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Postpartum Depression: Diagnosis and Treatment
Postpartum Depression: Diagnosis and Treatment

Section 18
Women’s Sexuality During Postpartum

CEU Question 18 | CEU Answer Booklet | Table of Contents | Depression
Counselor CEUs, Psychologist CEs, Social Worker CEUs, MFT CEUs, Nurse CEUs

Sexual desire in the majority of women generally decreases during pregnancy, although there may be a wide range of individual responses and fluctuating patterns (e.g., Barclay, McDonald, & O'Loughlin, 1994; Bustan, Tomi, Faiwalla, & Manav, 1995; Hyde, DeLamater, Plant, & Byrd, 1996). By the third trimester of pregnancy, approximately 75% of primigravidae report a loss of sexual desire (Bogren, 1991; Lumley, 1978.) A decrease in frequency of sexual intercourse during pregnancy is generally associated with a loss of sexual desire (e.g., Bogren, 1991; Lumley, 1978). By the third trimester, between 83% (Bogren, 1991) and 100% (Lumley, 1978) of primigravidae reported a decrease in frequency of sexual intercourse.

The general conclusion from empirical studies and clinical impressions is that many postpartum women continue to report a decline in sexual interest, desire, or libido (Fischman, Rankin, Soeken, & Lenz, 1986; Glazener, 1997; Kumar, Brant, & Robson, 1981). Women's loss of sexual desire generally leads to less sexual activity, and to loss of sexual satisfaction, although the association between these facets is far from linear (Lumley, 1978). Hyde et al. (1996) found that 84% of couples reported reduced frequency of sexual intercourse at 4 months postpartum. Enjoyment of sexual intercourse tends to return gradually after childbirth. Lumley (1978) found that there was a linear increase in the percentage of women who found intercourse enjoyable after birth, from nil at 2 weeks to about 80% at 12 weeks. Similarly, Kumar et al. (1981) found that, at 12 weeks after childbirth, about two thirds of the women found sex "mostly enjoyable," although 40% complained of some difficulties.

It is clear from the above studies that a significant proportion of women experience reduced sexual desire, frequency of intercourse, and sexual satisfaction over the perinatal period. However, less attention has been given to the magnitude of those changes, or to the factors that may contribute to them. This is the focus of this study.

Literature Review
A review of the literature suggests that six factors may be related to reduced sexual desire, frequency of sexual intercourse, and levels of sexual satisfaction during the postpartum period. These factors appear to be adjustment to changes in social roles (work role, mother role) of women during the transition to parenthood, marital satisfaction, mood, fatigue, physical changes associated with the birth of the child and breast-feeding. The role of each of these factors will be discussed in turn.

The perceived quality of social roles has been found to influence individual well-being and relationships (e.g., Baruch & Barnett, 1986; Hyde, DeLamater, & Hewitt, 1998). However, the impact of social roles on women's sexuality over the transition to parenthood has not been the subject of extensive empirical research. Only two published studies were located which examined the influence of women's paid employment on their sexuality during pregnancy and the early postpartum period (Bogren, 1991; Hyde et al., 1998). Bogren (1991) found no relationship between work satisfaction and sexual variables during pregnancy. However, insufficient information was provided regarding how work satisfaction was measured, nor were separate analyses reported for women and men. The larger study of Hyde et al. (1998) found that there were no significant differences between groups of homemakers, women employed part time, and women employed full time in their frequency of decreased sexual desire, nor in overall frequency of intercourse, nor sexual satisfaction at 4 or 12 months postpartum. Women's positive work-role quality was associated with a greater frequency of sexual intercourse during pregnancy, and greater sexual satisfaction and less frequent loss of sexual desire at 4 months postpartum. Nonetheless, work-role quality predicted relatively small amounts of variance in the sexual outcomes.

For most women, motherhood is a very positive experience (Green & Kafetsios, 1997). Recent mothers have reported that the best things about being a mother were watching a child's development, the love they received from children, being needed and responsible for the child, giving love to the child, helping to shape the child's life, having the child's company, and feeling contented (Brown, Lumley, Small, & Astbury, 1994).

The negative aspects of the mother role included confinement or lacking uninterrupted time and freedom to pursue personal interests (Brown et al., 1994). Other concerns were not having an active social life, needing a break from the demands of the child, inability to control or define the use of time, loss of confidence, and difficulties in coping with their infants' feeding and sleeping patterns. By 6 months postpartum, many infants' sleeping and feeding difficulties have been resolved. However, other aspects of infants' behaviors become more challenging (Koester, 1991; Mercer, 1985).

There is little empirical evidence that difficulties in the mother role are directly related to women's sexual functioning in the postpartum. Pertot (1981) found some evidence to tentatively suggest that problems in women's postpartum sexual responsiveness were related to difficulties with the mother role, since one of the adoptive mothers reported definite loss of sexual desire. It was expected that difficulties in the mother role would affect women's sexuality due to a general diminution of their well-being and disruption to their relationship with their partners.

A large body of research has demonstrated that the addition of the first child to the parental dyad results in a decrease in marital quality (see a review by Glenn, 1990). Evidence supporting a marital satisfaction decline across the transition to parenthood has been found in studies from many different countries (Belsky & Rovine, 1990; Levy-Shift, 1994; Wilkinson, 1995). After an initial "honeymoon" period in the first postpartum month, the trend to lower marital satisfaction becomes stronger by the third month postpartum (Belsky, Spanier, & Rovine, 1983; Miller & Sollie, 1980; Wallace & Gotlib, 1990). Different aspects of the marital relationship are reported to decline. By 12 weeks postpartum, there is evidence of a reduction in women's reported love for their partners (Belsky, Lang, & Rovine, 1985; Belsky & Rovine, 1990), and a decline in affectional expression (Terry, McHugh, & Noller, 1991).

Relationship satisfaction has been associated with measures of women's sexuality in the postpartum (Hackel & Ruble, 1992; Lenz, Soeken, Rankin, & Fischman, 1985; Pertot, 1981). However, none of the studies examined provided clear evidence of the relative contribution of relationship satisfaction to the prediction of changes in women's sexual desire, sexual behavior, and sexual satisfaction during pregnancy and after childbirth.

The extent to which the above changes in sexuality are due to changes in mood has received little attention. Evidence from self-report depressive symptom rating scales has consistently found higher scores antenatally than postnatally, although little is known about the relative severity of antenatal depression (see a review by Green & Murray, 1994).

Childbirth is known to increase women's risk of depression (Cox, Murray, & Chapman, 1993). A meta-analysis indicated that the overall prevalence rate of postnatal depression (PND) is 13% (O'Hara & Swain, 1996). An estimated 35% to 40% of women experience depressive symptoms in the postpartum which fall short of meeting the criteria for a diagnosis of PND, yet they experience considerable distress (Barnett, 1991).

Difficulty in the marital relationship is an established risk factor for PND (O'Hara & Swain, 1996). PND is also associated with women's loss of sexual desire after childbirth (Cox, Connor, & Kendell, 1982; Glazener, 1997), and infrequent intercourse at 3 months postpartum (Kumar et al., 1981). Elliott and Watson (1985) found an emerging relationship between PND and women's decreased sexual interest, enjoyment, frequency, and satisfaction by 6 months postpartum, which reached significance by 9 and 12 months postpartum.

Fatigue is one of the most common problems women experience during pregnancy and the postpartum (Bick & MacArthur, 1995; Striegel-Moore, Goldman, Garvin, & Rodin, 1996). Fatigue or tiredness and weakness are almost universally given by women as reasons for loss of sexual desire during late pregnancy and in the postpartum (Glazener, 1997; Lumley, 1978). Similarly, at approximately 3 to 4 months postpartum, fatigue was frequently cited as a reason for infrequent sexual activity or sexual enjoyment (Fischman et al., 1986; Kumar et al., 1981; Lumley, 1978). Hyde et al. (1998) found that fatigue accounted for considerable variance in postpartum women's decreased sexual desire, although at 4 months postpartum fatigue did not significantly add to the prediction of decreased desire after depression had been first entered into regression analysis.

The physical changes associated with birth and the postpartum may influence women's sexuality. During childbirth, many women experience tearing or episiotomy and perineal pain, particularly when they have had an assisted vaginal delivery (Glazener, 1997). Following childbirth, dramatic hormonal changes cause the vaginal wall to become thinner and to lubricate poorly. This commonly causes vaginal soreness during intercourse (Bancroft, 1989; Cunningham, MacDonald, Leveno, Gant, & Gistrap, 1993). Dyspareunia may persist for many months after childbirth (Glazener, 1997). Perineal pain and dyspareunia due to childbirth morbidity and vaginal dryness have been shown to be related to women's loss of sexual desire (Fischman et al., 1986; Glazener, 1997; Lumley, 1978). Experiencing pain or discomfort with sexual intercourse is likely to discourage women from desiring sexual intercourse on subsequent occasions, and to reduce their sexual satisfaction.

Strong evidence indicates that breastfeeding reduces women's sexual desire and frequency of intercourse in the early postpartum period (Forster, Abraham, Taylor, & Llewellyn-Jones, 1994; Glazener, 1997; Hyde et al., 1996). In lactating women, high levels of prolactin, maintained by the baby's suckling, suppress ovarian oestrogen production, which results in reduced vaginal lubrication in response to sexual stimulation.
- De Judicibus, Margaret A., McCabe, Marita P.; Psychological Factors and the Sexuality of Pregnant and Postpartum Women; Journal of Sex Research; May 2002, Vol. 39, Issue 2

Personal Reflection Exercise #4
The preceding section contained information regarding the sexual drive in women before and during the postpartum period. Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 18
What is one of the most common reasons given by women for their reduced sexual drive during late pregnancy and the postpartum period? Record the letter of the correct answer the CEU Answer Booklet.

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Postpartum Depression: Diagnosis and Treatment

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