Psychological factors and the sexuality of pregnant and postpartum women.

Sexual desire in the majority of women generally decreases during pregnancy, although there may be a wide range of individual responses and fluctuating patterns (e.g., Barclay, McDonald, & O'Loughlin, 1994; Bustan, Tomi, Faiwalla, & Manav, 1995; Hyde, DeLamater, Plant, & Byrd, 1996). By the third trimester of pregnancy, approximately 75% of primigravidae report a loss of sexual desire (Bogren, 1991; Lumley, 1978.) A decrease in frequency of sexual intercourse during pregnancy is generally associated with a loss of sexual desire (e.g., Bogren, 1991; Lumley, 1978). By the third trimester, between 83% (Bogren, 1991) and 100% (Lumley, 1978) of primigravidae reported a decrease in frequency of sexual intercourse.

The general conclusion from empirical studies and clinical impressions is that many postpartum women continue to report a decline in sexual interest, desire, or libido (Fischman, Rankin, Soeken, & Lenz, 1986; Glazener, 1997; Kumar, Brant, & Robson, 1981). Women's loss of sexual desire generally leads to less sexual activity, and to loss of sexual satisfaction, although the association between these facets is far from linear (Lumley, 1978). Hyde et al. (1996) found that 84% of couples reported reduced frequency of sexual intercourse at 4 months postpartum. Enjoyment of sexual intercourse tends to return gradually after childbirth. Lumley (1978) found that there was a linear increase in the percentage of women who found intercourse enjoyable after birth, from nil at 2 weeks to about 80% at 12 weeks. Similarly, Kumar et al. (1981) found that, at 12 weeks after childbirth, about two thirds of the women found sex "mostly enjoyable," although 40% complained of some difficulties.

It is clear from the above studies that a significant proportion of women experience reduced sexual desire, frequency of intercourse, and sexual satisfaction over the perinatal period. However, less attention has been given to the magnitude of those changes, or to the factors that may contribute to them. This is the focus of this study.

LITERATURE REVIEW

A review of the literature suggests that six factors may be related to reduced sexual desire, frequency of sexual intercourse, and levels of sexual satisfaction during the postpartum period. These factors appear to be adjustment to changes in social roles (work role, mother role) of women during the transition to parenthood, marital satisfaction, mood, fatigue, physical changes associated with the birth of the child and breast-feeding. The role of each of these factors will be discussed in turn.

The perceived quality of social roles has been found to influence individual well-being and relationships (e.g., Baruch & Barnett, 1986; Hyde, DeLamater, & Hewitt, 1998). However, the impact of social roles on women's sexuality over the transition to parenthood has not been the subject of extensive empirical research. Only two published studies were located which examined the influence of women's paid employment on their sexuality during pregnancy and the early postpartum period (Bogren, 1991; Hyde et al., 1998). Bogren (1991) found no relationship between work satisfaction and sexual variables during pregnancy. However, insufficient information was provided regarding how work satisfaction was measured, nor were separate analyses reported for women and men. The larger study of Hyde et al. (1998) found that there were no significant differences between groups of homemakers, women employed part time, and women employed full time in their frequency of decreased sexual desire, nor in overall frequency of intercourse, nor sexual satisfaction at 4 or 12 months postpartum. Women's positive work-role quality was associated with a greater frequency of sexual intercourse during pregnancy, and greater sexual satisfaction and less frequent loss of sexual desire at 4 months postpartum. Nonetheless, work-role quality predicted relatively small amounts of variance in the sexual outcomes.

For most women, motherhood is a very positive experience (Green & Kafetsios, 1997). Recent mothers have reported that the best things about being a mother were watching a child's development, the love they received from children, being needed and responsible for the child, giving love to the child, helping to shape the child's life, having the child's company, and feeling contented (Brown, Lumley, Small, & Astbury, 1994).

The negative aspects of the mother role included confinement or lacking uninterrupted time and freedom to pursue personal interests (Brown et al., 1994). Other concerns were not having an active social life, needing a break from the demands of the child, inability to control or define the use of time, loss of confidence, and difficulties in coping with their infants' feeding and sleeping patterns. By 6 months postpartum, many infants' sleeping and feeding difficulties have been resolved. However, other aspects of infants' behaviors become more challenging (Koester, 1991; Mercer, 1985).

There is little empirical evidence that difficulties in the mother role are directly related to women's sexual functioning in the postpartum. Pertot (1981) found some evidence to tentatively suggest that problems in women's postpartum sexual responsiveness were related to difficulties with the mother role, since one of the adoptive mothers reported definite loss of sexual desire. It was expected that difficulties in the mother role would affect women's sexuality due to a general diminution of their well-being and disruption to their relationship with their partners.

A large body of research has demonstrated that the addition of the first child to the parental dyad results in a decrease in marital quality (see a review by Glenn, 1990). Evidence supporting a marital satisfaction decline across the transition to parenthood has been found in studies from many different countries (Belsky & Rovine, 1990; Levy-Shift, 1994; Wilkinson, 1995). After an initial "honeymoon" period in the first postpartum month, the trend to lower marital satisfaction becomes stronger by the third month postpartum (Belsky, Spanier, & Rovine, 1983; Miller & Sollie, 1980; Wallace & Gotlib, 1990). Different aspects of the marital relationship are reported to decline. By 12 weeks postpartum, there is evidence of a reduction in women's reported love for their partners (Belsky, Lang, & Rovine, 1985; Belsky & Rovine, 1990), and a decline in affectional expression (Terry, McHugh, & Noller, 1991).

Relationship satisfaction has been associated with measures of women's sexuality in the postpartum (Hackel & Ruble, 1992; Lenz, Soeken, Rankin, & Fischman, 1985; Pertot, 1981). However, none of the studies examined provided clear evidence of the relative contribution of relationship satisfaction to the prediction of changes in women's sexual desire, sexual behavior, and sexual satisfaction during pregnancy and after childbirth.

The extent to which the above changes in sexuality are due to changes in mood has received little attention. Evidence from self-report depressive symptom rating scales has consistently found higher scores antenatally than postnatally, although little is known about the relative severity of antenatal depression (see a review by Green & Murray, 1994).

Childbirth is known to increase women's risk of depression (Cox, Murray, & Chapman, 1993). A meta-analysis indicated that the overall prevalence rate of postnatal depression (PND) is 13% (O'Hara & Swain, 1996). An estimated 35% to 40% of women experience depressive symptoms in the postpartum which fall short of meeting the criteria for a diagnosis of PND, yet they experience considerable distress (Barnett, 1991).

Difficulty in the marital relationship is an established risk factor for PND (O'Hara & Swain, 1996). PND is also associated with women's loss of sexual desire after childbirth (Cox, Connor, & Kendell, 1982; Glazener, 1997), and infrequent intercourse at 3 months postpartum (Kumar et al., 1981). Elliott and Watson (1985) found an emerging relationship between PND and women's decreased sexual interest, enjoyment, frequency, and satisfaction by 6 months postpartum, which reached significance by 9 and 12 months postpartum.

Fatigue is one of the most common problems women experience during pregnancy and the postpartum (Bick & MacArthur, 1995; Striegel-Moore, Goldman, Garvin, & Rodin, 1996). Fatigue or tiredness and weakness are almost universally given by women as reasons for loss of sexual desire during late pregnancy and in the postpartum (Glazener, 1997; Lumley, 1978). Similarly, at approximately 3 to 4 months postpartum, fatigue was frequently cited as a reason for infrequent sexual activity or sexual enjoyment (Fischman et al., 1986; Kumar et al., 1981; Lumley, 1978). Hyde et al. (1998) found that fatigue accounted for considerable variance in postpartum women's decreased sexual desire, although at 4 months postpartum fatigue did not significantly add to the prediction of decreased desire after depression had been first entered into regression analysis.

The physical changes associated with birth and the postpartum may influence women's sexuality. During childbirth, many women experience tearing or episiotomy and perineal pain, particularly when they have had an assisted vaginal delivery (Glazener, 1997). Following childbirth, dramatic hormonal changes cause the vaginal wall to become thinner and to lubricate poorly. This commonly causes vaginal soreness during intercourse (Bancroft, 1989; Cunningham, MacDonald, Leveno, Gant, & Gistrap, 1993). Dyspareunia may persist for many months after childbirth (Glazener, 1997). Perineal pain and dyspareunia due to childbirth morbidity and vaginal dryness have been shown to be related to women's loss of sexual desire (Fischman et al., 1986; Glazener, 1997; Lumley, 1978). Experiencing pain or discomfort with sexual intercourse is likely to discourage women from desiring sexual intercourse on subsequent occasions, and to reduce their sexual satisfaction.

Strong evidence indicates that breastfeeding reduces women's sexual desire and frequency of intercourse in the early postpartum period (Forster, Abraham, Taylor, & Llewellyn-Jones, 1994: Glazener, 1997; Hyde et al., 1996). In lactating women, high levels of prolactin, maintained by the baby's suckling, suppress ovarian oestrogen production, which results in reduced vaginal lubrication in response to sexual stimulation.

The principal aim of this study was to examine influences of psychological factors on changes from prepregnancy levels of women's sexual desire, frequency of intercourse, and sexual satisfaction during pregnancy and at 12 weeks and 6 months postpartum.

It was expected that during pregnancy and at 12 weeks and 6 months postpartum women would report a significant decrease in sexual desire, frequency of sexual intercourse, and sexual satisfaction compared to their prepregnancy levels. It was expected that women's reported relationship satisfaction would not change during pregnancy, but would decrease at 12 weeks and 6 months postpartum compared to their prepregnancy levels. Lower role quality and relationship satisfaction and higher levels of fatigue and depression were expected to predict changes to women's levels of sexual desire, frequency of sexual intercourse, and sexual satisfaction during pregnancy and at 12 weeks and 6 months postpartum. Dyspareunia and breastfeeding were also expected to have a negative influence on women's sexuality in the postpartum.

METHOD

Participants

One hundred and thirty eight primigravidae who were recruited at antenatal classes at five sites participated in the study. The participants' ages ranged from 22 to 40 years (M = 30.07 years). The partners of the women were aged from 21 to 53 years (M = 32.43 years). Data from four women were excluded from the analyses during pregnancy, as they were not yet in the third trimester. Responses were received from 104 women from this original group at 12 weeks postpartum, and 70 women at 6 months postpartum. It is unknown why there was a decline in response rate over the course of the study, but given the demands of caring for a young baby, it is likely that a substantial level of the attrition was related to a preoccupation with this task.

Materials

Participants completed a questionnaire package in the third trimester of pregnancy, and at 12 weeks and 6 months postpartum, which elicited the following information.

Demographic data. Date of birth, country of birth, occupation of both women and partners, the women's education level, and date of completion of the questionnaire were collected on the first questionnaire. The first questionnaire asked the expected date of the birth of the child. The second questionnaire asked the actual date of birth, and whether the mother experienced tearing or episiotomy. The second and third questionnaires asked whether sexual intercourse had been resumed following the birth. Participants who had resumed intercourse were asked "Are you currently experiencing physical discomfort with sexual intercourse which was not present before the birth?" Response choices ranged from 0 (None) to 10 (Severe). The second and third questionnaires asked whether the woman was currently breastfeeding.

Role quality scales. Work-role and Mother-role scales developed by Baruch and Barnett (1986) were used to determine role quality. Several questions on Baruch and Barnett's Mother-role scale were adjusted from those used for midlife women to make the scale more relevant to the anticipated role and actual role as the mother of an infant. Each scale lists an equal number of reward and concern items. The Work-role reward and concern subscales each contained 19 items, and the Mother-role subscales each contained 10 items. Participants used a 4-point scale (from Not at all to Very) to indicate to what extent items were rewarding or a concern. Each participant received three scores per role: a mean reward score, a mean concern score, and a balance score that was calculated by subtracting the mean concern score from the mean reward score. The balance score indicated role quality. The alpha coefficients for the six scales were reported to range from .71 to .94. In the current study, the alpha coefficients for the Work-role scale were .90 during pregnancy, .89 at 12 weeks postpartum, and .95 at 6 months postpartum. The alpha coefficients for the Mother-role scale were .82 during pregnancy, .83 at 12 weeks postpartum, and .86 at 6 months postpartum.

Depression scale. The 10-item Edinburgh Postnatal Depression Scale (EPDS) (Cox, Holden, & Sagovsky, 1987) is widely used as a community screening tool for postpartum depression. Each item is scored on a 4-point scale according to severity of symptoms, with a potential range from 0 to 30. The EPDS has been validated for antenatal use (Murray & Cox, 1990). The EPDS has increasingly been used for research as a linear indicator of dysphoria or distress (Green & Murray, 1994). The alpha coefficients for the EPDS in the current study were .83 during pregnancy, .84 at 12 weeks postpartum, and .86 at 6 months postpartum.

Fatigue scale. The 11-item self-rating Fatigue Scale was developed by Chalder et al. (1993) to measure the severity of subjective perceptions of fatigue. Respondents choose one of four responses to each item: better than usual, no more than usual, worse than usual, and much worse than usual. Scale scores potentially range from 11 to 44. In the current study, the scale had a coefficient alpha of .84 during pregnancy, .78 at 12 weeks postpartum, and .90 at 6 months postpartum.

Relationship satisfaction scale. Nine items from the 12-item Quality of Relationship subscale from the Sexual Function Scale (McCabe, 1998a) were administered for each wave of data collection. On the first administration, participants were asked to recall how items applied before conception, and also "now, during pregnancy." Items were measured on a 6-point Likert Scale ranging from 0 (Never) to 5 (Always). The 12-item Quality of Relationship subscale is reported to have a test-retest reliability of .98, and a coefficient alpha of .80 (McCabe, 1998a). In the current study, the scale had a coefficient alpha of .75 for baseline (before conception) and .79 during pregnancy, .78 at 12 weeks postpartum, and .83 at 6 months postpartum.

Sexual desire scale. Nine items asking about level of sexual desire were drawn from an earlier version of the Sexual Function Scale (SFS) (McCabe, 1998a). Desire is defined as "interest in or wish for sexual activity." Items referred to frequency of desire for sexual activity, frequency of sexual thoughts, strength of desire in different situations, the importance of fulfilling sexual desire through activity with a partner, and desire for masturbation. Three items asking about frequency of desire provided for a range of responses from 0 (Not at all) to 7 (More than ... or Many times a day). Six items sought a response on a 9-point Likert Scale, ranging from 0 to 8. Item scores were summed to provide a score ranging from 0 to 69. On the first administration, participants were asked to recall how items applied before conception and "now, during pregnancy." No previous psychometric data were available on the scale: however, the questions have face validity, and in the current study had an acceptable coefficient alpha of .74 at baseline, .87 during pregnancy, .85 at 12 weeks postpartum, and .89 at 6 months postpartum.

Frequency of sexual intercourse. In the first administration, respondents were asked to recall how often they typically had intercourse before conception (not just when they were trying to conceive), and during pregnancy and at 12 weeks and 6 months postpartum they were asked "How often do you typically have intercourse?". Respondents chose one of six fixed categories: rarely, not often (1-6 times a year), now and then (once per month), once a week, several times a week, or daily or more.

Sexual satisfaction scale. Nine items relating to female sexual satisfaction drawn from the Sexual Dysfunction Scale (McCabe, 1998b) were administered at each wave of data collection. Baseline required retrospective recall of how items applied before conception. Items included how often sexual activity with the partner was enjoyable, the partner's sensitivity as a lover, and the woman's own sexual responses. Items were measured on 6-point Likert Scale ranging from 0 (Never) to 5 (Always). Five items were reverse scored. Responses on these nine items were summed to provide a score which ranged from 0 to 45. The items all had face validity; however, no data were available on reliability for this subscale. In the current study, the scale had a coefficient alpha of .81 at baseline, .80 during pregnancy, .81 at 12 weeks postpartum, and .83 at 6 months postpartum.

Procedure

Written permission was obtained from four Melbourne metropolitan hospitals and one independent childbirth educator to recruit women attending antenatal classes to participate in the study. The study was approved by the Ethics Committees of each of the hospitals. In an endeavour to obtain a sample from a diverse socioeconomic group, a large public hospital group with a number of different childbirth education sites and three smaller private sector hospitals were included.

The researcher briefly addressed the classes, explained the purpose and requirements of the study, handed out a printed outline of the study, and answered questions about the study. The criteria for inclusion in the study were that each woman be over the age of 18, expecting her first child, and cohabiting with a male partner. Those who wished to participate were provided with a questionnaire package in an unsealed envelope. Return postage was prepaid and responses were anonymous. Informed Consent forms were sent back in the separate self-addressed envelopes provided. Informed Consent forms sought the names and addresses of participants and the anticipated dates of the babies' births, so that follow-up questionnaires could be sent out at approximately 2 and 5 months after the birth. Responses to the later questionnaires were matched by the dates of birth of women and their partners, which were included in each wave of data collection.

At approximately 2 months after the expected date of birth, questionnaires were mailed requesting completion of the questionnaires at 12 weeks after the birth. Responses were received from 104 women, a response rate of 75%. The periods since birth of the completed questionnaires ranged from 9 weeks to 16 weeks, mean = 12.2 weeks, SD = .13.

At 5 months postpartum, questionnaires were sent to 95 of the 138 women who participated in the first wave of data collection, and who met the criteria for inclusion in the postpartum studies. The remainder were omitted because at the time limit for collection of data for the current study they had not reached 6 months postpartum. Responses were received from 70 women, a response rate of 74%. Multivariate analyses of variance indicated that there were no significant differences between responders and nonresponders on any of the demographic variables at 12 weeks and 6 months postpartum, nor on the dependent or independent variables assessed at both prepregnancy and during pregnancy.

RESULTS

To determine whether women reported significant decreases in sexual desire, frequency of sexual intercourse, relationship satisfaction, and sexual satisfaction during pregnancy and at 12 weeks and 6 months postpartum compared to their recalled prepregnancy levels, a series of repeated measures MANOVA analyses were conducted with levels of time (prepregnancy, pregnancy, 12 weeks postpartum, and 6 months postpartum) as the independent variable, and sexual desire, frequency of sexual intercourse, sexual satisfaction, and relationship satisfaction as the dependent variables.

Comparing prepregancy to pregnancy (n = 131), there was a significant effect for time, F (4,127) = 52.41, p < .001. Univariate tests revealed significant differences for sexual desire [t(1,130) = - 8.60, p < .001], frequency of sexual intercourse [t(1,130) = - 12.31, p < .001], and sexual satisfaction [t(1,130) = - 6.31, p < .001]. In each of these variables, there were decreases from prepregnancy. However, for relationship satisfaction, there was a significant increase [t(1,130) = 3.90, p < .001] from prepregnancy to pregnancy.

Data from women who had not resumed sexual intercourse following childbirth were excluded from the postpartum analyses. At 12 weeks postpartum, the overall effect of time was significant, F(4,86) = 1290.04, p < .001. Univariate planned contrasts revealed that at 12 weeks postpartum compared with prepregnancy, women reported decreased sexual desire [t(1,79) = -8.98, p < .001], frequency of sexual intercourse [t(1,79) = - 6.47, p < .001], sexual satisfaction [t(1,79) = -3.99, p < .001], and relationship satisfaction [t(1,79) = 2.81, p < .01]. At 12 weeks postpartum compared with pregnancy, sexual desire [t(1,79) = 2.36, p < .05] and relationship satisfaction [t(1,79) = - 5.09, p < .001] were reduced, but frequency [t(1,79) = 5.58, p < .001] and sexual satisfaction [t(1,79) = 3.13, p < .01] had increased.

At 6 months postpartum, the overall effect of time was significant, F(4,47) = 744.45, p < .001. Comparing 6 months postpartum with prepregnancy, women reported decreased sexual desire [t(1,50) = -6.86, p < .001], frequency of sexual intercourse [t(1,50) = -2.77, p < .01], and sexual satisfaction [t(1,50) = -3.69, p < .001]. There was no difference in relationship satisfaction, [t(1,50) = .81, p > .05]. Comparing 6 months postpartum with 12 weeks postpartum, frequency of sexual intercourse had increased [t(1,50) = -2.18, p < .05], whereas there were no significant changes in sexual desire [t(1,50) = -1.26, p > .05], sexual satisfaction [t(1,50) = .91, p > .05], or relationship satisfaction [t(1,50) = -.82, p > .05]. The mean scores of the sexual and predictor variables are provided in Table 1.

To test the prediction that psychological and relationship variables would account for women's sexual functioning during pregnancy and at 12 weeks and 6 months postpartum, a series of nine standard regressions (sexual desire, frequency of sexual intercourse, and sexual satisfaction at pregnancy, 12 weeks and 6 months postpartum as the dependent variables) were performed with role-quality, relationship satisfaction, depression, and fatigue as the independent variables.

For sexual desire during pregnancy, [R.sup.2] = .08, F(5,128) = 2.19, p > .05. For frequency of sexual intercourse during pregnancy, [R.sup.2] = .10, F(5,128) = 2.97, p < .05, with the major predictor being fatigue. For sexual satisfaction during pregnancy, [R.sup.2] = .21, F(5,128) = 6.99, p < 001, with the major predictor being relationship satisfaction (see Table 2).

For sexual desire at 12 weeks postpartum, [R.sup.2] = .22, F(4,99) = 6.77, p < .001, with the major predictors being relationship satisfaction and fatigue. For frequency of sexual intercourse at 12 weeks postpartum, [R.sup.2] = .13, F(4,81) = 2.92, p < .05, with the major predictor being depression (women who reported more depressive symptoms reported less frequency of sexual intercourse). For sexual satisfaction at 12 weeks postpartum, [R.sup.2] = .30, F(4,81) = 8.86, p < .001, with the major predictor being fatigue (see Table 2).

For sexual desire at 6 months postpartum, [R.sup.2] = .31, F(4,65) = 7.17, p < .001, with the major predictors being depression, relationship satisfaction, and mother role. For frequency of sexual intercourse at 6 months postpartum, [R.sup.2]= .16, F(4,60) = 2.76, p < .05, with the major predictors being depression and mother role. For sexual satisfaction at 6 months postpartum, [R.sup.2] = .33, F(4,60) = 7.42, p < .001, with the major predictor being mother role (see Table 2).

To test the prediction that psychological and relationship variables would account for some of the changes in women's sexual functioning during pregnancy a series of three hierarchical regressions (sexual desire, frequency of sexual intercourse, and sexual satisfaction as the dependent variables) were performed with the baseline measures of each of the sexual variables entered on the first step, and role-quality, relationship satisfaction, depression, and fatigue entered on the second step.

For sexual desire during pregnancy, on step 1, [R.sup.2] = .41, F(1,132) = 91.56, p < .001. After step 2, F change (6,127) = 1.72, p > .05. For frequency of sexual intercourse during pregnancy, after step 1, [R.sup.2] = .38, F(1,132) = 81.16, p < .001. After step 2, F change (6,127) = 2.33, p < .05. The major predictor of change to frequency of sexual intercourse during pregnancy was fatigue. For sexual satisfaction during pregnancy, after step 1, [R.sup.2] = .39, F(1,132) = 84.71, p < .001. After step 2, F change (6,127) = 3.92, p < .01. Depression was the major predictor of change to sexual satisfaction during pregnancy (see Table 3).

To test the prediction that psychological, relationship, and physical variables would account for changes in women's sexual functioning at 12 weeks and 6 months postpartum, a series of six hierarchical regressions were performed with the baseline measures of each of the sexual variables (sexual desire, frequency of sexual intercourse, and sexual satisfaction) entered on the first step, and breastfeeding, dyspareunia, mother-role quality, relationship satisfaction, depression, and fatigue entered on the second step. (Breastfeeding was a dummy variable, with currently breastfeeding coded 1, not breastfeeding coded 2). Work-role quality could not be included in regression analyses as only 14 women had resumed work at 12 weeks postpartum, and 23 at 6 months postpartum.

At 12 weeks postpartum, for sexual desire at step 1, [R.sup.2]= .32, F(1,102) = 48.54, p < .001. After step 2, F change (6,96) = 4.93, p < .01. Dyspareunia, breastfeeding, and relationship satisfaction were the most important predictors of sexual desire after the baseline measure was taken into account. For frequency of sexual intercourse, at step 1, [R.sup.2] = .04, F(1,84) = 3.76, p > .05. After step 2, F change (6,78) = 4.87, p < .01. Breastfeeding and relationship satisfaction were the main predictors of frequency of sexual intercourse at 12 weeks postpartum after the baseline frequency of sexual intercourse was taken into account. That is, women who were breastfeeding reported a greater reduction in frequency of sexual intercourse compared with their prepregnancy baseline. For sexual satisfaction, at step 1, [R.sup.2] = .46, F (1,84) = 72.13, p < .001. After step 2, F change (6,78) = 4.78, p < .001. Dyspareunia, breastfeeding, and fatigue were the major predictors of women's sexual satisfaction at 12 weeks postpartum (see Table 4).

At 6 months postpartum, for sexual desire at step 1, [R.sup.2] = .50, F(1,68) = 69.14, p < .001. After step 2, F change (6,62) = 4.29, p < .01. Dyspareunia and depression contributed significantly to the prediction of the change to sexual desire. However, the contribution of depression was not in the direction expected, likely because of the group of women who scored very low on the EPDS and who reported low sexual desire. For frequency of sexual intercourse, at step 1 [R.sup.2] = . 12, F(1,63) = 8.99, p < .01. After step 2, F change (6,57) = 3.89, p < .001. Dyspareunia was the main predictor of change to frequency of sexual intercourse at 6 months postpartum. For sexual satisfaction at step 1, [R.sup.2] = .48, F(1,63) = 58.27, p < .001. After step 2, F change (6,57) = 4.18, p < .01. Dyspareunia and mother role were the major predictors of change to sexual satisfaction (see Table 5).

DISCUSSION

Our results support previous findings that during the third trimester of pregnancy women generally report reduced sexual desire, frequency of intercourse, and sexual satisfaction (Barclay et al., 1994; Hyde et al., 1996; Kumar et al., 1981). An interesting finding from the current study is that the quantum of change in women's sexual functioning, although statistically significant, was generally not of a great magnitude. Very few women reported total loss of sexual desire and sexual satisfaction, or complete avoidance of sexual intercourse during the third trimester of pregnancy.

Relationship satisfaction also increased slightly during pregnancy (Adams, 1988; Snowden, Schott, Awalt, & Gillis-Knox, 1988). For most couples, the anticipation of the birth of their first child is a happy time, during which there is likely to be an increased emotional closeness as they prepare their relationship and their home for the arrival of their baby.

Women who were more satisfied with their relationships reported higher sexual satisfaction; however, relationship satisfaction did not appear to directly influence changes to any of the sexual measures during pregnancy. However, it must be noted that women with higher relationship satisfaction were more positive about their anticipated mother role, and had lower rates of fatigue and depressive symptomatology.

Work-role quality was largely unrelated to women's sexual functioning during pregnancy. The differences between the findings in this study and that of Hyde et al. (1998), who found a small association between women's work-role quality and their frequency of intercourse in midpregnancy, may be due to the larger sample size surveyed by Hyde et al. (1998). Women surveyed by Hyde et al. (1998) were also at an earlier stage of pregnancy, when potential deterrents to intercourse may differ from those in the third trimester.

By 12 weeks postpartum, the majority of women had resumed sexual intercourse; however, many experienced sexual difficulties, particularly dyspareunia and lowered sexual desire (Glazener, 1997; Hyde et al., 1996). Relationship satisfaction was at a low point at 12 weeks postpartum (Glenn, 1990), and more than half of the women reported lower relationship satisfaction at this time than during prepregnancy. However, the level of change in relationship satisfaction was small, and consistent with previous research (e.g., Hyde et al., 1996): most women were moderately satisfied with their relationships.

Relationship satisfaction influenced women's level of sexual desire, and those with higher relationship satisfaction reported less decrease in sexual desire and frequency of intercourse. Depression was also associated with a lower frequency of intercourse, and fatigue negatively affected women's sexual functioning at 12 weeks postpartum (Glazener, 1997; Hyde et al., 1998; Lumley, 1978). Women with higher levels of dyspareunia also reported greater decreases in sexual desire, frequency of intercourse, and sexual satisfaction compared with prepregnancy (Glazener, 1997; Lumley, 1978). Similarly, women who were breastfeeding reported greater decreases in each of these sexual variables than women who were not breastfeeding (Glazener, 1997; Hyde et al., 1996). The reason for this reduction should be explored in future research. It is possible that breastfeeding provides sexual fulfilment for some women, which may generate guilt feelings in these women and lead to decreased level of sexual functioning in their relationship.

These results would suggest that there are a broad range of factors that have a detrimental impact on sexuality at 12 weeks postpartum--most particularly depression, fatigue, dyspareunia, and breastfeeding. This appears to be a stage of adjustment for many mothers, and depending upon adjustments in the above areas, they may or may not experience a fulfilling sexual relationship.

At 6 months after childbirth, women continued to report significantly decreased sexual desire, frequency of intercourse, and sexual satisfaction compared to their levels prior to conception satisfaction (Fischman et al., 1986; Pertot, 1981). The most marked reduction was in level of sexual desire.

By the time babies are 6 months old, their presence and aspects of women's mother role have a considerable impact on the sex lives of their parents. Many women have greater difficulty with the mother role at 6 months postpartum than at 12 weeks postpartum, due to their infants' more difficult behaviors (Koester, 1991; Mercer, 1985). Babies are well into the process of attachment, usually preferring to be cared for by their mothers; most can move around by crawling or sliding, and need considerable attention. In the cross-sectional analyses, mother-role quality was the strongest predictor of each of the sexual measures. Women with higher mother-role quality also had higher relationship satisfaction and less depression and fatigue at 6 months postpartum. This is consistent with research which has shown various associations between mother-role quality, infant difficulty, lower marital satisfaction, fatigue, and postnatal depression (Belsky & Rovine, 1990; Milligan, Lenz, Parks, Pugh & Kitzman, 1996). It may be that by 6 months postpartum the interaction between infant temperament and the parental relationship has been amplified.

Depression appeared to exert an unexpected positive influence on women's sexual desire at 6 months postpartum. These findings differ from those of Hyde et al. (1998), who found that depression was a highly significant predictor of loss of sexual desire of employed women at 4 months postpartum. This discrepancy may be due to problems with the sample in this wave of our study. The low rate of postnatal depression suggests a lower response rate in this study from women who may have become depressed after childbirth. The distribution of sexual desire by depression scores at 6 months postpartum was unusual, in that there was a cluster of women who were very low in both depression and sexual desire, and this cluster may have unduly influenced results for the sample as a whole.

Dyspareunia continued to have a strong influence on women's sexuality at 6 months postpartum, although the average level of dyspareunia at the later period was less than at 3 months earlier. It is possible that by this stage the expectation of pain with sexual intercourse for some women may have started a cycle in which they become less aroused sexually, which perpetuates vaginal dryness and discomfort with intercourse. Although dyspareunia may commence as a physical factor, it may be maintained by psychological factors. This relationship needs to be explored further in future research.

A major limitation of the current study is that only women were surveyed, and not their partners. An additional limitation is that before-conception measures required retrospective recall, and that prepregnancy and pregnancy measures were collected at the same time. It would have been preferable to take baseline measures earlier in the pregnancy. Ideally, baseline measures would be taken before conception. Further there was some attrition in participants throughout the study (25% between time 1 and time 2, and a further 26% between time 2 and time 3). This may have limited the generalizability of the findings.

In addition, the sample in the current study appeared to be biased to better educated women of higher professional status, like samples in many previous studies (e.g., Bustan et al., 1996; Glazener, 1997; Pertot, 1981). This is a problem which is not easily overcome, although multidisciplinary collaboration between gynaecological and mental health professionals may assist (Sydow, 1999).

The findings from the current study have important implications for the well-being of women, their partners, and the family. It is clear that a range of factors influence sexual responses during pregnancy and postpartum, and that these factors vary at different stages of the process of adjusting to childbirth. Fatigue is a constant factor influencing sexual responses during pregnancy and at 12 weeks and 6 months postpartum. Other variables assume significance at different stages of the pregnancy and postpartum periods. Providing couples with information about what sexual changes they may expect, the duration of those changes, and the possible influences on those changes, may help couples avoid making unfounded harmful assumptions about their relationship.

Table 1. Means, Score Ranges and Standard Deviations of Variables

Variable                           Mean   Standard Deviation   Range

Sexual desire
  Baseline                         35.06         8.16          12-55
  Pregnancy                        27.96        12.57           0-62
  12 weeks postpartum              25.85        11.39           0-56
  6 months postpartum              27.39        11.77           2-46
Frequency of sexual intercourse
  Baseline                          4.38          .91           1-6
  Pregnancy                         3.28         1.29           0-6
  12 weeks postpartum               3.65          .78           1-5
  6 months postpartum               3.97          .93           2-6
Sexual satisfaction
  Baseline                         32.05         5.70          17-45
  Pregnancy                        29.19         6.64          12-45
  12 weeks postpartum              30.09         6.50          11-43
  6 months postpartum              29.56         7.13          16-42
Relationship satisfaction
  Baseline                         33.16         5.31          19-45
  Pregnancy                        34.14         5.77          16-45
  12 weeks postpartum              31.65         6.13           5-42
  6 months postpartum              31.94         6.75          11-43
Work-role
  Pregnancy                         1.21          .81        -.90-2.63
  12 weeks postpartum               1.47          .74         .42-2.68
  6 months postpartum               1.35         1.03       -1.00-2.74
Mother role
  Pregnancy                         1.22          .69         -40-2.70
  12 weeks postpartum               1.90          .68        -.45-3.00
  6 months postpartum               1.94          .73        -.40-2.90
Depression
  Pregnancy                         7.94         4.26           0-19
  12 weeks postpartum               6.92         4.24           0-18
  6 months postpartum               6.29         4.50           0-23
Fatigue
  Pregnancy                        29.06         4.31          21-42
  12 weeks postpartum              26.10         5.45          11-39
  6 months postpartum              25.44         5.21          15-37
Table 2. Multiple Regression Analyses Predicting Sexual Variables

                                           Frequency of sexual
                      Sexual desire            intercource

Predictor          Beta      [R.sup.2]     Beta      [R.sup.2]

                                      During pregnancy

Fatigue           -.05         .08        -.31 **      .10 *
Depression        -.09                     .21 *
Relationship
  satisfaction     .09                     .14
Work-role          .03                     .04
Mother-role        .15                    -.07

                                      At 12 weeks postpartum

Fatigue           -.25 *       .22 **     -.10         .13 *
Depression         .16                    -.30 *
Relationship
  satisfaction     .32 **                  .18
Mother-role        .17                    -.01

                                      At 6 months postpartum

Fatigue           -.10         .31 ***     .03         .16 *
Depression         .39 **                  .23 *
Relationship
  satisfaction     .34 **                  .17
Mother-role        .39 **                  .40 *

                   Sexual satisfaction

Predictor          Beta      [R.sup.2]

                      During pregnancy

Fatigue           -.14         .21 ***
Depression        -.11
Relationship
  satisfaction     .29 **
Work-role          .07
Mother-role        .05

                   At 12 weeks postpartum

Fatigue           -.39 **      .30 ***
Depression         .08
Relationship
  satisfaction     .20
Mother-role        .16

                   At 12 months postpartum

Fatigue           -.13         .33 ***
Depression         .24
Relationship
  satisfaction     .23
Mother-role        .46 **

* p < .05. ** p < .01. *** p < .001.
Table 3. Multiple Regression Analyses Predicting Changes to Sexual
Variables During Pregnancy

                                     Sexual desire

Step and predictor               Beta       [R.sup.2]

Step 1
  Sexual baseline                .64 ***     .41 ***
Step 2
  Sexual baseline                .63 ***     .45 ***
  Fatigue                       -.01
  Depression                    -.18 *
  Relationship satisfaction     -.03
  Work-role                     -.03
  Mother-role                    .07
  Change to [R.sup.2]                        .04

                                 Frequency of sexual
                                     intercourse

Step and predictor               Beta       [R.sup.2]

Step 1
  Sexual baseline                .62 ***     .38 ***
Step 2
  Sexual baseline                .61 ***     .43 ***
  Fatigue                       -.19 *
  Depression                    -.00
  Relationship satisfaction      .07
  Work-role                     -.03
  Mother-role                   -.13
  Change to [R.sup.2]                        .05 *

                                Sexual satisfaction

Step and predictor              Beta        [R.sup.2]

Step 1
  Sexual baseline                .63 ***     .39 ***
Step 2
  Sexual baseline                .57 ***     .47 ***
  Fatigue                       -.02
  Depression                    -.24 **
  Relationship satisfaction      .07
  Work-role                      .02
  Mother-role                    .02
  Change to [R.sup.2]                        .08 **

* p < .05. ** p < .01. *** p < .001.
Table 4. Multiple Regression Analyses Predicting Changes to Sexual
Variables at 12 Weeks Postpartum

                                   Sexual desire

Step and predictor              Beta      [R.sup.2]

Step 1
  Baseline sexual measure       .57 ***    .32 ***
Step 2
  Baseline sexual measure       .44 ***    .48 ***
  Dyspareunia                  -.16 *
  Breastfeeding                 .22 **
  Fatigue                      -.12
  Depression                    .08
  Relationship satisfaction     .22 **
  Mother-role                   .06
  Change to [R.sup.2]                      .16 ***

                               Frequency of sexual intercourse

Step and predictor                   Beta      [R.sup.2]

Step 1
  Baseline sexual measure             .21       .04
Step 2
  Baseline sexual measure             .25 *     .30 ***
  Dyspareunia                        -.12
  Breastfeeding                       .36 **
  Fatigue                             .15
  Depression                         -.26
  Relationship satisfaction           .25 *
  Mother-role                        -.09
  Change to [R.sup.2]                           .26 ***

                                Sexual satisfaction

Step and predictor              Beta      [R.sup.2]

Step 1
  Baseline sexual measure       .68 ***    .46 ***
Step 2
  Baseline sexual measure       .52 ***    .61 ***
  Dyspareunia                  -.19 *
  Breastfeeding                 .17 *
  Fatigue                      -.22 *
  Depression                    .05
  Relationship satisfaction     .09
  Mother-role                   .03
  Change to [R.sup.2]                      .15 ***

* p < .05. ** p < .01. *** p < .001.
Table 5. Multiple Regression Analyses Predicting Changes to Sexual
Variables at 6 Months Postpartum

                                   Sexual desire

Step and predictor              Beta       [R.sup.2]

Step 1
  Baseline sexual measure       .71 ***     .50 ***
Step 2
  Baseline sexual measure       .60 ***     .65 ***
  Dyspareunia                  -.18 *
  Breastfeeding                 .04
  Fatigue                      -.16
  Depression                    .35 ***
  Relationship satisfaction     .12
  Mother-role                   .20
  Change to [R.sup.2]                       .15 **

                               Frequency of sexual intercourse

Step and predictor                   Beta        [R.sup.2]

Step 1
  Baseline sexual measure             .35 ***     .13 ***
Step 2
  Baseline sexual measure             .34 **      .38 ***
  Dyspareunia                        -.39 **
  Breastfeeding                       .10
  Fatigue                             .01
  Depression                          .20
  Relationship satisfaction           .07
  Mother-role                         .21
  Change to [R.sup.2]                             .25 ***

                               Sexual satisfaction

Step and predictor              Beta       [R.sup.2]

Step 1
  Baseline sexual measure       .69 ***     .48 ***
Step 2
  Baseline sexual measure       .53 ***     .64 ***
  Dyspareunia                  -.23 *
  Breastfeeding                 .04
  Fatigue                      -.07
  Depression                    .12
  Relationship satisfaction    -.10
  Mother-role                   .25 *
  Change to [R.sup.2]                       .16 **

* p < .05. ** p < .01. *** p < .001.

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Margaret A. De Judicibus and Marita P. McCabe
Deakin University, Victoria, Australia

Address correspondence to Marita P. McCabe, PhD, FAPS, School of Psychology, Deakin University, 221 Burwood Highway, Burwood, Victoria, Australia 3125; e-mail: [e-mail].