While we are awash with information on pregnancy and labour, little is said about the sexual difficulties women can face after childbirth. Catherine Shanahan learns of a new Irish study which explores this sensitive subject.
IT’S the subject of a pregnancy best seller, a $40 million (€37m) movie and the advice is endless online. What to Expect When You’re Expecting has been thrashed out across so many forums that women are in danger of suffering from information overload.
But this is hardly the case for women who find themselves at sixes and sevens sexually after childbirth, in a country where discussing “female problems” is as taboo as eating horse meat.
There is no bible to tell you What to Expect When You’re Done with the Expecting. There is no movie to guide you, post-childbirth, on what can happen — or not — between the sheets. Instead, we have magazines littered with tales of celebrity mums whose physical perfections are undiminished by a 10lb delivery and who leave us with the impression that they are “back in the sack” as soon as they leave the hospital.
For those of us living in the real world, however, reassurance is on the way.
It comes in the form of the early results of a groundbreaking Irish study, which gives a clear insight into the sexual problems that can affect large numbers of women in the weeks and months after giving birth.
The Maternal Health and Maternal Morbidity in Ireland longitudinal study, with the appropriate acronym MAMMI, is being conducted by Trinity College Dublin (TCD) and is the first in Ireland to examine the health and wellbeing of first-time mothers in the year after giving birth.
Deirdre O’Malley, a Health Research Board (HRB) research fellow in Trinity, who is responsible for the sexual health aspect of the study, believes many of its findings will give comfort to women concerned about issues such as lack of libido, vaginal dryness and painful sex.
“My main priority is to get the information [from the study] out there so women can recognise what changes are normal after childbirth, and what changes are not, and to know when to get help if a problem persists,” O’Malley says.
So what is normal? The Mammi stats indicate that vaginal dryness was a factor for a third of the women surveyed, even before pregnancy, a figure that increased to 43% of women three months after giving birth. However, at 12 months post-partum, the percentage affected had dropped back to 35%. These findings suggest vaginal dryness is relatively common, both before and after birth.
Mammi also found the percentage of women affected by painful penetration practically doubled three months after giving birth, jumping from 23% pre-pregnancy to 44%.
Reassuringly, this dropped back to less than one in five one year after the birth. As O’Malley points out, a lot of problems tend to self-resolve. “It’s only when they don’t that women need to seek help,” she says.
The study asked women about sexual activity levels and found significant changes occurred between the pre-pregnancy period and the 12 months after baby was born.
For example, pre-pregnancy, 54% said they had sex one to two times per week but this dropped to 41% 12 months after giving birth.
Perhaps unsurprisingly then, the number of women who reported having sex one to two times a month, increased from 14% pre-pregnancy to 51% a year after giving birth.
MAMMI, which recruited almost 1,500 women across three maternity sites — the Rotunda, Coombe and the University Hospital Galway — also asked women about satisfaction with their sex life. Half were “very satisfied” pre-pregnancy, but this dropped to one in four 12 months after baby was born. The numbers “moderately satisfied” increased from 35% pre-pregnancy to 43% a year after giving birth.
So what does all this mean? As O’Malley, who is also a midwife, points out, while women do experience changes in their sex life after having a baby, they may worry unnecessarily that they are the “odd one out”.
“They may be asking themselves ‘Am I the only one not having sex? Is there something wrong with me?’ but if they look at the Mammi stats, they may see that they are actually in the majority,” she says.
The truth is everyone changes physically, and, often emotionally, as various factors kick in.
“If you think about it, there’s this whole emotional upheaval, particularly for a first-time mum.
“Then there’s the sleep deprivation and the sense that you can only look after baby, and you have this whole new kind of love.
“And there is often a more negative perception of body image — both how women perceive their own body and how they think their partner perceives it. It can all be so overwhelming,” O’Malley says.
The pressure on women to resume having sex can also be overwhelming. The medical advice is to abstain for six weeks after giving birth, primarily to avoid the risk of infection. This applies to both vaginal delivery and C-section mums. But as O’Malley points out, for many women, this deadline is unrealistic and international research would appear to back that up.
In a study that tracked 1,507 Australian first-time mothers, 45% who had a C-section had sex after six weeks. But only 32% who had an episiotomy and 35% who sustained a tear had sex six weeks post delivery.
“In the real world, not very many women have resumed having sex after six weeks. Yet you have women believing there must be something wrong if they haven’t. That’s where our survey can provide reassurance. More than a quarter of women (26%) did not resume sexual activity until three to four months after birth.”
Mary, who agreed to be interviewed on condition her real identity would not be revealed, is a case in point. She and partner Sean attempted sex about two weeks after being discharged from hospital, but she felt so bruised and sore, she had to call a halt.
“Sean didn’t say much but I know it was difficult for him. All my attention was on the baby — how he was sleeping, feeding, if he was too warm or too cold and so on.
“We made a couple more attempts to have sex in the following weeks but each time I hit a wall of pain.
“It took about three months before I could have pain-free sex — a huge relief for both of us. It had been a tense time,” Mary says.
It would have made a huge difference if they’d been warned during the prenatal classes that sex may be out for a while, Mary says, but “the whole emphasis was on the birth”.
The couple expected once baby arrived that their sex life would get back on track, but even though the birth was relatively straightforward, Mary felt like her body had been “through a war zone” — she required stitches after her perineum ripped. When normality did return to their bed, Mary still felt things had changed.
“Once you cross the bridge of parenthood, sex is never the same again.”
Mary was fortunate in that her post-pregnancy sexual issues did not persist. However, other women are not so fortunate as Olga Cahalane, a senior community physiotherapist for women’s health, points out.
Cahalane, who works for the Health Service Executive in Cork , treats women of all ages for a variety of women’s health issues including bladder and bowel incontinence, prolapse and dyspareunia or painful sex. She has seen “a good few women in their 20s”, some of whom developed problems after giving birth, but is keen to emphasise they are in the minority.
“I wouldn’t like to scare women off childbirth or give the impression that it leaves everyone traumatised and scarred, because that is certainly not the case. A lot of women who give birth vaginally have a very simple uncomplicated birth.
“But the women referred to me have issues and have been referred to me by their GP or consultant.”
These issues range from tears and scarring during labour, to stress incontinence, to the significantly more distressing problem of pelvic organ prolapsed (POP). Where a woman requires stitches, it is likely to be at least three months before she feels like having sex, Cahalane says.
For others, the trauma of childbirth is still fresh and the thought of intercourse scares them.
“A lot of women feel almost numb down there... There is a fear that sex is going to be painful, that there will be no enjoyment,” Cahalane says, adding that for many, it’s a relief simply to be able to talk to someone about their experience.
The issue of stress incontinence is one Cahalane deals with regularly. This is essentially an inability to control the urge to urinate. The most common causes are pregnancy and childbirth, during which the sphincter and pelvic muscles are stretched out and weakened.
“Incontinence can be a great source of embarrassment to women and can turn them off sex.
“There’s the embarrassment of wetting the bed during orgasm, or when the woman is just relaxed enough for sexual intercourse. I’ve had women say ‘I’m just not doing it anymore because I wet the bed every time’.”
She advises women to regularly practice pelvic floor exercises to tighten up lax muscle, as well as restricting their fluid intake, particularly caffeine, which irritates the bladder.
At the more extreme end of the spectrum, she sees women with POP, a condition that occurs when a pelvic organ — such as the bladder — drops (prolapses) from its normal place in the lower belly and pushes against the vagina walls). This can happen when the muscles that hold the pelvic organs get weak or stretched from childbirth.
“Some of the women have no idea what it is. It feels like a ball sitting on their pelvic floor and it can block the entrance of the vagina, preventing sex. When I explain what it is to them, they are usually relieved to find it’s nothing dangerous like a tumour,” Cahalane says.
In these circumstances, understanding what has happened helps the woman explain to her partner why sex is difficult for her and that she is not rejecting him.
Cahalane’s big bug bear is the lack of emphasis placed on ensuring women are aware of how vital pelvic floor exercises are throughout their life. The pelvic floor muscles essentially form a sling to support the pelvic organ. “It should be part of the biology curriculum. As it stands, they learn too late,” she says.
For videos on pelvic floor exercises see: www.mammi.ie/videos.php
See page 10 for more on stress incontinence
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