Resumption of sexual activity and contraceptive use among postpartum women in the Kumasi Metropolis of Ghana

doi:10.21203/rs.3.rs-5000159/v1

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Research Article

Resumption of sexual activity and contraceptive use among postpartum women in the Kumasi Metropolis of Ghana

https://doi.org/10.21203/rs.3.rs-5000159/v1

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Background: The postpartum period presents challenges to women as they contemplate on the desire to space or limit childbirth while meeting the sexual demands of their partners and their own sexual desires. The study looked at the factors that determine the resumption of sexual activity after delivery and their influence on contraceptive use among postpartum women in the Kumasi metropolis.

Method: An analytical cross-sectional study was conducted using an interviewer administered structured questionnaire with both closed and open-ended questions, on 853 mothers aged 15-49 years, attending child welfare clinics with babies who were up to one (1) year old in the Kumasi Metropolis of Ghana.

Results: Majority (76%) of the women initiated sexual intercourse from 6 weeks after delivery but only 34% used contraceptives, despite the 99% awareness of postpartum family planning services.

Response to partners’ demand for sex was the most important stimulus for resumption of sexual activity while unavailability of the partner was the main reason for sexual inactivity after delivery. Marital status (AOR: 4.94, CI=2.99-8.15), residence after delivery (AOR: 0.53, CI=0.38-0.76), resumption of menses (AOR= 0.19, CI= 0.13 – 0.27), birth limiting (AOR= 0.68, CI= 0.45 – 0.98), and birth spacing (AOR= 0.40, 95% CI= 0.18– 0.91) significantly predicted resumption of postpartum sexual activity and contraceptive uptake.

Conclusion: Reproductive health service providers in the metropolis should highlight the return to fertility and timing of sexual intercourse after delivery, and adopt strategies to demystify the fear of side effects during counselling and provision of Family Planning services.

postpartum

contraception

sexual activity

family planning

The period after delivery is unique and challenging to women as they go through the process of caring for their newborns, breastfeeding, recovery from the stress of labour and possible complications during delivery and adjusting to the withdrawal of the physiological hormonal changes of pregnancy.¹ They also contemplate on the desire to space or limit childbirth while meeting the sexual demands of their partners and their own sexual desires.²

The postpartum period also provides an essential avenue for prolonged interaction and counselling of women towards contraceptive use. The healthcare provider is offered an opportunity to discuss and address the health concerns, particularly the reproductive goals of the woman. Exposure to postpartum family planning services is therefore a crucial component of the healthcare that is provided for women after delivery; to prevent unintended and closely spaced pregnancies.

Inadequate knowledge about the return of fertility in the postpartum period heightens the susceptibility of women to unintended pregnancies as many women and health providers erroneously assume that fertility returns only with resumption of menses.⁴ Women who resume sexual activity before the resumption of menses could be fertile, putting them at risk of a mistimed or unwanted pregnancy.⁴ Seizing the opportunity to offer family planning services to women in the postpartum period may result in an increase in the uptake of family planning methods and a reduction in unintended pregnancies.

Several factors influence the utilisation of postpartum family planning services. These include age, education level, counselling during antenatal and postnatal clinics, family size, resumption of menses, return to fertility, previous contraceptive experience, knowledge of family planning methods, opinion of partner, and others. Arguably the most important component of the client-related factors is resumption of sexual activity after childbirth since natural conception cannot occur without sexual intercourse. This probably accounted for the adoption of postpartum abstinence (PPA) as the traditional means of contraception in most societies in the developing world.¹

Periods of abstinence from sexual activity following delivery vary greatly among women. Generally, sexual activity in the postpartum runs a graduated course from initial infrequent and irregular activity progressing to more regular sexual encounters later.⁵ Studies have also shown that early initiation of sexual intercourse was observed in women who had spontaneous vaginal delivery and in those who stayed at home with their mothers than in-laws and aunts.⁶

Despite the regular interaction between healthcare providers and women during the postpartum period, not much is seen in uplifting the interest of women towards contraceptive use especially in developing countries. Postpartum contraceptive uptake is therefore low in the Kumasi Metropolis despite the high awareness levels and availability of the services.⁷ In the absence of contraception, the probability of pregnancy is related to the regularity of sexual intercourse. The information on initiation of intercourse after childbirth and the correlation with contraceptive use is important for the refinement of the measurement of exposure to pregnancy. It will also provide relevant information, both quantitative and qualitative; to inform policy and restructure programmes for effective postpartum contraceptive use in the metropolis and other communities.

This study therefore sought to look at the factors that determine the resumption of sexual activity after delivery and their influence on the utilisation of contraceptive methods among postpartum women attending child welfare clinics in the Kumasi metropolis.

The framework for this study is based on the dynamics and the extent to which the service-related factors and client-related factors influence each other to determine postpartum sexual activity and contraceptive use.

The study was cross-sectional with quantitative approach conducted from 4th -31st January, 2018 within the Kumasi metropolitan area (KMA). A structured questionnaire with closed and open- ended questions was used to collect data. The questionnaire was orally administered to the study participants in a face-to-face interview, following explanation of procedure and obtaining informed consent, in a language understood by the participants.

Two (2) female research assistants were trained in each facility for the data collection. The data collection took place concurrently at all the six (6) study sites during the working hours of the child welfare clinics. An average of eight (8) participants was recruited in each facility a day.

Data were collected on socio-demographic features, the past obstetric history, breastfeeding status and onset of menstruation after the delivery. The women were also asked whether they had resumed vaginal intercourse and if so, when after delivery and whether any contraceptive method was being used and the timing of method initiation. Reasons for non-contraceptive use were also obtained. Reason(s) for commencement of sexual intercourse or otherwise were also recorded.

The population for this study was all postpartum women aged 15–49 years, attending the child welfare clinics in the Kumasi metropolis. All women whose babies were up to one-year-old (0–12 months), reporting for immunisation and child welfare assessment who consented to participate in the study, were recruited. However, women attending child welfare clinic but had not delivered a baby in the last one year preceding the survey, those considered not fit to respond adequately to questions asked either due to the health condition of the mother or that of the child and those who had hysterectomy during delivery were excluded from the study.

The sample size for the study was calculated using the precision formula by Lesley Kish:

n = z² pq/ d².

According to Winfrey and Kshitiz,⁸ the postpartum contraceptive prevalence rate in Ghana is 21.3%.

However, assuming that 50% of postpartum women in the metropolis had resumed sexual activity,

n = (1.96)² (0.50) (0.50)/ (0.05)²

n = 384.16; ≈ 384

Using the default design effect (deff) of 2.0 in multistage sampling, to achieve the same reliability that a simple random sample (SRS) would produce, the sample size (n) is multiplied by 2;

384 x 2 = 768

Accounting for estimated non-response rate of 10% ≈: 77

N = 768 + 77

N (total sample size) = 845

Thus, the minimum sample size required for the study was 845.

A multistage sampling technique was used in this study. Each of the 5 sub-metropolitan health facilities within KMA in addition to Komfo Anokye Teaching Hospital (KATH) which is the only tertiary hospital in the Region was purposively selected. However, the number of clients selected from each facility was determined by probability proportionate to size (attendance) of postpartum women attending the child welfare clinics. Systematic sampling was then employed to get the required sample size for each facility.

Pre-testing of the questionnaire was undertaken at the Ejisu municipal hospital. This health facility offers child welfare and family planning services and has similar characteristics as the study health facilities. After the pre-testing, some questions were rephrased or changed from open-ended to closed format, to ensure clarity in order to elicit the correct response from the participants.

The raw data were edited and coded. A codebook that defined data to allow for statistical analysis was then developed. The data were field-edited daily and entered into Excel before they were exported into STATA (version 15) for analysis. Initial descriptive statistics in the form of frequencies and percentages were computed for the variables in the data set while further inferential analyses were done to explore statistical association between variables. Appropriate bivariate analyses were carried out to assess statistical association between dependent and independent variables, and stepwise logistic regression model was performed to identify the effect of the factors that were significantly associated with the postpartum resumption of sexual activity and contraceptive use. All computations were done at 95% confidence interval (CI) and Statistical significance was set at p-value of ≤ 0.05.

The age range of the respondents was 17 to 48years with the mean age being 30.20years (± 5.14). About 1% was below 20years while 3.99% was 40 years and above. Most (80.66%) of the women were married while 8.44% were single and 10.08% were in consensual unions. About 19% of the women had attained tertiary level of education and less than 5.0% had no formal education (Table 1).

Table 1

Socio-demographic characteristics of study sample
Variable	Frequency (N = 853)	Percentage (100%)
Age (years)
< 20	7	0.82
20–24	108	12.66
25–29	285	33.41
30–34	274	32.12
35–39	145	17.00
40+	34	3.99
Marital status
Single	72	8.44
Married	688	80.66
Widowed	4	0.47
Cohabiting	86	10.08
Divorced/Separated	3	0.35
Educational Level
None	35	4.10
Primary	80	9.38
Middle/JHS	323	37.87
Secondary	254	29.78
Tertiary	161	18.87
Income earning activity
Yes	665	77.96
No	188	22.04
Religion
Christianity	765	89.68
Islam	78	9.14
African Traditional	7	0.82
No religion	3	0.35
Total	853	100

Majority (76.00%) of the respondents had resumed sexual intercourse after the last delivery. Request for sex by the partner was the major reason (91%) for the resumption. Forty-three (6.62%) of the women engaged in sexual activity because the time seemed convenient for sexual re-union after delivery. Majority (61.57%) of the respondents who had not resumed sexual intercourse since delivery stated that their partners were not available. About 20% of the sexually inactive women indicated that their deliveries were associated with perineal/vaginal tears, episiotomies or caesarean sections while 14.30% were not sexually active because of the fear of getting pregnant. About 81% of the respondents had vaginal delivery though 0.47% was via vacuum extraction while the remaining 19% delivered by caesarean section (Table 2). Majority (62.13%) of the respondents practiced exclusive breastfeeding for 3 months. Unintended pregnancy was also recorded among 35 (4.13%) of the respondents.

Table 2

Socio-cultural and obstetrics variables
Variable	No (frequency)	Percentage (%)
Resumption of sexual activity Yes No	853 648 205	100% 76 24
Reason for resumption of sex after delivery Partner request It was convenient for me To fulfil cultural demand others	650 590 43 3 14	100% 90.77 6.62 0.46 2.15
Reason for sexual inactivity after delivery Partner not available Had vaginal/perineal tears during delivery Fear of pregnancy others	203 125 41 29 8	100% 61.57 20.20 14.29 3.94
Mode of delivery vaginal delivery C-section Assisted vaginal delivery (vacuum)	853 685 164 4	100% 80.30 19.23 0.47
Resumption of menses Yes No	853 606 247	100% 71 29
Residence after delivery In-law Mother Partner Others	853 42 368 440 3	100% 4.92 43.14 51.58 0.35
Unintended pregnancy Yes No	35 818	4.13% 95.87
Exclusive breastfeeding Yes No	853 530 323	100% 62.13 37.87

About a half (47.00%) of the sexually active postpartum women resumed sex at 4-6months, 39.00% at 6weeks-3months, and 2.00% occurred within the puerperium (Fig. 1).

Majority (71.00%) of the respondents had resumed menses within one year after delivery. About 45.00% of the respondents started experiencing their menses 6 weeks to 3 months after delivery while about 15.00% resumed their menses after the 6 months of delivery and 7.00% had their menses within the first 6 weeks (Fig. 2).

Majority of the women initiated contraceptive use after 6 weeks of delivery (Fig. 3).

Awareness of postpartum family planning services was very high (99%). About a third (34%) of the respondents was using a method of contraception at the time of the study. Majority (88.04%) of the women were counselled on healthy timing and spacing of pregnancies while return to fertility was the least information provided during counselling (table 3).

Table 3: Counselling on contraception
VARIABLE			YES (%)
Exposure to FP counseling during ANC period			841(98.51)
Exposure to PNC FP counseling			848 (99.41)
Place of FP counseling after last delivery
Child welfare clinic			141 (16.62)
Labour ward			9 (1.06)
Postnatal Clinic			690 (81.37)
Postnatal Ward			4 (0.47)
Info. provided during postpartum FP counseling
Family planning methods/contraceptives			62 (7.27)
Fertility intentions			24 (2.81)
Healthy timing and spacing of pregnancies			751 (88.04)
Lactation Amenorrhea Method			56 (6.57)
Return to fertility /Resumption of sex			8 (0.94)
Transition from LAM to other modern methods of FP			80 (9.35)
Awareness of postpartum family planning services			844(99)
Utilization of Family Planning Services			290(34)

The fear of side effects was the main reason for contraceptive non-acceptance (Fig. 4)

Determinants of postpartum sexual activity

Notably, tertiary education of partner (Adjusted OR = 0.19, CI = 0.04–0.87), income status of partner (Adjusted OR = 0.14, CI = 0.05–0.42), residence after delivery (Adjusted OR = 0.53, CI = 0.38–0.76), resumption of menses (Adjusted OR = 0.19, CI = 0.13–0.27), family size (Adjusted OR = 1.47, CI = 1.03–2.11), fertility intention (Adjusted OR = 0.45, CI = 0.33–0.80) and spacing of children (Adjusted OR = 0.40, CI = 0.18–0.91) were significant predictors of sexual activity resumption (Table 4).

Table 4

Multivariate analysis of the determinants of resumption of sexual activity
Variable	Unadjusted		Adjusted
Variable	OR	95% (CI)	OR	95% (CI)
Age
< 20 (REF)	1		1
20–24	1.08	0.20–5.92	0.98	0.17–5.40
25–29	1.20	0.22–6.35	1.10	0.20–5.86
30–34	1.59	0.30–8.42	1.46	0.27–7.83
35–39	1.08	0.20–5.83	1.00	0.18–5.45
40+	1.30	0.21–8.03	1.19	0.19–7.45
Educational status of partner
None (REF)	1		1
Primary	0.27	0.05–1.41	0.24	0.44–1.32
Middle/ JSS	0.42	0.09–1.87	0.37	0.07–1.71
Secondary	0.49	0.11–2.17	0.42	0.09–1.94
Tertiary	0.21	0.04–0.95*	0.19	0.04–0.87*
Others	0.33	0.02–4.92	0.52	0.02–9.48
Income status of Partner
Yes (REF)	1		1
No	0.14	0.05–0.40*	0.14	0.05–0.42*
Family Planning Counselling at Antenatal Clinic
Yes (REF)	1		1
No	1.58	0.34–7.27	1.56	0.32–7.49
Family Planning counselling at Postnatal Clinic
Yes (REF)	1		1
No	1.25	0.13–11.32	1.07	0.11–10.32
Place of FP counselling
Labour ward (REF)	1		1
Postnatal ward	1		1
Postnatal clinic	1.01	0.20–4.91	1.00	0.20–4.87
Child welfare clinic	0.55	0.11–2.76	0.54	0.10–2.73
Others	0.85	0.54–13.47	0.85	0.05–13.47
Exclusive Breast feeding
Yes (REF)	1		1
No	1.49	1.06–2.09*	1.38	0.98–1.95
Mode of delivery
Vaginal Delivery (REF)	1
C Section	1.05	0.70–1.57	1.07	0.71–1.61
Vacuum	0.95	0.09–9.21	1.29	0.12–12.97
Residence after delivery
Partner (REF)	1
Mother	0.55	0.40–0.76	0.53	0.38–0.76*
Inlaw	1.19	0.51–2.78	1.23	0.50–3.00
Other	0.47	0.04–5.34	0.85	0.06–10.73
Resumption of menses
Resumed (REF)	1
Not Resumed	0.20	0.14–0.28	0.19	0.13–0.27*
Family size (parity)
1 child (REF)	1
2–4 children	1.20	0.85–1.68	1.47	1.03–2.11*
5 + children	0.83	0.42–1.60	1.24	0.62–2.49
Fertility intention
Yes (REF)	1
No	0.66	0.45–0.99	0.68	0.45–0.98*
Not sure	0.51	0.33–0.77	0.52	0.33–0.80*
Spacing of children
< 2 yrs (REF)	1
2–3 yrs	0.61	0.30–1.26	0.63	0.30–1.50
> 3 yrs	0.38	0.17–0.82	0.40	0.18–0.91*
* p < 0.05, REF = Reference category

Determinants of postpartum sexual activity and correlation with contraceptive use

Marital status (Adjusted OR = 2.52, CI = 1.35–4.69), residence after delivery (Adjusted OR = 0.71, CI = 0.53–0.95), resumption of menses (Adjusted OR = 0.21, CI = 0.14–0.31), spacing of children (Adjusted OR = 1.87, CI = 1.29–2.71) and exclusive breastfeeding (Adjusted OR = 1.38, CI = 1.03 − 1.88) were significant predictors of contraceptive use postpartum (Table 5).

Table 5

The predictive effects of the determinants of sexual activity on postpartum contraceptive uptake
Variable	PPFP Uptake	Unadjusted		Adjusted
	No_ (%)	OR	95% (CI)	OR	95% (CI)
Marital status
Single (REF)	13 (4.47)	1		1
Married	246 (84.54)	2.52	1.35–4.69	2.52	1.35–4.69*
Divorced	0 (0.00)	1		1
Cohabiting	32 (11.00)	2.68	1.27–5.65	2.70	1.28–5.67*
Widowed	0 (0.00)	1		1
Educational level
None (REF)	10 (3.44)	1		1
Primary	21 (7.22)	0.88	0.36–2.15	0.90	0.37–2.18
Middle/JSS	121 (41.58)	1.49	0.69–3.22	1.52	0.70–3.29
SSS	78 (26.80)	1.10	0.50–2.41	1.12	0.51–2.45
Tertiary	61 (20.96)	1.50	0.68–3.39	1.56	0.70–3.48
Residence after delivery
Partner (REF)	167 (57.39)	1		1
Mother	112 (38.49)	0.71	0.53–0.95	0.71	0.53–0.95*
Inlaw	11 (3.78)	0.58	0.28–1.18	0.58	0.28–1.19
Other	1 (0.34)	0.81	0.07–9.08	0.77	0.06–8.59
Resumption of menses
Resumed (REF)	257 (88.32)	1		1
Not Resumed	34 (11.68)	0.21	0.14–0.31	0.21	0.14– 0.31*
Fertility intention
Yes (REF)	177 (60.82)	1		1
No	76 (26.12)	1.59	1.12–2.26	1.87	1.29–2.71*
Not sure	38 (13.06)	0.78	0.51–1.18	0.91	0.59–1.41
Spacing of children
< 2yrs (REF)	13 (7.39)	1		1
2–3 yrs	116 (65.91)	2.74	1.45–5.19	3.48	1.81–6.68*
3 yrs and above	47 (26.70)	2.70	1.35–5.40	3.30	1.62–6.72*
Educational status of partner
None	5 (1.72)	1		1
Primary	12 (4.12)	1.89	0.54–6.57	1.13	0.23–5.38
Middle/ JSS	90 (30.93)	1.75	0.61–4.98	1.31	0.37–4.60
Secondary	106 (36.43)	1.61	0.57–4.56	1.16	0.33–4.04
Tertiary	77 (26.46)	1.32	0.46–3.78	0.96	0.27–3.43
Others	1 (0.34)	1	0.08–11.93	1.56	0.10–23.80
Income status of Partner
Yes	286 (98.28)	1		1
No	5 (1.72)	0.73	0.26–2.09
FP counselling after delivery
Yes		1		1
No		1.28	0.21–7.76	0.74	0.26–2.10
Place of FP counselling at PNC
Labour ward	2 (0.69)	1		1
Postnatal ward	2 (0.69)	3.5	0.28–43.16	3.5	0.28–43.16
Postnatal clinic	252 (87.20)	2.01	0.41–9.76	2.03	0.41–9.86
Child welfare clinic	32 (11.07)	1.02	0.20–5.19	1.02	0.20–5.19
Others	1 (0.35)	1.10	0.07–18.34	1.16	0.07–18.34
Exclusive Breast feeding
Yes	165 (56.70)	1		1
No	126 (43.30)	1.41	1.05–1.88	1.38	1.03–1.88*
* p < 0.05, REF - Reference category, FP – Family Planning, PPFP – Postpartum Family Planning, PNC – Postnatal Clinic

The proportion of women who had resumed sexual intercourse after delivery (76.0%) is comparable to the 74.5% reported from Nigeria but relatively higher than the 10.6% and 72.5% recorded in Guinea and Congo DRC respectively.⁹ It is also higher than the 58.6% recorded for Ghana in 2003.⁹ It is however lower than the 93.2% and 93.7% rates from Ethiopia and Bangladesh respectively.⁹ These differences in rates of resumption of postpartum sexual intercourse are attributable to diverse cultural and religious practices, societal norms and sexual attitudes of women in different parts of the world. Moreover, the other studies were carried out within 6 months after delivery (where Lactational Amenorroea Method is effective), while the current study included women up to 12 months postpartum. The relatively higher rate of resumption of postpartum sexual intercourse in our study relative to what was recorded for Ghana in 2003 suggests declining postpartum sexual abstinence, which traditionally had been the main stay of birth spacing.¹⁰ This implies that, postpartum women are at increased risk of unintended pregnancy at shorter intervals if contraceptive counselling and utilisation of family planning services are not improved. Unintended pregnancy was recorded among 4% of the respondents this study. The intra-observer variation noted about the commencement of sexual activity among the respondents in this study could be allowed to the different factors cited as reasons why the women resumed sexual intercourse in the postpartum period aside the biologic variations. Most of the women resumed sexual activity to satisfy the demands of their husbands or partners. This is also noted to be the commonest reason in other African settings in Uganda and Cote d’Ivoire, for the recommencement of sexual activity among postpartum women^11,12 contrary to advance settings like Canada where desire for sex was the main reason cited for postpartum sexual resumption.¹¹

The postpartum contraceptive prevalence rate (34%) observed in this study is comparable to the 33% reported in Zambia¹³ but lower than the 39% recorded among referred postpartum women in KATH.¹⁴ It is however higher than the recorded rate of 15% by the Kumasi Metropolitan Area in 2012, ⁷ 21.3% for Ghana in 2008, ⁸ and even the 2014 prevalence rate of 22% for modern methods for all married women in the reproductive age in Ghana. This study also showed a higher use of postpartum contraceptives compared to the 8.0% found in a study in Nigeria that examined the relationship between the utilisation of maternal health care and postpartum contraceptive use.¹⁵ The rate of 34% recorded by this study for Kumasi Metropolis was an improvement over the previous patronage of contraceptive services. This reflects the increased levels of family planning campaigns and counselling in the health facilities (about 99% of the respondents in this study had exposure to family planning education at least during one area of the continuum of maternal care).

Most of the respondents received FP counselling during the antenatal period, especially at the antenatal clinic. Some were also directed to the family planning clinic while few of them received counselling during delivery. Nevertheless, FP counselling/education had no association with postpartum contraceptive uptake in this study setting. The insignificant effect of FP counselling on postpartum contraceptive use noted in the current study could be related to the FP information provided, which centred on timing and spacing of pregnancies at the expense of family planning methods and return to fertility. In this regard, issues pertaining to resumption of sexual intercourse and more critically, the fear of contraceptive side effects (which is the most important factor for contraceptive non-acceptance) are not addressed. Generally, postnatal counselling is expected to be a better determinant of contraceptive use than antenatal counselling because it provides immediate opportunity for service provision. However, shorter periods of encounter occur at the postnatal ward/ clinic.¹⁶ The PNC recorded most (81.37%) of the education/counselling sessions in this study. More frequent and regular encounters in the postpartum period occur at the child welfare clinic which has consistently recorded high attendance rates for the 0-11months old in Ghana.¹⁷ However, a few (16.62%) of the women had FP counselling at this unit since normally the welfare of the baby is the focus. Mass education about family planning was the main mode of ‘counselling’ during the use of maternal services in the setting of this study. Although it increases the awareness levels, the expected effects on contraceptive uptake are not realised. Thus, an evaluation of the integration of family planning services across the continuum of care, especially the child welfare clinics and the content of information provided during counselling is imperative.

Women differed in their postpartum resumption of sexual activity based on the marital status, parity and education but showed no significant relationship to age, income status or the religious affiliation. This concurs with similar studies in Nigeria,¹ Uganda ¹⁸ and Malaysia ¹⁸ but differed from others in Gambia ⁵ and Cote d’Voire. ⁵ These reflect the inconsistent pattern of the socio-demographic variables noted in diverse settings.

Several studies consistently suggest significant association between postpartum contraceptive use and background characteristics of respondents.¹⁹ Aside marital status, the current study however found no significant association between postpartum contraceptive uptake and socio-demographic characteristics of the respondents. This finding compared with a similar study in northern Ghana,²⁰

Thus, the disagreement between the realised influence of the demographic features on postpartum contraceptive use and what pertains in most literature could be allowed to cultural, religious and societal dynamics.

Previous studies have revealed inconsistent reports on the association between mode of delivery and resumption of sexual intercourse after delivery. The findings of this study suggested no significant difference in sexual activity between women who delivered by caesarean section and those who had a form of vaginal delivery; normal or assisted (p > 0.05). this agreed with the findings of Dabiri ²¹ and Barbara et al.²² The study however did not stratify the women based on complications such as tears or episiotomies experienced during delivery. Therefore, it could not be related to the suggestion that women who have vaginal delivery with stitches are far less likely to resume intercourse early compared to women who have a vaginal delivery without perineal stitches or who have caesarean sections.²² As has been found in other studies, the mode of delivery in our setting had no significant effect on postpartum contraceptive uptake.

This study showed reduced likelihood of sexual engagement among respondents who stayed with their mothers or other relations compared to those who resided in their matrimonial homes after delivery (CI = 0.38–0.76). In the setting of this study, just like many Akan communities in Ghana, women move to stay with their mothers or older relatives during the first few months after delivery. This keeps them away from sharing the same bed with their partners, invariably delaying the resumption of sexual activity and therefore initiation of contraceptive use. With modernization and societal evolution, some relatives or mothers rather move to stay and support the postpartum women in their matrimonial homes. Expectedly, these women exhibit similar postpartum sexual practices like those who stay with their partners alone. Thus, the critical differential is whether the partner is available or not.

In our setting, most women who moved to stay with relatives would have returned to their partners by three (3) months after delivery. These observations may explain the relative more regular and increased proportion of sexual activity from three (3) months after delivery noted in this study which is also collaborated by Borda and others.⁹ According to the 2014 Demographic and Health Survey (DHS), infrequent sex or partner being away is the 4th most common reason why contraceptors discontinue the use of a method and may be a crucial factor explaining the reason why some do not initiate a method.²³ This study therefore noted that, staying with a mother after delivery negatively affected contraceptive uptake (CI = 0.53–0.95).

The rate of menstrual resumption (71.00%) is fairly higher than what is cited in literature. Ndugwa et al. recorded menstrual resumption among 50% of the respondents at 6 months postpartum.²⁴ This variation reflects the poor exclusive breastfeeding practice in our setting thereby waving the associated amenorrhoeic effect on women within 6 months postpartum. Resumption of menses was shown in this study to have significant influence on the initiation of sex after delivery (95% CI = 0.13–0.27). This is consistent with the work of Ekabua et al.⁶ This suggests high susceptibility to pregnancy, especially as initiation of coitus was significantly associated with non-contraceptive use.

Women who had completed their families or wanted to space their children for more than 3years were 60% less likely to resume sexual intercourse compared to those who wanted to have another baby within 2years of delivery (95% CI = 0.18– 0.91). Family size was found in this study to have significant influence on postpartum sexual activity (CI = 1.03–2.11) but not postpartum contraceptive uptake (p > 0.05). This relationship is allowed to the overarching effect of fertility desires as the main predictor of utilisation of reproductive health services. Thus, irrespective of the family size, the desire to space or limit pregnancies is the main reason cited for contraceptive use.

This study suggested a less likelihood of sexual engagement (CI = 0.05–0.42) among women whose partners had poor income status even after the multivariate analysis. The poor financial status of partners may allow the women to have some level of autonomy and control in decision making, particularly in matters related to sexual activity. Resumption of sex may thus be at the convenience of the woman.

The finding of a significant association between the education level of partner and resumption of sexual intercourse (CI = 0.04–0.87) concurred with that of Osinde and associates.¹⁴ This further reflects the domineering role of men in our society particularly when it comes to the issue of sexual activity. Thus, the predisposition of the man determines the direction of engagement as over 90% of the postpartum sexually active women in this study responded positively to the sexual demands of their partners irrespective of the status of the woman. There was however no significant effect on family planning uptake with respect to the educational and financial status of the partner; an indication of poor male involvement in contraceptive services. Partner support is a crucial factor in family planning uptake in our setting. According to the 2014 GDHS, male opposition is one of the major hindrances to contraceptive use.²³

This study has established that, majority of postpartum women in the Kumasi metropolis are sexually active but few are using contraceptives. This will undoubtedly lead to increased rate of unintended pregnancy.

The time of resumption of sexual activity varies widely among couples, and is mainly influenced by partner‘s predisposition, socio-demographic and obstetric factors. Postpartum contraceptive uptake is mainly influenced by social factors and fear of contraceptive side effects.

Counseling has no association with postpartum sexual activity and contraceptive use because the information that is usually provided does not deal with contraceptive methods and their side effects, return to fertility and timing of intercourse.

Reproductive health service providers in the metropolis should put in more efforts to improve the sexual practices of postpartum mothers and the uptake of PPFP services at the facilities. Such measures may include; highlighting the return to fertility and timing of sexual intercourse after delivery, providing information on the various methods of contraception and adopting strategies to demystify the fear of side effects during counselling and provision of services.

Further studies into the level of male partner involvement in family planning and the factors that influence their sexual practices especially after delivery will help in the development of interventions aimed at meeting the unmet need for family planning among the postpartum mothers.

PPA

postpartum abstinence

SRS

simple random sample

KATH

Komfo Anokye Teaching Hospital

KMA

Kumasi metropolitan area

Confidence Interval

Odds Ratio

Family Planning

PPFP

Postpartum Family Planning

PNC

Postnatal Clinic

Ethics approval and consent to participate

The study was approved by the Committee for Human Research, Publication and Ethics, Kwame Nkrumah University of Science and Technology (CHRPE/AP582/17) prior to the commencement of the study in accordance with the Declaration of Helsinki. Administrative Clearance was also obtained from the Kumasi metropolitan Health Directorate (KMHD/INTRO/13). Study protocol was thoroughly explained to the study participants and written informed consent was obtained from them.

Consent for publication

Not applicable

Availability of data and materials

All data generated or analysed during this study are available from the corresponding author on reasonable request

Funding

This study did not receive funding from private, government or non-for-profit organization. It was self-funded.

Authors’ contributions

AP conceived the research idea and designed the study; AP and JBY were responsible for the data capture, analysis and interpretation; AP prepared the draft of the manuscript; KAD, ETD, KS, FA, GOA, KAA, SBB, CS, SAT, DZK and EK reviewed and edited the manuscript. All authors critically evaluated the final manuscript for important intellectual content and approved the final version of the manuscript.

Authors’ Information

AP: Fellow of the Ghana Colleges of Surgeons. Lecturer, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi-Ghana.

KAD: Fellow of Ghana and West African Colleges of Surgeons. Professor of Obstetrics & Gynaecology, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi-Ghana.

KS: Fellow of the Ghana Colleges of Surgeons, Senior Specialist Obstetrician Gynaecologist, Komfo Anokye Teaching Hospital, Kumasi-Ghana.

FA: Fellow of Ghana and West African College of Surgeons. Senior Lecturer and Head of Department, Department of Obstetrics and Gynaecology, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi-Ghana

GOA: Fellow of Ghana and West African Colleges of Physicians. Senior Lecturer, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi-Ghana.

ETD: Epidemiologist and Fellow of the West African College of Surgeons. Senior Lecturer, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi-Ghana

KAA: Fellow of Ghana and West African Colleges of Surgeons. Lecturer, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi-Ghana

SAT: Fellow of Ghana and West African College of Surgeons. Senior Specialist Obstetrician Gynaecologist, Ghana Health Service, Kumasi-Ghana

SBB: Fellow of the Ghana Colleges of Surgeons. Senior Specialist Obstetrician Gynaecologist, Ghana Health Service, Kumasi-Ghana

CMS: Fellow of the West African College of Surgeons. Consultant Obstetrician Gynaecologist, Komfo Anokye Teaching Hospital, Kumasi-Ghana

EK: Member of Ghana College of Surgeons. Specialist Obstetrician Gynaecologist, Komfo Anokye Teaching Hospital, Kumasi-Ghana

JBY: Biostatistician, Emergency Medicine Directorate, Komfo Anokye Teaching Hospital, Kumasi-Ghana

DZK: Obstetrics and Gynecology specialist, School of Medicine, University for Development Studies/ Tamale Teaching Hospital, Tamale-Ghana

Acknowledgements

Authors would like to acknowledge the staff of the Family Planning and Reproductive Health unit of Komfo Anokye Teaching Hospital for their support in the data collection.

Competing interests

The authors declare that they have no competing interests

Limitation of the study

Respondents might not provide accurate information due to recall bias. Some might have difficulty providing all the information about their sexual activities and even declined to respond to certain questions that may be very essential in the analysis. Only public health facilities were used for the study; therefore, the results might not reflect the status of private facilities.

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No competing interests reported.

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Resumption of sexual activity and contraceptive use among postpartum women in the Kumasi Metropolis of Ghana

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Background

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Determinants of postpartum sexual activity

Determinants of postpartum sexual activity and correlation with contraceptive use

Discussion

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