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Influence of Gestational Period on Sexual Behavior

Mervat A. Khamis, Manal F. Mustafa, Sahar N. Mohamed, Madiha M. Toson Obstetrics and Gynecology Nursing Department, Faculty of Nursing, Assiut University ABSTRACT
Various studies in the field of sexual and reproductive health have focused on understanding the relationship between the gestation period and sexual behavior. The majority of such research suggests that during pregnancy, both sexual desire and frequency of sexual relations decrease. The objective of the present study was to investigate whether there are any influences of gestational period on the sexual behavior, and to identify differences in sexual behavior among women before and during pregnancy. A cross-sectional analytic study design was carried out on a sample of 190 women attending the outpatient clinics of Assiut university hospital were consecutively recruited. Data was collected using a structured questionnaire to collect socio-demographic data, obstetric history, and information about womens sexual desire and practice of sexual intercourse before and during pregnancy, as well as their perceptions and beliefs. The mean age of women was 26.75.4 years. The results showed that 37.4% of women had better sexual desire during the whole of pregnancy, 47.9% had sexual satisfaction during the second trimester of pregnancy, and 75.7% felt change in sexual intercourse during pregnancy. A considerable proportion (43.7%) believed that sexual intercourse during pregnancy could lead to problems. The number of intercourses before and during pregnancy were positively correlated (r=0.80, p<0.001). Multiple logistic regression model revealed that history of abortion was the only statistically significant negative independent predictor of the practice of sexual intercourse during pregnancy. It is recommended that health care providers, especially nurses, should educate and counsel women regarding the safety of sexual intercourse during pregnancy if no medical risk is present.

Keywords: Female violence, sexual abuse, pregnancy, nursing

Corresponding Author: Dr. Manal F. Mustafa. Faculty of Nursing, Assiut University, Obstetrics & Gynecology Nursing Dep.

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INTRODUCTION Sexuality as a basic human experience comprises motives, feelings, thoughts, and behavior linked to biologically determined drives related to lust and reproduction, psychological needs related to love and affection, and social interactions related to intimacy and relationships. During this lifelong process, sexuality acquires rather stable personality, specific patterns of values, thoughts, and behavior.(1) Female sexual desire has evolved as one of adaptation designed to regulate decisions regarding choice of partner, timing of sexual intercourse, and timing of reproduction.(2) A reduction in sexual activity, vaginal intercourse and sexual desire occurs in many women as pregnancy progresses. Both the woman and her partner have concerns regarding complications in the pregnancy as a result of sexual intercourse. The majority of women wish to discuss these issues with their doctor, but are not always comfortable raising the topic themselves.(3) Sexual activity in pregnancy can be greatly influenced by cultural, social and religious beliefs, as well as the physical and psychological changes of pregnancy. Anxieties and fears of complications in pregnancy from sexual intercourse also have some effects on sexual behavior in pregnancy. Ignorance, old wives tales, and sometimes inappropriate medical advice compound such fears. Meanwhile, with regard to the physiology and psychology of womens sexual response during pregnancy, little is known and a great deal presupposed.(4) In a study of the perceptions and practice of sexuality in Nigerian pregnant women, the majority of the respondents (83.4%) considered that coitus should not be stopped during pregnancy. Whereas 19.3% of the respondents believed that sexual frequency should be increased

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during pregnancy, 73.9% considered otherwise, and 63.6% actually felt it should be reduced. Findings from this study suggest a mixed-feeling effect with a tilt towards a positive attitude to sexuality in pregnancy. The author suggested that restriction should not be imposed on sexual activity during a normal pregnancy to enhance marital harmony.(5) Meanwhile, sexual activities, attitudes, and complications related to intercourse were evaluated among Chinese pregnant women.(6) It was found that pregnant women had less sexual activities and desire during pregnancy. Culture, inadequate knowledge, and excessive anxiety are likely the important factors for the marked reduction in sexuality in Chinese couples. Moreover, Orucs et al. (1999)(7) reported that dispareunia was a common sexual disorder in a sample of pregnant women. They also found that pregnancy had a negative effect on orgasm quality and that frequency of intercourse decreased. Furthermore, the imminent birth and the third trimester of pregnancy have a strong influence on the prechildbirth female sexual response.(4) Meanwhile, these authors have claimed that breastfeeding generally leads to a rapid return of interest in sexual activity. Conversely, a study has shown that neither sexual desire nor frequency of sexual relations is affected by pregnancy. What have been observed were changes in sexual behavior, with the most frequent position being the woman on top of the man.(8) The authors also found that in some cases, intercourse was replaced by masturbation, and that the introduction of different sexual practices was gratifying for both members of the couple. The aim of this research was to assess the influence of gestational period on sexual behavior, and to identify differences in sexual pattern among women before and during pregnancy.

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MATERIAL AND METHODS

Research design and setting

A cross-sectional analytic study design was used in carrying out this research. The study was carried out in the obstetric & gynecology outpatient clinics of Assiut university hospital.

Population and sample

The sample comprised 190 women, whether currently pregnant or not, but with a history of at least one previous pregnancy, attending the study setting during the period of the study. The exclusion criteria were the presence of any disease or cause that prevent sexual intercourse during pregnancy. This sample size was large enough to estimate the prevalence of any abnormalities of sexual behavior during pregnancy of 35% or more, with an absolute precision of 7%, a 95% confidence level, and a 10% dropout rate, using the equation for a single proportion.

Data collection
A specially designed questionnaire was developed to collect the necessary data. It was based on review of related literature, and The first reviewed by experts from nursing obstetrics & gynecological nursing and medical related specialties. It included four sections. section was concerned with personal data such as age, education, residence, and job status. The second section was related to menstrual history. The third section covered the obstetric history, including history of the current pregnancy. The last section was concerned with detailed sexual history. It covered questions about sexual desire before and during pregnancy, causes of lack of desire if any, changes of desire with gestation period, sexual satisfaction and orgasm throughout

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pregnancy, changes in frequency and position of intercourse, and feelings after intercourse, as well as related perceptions and beliefs. After the development of the tool, a pilot study was carried out on 30 women from the obstetric & gynecological outpatient clinics in Assiut university hospital. The aim was to ascertain the relevance of the tool, and to detect any problems peculiar to the statements as sequence and clarity. It also helped to estimate the time needed to complete the questionnaire. The results of the pilot indicated that the statements of the questionnaire were clear and relevant, and few words and items had to be modified. The study was carried out during the period from Feb 2005 to May 2005. Eligible pregnant women were consecutively recruited until the sample size was completed. The aim was explained to them, and they were reassured about complete confidentiality of any obtained information. Moreover, the forms were anonymous in order to give them more trust to answer all the questions without fear of disclosure. RESULTS Table (1) shows that the age of women ranged between 17 and 40 years, with a mean of 26.75.4 years. Most of the women in the sample (75.3%) were living in urban areas. More than half of the women were housewives, with basic or secondary education (56.3% and 57.9%, respectively).

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Table (1): Socio-demographic Characteristics of Women in the Study Sample (n=190)

Characteristics
Age (years): <25 2530+ Range MeanSD Residence: Rural Urban Work: Housewife Working Education: Illiterate Basic/secondary University 45 110 35 23.7 57.9 18.4 107 83 56.3 43.7 47 143 24.7 75.3 73 57 60 17.0-49.0 26.75.4 38.4 30.0 31.6

Frequency

Percent

Womens menstrual and obstetric history is described in table (2). Most of them had their menarche at less than 15 years age, and the mean age at menarche was 13.91.0 years. The mean duration of menstrual flow and cycle were respectively 4.82.0 days, and 27.23.8 days. About two-fifths of the women were primigravida (43.2%), and nullipara (40.5%). More than half of the sample (55.8%) were in their third trimester.

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Table (2): Menstrual and Obstetric History of Women in the Study Sample (n=190)
Characteristics
Age at menarche (years): <15 15+ Range MeanSD Menses duration (days): <8 8+ Range meanSD Cycle duration (days): <28 28+ Range meanSD Gravidity: 1 2-4 5+ Parity: 0 1 2+ Had previous abortion: Number of living children: 0 1-3 4+ Currently pregnant Gestation weeks (n=154): <12 1224+ 12 56 86 7.8 36.4 55.8 77 26 87 28 77 94 19 154 40.5 13.7 45.8 14.7 40.5 49.5 10.0 81.1 82 87 21 43.1 45.8 11.1 148 42 20.0-60.0 27.23.8 77.9 22.1 185 5 3.0-24.0 4.82.0 97.4 2.6

Frequency
151 39 12.0-17.0 13.91.0

Percent
79.5 20.5

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According to table (3), 14.3% of the women sample did not practice intercourse during pregnancy, and most of the women have experienced decreased sexual desire during pregnancy (77.4%). This was mainly attributed to psychological factors (50.3%). Nonetheless, the majority (85.7%) do have intercourse during pregnancy. Meanwhile, about one third of women (34.2%) have mentioned having better sexual desire during the second trimester of pregnancy. Moreover, about half of them (47.9%) have mentioned feeling better sexual satisfaction during the second trimester. Also, one third (33.1%) have linked better satisfaction to certain positions. Overall, the majority of the sample (75.7%) have reported feeling change in sexual intercourse during pregnancy, but in only 26.6% this change was for the better. More than half of women (55.0%) felt fatigue after intercourse, and only 9.7% felt orgasm during pregnancy. Concerning womens perception about sexual intercourse during pregnancy, table (4) indicates that the majority of women knew that pregnancy leads to increase sensation in the breasts (83.2%), and that breast massage improves sexual intercourse (86.3%). Meanwhile, only 43.7% perceived that sexual intercourse during pregnancy could lead to problems, mainly abortion (84.3%). Also, the great majority of women (95.6%) admitted that certain symptoms decrease sexual desire during pregnancy, mainly vomiting (73.1%) and fatigue (65.1%). The table shows that the doctors were the main source of information (31.1%), while nurses accounted for 17.4% of the sources.

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Table (3): Desire and Practice of Sexual Intercourse During Pregnancy among Women in the Study Sample (n=190)
Frequency
Practice of sexual intercourse during pregnancy Yes No Sexual desire during pregnancy: No change Decreased Causes of decreased desire (n=147): Psychological Physical health Concern about fetus Sexual desire is better during: First trimester Second trimester Third trimester Whole pregnancy None Sexual satisfaction better during: First trimester Second trimester Third trimester Whole pregnancy None Sexual satisfaction better in certain positions: Better positions (n=55): Not mentioned Back Side Variable Sexually satisfied among those who practice (n=169) Feel a change in sexual intercourse during pregnancy Change is to the better (n=128) Feel orgasm at end of intercourse Before pregnancy During pregnancy Both Feeling after intercourse:@ Pleasure Fatigue Pain Colic
(@) Not mutually exclusive.

Percent
85.7 14.3 22.6 77.4 50.3 35.4 14.3 5.8 34.2 8.4 37.4 14.2 5.8 47.9 10.5 18.4 17.4 33.1 45.5 12.7 1.8 40.0 92.9 75.7 26.6 88.2 82.1 9.7 8.3 21.3 55.0 34.9 13.6

169 21 43 147 74 52 21 11 65 16 71 27 11 91 20 35 33 55 25 7 1 22 157 128 34 149 119 14 12 36 93 59 23

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Table (4): Perceptions about Sexual Intercourse during Pregnancy among Women in the Study Sample (n=190)
Perception
Pregnancy leads to increased sensation in breasts Massaging breasts is associated with premature labor Massaging breasts improves sexual intercourse Massaging breasts is contra-indicated with history of premature labor Sexual intercourse helps labor Sexual intercourse during pregnancy leads to problems Problems (n=83): Abortion Ante-partum hemorrhage Post-partum hemorrhage Premature labor Certain pregnancy-associated symptoms decrease sexual desire Symptoms during (n=175): First trimester Second trimester Third trimester Whole pregnancy Symptoms (n=175): Vomiting Nausea Fatigue Mastalgia Dyspnea Sources of information: Mother Doctor Nurse Daya Own job
(@) Not mutually exclusive.
@ @

Frequency
158 69 164 55 69 83 70 23 2 10 175 141 15 6 13 128 32 114 92 13 48 59 33 32 5

Percent
83.2 36.3 86.3 28.9 36.3 43.7 84.3 27.7 2.4 12.0 95.6 80.6 8.6 3.4 7.4 73.1 18.3 65.1 52.6 7.4 25.3 31.1 17.4 16.8 2.6

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Table (5) indicates statistically significant associations between the practice of sexual intercourse during pregnancy and womens obstetric data. It is evident that higher percentages of the women who practiced intercourse were primigravida or grand-multigravida (93.9% and 95.2%, respectively, p=0.043), nullipara (96.1%, p=0.01), with no history of abortion (92.0%, p=0.004), with no living children or more than four (96.1% and 100.0%, respectively, p=0.002), and were currently pregnant (92.9%, p=0.001), compared to those who did not have intercourse. Table (5): Relation between Women Practice of Sexual Intercourse during Pregnancy and their Obstetric Characteristics
Sexual intercourse during pregnancy No Yes (n=21) (n=169) No. % No. %
Gravidity: 1 2-4 5+ Parity: 0 1 2+ Had previous abortion: No Yes Number of living children: 0 1-3 4+ Currently pregnant No Yes Gestation weeks (n=154): <12 1224+
(*) Statistically significant at p<0.05

X2 test

p-value

5 15 1 3 6 12 13 8 3 18 0 10 11 0 5 6

6.1 17.2 4.8 3.9 23.1 13.8 8.0 28.6 3.9 19.1 0.0 27.8 7.1 0.0 8.9 7.0

77 72 20 74 20 75 149 20 74 76 19 26 143 12 51 80

93.9 82.8 95.2 96.1 76.9 86.2 92.0 71.4 96.1 80.9 100.0 72.2 92.9 100.0 91.1 93.0

6.28

0.043*

8.50

0.01*

Fisher

0.004*

12.64

0.002*

Fisher

0.001*

1.20

0.55

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The relation between womens satisfaction with sexual intercourse and their gestation weeks, perceptions, and practices is described in tables 6 and 7. associations. They point to a number of statistically significant Thus, more women in the third trimester felt sexual

satisfaction (98.8%, p=0.04). However, a higher percentage of women who had desire during pregnancy had no sexual satisfaction (96.9%, p=0.002). Meanwhile, higher percentages of women who were feeling change in sexual intercourse during pregnancy (97.7%, p<0.001), feeling orgasm (98.0%, p<0.001), and feeling fatigue after intercourse (97.8%, p=0.006) had sexual satisfaction. However, no statistically significant association could be before revealed and between the number and of intercourses/week during pregnancy sexual

satisfaction. Also, as shown in table (7), more women who had higher perceptions of the effects of breast massage, and the problems associated with sexual intercourse during pregnancy had sexual satisfaction. Figure (1) displays the correlation between the number of sexual intercourses/week before and during pregnancy. It points to a statistically significant strong positive correlation (r=0.80), which means that the number of intercourses during pregnancy is directly related to the number before pregnancy. Table (8) shows the correlation between the number of sexual intercourses before and during pregnancy and womens obstetric data. It indicates weak statistically significant negative correlations with gravidity, parity, number of abortions, and number of living children. This was noticed both with the number of intercourses before and during pregnancy.

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Table (6)

Relation between Women Satisfaction with Sexual Intercourse during Pregnancy and their Gestation Weeks, Desire, and Practice (among those who practice: n=169)
Sexual satisfaction No Yes (n=12) (n=157)
No. % 8.3 10.7 1.2 19.0 3.1 8.7 5.6 16.7 6.5 5.1 9.3 6.2 4.3 14.3 2.3 22.0 2.0 45.0 No. 11 50 85 34 123 21 17 10 72 37 39 61 45 12 125 32 146 11 % 91.7 89.3 98.8 81.0 96.9 91.3 94.4 83.3 93.5 94.9 90.7 93.8 95.7 85.7 97.7 78.0 98.0 55.0 6.54 0.04*

X2 test

pvalue

Gestation weeks (n=154): <12 1224+ Have desire during pregnancy Yes No No. of intercourses/week before pregnancy: 1 2 3 4 5+ No. of intercourses/week during pregnancy: 1 2 3 4 Feel there is a change in sexual intercourse during pregnancy Yes No Feel orgasm at end of intercourse Yes No Feeling after intercourse:@ Pleasure Yes No Fatigue Yes No Pain Yes No Colic Yes No Have problems during pregnancy Yes No
(*) Statistically significant at p<0.05

1 6 1 8 4 2 1 2 5 2 4 4 2 2 3 9 3 9

Fisher

0.002 * 0.48

0.496

0.06

0.80

Fisher

<0.00 1* <0.00 1*

Fisher

1 11 2 10 2 10 0 12 0 12

2.8 8.3 2.2 13.2 3.4 9.1 0.0 8.2 0.0 8.3

35 122 91 66 57 100 23 134 24 133

97.2 91.7 97.8 86.8 96.6 90.9 100.0 91.8 100.0 91.7

Fisher 7.68

0.47 0.006 * 0.22 0.37 0.22

Fisher Fisher Fisher

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Table (7): Relation between Women Satisfaction with Sexual Intercourse during Pregnancy and their Perceptions (among those who practice: n=169)
Sexual satisfaction No Yes (n=12) (n=157)
No. Pregnancy leads to hyper-feeling of breasts Yes No Breasts massage is associated with premature labor Yes No Breasts massage improves sexual intercourse Yes No Breasts massage is contra-indicated with history of premature labor Yes No Sexual intercourse helps labor Yes No Sexual intercourse during pregnancy leads to problems Yes No Certain symptoms decrease sexual desire Yes No Sexual satisfaction better in certain positions Yes No (*) Statistically significant at p<0.05 0 12 0.0 10.5 55 102 100. 0 89.5 Fisher 0.03* 5 7 3.2 53.8 151 6 96.8 46.2 Fisher 1.00 1 11 1.4 11.3 71 86 98.6 88.7 6.20 0.01* 2 10 3.4 9.0 56 101 96.6 91.0 Fisher 0.22 2 10 4.1 8.3 47 110 95.9 91.7 Fisher 0.51 3 9 2.0 47.4 147 10 98.0 52.6 Fisher <0.001* 0 12 0.0 11.0 60 97 100. 0 89.0 Fisher 0.009* 3 9 2.1 39.1 143 14 97.9 60.9 Fisher <0.001* % No. %

X2 test

p-value

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During Pregnancy

r=0.80, p<0.001

Before Pregnancy
Figure (1): Correlation between Number of Intercourses/Week before and during Pregnancy among Women in the Study Sample (n=190)

Table (8): Correlation between Number of Sexual Intercourse before and during Pregnancy and Womens Obstetric Characteristics
Pearson correlation coefficient (r) No. of intercourses Before pregnancy
Gravidity Parity No. of abortions No. of living children (*) Statistically significant at p<0.05 -0.22** -0.30** -0.22** -0.30**

During pregnancy
-0.16* -0.19** -0.25** -0.19*

(**) Statistically significant at p<0.01

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Table (9) displays the best fitting multiple linear regression model for the number of sexual intercourse during pregnancy and women socio-demographic and obstetric characteristics. It indicates that the number of intercourses before pregnancy is the only statistically significant independent positive predictor of the number of intercourses during pregnancy. As the r-square value indicates, the number of intercourses before pregnancy explains 58% of the variation in the number of intercourses during pregnancy. Table (9): Best Fitting Multiple Linear Regression Model for the Number of Sexual Intercourse during Pregnancy and Women socioDemographic and Obstetric Characteristics

Beta coefficient Constant No. of intercourse before pregnancy

r-square=0.58 Model ANOVA: F=207.81, p<0.001

Standard Error 0.15 0.04

t-test 0.93 14.42

p-value 0.36 <0.001*

0.14 0.56

Variables excluded by model: age, education, job, residence, gravidity, parity, number of children, gestation weeks, knowledge score

Table (10) illustrates the best fitting multiple logistic regression model for practice of sexual intercourse during pregnancy and women socio-demographic and obstetric characteristics. It indicates that abortion was the only statistically significant independent negative predictor of the practice of sexual intercourse during pregnancy. As the odds ratio indicates, the odds that a woman with a previous history of abortion practices sexual intercourse is 0.13 times that of a woman with no history of abortion.

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Table (10): Best Fitting Multiple Logistic Regression Model for the Practice of Sexual Intercourse During Pregnancy and Women Socio-demographic and Obstetric Characteristics

Beta Standard coefficient Error

pvalue

Odds Ratio (OR) 95% confidence limits

OR Lower limit Upper limit

Constant Abortion (reference: no)

5.19 -2.03

2.29 0.69

0.023* 0.003*

179.32 0.13 0.03 0.51

DISCUSSION Women experience many changes during pregnancy, which often accentuate their needs for physical and emotional support. According to published reports, pregnancy may present a life crisis that can affect sexual and marital relationships.(9-11) The physiological and psychological changes of pregnancy have a potential for destabilization, stress, and crisis and, therefore, demand processes of adaptation on various levels. During pregnancy, sexual satisfaction may be unchanged, increase, or decrease, which could result in negative effects on a womans long-term sexual and or psychosocial health.(12) The findings of the present study have shown that more than one third of women had better sexual desire during the second trimester, and another third have reported better sex during whole pregnancy. Therefore, sexual desire seems to increase from the first to the second trimester, and then decreases again. These results agree with Gokyildiz and Beji (2005)
(13)

who have studied the effects of pregnancy on sexual

life in Turkey, and found that sexual desire decreases as pregnancy progressed. Also in congruence with the present study findings, Oboro

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and Tabowei (2002)(14) have reported that some pregnant women find that they are experiencing better sex than they have ever had before, but other women also have reduced desire during the first trimester. The authors have related this to the changing hormones with pregnancy or because they have never felt so carefree about birth control. This is especially evident among women who have gone through fertility treatment, as the relationship between sex and pressure to conceive is over. They certainly do not need to worry about it now. Nonetheless, these result are in contradiction with Aslan et al. (2005)(15) who have shown that sexual functions are significantly decreased during pregnancy and worsen as the pregnancy progresses. The authors recommended that childbearing couples should be given information about the sexual problems and fluctuations in the patterns of sexuality during pregnancy. Other studies have also demonstrated that pregnancy is a stage in which both sexual desire and sexual satisfaction in the women are reduced.(16,17) This is particularly evident in the first and third trimesters. In early months, reduced sexual desire can be related to the many symptoms that often accompany the beginning of pregnancy such as fatigue, breast tenderness, nausea and vomiting. Thus, when the woman is feeling these symptoms, the last thing on mind is sex. In the third trimester, especially the last weeks of pregnancy, discomfort like breathlessness, fatigue, increased size, and downward pressure as the baby settles into the pelvis may again make sexual intercourse less comfortable and therefore less desire is felt.(14,1820)

However, Barclay et al. (1994)(21) and Bustan et al.(1995)(22) have

concluded that sexual desire in the majority of women generally decreases during pregnancy, although there are many individual responses and fluctuating patterns.

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As regards the frequency of sexual intercourse during pregnancy, the present study has shown a decrease, compared to before pregnancy. Meanwhile, the number of intercourses before and during pregnancy were strongly and positively correlated. Moreover, the number of intercourses during pregnancy were only predicted by the number of intercourses before pregnancy by multivariate analysis. The reduction in the frequency of sexual intercourse during pregnancy is in agreement with Eryilmaz et al. (2004)(23) who has similarly reported decreased frequency among pregnant women in Turkey. Furthermore, Orucs et al. (1999)(7) in Australia have demonstrated a progressive decline in the frequency of intercourse as the gestation period advanced. In the present study, statistically significant associations were revealed between womens gravidity, parity, and history of abortion and the practice of sexual intercourse during pregnancy. Higher percentages of the women who practiced intercourse were primigravidae, nulliparas, with no history of abortion, and with no living children. These characteristics actually imply that these women are newly married. This might explain the higher practice of sexual intercourse among them. The finding is however in disagreement with Fok et al. (2005)(6) who have reported that nulliparity was an independent predictor of reduction of sexual intercourse during pregnancy. As regards the history of abortion, the present study revealed that it had a statistically significant association with no practice of sex during pregnancy. This was further confirmed by logistic regression analysis, where the history of previous abortion was the only statistically significant independent negative predictor of the practice of sexual intercourse during pregnancy. This is in agreement with Hyde and Lalameter (2006)(24) who have emphasized that only women who

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have a tendency to miscarriage are advised to avoid intercourse during pregnancy. Moreover, Fok et al.(25) have claimed that the sexuality of both women and their partners are affected after abortion. It may be due to both psychological trauma and the worry of another unwanted pregnancy. Proper counseling may relieve their anxiety and improve sexual lives. As regards sexual satisfaction, the present study revealed that nearly half of women had better sexual satisfaction during the second trimester of pregnancy. A similar finding was reported by Ryding (1984)(19) who has attributed this to the decrease of the early symptoms of pregnancy such as fatigue, nausea, and vomiting. Additionally, with increased vaginal blood supply and discharge occurring at this time, a womens sexual feeling and desire for sex might increase. Moreover, Reamy et al. (1984)(9) have reported that womens full satisfaction correlates positively with the feeling of happiness at being pregnant. Nonetheless, sexual satisfaction might be influenced by other factors, such as the relationship with the husband, which was found to be the most important predictor of sexual satisfaction during pregnancy.(11) Concerning the relation between gestational weeks and sexual satisfaction, it was found that the majority of the women who were in the third trimester of pregnancy had sexual satisfaction, compared to those in the first and second trimesters, and the difference was statistically significant. This is in congruence with Reamy et al.(9) who has attributed it to women feeling more attractive by the end of pregnancy than before it. However, the present study finding might be explained by the fact that most of the women in the sample who were in the third trimester of pregnancy were in early weeks of this period, far from the last weeks where the symptoms of heaviness, fatigue, and pain are increased. In fact, the majority of women in the present study were

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aware that certain symptoms decrease sexual desire. This agrees with other studies which have mentioned that physical discomfort during pregnancy such as nausea, vomiting, breast tenderness backache, fatigue, feeling out of control of ones body may decrease the womens sexual interest or performance.(26-28) As for the preferred position, about one third of the present study women have linked their sexual satisfaction to certain positions during pregnancy. This is in congruence with Sipinski et al.(29) who have Conversely, Ekwo et al.(30) and Read et al.(31) highlighted the importance of suitable position for sexual gratification during pregnancy. mentioned that sexual positioning was found to have no influence. However, pregnant women should be counseled to use the coital position suitable for them and their partner, but there may be a need to change position in the advanced stage of pregnancy in order to avoid any discomfort.(5,18,32) This agrees with the present study finding, where pregnant women preferred variable positions for better satisfaction. Regarding the feeling of orgasm at the end of intercourse, it was found that only about one tenth of women in the present study felt it during pregnancy, although the majority have reported having been feeling orgasm before pregnancy. This finding is similar to that of the study of Orucs et al.(1996)(7) in China who have mentioned that pregnancy has a negative effect on orgasm quality and that frequency of intercourse decreased. Also, Haines et al.(33) have reported reduced orgasm as pregnancy progressed, especially in the last trimester. According to the present study findings, slightly more than half of the women have reported feeling fatigue after intercourse. This is in agreement with Lumley (1998)(34) and Bich et al. (1995)(35) who have similarly mentioned that fatigue is one of the most common problems

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women experience during pregnancy, and is considered the main reason for lowered sexual desire during late pregnancy. In fact, about one third of the present study sample have mentioned ill physical health as the main cause of decreased sexual desire during pregnancy. Although about half of the present study women had the wrong belief that sexual intercourse during pregnancy leads to problems as abortion, only a small minority of them have reported that the cause of decreased sexual desire is their concern and worries about their fetus. This reflects a paradox between beliefs, attitudes, and behaviors, since the great majority have sexual intercourse during pregnancy without any worries about harming their baby. The finding is in contradiction with Fok et al.(6) who have reported that the great majority of pregnant women in China were worried about the adverse effects of sexual intercourse during pregnancy on their fetus. These worries might be related to recommendation for sexual caution by medical providers as mentioned by Nichols and Zwelling (1997).(28) In fact, the main sources of information mentioned by the present study women were doctors and nurses. In this respect, the ACOG (2004)(36) and California Expanded AFP Screening program California Department of Health Services Genetic Disease Branch (2004)(37) have declared that sexual activity during pregnancy is safe for most women right up until labor, unless a womens doctor has advised against it. More recently, it has been ascertained that during a healthy pregnancy, intercourse can continue safely up to four weeks before the expected date of birth. However, in some cases, intercourse can cause infection or increase the chance of a premature labor or causes a miscarriage. Conversely, some studies have found that intercourse and orgasm can reduce the risk of preterm birth.(24)

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CONCLUSION The majority of studied women practiced sex during pregnancy, and were mostly satisfied. Nearly half of them had better sexual satisfaction during the second trimester. Also, there was some decrease of sexual desire during the first trimester, which could be attributed to some symptoms as vomiting, nausea, and fatigue. The pattern of sexual intercourse changed in terms of position, with a somewhat lowered frequency, although this followed the same pattern as before pregnancy. The main reason for limiting or avoiding sexual intercourse during pregnancy turned to be the history of previous abortion. RECOMMENDATIONS In the light of the study findings, and based on the prevalent misbeliefs revealed among women, it is important that health care providers, especially nurses, raise the topic of sexuality during pregnancy, advise women that sex can be safely practiced during pregnancy from the first day to the last day if they have no medical risk. They should also promote complete sexual satisfaction during pregnancy by clarifying any misconception through appropriate counseling. REFERENCES
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