Keywords

I’ve learned that people forget what you said, people will forget what you did, but people will never forget how you made them feel. (Maya Angelou (African American poet, 1928–2014))

1 Introduction

This chapter addresses the sexual aftermath of what happened in the process that took place between the midwife and the woman or the couple. It does not focus on the direct physical consequence of an intervention but on the psychological, relational, and possible sexual implications of the midwife’s approach and the surrounding context. Here are two examples:

  1. 1.

    The chapter does not deal with episiotomy causing dyspareunia, but it will deal with the emotional and sexual consequences of how the midwife introduces that episiotomy, communicates about the repair, and explains potential effects.

  2. 2.

    The chapter will address how repeated routine vaginal examinations can impact the woman’s feelings of bodily integrity and negatively influence sexual desire and arousability.

Relevant elements of this chapter are context, body integrity, vulnerability, respect, the relationship of the midwife with the couple, and quality of care. That may seem superfluous since most of these are standard healthcare and midwifery training elements. However, it appears that usually, the focus has not been on the implications in the areas of sexuality and intimacy.

We want to clarify that the specific relationship between the professional and the woman or couple is an essential element of optimal care. Research clearly showed that a well-established connection between the woman/couple and the HCP is a vital determining factor in the short-term and long-term development of a positive sexual life [1].

This chapter’s message relies much on practical examples.

2 Influencing Sexuality and Intimacy

Here, one can discern several lines along which sexuality and intimacy can easily be influenced, both aware and unaware. Some examples:

  1. 1.

    Physical exposure (or nudity), an unavoidable part of pregnancy examination and childbirth, is, for most women, seen as strictly reserved for partner-intimacy. The bare physical routine of pregnancy checks and childbirth can negatively colour the sense of intimacy for both the woman and her partner in the future.

  2. 2.

    There are direct associations between adverse sexual experiences in the past and the possible effects of routine midwifery practice on sexual well-being. For instance, in the sexually abused woman, being naked again, having her breasts touched, or undergoing vaginal penetration during a vaginal examination can easily evoke negative emotions and anxiety.

  3. 3.

    Childbirth can be a traumatic experience, generating long-standing emotional consequences, even when the physical aspects of the entire birthing process go smoothly. The woman still can experience it as traumatic because of too much pain, loss of control, or fear for the baby’s health. It can also happen because of poor communication between the HCP and the woman or the couple, or experienced lack of support [2]. Passing through such trauma related to the sexual organs of the body can influence the woman’s and partner’s sexual well-being.

  4. 4.

    There is the vulnerability of the delicate balance in the intimate relationship between the woman and her partner. The male (or female) partner’s presence at childbirth depends on the culture the couple lives in and how the midwife integrates the partner in the care and even the birthing process. The value of the partner’s presence depends partly on the couple’s relationship. For example, even in countries where the partners are invited to participate in the birth process, women experience the presence of their partner very differently, from very helpful to non-existing or a nuisance. In some couples, what happens during childbirth can forge a strong bond, whereas, in others, it can negatively impact the couple dyad, creating intimate and sexual distance.

  5. 5.

    There is a connection between how the woman is treated emotionally and how that influences her sexuality and intimacy. In particular, during pregnancy and childbirth care, the consequences of mistreatment, verbal abuse, discrimination, and non-consented procedures (in other words: repeated breaches of her physical and mental integrity), can negatively impact her self-image. At a later moment, such a negative self-image can easily lead to various sexual problems, dysfunctions, and relationship misunderstandings.

This chapter will address these themes with practical examples. Investigative questions will invite the reader to dwell on various automatisms during their standard daily care practices that could negatively impact women’s sexual well-being. Aiming to foster reflection on the self-evident daily professional routine, asking, ‘Am I providing the best possible care?’

3 The Need to Adapt Our Care to the Diversity of the People Entrusted to Us

The great diversity of people keeps our work interesting, but at the same time, it also creates complexity and presents a challenge. One size of care doesn’t fit all women and all couples.

  1. 1.

    The situation when a vaginal examination is needed. A few introductory words might suffice for the woman who delivered three children to ensure she knows what to expect. In the young primipara, who has never shown herself in the nude, even not for her husband, the first vaginal examination deserves another approach. A relaxed and precise description of how that is done, reassuring that she remains in control and can always signal discomfort, should ensure experiencing the examination in the best way possible.

  2. 2.

    Before examining the fundal height, a small verbal introduction and gaining consent to touch her will usually be sufficient. The same examination can need extensive preparation for a woman with a physical or sexual abuse history. A traumatic background requires more extensive preparation to instill a sense of safety before being able to undergo routine and seemingly harmless interventions. In that way, we minimise the chance of retraumatisation. With sexual abuse experience, simple, non-intrusive interventions such as measuring blood pressure can create feelings of ‘being caught again’. Application of the cuff, especially when it gets under pressure, can resurface frightening memories or even dissociation.

  3. 3.

    For proper repair of an episiotomy or rupture, one needs surgical skills. For some women, that just means ‘repairing the body’. For other women, the perineum is the entrance to their sexual garden of pleasure, and that entrance has to look and feel good. They could benefit when the HCP enquires how they think about reparative stitching instead of just stating that the rupture needs stitches. Besides, the HCP needs good communication skills when asking for consent, answering questions on the why and how, explaining to the woman/couple what one is doing, and adjusting the form and tone of the message to that specific woman and couple.

4 Dealing with Body Integrity

Being (partially) naked and being looked at doesn’t feel good for nearly all women. Experiencing that can create a temporary loss of the sense of body integrity, potentially influencing the woman’s and partner’s intimacy. It is a daily reality for maternity professionals to look at or be near vulnerable women and their nakedness. That everyday reality creates the risk that the HCP gradually loses the sense that nearly every woman is vulnerable when in the nude.

Building on this realisation, midwifery practice is loaded with many standard procedures that the pregnant woman easily can experience as a violation of her sense of integrity and physical self.

Here below some significant examples will be described.

4.1 Vaginal Examination (VE)

In the setting of reproductive care, physical touch is an inherent part of the daily routine. Vaginal examination (with fingers or ultrasound probe) is such a standard diagnostic procedure that it can make midwives and other HCPs forget that the vagina is, a very intimate area, only touched by the woman herself and sometimes her partner.

For women in labour, an adequately explained and consented VE can be positive and motivating when it confirms that labour is progressing. However, a VE can also be experienced as embarrassing, disturbing, and invasive, especially when explanation or consent is lacking. Women sometimes explicitly remark: ‘My vagina has become public property!’. That will not enhance erotic feelings after the birth. In Dutch research, 35% of women reported a negative experience with VE [3]. Based on that, the researchers recommend that the number of VEs during labour be restricted as much as possible; only be done after the woman’s informed consent; and preferably performed by as few different caregivers as possible.

Some points for reflecting on one’s own practise of any examination of a woman, including touching, might be the following:

  • What do I have to do before any bodily examination? Do I explain why I will do it? Do I ask for permission to do the examination? Is it enough to just announce it? Can I just start the examination because the woman should expect that during antenatal consultations?

  • Before performing a vaginal examination, do I ask: ‘Do you prefer to have your partner here or in the waiting room?’.

  • The message: ‘Please undress, I will be back in a minute!’ can mean a minute gain for the HCP. It can even be a way of fostering privacy during an intimate moment of undressing. But it might also come across as callous and impact the woman’s sense of integrity.

4.2 Respectful Daily Practice

Being seen, being heard, and being understood are ingredients of the feeling of being respected. To properly treat people with respect, one must understand the impact of feeling vulnerable as a client and what it means to be dependent on people who provide the care you need. This delicate mix of vulnerability and dependence makes it very difficult for clients to comment on or correct the professional’s self-evident routine actions.

The following reflective exercise intends to ask oneself and dwell on questions regarding the own clinical practice:

  • It is common to have shaved, trimmed, or styled pubic hair in some societies. In other societies, some women don’t shave, and both the woman and her partner can be very proud of her pubic hair. With that woman, what will you do when entering the labour ward or preparing to repair an episiotomy or a rupture? Do you ask permission to have the hair shaved? Do you just shave it? Do you only cut it shorter? And how do you communicate the why and how?

  • Like nearly any other intervention, shaving should, as much as possible, be tailored to the needs and desires of the client, considering any potential impacts on the client’s health and well-being. Research indicates that, regarding this topic, there is no clinical benefit of perineal shaving [4].

  • When a woman has to stay in the labour ward for many hours, how many midwives, physicians, students, laboratory staff, and others have, often unannounced, entered that room, and have seen her (partly) naked and/or in distress? Some women experience this as if their body has become public property (which is potentially a problem when trying to reestablish intimacy).

  • What is, during childbirth, the bed’s position in relation to the door where people enter the delivery room?

  • Did you, as an HCP, ever try to lay in that position (even with your panties on)? How did that feel when a colleague entered the room unannounced?

  • Even reflecting on the design of rooms and architecture of departments can lead to considerable benefits in daily well-being for women and couples attending the delivery and maternity ward.

Especially in this period of her life, with so many inherent insecurities, not feeling respected can negatively affect a woman’s sense of ‘being a woman’. That is essential for maintaining a healthy sexual relationship with her partner or re-developing it in postpartum.

In four low- and middle-income countries, they did extensive research on the treatment of women during facility-based childbirth. Physical abuse, verbal abuse, stigma, or discrimination was indicated in 35% of the >2.600 postpartum surveys. There were also direct continuous observations during childbirth. These ill-treatments were directly observed in 41% of the >2000 observations [5]. In 56% of the episiotomies and 10% of the caesarean sections, the women had not given consent.

The way we do things is often central to good practice.

Here below are some examples of a self-reflective exercise on the own practice:

  • Non-verbal communication, such as my face and my gaze, can convey important messages of respect or lack of it. How do I react when the next woman entering my office is severely obese?

  • How do I react to looking at a woman’s perineum who has undergone female genital mutilation? Will my gaze be understanding or inflict shame or even psychological damage!

  • After episiotomy or perineal rupture, repairing the damage is needed. When you have prepared everything, the husband positions himself behind you, entirely focusing on the vulva. Will you just ignore this or react to it thoughtfully towards both partners?

  • When, in a comparable situation, the husband requests: ‘Can you stitch it really tight?’, will you react to that situation? How will you respond without destroying your professional alliance with him whilst caring for her?

  • On the day after childbirth, you visit the woman in her private room in the hospital or birth centre. How do you enter the room? Do you just enter? Do you walk in after knocking on the door? Do you wait after knocking and get permission to enter? It could be that the woman is cuddling with her partner. Both could be in tears or engaged in any other behaviour that could confuse them (or you) when you suddenly break the privacy of that moment.

In respectful midwifery practice, small things often make a huge difference.

5 Traumatic Experiences

Giving birth can be a traumatic experience. A Dutch study investigated, at 3 years postpartum, recall of the birth experience. In low-risk women, 1 in 6 looked negatively back on childbirth [6]. We may assume that such traumatic experiences could influence sexuality or the intimate relationship, but there is no research confirming or denying that assumption.

In pregnancy and childbirth, traumatic events are sometimes inevitable. An unwanted Caesarean section can suddenly be unavoidable, and babies can even die. This chapter focuses on avoidable aspects. Since the inevitability of what has happened cannot be reversed, it is more important how we deal with it at that moment and afterwards. That includes explaining how this came to be, emotionally comforting the woman/couple, and conveying our heartfelt regret that this has happened.

In a group of nearly 2200 women with traumatic childbirth experiences, the researchers tried to distinguish the various ‘causes’ attributed to the traumatic experience [2]. In 47%, women indicated communication and lack of explanation caused the traumatic experience. Among the women who lost the baby, 63% mentioned ‘a bad outcome’ as one of the causes of the traumatic experience, but 37% mainly reported poor communication, lack of respect, and lack of support.

Every childbirth is an important event for the woman and the couple, even more so for a traumatic birth. That affects all segments of a woman’s life, including the relationship with her partner, intimacy, and sexuality. Integrating a degree of emotional aftercare and follow-up seems essential.

6 Boundaries

In times of worry and insecurity, one can be pleased with a person providing peace and reassurance. Although that role can be gratifying, the HCP should know that being very much appreciated can also have negative consequences. In persons in distress, the feelings for their HCP can become very strong and turn into infatuation. It’s not uncommon for women to be ecstatic about their male (and sometimes female) gynaecologist, midwife, paediatrician, or physiotherapist and sometimes develop romantic feelings. In psychotherapy, this process is called transference, based on emotions and unconscious needs that can sometimes be related to the woman’s past. In those situations, it will be apparent that psychological help is needed. In a couple with an apparently stable relationship, the midwife can more easily form a good alliance with both partners, a necessary element to deliver good care. When the couple’s relationship doesn’t seem stable, the midwife should develop a subtle choreography to achieve a good alliance with both partners without creating jealousy or rivalry.

Lastly, midwives and other HCPs are sexual beings too, have sexual feelings, and possibly have a partner. These are all treasures to be cherished.

The midwife’s daily practice should not be at the expense of the own sexual pleasure and sexual relationship. Surprisingly, there is very, very little literature on work-related trauma in midwives [7] and on developing sufficient sexual-health-related resilience in the education of young HCPs [8]. We couldn’t find anything on work-related influence on the midwife’s sexuality.

Just as the traumas in our patients can affect all spheres of their lives, we may assume that traumas in midwives will also affect their intimate life and sexual relationships.

There are two sides to being a midwife or maternity HCP. Witnessing childbirth and the transition to motherhood and parenthood is fulfilling and rewarding. But midwifery also faces sad and traumatic aspects of life. For many, it is difficult to find a good balance between empathising – feeling the patient’s pain so that we can provide good care – and not being overwhelmed by it. Not really letting in what is happening sometimes seems necessary to be able to continue working. However, without reflecting on that, it can ultimately cause personal and professional coldness. On the other hand, if we allow trauma and grief to enter too deeply, this could heavily impact our own mental health and well-being.

Several recent studies reported on psychological troubles in midwives. In Swedish midwives, the prevalence of moderate to severe symptoms of depression, anxiety, and stress was between 7–12% [9]. Among UK midwives, 37% scored in the moderate or higher range for stress, 38% for anxiety, and 33% for depression [10]. Among certified US midwives and nurse-midwives, 40% met the criteria for burnout [11]. When falling ill, most HCPs have difficulties stepping out of their professional, caring role and being a patient.

Burnout, stress, anxiety, and depression tend to be accompanied by decreased sexual desire and pleasure, with additional sexual damage when treated with antidepressants (see Chap. 17). In turn, that creates a breeding ground for relationship problems.

How should we react to those figures?

Regarding the care for pregnant women, we dare to guess that the midwife with the above-mentioned psychological disturbances will pay less attention to the sexuality of their clients. But we don’t know!

Regarding the care for the midwife, we dare to guess that, with a satisfying sexual life, the midwife will have fewer psychological disturbances and vice versa. Chap. 4 elaborates on the health benefits of sexuality that also apply to midwives and other maternity HCPs.

7 Not-Intervening as an Intervention

Although this chapter carries in its name ‘Sexual consequences of interventions’, we shouldn’t forget that omitting interventions also can have negative sexual consequences. Chap. 12 addressed that for high-risk and complicated pregnancies. All sexual information relevant to the woman’s or couple’s well-being but not mentioned by the HCP reinforces the taboo on addressing sexuality. And as such will increase the risk for sexual disturbances. In situations ripe with uncertainties, we believe that the HCP should pro-actively address and answer the ‘not asked questions’.

Chap. 26 gives practical advice on talking about sexuality with clients pro-actively.

8 Conclusion and Recommendations

During pregnancy and childbirth, the communication and approach of the midwife (and other HCPs as well) can play an essential role in the further development of the sexual well-being of the woman/couple. A continuous mantra for HCPs should be: ‘Our behaviour and communication have (also) sexual consequences!’.

In daily practice, awareness of the importance of how to address the woman/couple is an essential part of good practice. In midwifery education, we believe that ample time should be allocated to teaching and practising communication skills. Good communication is a prerequisite to delivering high-quality care. A valuable way to stay alert to the impact of one’s own practice is by asking for feedback from the woman and her partner throughout the process, especially at the last (postpartum) visit. Experts recommend offering every woman a postpartum visit with the caregiver who assisted her during the delivery for debriefing on the birth process.

Explicitly including sexuality in such an ‘exit interview’ can be a constructive way to gradually increase the own expertise in sexuality and intimacy.