Postpartum sexual activity and contraceptive use among women in a southwest health facility Osun State Nigeria

INTRODUCTION

Childbirth experiences brings about changes to the women's health and well-being. These changes could include fatigue, depression and changes in sexual function which have various challenging effects on them following delivery and baby care.^1-4 Culturally, couples do not stay together after childbirth in the past. This act was solely aimed to prevent unwanted or too early pregnancy.⁵ Meanwhile, most studies showed that interest in sexual activity often decreases throughout pregnancy; but, returns gradually to normal an average range resumption of intercourse with an average range resumption of intercourse between 5^th and 8^lh week after childbirth.^6,7

The post-partum period presents a rising risk in unwanted conception and often frustrated desire for contraceptive protection.^8,9 The risk has been shown to be greater among the first-time mothers who are naive about postpartum experience and misled by nonprofessional advices.¹⁰ Abstinence from sexual intercourse after childbirth until the child is fully weaned is a deep-rooted practice in different cultures and communities.^11,12

Also, in polygamous settings, women after childbirth are obliged to stay away from their husbands with the aim of offering them the opportunity to breast-feed for as long as 2-3 years without sexual intercourse. Recent reports however, suggested that most women resumed sexual intercourse within 3-6 months after delivery, which is a deviation from the taboo against sexual intercourse after birth.^13,14 This shift may not be unconnected to the introduction of modern contraceptive methods and monogamous marital settings leading to changes in the socio-cultural practice of the people.

Commencement of sexual intercourse after delivery without contraception undoubtedly increases the risk of unplanned pregnancies. Unwanted pregnancy could lead to emotional and psychological disturbances for both the woman and or the family as a whole. Report from a study revealed that prenatal care has a strong influence on subsequent use of modern contraceptive methods.¹⁵ Other studies however, have shown that most women resume sexual intercourse within 6 months post-partum without the use of a modern contraceptive method in many countries despite the provision of information about contraceptive methods by relevant health workers during antenatal and postnatal care.^16,17

Therefore, understanding the needs for reproductive health in postpartum women which includes proper perception of the relationship between resumption of menses and the use of a suitable contraception will help in creating awareness about the risk of earlier unplanned pregnancy vis-à-vis amenorrhea in the postpartum period as well as the removal of the provider barriers to the initiation of family planning.

Studies suggested that providers do not systematically communicate information about postpartum pregnancy risk to clients. Some providers rely on direct observation of menses to rule out pregnancy, and thus denying non-menstruating women a form of contraceptive method.¹⁸

This study was designed to establish the current sexual practices, time taken to resume sexual activity and prevalence of modern contraceptive usage among delivered mothers in our environment.

METHODS

Study area

The study was carried out at the State Specialist Hospital, Asubiaro, Osogbo, Nigeria. Osogbo is the capital city of Osun State, located in the southwest region of Nigeria. It shares borders with Ilorin Kwara state to its north, Ibadan, Oyo state to its south, Ogbomoso to its west and other neighbouring towns. There were several health care facilities, notably from private to government owned hospital. It also owned a teaching hospital of the state-owned university.

Study population

This study was done among women within 3-16 weeks postpartum period while attending infant welfare clinic.

Study design

The study adopted a cross-sectional design.

Sample size

The sample size was calculated based on prevalence rate (67.7%) of resumption of sexual intercourse after delivery.¹⁹

The minimum number of subjects derived for this study was 333. However, to account for non- response, 10% of the sample size was added. Hence a total of 366 postpartum mothers were recruited.

Inclusion criteria

Delivered mothers presenting at the above-named clinic for their baby’s care and immunization whose delivery was up to six weeks and above and consented, were included in the study irrespective of their social status or ethnic group. Those who failed to consent were excluded without any penalty and this did not affect the quality of care rendered at the facility.

Study procedure

Consented participants were recruited from the infant welfare clinic of the hospital where delivered mothers up to six weeks and above came to access immunization facilities for their children. Eligible women were consecutively recruited for the study after signing a written consent. Data were collected using a structured questionnaire which consisted of 3 sections, socio-demographic data, obstetrics and reproductive data, and sexual, gynaecological and contraceptive history. The questionnaire was pre-tested and validated at the designated clinic before being administered. The data were collected between the months of March 2021 and May 2021.

Data analysis

Data obtained was collated and sorted. The completed data were computed and analyzed using the statistical package for the social sciences (SPSS) version 21. Results were generated in tables.

Ethical clearance

Ethical clearance was obtained from the ethics and research committee of the State Specialist Hospital, the Hospitals' Management Board, Asubiaro, Osogbo, Nigeria. During the course of data collection, individuals were informed about the purpose of the study, confidentiality, and the right not to participate or withdraw at any time without any effect on their health or other services.

RESULTS

The response rate for the questionnaires was 92.9% (340/366) while 7.1% (16/366) withdrew from completing the questionnaires. They were from 3 ethnic groups comprising mainly of Yoruba 95% (323/340), 3.8% (13/340) were Igbo and 1.2% (4/340) were Hausa. Forty six percent (159/340) of them were into business (mostly traders), 17.4% (59/340) were civil servants. Muslims were 55.6% (188/340) and 44.1% (150/340) are Christians. Most of the mothers 92.6% (315/340) had at least secondary level of education and majority 97.1% (330/340) are married. Table 1 shows the socio-demographic features of the respondents.

Table 2 shows the obstetrics and reproductive features of the mothers which reveal that 33.8% (115/340) had their first deliveries and most of them 51.5% (175/340) were of parity 2-3. Also 40.6% (138/340) of them have resumed menstruation after delivery with a mean time of 18.15±14.32 weeks. Majority of the respondents 83.8% (285/340) delivered vaginally, 15.9% (45/285) of them had episiotomies and 3.2% (9/285) had vaginal laceration. Most of the episiotomies and vaginal lacerations 83.3% (45/54) healed well while the remaining developed chronic pain and infection.

Furthermore, 62.6% (213/340) of mothers had commenced sexual intercourse with a median time to resumption of coitus after delivery of 8.0 weeks and a mean of 11.37±8.85 weeks. Eighty (37.6%) of them commenced sexual intercourse within the puerperium (first six week post-delivery) and eight (3.8%) of them started as early as a week after delivery. About 78.4% (167/213) of the mothers resumed sexual intercourse based on husband's request and 18.3% (39/213) feels it is time for them to resume sexual intercourse. Other reasons for commencement of sexual intercourse include, self-initiated in 0.93% (2/213). Almost all 99.4% (166/167) of women who gave husband requests as reason for commencement of sexual intercourse would not have started at that time. The reasons given for not commencing sexual intercourse include, to prevent pregnancy 45.7% (58/127), to restore health 26.8% (34), lack of interest 22% (28/127) and presently staying with parents 5.5% (7/127).

The general prevalence of contraceptive usage among the respondents after delivery was 34.3%. Among those that have resumed sexual intercourse. More than half (116/213) of them were using a form of contraceptive method but only 50.2% (107/213) were using modern methods contraception which includes, male condoms 60.8% (65/107), injectables 16.8% (18/107), pills 13.2% (14/107), intra-uterine contraceptive device 6.5% (7/107) and sub-dermal implants 2.8% (3/107) while 7.8% (9 116) were using coitus interrupts. Out of the mothers using modem contraception methods only about 39.3% (42/107) had started the use before their first sexual intercourse after delivery and the remaining 60.7% (65/107) commenced contraception after sex. The husbands 34.6% (37/107) made the decisions for their wives to start, 32.7% (35/107) was self- initiated and 32.7% (35 107) were couples’ joint decision to commence contraception. This implies involvement of the women in about 65.4% (70/107) in decision making to commence modern contraception.

The reasons given for not commencing modern methods of contraception in this study include, none resumption of sex 29.5% (64/217), dislike for modern contraception 19.8% (43/217), to be done later 25.3% (55/217), fear of side effect 10.1% (22/217). This study also showed that 38.3% (85/222) of mothers who has had at least a previous delivery before this index pregnancy uses modern methods of contraception which includes, male condom 34.1% (29/85), injectable 23.5% (20/85), intra-uterine contraceptive device 18.8% (16/85), pills 20% (17/85) and sub-dermal implants 3.5% (3/85).

Furthermore, 49.1% (167/340) of respondents’ beliefs a woman can get pregnant before resumption of menstruation if there is unprotected sexual intercourse after delivery, while 26.8% (91/340) disagreed and the remaining 24.1% (82/340) does not know. However, 76.1% (162/213) of mothers who has commenced sexual intercourse has not resumed their menstruation while the remaining 23.9% (51/213) has resumed their menstruation. About ninety seven percent (331/340) of women are aware of exclusive breastfeeding but only 85.9% (292/340) of them are practicing it. Furthermore, only 41.4% (140/340) beliefs a woman can get pregnant despite practicing exclusive breastfeeding, 18.5% (63/340) does not agree conception is possible while 40.3% (137/340) were not sure.

Table 3 shows association between socio-demographic characteristics and pregnancy before resumption of menstruation after delivery.

Maternal age (p=0.001), educational status (p=0.001), occupation (p=0.001) and religion (p=0.015) were significantly associated with believe of likelihood of pregnancy occurrence before the onset of menstruation after delivery.

Table 4 shows relationship between socio-demographic characteristics and exclusive breastfeeding. Here maternal age (p=0.560), religion (p=0.179) was not significantly associated with practice of exclusive breastfeeding, whereas educational status (p=0.001) and occupation (p=0.008) are highly significant with likelihood to have positive impact on the practice.

The result shows that mother's marital status (p=0.286) and occupation (p=0.468) were not statistically significant. Hence these socio-demographic factors do not necessarily have likelihood with return of sexual activity after delivery.

Table 5, however shows that these two socio-demographic factors of marital status and occupation with (p=0.008) and (p=0.028) respectively were highly significant with increased positive likelihood to affect the factors influencing resumption of sexual intercourse by mothers post-delivery.

*Statistically significant.

*Statistically significant

*Statistically significant.

DISCUSSION

This study showed that 62.6% of mothers had resumed sexual intercourse with a mean time of 11.37±8.85 weeks. This rate is comparable with 65% and 66.6% reported from Sagamu in Nigeria and Kampala in Uganda.¹³ This was also similar to the rate of 67.6% found in Jos Nigeria.¹⁹ However, these values were higher than what was obtained in a similar study conducted in Ghana and Germany where the rates of 23.8% and 47% respectively was reported.¹⁶

Considering these rate differences in the postpartum sexual intercourse resumption, it may not be unconnected to diverse cultural, religious practices and most especially sexual attitudes peculiar to these regions. The relatively high rate of early commencement of sexual intercourse in this study may not be unconnected with the fact that some of the traditions which encourage postpartum abstinence after delivery is gradually going into extinction, and turning to mere history rather than being a practice.¹¹ Furthermore, the changing culture and views to sexual practices which could have had a religious undertone cannot be overlooked. For example, the influence of Christianity which forbade polygamy.

Respondents who had resumed sexual intercourse during postpartum gave various reasons while they resumed. Majority of them (78.4%) was due to husband's request. This very finding (husband's request) was comparable with 77.4% found from a similar study in Jos.¹⁹ The same was also noted as the commonest reason in other African settings like Uganda and Cote d'Ivoire.^20,21 The high percentage of husband factor may be due to the fact that women fear that their partners would seek sexual activity elsewhere if they delay sexual relationship for too long considering the fact that most of them might not had been sexually active during the period of pregnancy.²⁰

Also, in this study nearly all of the respondents (99.4%) who resumed sex post-delivery due to husband requests would not have started at that time but has to agree in other to satisfy their husband. On the contrary 0.94% (2/213) of the women initiated sexual activity by themselves, which was in contrast to the traditional practice of postpartum sexual abstinence by couples until the child was fully weaned from breast milk.¹¹ This observation was however very low compared with 14.8% of women who initiated sex in another study.²² This showed that no matter how small the percentage might be, women may also desired sex and they should not be denied. Loss of sexual desire accounted for 22% of failure to resume sexual intercourse in some respondents which was different from 11.9% obtained in a similar study.¹⁹

Despite this sexual exposure in postpartum, about half of them (50.2%) were using modern methods of contraception of which male condom accounted for about two-third (60.8%). This finding was contrary to what was obtained in another study where a low prevalence 19.9% was obtained.¹⁹ Low prevalence for contraceptive usage was also documented in Lusaka, Zambia.²³ Also of interest to note is the fact that out of the mothers using modern contraceptive only about one-third (39.3%) have started before the first sexual intercourse postpartum others started after commencement of sexual activity. This eventually supported low contraceptive usage as in other studies. The other two-third (60.7%) that started after sex were likely to be after-thought which might have been done due to fear of unintended pregnancy. This thought might further be supported because 38.3% of women in this study were using contraception before index pregnancy. In this study also educational level predicts contraceptive knowledge but this did not reflect in contraceptive usage. This observation was in keeping with finding from another study.²⁴

The role of men in the use of modern contraception was encouraging and commendable as seen in this study as about one-third (34.6%) of them made the decision to start contraception, another one-third (32.7%) was self-initiated by the mothers and the last one-third was a collective decision by the couple. This collectively showed about two-third input of delivered mothers in starting contraception postpartum. Despite the benefits contraceptive usage offers, respondents not using them have their reasons some of which include, none resumption of sex in more than one- fourth (29.5%), another 10.1% due to fear of side effects. These same findings are similar to documented finding in another study where 25.2% and 12% values respectively were found.²⁵ Husband not always around (25%) was another important factor which cannot be overlooked. This did not put the woman under any pressure for early contraceptive use. Other reasons given were dislike for contraception in less than one-fourth (19.8%), another one-fourth (25.3%) said it will be done when they are ready.

Regarding the perceptions held by delivered mothers about fertility return which was linked to return of menstruation, about half (49.1%) of the responders were of the opinion that a woman can get pregnant if her menstruation had not returned postpartum if exposed to unprotected sexual intercourse, whereas about one-quarter (26.8%) had a contrary opinion while another quarter (24.1%) did not know the answer to the question. These perceptions or misconception was one of the major points of discussion at the Global online Discussion Forum on fertility return and pregnancy risk after delivery.¹⁸

Finally, from this study, maternal age (p=0.001), mode of delivery (p=0.002) and onset of menstruation (p=0.001) were statistically associated with early resumption of postpartum sexual activity. This agrees with findings from other studies.^5,16,26 This was contrary to another study finding where maternal age, mode of delivery and onset of menstruation are not significantly associated with early resumption of postpartum sexual activity.¹⁹ However, other socio-demographic characteristics like parity (p=0.444), educational status (p=0.251), history of genital injury (p=0.263) and exclusive breastfeeding (p=0.449) were not significantly associated with early resumption of postpartum sexual activity. This forgoing findings now agrees with study but in contrary to other studies.^15,16,19,26

Limitations

Despite all our findings and utmost assurance of confidentiality, cultural stigma associated with admitting sexual desire, especially in a period in which it was considered a taboo may affect the reasons given for resumption of sexual intercourse as well as admission by women the resumption of postpartum sexual intercourse. These were serious huddles crossed in collecting necessary information. Some of them saw the questions as been odd hence withdrew from participating.

CONCLUSION

The above findings therefore suggests that early commencement of sexual intercourse is common to most women in our setting irrespective of different socio-demographics and obstetric characteristics probably as a result of the influence of modern way of life and demand for sex by their husbands, which might have been promoted by the monogamous setting of most families. It is therefore recommending that discussion with couples about postpartum sexuality and contraception should be part of routine antenatal and immediate postpartum care in order to prevent unplanned pregnancies and improve their health seeking behavior.

ACKNOWLEDGEMENTS

Authors would like to thank co-authors, and technical staff of the state hospital Asubiaro Osogbo.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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