" and "sexuality AND pregnancy" were used to find relevant journal articles. To discover articles on patient education and learning theory, search terms included "effective patient education" and "adult learning theory." Date filters were set to include only articles within the past 10 years, with a preference for articles in the past five years. In addition, the only articles that were included were those that had a full text available through the databases accessed within the University of Utah Spencer S. Eccles Health Sciences Library. Female sexuality is characterized by a complex interplay of psychologic, biologic, emotional, social, personal, and cultural factors (Murtagh, 2010). Changes to sexuality in pregnancy are also characterized by changes in the aforementioned domains. Despite these significant changes, the majority of pregnant women do not currently receive information about sexual health in pregnancy from their providers. A meta-analysis of 59 studies from 1960 to 1996 on sexuality in pregnancy highlighted that 68% of primigravid women never received communication about sexuality throughout the course of their pregnancy (Murtagh, 2010). This is echoed in additional qualitative research conducted in Turkey where only 35.7% of women had received information on sex during their pregnancy, with 5.7% of this group receiving information from media sources only (Erenel, Eroglu, Vural, & Dilbaz, 2011). This SEXUALITY IN PREGNANCY 10 demonstrated deficit in provider-initiated conversation about sex in pregnancy perpetuates fears and myths, and can have lasting implications on the overall health of the woman and her relationship. A model of patient education about sex in pregnancy can help promote sexual health in this transitional life period that then extends to physical, emotional, and mental health throughout the lifespan. Female sexual function Female sexual function varies greatly and has complex relationships with the biology, culture, psychology, society, and person of the individual. There is a wide spectrum of normal female function. Historically, female sexual response was viewed similarly to men's as a linear progression. The more recent model of female sexuality by Rosemary Basson incorporates psychosocial issues and demonstrates a model that is more complex and circular (Murtagh, 2010; Association of Reproductive Healthcare Professionals [ARHP], 2008). The model involves a complex interplay of spontaneous sexual drive, sexual stimuli, sexual arousal, emotional intimacy, and relationship satisfaction that all contribute to the female sexual response. Understanding this model of female sexuality is important to the discussion of sexuality in pregnancy as there are common changes during pregnancy in all aspects of the cycle. Female sexual dysfunction disorders A brief overview of female sexual dysfunction disorders lends further insight into sexual function in pregnancy. Generally, there are four main categories of female sexual dysfunction including arousal disorder, desire disorder, orgasmic disorder, and dyspareunia (Murtagh, 2010). Arousal disorders can include situations in which there is a lack of physical arousal sensation, subjective arousal, or both. Additionally, persistent arousal is categorized here. Desire or interest disorders are characterized by a lack of desire or interest prior to or during the sexual SEXUALITY IN PREGNANCY 11 encounter. Orgasmic disorder can occur as a primary disorder in which an orgasm cannot be achieved in the presence of arousal and desire, or a secondary disorder in which arousal or desire are the primary disorder. Dyspareunia is defined as pelvic or vaginal pain and can have a variety of differential diagnoses. Dyspareunia can be without organic pathology, or occur secondary to a medical illness. Women can be more at risk for sexual dysfunction disorders based on age, medical history, current medications, and lifestyle (Murtagh, 2010). The understanding of these disorders is important in the conversation of sexuality in pregnancy, as it would be important for the provider to assess whether the complaint during pregnancy is novel or existed prior to pregnancy. Sexual function in pregnancy Pregnancy is separated into three trimesters, each around 13-14 weeks in length. The body of research on sex in pregnancy is in agreement that with increasing gestational age the frequency of sexual intercourse declines. A retrospective pilot study in Turkey determined through questionnaire that only 5.1% of women did not have intercourse in the first trimester of pregnancy. This percentage increased to 13.4% in the second trimester, and again sharply to 58.6% in the third trimester (Erenel et al., 2011). With regard to sexual satisfaction, sexual desire, and sexual arousal the data is less clear. A thorough literature review suggests that the lack of a validated tool for assessing sexuality in pregnancy, combined with large variations in culture, age and other uncontrolled variables create barriers to consistency in the data. While some studies attempt to understand changes between trimesters of pregnancy, other studies attempt to understand changes between preconception and pregnant states. As demonstrated by Erenel et al.'s (2011) pilot study, we can see evidence of changes to sexual satisfaction. Of women surveyed, 38.1% stated they always enjoyed sex before pregnancy. A decrease is seen in SEXUALITY IN PREGNANCY 12 pregnancy, with only 9.5% of women answering the same. Similarly, lack of female orgasm in intercourse was 8.5% before pregnancy, with an increase to 47.3% during pregnancy. These trends are echoed in research by Esmer et al. (2013), who used the Female Sexual Function Index (FSFI) to demonstrate a significant decrease from pre-pregnancy values in all domain scores (desire, arousal, lubrication, orgasm, satisfaction, pain) and overall score. A majority of the changes to sexuality in pregnancy can be expected and predicated by common complications and changes during pregnancy. However, failing to provide patients anticipatory guidance, reassurance, and suggestions for modification in the face of these changes is a major gap in health assessment and treatment. Physical and hormonal changes Normal physical and hormonal changes in pregnancy may have significant impact on the sexuality of pregnant women. During the first trimester, many women experience nausea, vomiting, fatigue, and breast tenderness that can negatively impact sexual desire and sexual frequency. Additionally, concerns for physical harm or miscarriage may persuade women to avoid sexual intercourse (Murtagh, 2010). Although the second trimester is typically considered the "honeymoon period" in the pregnancy, low back pain, pelvic congestion, and fatigue still remain persistent discomforts that can impact sexuality. Factors in the third trimester leading to changes in sexuality include engagement of the fetal head, pelvic congestion, vaginal discomfort, symphysis pubis or sacroiliac joint dysfunction, hemorrhoids, uterine irritability, and urinary incontinence (Johnson, 2011). While all of these physical changes in pregnancy are expected and seen in a majority of women, their effect on sexual functioning needs mentioning in prenatal care. SEXUALITY IN PREGNANCY 13 Additionally, studies indicate that pregnancy is characterized by a diminished clitoral sensation, orgasmic disorder, and decrease in libido (Johnson, 2011). In a study by Erol et al. (2007), out of 589 women surveyed, diminished clitoral sensation was observed in 94.2%. When sexual health is not discussed openly in the provider-patient setting, a woman with diminished clitoral sensation may assume she is an outlier. Increases in progesterone, estrogen, prolactin, and relaxin can create profound changes to vaginal sensation and lubrication (Johnson, 2011). These hormonal changes are culpable for many of the physical changes listed above, including the nausea and vomiting so common during the first trimester. Normalizing these changes can help women communicate openly with their partners about accommodations that will help promote healthy sexual function in pregnancy. Of note, some women experience an increase in libido or desire during pregnancy. It is equally important to reassure women with increased sexual desire of the normalcy of these changes as it is the women with decreased sexual desire (Foux, 2008). Psychological and emotional changes Psychological and emotional changes in pregnancy are more individualized and varied than the hormonal and physical changes discussed above. Common factors related to these domains of health in pregnancy include changing body image, ambivalence, relationship changes, and sexual guilt. Around half of all pregnancies in the United States are unintended (Centers for Disease Control and Prevention [CDC], 2015). The psychologic and emotional consequences of an unintended or unplanned pregnancy can greatly affect the other domains of health, including sexuality. In the half of pregnancies that are intended and desired, it is not uncommon to have feelings of ambivalence in early pregnancy (Johnson, 2011). Fear of miscarriage can take a large psychological and emotional toll, primarily in women with past SEXUALITY IN PREGNANCY 14 losses. A major area of psychologic change is the role transition to parenthood. The anticipation of life, social, and role changes can cause significant stress for the individual and the couple. This is very entwined with the status of the couple relationship and sense of sexual fulfillment in pregnancy. As Foux (2008) states, "Women who were more satisfied with their relationship reported higher sexual satisfaction, were more positive about their anticipated mother role and experienced fewer fatigue and depressive symptoms" (p. 275). The changing body can present a body image crisis for some women. A cross-sectional study on sexuality in pregnancy found that 41.5% of women felt less attractive while pregnant (Pauleta, Pereira, & Graça, 2010). Women may also feel self-conscious of their changing body and be reluctant to engage in sexual intercourse with their partner. Despite these changing body images, Pauleta et al. (2010) also report that a vast majority of women did not notice a decrease in sexual interest from their partner throughout the pregnancy. If regular intercourse is not occurring, women may harbor sexual guilt that their partner's needs are not being met. However, a key study on the sexuality of men in pregnancy indicated that if sexual activity is decreased, increased affection can compensate for the decrease in sexual intercourse (Polomeno, 2011). Absolute and Relative Contraindications A discussion of sex in pregnancy should not occur without including information about the absolute and relative contraindications to sexual intercourse in pregnancy. Absolute contraindications are few and include vaginal bleeding, preterm premature rupture of membranes, placenta previa, and premature dilation of the cervix (Johnson, 2011). Women with a history of preterm birth or who are pregnant with multiples have relative contraindications and should have a conversation with their healthcare provider about their specific clinical picture. SEXUALITY IN PREGNANCY 15 During sex and orgasm, endogenous release of oxytocin, stimulation of the cervix and lower uterine segment, and the prostaglandins found in semen have been theorized to increase risk for preterm labor. Although women may experience uterine irritability and contractions for an isolated period following intercourse in pregnancy, current studies have not shown an increased risk for preterm labor or birth (Lockwood & Magriples, 2016). Thus, in the absence of the listed above absolute contraindications, there is no evidence to advise against sexual activity in pregnancy. However, perpetuated fears and myths surrounding sexual activity in pregnancy are abundant. Common fears include, but are not limited to: fear of injuring the fetus, miscarriage, infection, bleeding, and preterm labor. Although these fears are not founded in current research, Johnson (2011) highlights a study surveying 589 pregnant women found that 41% refrained from sexual activities in the third trimester due to fear of preterm labor or harming the baby. A similar study by Johnson (2011) echoes this finding, with report of 57% of women reporting concerns about the risk of vaginal bleeding after sexual intercourse. In reality, however, only 13% of them reported this outcome following intercourse. This discordance in perception and reality has the potential to negatively affect sexual health in pregnancy. In the face of these myths and in line with current research, women who desire sexual activity in pregnancy should be encouraged by their providers to engage in safe, consensual sexual intercourse throughout pregnancy. Barriers in current practice Both providers and patients create barriers to open communication about sex in pregnancy. Provider barriers include lack of confidence, lack of knowledge or skills, or a personal discomfort in discussing sex with their patients (Foux, 2008). System barriers include lack of time and a lack of known resources for patient educational support. Patient barriers SEXUALITY IN PREGNANCY 16 include fear of bringing up a sensitive topic, embarrassment, or shame. Per Zaksek's (2015) interpretation of World Health Organization definitions, "sexual health is a complex biological and sociological concept that requires a positive and responsible approach to sexuality and sexual relationships. It cannot be merely defined as the absence of sexual dysfunction" (p. 87). The phrasing of "positive and responsible approach" highlights the need for providers to adapt a proactive approach to initiate conversation with patients in the prenatal period about changes to sexuality in pregnancy. Strategies for communication As women may transfer in and out of a given obstetric practice at any point in the pregnancy, it is important to not defer key information to subsequent visits. Because many patients do not freely discuss sex and sexuality, it is prudent for the clinician to read patient cues and proceed accordingly in the conversation. Zaksek (2015) suggested the providers first ask permission to talk about personal or sensitive issues, and then begin the conversation with openended questions. In contrast to provider perceptions, taking a sexual history does not require a significant amount of time. Possible questions could include the following: − Are you or your partner having any sexual difficulties at this time? − Are you satisfied with your current sexual relationship? − Do you have any sexual concerns you would like to discuss? A well-established model for discussing sex with patients is the PLISSIT model, or ‘Permission, Limited Information, Specific Suggestions, and Intensive Therapy" (Murtagh, 2010; Foux, 2008). Although more time consuming, this model provides all of the necessary steps to create open communication on sex in pregnancy. Providers should seek training to provide patients with helpful suggestions and referrals as needed. SEXUALITY IN PREGNANCY 17 Implementation to practice Suggestions for practice include comprehensive patient education in written and verbal format on sexuality in pregnancy including, but not limited to (Foux, 2008): 1. Reassurance of normal changes in sexuality in trimester framework 2. Absolute contraindications to sex in pregnancy 3. Specific suggestions for modifications to make sex more comfortable in pregnancy 4. Alternatives to vaginal intercourse to promote intimacy 5. Discussion of sex and relation to labor and uterine contractions The provision of a standardized, plain-language handout on sex in pregnancy allows patients to obtain reliable information in a private manner, and serves as a springboard for further discussion with their provider. Neglecting to assess and recognize sexual changes in pregnancy represents a failure to acknowledge a major domain of overall wellness. A review of the current literature has established that a major deficit exists in current practice in the face of a clinically recognized need. The creation of a standardized, evidence-based, free handout has the ability to make an impact in the lives of women and their partners and can serve as a tool for providers to use in the clinic setting. Patient Education Perhaps the best introduction to a review of emerging patient education tools is Kreps and Neuhauser's (2010) statement, "There is a communication revolution brewing in the modern health care system fueled by the growth of powerful new health information technologies (HITs) that hold tremendous promise for enhancing the delivery of health care and the promotion of health" (p.329). Current research suggests that a majority of Americans go to the internet as a SEXUALITY IN PREGNANCY 18 primary source of health information. Data from the Centers for Disease Control (2011) shows that 61% of Americans have used the internet to search for health information. On average, women were 10-20% more likely to use the internet to obtain health information in comparison to their male counterparts across all age groups (CDC, 2011). A study by Hesse et al. (2005) demonstrated that the majority of individuals go to the internet for health information before going to their provider. Rather than viewing the internet as a supplement to the health information patients receive from their care providers, we should view online HIT as a method being enthusiastically consumed by the public for the purpose of health promotion and literacy. (Hesse et al., 2005) Understanding how patients use and access health information is an important basis in the future development of innovative patient education. O'Grady, Witteman, and Wathen (2008) proposed an adaptation of Kolb's experiential learning theory to help understand health information seeking behavior that they titled the experiential health information processing model. Within this model, there are four main processes that take place. The first is a concrete experience such as an event or diagnosis. In the context of sexuality in pregnancy, this could be an episode of dyspareunia or comment on sexual frequency from their sexual partner. This concrete experience creates a need for health information. The second step is observation and reflection, where the individual contemplates the event and how it has personally impacted them. The need for additional information grows as patients engage the online environment, read health information, and reflect on their experience within the context of the new information. The third step occurs with the formation of concepts and generalizations. There are a number of pregnancy forums such as "The Bump," or "What to Expect," where women can pose a question to the forum and read responses on similar topics. Lastly, the final step involves active SEXUALITY IN PREGNANCY 19 experimentation with the new knowledge gained. In this step, the patient proceeds to a treatment decision. In the context of sexuality, this could be implementing a new sexual position suggested in the forum, or scheduling an appointment with their provdider. Thus, the wider availability of online or readily-available sources of education that have been reviewed for correct, evidence based information, can direclty impact the health seeking behavior of women in pregnancy. Patients have a right to access evidence-based information (EBI) as a prerequisite for informed decision making in their personal health. McMullan (2005) highlights a strong correlation between internet use and improved self-efficacy. When self-efficacy is increased, patients are empowered to make health decisions and speak directly with their clinician about complex medical issues (McMullan, 2005). The U.S. Department of Health and Human Services ([USDHHS], 2008) defines health literacy as, "the ability to obtain, process, and understand basic health information and services to make appropriate health decisions" (para.1). The same issue briefly highlighted that only 12% of adults in the United States have "proficient" health literacy, with a majority of the population falling in the "intermediate" health literacy category. Adults at a below basic health literacy level are least likely to use written material. For all levels, no type of print material was as valuable as non-print sources (USDHHS, 2008). The implications of these findings are to address the current gap in health information available to the public that is appropriately suited to multiple health literacy levels. In the goal to promote universal access to health information, the USDHHS (2008) suggests that health care provider organizations should step up in distributing "understandable materials for their members to use with their patients and families." SEXUALITY IN PREGNANCY 20 McMullan (2005) reviewed studies to determine three typical outcomes of internet health searches and their effect on the patient-provider relationship: 1) The health care provider feels threatened and reacts by asserting their expert opinion 2) The health provider and patient work together to understand the information 3) The health professional guides patients to reliable online information The suggestion proposed by McMullan (2005) is a combination of outcome two and three. In outcome two, a patient-centered approach, the provider is allowed the time for shared decision making with the patient in the face of the newly discovered information. This outcome, however, is limited by office time with the provider. Combining outcome two with outcome three (referred to as the "Internet prescription"), can help empower patients to learn to appropriately filter online information, as well as provide vetted, evidence-based online resources to patients (McMullan, 2008). The combination of these two outcomes creates a patient-centered, yet provider-guided environment to improve communication and also empower the patient to find EBI on their own. Andragogy and Adult Learning Theory Andragogy is a term coined in the middle 19th century and popularized in the United States by Malcolm Knowles in the 1970s. The term itself refers to the practice of educating adults, and specifically, the concept of self-directed learning. Ozuah (2005) uses Knowles' six assumptions that explain that adult learners must have an understanding of the value and worth of the information before attempting to learn it, and that they prefer autonomy and self-direction in their learning. Significant weight is given to the learner's past experiences, their readiness to learn rests on the individual's appreciation of the relevancy of the topic to their real-life SEXUALITY IN PREGNANCY 21 situations and problems, and adult learners are driven by internal motivation and the attainment of personal goals. This information is valuable when creating patient education available to wide audiences and fits well in the theoretical framework of the health belief model. In line with adult learning theory, patients will seek out information when they have determined a need to know and are motivated by life experiences. In the context of sexuality in pregnancy, motivation for learning could arise from partner suggestion, or an acute change to sexuality such as dyspareunia. To further clarify adult learning theory, Ozuah (2005) suggests that adults learn best when they have a desire to learn, can learn in a non-threatening environment, and have opportunities to have control over the learning process. Online patient education is in line with many of these principles of adult learning. In the online format, patients are in a non-threatening environment and have control over their learning process. Patients choose the amount of time they spend digesting the information, and also the format they chose to receive it in. Additionally, the information is accessible on a continuous basis and ready for when the learner determines the need. In an ideal scenario, the patient could use the patient education tools as a bridge to start a conversation with their provider. Share with Women In an article on what constitutes evidence-based patient information, Steckelberg et al. (2009) suggests the following: readable serif 12-point type style, appropriate space between lines, printed on paper that has contrast between text and paper, left-alignment, clear labeling of all charts and illustrations, avoidance of text wrapping, easily recognizable headings, and the signaling of main points with bolding or highlighting. Additionally, the NIH Plain Language Coordinating Committee recommends between fourth and eighth grade reading level for public SEXUALITY IN PREGNANCY 22 health information (Steckelberg, Bunge, & Mu, 2010). Share with Women handouts typically range from a Flesh-Kincaid reading level of six or seven and use plain language to help promote understanding of complex medical issues such as induction of labor and genetic testing in pregnancy. Podcasting A podcast is a digital audio file, typically in a series, available on the Internet for personal download by subscribers (Oxford English Dictionary, 2016). The podcast is a relatively new form of patient education, but has virtually exploded due to the ease of production and patient popularity. Demonstrated use of podcasts in diabetes education for African American men revealed a 40% increase in posttest knowledge (Johnson, Ross, Iwanenko, Schiffert, & Sen, 2012). In contrast to written education, podcasts are often informal conversations on popular health topics. Dr. Robert Rodvien (2011) suggests podcasts can be a helpful adjunct to the patient-provider relationship, saving valuable office time. He suggests providers can either create their own podcasts or search the internet for related podcasts to suggest for patients. He suggests the podcast as an effective tool because it allows to select a few major topics presented in casual terms. Additionally, people can listen to it in the comfort of their own home, pausing and repeating as often as necessary (Rodvien, 2011). The appeal of podcasts is undeniable, a Google search reveals thousands of results for podcasts, hundreds of which are on health topics. As Dr. Rodvien (2011) states, "We as health care professionals need to aggressively use all the educational tools available to us. Audio podcasts may be one small but very significant step in the right direction" (para. 9). Currently there are three main podcasts on the topic of sexuality in pregnancy that query with a Google search. One is a podcast in the Sexual Medicine and Health series that is done by SEXUALITY IN PREGNANCY 23 Dr. Michael Krychman and Dr. Haywood Brown, professor and chair of the obstetrics and gynecology department at Duke School of Medicine. In reviewing this podcast, it contains evidence-based information from an ACOG-member guest speaker and is approximately 13 minutes in length. The remaining two podcasts are less formal, the information is not referenced, and the guests/speakers are not credentialed. It would be time consuming for providers to listen and determine the quality of podcasts on their own time. There is a need for professional organizations to endorse existing podcast series or to create their own as a way for patients and providers to know that the information provided has been reviewed and determined to be accurate. Selected Theoretical Framework This project was developed within the framework of the health belief model. This theoretical framework supports this DNP project as it was developed to understand and predict health behaviors with a focus on attitudes and beliefs of individuals. At the core of the health belief model, individuals must feel that a negative health outcome can be avoided, that by taking a recommended action they will avoid the negative outcome, and that they can successfully take the recommended health action (Glanz et al., 2002). There are four major constructs of the health belief model: perceived susceptibility, perceived severity, perceived benefits, and perceived barriers. Susceptibility refers to perceived risk and severity refers to the severity of the consequences. To effectively change health behaviors, the individual must believe they are susceptible to negative outcomes and that the consequences are sufficiently severe. Perceived benefits relate to the individual's views that the health action will benefit them, and the barriers are any obstacles that may prevent them from accomplishing the action. More recently, two additional components have been added to the health belief model. These are "cues to action" SEXUALITY IN PREGNANCY 24 and "self-efficacy" (Glanz et al, 2002). A cue to action is an event that activates the change in behavior. Self-efficacy refers to the innate confidence the individual has in their ability to complete the action. This model relates to this project with regard to how a patient perceives the threat of changes to sexuality in pregnancy, and also how they engage in information seeking and health promoting behavior. A cue to action could occur in the form of a recognized change to sexuality during the pregnancy, or as a reaction to partner comments or feelings. As sexuality is both individual and shared between partners, a perceived susceptibility and severity would likely need to be felt or communicated by both sexual partners to some degree for the health belief model to be engaged. This model is a very good framework for viewing sexuality in pregnancy, as the action of engaging in searches for online education is often in response to a perceived threat or susceptibility. It is then the role of the patient education tools to help provide the individual with the tools for benefit. Implementation and Evaluation Implementation of the scholarly project was initiated by conducting a thorough literature review to establish current existing standards for provider-patient communication on sexuality in pregnancy. The literature review helped to clarify expected changes to sexuality during each trimester, how women felt about these changes, and the provider role in anticipatory guidance and suggestion. The completed literature review was evaluated by the project chair and edits made based on continual feedback. Evaluation also occurred during the DNP project presentation through approval from the project committee to move forward with the remaining objectives in the scholarly project (Appendix A). To achieve the second objective, the Journal of Midwifery and Women's Health (JMWH) was contacted to assess their desire for collaboration SEXUALITY IN PREGNANCY 25 on a patient education handout for the "Share with Women" series available to patients and providers through the American College of Nurse Midwives website. The editor-in-chief of the journal expressed interest and an educational handout was created within the limitations of their format. The handout was completed and evaluated in collaboration with the Eccles Health Sciences library health literacy tool to assess the patient educational handout to ensure it was at an appropriate reading level for the target audience. In addition, the handout was evaluated by the project content expert for content. The third objective was achieved through collaboration with a local mental health center, The Healing Group, specializing in women's mental health needs and postpartum depression. Through this collaboration, a podcast was recorded on January 31, 2017 by clinical social worker, Braxton Duston, and was then edited and aired on their regularly disseminated podcast, Birds and Bees. The podcast incorporated the information from the completed literature review and addressed identified gaps in patient education including normal changes, fears and myths, as well as evidence-based suggestion. To achieve this objective, there was significant collaboration and input from my content expert on sexuality in pregnancy before the recording. This objective was met with the completion of the recording, but the evaluation of the podcast content would occur within the subsequent objectives of the focus group and dissemination. In the next phase of the project, the patient education tools created within the scholarly project including the patient education handout and podcast were evaluated through the use of a focus group of six pregnant or postpartum women. IRB approval was secured through the University of Utah, and an exemption letter was received on December 19, 2016 (Appendix B). A focus group script was drafted in collaboration with the project chair to guide the focus group (Appendix C). Women were recruited through family members, friends, and community SEXUALITY IN PREGNANCY 26 channels. After informed consent from participants was obtained, an initial discussion occurred to determine the perceived need for education on sexuality in pregnancy. The podcast was then played for the participants and the education handout reviewed. This was followed by a discussion evaluating the educational tools and encouraging suggestions for improvement. In addition, the focus group was audio recorded for review and incorporation into the final project results summary. For the final objective of dissemination, the "Share with Women handout was submitted to the JMWH (Appendix D). The handout will be peer reviewed Second, an abstract proposal for poster presentation at a local ACNM meeting was submitted and accepted for podium presentation on April 13 2017 (Appendix E). Objective #1: Determined the current standards of practice on discussion of sexuality in pregnancy. Implementation − Conducted a review of current literature to determine practice standards and identify deficiencies. Evaluation − Completed literature review was reviewed by project chair and content expert with feedback on thoroughness #2: Developed a patient education handout on sexuality and sexual health in pregnancy. − Contacted JMWH to inquire about Share with Women template for patient education and if collaboration would be possible Drafted handout Worked with Eccles librarian on obtaining certification of appropriate reading level of handout Contacted The Healing Group to determine interest in collaboration on podcast. Developed talking points in conjunction with content expert on sexuality in pregnancy. Recorded podcast episode − Developed discussion points that will evaluate the content presented in the patient education tools Identify six pregnant and postpartum women to participate in a focus group − − − #3: Developed and record a podcast on sexuality in pregnancy. − − − #4: Evaluated the effectiveness of the developed patient education tools. − − − − − − − Feedback will be provided from JMWH on topic relevancy and format for Share with Women series Patient educational handout developed and approved by project chair and content expert Received feedback from The Healing Group on appropriateness of topic for The Birds and Bees podcast. Reviewed podcast content with content expert. Podcast recorded successfully and available online for public listening Focus group questions reviewed and approved by content chair Six women identified and contacted for their availability to participate in a focus group SEXUALITY IN PREGNANCY − − #5: Disseminated patient information on sexuality in pregnancy. − − 27 Contacted the women and arrange a meeting time for a 1 hour focus group Conducted a recorded focus group with approved list of discussion points Submitted patient education handout to JMWH Share with Women series Submitted abstract for local ACNM poster presentation − Focus group occurred with recorded discussion for review and analysis of feedback − Educational handout accepted by JMWH Acceptance for poster presentation at local ACNM meeting − Results In total, seven women were recruited to participate in a focus group that took place on March 17, 2017. Only six women were able to participate, as one participant ended up giving birth just prior to the focus group. The women were all Caucasian, ages 26 to 38, all in heterosexual monogamous relationships. Three of the women were currently in their first pregnancy at gestational ages ranging from 16 to 24 weeks. Two women were postpartum and had given birth within the past year. The last was a multiparous woman in a current pregnancy at 30 weeks' gestation. The women were asked questions based on a previously drafted script (Appendix C). Four questions were asked prior to the women listening to the podcast and reviewing the patient handout, and then a discussion occurred guided by an additional seven questions following the podcast and handout presentation. Consistent with the literature review findings, 100% of participants said that their provider did not bring up sexuality in pregnancy unless they brought it up first. Two of the women had experienced vaginal spotting following intercourse, and only when questioned did their provider mention that this can be a normal occurrence. In addition, 100% of participants affirmed that this was information they desired during their pregnancy. One of the primiparous participants stated, "Absolutely. I had a lot of questions about sexuality and pregnancy. My husband and I have both wondered whether he could potentially "poke" the SEXUALITY IN PREGNANCY 28 baby. Ha ha. Sounds absurd, but we were worried. We're also worried about missionary position now that I'm 20 weeks along and any pressure to my stomach is painful." Additionally, the multiparous woman currently pregnancy highlighted, "I loved hearing you debunk the myths of having sex in pregnancy. I thought this was a great way to provide information to women about sex in pregnancy but also something that a woman can use to share with her husband to provide him with this important information." A majority of the participants enjoyed the platform of podcasting to receive the information on sexuality in pregnancy. Some responses that highlighted the utility of the podcast can be read below: − "Yes! I am a busy mom, and listening to something is sometimes easier to find time for than reading these days." − "Absolutely. Podcasts feel informative and intimate. A lot of podcast hosts feel like friends because the conversations are often intimate." − "Recently I have been spending more time listening and seeking out podcasts that are of interest to me. I think that receiving information this way is great and it's easy to share if you hear something you really like!" Two participants, however, leaned more toward the handout as the preferred method of receiving the information and highlighted that "Had I not been involved in this survey, I may have skipped over the podcast because of the length. I'd suggest breaking it into specific topics and keeping it around 20 minutes each." Another said, "This discussion was fun and helpful, but the handout was definitely necessary to summarize the important points." This indicates that although many enjoyed the podcast, the importance of still maintaining more traditional patient education platforms is also necessary. SEXUALITY IN PREGNANCY 29 There are significant limitations of this focus group. First, the fact that all women were Caucasian does not reflect the perspectives of a diverse community of women. The age range of the group leaves out the perspective of pregnant adolescents and younger age women. Additionally, the small number of participants limits the reliability of the data in a qualitative sense. The focus group did not produce as robust discussion as was intended, with limited suggestions given for revisions to the podcast and handout. This could potentially be due to the fact that the creator of the educational materials was in the room, and the participants did not want to offend the researcher. In the future, it would be suggested to provide a platform for anonymous response to encourage more honest feedback. Following the focus group, the patient education handout was submitted to the JMWH for publication. Correspondence from the editor of the journal indicates that there is some backlog within the organization related to editing and publishing content. The educational handout will be edited and revised by the Share with Women team and submitted for publication when they are able. Future Recommendations This project was limited in its scope of dissemination within the midwifery community. In addition, the podcast selected for dissemination is only listened to by a select community within the state of Utah. Information on sexuality in pregnancy is pertinent to all pregnant women, including those cared for by both midwives and physicians. This project could easily be expanded to include patient and provider education that is readily accessible to physicians. This could occur in a similar manner, with an article or patient education handout for publication in the journal for the American Congress of Obstetrics and Gynecology. SEXUALITY IN PREGNANCY 30 In addition, the new approach to using podcasting for patient education can be significantly expanded upon. As healthcare and technology continue to join forces, podcasting as a mechanism to present patient education in an informal setting can be a valuable tool for dissemination. There is a large potential for the branding of podcasts specific to the obstetric and midwifery community. Recording a podcast is helpful only if patients and providers are able to identify that it contains evidence-based information. Endorsement or branding from ACNM or ACOG on a series of podcasts providing education on pregnancy-related topics is an area for future recommendation and expansion of this project. In addition, podcasts on this topic or others in the future should include an interactive session of questions from listeners to be a more effective tool for patient education. DNP Essentials This project aligns well with the American Association of Colleges of Nursing (AACN) DNP Essential VIII that defines advanced practice nursing. This DNP essential highlights the need for specialization within advanced practice nursing to meet the needs of an increasingly sophisticated healthcare system. As a student in a specialty track DNP program in Women's Health and Midwifery, attention to all aspects of health during pregnancy represents specialization and competency in practice. This project addresses the gap in sexual health education during routine prenatal care and aligns with the goal of DNP education to "conduct a comprehensive and systematic assessment of health and illness parameters in complex situations, incorporating diverse and culturally sensitive approaches" (AACN, 2006, p.16). Sexual health and sexuality are important components to overall health and are intimately linked with physical, emotional, and psychological wellness of the individual. Advanced practice nurses should feel comfortable accurately assessing and counseling patients on sexual health and wellness. This SEXUALITY IN PREGNANCY 31 DNP project aims to create a patient education tool to help facilitate the conversation on this topic. The spirit of quality improvement within advanced practice nursing degree supports this DNP project and the creation of an evidence-based tool for patients. An additional area where this project is in close alignment with the goals of DNP essential VIII is the acknowledgement of pregnancy as an important health transition. This acknowledgement is in line with the function of this DNP essential to prepare graduates to "educate and guide individuals and groups through complex health and situational transitions" (AACN, 2006, p.17). For women, the transition through pregnancy and into motherhood represents a complex health and situational transition that providers should acknowledge and be aware of, regardless of DNP area of focus. Conclusion Sexuality in pregnancy and the early postpartum period is a topic that should be included and discussed openly in routine prenatal care. Evidence clearly demonstrates an existing deficit in patient education and patient-provider communication on this subject. This lack of communication and education leads women to alternate forms of information, including websites or word-of-mouth information that may not be evidence-based. The potential for misinformation on this topic can often serve to further perpetuate fear and hesitation for women and their partners. In addition, research indicates that healthy sexuality and partner communication during pregnancy can translate to better overall wellness for the individual and the couple involved. This project sought to develop new approaches to patient education in a changing landscape of health literacy and technology. This includes a written patient education handout that is both published for providers in the JMWH and also available to patients and providers online in the "Share with Women" series. This handout is a searchable education resource that SEXUALITY IN PREGNANCY 32 patients can access on their own, or providers can print and provide to their patients. A podcast was also recorded for the local community on sexuality in pregnancy. The podcast covered subjects like common fears and myths on sexuality in pregnancy, suggestions for modifications to sex in pregnancy, and common reasons why sexuality is affected. This creation and provision of standardized, evidence-based, free patient education has the potential to increase patient education on sexuality in pregnancy. As demonstrated through a pilot focus group, women are not discussing sexuality in pregnancy with their providers. All participants indicated their providers did not mention this topic unless they brought it up first. Additionally, most women in the focus group found the podcast to be a private, entertaining, and informative way to get information on this topic. However, some women still preferred to get information from print source, as this provided a quick summary of information that they could access without a significant time commitment. All participants indicated the information was desired, whether currently pregnant or postpartum. This project demonstrates the need for patient health education to move from the provision of physical paper handouts to the online environment. This education can take on newer forms such as podcasting, or can remain in more traditional formats like print media. However, as the internet remains a primary source of health information, it is up to healthcare providers to meet this need by providing quality, evidenced-based information to meet the demand of patients. SEXUALITY IN PREGNANCY 33 References American Association of Colleges of Nursing. (2006). The Essentials of Doctoral Education for Advanced Nursing Practice. Retrieved from http://www.aacn.nche.edu/dnp/Essentials.pdf American College of Nurse-Midwives. (2016). Share with Women. Retrieved from http://www.midwife.org/Share-With-Women Association for Reproductive Healthcare Providers. (2008). Female sexual response [Clinical Fact Sheet]. Retrieved from http://www.arhp.org/publications-and-resources/clinical-factsheets/female-sexual-response Centers for Disease Control and Prevention. (2011). Use of the Internet for health information: United States, 2009. National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/products/databriefs/db66.htm Centers for Disease Control and Prevention. (2015). Unintended pregnancy prevention. Retrieved from https://www.cdc.gov/reproductivehealth/unintendedpregnancy/ Erenel, A. S., Eroglu, K., Vural, G., & Dilbaz, B. (2011). A pilot study: In what ways do women in Turkey experience a change in their sexuality during pregnancy? Sexuality and Disability, 29(3), 207-216. http://doi.org/10.1007/s11195-011-9200-1 Erol, B., Sanli, O., Korkmaz, D., Seyhan, A., Akman, T., & Kadioglu, A. (2007). A crosssectional study of female sexual function and dysfunction during pregnancy. Journal of Sexual Medicine, 4(5), 1381-1387. http://doi.org/10.1111/j.1743-6109.2007.00559.x Esmer, A.C., Akca, A., Akbayir, O., Goksedef, B. P. C., & Bakir, V. L. (2013). Female sexual function and associated factors during pregnancy. The Journal of Obstetrics and Gynaecology Research, 39(6), 1165-72. http://doi.org/10.1111/jog.12048 SEXUALITY IN PREGNANCY 34 Foux, R. (2008). Sex education in pregnancy: Does it exist? A literature review. Sexual and Relationship Therapy, 23(3), 271-277. http://doi.org/10.1080/14681990802226133 Glanz, K., Rimer, B.K. & Lewis, F.M. (2002). Health Behavior and Health Education. Theory, Research and Practice. San Fransisco: Wiley & Son Hesse, B. W., Nelson, D. E., Kreps, G. L., Croyle, R. T., Arora, N. K., Rimer, B. K., & Viswanath, K. (2005). Trust and Sources of Health Information. Arch Intern Med, 165(May 2016), 2618-2624. https://doi.org/10.1001/archinte.165.22.2618 Johnson, C. E. (2011). Sexual health during pregnancy and the postpartum. Journal of Sexual Medicine, 8(5), 1267-1284. http://doi.org/10.1111/j.1743-6109.2011.02223.x Johnson, J., Ross, L., Iwanenko, W., Schiffert, J., & Sen, A. (2012). Are podcasts effective at educating African American men about diabetes? Am J Mens Health, 6(5), 365-367. https://doi.org/10.1177/1557988312444717 Kreps, G. & Neuhauser, L. (2010). New directions in eHealth communication: Opportunities and challenges. Patient Education and Counseling, 78(3), 328-336. http://dx.doi.org/10.1016/j.pec.2010.01.013 Lockwood, C.J. & Magriples, U. (2016). Initial prenatal assessment and first trimester prenatal care. In T. W. Post (Ed.), UpToDate. Retrieved from http://www.uptodate.com/home Mcmullan, M. (2006). Patients using the Internet to obtain health information : How this affects the patient - health professional relationship, 63, 24-28. https://doi.org/10.1016/j.pec.2005.10.006 Murtagh, J. (2010). Female sexual function, dysfunction, and pregnancy: Implications for Practice. Journal of Midwifery & Women's Health, 55(5), 438-446. http://doi.org/10.1016/j.jmwh.2009.12.006 SEXUALITY IN PREGNANCY 35 Mcmullan, M. (2006). Patients using the Internet to obtain health information : How this affects the patient - health professional relationship, 63, 24-28. https://doi.org/10.1016/j.pec.2005.10.006 Ozuah, P. (2005). First, there was pedagogy and then came andragogy. Einstein Journal of Biology & Medicine, 21(2), 83-87. Retrieved from http://prodeinsteinwebsite.vipprod.dmz.yu.edu/uploadedFiles/EJBM/21Ozuah83.pdf Pauleta, J. R., Pereira, N. M., & Graça, L. M. (2010). Sexuality during pregnancy. Journal of Sexual Medicine, 7(1 PART 1), 136-142. http://doi.org/10.1111/j.17436109.2009.01538.x Polomeno, V. (2011). Men's sexuality in the perinatal period: What do perinatal educators need to know? International Journal of Childbirth Education, 26(4), 35-40. Rodvien, R. (2011). How podcasts can help patients with health literacy. Retrieved from http://www.kevinmd.com/blog/2011/05/podcasts-patients-health-literacy.html Steckelberg, A., Bunge, M., & Mu, I. (2010). Patient Education and Counseling What constitutes evidence-based patient information ? Overview of discussed criteria, 78, 316-328. https://doi.org/10.1016/j.pec.2009.10.029 Stevens, K.R. (2013). The Impact of Evidence-Based Practice in Nursing and the Next Big Ideas. Online Journal of Issues in Nursing, 18(2), 4. doi: 10.3912/OJIN.Vol18No02Man04 United States Department of Health and Human Services. (2011). America's Health Literacy: Why We Need Accessible Health Information [Issue Brief]. Retrieved from https://health.gov/communication/literacy/issuebrief/ SEXUALITY IN PREGNANCY 36 World Health Organization. (2016). Defining sexual health. Sexual and reproductive health. Retrieved from http://www.who.int/reproductivehealth/topics/sexual_health/sh_definitions/en/ Zakšek, T. Š. (2015). Sexual activity during pregnancy in childbirth and after childbirth. In A.P. Misvek's (Eds.), Sexology in Midwifery (87-115). Slovenia: InTech. SEXUALITY IN PREGNANCY 37 Appendix A DNP Project Proposal SEXUALITY IN PREGNANCY 38 SEXUALITY IN PREGNANCY 39 SEXUALITY IN PREGNANCY 40 Appendix B IRB Approval Letter SEXUALITY IN PREGNANCY Appendix C Focus Group Guided Topic Questions 6-10 pregnant or postpartum (birth within past 2 years) women • Informed consent • Prior to handout and podcast: 1. Did your provider discuss changes to sexuality during your pregnancy? 2. Would you have desired this information? 3. Did you seek information elsewhere on this topic? Where? 4. What was the information or advice you received? • Listen to podcast and review patient education handout • After handout and podcast: 1. Did you find this information valuable? 2. After reviewing the podcast and handout, are you more likely to bring up this topic with your midwife or OB provider? 3. Was there any other information that you would have liked to be included in either the podcast or handout? 4. Did you like the platform of podcasting to receive health information? 5. Would you recommend this information to others? 6. Do you have suggestions for improvement to the podcast or handout? 7. Do you have any other questions related to this topic? 41 SEXUALITY IN PREGNANCY 42 Appendix D Share With Women Handout Sex in Pregnancy Is it safe to have sex while I am pregnant? Yes, it is safe for most women to have sex throughout their pregnancy. Unless your provider has told you specifically to not have intercourse for a medical reason, you can safely enjoy sex in all three trimesters of pregnancy. The baby is protected during sex by the amniotic sac and amniotic fluid inside the uterus. When should sex be avoided? Common reasons why your provider will advise you to abstain from intercourse include: − Leaking amniotic fluid − History of preterm labor or birth or current preterm contractions − Vaginal bleeding − Placenta that covers the cervical opening (placenta previa) If you are unsure if it is safe to have sex in your pregnancy, ask your provider. Will my sex drive change in pregnancy? Many changes occur during pregnancy both physically and emotionally. It is common for your sexual desires to be different now that you are pregnant. Some women may notice an increase in sex drive while others may notice a decrease in sex drive. Here are some specific trimester related changes that can affect sex drive in pregnancy: − First trimester: Many women experience fatigue, nausea and vomiting in the first trimester which can lead to a decrease in sexual desire. − Second trimester: Increased blood flow to the pelvic area can lead to heightened sexual sensation, but can also lead to discomfort during sex. The breasts become larger and more sensitive and it may be uncomfortable to have them stimulated during sex. − Third trimester: As the pregnancy continues, the uterus and abdomen become larger making it difficult to find comfortable sex positions. The changing body may trigger feelings of selfconsciousness that can decrease sexual desire. How can I have sex comfortably while pregnant? − − Ensure adequate lubrication: Use a good amount of a water-based or natural lubricant Try a different position: o Woman on top: female facing forward or backward o Spooning o Rear entry: can be done standing or on hands/forearms and knees o Side Lying − Communicate with your partner: Let your partner know what feels good and what doesn't. Also, help guide the pace, depth, and speed of intercourse to ensure comfort. If intercourse continues to cause discomfort, try an alternative way to be intimate such as massage, mutual manual stimulation, oral intercourse, or cuddling. SEXUALITY IN PREGNANCY 43 What if I don't want to have sex while pregnant? It is important to talk to your partner. Tell your partner how you feel, and specifically how you feel about sex in the pregnancy. Encourage your partner to communicate with you about their feelings about sex in the pregnancy. If sex is not something that is desired or possible, there are many other ways to be intimate including massage, oral or manual stimulation, cuddling, or simply spending quality time together. Does sex cause me to go into labor? Sex during pregnancy, especially in the third trimester, can cause cramping or contractions immediately following intercourse and during orgasm. This is because male semen contains prostaglandins and orgasm releases the body's own oxytocin, both of which can trigger uterine activity. These contractions will typically subside over 1-2 hours. If they continue or become stronger, you should contact your provider. A small amount of vaginal bleeding or spotting may also be present following sex. This is due to the increased blood flow to the cervix. Intercourse may cause mild spotting for 24-48 hours after sex, but if bleeding is heavy or continues past this point you should also contact your provider. What about oral and anal sex? Oral sex is safe in pregnancy. However, make sure your partner does not blow air into the vagina during oral sex. A burst of air into the vagina has the potential to block a blood vessel which can be a lifethreatening condition for mom and baby. Anal sex can also be enjoyed in pregnancy, although caution should be used to ensure clean hygiene to prevent bacteria spreading from rectum to vagina. Additionally, anal sex may be uncomfortable if hemorrhoids are present. How soon after my baby is born can I have sex? The typical recommendation is to wait 4-6 weeks before having sex. Before sex is resumed, the cervix needs to close, postpartum bleeding should have stopped, and all tears or lacerations should be healed. Every woman is different. Some women may feel ready at 4 weeks while other women may need 10 weeks. Communicate openly with your partner and use other ways to be intimate with each other while not having sex. When sex is initiated, take it slow and use plenty of lubrication. Ensure to use a method of birth control to avoid an unintended pregnancy. For More Information Cleveland Clinic Sex during pregnancy. https://my.clevelandclinic.org/health/diseases_conditions/hic_Am_I_Pregnant/hic_Coping_with_the_Phy sical_Changes_and_Discomforts_of_Pregnancy/hic_Sex_During_Pregnancy Mayo Clinic Sex during pregnancy: What's OK, what's not. http://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-depth/sex-duringpregnancy/art-20045318?pg=1 UCSF Medical Center Sex during pregnancy. https://www.ucsfhealth.org/education/sex_during_pregnancy/ SEXUALITY IN PREGNANCY 44 Appendix E DNP Defense Poster