We explored prominent themes related to attitudes, beliefs, and practices around sex during pregnancy and postpartum that emerged from questionnaires and qualitative data (FGDs and IDIs) with the four stakeholder groups included in the multi-country study.
Basic demographics of the study sample are presented in Tables 1 and 2. Across study sites, 78% of women reported living with their spouse or primary sex partner. Most women and men reported having vaginal sex with their primary partner/spouse in the past three months. During the pregnancy and breastfeeding periods, a majority of women and men agreed that decisions around having sex were made jointly between partners (Table 1). Despite this agreement, our qualitative data suggest that women and men may have different intentions behind their decisions when it comes to having sex. For example, women often agreed to have sex to prevent their partner from finding outside sexual partners, whereas men more commonly desired sex for their own satisfaction. These differences are explored in more depth below.
Women and men also reported abstinence during pregnancy or post-partum periods (Fig. 1): overall, 75% of the women reported practicing abstinence at some point(s) during pregnancy or postpartum. However, there was no given period in which more than 35% of women reported abstinence, indicating that the timing of abstinence differed between participants. Abstinence increased in frequency as the pregnancy progressed (from 23 to 31%), and women most frequently reported postpartum abstinence (35%). Similarly, 79% of men reported practicing abstinence with their primary partner/spouse, with highest rates of abstinence occurring postpartum (44%) and in the final trimester of her pregnancy (37%).
Beliefs, Attitudes, and Practices About Sex During Pregnancy and Postpartum
During FGDs and IDIs, participants shared diverse views about the cultural beliefs that impact sexual behaviour during the pregnancy and postpartum periods. While the findings presented here reflected variation on individual, study group, and site levels, there was more consistency expressed across groups and sites than there were differences.
Pregnancy: Benefits of Sex
Across all sites, participants mentioned that sperm is slippery and helps to open the birth canal, thus facilitating delivery. By this logic, participants explained that having sex close to the time of delivery is healthy and encouraged by health care providers (HCPs). Overall, participants also mentioned that sperm is seen as nutritious and contributing to the growth and development of the fetus:
Some say when you are pregnant you must have sex so that the baby can grow, the sperms grow the baby. (Red, pregnant/breastfeeding woman, age 30, Johannesburg)
Men in Malawi and South Africa felt that unprotected sex is beneficial during pregnancy because of the belief that the sound that sperm makes when it hits the womb energizes the fetus. This also means that a condom would interfere with the process. Enoch explains the importance of fetal exposure to sperm:
...Basically when they say you get a healthy baby they mean your baby becomes energetic when you don’t use condoms, and when you ejaculate inside your woman apparently the sperms hit the womb and because of that sound the foetus become energetic because when the sperms get there the foetus becomes lively. (Enoch, man, age 33, Johannesburg).
The perceived positive effect of unprotected sex that Enoch and others explained disincentivizes men from using condoms with their pregnant partners and may contribute to women’s risk of acquiring HIV during this time.
Pregnancy: Harms of Sex
A dominant theme among women was a concern that having sex close to delivery results in the baby coming out covered in sperm. One woman in Zimbabwe explained that this is not only deeply embarrassing for the mother, but is also seen as unhygienic:
As we grew up we were taught that after 7 months, you are not supposed to have sex with your husband because those sperms will be all over the baby such that you can even hear them saying, “Your baby is disgusting, your baby is coming out covered like this, and you are untidy.” (Tendai, pregnant/breastfeeding woman, age 37, Chitungwiza)
This view was echoed widely by women across sites who attributed sex in close proximity to delivery to various adverse effects for the baby. Further, at all sites but Uganda, participants stated that sex at certain stages of pregnancy or in certain positions will potentially hurt the baby’s head. Several women and grandmothers pointed to the balancing act of negotiating this risk to the baby with a male partner’s sexual satisfaction. One grandmother in Chitungwiza explains that while sex is no longer prohibited late in pregnancy, there are precautions that should be taken:
But things are now changing. Sex is no longer prohibited, you can have it anytime. But you should be careful on how you do it. You should avoid very deep penetrations so that you do not hurt the baby’s head. You just do it to make him [man/partner] feel satisfied. (Mbuya Rutendo, grandmother, age 44, Chitungwiza)
Postpartum: Benefits of Sex
To maintain harmony in the spousal relationship, participants explained that having sex throughout the pregnancy and postpartum periods may be beneficial in that it keeps both partners sexually satisfied and prevents either one from seeking sexual partners outside of the relationship, a practice more commonly described for men. Thus, continued spousal sexual relations were perceived to reduce the risk of introducing HIV into the relationship. This was a popular view in all study groups. In their interviews, HCPs noted that they typically encourage women to have sex throughout their pregnancy until they go into labor, and to resume sex about 6 weeks after delivery in order to allow sufficient time for healing and recovery.
Postpartum: Harms of Sex
Participants at all sites highlighted community views that sex and sperm may have detrimental effects for the baby or for the parents after delivery. Having sex while the baby is “too small,” for example, was widely considered dangerous for the baby’s growth and development. In Zimbabwe, grandmothers mentioned that frequent sex during the breastfeeding period may cause the baby to lose weight:
When we were growing up we were told that when you are breastfeeding…you should not frequently have sex because the baby will lose weight. (Mbuya Tsitsi, grandmother, age 42, Chitungwiza)
Participants across sites echoed the belief that when resumed “too early” after delivery, sex causes the baby to lose weight and become weak. Men and grandmothers in Malawi described a specific illness called Tsempho that presents with weight loss and weakness, either for the baby or the husband, and occurs when sex is resumed too soon after delivery:
Let me just say more on that, they say that if a woman have sex with her husband before the end of the six-months period…the child suffers from ‘Tsempho’… (Mike, man, age 21, Blantyre)
Despite wanting to preserve their sexual relationships, it was widely acknowledged across groups that women often do not want to have sex at certain times during the pregnancy and post-delivery periods due to physical discomfort, pain, healing (postpartum), hormonal changes, or general sexual disinterest. Regardless of women’s desires and preferences, discussions around sex frequently emphasized the goal of satisfying men’s needs to both preserve the relationship and mitigate the risk of HIV acquisition, if he seeks concurrent sexual relationships.
…If you ask breastfeeding mothers what their motive for sex is, they will tell you that they are just having sex to satisfy their husbands so that they don’t venture into other sexual relationships. (Key informant (family planning counselor), man, age 50, Chitungwiza)
Women across sites explained that consideration for a woman’s personal health and healing process from delivery factors into decision making about appropriate timing to resume sex:
It may also depend on the type of delivery the woman had. Others deliver through operation and others normal but they do have vaginal tears. So, it all depends on the type of delivery that will ensure you do not feel pain once you resume sex. (Lucy, pregnant/breastfeeding woman, age 29, Blantyre)
HIV Risk Behaviours During Pregnancy and Postpartum
While a majority of women and men agreed that having sex during pregnancy and postpartum is a joint decision between partners, underlying reasons for having sex may stem from various beliefs regarding partners’ needs and desires for themselves and their families.
Overall, participants reported that men find other sexual partners during these maternal periods for many reasons, including women’s disinterest in sex, men’s lack of attraction to their partner, culturally prescribed periods of abstinence, fear of hurting the baby (particularly during later stages of pregnancy), and fear of conceiving during the postpartum period. Men themselves spoke openly about their beliefs and tendencies to find sex outside of their relationship during these maternal stages. They often described a tension between their perceived biological drive for sex and “sparing” their pregnant partner from sex she (presumably) did not want to have. Despite this tension, men explained that they are expected to have sex with their wives:
Most men believe that when women are pregnant, they must go out, and reserve their wives [Spare their wives from sex]. So that is where the challenge is because that is when you get whatever you get there [Acquire HIV]. You come back home and want to fulfil your conjugal duties….In doing so, you will be infecting her with the disease that you would have acquired from outside. (Pizza, man, age 28, Chitungwiza)
In addition to recognizing the risk men introduce into their relationships, participants across sites and study groups explained that when left sexually unsatisfied, women may also seek other sex partners during the pregnancy and postpartum periods. Of note, this concern was voiced by both women and men. Men highlighted that this is something husbands have a responsibility to prevent by keeping their partners happy and sexually satisfied.
If left unsatisfied, then the problem will come that she will invite another man into the house [for sex]. She has nothing to fear in terms of getting pregnant because she is already pregnant of you [husband]. So this invited man may bring the HIV...A loving man must love his wife and make her happy when having sex. (Boloma, man, age 53, Blantyre)
Like Boloma, other participants stated that couples where the woman is pregnant are less motivated to use a condom when preventing pregnancy is not necessary, thus introducing another layer of HIV risk.
And when you are sleeping [having sex] with your partner while pregnant the partner would be like there is no need for a condom because you are already pregnant so let’s just not use it at all, while you don’t know what he is doing when you are not there so it’s very high risk to get infected while pregnant. (Apple, pregnant/breastfeeding woman, age 24, Johannesburg)
Women at several sites echoed this belief that pregnant women and their partners are less likely to use condoms than couples who are trying to prevent pregnancy.
Participants expressed varying views of a woman’s attractiveness during pregnancy and linked these perceptions to an increased risk for HIV during pregnancy. There was a lack of consensus: many participants believed that men find pregnant women more attractive, which puts them at risk because they are highly sought after by other men. These divergent perceptions are expressed by three different participants below.
Men believe that if a woman is pregnant they have hot bodies and they enjoy sex with pregnant women more than with women who are not pregnant. So, if she is a pregnant single mother they would want sex with her, by so doing she gets exposed. (Key informant (religious leader), woman, age 51, Kampala)
A South African grandmother echoed a common perspective across study groups in explaining that a pregnant woman is at high risk for HIV not only because she is seen as sexy and desirable by men, but also because she wants sex from men during this time:
Pregnant women become so beautiful and you would hear a man saying, “Yes if my wife could be pregnant,” so they are at high risk because it means some internal things attract men…So you might get it [HIV] by accident because a woman is sexy she would find herself sleeping with a wrong person. So the truth is pregnant women becomes attractive and they also want the men. (Guest, grandmother, age 67, Johannesburg)
In contrast to this belief, some male participants explained that women are viewed as unattractive during pregnancy, leading men to crave sex with other women than their spouse:
And the man himself looks at the pregnant [woman] and sees that she is no longer attractive. Then you end up getting some other woman. And when the woman is pregnant, she can easily contract diseases especially those that are sexual. (Joy, man, age 28, Kampala)
Thus, discussion related to attractiveness during pregnancy was framed in the context of heightened HIV risk, both for participants who believed women are more attractive (e.g., they are pursued by men for sex) and those who thought women are less attractive during pregnancy (e.g., their partners seek sex outside of the relationship).
In discussions about the above HIV risk behaviours, women and men described several HIV prevention strategies including HIV testing, condom use, abstinence and being faithful to their partner. There were frequent references to men rejecting condom use and HIV testing because of a fear of knowing their HIV status as well as a reluctance to acknowledge their own risk behaviours. Barbra explains that one way men avoid HIV testing is by choosing to adopt their partner’s negative test result as their own—a particularly risky assumption during pregnancy:
One of the challenges we find is that men usually decline to go for HIV testing…They usually say “You can go for testing, if they find you HIV negative then I am also HIV negative.” That is one of the biggest challenges we face; men fear to be tested for HIV yet they are promiscuous. (Barbra, pregnant/breastfeeding woman, age 36, Kampala)