Sex and Sexuality in Pregnancy

There are many reasons for forbidding coitus during gestation: First, the danger of abortion, which is caused by the impact of the penis against the cervix. . . . Second, the nervous shock is not well borne by a woman whose nerve energy is already overtaxed. . . . Third, animals do not copulate when the female is pregnant, . . . it would be wise for him (man) to follow their instincts. . . . Fourth, the danger of infection. . . . The danger from coitus is greatest in the first three months, when usually the fact of pregnancy is not always sure, and in the last three months, when the abdominal tumor is large and the element of infection more prominent. It is wise to restrict the practice to the intervening months, or better, advise against it entirely.¹

This quotation from DeLee provides historical perspective over one-half century later on the advisability of sex during pregnancy. In the absence of specific physician instructions about this frequently misunderstood aspect of pregnancy, patients often must rely on anecdotes, old wives' tales, and other unreliable sources of information. Unless physicians are familiar with the scientific data in the area, the potential for providing patients with misleading or incorrect information is great.

Changes in sexuality can be significant during pregnancy and in the postpartum period.  A review of the literature reveals that many women experience decreased sexual desire and frequency of intercourse due to a variety of, often unspoken, physical and psychological factors.  Because most couples continue some coital relationship during pregnancy, it is hoped that physicians and other healthcare providers take a more active role in counseling obstetric patients about intercourse during pregnancy.

Although not intended to be a guide to educating patients, this chapter should provide a basis on which physicians can better inform both themselves and other healthcare providers under their direction. It is only with a greater knowledge base that healthcare providers can decrease their own anxiety about sexual matters and thereby aid the patient and her sexual partner in dealing with this potentially sensitive topic. Physicians' reticence stems both from their own discomfort with the topic and from a lack of extensive conclusive data about the effects of coitus and orgasm on pregnancy. This chapter highlights factors affecting sexuality during pregnancy, studies of sexual activity in pregnancy, possible complications of sexual intercourse during pregnancy, and circumstances affecting postpartum sexuality. The chapter concludes with clinical guidelines and implications for research.

Viewed from the obstetric standpoint, the physical changes of pregnancy are obvious, but the connection between these changes and sexuality often is not clear, either for a physician or a patient. Normal physiology becomes a source of numerous deterrents to sexual activities.

The nausea and vomiting of early pregnancy can prevent a woman from expressing her sexuality paradoxically at a time when the couple as a unit might feel the closest. Sexual desire and performance are also hindered by the fatigue common in pregnancy. Although decreasing in the second trimester, fatigue increases in the third trimester, when physical changes make sexual expression both awkward and uncomfortable. In addition, heartburn associated with reflux esophagitis prevents patients from responding sexually as they would desire. Urinary frequency and urgency can become hindrances to sexual response, as can constipation, fetal movement, and back pain.

The breasts are especially tender in early pregnancy, in response to both hormonal and vascular alterations. If not anticipated, the milk let-down associated with orgasm, which often occurs later in pregnancy, can be very distressing to both a patient and her sexual partner.

The amount of vaginal secretions normally increases in pregnancy and is further augmented during sexual arousal.² As a result, men who normally actively participate in oral sex may feel inhibited by the significant change.³ In addition, the cervix is more likely to bleed during pregnancy because of direct trauma from penile thrusting. An uninformed couple can be alarmed by unexpected postcoital bleeding.

The normal engorgement of genitalia during pregnancy is further exacerbated during sexual arousal. Vasocongestion is not well relieved, even after orgasm, and the residual sensation of fullness in the pelvic organs may be uncomfortable enough to cause a women to avoid coital activity.² Orgasm may be accompanied by cramping or muscle spasms.²

Alterations in the endocrine environment during pregnancy cause vaginal discomfort for some women particularly in the first and third trimesters of pregnancy.  Muscle fibers of the vaginal wall increase in size and connective tissue in the vagina decreases and the collagen fiber area decreases due to the loss of smooth muscle cell contractility.⁴  

Androgen hormones such as testosterone, androstendione, and dehydroepiandrosterone promote sexuality in men and women.  Diminished androgen levels in women have been proposed to contribute to the sexual dysfunction common during pregnancy.  However, no studies to date have confirmed such a relationship.⁵

As shown in Table 1, women report many different reasons for changing their sexual behavior during pregnancy. The leading cause, verbalized by 46% of the population, is “physical discomfort.”⁶

Table 1. Factors that inhibit sexual activity during pregnancy and postpartum

Desire for sex and sexual functioning are affected by many environmental, interpersonal, and intrapersonal considerations. Sexual performance can be inhibited by lack of knowledge or by anger, fear, and other potentially negative attitudes.  A patient and her partner must understand that both are stressed from a sexual standpoint during pregnancy.  Many women perceive a decline in the importance of sexuality and intercourse.  As pregnancy progresses, an increasing number of women report discontentment with their present sex life.⁷  Clear understanding allows the couple to be more open in their communication, making sexual adjustments easier during pregnancy. Prenatal counseling can reassure couples that their problems are no different than those of any other couple during pregnancy.

Pregnancy can precipitate psychological conflicts in a woman that have not previously arisen. Recollections of childhood rivalries with siblings or her own mother, conflicts about her role as a woman, conflicts about her own dependency needs, and hostility toward her husband all can create problems for a pregnant woman.⁸

A major concern for a woman is her perceived loss of attractiveness. About one-fourth to one-half of pregnant women feel less attractive than before conception.⁹ A pregnant woman's attractiveness as perceived by herself and her partner correlates positively to coital activity and sexual enjoyment.^{10, 11, 12} A man, conversely, must deal with his love for a partner despite her radically altered physique. Either the direct verbalization of disinterest or more subtle avoidance behaviors can reinforce a woman's sense of unattractiveness. As a result, the real or perceived tendency for a man to become involved in extramarital affairs may become a concern.^{3, 13}

A prospective father is also susceptible to very strong emotions during his mate's pregnancy. The expected child is living proof of the father's manhood.¹⁴ At the same time, a man may feel great anxiety about his ability to provide financially for the new family. Jealousies may arise as a mother gives higher priority to her fetus than to her spouse. The move from the role of lover to the role of parent is not easy for either a mother or father. Long-repressed conflicts over incestuous feelings must often be dealt with.

Problems arise not only from individual needs but also from interaction within a couple. Pregnancy is one step in the development of a sexual relationship between two individuals. A couple moves from a relationship without sex to one in which sex has a role for pleasure only. Subsequently, sex becomes a means to an end rather than the end itself (i.e., sex is used for procreation). If pregnancy does occur, a couple must deal with the problems of sexuality during pregnancy before reverting to sex for pleasure. Unfortunately, each step provides room for misunderstanding as well as for sexual growth. As discussed subsequently, interest in sexual activity generally declines during pregnancy. If, however, the interest levels of the two individuals are dissimilar, one partner can perceive the other as either too demanding or rejecting.¹⁵ Each partner's comfort with his or her own sexuality helps determine how communicative a couple is during these difficult months. A physician's guidance can be of great help particularly in the previously infertile couple.

The background to these psychological factors is the unspoken fear of both partners that penile penetration can cause injury to the fetus. Dissemination of truthful information by a healthcare provider can help minimize or eliminate these unsubstantiated fears.

Coital Frequency

As part of their original work, Masters and Johnson³ published the first scientific data on sexual activity during pregnancy (Table 2). A decrease in first-trimester sexual activity was noted, with an increase over prepregnancy levels in the second trimester and the greatest decline in activity during the third trimester. Falicov¹⁶ and Bogren⁸ found a similar decline in sexual activity in the first and third trimesters, with the second trimester similar to prepregnancy sexual activity levels. Kenny¹⁷ and Morris¹⁸ found less sexual activity only in the third trimester compared with prepregnancy levels.

Table 2. Sexuality according to pregnancy trimester compared with prepregnancy level

Study	Sample	Design	First trimester			Second trimester			Third trimester
			C	L	O	C	L	O	C	L	O
Masters and Johnson, 19663	101 F, 79 M, US	Prospective	↓	↓	–			–	↓	↓	–
Falicov, 197316	19 F, US	Prospective	↓	↓	–			–	↓	↓	–
Kenny, 197317	33 F, US	Retrospective							↓	↓
Solberg et al., 19736	260 F, US	Retrospective	↓	↓	↓	↓	↓	↓	↓	↓	↓
Morris, 197518	114 F, Thailand	Cross-sectional		–	–		–	–	↓	–	–
Tolor and DiGrazia, 197619	216 F, US	Cross-sectional	↓	↓	–	↓	↓	–	↓	↓	–
Robson et al., 198120	119 F, GB	Prospective	↓	↓	↓	↓	↓	↓	↓	↓	↓
Ryding, 198421	50 F, Sweden	Prospective	↓	↓	↓	↓	↓	↓	↓	↓	↓
Reamy and White, 198510, 11	52 F, US	Prospective	↓	↓	↓	↓	↓	↓	↓	↓	↓
Elliott and Watson, 198522	128 F, 87 M, GB	Prospective	↓	↓	–	↓	↓	–	↓	↓	–
Pepe et al., 198723	175 F, Italy	Prospective	↓	–	–	↓	–	–	↓	–	–
Bogren, 19918	81 F, 81 M, Sweden	Prospective	↓	↓	↓				↓	↓	↓
Barclay et al., 199424	25 F, 25 M, Australia	Prospective	↓	↓	–	↓	↓	–	↓	↓	–
Adinma, 199625	440 F, Nigeria	Prospective	↓	–	–	↓	–	–	↓	–	–
Haines et al., 199626	150 F, China	Retrospective	↓	–	–	↓	–	–	↓	–	–
Oruc, 199927	158 F, Turkey	Prospective	↓	–	↓	↓	–	↓	↓	–	↓
Naim and Bhutto 200028	150 F, Pakistan	Cross-sectional	↓	–	–	↓	–	–	↓	–	–
Gökyildiz and Beji 2005 29	150 F, Turkey	Retrospective		↓	↓	↓	↓	↓	↓	↓	↓
Erol et al., 20075	589 F, Turkey	Cross-sectional									↓
Aslan G et al., 200530	40 F, Turkey	Prospective	↓	↓	↓	↓	↓	↓	↓	↓	↓

C, coital activity; F, female; GB, Great Britain; L, libido; O, orgasmic function; US, United States; , more than prepregnancy level; ↓, less than prepregnancy level; , equal to prepregnancy level; -, not measured.

Thirteen other studies have shown a progressive decline in sexual activity during pregnancy. This progressive decline has been reported in the United States,^{6, 10, 19} Europe,^{20, 21, 22, 23} the Middle East,^{5, 27, 28, 29, 30} Asia,²⁶ Australia,²⁴ and Africa.^{13, 25} Those studies failing to show a linear decline often used small samples,^{16, 17} were cross-sectional in design,¹⁸ or used nonrepresentative populations.³

A variety of reasons have been suggested for this decrease in sexual activity. Early in pregnancy, some women report fears that intercourse will cause miscarriage; during the third trimester, both mothers and fathers report fears that intercourse or orgasm may harm the fetus.^{5, 7, 8} Such concerns may also contribute to the declined duration of coitus.  The frequency of couples having coitus for 2 minutes or less increased progressively throughout the course of pregnancy and was highest during the third trimester.²⁹ However, there is currently no strong research evidence of increased pregnancy complications associated with sexual activity during pregnancy. Other reasons for decreased coital frequency include physical discomfort associated with intercourse, particularly in the man-on-top position, and loss of interest in sex.

Sexual Interest

Masters and Johnson³ reported that “sexual tension and effectiveness of performance” declined in the first trimester of pregnancy in nulliparous women, whereas multiparous women reported little change (see Table 2). They described an improvement in performance and sexual arousal during the second trimester in women studied, with no significant differentiation between nulliparous and multiparous subjects. During the third trimester, most subjects reported a decline in sexual interest. Kenny¹⁷ found a decrease in libido during the third trimester only. Others have reported decreases in libido in women during the first and third trimesters, with no change from prepregnancy levels during the second trimester.^{8, 16} All other researchers have found a steady decline in libido during pregnancy, regardless of parity.^{6, 10, 19, 20, 21, 22, 24} The evidence from the earlier studies is somewhat conflicting, but it seems reasonable to assume that most women experience a decline in sexual interest during the end of pregnancy.

Although inadequately studied, male sexual interest either remains unchanged²⁴ or decreases during the third trimester.^{3, 8} The effect of the partner's pregnancy on the male may vary—some men find their wives increasingly attractive, whereas others are fearful of “hurting them” or feel that their intrauterine presence renders sex “improper.”¹⁵

Although associations between sociodemographic variables and sexual behavior has rarely been significant, sexual interest has been found to decrease more in expectant mothers with a stronger religious affiliation.^{6, 8, 22} According to Gokyildiz, women aged 19-29 and those in marriages lasting less than 2 years have a higher frequency of desire compared to other pregnant women.²⁹  A relative relationship between education level and frequency of desire was also observed. However, sexual interest before pregnancy appears to be the best predictor of interest during pregnancy, regardless of gender.^{2, 15}

Orgasmic Function

Solberg and colleagues⁶ reported that orgasmic function decreased as pregnancy progressed (see Table 2). The percentage of coital acts leading to orgasm progressively decreased, as did the strength or intensity of orgasm experienced by the patient. In a small percentage of women, however, orgasmic intensity was noted to be increased at all stages of pregnancy. Although most researchers have reported a steady decrease in orgasmic function during pregnancy,^{10, 20, 21, 27} two authors reported decreases during the first and third trimesters but not during the second trimester.^{8, 29} A small, retrospective study found no change in the frequency of orgasms throughout pregnancy.¹⁷ Another study found orgasmic disorders to be common throughout pregnancy but less pronounced in the second trimester according to objective measurements of the Index of Female Sexual Function (IFSF).⁵ No data on male orgasm have been collected.

The consistent reduction in orgasmic function during pregnancy may be related to changes in physiologic response or to an active repression of orgasm to protect the baby.²

Noncoital Behavior

Solberg and colleagues evaluated noncoital sexual behavior.⁶ Sixteen percent of women had used masturbation to achieve orgasm before pregnancy. Most of these women did not continue this practice during pregnancy. Of those who practiced orogenital stimulation, approximately half did not use this type of sexual activity during pregnancy. Only 2% of women had recommendations given them by physicians or other healthcare personnel regarding sexual activities that might be used instead of coitus. Of these, hand stimulation was the activity recommended for both partners. As opposed to women, masturbation in men has been shown to remain stable throughout pregnancy.³¹

Several studies have noted declining clitoral sensation throughout pregnancy.^{29, 5} Erol et al. reports diminished clitoral sensation to be the most common cause of sexual dysfunction followed by loss of sexual interest and orgasmic disorder.⁵ 

Activities that could replace sexual activities yet maintain intimacy of a couple's relationship have been addressed by Tolor and DiGrazia in a questionnaire of 216 women.¹⁹ Women indicated a preference for even less coital frequency than was actually occurring. It was noted that the women reported a high need for close physical contact during all stages of pregnancy. As an alternative to sexual intercourse, the most frequent response was simply wanting to be held. The investigators acknowledge that merely informing couples of the possible changes in sexual interest is insufficient and that the increased need for physical contact should be included in prepregnancy counseling.

One sexual activity is a potential danger to a women during pregnancy. An infrequently used type of cunnilingus consists of a partner's forcing air into the vagina. Several deaths to mother and fetus from air embolism have been reported after this activity.^{32, 33}

Behavioral Change

Because of anatomic considerations, coital positions differ as pregnancy progresses. Solberg and colleagues' data included an evaluation of coital positions used.⁶ There was a significant decrease in the male superior position, which had been used by couples approximately 80% of the time before pregnancy. In the last trimester, the side-by-side position was the most frequently used coital position, whereas the rear-entry position, rarely used before pregnancy, also became more popular. No association was found between position used and orgasm rate or coital frequency.

Despite numerous attempts to link sexual activity with complications of pregnancy, true risks to the fetus are largely unconfirmed. Nevertheless, it is still a widely held opinion that sexual behavior and response may in some way be related to untoward outcomes.

Prematurity

The collaborative perinatal project, a large, early study conducted in the United States,³⁴ reported an association between higher rates of premature labor and premature rupture of membranes (PROM) and intercourse during the third trimester (Table 3). These findings were questioned as possibly being related to other factors, such as social class or maternal age.³⁵ All other studies have failed to confirm a relationship between coital activity and prematurity,^{36, 37, 38, 39, 40} PROM,^{40, 41, 42} premature labor,^{42, 43} gestational age,⁴⁴ gestational length,⁴⁵ or low birth weight (LBW).^{38, 41}

Table 3. Relationship of sexual activity to pregnancy complications

+ , positive relationship; –, no relationship; ND, no data; F, female; GB, Great Britain; US, United States.

Two small, early studies found higher rates of prematurity in orgasmic women during the third trimester.^{37, 46} All other studies failed to find a relationship between orgasmic frequency and prematurity,³⁸ PROM,^{6, 42} premature labor,^{6, 42, 43} or LBW.³⁸ Studies failing to show a relationship between sexual activity and prematurity have been conducted in the United States,^{6, 38, 39, 43, 45} Great Britain, ^{42, 44} Israel,⁴¹ Finland,⁴⁰ and Jamaica.³⁶

Fetal Distress

Several studies have researched potentially negative effects of maternal sexuality on the well-being of the newborn infant. Although coital frequency during pregnancy has been associated with fetal distress and perinatal deaths, these studies suffer from either small samples ⁴⁴ or incomplete control for confounders³⁴ (see Table 3). Larger and more representative investigations have observed no overall association between sexual activity and either fetal distress⁴⁷ or perinatal mortality.^{36, 41, 45}

Proposed mechanisms for prematurity or fetal distress include uterine contractions through female orgasm or through male orgasm, prostaglandins in sperm, sexually transmitted infections, and “mechanical” stress through intercourse.²

Vaginal Bleeding

Many women will experience some vaginal bleeding or spotting after coitus, especially during the first trimester of pregnancy, and will continue to have a successful pregnancy.  Medical attention is warranted when bleeding or spotting continues for several days or is accompanied by clots and abdominal cramping.  Deep penile thrusting may cause bleeding in the later stages of pregnancy.  Prolonged bleeding in the second or third trimester should be reported to a clinician immediately to evaluate potential problems such as placenta previa or placental abruption.²⁹  Health practitioners should educate couples on the normal aspects of bleeding as well as bleeding requiring medical attention.   

Infection

A subgroup of women who have frequent intercourse and genital colonization by certain microorganisms may have elevated risks of preterm delivery.^{10, 39, 41, 43, 45} The Vaginal Infections and Prematurity Study Group³⁹ found that women who had frequent intercourse and were colonized with Trichomonas vaginalis, Mycoplasma hominis, or bacterial vaginosis were at increased risk of preterm delivery. Frequent intercourse in women without such colonization was not associated with preterm delivery.

Identification of at-risk pregnant patients begins with taking a standard history of sexual behavior and previous vaginal infections, both sexually and nonsexually transmitted. The information obtained augments routine screening practices by identifying patients at risk. In particular, patients with common clinical symptoms (abnormal vaginal discharge, dysuria) and complications such as septic abortion, preterm labor, and premature rupture of membranes should be evaluated for vaginal colonization.

It may be concluded that intercourse or orgasm, or both, need not be interdicted in late pregnancy for most obstetric patients. Sexual activity does result in uterine contractions, and thus restrictions might be considered in those for whom premature labor is a threat. It seems likely that the sexual desire of most women has already declined by the last few weeks of pregnancy, but for those who are still sexually active, there seems little evidence to advise against coitus unless there are strong contraindications. Table 4 provides indications for abstaining from intercourse during pregnancy.

Table 4. Indications for abstaining from intercourse during pregnancy

  Vaginal bleeding
  Placenta previa
  Premature dilatation of the cervix
  Rupture of the membranes
  History of premature delivery
  Multiple pregnancy

(Adapted from Mills JL, Harlap S, Harley EE: Should coitus late in pregnancy be discouraged? Lancet 2:136, 1981.)

As is true for sex during pregnancy, resumption of coital activity postpartum has many complicating factors. Tiredness, lack of sleep, and stress are commonly reported in the postpartum period.⁷  According to DeJudicibus, fatigue significantly contributed to diminished sexual activity 12 weeks after childbirth.⁴⁸  The traditional postponement of sex for 6 weeks after delivery was based on fear of introducing infection through an open cervix and fear of harming vaginal and perineal sutures. This standard did not, however, consider individual variability of interest and physical comfort and the actual experience of patients.  Sexual activity may generally be resumed when the vagina, cervix and uterus have healed as indicated by the cessation of lochia.⁴⁹  

In the first 6 to 8 weeks postpartum and during breastfeeding, the sexual arousability of mothers is physiologically reduced, the walls of the vagina are thinner, and orgasm is less intense.² The high levels of prolactin in lactating women suppress ovarian estrogen production, with consequent changes in vaginal lubrication and atrophy of the vaginal epithelium.¹⁵ Three months postpartum or after breastfeeding has ceased, these changes regress; some women then experience orgasm more intense than prepregnancy.³ 

The birth of a child unalterably changes a couple's relationship. Many mothers and fathers are afraid of the resumption of intercourse.^{2, 15} New fathers can be jealous of the neonate or become engrossed in the child to the exclusion of the mother.³ The child is often in close proximity to the parents, and they may avoid coitus for fear of alarming the infant. Additionally, if the child is kept in a separate room, the fear of not being able to hear a newborn's cry hinders relaxation and spontaneity.

Sexual function can be influenced by a woman's ability to adjust to motherhood.  Often this transition period can be accompanied by concerns of confinement or lack of personal freedom.  DeJudicibus reports a positive mother role quality to be the strongest predictor of sexuality 6 months postpartum.⁴⁸ 

Many women are worried about the sexual satisfaction of their spouses. Studies show that up to one-fourth of young fathers begin an extramarital affair at that time; however, before the pregnancy, 15% of the men had already had affairs.³ In the long run, the sexual relationship of at least one-third of the couples worsens and sexual problems are most pronounced 3–4 years after the birth.²

As many as 10% of women experience postpartum depression according to The American College of Obstetricians and Gynecologists in 2005.  Postpartum depression can adversely affect a woman's sexuality and desire for intercourse.  Couples should allow adequate time for both partners to adjust to the physical and psychological changes associated with pregnancy and subsequently parenthood before resuming sexual intercourse.⁴⁹

Compared with the time before pregnancy, female sexual activity is reduced in most cases up to 3 to 4 months postpartum^{3, 20, 21, 22, 25, 50, 51, 52, 53, 54, 55, 56, 57} and may remain low up to 1 year postpartum^{20, 51} ). (Table 5)  In a literature review analysis by DeJudicibus, sexual desire remains diminished 6 months after childbirth.⁴⁸  Although inadequately studied, male sexual satisfaction is generally decreased from prepregnancy levels.^{22, 51}

Table 5. Sexual activity according to postpartum month compared with prepregnancy level

Study	Sample	Design	Postpartum (months)
			1–2		3–4		6–9		12
			C	L	C	L	C	L	C	L
Masters and Johnson, 19663	101 F, 79 M, US	Prospective	–	–	–	↓*	–	–	–	–
Tolor and DiGrazia, 197619	216 F, US	Cross-sectional			–	–	–	–	–	–
Lumley, 197857	30 F, 20 M, Australia	Prospective	–	–	↓	–	–	–	–	–
Robson et al., 198120	119 F, GB	Prospective	–	–	↓	↓	–	–	↓	–
Ryding, 198421	50 F, Sweden	Prospective	–	–	–	↓	–	–	–
Elliott and Watson, 198522	128 F, 87 M, GB	Prospective	↓	↓†	↓	↓†	–	–	–	–
Alder and Bancroft, 198856	91 F, GB	Prospective	–	–	↓	–†		–	–	–
Forster et al., 199450	19 F, Australia	Prospective	–	–	↓	↓†	–	–	–	–
Al-Bustan et al., 199555	220 F, Kuwait	Prospective	↓	–*	–	–	–		–	–
Adinma, 199625	440 F, Nigeria	Prospective	↓	–†	–	–	–	–	–	–
Glazener, 199754	215 F, Scotland	Prospective	–	↓†	–	–	–	–	–	–
Byrd et al., 199851	570 F, 550 M, US	Prospective	↓	↓†		↓†		↓		↓
Barrett et al., 200053	796 F, GB	Prospective	–	–	↓	↓	↓	↓	–	–
DeJudibus 200248	138 F, Australia	Prospective	↓	↓	↓	↓	–	–	–	–

C, coital activity; F, female; GB, Great Britain; L, libido; US, United States; , more than prepregnancy level; ↓, less than prepregnancy level; , equal to prepregnancy level; –, not measured.
*Greater in nonbreastfeeding than breastfeeding women.
†Greater in breast feeding than nonbreastfeeding women.

Intercourse is resumed, on average, 6–8 weeks after the birth in the United States,^{16, 19, 51} Europe,^{20, 22, 52, 53, 54, 58, 59} the Middle East,⁵⁵ and Africa.²⁵ By the sixth week postpartum, about half of couples practice intercourse^{19, 20, 22, 25, 51, 59}; by the second month, about two-thirds of couples have coitus^{16, 54, 55}; and by 1 year, almost all couples have resumed intercourse.^{52, 53, 58} Compared with the prepregnancy period, however, coital frequency is reduced in most couples during the first year after birth.² Noncoital sexual activities, such as orogenital sex, also decline postpartum.⁵²

Dyspareunia

Over 50% of all women experience pain during their first intercourse after the birth. Six months postpartum, 36% of breastfeeding and 16% of the nonbreastfeeding mothers still suffer from dyspareunia; 13 months postpartum, 22% still have problems.² Dyspareunia may be secondary to a hypoestrogenization from breastfeeding^{15, 52, 53} or from an episiotomy.^{20, 21, 22, 52, 53, 54}

A significant relationship between episiotomy pain and sexual activity has been found in some studies⁶⁰ but not others.^{22, 54, 55, 59} The more severe the laceration, the later intercourse is resumed.⁵⁹ In fact, women with a cesarean section resume intercourse somewhat earlier than women who deliver vaginally.^{31, 51}Table 1 depicts factors that inhibit sexual activity during the postpartum.

Breastfeeding

Breastfeeding presents several unique potential problems. Infant suckling can be accompanied by erotic feelings in up to one half of mothers.² Some women may experience guilt feelings, and some may stop nursing because they are afraid of the sexual stimulation.^{2, 3} One-fifth of breastfeeding women have problems with contraception or with milk leakage.^{3, 16, 20, 23, 25, 56, 57} Moreover, nipple tenderness and fatigue can result from the frequency of breastfeeding during the early postpartum period (see Table 1).

Not surprisingly, breastfeeding has been shown to negatively affect sexual activity in most^{22, 25, 50, 51, 54, 56} but not all^{3, 55} studies (see Table 5). Women who breastfeed resume intercourse at a later time,^{25, 50} are less sexually interested,^{22, 51, 54} suffer from coital pain more often,^{2, 15} and enjoy intercourse to a lesser degree.^{22, 51, 56} The cessation of breastfeeding has a positive effect on sexual activity but has no effect on sexual responsiveness or orgasm.⁵⁰

In summary, childbirth brings about a change in the sexual relationship. Dyspareunia and breastfeeding, in particular, may affect a woman's level of sexual activity. Education by a physician in regard to the psychological and physiologic sequelae of childbirth is essential in assisting couples through this rewarding, but often stressful, period of their lives.

Although a large amount of research has been conducted in the past several decades regarding sexuality during pregnancy and childbirth, more focused research is needed. Noncoital measures of sexuality should be measured because women often have intercourse to please their partners, and thus, coital activity is not the best measure of female sexuality. Research should include the partner because sexuality mostly involves two persons. Data on the complex interplay of physical, psychological, and relational factors are needed. More analyses of the relationships between sexuality and physiologic data, such as episiotomy, hormonal status, and vaginal tonicity in the postpartum period are needed. Finally, prospective data going beyond the third month postpartum are necessary because psychosexual adaptation to parenthood takes much longer than physical adaptation to motherhood.

In their role as providers of health education and preventive care, physicians have many opportunities during prenatal care to give accurate information and dispel myths. Many patients may be reticent but would welcome a discussion of sexual matters if approached sensitively by their physician. Counseling can relieve a couple's anxiety and enhance adjustment to their changing relationship, which may help prevent the development of longer-term conflict.

Couples should be advised that they may experience a decline in sexual satisfaction during pregnancy and after childbirth, but that they may expect a gradual recovery during the following year. Because breastfeeding offers many advantages for the infant but significantly affects sexual expression, anticipatory guidance regarding expected changes is particularly important. The knowledge that they may experience less sexual interest postpartum and resume intercourse a bit later than nonbreastfeeding couples may help breastfeeding couples continue the nursing process despite sexual problems. Particularly, couples will benefit from understanding the hormonal effects of breastfeeding and therefore not conclude that there is a problem in their relationship. Practical advice might include instruction in the use of a water-soluble lubricant and pads if the let-down response occurs with arousal or orgasm, and reassurance that orgasm from breastfeeding is a normal response for some women.

Accurate information about sexuality can help dispel myths as a couple goes through the important transition of pregnancy and childbirth. Because many patients are hesitant to broach the subject, discussion of expected changes should be routinely introduced by physicians during prenatal care. Most patients welcome the freedom to discuss this topic if approached sensitively, and the physician can benefit by a better understanding of the couple's relationship as they form a new family.