Background

Risk in pregnancy refers to the possibility of complications that are not expected to occur under normal conditions but already exist or occur during pregnancy. Anatomical, physiological, and psychological changes experienced during pregnancy create a potential risk for the health of pregnant women and fetus, because they disrupt the balance between health and disease [1]. Risk perception during pregnancy is defined as “feelings, thoughts, and awareness of pregnant women about possible harm to themselves and their babies” [2]. Risk perception during pregnancy is a complex process based on many personal, physiological, psychological, and cultural factors. In addition to these, previous experiences, adaptation to pregnancy, period when the risk occurs, social support sources, lack of knowledge, attitudes of pregnant women toward risks [3], medical risk, psychological elements, clinical features of the risk, gestational age, and stances of health professionals are other factors associated with the level of risk perception [4, 5]. Risk perception may be perceived differently by each pregnant woman. Women make decisions based on their perception of whether their risk increases or decreases rather than the actual risk [6]. Risk perception is a strategy used to reduce maternal and perinatal mortality and morbidity [7].

Pregnancy is a period when pregnant women and their partners avoid sexual intercourse due to wrong beliefs and attitudes about sexuality. False notions during pregnancy are that sexual intercourse can be dangerous, the penis can enter the uterine cavity, rupture the fetal membranes, and harm the fetus [8]. During pregnancy, not only beliefs and attitudes toward sexuality, but also anatomical, physiological, and spiritual changes experienced by women are also associated with sexual life during this period [9]. Biopsychosocial, physical, and hormonal changes during pregnancy are associated with physical pleasure and sexual activity in lives of women. It is stated that sexual desire, frequency of sexual intercourse, and sexual orgasm differ in pregnant women, especially when compared to the period prior to the pregnancy [10, 11]. It is reported that hormonal, physical, and psychological changes during pregnancy, personality traits, marital satisfaction of couples, and sexual beliefs and attitudes during pregnancy are associated with sexual health and a decrease in the frequency of sexual intercourse [12,13,14]. Research shows that there are positive beliefs as well as negative beliefs about sexuality during pregnancy. Maintaining a healthy sexual life during pregnancy will support marital satisfaction, prevent marital betrayal, and be positively associated with fetus health [15, 16].

Previous studies have examined sexual function, sexual beliefs, body image, and sexual quality of life during pregnancy [17,18,19]. However, less attention has been given to how pregnancy-related risk perception is associated with attitudes toward sexuality during pregnancy. This gap is important because perceived risk may shape women’s concerns, avoidance behaviors, and need for counselling, even when there is no medical contraindication to sexual intercourse. Understanding this relationship may provide useful evidence for midwives, nurses, and other healthcare professionals who provide antenatal counselling. Therefore, this study was conducted to examine the relationship between pregnancy risk perception and attitudes toward sexuality during pregnancy among pregnant women in Türkiye.

Methods

Study design and setting

This descriptive, cross-sectional study was conducted with pregnant women aged 18 years or older who applied to family health centers in a district of the Mediterranean Region of Türkiye and reported no high-risk condition during the current pregnancy. Inclusion criteria were being pregnant, being 18 years of age or older, being able to communicate in Turkish, volunteering to participate, and having a pregnancy without a reported medical high-risk condition. Exclusion criteria were having a diagnosed high-risk pregnancy, having a medical recommendation to avoid sexual intercourse, having a psychiatric or cognitive condition that prevented completion of the questionnaires, and providing incomplete or inconsistent questionnaire data. Before the study, sample size was calculated using G*Power 3.1.9.7 with correlation = 0.18, alpha = 0.05, and power (1-beta) = 0.85. The minimum required sample size was 271. Considering possible data loss, data were collected from 325 pregnant women. After excluding incomplete or incorrect forms, the study was completed with 306 pregnant women.

Study instruments

Personal information form

Personal Information Form is a form prepared by the researchers that contains the introductory information of the women participating in the study.

Perception of pregnancy risk questionnaire (PPRQ)

The scale was developed by Heaman and Gupton to evaluate the risk perception of pregnant women. Although there were 11 items in the first version, it was later revised by the authors, and the final version consists of 9 items. The scale is a visual analog measurement tool. It has a two-factor structure: risk perception toward the baby and risk perception toward oneself. The risk perception toward the baby factor consists of 5 items (items 2, 6, 7, 8, and 9), and the risk perception toward oneself factor consists of 4 items (items 1, 3, 4, and 5). Each item is scored on a 0–100 mm line ranging from “no risk at all” to “extremely high risk.” The total score is calculated by summing the item scores and dividing by 9. Subscale scores are calculated by summing the items within each subscale and dividing by the number of items in that subscale. The PPRQ has no established cut-off point; therefore, in this study, total and subscale scores were analyzed as continuous variables. Higher scores indicate higher perceived pregnancy-related risk, and no categorization such as low, moderate, or high risk perception was applied. The Turkish validity and reliability study was conducted by Evcili and Dağlar [20]. In the Turkish validity and reliability study, the total Cronbach’s alpha coefficient was 0.84. In this study, the total Cronbach’s alpha coefficient was 0.86.

Attitude scale toward sexuality during pregnancy (ASSP)

Attitude Scale toward Sexuality during Pregnancy is considered a valid and reliable tool to determine the attitudes of pregnant women and men whose wives are pregnant toward sexuality during pregnancy.

The Cronbach Alpha coefficient of the ASSP scale, which consists of 34 items and three sub-dimensions, was found to be α = 0.902 [9].

The Anxiety About Sexual Intercourse During Pregnancy sub-dimension consists of 9 items (7, 10, 15, 18, 22, 25, 26, 27, 30), the Beliefs and Values Toward Sexuality During Pregnancy sub-dimension consists of 10 items (3, 4, 8, 9, 12, 13, 16, 17, 19, 29), and the Approval of Sexuality During Pregnancy sub-dimension consists of 15 items (1, 2, 5, 6, 11, 14, 20, 21, 23, 24, 28, 31, 32, 33, 34).

The scoring of the items expressing positive attitudes (1-2-5-6-11-14-20-21-23-24-28-31-32-33-34) in the ASSP is coded as “totally disagree” = 1, “disagree” = 2, “moderately agree” = 3, “agree” = 4, and “totally agree” = 5 while the items expressing negative attitudes (3-4-7-8-9-10-12-13-15-16-17-18-19-22-25-26-27-29-30) are reversely coded and scored as “totally disagree” = 5, “disagree” = 4, “moderately agree” = 3, “agree” = 2, and “totally agree” = 1.

It was calculated that the lowest score that can be obtained from the sub-dimension “Anxiety Toward Sexual Intercourse During Pregnancy” is 9, the highest score is 45; the lowest score that can be obtained from the sub-dimension “Beliefs and Values Toward Sexuality During Pregnancy” is 10, the highest score is 50; and the lowest score that can be obtained from the sub-dimension “Approval of Sexuality During Pregnancy” is 15, the highest score is 75. The lowest total score that can be obtained from the Attitude Scale toward Sexuality during Pregnancy is calculated as 34 and the highest total score is 170. An increase in the total score obtained from the ASSP indicates that attitudes toward sexuality during pregnancy are positive, and a decrease in the total score indicates that attitudes toward sexuality during pregnancy are negative. When considered in terms of sub-dimensions, an increase in the score obtained from the “Anxiety Toward Sexual Intercourse During Pregnancy” sub-dimension indicates that anxious attitudes toward sexual intercourse during pregnancy decrease, while a decrease in the score indicates that anxious attitudes toward sexual intercourse during pregnancy increase. An increase in the score obtained from the “Beliefs and Values Toward Sexuality During Pregnancy” sub-dimension indicates that attitudes involving beliefs and values toward sexuality during pregnancy are positive, while a decrease in the score indicates that attitudes involving beliefs and values toward sexuality during pregnancy are negative. An increase in the score obtained from the “Approval of Sexuality During Pregnancy” sub-dimension indicates a more approving attitude toward sexuality during pregnancy, while a decrease in the score indicates a disapproving attitude toward sexuality during pregnancy.

The cut-off point of the ASSP was determined as 111.5 in the scale development study. In the present study, this cut-off point was used only to describe the proportion of participants with positive or negative attitudes toward sexuality during pregnancy; all inferential analyses used continuous ASSP scores. Participants with a total ASSP score of 111.5 or above were classified as having a positive attitude, and those with a score below 111.5 were classified as having a negative attitude. The Cronbach’s alpha coefficient for this study was 0.874. Necessary permission to use the scale was obtained.

Research variables

Dependent variables

Scores obtained from the Attitude Scale toward Sexuality during Pregnancy and the Perception of Pregnancy Risk Questionnaire.

Independent variables

Sociodemographic characteristics and pregnancy-related characteristics.

Data collection

For the study, permission was obtained from Burdur Mehmet Akif Ersoy University Non-Interventional Clinical Research Ethics Committee (Meeting No: 2021/12, Decision No: GO 2021/410) and from the institution where the data were collected. Data were collected by face-to-face interview between 01.06.2022 and 01.02.2023. The questionnaire consisted of four parts. In the first part, participants were informed about the study through an informed consent form, and their consent was obtained. The second part included the Personal Information Form, the third part included the Perception of Pregnancy Risk Questionnaire, and the fourth part included the Attitude Scale toward Sexuality during Pregnancy. Interviews were conducted in a private setting as far as possible to support participant comfort and confidentiality. Data collection took approximately 10–15 min for each participant.

Data analysis

Data were analyzed using IBM SPSS Statistics version 25. Descriptive statistics were presented as numbers, percentages, means, and standard deviations. The Kolmogorov-Smirnov test was used to assess the normality of continuous variables. Independent samples t-tests were used to compare two independent groups. One-way analysis of variance (ANOVA) was used for comparisons involving more than two independent groups. When ANOVA results were statistically significant, Bonferroni post-hoc tests were performed to identify pairwise group differences. Pearson correlation analysis was used to examine the relationships between PPRQ and ASSP scores. Correlation coefficients around 0.10–0.29 were interpreted as weak correlations. A p-value of < 0.05 was considered statistically significant.

Results

Table 1 shows the distribution of the pregnant women according to their descriptive characteristics. According to the table, 50.7% of the pregnant women were between the ages of 20–29, 36.3% were high school graduates, 78.8% were housewives, 69.0% had a nuclear family, and 47.7% of them had an income equal to their expenses. Moreover, 48.7% of the participants had their first pregnancy, 64.7% had a planned pregnancy, 52.9% were in the last trimester, and 20.9% had miscarriage/abortion experience. Furthermore, 55.2% of the pregnant women stated that they had sufficient knowledge about sexual intercourse during pregnancy, 41.8% of them stated that they had sexual intercourse three or more times a week prior to pregnancy, and 69.3% of them stated that they were satisfied with their sexual intercourse prior to pregnancy. 48.4% of the pregnant women answered yes to the question of “Did You Abstain from Sexual Intercourse During Pregnancy?”

Table 1 Distribution of pregnant women according to their descriptive characteristics
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Table 2 presents the mean PPRQ scores. The mean total PPRQ score was 41.75 +/- 13.97. The mean score for risk perception toward oneself was 42.37 +/- 17.13, and the mean score for risk perception toward the baby was 40.98 +/- 16.58.

Table 2 Mean scores of pregnant women on the perception of pregnancy risk questionnaire
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Table 3 presents the mean ASSP scores and the classification of attitudes according to the ASSP cut-off point. The mean total ASSP score was 104.99 +/- 23.23. According to the cut-off point, 23.9% of the participants had a positive attitude and 76.1% had a negative attitude toward sexuality during pregnancy.

Table 3 Mean scores of pregnant women on the attitude scale toward sexuality during pregnancy
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Table 4 presents PPRQ and ASSP scores according to descriptive and pregnancy-related characteristics. PPRQ scores differed significantly according to age, education level, working status, economic level, number of pregnancies, planned pregnancy status, pregnancy trimester, frequency of sexual intercourse prior to pregnancy, sexual intercourse satisfaction prior to pregnancy, and abstinence from sexual intercourse during pregnancy. ASSP scores differed significantly according to education level, working status, family type, economic level, number of pregnancies, planned pregnancy status, pregnancy trimester, miscarriage/abortion history, sufficient knowledge about sexual intercourse during pregnancy, frequency of sexual intercourse prior to pregnancy, sexual intercourse satisfaction prior to pregnancy, and abstinence from sexual intercourse during pregnancy.

Table 4 Mean scores of pregnant women on the perception of pregnancy risk questionnaire and attitude scale toward sexuality during pregnancy according to their descriptive characteristics
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Table 5 presents the correlations between PPRQ and ASSP scores. Risk perception toward the baby showed a weak positive correlation with approval of sexuality during pregnancy (r = 0.195, p = 0.001) and total ASSP score (r = 0.143, p = 0.012). Risk perception toward oneself showed weak negative correlations with anxiety about sexual intercourse during pregnancy (r = −0.195, p = 0.001), beliefs and values regarding sexuality during pregnancy (r = −0.124, p = 0.031), approval of sexuality during pregnancy (r = −0.271, p < 0.001), and total ASSP score (r = −0.215, p < 0.001). The total PPRQ score was not significantly correlated with the total ASSP score (r = −0.016, p = 0.784).

Table 5 The relationship between the scores that the pregnant women got from the perception of pregnancy risk questionnaire and the attitude scale toward sexuality during pregnancy
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Discussion

Risk perception during pregnancy includes women’s feelings, thoughts, and awareness regarding possible harm to themselves and their babies [2]. It is a complex and subjective phenomenon associated with personal, psychological, obstetric, clinical, and social factors [6]. In the present study, PPRQ scores varied according to several sociodemographic and pregnancy-related variables. This variation supports the view that perceived pregnancy risk is not only a clinical construct but also a context-dependent experience shaped by previous pregnancy experiences, gestational stage, knowledge, socioeconomic conditions, and social environment. The observed associations should not be interpreted as causal because of the cross-sectional design.

The mean total PPRQ score in this study was 41.75 (SD = 13.97). Previous studies have reported different mean pregnancy risk perception scores in different samples and contexts [5, 21]. These differences may be related to sample characteristics, obstetric history, measurement approaches, access to antenatal information, and sociocultural context. Because the PPRQ has no established cut-off point, the present study treated risk perception as a continuous variable rather than categorizing it into low, moderate, or high levels. This approach is important for avoiding unsupported interpretation of the score level and for improving comparability with future studies.

Risk perception toward the woman herself was slightly higher than risk perception toward the baby. Sangin and Phonkunsol [5] also reported higher maternal self-risk perception than baby-related risk perception among women of advanced maternal age. This pattern may indicate that pregnant women are particularly attentive to bodily changes, childbirth-related concerns, possible complications, and their own vulnerability during pregnancy. It does not necessarily mean that fetal concerns are less important; rather, maternal and fetal risk perceptions may be experienced differently. In antenatal care, exploring both maternal and fetal concerns may help midwives and nurses provide individualized counselling without increasing unnecessary fear.

Attitudes toward sexuality during pregnancy are closely linked to beliefs, values, previous experiences, and the quality of partner communication [22,23,24]. In this study, ASSP scores were associated with education level, working status, family type, economic level, parity, planned pregnancy status, trimester, sexual knowledge, previous sexual satisfaction, and abstinence during pregnancy. These findings are consistent with the view that sexuality during pregnancy is shaped by biomedical, psychological, relational, and sociocultural factors rather than by a single determinant.

Economic status and education level were associated with attitudes toward sexuality during pregnancy in the present sample. Previous studies have reported that socioeconomic and educational characteristics may be related to sexual function and attitudes during pregnancy [9, 25, 26], although findings are not fully consistent across studies [27]. Differences across studies may reflect variation in sample composition, access to antenatal counselling, cultural norms, and willingness to discuss sexuality in research settings.

An unexpected finding was the weak positive correlation between risk perception toward the baby and approval of sexuality during pregnancy. This finding requires cautious interpretation because the magnitude of the correlation was weak. One possible explanation is that women who are more attentive to fetal well-being may also be more likely to seek accurate information about pregnancy-related health behaviors, including the safety of sexual intercourse during pregnancy. Therefore, higher perceived risk toward the baby may not necessarily reflect fear or avoidance; it may also reflect greater awareness, monitoring, and engagement with antenatal health information. Another possible explanation is that women who receive accurate counselling may recognize pregnancy-related risks while maintaining more positive attitudes toward sexuality when no medical contraindication exists. This interpretation remains tentative, and qualitative or mixed-method studies are needed to explore the meanings underlying this association.

The weak negative correlations between risk perception toward oneself and ASSP scores suggest that women who perceive greater personal risk may report less positive attitudes toward sexuality during pregnancy. This association may be related to concerns about bleeding, pain, preterm labor, bodily changes, or uncertainty about whether sexual intercourse is medically safe during pregnancy. In this context, lower ASSP scores may reflect precautionary or avoidant attitudes rather than sexual dissatisfaction alone. Cultural and religious norms may also provide an important context for interpreting these findings. Although these factors were not directly measured in the present study, attitudes toward sexuality during pregnancy in Türkiye may be shaped by modesty, taboos, marital expectations, fetal protection concerns, and misconceptions about possible harm to the baby or mother [8, 28]. More broadly, previous studies have shown that sexual function during pregnancy is associated with multiple maternal and pregnancy-related factors [29, 30]. A systematic review and meta-analysis further demonstrated that the prevalence of female sexual dysfunction varies across pregnancy trimesters [31], while other studies have reported changes in sexual desire, frequency of sexual intercourse, satisfaction, and overall sexual functioning as pregnancy progresses [32,33,34,35,36]. Future studies should examine cultural, religious, relational, and informational factors more directly.

Limitations

This study has several limitations. First, the cross-sectional design does not allow causal inferences; therefore, the findings should be interpreted as associations rather than causal relationships. Second, although the sample size was determined by power analysis, the participants were recruited from family health centers in a single district in Türkiye, which may limit the generalizability of the findings and may have introduced selection bias. Third, the study did not include a control or comparison group. Fourth, only women without high-risk pregnancies were included; therefore, the findings may not be generalizable to women with high-risk pregnancies or medical contraindications for sexual intercourse. Fifth, the data were based on self-report measures and were collected through face-to-face interviews on a sensitive topic, which may have increased the risk of social desirability bias. Finally, the statistically significant correlations observed in this study were weak, indicating that their practical significance should be interpreted cautiously.

Conclusion

This study found weak associations between pregnancy risk perception sub-dimensions and attitudes toward sexuality during pregnancy among pregnant women in Türkiye. Risk perception toward oneself was weakly and negatively correlated with attitudes toward sexuality during pregnancy, whereas risk perception toward the baby showed weak positive correlations with approval of sexuality during pregnancy and total ASSP score. These findings should be interpreted cautiously because of the cross-sectional design and the weak magnitude of the correlations. Antenatal counselling provided by midwives and nurses may benefit from addressing women’s concerns, misconceptions, and information needs regarding sexuality during pregnancy, particularly when no medical contraindication exists. Future multi-center, qualitative, and mixed-method studies are recommended to explore the cultural, relational, and informational factors underlying these associations.