Intimate partner violence during pregnancy and time to return to sexual activity after childbirth: analysis of the BRISA prenatal cohort

Abstract: This study aimed to analyze whether there is an association between intimate partner violence during pregnancy and time to return to sexual activity after childbirth in the BRISA cohort in São Luís, Maranhão State, Brazil, between 2010 and 2013. This is a longitudinal study conducted with 665 women. Intimate partner violence during pregnancy was measured using an instrument created and validated by the World Health Organization to measure violence against women. Time to return to sexual activity after childbirth was investigated using a structured questionnaire. Logistic regression models were used to analyze whether there is an association between intimate partner violence during pregnancy and time to return to sexual activity after childbirth. The prevalence of violence by an intimate partner during pregnancy was 24.06%. The prevalence of women who returned to sexual activity within 3 months after childbirth was 67.96%. When analyzing the association between exposure and outcome, no association was found in the crude model (OR = 0.88; 95%CI: 0.60-1.30), nor in the adjusted model (OR = 1.00; 95%CI: 0.61-1.63). The study results highlight the importance of providing comprehensive care to women, considering both physical and psychological aspects, since violence has a significant impact on several aspects of women’s lives.


Introduction
Violence against women is intrinsically linked with social, historical, and cultural aspects, reflecting the long history of gender inequality and oppression.Since ancient times, a patriarchal system has existed with undeniable submission to the dominant gender and in which men had economic, political, and sexual control over women.These gender norms, rooted in culture, often perpetuate violence, undermining women's autonomy and well-being 1 .
Intimate partner violence represents a serious public health problem and affects women all over the world 2 .The phenomenon of violence against women can occur in different ways, affecting physical, property, psychological, moral and/or sexual aspects 3 in women of different ages, origins, ethnicities, social classes, marital statuses, education levels, and sexual orientations 4 .
The pregnancy-puerperal cycle is a period in which more protection and care are expected for the mother-child binomial 5 ; however, national and international studies report a high prevalence of intimate partner violence during pregnancy 6,7,8,9,10,11 .The occurrence of violence during this period or after birth is a reason for concern, as it can trigger obstetric complications that affect the health and quality of life of the mother and the fetus/neonate 12 .
Pregnant women exposed to a situation of violence are more vulnerable to psychological suffering, with increased levels of stress, sadness, anguish, mental disorders, and suicidal ideation.It can lead to low adherence to prenatal care, risk of gynecological and obstetric problems such as urinary and vaginal tract infections, prenatal hospitalizations, serious maternal morbidities, and risk of miscarriage, intrauterine growth restriction, prematurity, perinatal death, and breastfeeding problems.In addition to physical and psychological consequences, it is believed that intimate partner violence may be related to sexuality after childbirth, but this relationship has not been fully explained in the literature 13 .
Historically, women's sexuality has often been ignored, discouraged or reduced to the role of reproduction, and during the postpartum period, this issue is even more neglected due to the focus on motherhood 14 .The arrival of a child involves a number of emotional and social changes in the life of the woman, the family, and the parents, including hormonal, anatomical, psychological, and social changes, as well as different types of dissatisfaction regarding female health.In this period, up to 86% of women make sexual complaints, particularly in relation to dyspareunia and decreased sexual desire 15 .
The main concerns expressed by women during this period include fear of pain, fear of a new pregnancy, baby care, and insecurity about their own bodies 16 , in addition to anxiety and depression, particularly in the immediate postpartum period 17 .
Although many women report a decline in sexual interest or desire after childbirth, about 80% of couples return to sexual activity within 12 week of childbirth.After six months, most women have resumed sexual intercourse and, after 12 months, most of them consider their sexual life similar to the pre-pregnancy period 18 .
However, this period can vary, as several factors can influence sexual function and the return to sexual activity after childbirth, such as maternal age, breastfeeding, depression, tiredness, sexual inactivity in the first trimester of pregnancy, presence and degree of perineal injuries, body image after childbirth, concern about a new pregnancy, and urinary infection 19,20 .
Sexuality has different meanings and expressions that are experienced by every woman in her daily life, making it an important aspect to be emphasized and referred to specialized care 21 .Understanding how women experience sexuality after childbirth is required, since expectations for this period are not always similar, with distinct changes, contexts, and challenges 22 .
In the context where women are exposed to violence, negotiations of sexual practices after childbirth may be more difficult, as they are subjected to the oppression of their violent partners.Also, a significant number of women do not receive information or guidance on sexual health during pregnancy, including when to return to sexual activity after childbirth 23 .These women often return to sexual activity without desire, just to maintain intimacy and fulfill the expectations of their partners, which can contribute to the emergence of sexual health problems 24 .
Although violence and sexual concerns are frequent problems in the pregnancy-puerperal cycle, studies on intimate partner violence and its relationship with women's sexuality are still limited.

Participants and sample
A convenience sample was used in the prenatal phase.Pregnant women were contacted at a prenatal visit conducted up to the 5th month of pregnancy; they should have been submitted to at least one obstetric ultrasound exam before the 20th week of pregnancy, and have a single fetus and gestational age between 22 and 25 weeks at the time of data collection.In total, 1,447 pregnant women were interviewed from February 2010 to June 2011 27 .
Childbirths of pregnant women occurred from May 2010 to November 2011.A total of 1,381 mothers were interviewed once again within 24 hours after birth, constituting the childbirth sample.
The 2nd follow-up was conducted between September 2011 and March 2013.Participants were invited by telephone to attend the Maternal and Child University Hospital (HUMI, acronym in Portuguese), Federal University of Maranhão (UFMA, acronym in Portuguese), when the children were between 12 and 35 months old.In total, 1,151 mothers were interviewed; of those, 1,081 reported having suffered or not violence during pregnancy.For the purposes of this study, 416 interviewees who reported violence by another person were excluded, totaling 665 participants who did or did not suffer intimate partner violence during pregnancy (Figure 1).

Data collection instruments
For data collection, interviews were conducted at three moments, with the application of structured questionnaires.

Exposure variable
Violence during pregnancy was assessed using the World Health Organization Violence Against Women instrument (WHO VAW) 28 , validated in Brazil 29 , which has 32 self-administered questions, which investigates whether the woman has suffered violence during the current pregnancy and in the 12 months before that.The questionnaire has questions related to the occurrence and frequency of different types of violence (psychological, physical, and sexual violence).
In this study, exposure meant suffering intimate partner violence during pregnancy.This variable was measured through the question: "Who did this to you?" with the possible answers in the questionnaire: "current husband/partner/boyfriend", "ex-husband/partner/boyfriend", "father", "stepfather", Cad.Saúde Pública 2024; 40(5):e00094223 "mother", "stepmother", "brother/sister/other family member who lives in the same house", "family member who does not live with you", "neighbor or other acquaintance", "other", and "there was no violence".In this study, this variable was grouped into two categories: "those who did not suffer violence", and "those who suffered intimate partner violence during pregnancy (current or former partner)".

Outcome variable
Time to return to sexual activity after childbirth was investigated using a questionnaire applied to mothers at the 2nd follow-up with the question: "When did you resume sexual activity after childbirth?".The answers were: "0 to 14 days after birth", "30 days after birth", "1 to 3 months after birth", "3 to 6 months after birth", "9 months after birth", "has not yet returned to sexual activity", and "I don't know".However, in this study, we chose to categorize it as "up to 3 months after birth" and "3 months or more after birth".The criteria to define this cutoff point were based on the literature, which shows that several factors can influence sexual function and the return to sexual activity immediately after childbirth, leading to reduced sexual interest or desire during this period 18,19,20 .
Continuous variables of the pregnant woman's mental health were also assessed, such as level of perceived stress using the Perceived Stress Scale (PSS-14) 32 ; anxiety symptoms using the Beck Anxiety Inventory (BAI) 33 ; and symptoms of depression using the Center for Epidemiologic Studies-Depression scale (CES-D) 34 .Social support was determined using the Medical Outcomes Study scale (MOS), translated into and adapted for Portuguese 35 , with the results categorized as appropriate and inappropriate, using the upper tertile as the cutoff point 36 .

Data analysis
First, distributions of continuous variables were evaluated using the Shapiro-Wilk test for descriptive analyses.Absolute and relative frequency of categorical variables, median, and interquartile range of continuous variables were calculated.According to time to return to sexual activity after childbirth, categorical variables were compared using the chi-square test and continuous variables were compared using the Mann-Whitney test.A directed acyclic graph (DAG) was created in DAGitty 3.0 (http://www.dagitty.net/),which identified the minimum set of adjustment variables to minimize possible confounding biases, selecting the following variables: maternal social support, economic classification, skin color of pregnant woman, education of pregnant woman, education of intimate partner, history of violence, age of pregnant woman, age of intimate partner, occupation of pregnant woman, pregnancy planning, and marital status of pregnant woman (Figure 2).To assess the association between intimate partner violence during pregnancy and time to return to sexual activity after childbirth, logistic regression was used (crude and adjusted analysis) and the odds ratio (OR) was calculated with respective 95% confidence intervals (95%CI).

Figure 2
Directed acyclic graph for the association between intimate partner violence during pregnancy and time to return to sexual activity after childbirth.

Ethical aspects
The

Results
The analytical sample of this sample consisted of 665 participants.Among them, 67.96% reported having returned to sexual activity within 3 months after childbirth.Most pregnant women were 25 years old or more (61.05%);self-declared mixed-race (66.92%), and had between 9 and 11 years of education (75.79% 74.89% of pregnant women reported inappropriate social support, 59.1% said they had not planned the pregnancy, and 52.03% of mothers reported vaginal delivery. A significant difference was observed in time to return to sexual activity after childbirth in relation to some variables such as partner's education and type of delivery.Regarding the presence of stress, and symptoms of anxiety and depression, the participants presented median of 21 (17-26) points on the PSS-14 scale, 14 (8-23) points on the BAI scale, and 10 (6-18) points on the CES-D scale (Table 1).
When analyzing the association between intimate partner violence during pregnancy and time to return to sexual activity after childbirth, no association was observed in the crude model (OR = 0.88; 95%CI: 0.60-1.30)or in the model adjusted for possible confounding variables (OR = 1.00; 95%CI: 0.61-1.63)(Table 2).
As a sensitivity analysis, we assessed the association between each type of violence and time to return to sexual activity after childbirth (Table 3).

Discussion
The findings of this study did not show any association between intimate partner violence during pregnancy and time to return to sexual activity within 3 months after childbirth and more than 3 months after childbirth.
Although intimate partner violence against women can be considered a global problem, existing evidence is still not sufficient to explain different issues resulting from this phenomenon that negatively affect maternal and child health.
According to a literature review, only one study was found evaluating the relationship between intimate partner violence and sexual issues after childbirth related to depression.This review assessed 700 women treated in basic health units located in the west zone of São Paulo and did not show any association between studied exposure and outcome 37 , in agreement with the results found in our study.
A common aspect between the two studies is the fact that they both assessed violence during pregnancy, ignoring violence that occurred after childbirth, a situation that may have influenced the results, as recent violence has a stronger impact on women's health 38 and, consequently, may affect the return to sexual activity after childbirth.
Data about violence were collected only in the second trimester of pregnancy; therefore, the results reflect responses to questions about episodes of violence that occurred at two specific moments (before and during pregnancy).However, although violence in the postpartum period was not assessed in our study, it is important to consider that suffering violence during a delicate period such as pregnancy can be a predictor of future violence.A longitudinal study conducted with 1,083 women in Hong Kong to investigate the trajectory of partner violence before, during, and after pregnancy observed that a high proportion of women suffered intimate partner violence continuously during pregnancy and after childbirth 39 .
In our study, the prevalence of women who suffered intimate partner violence during pregnancy was lower (24.06%) when compared to women who did not suffer intimate partner violence (75.94%).This result may suggest an underestimation of cases.According to the literature, several factors may obstruct the production of data on violence and pregnancy, including feeling of guilt, shame, fear and stigma that women who are victims of violence experience 40 , as well as inadequate or late access to prenatal care, which may occur due to prohibition by the partner or deep psychological stress experienced by the pregnant woman 41 .
Most women (67.96%) in our study reported return to sexual activity within 3 months after childbirth.Physical, psycho-emotional, and sociocultural aspects can inhibit desire, arousal, and lubrication, influencing the return to sexual activity in the postpartum period.Around half of women return to sexual activity between 5 and 6 weeks after childbirth, and around 90% are already sexually active 3 months after childbirth.However, when they do not return to sexual activity more than 12 weeks after childbirth, the situation must be evaluated, which may indicate a worse sexual prognosis and sexual inactivity 15,42 .
Cad. Saúde Pública 2024; 40(5):e00094223   Although it was not the primary objective of this study, a significant difference was found in time to return to sexual activity after childbirth in relation to some variables, such as type of delivery and partner's education.Women who returned to sexual activity within 3 months had a higher prevalence of vaginal birth, while those who returned after 3 months had a higher prevalence of cesarean section.However, a recent review study showed that there is no consensus on an association between the type of delivery and changes in sexual function, showing that vaginal deliveries, whether instrumented or not, and cesarean deliveries, whether elective or emergency, can alter sexual function in the short, medium, and long term 43 .
Regarding partner's education, study participants who returned to sexual activity within 3 months stated that their partners had between 9 and 11 years of education (64.92%).No direct relationship was found in the literature between the partner's education years and sexual activity in the postpartum period.Despite this fact, education is believed to influence other aspects of the relationship, such as communication and understanding of the importance of postpartum recovery.A population-based study found a statistically significant association between impaired communication and intimate partner violence.In this context, poor education can impact interpersonal relationships and the resolution of everyday problems, which can result in violence 44,45 .
Also, a high prevalence of inappropriate social support among study participants should be highlighted, although this variable did not affect the time to return to sexual activity after childbirth.
Some studies report a relationship between sexual violence and female sexual dysfunction.This form of violence seems to have a more significant impact on a woman's ability to maintain a satisfactory sexual life 46,47,48 .However, in the sensitivity analysis conducted in our study, no statistically significant difference was observed between the type of violence and time to return to sexual activity after childbirth.Also, a low prevalence of women reporting sexual violence was observed in our study.
According to the literature, intimate partner violence is considered a stressor for many women and significantly contributes to mental disorders in the pregnancy-puerperal period, including depression, suicidal ideation, post-traumatic stress disorder, and anxiety disorders 49 .Combined with that, studies indicate that psychological factors are involved in sexual behavior, desire, and satisfaction, in addition to postpartum depression, related to reduced frequency and interest in sexual rela-   tions between 8 and 12 weeks after birth and low sexual drive 6 months after childbirth when compared to women without postpartum depression 50 .The result of non-association between intimate partner violence during pregnancy and time to return to sexual activity after childbirth found in our study may be related to non-inclusion of women's mental health variables in the analysis, a situation justified by the fact that these variables appear as mediators, requiring another type of analysis not included in the objective of this study.
In our study, data on violence were based on the self-report of participants and their willingness to report true information, and women who are victims of partner violence often find it difficult to identify such violence.However, a self-administered instrument was used to reduce the chances of participant omission of violence and the identity of aggressors 51 .
This instrument proved to be appropriate for the assessment of intimate partner violence against women, and it was used in other studies that also investigated the prevalence of intimate partner violence during pregnancy 9,52,53 .
A limitation to be considered is the use of a convenience sample from the municipality of São Luís only, without representation of single women, since all participants included in the sample reported being married or in a consensual union.This lack of diversity may restrict the generalization of findings to a broader population.
Cad. Saúde Pública 2024; 40(5):e00094223 Although this study did not present results about a possible association between intimate partner violence during pregnancy and time to return to sexual activity after childbirth, it is important to highlight methodological aspects regarding this analysis.Strengths include the fact that it is a cohort study; the use of instruments recognized and validated in Brazil, including the WHO VAW; and the use of a DAG to minimize possible confounding biases.
Also, to the best of our knowledge, no study was found in the literature assessing the same exposure and outcome, and many of the studies that address violence during pregnancy and sexuality in the postpartum period use a qualitative approach, which makes our study relevant.

Conclusion
Although no association was found between intimate partner violence during pregnancy and time to return to sexual activity after childbirth, our study fills gaps in scientific knowledge about the negative outcomes of violence, suggesting new perspectives and paths for expanding comprehensive care to women's health.Therefore, the importance of health professionals should be highlighted in terms of enforcement of policies to fight against violence and provision of continuous care to women in the pregnancy-puerperal cycle, considering physical and psychological aspects, as violence leads to painful consequences and negatively affects several aspects of women's lives, including sexual and reproductive health.

Figure 1 Flowchart
Figure 1Flowchart of the population and sample of BRISA cohort participants analyzed in the study.São Luís, Maranhão State, Brazil.
). Regarding marital status, 72.03% were in a consensual union, 54.89% did not live with children at the time of the interview, and 49.92% had no job.Regarding intimate partners, 74.14% of the participants reported their partners were 25 years old or more and 74.59% reported their partners had between 9 and 11 years of education.Most participants (69.32%) were from C socioeconomic group.Regarding intimate partner violence during pregnancy, 24.06% of participants reported such violence.Regarding intimate partner violence 12 months prior to pregnancy, 25.26% reported it.Also, Cad.Saúde Pública 2024; 40(5):e00094223

Table 1
Characterization of general sample and prevalence of return to sexual activity after childbirth according to demographic and socioeconomic variables and health conditions of participants in the BRISA cohort.São Luís, Maranhão State, Brazil, 2010-2011 (n = 665).

Table 3
Association between types of intimate partner violence during pregnancy and time to return to sexual activity after childbirth among participants in the BRISA cohort.São Luís, Maranhão State, Brazil, 2010-2011.