Sexual and reproductive health‐related questions and concerns of newly married couples: A qualitative content analysis

Abstract

Background and Aims

Approximately half of Iranian marring couples have poor sexual knowledge and attitudes. This article delves into the main concerns and queries regarding sexual and reproductive health among Iranian newly married couples.

Methods

We conducted a content analysis of the sexual and reproductive health questions and concerns that were anonymously submitted by newly married couples to the researcher via social media in 2021–2022.

Results

A total of 141 questions and concerns that were related to sexual and reproductive health were considered for content analysis. Findings illustrated two main categories: (1) the need to create a reproductive life plan, and (2) the need for sexual knowledge and counseling. The first category consisted of three subcategories: “Poor contraceptive knowledge,” “Need for support in case of a missed period or unplanned pregnancy,” and “Need for preconception care.” The second category included three subcategories: “Concern regarding virginity,” “Sexual problems on the honeymoon,” and “Sexual problems in newlyweds.”

Conclusion

Iranian newly married couples need long‐term specialized services addressing their reproductive life planning and sexual knowledge needs. Integrating reproductive life planning and comprehensive sex education into the primary care services for newly married couples can help to reduce delayed childbearing, unintended pregnancy, unsafe and illegal abortion, and subsequent infertility.

1. INTRODUCTION

Sexual and reproductive health (SRH) plays an important role in the overall well‐being of an individual. ¹ It is essential for individuals and couples to ensure healthy reproduction, achieve a better marital relationship, make healthier sexual decisions, and contribute to the social development of their societies. ² Evidence suggests that in the Middle East, including Iran, sexual matters are considered very sensitive topics. ³ Due to strong cultural traditions, taboos, and lack of information, SRH problems tend to be concealed in embarrassment and secrecy. Therefore, SRH needs are mainly neglected and receive less attention in public policy discussions. ² Healthcare systems naturally do not provide a comprehensive package of sexual health services to individuals who are planning to marry. Accordingly, in societies such as Iran, premarital couples are in great need of SRH education. ³ Hence, it is expected these young people who enter a marital relationship have some educational needs in this regard, while little is known about the nature of their educational needs.

Needs assessment is a critical step in developing SRH educational programs. ⁴ Previous studies suggest the SRH educational needs of married couples should be assessed to better understand the real sexual and reproductive needs of couples. A study on engaged Iranian couples showed that a high percentage of both men and women (44.8% and 56.6%) reported a high or very high need for receiving information regarding SRH matters, especially in topics related to sexuality. ² Premarital education is one of the greatest opportunities to enhance couples' knowledge regarding their role in establishing a fruitful relationship and positively influence their sexual and reproductive attitudes and behavior. ⁵ In Iran, the Ministry of Health has the responsibility of organizing premarital counseling programs nationwide, which are mandatory for all couples intending to marry. ⁶ However, research suggests that the existing content of these premarital educational programs does not adequately address the specific educational needs of couples. ⁷ Noteably, a study conducted in Iran revealed that 58.5% of participants expressed dissatisfaction with the sexual health component of the premarital education classes, describing it as insufficient. ⁶ A research conducted by Hamzehgardeshi also showed that married couples reported a greater need for SRH education. Around 10% of 10,000 men and women who participated in this study stated that sexual problems and needs are the main reasons for the majority of marital conflicts. Furthermore, 24% of men and 23% of women reported the lack of sexual skills to be a cause of sexual disorders. Given that the most common way of education on sexual health in Iran is premarital counseling, it needs to be devised based on the main and exact SRH needs of couples. ⁸ Considering the needs of the target group is one of the ways to ensure the effectiveness of premarital education programs and better sexual and reproductive health. ⁵

While in most developing countries, premarital counseling is the formal method of education on sexual matters and can improve couples' awareness, it is not satisfactory, and there are still many challenges in this regard. ⁸ According to the American Psychological Association, premarital education programs serve as a prevention strategy to reinforce marriages. ⁹ On the other hand, providing high‐quality services results in greater satisfaction of clients, adherence to recommendations, and greater effectiveness, as well as economic growth. Therefore, the improvement of the current situation of SRH education is necessary in developing countries, including Iran. ¹¹

Notwithstanding Iran's progress in addressing SRH and its move toward becoming a healthier society, identifying culturally appropriate SRH information still remains a significant need. ² Hearing the voices of newly married couples and recognizing their SRH needs can promise to develop effective premarital SRH educational programs. In this study, we aimed to explore Iranian newly married couples' questions or educational needs related to SRH in Iran.

2. MATERIALS AND METHODS

2.1. Study design and data collection

This study was conducted as part of a nationwide study aiming to evaluate whether a fertility educational program can effectively increase fertility knowledge, childbearing intention, and the planned pregnancy rate among couples referring to premarital screening centers. ¹⁰ A total of 1200 marrying couples (women aging from 18 to 35 years, men aged 18–45, with no previous marriage) were invited between June 22, 2021 and March 16, 2022 to participate in the study during premarital screening in public health centers affiliated with universities of medical sciences of five cities of Iran (Tehran, Mashhad, Tabriz, Ahvaz, and Shiraz) through in‐person communication. To minimize loss to follow‐up, we provided an incentive to the participants, which was a gift voucher for free SRH counseling during the clinical trial study. The link to the web‐based questionnaire with a gift voucher was shared on social media (WhatsApp) by F.R (female, Ph.D. in reproductive health). Because of the Covid‐19 pandemic, interested participants submitted their questions through social media, and the principal investigator (F.R) responded to all of them as soon as possible through text/voice messages or phone calls with the prior arrangement as needed. If the questions were not in the field of SRH or more evaluation was needed, the participants were referred to a general physician, psychologist, or another relevant specialist at the health center. It is important to note that the present study constitutes a secondary analysis of data, with a specific focus on participants who approached the researcher with questions related to SRH. No participants were interviewed as part of this research, and our analysis solely encompassed questions from a subset of the original 1200 couples who participated in the primary study. Among these couples, we received a total of 183 questions, which underwent qualitative analysis. The aim of this paper is to explore and discuss these questions to uncover any underlying SRH needs.

2.2. Study context

Premarital sexuality and sex education present significant challenges in Iran, ¹¹ where obtaining a marriage license is a prerequisite for official marriage. To address these issues, couples are required to attend a 5‐hour compulsory premarriage education program at public health centers. The primary focus of this program is to enhance life skills, provide sexual and reproductive knowledge, and educate about childbearing. Furthermore, the premarriage program in Iran incorporates additional components such as genetic counseling, laboratory testing, and administering the diphtheria‐tetanus boosters. In the first marriage, it is mandatory to assess Beta‐thalassemia, VDRL, and urine opioid for men, while women undergo urine opioid testing. Optional screenings include HIV and HBV. The context of the study encompasses five major cities of Iran (Tehran, Mashhad, Tabriz, Ahvaz, and Shiraz). The study population consists of young couples who attend premarital courses in public health centers affiliated with public universities of medical sciences.

2.3. Data analysis

We conducted a content analysis of the SRH‐related questions that were submitted to the researcher. A thematic analysis was performed, following the steps of Graneheim and Lundman. ¹² All the submitted questions were copied in a Microsoft Word file and the SRH‐related questions were collected and put in a new separate file. It should be noted that in some of the questions sent, more than one topic was raised. The principal investigator (F.R) conducted initial open coding of the questions manually, and the submitted questions were labeled and considered meaning units. F.R and M.G (female) then printed the coded questions to obtain a complete visual presentation of the data and then sorted the codes into meaningful subcategories and categories based on their similarities and differences. Categories derived from this analysis were initially discussed between the researchers (F.R and M.G) to find agreement in sorting the codes and then cross‐checked by an expert in qualitative research (F.K.F). We used consolidated criteria for reporting qualitative studies (COREQ) during the data collection, analysis, and report of the results. ¹³

2.4. Trustworthiness

The concept of trustworthiness in qualitative research was introduced by Lincoln and Guba ¹⁴ by criteria of credibility, confirmability, dependability, and transferability. Credibility was achieved in our research by long engagement of the researcher in the field and debriefing sessions with key project members (peer‐checking) to reduce research bias. The authors' experiences in reproductive health and qualitative research methodology enhanced the confirmability. The data analysis process was checked and approved by all research team members. A detailed description of the study methods was done to ensure dependability. The study context was described in detail to enable generalizing the results to other contexts or settings and to meet an appropriate level of transferability.

3. RESULTS

A total of 183 questions were submitted through social media, 42 questions were beyond the scope of SRH, and finally, 141 questions were included in the process of data analysis. The questions the participants asked were coded openly to identify and explore their educational needs. The issues raised by submitted questions were clustered into two categories based on the content analysis: (1) the need to create a reproductive life plan and (2) the need for sexual knowledge and counseling. The need to create a reproductive life plan consisted of three subcategories: “poor contraceptive knowledge,” “need for support in case of missed period or unplanned pregnancy,” and “need for preconception care.” Need for sexual knowledge also included three sub‐categories: “concern regarding virginity,” “sexual problems on the honeymoon,” and “sexual problems in newlyweds.” Since the questions were submitted anonymously to the first author, the participants' demographic characteristics are unavailable. The number of submitted questions by newly married couples based on category/subcategory is reported in Table 1.

Table 1.

Number of submitted questions by newly married couples based on category/subcategory.

Categories	Questions N	Subcategories	Questions N
Need to create a reproductive life plan	75	Poor contraceptive knowledge Need for preconception care Need for support in case of missed period or unplanned pregnancy	39 25 11
Need for sexual knowledge and counseling	66	Concern regarding virginity Sexual problems on the honeymoon Sexual problems in newlyweds	14 20 32
Total	141	‐	141

3.1. Need to create a reproductive life plan

More than half of the submitted questions were about need for reproductive life planning after marriage including questions related to contraception methods, preconception care and missed period or unplanned pregnancy.

3.1.1. Poor contraceptive knowledge

The more commonly asked questions were related to contraception (39 questions). The participants' needs for family planning were more focused on choosing the right and most effective method of contraception, side effects of contraceptive methods, and contraception's failure rate. For instance,

“I just got married. What is 100% effective method of birth control? I mean which method is more effective? I don't intend to become pregnant for the next few years. If I use a method for a few years, can I get pregnant again later? I have been told that it is not good to take contraceptive pills for a long time”, and “My wife and I don't want to have children now. What are other methods we can use beside a condom so that my wife doesn't get pregnant? Are oral contraceptives safe? Condoms ruin my pleasure, and I prefer another method.”

Some couples needed more detailed information about how to use the emergency pills after unprotected intercourse, and its effectiveness or failure rate. The following are some questions asked in this regard: “What is the chance of getting pregnant in a vaginal sex without condom? My wife took an emergency pill after 4 h. How effective is the emergency pills? She is supposed to have her next period within 3‐4 days. Is it possible that she still get pregnant after taking this pill?”, and “I took an emergency pill a few days after my period and I still haven't had a period, and last night I had an unprotected sex again. Can I take the emergency pills twice in one menstrual cycle?” Some women intended to use contraceptive pills to delay their menstruation for personal reasons such as travel, wedding party or fasting during Ramadan. For instance: “My wedding party is next week and my period will normally begin at the same time. Can I take contraceptive pills if I want to effectively delay my period for 4‐5 days? What is the best time for me to start taking the pill? I am seeking a pill with minimal side effects such as nausea. What is the most popular brand of contraceptive pill in Iran?”

3.1.2. Need for support in case of missed period or unplanned pregnancy

The participants frequently asked questions related to timing of menstruation, causes of delayed or missed period, pregnancy testing, and unplanned pregnancy. The following are examples in this regard: “Do I have any problem if my period is not regular? What is the reason for spotting 2‐3 days before the beginning of period?” Anxiety of a delayed period or anxiety of facing an unplanned pregnancy, especially, during the period of Aghd (the time between the legal/official registration ceremony and the wedding ceremony in Islamic countries) was commonly reported by new couples. The participants were not informed about the fertility window and when to take a pregnancy test. Since the signs and symptoms of early pregnancy, pre‐menstrual syndrome (PMS), and menstruation are very similar, it was a cause for concern. The reported concern about missed or late periods was striking and some participants needed consultation: “I had spotting yesterday after a sex without penetration. It is just around the time of my period, the spotting stopped and I haven't gotten my period till now. This has never happened to me before. I am a little worried. What could be the reason for spotting? Is it a sign of pregnancy, my period or a damage to the hymen due to vaginal stimulation by my fiancé?” They were concerned about unplanned pregnancy and submitted questions about the possibility of pregnancy without vaginal intercourse several times: “Is pregnancy possible only during the ovulation period? I had sex today without penetration and I should have my next period within 10 days, Will I get pregnant? I get stressed out, some semen may enter the vagina”.

Participants need support in case of delayed period or an unplanned pregnancy. For example, one man said: “Now, after almost 60 days, my wife is still not menstruating, and since I don't use condom, is it possible that my wife is pregnant? If she is pregnant, then taking the emergency pill is still effective? In this case, what should be done to prevent the formation of the fetus? Is there an option for abortion? Is abortion restricted by law or religion at this stage?” One of the participants was seeking an abortion because of unplanned pregnancy: “We used pregnancy testing kits at home and it was positive and I don't know what to do. Is it possible to have an abortion? For abortion, it is possible by taking medicine or the surgery is needed?”

3.1.3. Need for preconception care

Some of the submitted questions on the genetic screening indicated that received premarital counseling in the health center was inadequate. For instance, “My fiance's brother has Multiple Sclerosis (MS), is it possible that our children have the same problem in future? I did not ask him to give a genetic test, is it necessary to do this?” Or “Does the pre‐marriage screening show that our blood group or DNA is suitable for marriage or matches to each other?” They were worried about fetal abnormalities and wanted to know about prenatal screening: “We want to have a baby and I am stressed. I don't know what to do, I want to have information before pregnancy. For example, I am worried about the occurrence of abnormalities in my baby because I have anemia and hypothyroidism.”

Couples wanted to know more about recommended immunization. One woman asked: “I could not inject the tetanus vaccine in time of pre‐marriage counseling in the health center because I had just received the corona vaccine. Can I now go there again to get vaccinated? Why is it necessary?” Another man needed information about HPV vaccination before marriage: “I have HPV now, I met a doctor before, and he used liquid nitrogen to freeze off the warts. The doctor said to me that we could have sex but my wife should be vaccinated and screened every year. How can I find this recommended vaccine?”

The participants also asked about laboratory testing. For instance: “Is HIV test included in premarital screening?” Some participants were not aware of substance abuse screening and the effect of herbal or chemical medicine on the result of this test. For example, one woman asked about substance abuse screening: “They told me that the test result is not ready today because it is suspected of substance abuse. I am not addicted, I only went to Attari (traditional herbal drugstore) and bought slimming pills to lose weight for my wedding because I thought my wedding clothes would fit better. I am just afraid of scandal for the family now. I am very embarrassed to tell them about my fault (shame sticker). They said that the medicine in the specimen would be separated before detection… What does separation mean? Is it necessary to do a repeat test tomorrow?”

Furthermore, the following questions indicate concerns about fertility and infertility status. “I am concerned about not getting pregnant. I am 34 now. Do you think I should have a check‐up for my fertility status?” and “My wife and I just got married. My wife is 22 years old. Before this, we were friends for 4 years and we had irregular sexual relationship without any contraception but she didn't get pregnant. Her menstrual period is irregular and the date of her menstruation move back one week every month. Do you think there is any problem for getting pregnant in future?”

3.2. Need for sexual knowledge and counseling

A total of 66 questions were about couples' need for sexual knowledge, and couples had concerns regarding virginity, their experiences on the honeymoon, and sexual problems.

3.2.1. Concerns regarding virginity

According to some questions, preserving virginity was a main concern for both men and women. Fear of not being a virgin due to damage to hymen even in nonpenetrative sex was also common in women. Some considered it the right of a man or his family to request a virginity test: “I think this is my right. Do I have the right to ask my wife to do a virginity test?” or another man asked a question that showed his concern about marring to a nonvirgin girl: “I got married to my cousin one week ago. She told me that she had no sexual relationship with anyone before, but in our first sexual experience, I found out that she knew all about sex and she was lying. I trusted her at first because of their consanguineous marriage and did not request a virginity test, but I was wrong. How can I trust my wife anymore?”

Some participants requested advice regarding the necessity of doing a virginity test and felt that taking a virginity test was humiliating, on the other hand, they were afraid of dishonor or slander. “My fiancé asked for a virginity test; I felt upset about that. I have never been in a sexual relationship with anyone but I don't like to check my virginity. Could he legally force me to take the test? What if I refuse to check the hymen, and he slanders me later?”

They needed information about experiencing orgasm despite the nonpenetrative intercourse to preserve virginity. For example, some couples asked: “We want to ask about sexual relationships during the Aghd or engagement period. We're going to address intimacy without sexual intercourse. How can we experience orgasm without intercourse?” and “We just got married and I want to ask you: how can we have an anal sex without losing my virginity? How can we have anal sex without pain? Is there another type of sexual relationship that don't broke my virginity?”

3.2.2. Sexual problems on the honeymoon

The participants commonly showed their needs for the premarital sex education because the first experiences of the sexual intercourse raised some questions. Participants needed to be prepared before the first sex for a better experience. They wanted to know about issues such as the amount of normal bleeding or the cause of not bleeding, pain interfering with sexual intercourse, and vaginal burning during the first intercourses. For instance, “I didn't bleed or feel pain at the first time I had sex. What's wrong?!” and “I had relatively heavy bleeding in the first sex, and I still have spotting. I do not know what has happened. Is it normal? The bleeding and severe pain don't let me enjoy sex. We have not been able to achieve complete penetration because of pain.”

3.2.3. Sexual problems in newlyweds

Twenty‐two percent of the questions were about newlyweds' experiences of not enjoying sex, lack of sexual desire, lack of sufficient sexual arousal, premature ejaculation, or erectile problems that expressed the need for sexual education/counseling. For example, a man reported the lack of sexual desire in her wife: “My wife refuses to have sex and this is me that always insists. We have been engaged for 4 years. I feel that she doesn't like to have the sexual relationship. What should I do? She never initiates sex and doesn't show any desire for it. She always says that it's still very soon for sex and we haven't gotten married officially and I'm afraid”. Another woman asked: “What is the cause of problem in erection? My spouse pretend that he has no problem and he doesn't want to see a doctor. I'm worried and told him to see a doctor, but he said we are engaged now (Aghd period) and everything will be ok eventually.”

Some couples had a problem in vaginal penetration, and the attempted penetration led to pain, fear, and frustration. A woman said: “I have been married for about one month. We tried to have a vaginal sex several times, but I had pain and stress, and my husband didn't insist. I had enough discharge, and my spouse had no problem with erection. I feel my vaginal opening is small and difficult to insert. I studied vaginismus, but it didn't help, and when we have sex, it is still this problem that prevents vaginal penetration and disappoints my spouse. Do you think I have a serious problem? Should I see a doctor?” Another woman submitted a question that reflected her fear of divorce because of problem in sex: “All I do is cry (crying sticker). I was crying so much that I couldn't talk to you. I preferred to hang up. One of our family members divorced after three years of marriage because she was still a virgin. This was the third sex that we had, and he failed to penetrate. I am in so much pain that I don't understand anything at that moment…”

4. DISCUSSION

To date, a limited number of studies have been conducted to explore the hidden real needs of newly married couples in sexual and reproductive behaviors in Iran. In the current study, newly married couples expressed their openness towards receiving virtual counseling on SRH from a reproductive health specialist. The findings have identified two significant categories: “need to create a reproductive life plan” and “the need for sexual knowledge and counseling”. These categories have emerged to address the unmet needs of SRH services among these couples.

The existing premarital educational curriculum has demonstrated limited effectiveness in addressing the aforementioned questions and concerns. This is consistent with a recent study in Iran that showed inadequate levels of premarital sexual knowledge and unfavorable attitudes among the majority of participants. ³ A review study by Mehrolhassani et al. also reported poor content of educational material, low duration of the training, and moderate to weak knowledge and attitude regarding SRH in Iran. ¹⁵ Although couples in Iran receive premarriage SRH education, this education is very short (90 min) and basic and only includes an introduction to reproductive anatomy and physiology. Since premarital sex education for adolescents and youth is prohibited in Iran, it seems that the opportunity for premarriage education should be seized.

Our participants need to create a reproductive life plan and have access to counseling regarding contraceptive methods, preconception care, and how to deal with a missed period/unplanned pregnancy. Reproductive life planning is inclusive of both sexes and consists of preconception care and family planning. It can increase fertility knowledge ¹⁶ and serves as a framework for promoting reproductive health across the life span of both men and women and, in turn, improves pregnancy and infant outcomes. ¹⁷ The educational program for marrying couples in Iran mainly focused on childbearing and omitted family planning. Although most of the submitted questions by the couples were related to family planning methods, access to free family planning information and services in the public health system is also restricted due to newly adapted pro‐natalist population policies. ¹⁸

Currently, providing family planning services or promoting them are prohibited in the state clinics in Iran, and it seems that the Youthful Population and Protection of the Family law, despite all its strengths in supporting childbearing, might lead to a widening gap in fertility control between rich and poor people. It might increase inequalities in access to contraceptive methods, especially in marginalized women and girls. ¹⁹ Since most of couples are busy with planning for the wedding ceremony immediately after receiving a permit for marriage registration, it is important to make them aware that using these services is optional but critical, and they can come back any time later. Midwives and reproductive health specialists in Iran are considered to be the best option for providing these services to couples.

The participants expressed their concerns about late or absent menstruation during the period of Aghd and needed support because the social norms are still against premarital sex or being pregnant before the wedding ceremony in Iran. ²⁰ Similarly, because of the customs, premarital sexuality is a social taboo in China. The cultural prejudice against premarital sexuality even makes it quite sensitive to discuss this topic publicly. ²¹ Although pre/extramarital sexual relations are illegal and taboo in Iran, some evidence shows important minorities of young males and females are involved in such relations. ²² Due to significant increases in premarital sexuality, healthcare providers should provide professional counseling to fulfill couples' needs and support them in case of delayed menstruation or unintended pregnancy. Particularly because of a high rate of unwanted pregnancy (27.9%) ²³ and legally prohibited abortion in the country, ²⁴ poor access to fertility control methods might have adverse consequences. The result of two qualitative studies in Iran also declared that most of the unplanned pregnant women used justification strategies to terminate the pregnancy and had negative reactions toward it. Although social barriers to abortion influenced most women to continue an unplanned pregnancy, it resulted in unsafe behavior during the pregnancy and perinatal depression. An unsafe, illegal abortion could have potentially life‐threatening complications. ²⁵ , ²⁶ Since fear of unplanned pregnancy may result in anxiety about having sex and, in turn, ruin the sex life, providing special support and counseling for newly married couples is highly recommended.

Some couples needed preconception care and receiving information regarding their fertility status immediately after marriage. Due to postponing marriage and childbirth to achieve higher levels of education and higher income, preservation of fertility and optimizing health before pregnancy is becoming increasingly important. ²⁷ Therefore, optional access to preconception care services or the assessment of fertility status in newly married couples appears necessary.

The need for sexual knowledge and counseling was another category that showed the importance of premarital sexual education. Since sexual intimacy and sexual relationship is only acceptable within the institution of marriage within Iranian society and premarital sex is considered sinful according to the Islamic religious perspective, ²⁸ there is no comprehensive sexuality education before marriage in Iran. Sexuality education at the time of marriage is very short and basic. Similarly, another study in Iran showed that engaged Iranian couples wished to receive more information about sexuality and SRH issues. ² The study findings confirm a need for comprehensive and culturally sensitive sexual education for Iranian couples. Given the increasing divorce rates observed in recent years in Iran, the need for such culturally appropriate education to promote a healthy and stable family life is highlighted. ²

Preserving virginity even during the time between the legal/official registration ceremony (Aghd) and the wedding ceremony (Aroosi) was important for some newly married couples (both men and women). After the Aghd, couples can have sex without religious prohibition. However, some postpone having sex until after the wedding party because women prefer not to lose their virginity before everything has been finalized. ²⁹ This finding confirms that cultural issues are more important than religious prohibitions. ³⁰ Although in modern Iranian society, delay in marriage has increased premarital sexual relationships, ³¹ the cultural and social values emphasize the preservation of virginity. ²⁸ In our study, the couples that were worried about losing virginity only tried physical intimacy or non‐penetrative sex, but they needed help to experience orgasm. Some men wanted their wife to be a virgin until marriage and requested a virginity test, while women felt humiliated by this request. Iran is a mixture of tradition and modernity, but the traditional culture is still dominant and female virginity is a source of pride. ³² Female virginity, dating without sexual activity, and heterosexual relationships are socially approved within Iranian society. However, in a recent study in Iran, males were less likely to insist upon the necessity of preserving the virginity of girls until marriage (43%) than females (61%), which means women are more worried about protecting virginity until marriage. ²⁸

Another issue raised in the questions was sexual problems on the honeymoon and the myth and dysfunctional beliefs regarding the hymen and virginity. Some women were worried about whether they bleed at the first time they had sex or not. A recent study showed that only 52.5% of the women reported bleeding at the first penile–vaginal intercourse, and half of men that encountered no bleeding at the first intercourse had a violent reaction. A study in Iran revealed that valuing bleeding as a sign of virginity would damage the couples' marital relationship and sexual life, emphasizing the need for sexual education. ³³

The considerable number of submitted questions from newly married couples on how to manage their sexual problems demonstrate that they need a reliable source of sexual information and access to sexual health clinics. The high prevalence of sexual problems can threaten the quality of sex life, marital intimacy, and mental health. ³⁴ Hence, it is necessary to be considered in couples' healthcare planning. Our findings confirm the importance of establishing a formal systematic framework for providing sexual health services. Otherwise, informal help‐seeking behavior may lead to delay in help‐seeking for sexual health issues, relationship discord, and impacts on the quality of sex life. ³⁵ Providing access to SRH services besides the education program would benefit newly married couples.

4.1. Strength and limitation

Through the analysis of anonymously submitted SRH‐related questions, we conducted an assessment of the genuine information needs regarding SRH among newly married couples. The researcher in this study tried to establish a strong and trustworthy rapport between a reproductive health specialist and the participating couples, in order to uncover their hidden needs. By utilizing a social network platform, the couples were able to engage in disscussions on sensitive topics with the researcher, free from the fear of stigma or negative judgement. The findings of the data analysis were not disclosed to the participants. However, we sought to enhance the credibility of the results through investigator triangulation and by incorporating relevant supporting and contrasting literature into the discussion. A full description of the procedures and outcomes ensured a satisfactory level of transferability. It is important to note that due to the COVID‐19 pandemic, the premarriage education sessions, including SRH training sessions (90 min) were held virtually during the study period. This might have an impact on the level of their sexual and reproductive knowledge. Not having a male colleague to participate in answering men's questions was one of the limitations of this study, which may have discouraged some men from asking questions. Although the current study yields important insight into understanding newly married couples' needs in the field of SRH, it only reveals the questions of those who took part in our study.

5. CONCLUSION

This study provides valuable insights into the understanding of SRH needs among Iranian newly married couples, highlighting the importance of addressing these issues in Iran's policy agenda. Specificely, there is a pressing demand for specilized services that cater to reproductive life planning and provide reliable information sources for sexual knowledge for this population. The lack of easily accessible SRH clinics for young couples can lead to reliance on unreliable sources of information, which can have negative effects on their overall health. Initiating reproductive life planning and sex education for newly married couples within community health services can enhance timely childbearing, intended pregnancy, and prevent unsafe and illegal abortion, and its consequent infertility. Designing new interventions to meet the SRH needs in newly married couples is highly recommended. Based on the results of the present study, in future studies, interventions should be designed and evaluated that respond to the real needs of couples and can guide policymakers in designing new educational curricula in premarital courses. Additionally, providing long‐term counseling services for newly married couples is highly recommended, considering the potential difficulties that may arise within their sexual relationship over time. Such counseling services can have a significant role in addressing and overcoming these challenges.

AUTHOR CONTRIBUTIONS

Fahimeh Ranjbar: Conceptualization; funding acquisition; investigation; methodology; project administration; supervision; writing—original draft; writing—review & editing. Farideh Khalajabadi Farahani: Formal analysis; methodology; Writing—review & editing. Maryam Montazeri: Data collection; review & editing. Shayesteh Jahanfar: Formal analysis; methodology; validation; writing—review & editing. Maryam Gharacheh: Conceptualization; methodology; validation; writing—original draft; writing—review & editing.

CONFLICT OF INTEREST STATEMENT

The authors declare that there is no conflict of interest.

ETHICS STATEMENT

In the current study, all methods were performed in accordance with the relevant guidelines and regulations (Declaration of Helsinki). Ethical approval for this study was obtained by the ethics committee of the National Institute for Medical Research Development (NIMAD) (IR.NIMAD.REC.1399.123). Participants signed an electronic informed consent. Furthermore, the participants sent their questions to the researcher voluntarily, which was used in a deidentified form (without personal information) for data analysis. All the submitted questions were responded to as soon as possible (within 24 h) by F.R. The participants did not need to send their identity information before asking a question, and it was completely possible to send their questions anonymously. Only the first author had access to the submitted questions through a WhatsApp account. Also, to ensure data confidentiality, each question was given an identification code, and all computers were secured with passwords.

TRANSPARENCY STATEMENT

The lead author Maryam Gharacheh affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Ranjbar F, Khalajabadi Farahani F, Montazeri M, Jahanfar S, Gharacheh M. Sexual and reproductive health‐related questions and concerns of newly married couples: a qualitative content analysis. Health Sci Rep. 2023;6:e1479. 10.1002/hsr2.1479

DATA AVAILABILITY STATEMENT

All authors have read and approved the final version of the manuscript. FR had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis. The data that support the findings of this study are available by the National Institute for Medical Research Development (NIMAD), but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are, however, available from the corresponding author upon reasonable request and with the permission of NIMAD. You can direct correspondence to gharacheh.m@gmail.com.