Introduction
Sex in pregnancy remains a rarely discussed issue majorly because of the societal norms and embarrassment in asking queries relevant to sex. A pregnant woman undergoes changes both physically and psychologically because of the hormonal changes which is seen to affect her sexual life.1, 2 The biological changes in pregnancy brought by the hormonal surge of estrogen, progesterone and prolactin is known to decrease their libido.1, 3, 4
In our country discussing about sex and sexual health is considered a taboo, thus preventing couples from coming forward and discussing sex related problems with their physicians. Even physicians shy away from this topic. This study aims to bring forth the hidden problems involving the sexual life of a married couple who are eagerly waiting for parenthood. Sex in pregnancy is feared by a lot of couples mainly because of the fear of abortion or preterm labour or other pregnancy complications.5, 6, 7 Maintaining sexual relations in pregnancy also depends on a very large extent, infuenced by the commands of elders at home, especially in countries like India where societal and religious beliefs play a very important role in decision making. These myths and notions involving sex in pregnancy needs to be dissolved so as to ensure a healthy and blissful sexual life of a couple.
Many pregnant woman are uncomfortable and shy in discussing sexual health during pregnancy with the health workers and doctors and for many pregnancy is a time for no-sex because of multiple reasons. This is not confined to Indian women but other Asian countries like China also mention about the embarrassment faced by their women when they had to confront questions about sexual health and the various reasons which prohibit sexual activities in pregnancy.2, 8, 9, 10
This study is an attempt to bring to the forefront the sexual changes which take place in all three trimesters of pregnancy and to discuss the various factors which influence sexual activity in a cross-sectional population of Indian women where the societal and cultural beliefs have a huge impact on their personal beliefs and behaviour. There is limited knowledge about sexual and reproductive health in Indian women of reproductive age group particularly in rural India where 92% of the married women had no say in their general health care and 94% could not choose their own doctor.11 Such a serious plight of health awareness in India calls for a unified effort to bring to the notice of all health care professionals various facts about the sexual health in pregnant woman which will further help them in providing proper advise and counselling related to sexual health.
This study is an attempt to understand the attitude, knowledge and behaviour of pregnant women regarding their sexual life, the problems they face, the fears they encounter, what holds them from carrying on with their normal sexual behaviour and ways to dispel these psychological issues. Thus, we have attempted to bridge the gap between expectant mothers and the health care provider concerning their sexual well-being.
Materials and Methods
We did a cross-sectional observational study in the Obstetrics and Gynecology department at VMMC and Safdarjung Hospital, New Delhi over a period of thirteen months from March 2016 to August 2017. This hospital is one of the largest tertiary care hospital in New Delhi with over 25,000 deliveries a year and being a government funded institute caters mainly to the poor patients.
The representative sample consisted of 205 pregnant woman who came to the hospital OPD for regular check-up and inpatients who were admitted for various reasons. All consenting gravid women in different trimesters of pregnancy without any pregnancy complications were included in the study. Women with complications like early pregnancy bleeding, ante-partum haemorrhage, leaking per vaginum were excluded from this study. Women were asked open end questions about their sexual habits in pregnancy and the various factors which affected it. Information like age, gravida, parity, education, socio-economic status, previous obstetric history, the frequency of sex, sexual interest and factors which influence their sexual behaviour could be elicited from the questionairre. They were also enquired about their knowledge of sexual health and any opinion sought about by their health care professionals. The primary aim of this study was to find out about the sexual practises in women in all three trimesters and to evaluate the different factors which have an impact on sexual behaviour.
Categorical variables are shown using percentage. Graphical representation of nominal data was done using bar graphs. Numerical data was shown using median (IQR). Student independent t -test was done to test the association of numerical data. The level of statistical significance was p< 0.05. Outcome variables included frequency of having sex two or less than two times during pregnancy and more than three times during pregnancy. Data was analysed in SPSS version 25.
Results
The socio-demographic profile of the patients in their third trimester has been listed in Table 1.
Table 1
Socio-demographic details
|
Median |
IQR |
F (df) |
p value |
|
|
Age in years |
24 year |
6 |
0.25(1,203) |
0.618 |
|
Gravida |
2 |
2 |
0.75(1,203) |
0.430 |
|
Parity |
0 |
1 |
4.5((1,203) |
0.015 |
|
Per capita income (₹) |
11000 |
5500 |
1.75(1,203) |
0.192 |
Sexual activity in pregnancy
Table 2 summarises the coital frequency throughout the duration of pregnancy. Out of the 205 participants, eleven women (5.4%) never had any sexual activity throughout pregnancy. Around 101 (49.2%) of them, had coitus one to two times and the remaining 93 participants (45.4%) could have sexual intercourse for more than three times during the entire period of pregnancy.
Table 2
Frequency of sexual Intercourse during pregnancy
|
Frequency of Coitus |
N |
Percentage |
|
No coitus |
11 |
5.4 |
|
1-3 |
101 |
49.2 |
|
>3 |
93 |
45.4 |
We observed a reduction in the frequency of sexual activity in the third trimester with only 13/205 women(6.3%) reporting it, and another 75/205 women(36.6%) and 90/205 (43.9%) could continue sexual practices in the first and second trimesters, respectively. For 16/205 participants, sex was possible in all three trimesters (Table 3). It was seen that around 10% women had gone to their mother’s house on confirmation of pregnancy for safe confinement which is a common practice in India and especially in cases of first pregnancy.
Types of sexual activities
The various types of sexual practices are encapsulated in Table 4. It was observed that majority of the study participants (75.6%) indulged in vaginal intercourse. Among the study population, 25/205 (12.2%) of the women indulged in oral sex and 17/205 (8.3%) found sexual appeasement in masturbation. It was also revealed that 8/205 (3.9%) of the women practised anal intercourse.
Table 4
Type of sexual activity
|
Type of Sexual Activity |
Number |
Percentage |
|
Vaginal Intercourse |
155 |
75. |
|
Oral |
25 |
12.2 |
|
Masturbation |
17 |
8.3 |
|
Anal |
8 |
3.9 |
Libido, the desire to have coitus, during pregnancy was found to decrease in majority of the participants while it remained the same as prior to conception in 63/205(30.7%) of the women. Sexual urge was found to increase in 64/205 (31.3%) of women.(Figure 1)
Prohibiting factors for sex
When we tried to reason out the various causes which caused the inhibition in sexual activities during pregnancy we found that the risk of onset of preterm labour, bleeding and the chances of infection to the baby remained the most cited ground for non-indulgence in sexual activity seen in 42/205, 74/205, 44/205 women respectively. Another 18.5% quoted the fear of injuring the fetus as a factor for hindering sexual activities (Table 4). Only seven(3.4%) study participants had no problem in practicing sex.
Perineal hygiene practises
Figure 2 reviews the perineal hygiene practices commonly carried out. Another revelation was that many patients used soap and water (32.6%) and antiseptic mostly. Dettol and water (3.9%) for their perineal hygiene. More than half of the population used water only for cleaning their perineum. These women had no formal knowledge on the correct practices for maintaining vaginal hygiene.
Sources of information
When we enquired about their source of information about sex in pregnancy, more than half of women relied on the advise of the elders in their family and only 25% sought the help of a health-care professional. Majority of them did not seek any medical advise and were dependent on the commands of their family members. (Figure 3)
Discussion
The study shows a definite decline in the coital frequency towards the third trimester of pregnancy which has also been seen in other studies.5, 12, 13, 14 This can be attributed to the reduction in libido in many females during pregnancy which was also seen in other studies. 5, 12, 15 Erol et al. found diminished clitoral sensation as the most common sexual dysfunction followed by lack of libido and orgasmic disorder. He found no correlation between female sexual function scores and serum androgen levels in pregnancy.16
Systematic reviews by Von Syndow 17 and Serati et al.18 have shown that the frequency of coitus does not change or changes only minimally during the first and second trimesters of pregnancy. A study on Taiwanese women has shown that 13.9% of women ceased coitus completely as compared to 9.8% in our study. 19
Many studies have also shown that the both the frequency and the desire for sexual intercourse reduced in third trimester.6, 7, 20 This depends on many physical factors and hormonal changes of estrogen, progesterone and prolactin which causes breast tenderness, weight gain and fatigue which in turn causes difficulty in getting aroused.5, 13, 21
Many women also gave history of non-consensual sex in our study. Similiar study showed pressured sex rate of 19%.5
A look into the causes deterring the carnal desire in women is the fear of harming the baby or the risk of early setting in of labour pain or risk of infection or bleeding. Many studies have highlighted decrease in sexual activity in couples because of the fear of pregnancy complications in both the partners.5, 6, 7, 15
Proper counselling and approach by the doctors regarding these issues will help women discus their physical as well as psychosexual problems, concerns regarding decrease in sexual activities and any other related problems. Indian women are particularly shy and feel embarrassed to discuss sexual problems. An open free relationship will help to bridge this gap of communication. This type of embarrassment in discussing their sexual life is also found in women of other Asian countries like Chinese women who feel shy to discuss topics related to their sexual life with their doctors.9, 10
Then there is lack of awareness and proper information about clean vaginal practices. Effort must be made to discuss these issues.
Vaginal intercourse remained the most common type of sexual intercourse as seen in other studies.5 Some studies noted a decrease in vaginal intercourse and rise in other forms of sexual activity like manual sex, anal and oral sex because of the fear of harming the fetus.2
Many women seek safe confinement in pregnancy because of which they often go back to their mother’s family, as seen in our study. This was also seen in Chinese women where sexual prohibitions during pregnancy are aimed to avoid problems in pregnancy.8 Many mothers and mother in laws play a pivotal role in decision making for the couple in India thus indicating that social and cultural issues cannot be overlooked, as was also pointed by Pautela et al.1 In other Asian countries like China and Taiwan, too familial influence seems to play a significant role in decision making.9, 10
Limitations
The present is an observational study carried out among women belonging to low socio-economic status visiting only one tertiary care hospital, because of this small sample size the study cannot be generalized to the entire cohort of pregnant women belonging to different strata of society.
Recommendation
The sexual life of a married couple, especially in India, remains largely an untouched topic. Couples are reluctant to come forth with their problems owing to societal norms and personal embarrassment. Health-care professionals, too, have not been trained to counsel such couples and create an atmosphere congenial to discuss such issues and not to brush them aside. It is imperative that medical professionals come forward to help these couples discuss their sexual lives freely and devote some time to ease their married lives.
Conclusion
A healthy approach for the patients to discuss all sorts of sexual and reproductive health problems should be inculcated. The initiative can be taken from the side of the doctors to promote a uninhibited discussion on these issues to newly married couples and to all couples in general in order to allay their unspoken fears regarding their sexual relationship and the impact on their baby. The emotional and physical aspects of the patients should be dealt with simultaneously to encourage a healthy sexual life among married couples expecting a child.
