Keywords

1 Introduction

This chapter is the first of two dealing with sexuality during pregnancy. Whereas Chap. 12 will address sexuality in complicated pregnancies, this chapter will focus on the uncomplicated, physiological pregnancy. It will start by briefly summarising the physiological and psychological changes in pregnancy that impact a woman’s sexuality with attention to changing body awareness and changing social roles. Sexuality is also influenced by the partner, the society and culture of the couple. Those elements, however, will get limited attention. Chapter 22 will give details on the sexuality of the male partner in the phase of pregnancy and young parenthood, and Chap. 23 will delineate cultural aspects. Healthcare professionals (HCPs), usually midwives, who have the expertise to guide women through pregnancies, need to address this vital area of sexuality with all its changes for women and couples.

2 Pregnancy: A Unique But Challenging Time

All couples enter partnership and pregnancy with their shared experiences, behaviours, dreams [1]. A woman’s thoughts and feelings about pregnancy, her acceptance of it and consequently her attitude towards sexuality in pregnancy are very much influenced by how the couple decided to become pregnant. Some women experience pregnancy as a loss of identity and perceive their bodies as no longer their own, while others thoroughly enjoy this period. A planned pregnancy that both partners desire can increase the enjoyment of pregnancy and, consequently, sexuality during this time [1].

Many other factors influence a woman’s attitude towards pregnancy and sexuality also: her current life situation, sense of security, relationships with others, self-acceptance, reaction to the hormonal changes of pregnancy and last but not least, her expectations of motherhood.

The partner’s support and attention can strongly impact the woman’s feelings about pregnancy [2]. However even if the pregnancy was planned and desired by both, it is normal to have ambivalent feelings. Nowadays, most women have the opportunity to build a career, have a baby and step a while out of the career path. Then, dedicating one’s life to a dependent child can be perceived as losing one’s professional identity, freedom, etc. In this context, confronting these significant lifestyle changes can lead to grief and a sense of loss. Despite mutual consent with the partner for a child, these women’s feelings of sacrifice can affect their (sexual) relationship.

Pregnancy also challenges the partner. Some will experience insecurities about career and parenting abilities. Besides, the pregnant woman gradually changes from a lover to a mother, which can affect the climate of the relationship. Therefore, it is important to talk about feelings during pregnancy and address insecurities so that they do not become a problem for the couple. If such emotional challenges are left unresolved, they can easily affect the couple’s relationship and sexual wellbeing over time.

Despite the individual differences in the way women experience (each and every) pregnancy and even the different stages of the same pregnancy, there are some general physiological and psychological changes that pregnancy brings to each woman and her partner, which already can change sexuality during this time.

3 Physical and Psychological Changes in Pregnancy Which Might Influence Sexuality

As indicated above, during pregnancy, the woman experiences changes in all areas of her life—physical, emotional and social. We will discuss only those most likely affecting her intimacy and sexuality.

3.1 Physiological Body Changes

In the first trimester of pregnancy, specific physiological changes (such as the absence of menstruation) can positively impact a woman’s sexuality. Other changes, such as nausea and fatigue, are normal, but not pleasant and can negatively affect sexual desire and arousability.

In the second trimester of pregnancy, the volume of the breasts increases, which some women find uncomfortable or even painful, affecting sexual intimacy. Some women might feel more feminine because of the increased breast size and some might not. The increased blood flow to the genitals strengthens the sensitivity of this area, which can facilitate the achievement of orgasm and increase sexual desire. Nausea usually disappears during this time, and most women begin to enjoy the pregnancy, which can also affect their levels of sexual desire and willingness to have sex.

In the third trimester, women may experience heaviness and shortness of breath as the uterus grows. Fatigue becomes again more familiar. Women often report insomnia because even at night, they have to urinate frequently. The enlarged uterus can cause feelings of clumsiness and affect self-confidence. And the awareness that the baby will soon be a reality can trigger a change in social roles (with the focus shifting from partner, employee, etc., almost exclusively to motherhood). All of these situations can be reasons why interest in sexuality can wane.

The above-mentioned physical symptoms are not pathological, but they are not always pleasant and interfere with a woman’s daily activities. It is relevant to remember that nowadays, many women postpone their pregnancies. Pregnancies at an older age of the mother and father however increase the risk of complications and these are addressed in the next chapters.

3.2 Psychological Changes

Reva Rubin, a maternity nursing specialist, described that a woman goes through three stages of psychological acceptance during pregnancy, usually corresponding to the trimesters [3]. These psychological considerations and focusses also play an important role in the context of a woman’s interest in sex.

In the first trimester woman’s interests are directed towards how being pregnant will change her life. She largely will focus on herself and her physical changes. This self-centred view is necessary for woman and her transition to motherhood, but it can lower sexual desire because her mind is pre-occupied with the changes she is going through.

In the second trimester, attention turns to the baby; it is usually closely associated with awareness of the first movements of the fetus. Protective feelings towards the unborn child come to the forefront, and the child’s benefits are the focus of the woman’s attention, so it is common and logical that fear of harming the baby during sexual intercourse arises. Some researchers say that fear of the harmful effects of sex on the baby is a main reason for low sexual activity in pregnancy [4]. However, as Gianotten [1] writes, these fears are often culturally based. Couples might also have more sex during pregnancy than before. For instance, one tribe in Africa frequently practises intercourse during pregnancy because the act is crucial to ‘finish’ the baby (intercourse has to create all body parts). Southeastern Nigerians also practise sex during pregnancy because they believe it dilates the vagina and facilitates childbirth [5].

The third trimester is often marked by the woman becoming aware of the upcoming birth. That realisation can cause anxiety due to worries about the safety of herself and the baby. Common issues also include awareness of the changed body image or disturbing physical changes caused by pregnancy.

3.3 Social Changes

How woman accepts this period is also affected by how her culture views the pregnancy. How is pregnancy portrayed in the media? And how is it taken by the relevant intimates-especially her partner. Because of her physical changes, the idea of the baby (and impending parenthood) is more tangible to the pregnant woman than to her partner. Realising and accepting the imminent fact that their roles will change dramatically will arise later in her partner. Since this can create tension in the relationship, addressing and explaining this ‘time gap’ in accepting future parenthood can be beneficial. An unsatisfactory relationship and disturbed intimacy usually will impair sexuality and vice versa. As said, the pregnant woman’s male partner usually does not feel the physiological changes of pregnancy, however some do - psychosomatic symptoms are called ‘couvade syndrome’ and reflect the woman’s fatigue, exhaustion and nausea. Some claim that couvade syndrome is more common in men facing unplanned pregnancies, suggesting that it is often related to unresolved issues of paternity acceptance [6]. Couvade symptoms have also been linked to possible hormonal changes in the male partner, such as a drop in cortisol and testosterone levels. That can also decrease sexual desire as a side effect [7]. Couvade symptoms are more common during first pregnancy, especially in the first trimester and around birth [1]. However, even without experiencing any physical changes, pregnancy significantly impacts the man’s emotions, which requires psychological adjustment and recognition by his partner and their HCPs. Just as in pregnant women, ambivalent feelings about pregnancy and the baby are common and not abnormal among expectant fathers. Joy and anxiety about the future may be intermingled.

In some cases, men have concerns about future financial responsibilities. And some can feel excluded from the dyad formed between the expectant mother and the coming baby. Common concerns are also fears about the birth process. Childbirth is felt as dangerous for his wife and the baby and not in his control. All these feelings affect the dynamics of the partners and can therefore also affect their sexual life.

These changes are relevant for understanding pregnancy’s changes to a couple’s relationship.

The following sections will provide information about the woman’s sexuality and include details on every trimester. Chapter 22 will pay extra attention to the male partner, and Chap. 21 to the lesbian couple’s pregnancy. Although a bit old, we derived much information from an extensive meta-analysis on sexual behaviour in pregnancy by Kirsten Von Sydow [5], and we will draw some parallels with more recent research.

4 Sexuality in Pregnancy: Diversity of Normalcy

As explained above, both partners’ physical and psychological factors may influence their sexual desire and response. In an uncomplicated pregnancy, the couple may continue with sexual activity until the end of the pregnancy [8], but the couple’s desire may vary as the pregnancy progresses. Some researchers report less sexual activity by couples during these 9 months [9]. On the other hand, rare studies have found that some couples regularly continue having sex until childbirth [10]. More commonly, a decline is reported, estimated to be as high as 50% [11]. Some couples stop having sex as soon as they know they are pregnant [5]. In general, a slight decrease in the frequency of coital activity is observed in the first trimester, followed by a slight increase in the second trimester and a sharp drop in desire and coital activity at the end of pregnancy. Studies that examined sexual desire, arousal and frequency of orgasm report a reduction in all of these parametres of sexual function [12]. In interpreting information from different research articles, the midwife/HCP must be aware of often interfering cultural biases plaguing sexuality research from both the respondents’ and the researcher’s sides.

Sexual desire and ability to become aroused and achieve orgasm in pregnancy is very individual; it varies from woman to woman, pregnancy to pregnancy and even trimester to trimester. It is also very much related to the quality and satisfaction of the partnership [13]. The quality of sexuality before the pregnancy has a significant impact on sexual satisfaction post-partum and during young parenthood [1]. Therefore, in terms of prevention, it is vital to regularly address and eventually educate on sexuality and intimacy in pre-natal check-ups to prevent developing problems or resolve them promptly.

4.1 First Trimester

The commonly accepted view is that women in the first trimester are less interested in sexual activity due to fatigue, nausea or morning sickness. Women prefer non-genital stimulation to penetration [5]. However, this may also be the result of uncomfortable or even painful sensations. In nulligravid and primigravid women, breast volume can increase by 25% during sexual arousal. When the hypercongestion of arousal augments the pregnancy-related physiological enlargement of the breasts, the breasts can cause discomfort or even pain (and eventually avert women from sex) [1].

Experts report differences in sexual desire among couples, with the male desire usually being higher. That difference can cause tension in the relationship through feelings of rejection from the partner with greater desire and guilt from the partner with lower desire [6]. Therefore, good health care should address sexuality individually, starting from the perception of this couple’s sexuality during pregnancy. HCPs should avoid assuming fixed norms and average behaviours not to provoke feelings of inadequacy. They should start from a frame of reference in which any changes in women’s sexuality as a direct result of pregnancy are normal. We think that providing all couples with appropriate education about sexuality is neccessary. Some midwifery researchers caution that only quantitative measures of changes in sexual components, usually estimated with validated instruments (the FSFI as most commonly used), cannot explain the broader context of changes in the couple’s sexuality and partnership and are not explanatory enough, because they do not capture individual aetiology of individuals’ issues [14]. Therefore starting by assessing this couple’s ideas about sexuality and their common sexual practice can help avoid misconceptions and miscommunication.Footnote 1

4.2 Second Trimester

In the second trimester, increased vasocongestion of the vagina and vulva may improve sexual arousal and sexual desire in some women so that they have similar or even higher levels of sexual desire and arousal than before pregnancy. Another advantage of the pregnancy is perceiving the moist vagina as sexual lubrication and this acts as a potential trigger for greater arousal. Hypercongestion can also contribute to more intense orgasms, and some women may experience multiple orgasms. For about 50% of women, their ability to orgasm improves during this time (some even experience reaching orgasm faster). However, these physical changes can also have disadvantages. Pregnancy-induced hypercongestion combined with sexual arousal can lead to vulvar numbness or hypersensitivity and even pain during penetration. As a result, about 30% of women are unable to or have difficulty reaching orgasm.

Male hormone levels also alter when the man is expecting a baby. They have low testosterone and cortisol levels, while oestrogen levels are higher. During pregnancy, also their prolactin levels increase [7]. Low testosterone may be the reason why sexual desire decreases in some of the expectant fathers. Therefore, the sexual desire of women in the second trimester is sometimes higher than that of their male partners [1].

All women can usually feel fetal movements by the end of the 20th week of pregnancy. According to Reva Rubin [3], this is a trigger for women to perceive the unborn baby as a separate individual, no longer a part of their body, but an entity in its own right. However, feeling the baby’s movements after coitus can be psychologically unsettling for some women; they may fear that the baby is uncomfortable or even in pain, or they may lack a sense of privacy—they can have the feeling that they are not alone with their partner during intercourse. Therefore, it is helpful to explain to expectant mothers and fathers that baby movements after orgasm are normal and that intercourse and orgasm cannot hurt her. The baby is secured by amniotic fluid in the amniotic sac, within the uterus.

4.3 Third Trimester

Similar to the functional changes, sexual behaviour also changes as pregnancy progresses. In the third trimester, the decrease in sexual activity is common again. Reasons may include an enlarged uterus, overly sensitive nipples and enlarged breasts that cause physical discomfort [15]. During this period, women experience a prolonged period of arousal, which often leads to a different orgasmic experience. The normal, rhythmic, clonic contractions can be replaced by one prolonged, tonic spasm, which can be experienced as painful [5]. After intra-vaginal (or anal) ejaculation, the semen’s prostaglandins may intensify the orgasm contraction. Complete resolution can become impossible due to the constant state of hypercongestion in the vaginal and vulvar areas [1].

During pregnancy, the body changes dramatically, leaving some women feeling unattractive in the last trimester [15]. Acceptance of the changed body image is not only related to weight gain but also to many other changes in the pregnant body (larger breasts, stretch marks, hyperpigmentation of the skin, oedema of the ankles, etc.) and also to physical functioning (some feel clumsy, slow, some report stress incontinence, etc.). Nonetheless, some women feel more attractive during pregnancy; the hormones and congestion make them glow and shine, sometimes leading to a greater sense of femininity. The perception of the attractiveness of the pregnant body increases a woman’s sexual desire and enjoyment of sex. Results from Pascoal et al.’s [16] study suggest that body dissatisfaction is strongly associated with sexual distress, which is associated with lower sexual and relationship satisfaction [13]. This confirms older findings reported by Von Sydow [5]. Male partners also have various perceptions. Some men are attracted to pregnant bodies, while others are not. There is much debate about the public image of pregnant women, particularly concerning the influence of the media and pregnant celebrities [6].

The most common fears of couples who engage in penetrative sex during pregnancy are injury to the unborn child, induction of pre-mature birth, rupturing of the membranes or causing infection [11]. Therefore, one of the main tasks for midwives and other HCPs accompanying the couple through the pregnancy is to answer the expressed (and also the not-asked) questions, clearly explaining the physiological changes during pregnancy and the associated potential risks to sexuality and reassure where needed. For example, logical and straightforward advice such as that the onset of labour is a complicated process and that in normal pregnancies, labour cannot be induced by sexual intercourse until the baby is at term.

5 Counselling Sexuality to Pregnant Couples: Overcoming the Taboo

Many HCPs avoid talking to women and their partners about sex in pregnancy, often arguing that they do not want to invade the couple’s privacy. On the other side, couples expect them to open up this conversation and hope that they will not have to bring up the subject themselves [15]. The topic of sexuality in pregnancy is sometimes hidden or made misty by using the term intimacy when meaning sex. Another miscommunication occurs when HCPs or couples say sex when meaning penetration. Buehler [6] writes that it is essential to address sexuality directly. Our readers will find more detailed information on ‘how to do’ this in Chap. 26. At the same time, we need to be aware that talking about sexuality might bring to light other things that, at first glance, have nothing to do with sexuality but underpin the climate in the relationship and can have a profound impact on the couple’s relationship and therefore also on sexuality. That is why it is crucial to take enough time when starting the conversation about sexuality in pregnancy. Ideally, the first conversation should occur already when planning a pregnancy or at the beginning of the pregnancy. We should include both partners in that conversation about sexuality (if needed, followed by individual talks). In many countries, men are actively involved in their partners’ pregnancies, attending pre-natal checks and ultrasound examinations, providing birth support, and caring for the baby, so they are also more emotionally affected by pregnancy. In general, gender roles are changing and these changes are even more profound when it comes to the active involvement of fathers-to-be in the perinatal period. HCPs should use their presence at antenatal visits, antenatal classes and counselling sessions to open up the topic of sexuality and intimacy as well. Investing in feelings of mutual support and emotional empathy and maintaining a connection through shared intimate and/or sexual experiences before and during pregnancy are necessary to maintain a solid relationship foundation to survive the challenges of the post-partum period and early years of raising children. Therefore, facilitating an open conversation about sexuality during pregnancy should become a part of routine holistic care for pregnant couples.

There are sexual issues that can be quickly resolved. For example, with counselling about different sexual positions, we can resolve the challenge of abdominal pressure in late pregnancy. Usually, women prefer woman-on-top positions, side positions or posterior positions [5], which are more suitable due to the enlarged uterus. Psychoeducation regarding the baby’s safety during intercourse can also relieve some of the stress in the couple. It is also beneficial to discuss with the couple sexual activities that are different from coital activity, which are acceptable to them. In such a way, the HCP can help reconnect them when they suffer from desire differences. Some couples need advice regarding relief from the tension caused by ‘pent-up sexual energy’. Non-penetrative forms of sexuality can become very relevant, especially in the third trimester and early post-partum period (the sexual restart phase). Exploring sensual pleasure and intimacy as outercourseFootnote 2 options and developing new sexual scripts will be very new for many couples but can help resolve sexual frustrations successfully. We call this process ‘renegotiating intimacy’. For example, masturbation or mutual masturbation may help to keep the couple’s sexual relationship healthy during pregnancy [1] and might be acceptable to some clients. However, attitudes towards masturbation are also shaped by cultural acceptance and expected male/female roles in the society. Cultural norms and prejudices can have a massive impact on sexual behaviour of the individual, and for pregnancy, in particular, every culture has unwritten rules. Women can feel confused when their feelings and desires differ from society’s norms. Therefore, in counselling, HCPs should emphasise the individual variability of sexual response in pregnancy, reassuring the couple. Women receive a lot of misleading advice, so HCPs need to start the conversation about sexuality to debunk myths and traditional beliefs and try to reduce unfounded fears and anxieties. We should conduct such conversations with sensitivity and respect.

6 Conclusion

Sexual behaviour in pregnancy is influenced by various hormonal, emotional and social factors, reflecting the biopsychosocial nature of sexuality. This mixture of influences ‘gives birth’ to a very different sexual life during pregnancy. The woman may have less or more sexual desire than her partner. She may have trouble accepting her pregnant body image, or her partner may have a problem accepting his lover becoming a mother. Both may have barriers to sexuality at this time, stemming from cultural misbeliefs. The woman may have concerns about becoming a mother. The partner may also have ambivalent feelings about pregnancy, even with strong childwish. Partners may feel left out of the process, as the pregnant woman is the radiant centre of everyone’s attention. Situations are complex, so there is no prescribed guide on what to advise all pregnant women and their partners regarding sexuality during pregnancy except that maintaining their sexual wellbeing is an essential factor in their general health and wellbeing. It is essential to talk in-depth about sexuality, listen actively and without prejudice, create an intimate atmosphere and maintain professional standards while building a trusting relationship in which couples feel safe to share their thoughts, problems and desires.