Alteration of Mother’s Sexual Activity during Pregnancy

Sexual activity during pregnancy is one of the significant issues for both pregnant mother and healthcare provider, though rarely disclosed. Studies on this topic have been done broadly, though still no conclusion. The aim of this study was to analyze the change of mother’s sexual activity before and during pregnancy and to describe resources used by mother to find sexual activity information. A descriptive cross sectional study was conducted on pregnant mothers who undergo antenatal care at Tegalrejo public health center, Yogyakarta. Sample was determined using quota sampling which total sample was 78 pregnant mothers (26 pregnant mothers per trimester) without significant health problem related to their pregnancy, such as high risk pregnancy condition and vaginal bleeding. Data were collected using Indonesian version of Pregnancy Sexuality and Response Inventory


INTRODUCTION
Sexual health is an important aspect in achieving quality of life for both man and women (1). World Health Organization define sexual health as "a state of physical, mental and social well-being in relation to sexuality". Therefore, sexual health is not merely related to intimacy, being free from disease or dysfunction, more broadly it related to sexual activity, pleasant and safe sexual experience, and free from coercion; discrimination; and violation (2). Sexual activity include biological, emotional and physical aspects. Biological aspect ranges from holding hands, kissing the cheeks or lips, and developing to sexual intercourse. Emotional aspect is shown through the emotional attachment between partners, including sexual arousal, response to sexual stimulation, and sexual satisfaction. While the physical aspect related to medical condition, such as pain and psychological distress during sexual intercourse (3).
Sexual activity during pregnancy is one of the significant issues for both pregnant mother and health care provider, though rarely (PSRI) questionnaire which reliable to used (Cronbach's alpha: 0.714). Data on sexual activity (biological, emotional, and physical aspects) in each trimester were analyzed by paired t test. Data on sexual activity among trimesters in several sub-aspects (frequency, desire, and pain during intercourse) were analyzed by Kruskal wallis and followed by post hoc analysis on significant result. Result showed the significant changes of biological aspect of mother's sexual activity before and during pregnancy, especially in the second (p 0.002) and third trimester (p 0.000) and the changes tend to decline. Significant decline also found in emotional aspect of all trimesters (p<0.05). In line with biological aspects, physical aspect also showed significant decline in the second (p 0.000) and third trimester (p 0.000). Pregnant mother got numerous resources related to sexual activities during pregnancy, yet the most common was from healthcare provider (35.9%). Providing the right information related to this topic will help the mother to understand their sexual activity changes and to choose the right decision in performing sexual activity.
Keywords: sexual activity, pregnancy, mother disclosed. Women's physical, psychological, and social changes will determine further sexual perception and practice along pregnancy (4).
Women's complain related to their physical problem or discomfort during pregnancy may leads to avoidance of sexual intercourse during pregnancy. Deterioration of sexual activity during pregnancy due to the lack of understanding related to this topic may affect not only mother's physical health but also their psychological health, relationship with their spouse, and quality of life (5). Thus needed further evaluation about mother perception related sexual activity along pregnancy and their health concern during pregnancy.
Many studies on sexual activity during pregnancy have been done broadly, though still no conclusion. Sexual desire, orgasm and frequency of sexual activity during pregnancy show reduction compared to before pregnancy (2,5).
However, several previous studies showed vary result that experience of orgasm has no change during pregnancy, while others report that the achievement of orgasm decreases as well as the frequency of intercourse (8).
Religion and cultural boundaries are the general issue usually emerged by the researcher in assessing sexual activity during pregnancy (9,10,11,12). Common perception that sexual activity is taboo to talk, also make it difficult to dig up (9,11). Especially in Indonesia, research related to this topic is still limited. Several published studies conducted in Indonesia generally assess the mother attitude related to sexual activity dan sexual function during pregnancy. Cedli study on husband sexual function during pregnancy showed that the most of husband show decrease on their sex drive, erection and frequency of sexual activity. However, there was no change in sexual satisfaction (13). Study conducted by Tawulo found that the majority of mother show negative attitude related to sexual activity during pregnancy. Mother and their spouse choose abstinence especially in the last trimester (12).
It could be related to cultural background which mother avoid to discussing about their sexual desire and needs (9,12). Preliminary observation showed that mother feel uncomfortable to discuss their sexual problem during pregnancy to physician or other healthcare provider. Midwife interviewed also stated that specific counseling related to this topics not been done yet. Jarnali & Mosalanejad stated that majority of the mothers never discuss their sensitive topics to healthcare provider throughout their pregnancy (14). Perception about adverse effect of sexual activity during pregnancy such infection and afraid to harm the baby during intercourse are still grow in our community (15). Whereas, mothers openness to discuss about their sexual problem during pregnancy could help them to make the right decision and enhance their quality of life (16).
Understanding mother sexual activity during pregnancy in specific region, will helping healthcare provider to realize the change of mother's sexual function and directing health professionals to provide comprehensive care according to their needs (3). The purpose of this study is to analyze the change of mother's sexual activity before and during pregnancy and to describe resources used by mother to find information related to sexual activity during pregnancy.

MATERIALS AND METHODS
This cross sectional study was conducted and related health concern of pregnant mother.
Data collection was done by questionnaire distribution to mother who undergo antenatal care in Tegalrejo public health center. The questionnaires were fulfilled by pregnant mother in the waiting room while waiting for their turn to be examined. Based on this study design, the questionnaire was distributed to pregnant mother based on their current gestational age or trimester until fulfill the study quota, which 26 pregnant mothers per trimester. Data collection accomplished one month. After that, the complete questionnaires added to the database for further analysis.
Data on mother's sexual activity (biological, emotional, and physical aspects) in each trimester were analyzed by paired t test. Data on mother's sexual activity among trimesters in several sub-aspects (frequency of intercourse, sexual desire, and pain during intercourse) were analyzed by Kruskal wallis and followed by post hoc analysis on significant statistic result.
Resources of information related sexual activity during pregnancy was analyzed using frequency distribution or percentage.

RESULT AND DISCUSSION
This study engaged 78 pregnant mother activity among trimesters can be tested.

The Change of Biological Aspect
Biological aspect of sexual activity consists of intercourse's frequency, orgasm, and the initiation of intercourse. Frequency of intercourse generally chosen by mother was 1-2 times per week for all trimesters and abstinence was increasing along with gestational age increase. Similar, experience of orgasm also showed decline as long as gestational age increase. Overall, Table 2 showed significant decrease of biological aspect of mother's sexual activity especially in second and third trimester (p<0,05) compared before pregnancy. In addition, analysis of intercourse frequency among trimesters showed no significant differences (p=0,143), yet appear decrease throughout pregnancy as showed in Table 3.
Finding of decline intercourse frequency on this study has similar result with previous studies (5,10). The main reason for this decline are mother's fear to harm the fetus, bleeding or other negative effects, and physical discomfort (1,10). Even, some mother and spouse decided to abstinence. In fact, abstinence is only recommended for pregnancy with specific condition which may bring harm to the mother and/or fetus such antepartum hemorrhage due  Generally, this study show decrease of biological aspect of sexual activity experienced by pregnant mother, especially on the third trimester. However, mother with low-risk pregnancy are expected to feel comfortable to performing their sexuality (e.g. sexual intercourse) during pregnancy and not to worry to their negative thought (19).

The Change of Emotional Aspect
Emotional aspect of sexual activity includes desire, arousal, and satisfaction during sexual activity. Table 4 show the significant change on emotional aspect during all trimester (p<0,05). Sexual satisfaction also showed decline during pregnancy, especially in the last trimester and has supported several previous studies (5,19). During the third trimester, pregnant mother and spouse would avoid sexual intercourse, due to various condition such as uterus contraction, feeling of harming the baby, decrease of libido, fatigue, pain during intercourse, and several pathological condition (e.g. premature rupture of membrane, placenta previa) (6,20). Thus, mother and spouse cannot fully enjoy their sexual intercourse and results in decreased sexual satisfaction (21).

The Change of Physical Aspect
Physical aspect that consists of pain during intercourse (dyspareunia) and difficulties during sexual intercourse showed significant change in second and third trimester (p<0,05) when compared to before pregnancy. The comparison of physical aspect among trimesters also shows significant change (decline), especially on the second and third trimester. This finding also supports previous studies (18). Physiological change of pregnant mother such as enlarged abdomen, fetal weight gain and the use of muscle that rarely used before pregnancy would results in imbalance posture, lumbar pain and difficult sexual intercourse that generally experienced during third trimester (6,18).   Actually there are no standard for sexual activity, means everything related to sexual activity called normal when both side feels comfortable (17).
However, their worries about fetal wellbeing and their labor would make the mother and spouse feel doubt in doing sexual intercourse and decrease sexual satisfaction during intercourse.
Thus, sexual activity during pregnancy is one of the important consultation topic should be given by health care provider.
This study has several limitations. First, the data collection method was done through cross sectional. Thus, the study result could not analyze mother sexual activity over period of time (along preconception, pregnancy, and postpartum period). In addition, this design may leads to recall bias and could not guaranteed to be representative. Second, the number of sample for each trimester was limited. Therefore, further study need to be done with more advance design such as cohort design with more extensive sample. This strategy may reduce the possibility of recall bias and improve the generalizability of findings.

CONCLUSION AND RECOMMENDATION
All aspects of mother's sexual activity during pregnancy showed several changes when compared before and during pregnancy.
This change tends to be similar for all trimesters, means that mother's sexual activity during pregnancy showed decline trend when compared to pre-pregnancy. In addition, comparison of sexual activity among trimesters also showed decline trend, such as intercourse frequency; desire and mother's difficulties during intercourse, especially during the last trimester. Providing the right information and consultation related to this topic might help the mother to understand their physiological change related to sexual activity and help the mother and their spouse to choose the right decision in performing sexual activity during pregnancy.