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January 2000, Volume 50, Issue 1

Student's Corner

Sexuality during Pregnancy in Pakistani Women

Maryam Naim  ( Final Year Medical Students, The Aga Khan University Hospital, Karachi. )
Erum Bhutto  ( Final Year Medical Students, The Aga Khan University Hospital, Karachi. )

Abstract

Objective: We investigated the patterns of sexual activity during pregnancy and explored all beliefs related to coitus during pregnancy in women with the objective of promoting awareness and assisting health care providers in understanding and dispelling fears/misconceptions prevalent in our culture.
Methods: A cross-sectional, KAP (Knowledge, Attitude, Practice) study was conducted using questionnaires to interview 150 healthy pregnant women attending antenatal clinics at Aga Khan University Hospital (AKUH) and Lady Dufferin Hospital, both located in Karachi, Pakistani. Data was analysed using Epi Info 6 statistical package.
Results: The mean frequency of intercourse during pregnancy (1.6 times/ week) was less than before pregnancy (3.5 times/week). Husbands were the main initiators of sexual activity (44%) while the wives only rarely did so (0.7%). Some (13.3%) women felt it served to keep husbands around. Coitus during pregnancy was gratifying in 64.7% and painful in 37.3% of respondents. Most (45.4%) believed coitus was harmful for the foettts. Others (28.7%) thought it did not make any difference whereas 4.7% believed that it made a difference if the foetus was female by gender. 22.7% women believed that coitus during pregnancy caused abortions early in pregnancy and 6.7% that it induced pre-term labour. 26% did not know the means by which the harmful effects were produced but still maintained their beliefs. Some (10.7%) thought it could actually help widen the birth canal and facilitate labour. Majority (85.3%) -believed that frequency should be lowered during pregnancy, 10% thought that it should be continued as before and 4% that it should be stopped completely
Conclusion: This study suggests a mixed attitude towards sexuality in pregnancy with a tilt towards the belief that it is harmful and should therefore be decreased during pregnancy, specially during the last trimester. It is the responsibility of health care providers to dispel fears and clarify any misconceptions regarding such matters (JPMA 50:38, 2000).

Introduction

Pregnancy is a very special state in which a woman undergoes phenomena changes both physically and emotionally. In many societies since ancient times, coitus during pregnancy has been cautioned against even if not totally forbidden. Studies done in the past on this issue have had conflicting results. Retrospective data suggests that coitus could induce preterm birth or histological chorioamnionitis1-4, There is, at the same time, evidence to the contrary that suggests no such association between sexual intercourse and adverse pregnancy outcomes5-11.
Risk associated with sexual intercourse during pregnancy are infections and preterm labour and deliveiy8.
Several mechanisms for association between sexual activity during pregnancy and abnormal foetal outcome have been postulated. Lower genital tract microfiora have been implicated in preterm labour. These may ascend through the cervix and infect the uterus and placenta leading to chorioamnionitis and foetal sepsis. Bacterial contamination of amniotic fluid during coitus can lead to amniotic fluid infection and increased perinatal mortality’. Another mechanism postulated is increased uterine contractions caused by orgasm12,13 and nipple stimulation14 both believed to cause release of oxytocin. Seminal fluid, which contains prostaglandins, when absorbed through vaginal mucosa, is also thought to stimulate uterine contractions15.
Beliefs in our society are shaped by a combination of factors: oldwives1 tales, religious decrees, cultural practices, some medical advice and women’s own perceptions. As women are given to niore thinking during this period of relative disability and confinement, tremendous.
The purpose of this study was to assess the sexual behaviour and beliefs related to coitus during pregnancy in women with respect to the frequency of intercourse, views regarding the effect of sexual activity and desirability or not of continuation of sexual activity during pregnancy.

Material and Methods

This study involved a questionnaire-based interview of 150 pregnant women attending antenatal clinic at the Aga Khan University Hospital and Lady Dufferin Hospital, both located in Karachi, Pakistan. As Karachi is a cosmopolitan city, the women belonged to different ethnic groups. The interviews were conducted by the study designers authors themselves during usual antenatal clinic sessions. An informed verbal consent was taken from each subject. Refusals were not pursued any further. No responses to some questions, during the course of interview, were also respected. Confidentiality of respondents was maintained at all times.
The questionnaire was divided into eight different sections and elicited information on demographics, marital details, parity, sexual activity before and after pregnancy, beliefs on sexual activity during pregnancy, source of beliefs, continuation of sexual activity (i.e., whether it should be stopped, lowered in frequency or continued as before).ln all questions related to frequency the latter was assessed separately for each trimester. The completed questionnaires were edited and coded. Frequency tables were then generated and descriptive data retrieved using Epi Info 6 statistical package.

Results

The respondents were predominantly 20-30 years old (71.3%), Muslim women (96%) hailing from cities (94.7%) in urban Sindh (80.7%). Most were educated up to intermediate level (32%) and were mainly housewives (91.3%). In comparison most of their husbands were educated tip to Bachelor’s level (28%) and were employed with an average monthly income of below Rs. 5000 (52%). The couples were mainly in their first marriage (respondents 98.7%, husbands 96.7%) and had been married for between 1-5 years (36%). They lived mainly in joint family systems (70%) with an average of members per household (44%) (Table 1).



Table 2 shows that the respondents were primarily multigravidas (61.3%) who were in their third trimester of pregnancy (54%). Most of the pregnancies were unplanned (63.3%). A majority of the respondents had a good obstetrical history with no history of abortions (70.7%).
Husbands were the main initiators of sexual activity (44%) while the wives only rarely did so (0.7%). By and large sexual activity was reported as gratifying in 64.7% of the respondents whereas it was painful in a smaller percentage (37.3%). Only 13.3% felt it helped keep the husband around and was not considered important in fulfilling marital obligations by 42.7% women (Table 3).


Majority (99.3%) of the women decreased the frequency of intercourse during pregnancy from a mean of 3.5 times per week to 1.6 times per week (Table 4).

The predominant frequency prior to pregnancy was 1-5 times per week (76%) and this remained the trend in the first two trimester (66.7% and 40% respectively). In the third trimester, however, most of the respondents had no sexual contact with their husbands (26%). Reasons for decreased frequency cited were mainly that it was harmful for the foetus (45.4%) and also that the experience was uncomfortable (46%).
While the majority maintained that coitus was harmful (45.4%) during pregnancy, 28.7% had no percentage (4.7%) felt it made a difference if the foetus was female (Table 5). Of those that strongly believed in the harmful effects, 23.3% did not know the actual means by which this happened while 22.7% felt it caused abortions early in pregnancy and 6.7% thought that it caused preterm labour. 10.7 % believed it could actually help widen the birth canal and facilitate labour (Table 5).


The source of belief disclosed in the majority of cases was the respondent’s own self (62%) (Table 5). In response to a question on continuity of sexual activity during pregnancy, majority (85.3%) advocated a decrease in frequency during pregnancy and suggested frequencies of 1-5 times per week in the first and second trimesters (59.3% and 48.7% respectively) and total abstinence in the third trimester (42.7%).

Discussion

Pakistani society is male dominated, in which the husband is the executive head of the household, in this society matters pertaining to sexuality are taboo and women are expected to behave shyly when it comes to such matters. It is therefore not surprising that sexual activity was initiated by the husband in 44% of the cases and a large number (40.7%) of women engaged in such activity in order to fulfil marital obligations. it is reassuring to see that most women did not fear their husbands infidelity (69.3%). This is in contrast to a Nigerian study down in 1995,16 where only 15.9% could say the same with confidence. A gratifying effect was appreciated in a majority (65%) of women.
The decrease in frequency of intercourse during pregnancy is consistent with a previous report16. The main reason for this decrease is a fear of injury to the foetus and coitus being thought to lead to abortion and preterm labour. It was surprising, however, to see that although 22.7% women believed that intercourse caused abortion in early pregnancy, only 10.7% refrained from it in the first trimester whereas 66.7% continued at the same frequency as prior to pregnancy (i.e., 1-5 times per week). Abstinence from intercourse was seen mostly in the last trimester. This was not due to fear of premature labour alone but also due to different cultural beliefs in various households. A large majority of Pakistani couples live in a joint family set up (70%) where women receive continuous advice from elders and relatives in the house. In such cases it is common to see women hold common perceptions without knowing why the beliefs existed. Of those that tried to provide a reason, 4.7% interestingly believed that as the baby is fully formed by the 7th month, continuing coitus in cases where the child could be a female, leads to sinful/harmful effects. A few (4%) felt that it could actually harm the mother. Although majority of the beliefs were a product of culturally held views, in some cases they could also have been influenced by remnant fears/concerns from poor obstetric experiences in the past. Various studies have already shown that frequency of intercourse is not associated with an increase in preterm delivery5-7. However, it needs to be avoided if there is vaginal bleeding or if premature rupture of membranes occurs5,17. This was the reason why a few of our respondents (4.7%), with a poor past obstetric history, had been advised by their doctors to observe abstinence during pregnancy (Table 5).
Although most women (85.3%) advocated a reduction in frequency for future pregnancies, the new frequency (1-5 times per week) suggested by most women (59% in their 1st trimester and 49% in the 2nd) were not any different from the one they already were following in the current pregnancy (also 1-S times per week by 67% women in their 1st trimester and 40% in the 2nd). This again reflects the conflict women feel between deciding to keep the baby from harm and pressures to fulfil marital obligations.
One limitation of this study was that it comprised mostly of women from urban Sindh, with some level of basic education. As 70% of Pakistan’s population lives in rural areas and greater than 80% are uneducated, it would be difficult to extrapolate these results and apply them to Pakistani women in general. Since the purpose of this study was restricted to assessing knowledge, attitude and practice, we leave the task of finding an association between coitus during pregnancy and abnormal foetal outcome to future studies.
It is concluded that unless a woman has contraindications, as previously mentioned, she should have intercourse as often as desired by her and her husband. Health care providers should, when needed, clarify misconceptions and dispel any unnecessary fears associated with this practice.

Acknowledgements

We extend our gratitude to Di-. Shehnaz Wasti for her support and advice and to Dr. Setna for allowing us to interview the ladies at his antenatal clinics at Lady Dufferin Hospital. We would also like to thank the doctors and nurses of the antenatal clinics at the Aga Khan University Hospital for their co-operation in this project.

Reference

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