Maternal Sexuality after Child Birth among Iranian Women
The aim of this study was to investigate the sexual function of mothers at one year postpartum and associated factors. Four hundred and ninety Iranian women were recruited randomly at four time periods from child birth: first 3 months, 4 to 6, 7 to 9 and 10 to 12 months, from January to July 2008. All mothers were married, literate and agreed with participation. The exclusion criteria were, (a) loss of baby, (b) living far from their partner, (c) psychological problems and (d) serious medical diseases. Data on socio-demographic factors, obstetric, medical, last delivery and postpartum history was obtained. The sexual function was evaluated by the 19th item questionnaire of Female Sexual Function Index (FSFI). The mean resumption of intercourse was 57.17±27.95. Twenty-four had no sexuality. The most common reasons were fear of pain, no interest, worrying about another pregnancy, feeling tired and bleeding. All dimensions of women 's sexual function were at the lowest level in early postpartum. Sexual activity had significance correlation with an older maternal age, a longer marriage duration and higher number of children. Mothers diseases, neonate problems and tuboligation were associated with lower scores of sexual function. There was no association with delivery type and perineal injuries. Sexual parameters decrease at the first 3 months of postpartum and recovery during the following months. More consultation and direction of postnatal sexuality recurrence is needed.
Sexual functioning is recognized as a multidimensional phenomenon and is influenced
by many bio-psychosocial factors. Child birth and postpartum periods have a
substantial impact on the sexual behavior of mothers. In general, sexual functioning
typically declines during pregnancy and remains low during the postpartum period
for many women. According to review of literatures sexual activity tends to
be reduced for several months as compared with the pre pregnancy level and sexual
problems occur relatively often (Von Sydow, 1999). The
literature estimates a range of short term postpartum sexual problems from 22
to 88% (Hicks et al., 2004). It is reported that
in the first three months after delivery a high percent of women experience
sexual problems (Xu et al., 2003; Barrett
et al., 2000). Of course, there is less agreement in the findings
of research on the resumption of sexual activity and it's prevalence following
child birth (Von Sydow, 1999). It may reflect differences
in cultural, racial, socio-economic and health variables among countries.
Maternal sexuality during postpartum may be correlated with some factors such
as maternal age ( Van Brummen et al., 2006; Al-Bustan
et al., 1995), sexual intercourse during pregnancy (Van
Brummen et al., 2006), mode of delivery (Hicks
et al., 2004; Barrett et al., 2000;
Barrett et al., 2005; Rowland
et al., 2005), breast feeding (Al-Bustan et
al., 1995; Rowland et al., 2005 ; Hyde
et al., 1996; Alder, 1989), parity (Al-Bustan
et al., 1995, Rowland et al., 2005),
level of education (Al-Bustan et al., 1995),
duration of marriage (Al-Bustan et al., 1995),
psychological variables (DeJudicibus and McCabe, 2002)
and physical factors related to delivery (Lamarre et
Moreover, sexual difficulties experienced by the new mother may cause much
distress, familial discord and divorce, influence the quality of their life,
their self esteem, physical and mental well being and interpersonal relationships.
A greater understanding of problems in female sexuality after child birth is
basic to plan an effective treatment and to develop prevention strategies. Sometimes
postpartum sexual concerns lack professional recognition, with health care providers
focusing exclusively on the infant's adjustment. Also, many mothers do not ask
consultants regarding their concerns. Therefore many of researchers emphasis
health care workers need to be made aware of this silent problem and should
counsel the women in their care (Abdool et al., 2009;
Glazener, 1997; Saurel-Gubizolles
et al., 2000).
On the other hand, most studies of sexuality after birth suffer from methodological problems, such as, non random convenience and small sample, not providing operational definitions of terms and do not use of standard scales. Furthermore, the results of some studies are in contrast with each other.
The purpose of this study is: (1) to provide descriptive data on the sexual function of mothers at four time periods from child birth through 12 months postpartum and (2), to evaluate which factors are associated with sexual activity during this time.
MATERIALS AND METHODS
A cross sectional study was conducted of women attending the mother and child health services during one year after delivery in the North of Iran from January to July 2008. Sample size was determined to be at 95% confidence interval and 49.6% prevalence of female sexual dysfunction in a pilot study. Using this assumption, a sample size of 480 was required. With a project subject drop out rate of 10%, the total number required was determined to be 528. The year after child birth was divided into four periods of time: first at 3, 4 to 6, 7 to 9 and 10 to 12 months. A systematic random sampling design was used.
Participants must meet a number of criteria to be included in the sample including, (1) attending from 6 weeks to one year post delivery, (2) being sufficiently literate to complete questionnaires, (3) agree to participate in the study and (4) to be married. The exclusion criteria were, (1) loss of baby, (2) living away from partner, (3) psychological problems and (4) serious medical diseases.
A questionnaire was completed for each woman by gathering information about
them and pulling their medical reports, including socio- demographic factors,
obstetric and medical history, last delivery and postpartum history, along with
contraceptive practices after child birth. Then, a 19 item questionnaire of
Female Sexual Function Index (FSFI) was completed by each woman. This clinical
tool has the advantage of being standardized, easy to administer scores and
provides normal values in general and pathological populations (Safarinejad,
2006; Rosen et al., 2000). The FSFI evaluates
six domains of female sexual functioning during the last four weeks which includes:
desire, arousal, lubrication, orgasm, satisfaction and pain during sexual intercourse
(Safarinejad, 2006). The full scale over range is from
2 to 36, with higher scores associated with a lesser degree of sexual dysfunction.
Analysis of data was made by the use of descriptive statistic, t-test, ANOVA
Of the 528 women who were recruited, 38 (7.2%) were excluded from analysis because of incomplete responses (26), non-attendance of husband (4), hysterectomy (1) and serious medical and psychological problems after delivery (7). A total of 490 women were assessed and their characteristics are given in Table 1. The mean was 26.38±4.79 (15-39) years for maternal age; 20.56±3.74 (13-36) for marriage age; 5.87, SE: 0.18 (1-21) years for marriage duration and 26.54±4.68 (15.11-46.07) for Body Mass Index (BMI).
|| Socio demographic characteristics of subjects
|1Body mass index, 2Progesterone only
pills, 3Intra uterine device, 4Tuboligation, 5Oral
contraceptive pills, 6Demedrogyprogesteron acetate
The range of resumption of intercourse was between 15 to 210 days after delivery,
with mean of 57.17±27.95. Twenty-four (4.9%) had no sexuality, which
the minimum time from delivery was 45 days and the maximum time was 12 months.
Also, 259 women (52.9%) had delayed sexuality for more than 45 days of postpartum
(in Iran, it is recommended delaying intercourse until 6 weeks post child birth).
Mothers reasons for having no sexuality or delaying were fear of pain
(8.6%), no interest (3.5%), worrying about another pregnancy (2.5%), being tired
(2.2%) and bleeding (0.6%). Forty-three women (8.8%) reported problems in sexuality
and 196 (40%) had felt a decreased desire in comparison with pre-pregnancy,
however, only 12 (2.4%) of Mothers discussed their issues with a health care
The sexual functioning items scores by 4 periods postpartum were significantly different by ANOVA (Table 2). Scheffe test indicated significant differences of desire, arousal, lubrication and total score between first, third and fourth 3 months; for orgasm, satisfaction and pain between first and third 3 month.
There was a significant correlation between sexual function and some socio-demographic variables (Fig. 1).
||Comparison of sexual functioning items by 4 points after postpartum
||Correlation between sexual function and maternal characteristics
A direct and strong correlation (r = 0.17, p = 0.0001) was seen with postpartum
duration. Higher maternal age (r = -0.12, p = 0.006), marriage duration (r =
-0.08, p = 0.05) and number of children (r = -0.09, p = 0.02) were correlated
with a decrease of sexual function. Forty-eight (9.8%) of mothers had neonate
with problems such as, low birth weight, anomaly and medical disorders. Total
sexual functioning scores was significantly lower in them (19.79±8.24
vs. 23.31±5.64, p= 0.006). Also, 11.4% of mothers had a medical disease
and their scores were lower than the healthy mothers (21.11±6.68 vs.
23.20±5.91, p = 0.01). The lower score was related to nervous and skeletal
diseases. Also, sexual function was related to contraceptive methods (p = 0.04).
The lowest score was related to tuboligation (20.34±7.67) and the highest
one (26.85±7.45) was in Intra Uterine Device (IUD). The incidence of
Episiotomy was 25.1%, tear of perineum 7.3%, unwanted pregnancy 13.3%, urinary
incontinence 4.3% and unpleasant body image 64.5%; however, there was not a
correlation between them and sexual function.
Child birth and the postpartum period represent a major life transition. It
usually has a substantial impact on psychophysical status of the mother. Clinical
experience suggests that sexual dysfunction is common in postpartum (Von
Sydow, 1999). While some reviews (Von Sydrow, 1999)
have described normative sexual practices during postpartum, social varieties
and local taboos surrounding the sexual functioning of mothers can be reasons
for differences in results from various populations.
The results showed that all dimensions of women 's sexual function were at
the lowest level in early postpartum. These parameters were greater at 4 to
6 months and were best at 7 to 9 months after child birth. A slight decrease
of sexual function score was seen at the end of one year. A possible explanation
for the lower score of sexual activity in early postpartum is biological. Suppression
of estrogen results in decreased vaginal lubrication, making intercourse uncomfortable
in breastfeeding women (Lamarre et al., 2003;
Meston and Frohlich, 2000). Elevated prolactin levels
are associated with a decreased sexual interest (Lamarre
et al., 2003; Meston and Frohlich, 2000).
Also, prolactin with the decrease levels of testosterone is related to sexual
desire in women (Lamarre et al., 2003). In later
months, when mothers begin supplement nutrition for their baby, the rate of
breastfeeding will be decreased, thus, levels of hormones change and their effect
on sexuality will be reduced. On the other hand, mother must not do all of the
feeding, especially at night, therefore, they are less fatigued. The second
possible explanation is psychological factors. In early postpartum, mothers
may be fearful of pain or infection or may have and think less regarding the
effects of birth. Further, the slight decrease in the year after postpartum,
may be due to psychological factors, such as worry about pregnancy, lack of
contraceptive and effects of breastfeeding. A majority of women did not use
any particular methods. Moreover, the quality of mothers role and fatigue impact
measures of sexuality (DeJudicibus and McCabe, 2002),
therefore, with growth of baby and especially starting to walk in one year after
birth, the responsibility of mothers increase and makes her more tired. Several
studies found similar results. Sexual problems were reported in 83% of women
by Barrett et al. (2000) and 70.65 by Xu
et al. (2003) in the first 3 months after delivery, then declining
to 64 and 34.2%, respectively at 6 months. Also, in another report by Barrett,
three months after delivery 58% of mothers experienced dyspareunia, 39% experienced
vaginal dryness and 44% suffered from loss of sexual desire (Barrett
et al., 1999).
The most common reasons for delaying or not resuming intercourse reported:
were fear of pain, no interest and worry about another pregnancy, feeling tired
and bleeding. Another author reported similar reasons (Rowland et al., 2005 ; Alder, 1989). However, most women do not share
their concerns with their health care provider, regarding their sexual problems
(Barrett et al., 2000, 1999).
In this study, with women who had postnatal sexual problems, only 2.4% reported
discussing them with a health care staff. On the other hand, health care providers
rarely discuss problems with intercourse in routine postnatal health services
in Iran. Their focus is exclusively on infants. Moreover, postnatal care workers
do not have enough knowledge base and clinical skills to relay important information
regarding postpartum sexuality to their clients. Thus, it will be beneficial
for couples to be informed about sexual changes after delivery and take appropriate
consultation or management, such as the use of vaginal lubricants.
According to the results, sexual activity had a correlation with older maternal
age, longer marriage duration and higher counts of number of children. This
may be due to higher levels of energy and less fatigue in younger women with
fewer children. Other studies have shown such correlation with age both in general
population (Safarinejad, 2006) and women after delivery
(Rowland et al., 2005). Also, Al-Bustan
et al. (1995) reported shorter duration of marriage, characterized
the sexuality pattern positively.
Although, the relation between some socio-demographic factors such as level
of education, occupation status (Safarinejad, 2006)
and BMI (Eposito et al., 2007) has been reported
in general population of women, we did not find such association in postpartum
women. It may reflect differences in sexuality patterns prior and after delivery
and delivery related factors on post partum sexuality.
We found an association between sexuality and contraceptives. The lowest score of sexuality in TL can reflect psychological effects of negative views pertaining to sterilization methods among the Iranian women. IUD is a device that has no hormonal effects, no interference with sexuality and does not need to be regularly used by mother, so she is not as worried about forgetting or its incorrect use. It appears these factors are the reasons for better sexuality with IUD.
The inability of mothers who had disease and also, psychological factors in mothers whom neonates had problems, are probable reasons for lower sexuality scores after delivery.
Some studies reported an association between mode of delivery (Hicks
et al., 2004; Hyde et al., 1996;
Klein et al., 2005) and perineal injuries (Van
Brummen et al., 2006; Klein et al., 2005)
with sexual function. Often cesarean method has been assumed to protect sexual
function after child birth, because it avoids prineal trauma. The study results
showed women who underwent cesarean section did not experience greater sexual
health in each of postpartum periods, than women with a vaginal birth. Barrett's
study outcomes provided no basis for advocating cesarean section as a way to
protect women's sexual function after birth (Barrete et
al., 2005). Klein et al. (2005) reported
similar frequency of dyspareunia for each mode of delivery and greater dissatisfaction
for vaginal birth in primiparous. Overall, women who had intact perineum had
less dyspareunia than those undergoing cesarean section (Klein
et al., 2005). Others reported coitus was delayed in cases of vaginal
laceration, with the significance related to the extent of laceration (Van
Brummen et al., 2006). Although we did not find this association,
there was no case of high degree laceration of perineum in this study. Present
results, however, are consistent with those that reported delivery mode and
episiotomy were not associated with intercourse resumption (Xu
et al., 2003; Connolly et al., 2005).
A possible reason is that any tear or incisions of perineum and cesarean heal
about 6 weeks, the time that women are allowed to resume intercourse, according
to health protocols in Iran. In a systematic review of literature, Hicks
et al. (2004) reported associations between cesarean delivery and
sexual dysfunction were inconsistent. It may also reflect the differences of
study designs such as the interval of assessment from delivery, different types
of questionnaires or trials performed (self applicable questionnaire, mailed
questionnaire, personal interview) or the effect of cultural and racial differences.
The major change in postnatal sexual function is reducing sexual parameters at the first 3 months. Many couples can expect a recovery in sexual function during the following months. Sexual difficulties experienced during postpartum can cause much distress, relationship problems and influence their quality of life and physical and mental well being. Thus, consultation for recognition and management of postnatal sexual problems needs to improve, as well as educational factors that might contribute to sexual activity change, in addressing the unmet needs of postpartum couples.
This study was financially supported by a Research Grant No. 86-73 from the Mazandaran University of Medical Sciences, Sari, Iran. Also, we would like to thank the mothers that participated in this study.
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