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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 12  |  Page : 1648-1655

Resumption of Sexual Intercourse and Family Planning use Among Postpartum Women Attending Infant Welfare Clinics in Ibadan, Southwest Nigeria – A Cross-Sectional Study


1 Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
2 Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria
3 Center for Population and Reproductive Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
4 Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences; Center for Population and Reproductive Health, College of Medicine, University of Ibadan, Ibadan, Nigeria

Date of Submission19-Feb-2020
Date of Acceptance25-Jun-2020
Date of Web Publication23-Dec-2020

Correspondence Address:
Prof. O Ojengbede
Center for Population and Reproductive Health, College of Medicine, University of Ibadan
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_76_20

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   Abstract 


Background: Women may resume sexual intercourse anytime during the postpartum period with little consideration for contraceptive. Aim: To determine factors associated with resumption of sexual activity, explore FP practices and influence on sexual resumption among postpartum women. Subject and Methods: A cross-sectional study of postpartum women at the infant-welfare clinic of Adeoyo Maternity Teaching Hospital and University College Hospital, Ibadan between July and October, 2014. Data on socio-demographic characteristics, contraceptive use, and sexual behavior were collected using interviewer-administered semi-structured questionnaires. Associations were tested using Chi-square tests and Logistic regression analysis for crude and adjusted odds ratios. Level of significance was 5%. Results: There were 256 women with mean age of 29.1 years(SD = 5.2). Majority had tertiary education; were currently married in monogamous marriages and had 1-3 children. Ninety-one(38.7%) had started sexual intercourse at the time of interview. Among those who had not started having sex, about a quarter (24.2%) gave no reason and 20% felt it was too early. The fear of pain and child-spacing were reasons given by 5.7% and 5.1% respectively. Current use of contraceptive method was 20.7% among women and 36.4% among women who had resumed sexual activity. On multiple logistic regression, Family-planning users were about five times more-likely than non-users to resume sexual intercourse (Odd Ratio = 5.66, 95% Confidence interval = 2.61 – 12.28). Conclusion: Women commonly resume sexual intercourse during postpartum period without contraceptive use. Interventions during antenatal and early postnatal periods are needed to improve early adoption of Family planning by postpartum women.

Keywords: Postpartum contraceptive, postpartum family planning, postpartum sexual intercourse, post-delivery sexual intercourse, puerperium sexual intercourse


How to cite this article:
Adedokun B, Abdus-Salam R A, Babawarun T, Morhason-Bello I, Ojengbede O. Resumption of Sexual Intercourse and Family Planning use Among Postpartum Women Attending Infant Welfare Clinics in Ibadan, Southwest Nigeria – A Cross-Sectional Study. Niger J Clin Pract 2020;23:1648-55

How to cite this URL:
Adedokun B, Abdus-Salam R A, Babawarun T, Morhason-Bello I, Ojengbede O. Resumption of Sexual Intercourse and Family Planning use Among Postpartum Women Attending Infant Welfare Clinics in Ibadan, Southwest Nigeria – A Cross-Sectional Study. Niger J Clin Pract [serial online] 2020 [cited 2023 Feb 8];23:1648-55. Available from: https://www.njcponline.com/text.asp?2020/23/12/1648/304437




   Introduction Top


The postpartum period is critical in the life of the mother and newborn; hence, the implementation of key -interventions during this period has profound implications for the improvement of maternal and child health. In the developing countries, the period is characterized by a range of cultural practices; some of which may be harmful to the mother and child.[1],[2]

Sexuality during the postpartum period has been the subject of several studies in the developed world[3],[4],[5] but has received relatively little attention in developing countries. Moreover, few studies have examined sexual behavior and the adoption of family planning (FP) practices in traditional African settings characterized by large family sizes and poor contraceptive use. In some African settings, a study of postpartum women in Ouagadougou showed that half of the women studied abstained for six or more months; thereafter, some women incorrectly used adopted methods or never adopted any method.[6]

The sexuality of women in the postpartum period in Nigeria has been the focus of previous studies which suggest that the proportion of women resuming sexual intercourse in the postpartum period has been on the increase.[1],[7]

Some studies in Nigeria conducted among postpartum women revealed mixed results. Anzaku and Mikah in 2014 studied women at an infant welfare clinic and found that about two thirds had resumed sexual intercourse 8.2 + 2.9 week after childbirth.[8] Ezebialu and Eke in 2012 studied women during their first postnatal visit and reported that 29.7% had resumed sexual intercourse; whereas 22% used modern contraceptive methods.[9] Previous studies have examined the association between FP use and resumption of sexual in the context of HIV positive women; where lack of breastfeeding has increased the risk of early return of fertility and unwanted pregnancy.[10],[11]

The contraceptive prevalence rate among currently married women in Nigeria is 17%, with an unmet need of 19% giving a total demand for family planning of 36%; and the prevalence of the use of modern contraceptive methods was 12%.[12] According to the Nigeria Demographic health Survey,[12] the prevalence of mistimed and unintended births was 8% and 3%, respectively.[12] This suggests that at least 11% of pregnancies could have been prevented with the use family planning. Modern contraceptive use is higher among married women with 3–4 children (15%) compared to women with 1–2 children (11%); women in urban areas, educated women with more than secondary education and among women from higher wealth quintile. In Oyo state, Southwest Nigeria, the prevalence of modern contraceptive use is 22.2%.[12] A previous study showed that the unmet need for contraception among postpartum women range from 45 to 80%.[13]

Many postpartum women want to delay or avoid pregnancy;[14] desire contraceptive use, resume sexual intercourse but do not use any contraceptive method for various reasons. Studies have assessed and demonstrated increased sexuality among postpartum women with only a few assessing the use of contraceptive and relationship to sexuality in this group. There is a paucity of research assessing several aspects of the recommencement of sexual activity among postpartum Nigerian women especially in the use of contraception when vaginal intercourse is resumed; the difference between timing of resumption of vaginal intercourse and characteristics of multiparous versus primiparous women. Integrating family planning into postpartum/immunization services will enhance access and uptake among postpartum women at a time when they are least desirous of pregnancy. Infant welfare/immunization clinic visits will provide multiple timed opportunities for counseling, introduction, and uptake of family planning in the postpartum period particularly in an integrated model.

The objective of this study was to determine the factors associated with resumption of sexual activity among postpartum women in Ibadan, Nigeria and to explore FP practices and how they influence resumption of sexual activity.


   Subjects and Methods Top


Study design: This was a cross-sectional study of postpartum women attending infant welfare clinics with their babies. Ethical approval date - 03 March, 2014.

Study area and setting: The study was conducted at the infant welfare clinic of Adeoyo Maternity Teaching Hospital and University College Hospital between July and October 2014.

Eligibility Criteria: Postpartum women and nursing mothers attending infant welfare clinics of the study health facilities during the study period. Inclusion criteria were postpartum women and nursing mothers who were less than 6 months post-delivery.

Exclusion criteria were women that declined participation and women more than 6 months post-delivery.

Subject selection: Women meeting the eligibility criteria were identified, counseled, and selected consecutively following written informed consent. All eligible consenting postpartum women attending the infant welfare clinic on the clinic days were enrolled for the study.

Sample size: A minimum sample size of 213 women was calculated using a prevalence of resumption of sexual intercourse of 40%,[15] difference of 7.5% and non-response rate of 30%. A total of 256 women were interviewed.

Data collection and variables: Data were obtained using pretested semi-structured interviewer-administered questionnaires. The questionnaire was designed based on variables from existing literature; pretested and revised to ensure the quality of the information collected. The questionnaire was used to obtain information on the sociodemographic characteristics, family planning use, and sexual behavior since delivery. The main variables were family planning use and resumption of sexual activity. Respondents were asked if they were using any form of FP method. Other data included FP method used, satisfaction with method used, and reasons for non-use. Respondents were also asked if they had resumed sexual intercourse since delivery.

Resumption of sexual intercourse in this study is defined as resumption of first sexual intercourse in the postpartum. The time of resumption of sexual intercourse is described as the time (from delivery) when the first sexual intercourse took place in the postpartum period. Resumption of sexual intercourse since delivery was the main dependent variable; questions were also asked about persons initiating sexual activity, satisfaction with sex acts, discontinuation of sexual activity, and reason for not initiating sexual activity among those who had not resumed sex.

Data analysis: Data were summarized using frequencies and proportions for qualitative data and means (SD) for quantitative data. Association between resumption of sexual intercourse and variables was tested using Chi square tests. Independent variables were selected for cross-tabulation based on significant associations with resumption of sexual intercourse from previous studies.[7],[9],[10],[16] The variables significant on Chi-square tests were selected and subjected to logistic regression analysis. The crude and adjusted odds ratios were calculated using logistic regression analysis. Level of significance was at 5%.


   Results Top


Demographic and obstetric variables

There were 256 women with a mean age of 29.1 years (SD = 5.2). [Table 1] shows sociodemographic and obstetric characteristics of the women. Almost half of the respondents had tertiary education, majority were currently married, and about a tenth in polygamous marriages; most had 1-3 children. Over three-quarters of the women booked for antenatal care in the antecedent pregnancy (81.2%). Majority of the women reported they were currently living with their husband (95.3%). The mean duration since childbirth was 2 months (SD = 0.9). There were 56 women (21.9%) presenting at 6 weeks or less postpartum, 47 women (18.4%) who had delivered between 6 and 8 weeks and 153 women (59.7%) had delivered for 2 months to 6 months prior.
Table 1: Sociodemographic and obstetric characteristics of women studied

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Resumption of sexual activity and family planning

As shown in [Table 2]; 99 (38.7%) women reported they had recommenced sexual intercourse at the time of the interview. When disaggregated by time since delivery, 35.7% delivered less than 6 weeks and 46% delivered more than 2 months. In most cases (91.9%), the husband initiated sexual activity, and most women reported enjoying the sexual acts. There were 13 (13.3%) women that reported they discontinued sexual activity after they started. The main reasons given for discontinuation of sexual intercourse after resuming in the postpartum included vaginal pain, dyspareunia from episiotomy and perineal tears, and not been on family planning.
Table 2: Variables related to resumption of sexual activity

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Among those reporting they had not started having sex, about a quarter (24.2%) gave no reason and about 20% felt it was too early. The fear of pain and the purpose of child spacing were reasons given by about 5% of women each.

The proportion of women currently using a FP method at the time of the interview was 20.7%. Among those who had resumed sexual activity, the proportion of FP users was 36.4%. There were 63 (63.6%) women who had resumed sexual activity and not using a form of FP. Among non-FP users, over a third (37.4%) would have FP done in the future, whereas about a quarter (23.7%) said they do not like FP; another 21% gave no reason for non-use. [Table 3] Condom was the most commonly reported method (18, 32.7%), followed by 20.8% each for implant and intra uterine contraceptive device. Injectable contraceptives were reported by 15%, whereas 9% practiced withdrawal method; and 6% reported using oral pills. Over three quarters (77.4%) were happy with FP method used. However, about a third indicated interest in changing FP method.
Table 3: Family planning and resumption of sexual activity

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Factors associated with resumption of sexual activity

The associations between resumption of sexual activity, family planning, and other variables are shown in [Table 4]. Cross-tabulations showed significantly higher proportions reporting resumption of sexual activity among those on FP methods, booked women, and those with tertiary education. On multiple logistic regression, FP users were about five times more likely than non-users to resume sexual intercourse (OR = 5.66, 95% CI = 2.61–12.28). None of the sociodemographic factors was significant on multiple logistic regressions.
Table 4: Association between resumption of sexual intercourse and variables

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   Discussion Top


This study found that over a third of the postpartum women who delivered less than 6 months preceding the study had resumed sexual intercourse with or without resumption of menses by the time of the interview; but only about one-fifth of respondents were currently using a FP method. Sexual intercourse was mostly initiated by the husbands, most were satisfied with the sex but a few discontinued it after starting. There was a strong association between family planning use and resumption of sexual activity.

The findings of this study demonstrate the need to understand the sexual behavior of postpartum women, contraceptive preferences, and choices, and need to introduce postpartum women to the importance of early initiation of family planning in the postpartum period. The sexual behavior and FP practices in the postpartum period are important in the prevention of unplanned, unwanted pregnancies and child spacing with important implications for improving maternal and child health and reducing maternal morbidity and mortality.

The prevalence of resumption of sexual activity (39%) was higher than 28% reported at 6 weeks, but lower than 63% at 3 months postpartum in a Nigerian cohort study by Adanikin et al.[7] This prevalence is similar to the findings from a previous study that reported 40% of women studied had resumed vaginal sexual intercourse in the puerperium despite low contraceptive use.[15] The proportion of women that resumed sexual activity in this study is also lower than that reported by a study in Jos, Nigeria which reported about 68% at three and half months[8] and another by Okeke et al. which reported 69%[1]; our finding was higher than the proportion reported in another study of Nigerian women at postnatal visits by Ezebialu and Eke that reported 30%.[9] These studies used different study designs and recruited women at different postpartum dates in different settings making a comparison of the proportions reporting resumption across the studies difficult. However, the studies altogether suggest that women tend to resume sexual intercourse in the early postpartum period and increasingly. This suggests that women may resume sexual intercourse before the resumption of ovulation and menstruation and are at risk of pregnancy in the postpartum period.

Only about a third of those that resumed sexual intercourse were using FP in our study; higher than 19%[8] and 22%,[9] but lower than 65%[7] from previous reports. The risk of unwanted pregnancy and short interpregnancy interval is higher when sexual intercourse is resumed before FP use, especially as ovulation could precede the return of the menses. Concerning the reasons why women had not resumed sexual intercourse, about a quarter gave no reason and about one-fifth felt it was too early. The fear of pain and the purpose of child spacing were reasons given by a few of the women. Anzaku et al. similarly reported that about 22% of women studied felt it was early[8]; however, in contrast to our findings, “husband being unavailable” was the most common reason reported by 38% of their respondents. In our study, husband's absence was reported by about one-tenth of women yet to initiate sexual activity. Prevention of pregnancy or child spacing as a reason for delaying sexual intercourse also differed between our study and Anzaku et al.; this was reported by about 4% and 16%, respectively. Similar to Adanikin et al. and Ezebialu et al., significant proportions of women that had not resumed sex after delivery felt it was too early or they were worried about another pregnancy. The relatively smaller proportion of women in this study reporting fear of painful discomfort as reason for delayed resumption of sexual activity appears to be consistent across studies.[7],[8],[9]

Regarding contraceptive choices, condoms were the most commonly reported in this study (18, 32.7%), followed by implants and IUD. A higher frequency of condom use among postpartum women has also been reported by other studies.[7] This implies poor use of modern long-acting reversible contraceptives which are more effective in pregnancy prevention. Furthermore, even though postpartum women desired family planning, they opted for less effective methods. This may be due to inadequate counseling and information on family planning and methods of contraception.

The most commonly reported reason for not using FP in this study was that the women planned to adopt FP later; this finding was reported by over a third of the women yet to use FP. This reason may suggest that women may perceive FP as not required or useful in the early postpartum period, it may be inferred that these group of postpartum women do not appreciate the possibility of an unexpected pregnancy in the postpartum period. Another reason for not using FP was that the participants did not like them due to previous experiences the women had with FP methods such as unpleasant side effects. Women that did not like FP and who had no reason constituted about half of the non-FP users. This suggests a large proportion of women who had no plan to use FP. Husband's refusal and fear of side effects were less important reasons in this study.

The strong positive association between FP and resumption of sexual activity after adjusting for sociodemographic characteristics in this study has been reported in previous studies.[10],[11],[16],[17] None of the demographic characteristics was significantly associated with resumption of sexual activity on multiple logistic regression, and this has been reported by previous studies.[7],[8],[18] We also found no significant association between resumption of sexual activity and mode of delivery and perineal tears, a finding supported by several previous studies.[18],[19],20] The lack of an association between perineal injury and resumption of sexual activity could be a reflection of the nature of our study population that included only parous women.

The findings from our study underscore the significance of early introduction of FP to women postpartum; and the ways of achieving this may include family planning counseling during antenatal care, counseling, and introduction of women to FP immediately postpartum or from the early immunization visits. Other authors have also recommended FP counseling during antenatal care to improve postpartum FP use.[21] Improved FP uptake in the early postpartum period may also be realized by integrating FP with other services, such as postnatal care, cervical cancer screening services, infant welfare/immunization services as a strategy to encourage early adoption of FP.[6] The finding of this study also provides evidence for decision making and integration of family planning services into infant welfare/immunization clinics which provides extended contacts with women after delivery and opportunity to introduce, reinforce counseling of postpartum women on family planning, enhance informed contraceptive choices and to provide follow-up and family planning support for these women.

The limitations of this study include the cross-sectional nature of the design and the study population that consisted of only women less than 6 months post-delivery. A longitudinal study of postpartum women may provide more information about the sexual practices of postpartum women; their attitude and uptake of family planning over the extended postpartum period. Also, a non-probability sampling technique was used for this study. The resumption of sexual intercourse was defined by resumption of first sexual intercourse in the postpartum. This could have been limited to women who have resumed and have continued having sexual intercourse. However, limiting the definition to women that were “currently sexually active” at the time of the interview would have led to missing the information on women who resumed sexual intercourse in the postpartum and discontinued it for various reasons. Furthermore, the women who discontinued sexual intercourse after resuming in the postpartum were few. Although, there was a delay in publishing this data, the issues discussed are topical and still relevant to the current practices of postpartum women and their care.

It is imperative that future research should consider integrating family planning clinic sessions into the infant welfare clinics as a “one stop shop,” particularly in a country where follow-up is challenging. In addition, it is also important that future studies should consider evaluating the effect of using structured family planning schedule during postpartum to improve compliance and quality service delivery.

In conclusion, this study has shown that women commonly resume sexual intercourse in the postpartum period, in many cases without FP use. We found a strong association between FP use and resumption of sexual activity. Also, some women delayed resumption of sexual intercourse due to concerns and worry about the possibility of getting pregnant. Counseling in the antenatal and postpartum period is required to address these concerns and promote early adoption of FP. Integrating FP services with infant welfare/immunization services may also provide a one-stop access to health services for mother and the newborn. This will enhance early uptake of a contraceptive method and prevent unintended pregnancies while allowing sexual satisfaction among postpartum women.

Financial support and sponsorship

Self-sponsored.

Conflicts of interest

There are no conflicts of interest.

DECLARATION:

Consent for publication: Not applicable

Availability of data and materials:

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests: The authors declare that they have no competing interests.

Funding: NONE

Sponsorship: Self-sponsored

Authors' contributions: Contributions by each author

All authors contributed to the preparation of this manuscript. BA, AA, TB, OS, IM, and OO contributed to the conceptualization, design, data collection manuscript writing, and manuscript review; BA and TB, contributed to the data analysis. All authors read and approved the final manuscript.

Acknowledgements: Not applicable



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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