Introduction

According to the Ministry of Health (MS - Ministério da Saúde) the idea about sexual rights results, in particular, in the acceptance of different types of sexual expression, autonomy to make decisions about the use of the body and gender equality.¹ These questions underlie freedom of expression and stimulate a culture in which female sexuality is valued and motivates a greater positioning of its actions in relation to its entire social life.²

Considered as a complex phenomenon, female sexuality has varied determinants, and sexual intercourse can be motivated by several factors: psychological, sociocultural and relational. Throughout her sex life, the woman experiences a series of physical and emotional adaptations. In this sense, the puerperium deserves a closer look, since it entails important changes in the lives of women, partners and families.³

The puerperium begins after placental exit extending up to 6 full weeks after delivery. This definition is based on local and systemic changes caused by pregnancy in the maternal organism, which by the end of this period have already returned to the pre-pregnancy state.⁴ However, many studies understand as remote postpartum the period beyond the 45th day up to 12 months following childbirth, since in addition to the relevance of these physiological mechanisms for the restoration of pre-pregnancy status of women, the puerperium is also characterized by marked changes in various other aspects of female life, whether conjugal, family, social or professionals.⁵

At this stage, the estrogen and progesterone deficiency associated with increased prolactin cause reduced sexual desire and vaginal lubrication, which justifies women's dissatisfaction with sexual response. The perineal floor is responsible for the function that allows sexual intercourse and childbirth, however, internal lacerations resulting from the passage of the fetus may cause difficulties in obtaining sexual pleasure. In addition, estrogen is also responsible for the elasticity and viscosity of the skin and vaginal mucosa, and therefore its reduction leads to dyspareunia and, consequently, to long-term decreased libido.⁶

The postpartum sexual course occurs not only in the physiological, endocrine and genital realms, but in its entirety as a person. The postpartum period is a period of conflict in which feelings of joy, fear, relief, anxiety, fulfillment, doubt, among others, alternate in women. It is quite common for many women to feel puerperal-related fears, as many of them are still unprepared to face the challenges of being a mother.⁷

During this period, the experience of sexuality is very complex, and is generally associated with decreased biological, psychological, marital and family well-being, often implying a restructuring in the couple's life. Women's demotivation for sexual intercourse is related to physiological, psychological, social and emotional changes; caring for the newborn; the couple's belief in the myth of irreparable damage to the female genital tract; and yet, the partner not realizing the desire in the woman, is uncomfortable with his desires and generates in the woman the feeling of not being more attractive and desirable.⁸

Therefore, the reality of motherhood and fatherhood configures significant changes in family life, especially regarding the return of sexuality in this period. Moreover, the change to the role of child nurturing and caregiver has been one of the greatest difficulties encountered by women in the postpartum period due to social, cultural and esthetic issues.⁹

Breastfeeding can lead to different feelings and sensations for women when related to sexuality, as it has sociocultural aspects with different meanings and aspects in each woman's life. During the postpartum period, expectations are focused on the baby care, underestimating the mother / nurse's feelings, desires, physical and emotional conditions.¹⁰

In this context, the puerperium is one of the most remarkable moments for women and their families, especially regarding sexual interaction with their partners given this new reality, since the arrival of a baby requires a new family routine. However, women who are not surrounded by expectations do not always experience this period in a similar way, as they are immersed in different contexts, changes and challenges.

Given this, the relevance of the study is based on the possibility of understanding and analysis of perspectives and maternal adjustments regarding sexuality in the puerperal period, emerging from that, different experiences with different implications and adaptability for each countryside woman / mother. In addition, we it is intended to highlight the prominent role of prenatal care, due to the clarification for the pregnant woman about the physiological and social changes that will occur in the postpartum period.

Therefore, seeking to understand the main expectations and adaptations in the postpartum period with regard to sexuality, in a different locus - Pernambuco outback - a research question emerges: What are the maternal perspectives and adjustments regarding postpartum sexuality? Therefore, it was intended to analyze the perspectives and maternal adaptations of postpartum sexuality and identify if there were prenatal orientations.

Method

This is a qualitative, exploratory and descriptive research conducted in a tertiary level maternity hospital that exclusively serves users of the Unified Health System (SUS – Sistema Único de Saúde). It is the only reference center for high obstetric and neonatal complexity in the Integrated Development Region (RIDE – Região Integrada do Desenvolvimento) of Petrolina Pole - Pernambuco (PE) and Juazeiro - Bahia (BA).

Twelve puerperal women admitted to the hospital's joint housing took part in the reasearch, from September to October 2017, who were selected by a non-probabilistic intentional sample, with closure by theoretical saturation. The inclusion criterion was to be in a physical and psychological condition to answer the questions, evaluated by the researcher in charge, and the exclusion criteria were to be in the immediate postpartum caesarean section and / or to have a diagnosis of psychological disorder. As this is a very intimate theme, it was observed that, on average, every 4 or 5 mothers who met the inclusion criteria and were invited to collaborate, only 1 accepted to participate in the research.

In order to ensure confidentiality and privacy in the interviews, the women who agreed to participate were taken individually to the rooming-in office. A semi-structured interview was conducted, containing data for sociodemographic and obstetric characterization, as well as open questions about the perspectives and maternal adjustments related to postpartum sexuality. The mothers were approached with the following questions: “Tell me what your expectations are about returning to sexual activity after childbirth; Tell me about the feelings and meanings you ascribe to this moment; What do you think are the greatest difficulties regarding postpartum sexuality? How would you like the return to sexuality with your partner during this period to be? What orientations were given during the prenatal time regarding the puerperal period and the return to sexual activity after delivery?” The interviews were recorded and lasted an average of 20 minutes.

For analysis and interpretation of the results, the Thematic Content Analysis technique was used. This type of analysis aims at describing the message content and categorization according to the themes that emerge from the text. The participants were identified by the initial “I” (interview) and listed according to the order of application of the instrument.

All interviewees signed the two-way Informed Consent Form and received a copy of it. The research was approved by the Ethics and Research Committee of the Federal University of Vale do São Francisco, under expert report no. 1,896,604 on January 23, 2017.

Results and discussion

Twelve puerperal women, aged between 18 and 29 years old were interviewed, in which 10 declared a stable union with their partner and two were married. Regarding the level of education, four had incomplete elementary school, two had incomplete high school, four had completed high school and two had incomplete higher education. Six puerperal women were primiparous, 9 had caesarean section and 10 claimed to have had some complications during pregnancy, the latter being justified because it is a reference hospital for high-risk pregnancy.

During the analysis, the content of the interviews was grouped into thematic categories, according to the similarity in relation to the subjects covered.

Expectations about return to sexual activity

This category addresses the main expectations about the return to sexual activity with the partner. Reports have shown that fear of pain was often associated with sexual intercourse after childbirth.

Having a relationship again makes me a little apprehensive, especially because of the pain, because it will hurt?! (I3)

[...] I get a little nervous, because for me I think it will hurt [...]. (I7)

[...] I think the pain is like a first time again, you get a little stuck, thinking, ah it will hurt [...]. (I9)

This feeling was expressed by eight out of the 12 postpartum women interviewed, with no distinction between the responses and the mode of delivery (cesarean section or vaginal delivery).

So, I wonder about feeling pain, because the body is recovering from normal birth, right?! (I1)

[...] about cesarean postpartum I have no experience so I'm afraid of hurting, due to surgery, I will get information got it?! (I10)

The fear of feeling pain was highlighted in the mothers' report, since dyspareunia is one of the aspects with the highest incidence in resuming postpartum sexual activities. Regardless of the mode of delivery, low estrogen levels during this period tend to reduce vaginal lubrication and elasticity, causing pain and discomfort during penetration, which justifies the postpartum period as a period of reduced or absent activity for most women, especially with regard to coitus. In addition, there is also concern about the length of time required for the genital tract to recover from childbirth, particularly in the event of episiotomy or laceration. Pain, at the moment of sexual intercourse, negatively influences the experience of female sexuality, both in the impairment of sexual health and in the practice of the relationship, generating dissatisfaction in women.^6,12

A review study states that there is no consensus in the literature regarding the correlation between the mode of delivery and female sexual dysfunction. Dyspareunia in the first three months was significantly associated with vaginal births, but the percentage decreases after six months postpartum, with significant improvement in sexual function. Elective caesarean section does not appear to be advantageous compared to vaginal delivery for sexual function at 6-24 weeks postpartum, as the woman returns to sexual activity normally, regardless of the mode of delivery.¹³

However, intercourse in the postpartum period can be very painful and very uncomfortable, therefore, capable of generating conflict with the partner, breakdown of the relationship and withdrawal from the couple. At this time, caresses and preliminaries can stimulate greater vaginal lubrication, and the use of artificial lubricants also helps to minimize painful sensation during penetration.

Another fear expressed by women was the fear of a new pregnancy during the puerperal period. According to the testimonies of women, the possibility of early pregnancy negatively influences sexual recovery, as observed in these statements:

Woman, [...] getting ready, so as not to see another pregnancy, I was already wondering: what is the medicine that I am going to take?! (I3)

[...] it will take a while, because we should not think about these things, we have to think about well-being, to prevent against an early pregnancy, I think we should let the protection pass, then spend a few more days, then when you start taking the right medication, then think about doing it. (I5)

The fear of a new pregnancy was determinant for most of the interviewed mothers, demonstrating that the knowledge and information related to this subject are insufficient or precarious, which can sometimes cause feelings of doubt and insecurity in women or couples and the fear of a new pregnancy. Therefore, it is ideal that there is clarification on postpartum family planning, preferably even during prenatal care, because the acceptance of the method, the credibility in its effectiveness, the motivation to use it and the correct orientation of the health professional are determining factors for the success of the chosen method.¹²

Study reinforces that the choice of contraceptive method should always be individualized and discussed since prenatal. When guiding the use of contraceptive methods in the puerperal period, it is recommended to consider some issues such as postpartum time, the return or not of menstruation, the pattern of breastfeeding and the possible hormonal implications on lactation and infant.¹

Therefore, to avoid a new postpartum pregnancy it is necessary for the postpartum woman to know the appropriate contraceptive methods and feel safe to adopt the option that is most convenient for her. In contrast, family planning assistance currently provided by Family Health Units needs to overcome some shortcomings, especially regarding the uneven and unsatisfactory provision of methods, which results in fewer choices for women.

In addition, according to some testimonies, the postpartum women feel insecure about the physical changes that occur in the pregnancy-puerperal cycle. For these women such changes imply a negative evolution of body image.

[...] you are insecure with your body because you are still returning to normal [...]. (I7)

[...] there will always be insecurity, because the body will not be the same way. (I8)

Body changes, whether physical or hormonal, that occur throughout the pregnancy-puerperal cycle are sometimes associated with the feeling of loss of self-esteem due to subjective perceptions of poor physical attractiveness and inability to seduce. Commonly, biological adaptation occurs around 6-8 weeks after delivery, however, the return to body image prior to pregnancy hardly happens during this period, often resulting in the negative evolution of the couple's self-image and marital relationship.^12-15

According to authors, self-perception of the body in the postpartum period is associated with the way in which the postpartum woman understands the body changes that have occurred, given the subjectivity, relationships and culture of each woman. Sexuality is intrinsically involved in all this new reality that women experience, whether related to themselves, their body and their femininity, or the contact and communication with their partner.¹⁶

So, women's perceptions about their bodies in the postpartum period are linked to body image before pregnancy because they feel uncomfortable with the current body, affecting self-esteem, self-image, sexuality and relationship with their partner.

The following statements show that postpartum sexuality for postpartum women is conditioned on the woman being comfortable with herself and willing to restart her sex life with her partner.

[...] it is comfortable for me, so that it is good for both me and him. (I1)

[...] understand that we are in a period that is being readjusted, it has to be at the right time. (I4)

Most postpartum women find it hard to feel sexual desire for their partner because they need time to reconnect with their body and feelings. Therefore, it can be said that, besides the information transmitted by the media and professionals, there is the subjectivity of each woman and the self-knowledge about her own body. They may lack scientific knowledge about uterine involution or endocrine phenomena occurring in the puerperal period. However, it was found that for them the most important is their physical, psychological well-being and respect for their own body time. This is empirical knowledge about oneself and determining their return to sex after childbirth.¹⁶

Thus, the experience of postpartum sexuality should be based not only on the physiological recovery of the body, but, above all, on the emotional restoration, different for each woman.

Couple strategies and adjustments for postpartum sexuality

In this category, the baby care routine was declared by the interviewees as a setback to the return of sexual intimacy. In the speech of some women it could be seen that the priority is the maternal demands to later think about the relationship with the partner, as revealed below:

[...] now with a baby you will have the child and you have less time to be with the husband. (I4)

[...] it is very tiring, you take care of the child, most of the time you are not even in the mood to have a relationship with your husband. (I5)

[...] breastfeeding, the routine with the baby, is like an obstacle between the couple. (I7)

In the postpartum period, the couple usually focuses their affection and attention on the newly arrived child, which sometimes results in marital conflicts and tensions. As seen in the mothers' report, the authors state that the maternal role interferes with the couple's sexuality, as the routine of care with the baby requires time and dedication to meet the needs and establish the bond that will be fundamental for the newborn's development.¹⁴ Another study found that postpartum sexual concerns are profound and moderately distressing in new parents, and that increased frequency and severity of these concerns was associated with decreased relationship well-being in both members of the couple.¹⁵

In this regard, with attention focused on the baby, the challenge is to reconcile the roles and adapt to this new routine full of demands. The time to devote to the relationship, whether in the sexual or affective, will be shorter, but also needs care and affection.

Given the adjustments that are necessary for the good sexual relationship of the couple in the postpartum period, the mothers stated that dialogue with their partner is important for maintaining the relationship.

[...] look for each other and talk about it. (I3)

We have to sit and talk, set a certain time for the sexual relationship to come back [...]. (I5)

[...] over the days, we have to talk about it. (I6)

The birth of a child requires a reorganization in the family routine and adaptation of the couple to a new reality. It is a time when women are sensitive and more vulnerable to emotional instability, so understanding and support in the family context is critical. The participation of the partner in this period deserves attention, since he experiences psychological sensations similar to those of women. In turn, the direction of events may have a favorable or unfavorable impact on the couple's relationship.⁶

The various changes that occur in the puerperal period commonly affect the couple's affective and sexual relationship and may compromise family balance and / or aggravate difficulties. Dialogue and understanding between the couple are of great importance in helping to overcome the enormous changes that the birth of a child brings. Thus, the exclusive space of affective-sexual relationship of the couple is equally an important need to be valued postpartum.^14-15

Thus, it is important that there is a lot of dialogue, understanding and tolerance to understand that they are going through a phase of rearrangements and experiences that, if well managed, will bring the couple closer, harmony and complicity.

It was also stated by the mothers that in addition to the role of parents, it is necessary for the couple to re-perceive themselves as husband and wife in the family relationship. Some interviewees signaled this need:

[...] see yourself as a woman again, show affection toward your partner. (I2)

[...] return the bond of the couple, see each other as husband and wife again, because in the early days we take a break. (I7)

One study reveals that in addition to fears related to physical recovery, parental tasks and concern about motherhood are obstacles to satisfactory sexuality, as husband and wife look less at each other and more at the baby, for being the center of attention, making the couple's value unrecognized and feeling rejected.¹²

In this context, the mothers emphasized the need to resume the relationship and intimacy of the couple. For this reason, the availability to understand and get closer to the partner, to take time for two, to demand more attention to the partner and to show affection is essential, as they favor the restoration of the relationship of the couple and facilitate the return to sexual intimacy.

Prenatal information on postpartum sexuality

Finally, when asked about the prenatal guidance regarding postpartum sexuality, most women reported not having received information from professionals.

There wasn't, so I know because in our family we always keep talking. (I1)

No, so if I hadn't called, I had to take medicine, use a condom, but none of that was mentioned during prenatal care. (I2)

No, about postpartum there was no guidance [...] I like to be informed, so I searched the internet. (I5)

No, not during prenatal, but my mother already mentored me. (I8)

Only one of the interviewees reported receiving any prenatal counseling.

We had, we had follow-up about the return, about the contraceptive methods, we had it all in prenatal care, everything different, very attentive the nurse, the doctor, everything well explained, wonderful, there were lectures, a lot of different things. (I9)

Comprehensive female health care includes being aware of issues related to sexual health in the different cycles of women's reproductive life, and requires from the health professional, especially the nurse, knowledge about the physiological and behavioral processes that affect women in the pregnancy-puerperal cycle, enabling the articulation of strategies to cope with this reality.¹⁷

A study of 200 puerperal women states that the majority (83%) of women experience sexual problems in the first three months postpartum. In this sense, sexual performance during pregnancy and after childbirth is a concern that involves not only the woman, but the couple, reinforcing the need for health professionals to receive and clarify about the postpartum's changes in sexual function and interest.¹⁷

Therefore, it is understood that the guidelines on the return to sexuality, postpartum contraception and family planning cannot occur only in the postpartum consultation. Such clarifications are fundamental in prenatal care because they increase the possibility of correct use of the contraceptive method and allow a positive experience in face of the difficulties faced in the postpartum by couples.

Conclusion

Through this study it was found that among the perspectives of women about postpartum sexuality, the fear of pain during the relationship is highlighted, not being influenced by the type of delivery, agreeing with other studies found in the literature. Fear of a new pregnancy was also reported by the mothers, reaffirming the importance of counseling regarding postpartum contraception during prenatal care.

It is true that the organic changes in the puerperal period greatly interfere with women's sexual behavior, however, in the midst of interviews it was observed that women's perceptions of their bodies are linked to the ideology of the biological body, affecting self-perception and negatively influencing your sexuality and relationship with your partner. In addition, newborn care becomes a priority in the family routine and, according to the mothers, makes the couple's sexual experience postpartum difficult.

After the baby is born, the couple must make many adjustments to gradually regain their intimacy. Taking time to be alone, sharing your feelings, desires, fears, and needs enables you to restructure the relationship, securing the place of the relationship, and time and space to cultivate it.

In this context one can affirm the importance of comprehensive health care for women throughout the pregnancy-puerperal process. The nurse has a fundamental role, as she has the knowledge to offer necessary information regarding the puerperium, its transformations and demands, in order to favor a maternal experience of return to effectively healthy sexuality and well-being.

This study had some limitations because it is a subject that involves sexual intimacy, so many mothers, when invited, refused to participate. Thus, further research on the sexuality of women in the postpartum period is imperative in order to know and provide a better understanding of the subject.

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Autor correspondence

Mônica Cecília Pimentel de Melo

E-mail: monquinamelo@gmail.com

Address: Av. José de Sá Maniçoba S/N, bairro Centro, Petrolina – PE, Brasil. UNIVASF/Colegiado de Enfermagem.

ZEP Code: 56.304-917

Authors Contributions

1 – Larissa Karla Rocha Siqueira

Conception and planning of the research project, obtaining and analysis and interpretation of data and writing.

2 – Mônica Cecília Pimentel de Melo

Critical review, adjustments and corrections.

Name 3 – Ramon José Leal de Morais

Critical review, adjustments and corrections.

How to cite this article

Siqueira LKR, Melo MCP, Morais RJL. Postpartum and sexuality: maternal perspectives and adjustments. UFSM. 2019 [Acess at em: 2019 jun 15];vol.9 ex:1-18. DOI:https://doi.org/10.5902/2179769233495