All ten participants were primiparous heterosexual women, mostly with professional employment and living in Tarragona (Catalonia, Spain), with an average age of 33 years (range of 28 to 36). The complete demographic data for each participant is provided in Table 2. From the transcribed data, a total of 207 descriptive codes were identified. After grouping these codes by similarity, interrelated themes emerged from the data. The five themes that described the meaning of postpartum sexual health, included: 1) not feeling ready, 2) inhibiting factors, 3) new reality at home, 4) socio-cultural norms, and 5) clinicians within the health system. To evidence these themes, exemplar quotations from the participant interviews were selected and provided by theme in the analysis below.
Not Feeling Ready
The theme ‘not feeling ready’ refers to the wide array of emotions and feelings women experienced after giving birth, either in relation to their sexual health, motherhood, or the new relational context. Almost all the women reported being willing to and trying to have intercourse with reservation about their readiness. They described being motivated by the desire to return to what they perceived to be the ‘normal’ (pre-pregnancy) way in relationships. Although they did not feel directly pressured, some women stated they wanted to please their partners, so they did not always feel rejected.
"You have to have willpower, we have to try to do it at least once a week because otherwise it [intercourse] will be more difficult, right? [...] Because later it will be worse. Yes, you must make an effort" (Irene).
Almost all the women reported they had no sexual desire; describing their return to an active sexual relationship as complicated and scary, especially because they feared the unknown including the prospect of physical pain with intercourse. Several women reported they dwelled more on their fears rather than the possibility of enjoying sexual activity. Half the women confessed they did not feel ready to resume intercourse, either due to physical and/or emotional reasons.
"Okay, I still do not feel one hundred percent ready, and except for the last two times, which have been normal, with the rest I had to be careful because I still had difficulties” (Raquel).
The loss of libido, changing roles, breastfeeding, awareness of the newborn, and feeling that the ‘entire weight’ of the new family fell on them, contributing to the women feeling sad, seeking to escape, and thinking they were unfit mothers. The women felt alone as their husbands returned to work, increasing their sense of overload and their insecurity about not knowing how to care for their newborn.
"At first, I told him, I was very happy before [having the baby]. I could not deal with everything. The first month and a half I was sunk; the whole day having the baby hooked to my breast, I was alone, he went to work right away, you know?" (Vanesa)
To mitigate these feelings, the women needed to find a moment for themselves to feel liberated; to recover their physical and mental energies. Almost all the women reported they were able to cope with their situation when their partners were understanding and supportive. Feeling respected and encouraged by their partners gave the women a sense of security, a peace of mind.
"My husband supports me in all of this. He is a very quiet person, you know? He helps me with the baby [...] He understands that there are times when I do not feel like it [having sex] or that I am not motivated. And yes, he gives me all the support" (Laura).
The ‘inhibiting factors’ describes the physical experiences of the women during the postpartum period, especially during ‘la cuarentena”, a culturally-based family ritual to support the new mother during the 40 days following birth that includes no sexual activity[95, 96]. In terms of resumed sexual activity at the time of their interview, only two women remained celibate. Nevertheless, their experience was congruent with the other women. In general, the women described the pain and discomfort they experienced with the first vaginal penetration. Almost all participants highlighted the principal problem as the episiotomy stitches hampering their return to sexual activity.
"Resuming sexual intercourse was hard, very hard. The truth is that ... it was very difficult for us. Firstly because, well, I do not know if it was normal or it was not normal, but the stitches took a long time to reabsorb and everything really hurt” (Raquel).
Other problems described by the women were bleeding, feeling dirty, pelvic floor problems, and sensitivity alterations.
"I was not in the mood for sex. It was because of the bleeding... I felt dirty, it was very unpleasant. You have the period every month and it is uncomfortable, but this [postpartum] it was diferent, harder. I was thinking all the time that I needed to wash myself down there” (Patricia).
The women associated sexual activity as intercourse; indicating there was no foreplay or other physical contact with their partners or with themselves. Most of the women had no sexual desire; reporting vaginal dryness and other physical changes that hampered intercourse. The two women who reported feeling sexual desire following childbirth, also were less concerned about their physical changes. The women indicated a lack of time and decreased libido led to “fast sex”, with no prior stimulation. The women recognized this might have limited their sexual desire.
"During the ’cuarentena’? No, not by any means, not desire, not motivation. Following the ’cuarentena’, it took us a while to start having sex. I’ve noticed that I do not have as much desire as I used to; before giving birth, we had sex at least once a week, and now maybe once every other week or every 3 weeks. I think it’s because of the libido, I don’t know where it’s gone [laughs]” (Laura).
The women explained they had to go slowly with intercourse, trying to move into ‘gentle’ positions, and stopping when they felt unable to continue. Both the rhythm of the sexual relationship and the frequency of intercourse changed; however, the women felt this was common while worrying they would not recover to their previously satisfying sexual health.
"We went very little by little, without doing any uncomfortable positions. I didn’t feel bad at any time; I knew if it went wrong, I could stop and try again. Finally, it was good, very good indeed” (Patricia)
The physical changes associated with childbirth led to negative reports of sexual health during the postpartum period. Although the women did not report feeling rejected by their partners, they were acutely aware the physical changes (e.g. round belly and stretch marks) negatively impacted their self-image, made them feel less attractive, and reduced their libido. The women also stressed they perceived their breasts much differently; previously a symbol of femininity and sensuality, they were basically a ‘feeding machine’ for the baby with almost no sensitivity.
"Besides all your body changes, there are also the breasts; they are not as they were before giving birth. You are there the whole day watching your baby suckling and… that negatively influences your libido, for sure. Now when my partner touches them, he does it in another way it's ... it's weird, now it's weird" (Esther).
New Reality at Home
The ‘new reality at home’ theme describes the impact of the arrival of the newborn regarding changes in family roles, distribution of household responsibilities, care of the newborn, and the sexual relationship. More than half the women reported their relational priorities significantly shifted after childbirth. The women devoted most of their time to caring for their baby; contributing to the feeling of losing their womanhood and producing the nostalgia for needing their personal space. Following the birth, the women felt overloaded until they found a harmony with their baby. Many women used the expression "24/7", referring to the total dependence of their baby, which caused distress. They highlighted the need for balance in caring for their baby and attending to their partner; achieving this relational balance required mutual support and reciprocal collaboration.
"We want the baby a lot and, but you know? You have a child, fact; but you also have a partner, right? We are aware that the baby will always be here, and we will give him what is right and everything, but we also need to have this “couple moment” (Patricia).
In addition to reducing sexual desire, breastfeeding was also described as a stressful and worrisome burden. The women wondered if they were correctly feeding their babies. And, they felt completely ‘tied down’ by breastfeeding, their exclusive responsibility. In contrast, the women fondly described the intensely close bond that emerged between themselves and their baby while wondering with frustration where is their partner in this picture.
"And he [partner] seemed to have no child, and even worse, as breastfeeding is ’a maternal thing’, he was there as a movie extra. When breastfeeding came to an end, oh gosh! What a change! What a relief!” (Raquel).
The inability to sleep at night was highlighted as a critical problem by all the women. Those who could rest properly felt more energetic, both regarding their ability to engage in sexual activity as well as care for their baby. Rest required support from their partners, while good communication was important when the women felt tired. However, the communication was not always good as the loss of their role as a woman coupled with being a new mother led some couples to distance themselves from each other. There were more arguments, especially about the distribution of household tasks and the care of their baby. Some women reported feeling that they were the only one leading the way while their partners were merely bystanders. The lack of personal time and the distancing required couples to ‘book’ a time for intimacy. This translated into scheduled versus spontaneous sexual activity, further hindering their sexual desire. Finally, more than half the women felt the presence of their baby in their bedroom was a negative factor for intercourse. With the baby present, the women felt uncomfortable as the total loss of privacy resulted in feeling less intimate.
"The crib is in the next room, there's no privacy, you know? We're tired, we want to go fast and of course, it [having sex] takes time" (Ruth)
There were beliefs and preconceived ideas the women mentioned as being part of their social and cultural backgrounds which influenced their sexuality after childbirth. All the women stressed they avoided preconceived ideas about sexual health during the postpartum period to experience it calmly and naturally.
"And the best thing you can do for everything, is to carry nothing, no preconceived ideas. But nothing uh, neither during pregnancy, nor in childbirth, nor in the postpartum, nor in relationships, nothing. That is, whatever happens you will manage it the best you can.” (Raquel).
The women felt the pressure exerted on them by society was unhelpful in dictating how they should live and in what way they should behave as a mother. They felt all the responsibility for the household was theirs. The society expected them to know how to do everything and how to satisfy everybody except themselves. This pressure provoked tiredness and negatively affected their sexual health.
"And on top of that [becoming a mother] you have to know everything, that is, you have to be a mother, a woman, a housewife and a friend, and you have to be perfect and stupendous at all times, and this is hard. Am I supposed to be ready for … [sex], you know? When I am exhausted? Excuse me, but no! The mother is in charge of everything, no matter if you are young or old, if you are expert or novice… it seems that you have to know from the first day how to change a diaper!" (Raquel).
Some of the women mentioned the difficulties and negative parts of motherhood, especially in relation to their sexual health, were not explained by anyone. They reported everyone tended to idealize the arrival of the baby or overlooked the difficult situations. When the preconceived ideas and incorrect expectations clashed with the reality of their lived experience, the women felt as if they were doing things wrong. All the women agreed the discussion of postpartum sexual health was taboo, as the topic provoked shame in both the mothers and the other people in their world. The women argued more information needed to be shared with them, including life experiences from other mothers, to understand the meaning of being the new mother in the context of being part of a couple.
"It is not difficult for me to talk about sex, but I do believe that there are people who are quite shy in this regard, not me I repeat. Your friends and relatives don´t explain anything to you about sex, they may want to, but they don’t do it” (Esther)
On the other hand, having the support of friends and other mothers helped the women to have a better experience, and to understand what was happening by giving them an opportunity to exchange information freely among equals. Sharing their own experiences reassured them of their normalcy. Interestingly, more than half the women tended to seek normalcy, defined, in their own words, as “what others do”.
"If you go and someone tells you ‘it was the same for me too!’ or ‘I don’t know if that is normal either’, it's like you go home more calmly, because I'm not the only one, right? (Esther).
Another relational factor identified in the collective experiences of the women was their personal interpretation of sexual health; this was quite similar for all of them. The women emphasized their need to connect with their partners positively and actively. Although they wanted to have sex with their partners as in the past, this was difficult after childbirth since the women needed to prioritize their baby.
"It [having sex] was one of the hardest parts of the difficulties of having a child, I’d say the hardest. You think that everything is going to be perfect after having the baby, but it turns out that it's not all that perfect and sex, at all!" (Raquel).
Clinicians within the Health System
Finally, the women felt their experiences with the health system in the postpartum period could have been much better. Most participants confessed to having personal doubts in the postpartum period, mainly about their ability to care for their baby. Although all the women attended postpartum maternal education classes, they felt lost and alone; not only in relation to caring for their baby, but also in resuming sexual activity.
"Yes, at some point I had many doubts, too many. I became an expert in reading, oh my God! Anything that happened to the baby, anything that I experienced looking after him…it was huge. You have many, many doubts. You are completely lost" (Ruth).
The women recognized their exclusive interest in caring for their baby resulted in neglecting themselves and experiencing postpartum sexual health in an unexpected way. They believe the clinicians should be responsible for preparing them to manage the changes they would experience. The women wanted to talk openly, explicitly, and without generalizations, with someone about their sexual health in the postpartum period. Above all, the women wanted their clinicians to be honest and direct about their sexual health, without glossing over the negative aspects and addressing the real difficulties they would most likely experience following childbirth.
"They [clinicians] prepare you for the postpartum, yeah, but just physical things down there, nothing about sexuality. They told us before we left hospital, that you may have a bad time, you may cry, but I didn’t think it would be like this" (Vanesa).
Several participants stated that they preferred to consult the internet instead of their clinicians as their primary source of information.
The women emphasized that their need to share their sexual experiences with their healthcare provider could be addressed with a protocol-based postnatal follow-up, to provide time with the healthcare provider to speak about their sexual health. Also, the women thought they should be able to speak to other mothers about their problems, including their sexual health. Four of the participants admitted they felt neglected, as the attention of their clinicians focused exclusively on the baby. Almost all the mothers had doubts about their sexual health; in particular, they feared having pain or uncomfortable feelings during intercourse, they were uncertain about when they should resume sexual activity, and they wanted to know how long it would take for them to return to pre-pregnancy. As such, participants reported seeking information from other sources.
"So, yes, I would have gone to a group meeting but one you could freely not say anything about breastfeeding or babies. Just about all the other doubts we might have or just to explain how we were dealing with the new situation. I think this would be very effective, at least in my case, I would have signed up and I would have appreciated it" (Irene).