Determining sexual knowledge and the role of sexual beliefs at postpartum period on Turkish women

Background: Beliefs and knowledge about sexuality affect sexual life related dynamics in postpartum period. This study was conducted in order to determine postpartum women’s knowledge and beliefs about sexuality. Materials and Methods: The study had a descriptive, cross-sectional design. The study sample consisted of 400 women who gave birth in Antalya, Turkey. Data were collected with a data collection form developed by the researchers at face to face interviews. Results: The results of the study showed that 67% of women have right information about the restriction of sexual intercourse at postpartum period and the need of sexuality for women and 30.8% think that sexual intercourse should be resumed before 40 days. But it was determined that the sexual belief about dirtyness of postpartum women and necessity of waiting 40 days to resume sexual intercourse of the women were 88%. The proportion of women receiving information about sexuality at postpartum period were 50.8%. Women’s myths about anal/oral intercourse were 67-75%. Conclusion: In conclusion, it was determined that women have lots of myths about postpartum sexuality and women’s knowledge is insufficient. It can be recommended that knowledge and beliefs of postpartum women about sexuality should be evaluated and health care should be offered in accordance with their needs.


INTRODUCTION
Sexuality is a need and drive considered necessary for maintenance of mankind but not regarded necessary for maintenance of personal life.It is a quite complex concept involving not only biological functions but also thoughts, emotions, social ties, consciousness and duties (1).According to the World Health Organization (2), it comprises a combination of physical, emotional, intellectual and social effects which enrich the personality, communication and love.It is also shaped by an interaction of social and cultural factors as well as physiological and psychological factors.One of the most important elements of development of sexual behavior is attitudes of the cultural structure and the society to sexuality (3,4).Women experience sexuality depending on their cultural expectations.All sexuality related behavior and attitudes are shaped by family, society, culture, laws and religions.Doctrines imposed by family and causing the belief that sexuality is something to forbear may forbid satisfaction from and expression of sexuality (4).
In the Turkish society, sexuality is considered a taboo and people do not talk about freely due to its social and cultural aspects (5).The religion remarkably affects how sexuality is experienced in Turkey (6).According to results of a study by Pew in 2011 (7), 98.6% of the population in Turkey is Muslim.Quran and other Islamic sources provide information about how people should behave in their marital and extramarital relationships during their different stages of life (4,8).These sources guide thoughts and attitudes of people about their sexual lives.To exemplify, concerning sexual intercourses during menstruation and lactation, Baqara section of the Quran states "And they ask you about menstruation.Say, it is harm, so keep away from wives during menstruation.And do not approach them until they are pure.And when they have purified themselves, then come to them from where Allah has ordained for you.Indeed, Allah loves those who are constantly repentant and loves those who purify themselves."(9).In addition, researches shows that friends, social circles, newspapers, magazines, films and pornographic materials, considered as unreliable sources, can be effective in sexuality in Turkey (5,10).These sources supply a lot of insufficient, wrong or exaggerated information about sexuality.
Women go through some stages in their lives likely to affect their sexuality such as pregnancy, postpartum period, lactation and menopause, which are related to reproduction (11,12).In the postpartum period, as well as physical factors, some practices and beliefs originating from culture and the social structure were effective in sexuality of women (12)(13)(14)(15)(16).It is important that sexual lives and sexual life related knowledge and beliefs of postpartum women should be evaluated.Then it can be possible to support correct knowledge and beliefs and to change wrong ones.Therefore, this study was conducted to determine sexual knowledge and beliefs of postpartum women in Turkey within the cultural influence.

Study Design
The study had a descriptive, cross-sectional design for determining women's thoughts, knowledge and beliefs.

Setting and Sample
The study population comprised of all the women giving birth in obstetrics clinics of three state hospitals in Antalya, Turkey.As the majority of births in Antalya take place in state hospitals, three of the three state hospitals in Antalya are included in the sampling; private hospitals are not included.The number of births in these three state hospitals in Antalya was 9400 at total in 2014.The sample size was determined using the formula " n = N.t 2 .p.q/d 2 .(N-1) + t 2 .p.q " (17).In the formula; at the alpha = 0.05 error level, the theoretical t value was taken as 1.96 and the lowest number of samples to be taken in this way was found to be 370.A total of 400 samples were reached by taking about % 10 more of the determined sample.Since the number of births differed between the hospitals to be sampled, stratified simple sampling method is applied.All the women in study sample were Muslims.
Inclusion criteria were as follows: • Being aged 18-45 years, • Being able to speak Turkish and answer questions in Turkish, • Living with spouses, • Giving birth to a healthy baby (Apgar score >7) and having their babies with them.Exclusion criteria were as follows: • Being diagnosed with a psychiatric disorder, • Having complications in pregnancy, delivery and postpartum period.
The study was conducted with the women before their discharge from hospital between 15 April and 15 September in 2015.Data were collected with a data collection form developed by the researchers in light of the literature (12, 14-16, 18, 19) at face to face interviews.All the interviews performed by one of the researchers and interviews lasted 30 minutes on average.Interviews performed with attention to privacy in patients' rooms.
Obtained data were analyzed with SPSS Statistics Based v23, the license of which was obtained by Akdeniz University, and evaluated with descriptive statistics, frequencies, percentages and Chi-square test.

Ethical Considerations
All procedures performed in this study were in accordance with ethical standards of institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.Ethical approval was obtained from the Ethical Committee for Clinical Research of Akdeniz University on 11 February 2015 (approval number: 70904504) and from the hospitals where the study was performed.In addition, informed consent was taken from all the participants.

RESULTS
In this study, 57% of the women were aged 20-29 years, when the rate of fertility is the highest, and the mean age of all the women was 27.66±5.68years.Sixty-three point eight percent of the women were primary and secondary school graduates and 79.5% of the women were unemployed.Fifty-three point five percent of the women had a marriage based on a previously established friendship and 72.2% of the women lived with their nuclear families.The mean duration of marriage was higher than five years in 53.8% of the women.Sixty-five point eight percent of the women were multipara and 72.8% of the women had a planned pregnancy (Table 1).Fifty-seven percent of the multipara women reported that they restarted sexual intercourse 40 days after previous births.Eighty-seven point five percent of all the women said that they had no sexuality problems before their pregnancy.Fifty point five percent of the women reported that they are planning to start sexual intercourse six weeks (40 days) after delivery.Only 3.3% of the women reported that they are planning to start sexual intercourse less than 40 days after delivery.Forty-one point eight percent of the women reported to receive information about general sexuality and 50.8% of the women reported postpartum sexual information receival and the source of information was health professionals in 90.1% of the women (Table 2).In this study, 52,6% of the women not experiencing pain during pre-pregnancy sexual intercourse planned to start their sexual intercourse six weeks after delivery and 26.7% eight weeks after delivery respectively.Thirty-five point four percent of the women experiencing pain during pre-pregnancy sexual intercourse planned to start sexual intercourse six weeks after delivery and 33.3% of them planned 9 weeks or more after delivery respectively.The difference between the groups was significant ( 2 =8.401, p=0.038; p<0.05).The difference was found to be due to the desire of the women experiencing pain during pre-pregnancy sexual intercourse to wait for a longer time to start sexual intercourse (Table 3).
About 67% of the women had the correct information about the reason for not having an sexual intercourse after delivery and about sexual needs of postpartum women.Sixty-three point five percent of the women thought that return to sexual life earlier than 40 days after delivery is wrong.The rate of the women thinking that postpartum masturbation is wrong was 49.5% (Table 4).Fifty-three point two percent of the women knew that breastfeeding can reduce sexual desire, but only 20% of the women knew that breastfeeding can be related to vaginal dryness and pain during sexual intercourse.Sixty-five percent of the women accepted that breasts are important in sexual life, but 63.8% thought that breastfeeding did not related to sexual satisfaction (Table 4).
Ninety-two-point eight percent of the women agreed about the need for postpartum family planning, but only 39.5% of the women thought that using contraceptives could increase the frequency of sexual intercourses (Table 4).
In this study, all of the interviewed women were Muslims.Eighty-eight percent of the women believed that they should not have sexual intercourse earlier than postpartum 40 days.The rate of the women not considering sexuality only as sexual intercourse was 69%.Sixty-one point eight percent of the women believed that women do not lose their attractiveness in the postpartum period.Seventy-four-point eight percent and 35% of the women believed that anal intercourse and masturbation were sins.However, 39.5% of the women did not know whether masturbation was a sin.Sixty-six-point eight percent of the women did not approve of oral intercourse in the postpartum period.The rate of the women not disregarding their sexual needs was 61.8%.Seventy-one percent of the women thought that prioritizing only their spouses' sexual needs was wrong and 86% of the women reported that demanding sexuality from their spouses was not a shame.Seventy-two-point five percent of the women believed that they could get pregnant during lactation.Only 4.5% of the women believed that they should not have a sexual intercourse during lactation and only 6.5% of the women believed that having a sexual intercourse could transmit some diseases to their babies.Forty-one-point eight percent of the women did not know whether breastfeeding could sexually stimulate their spouses.Forty-two-point five percent of the women did not find disgusting leaking of milk from the breast during sexual intercourse.Forty-eight percent of the women reported that sleeping in the same room with the baby would not affect sexuality negatively, but 50.2% of the women reported that having someone else to help at home at postpartum period negatively affects sexual life (Table 5).

DISCUSSION
Knowledge and practices of women about postpartum sexuality are affected by their cultural beliefs (13,16).The results of this study will be discussed under the headings of time to start sexual life in the postpartum period, knowledge of postpartum sexual life, knowledge of breastfeeding and sexuality, knowledge of postpartum family planning and sexuality, beliefs about postpartum sexual life and motherhood, beliefs about breastfeeding and sexuality and other beliefs about sexual life.

Time to Start Sexual Intercourse in the Postpartum Period
In the present study, 30.8% of the women had the correct knowledge of returning to sexual life 40 days after giving birth.However, 88% of the women considered themselves as "dirty" and therefore postponed sexual intercourse.Despite having this knowledge and belief, 96.7% of the women planned to return to sexual intercourse 40 days after birthing or after a longer time.In addition, 94.6% of the multipara women were found to start sexual intercourse 40 days or more after their prior deliveries.The postpartum period is a special stage during which women withhold their sexual life for a certain period (11,12).According to Islamic beliefs, women do not have a sexual intercourse for 40 days during lactation.This belief changed into the misbelief that lactating women are "dirty", which was established in the society (20,21).According to results of the 2013 Turkey Demographic and Health Survey (2013 TDHS) (22), 83.5% of Turkish women have sexual abstinence for 40 days at lactation.In a study by Şahin (23) on women in their the postpartum third month, the mean time to return to sexual life was found to be 40 days.In a qualitative study by Holroyd et al. (13), Chinese women were shown to consider postpartum women as "dirty" and sexual intercourse as inappropriate for at least one month after having birth.In a study by Trutnovsky et al. (16), time to start sexual life was 7.1 weeks after delivery.Consistent with the results of the studies from Turkey (22,23) and other countries (13,15,16), the current study revealed that the women adopted the belief that they had to wait for 40 days to start sexual intercourse.In the present study, time to return to sexual life was found to be related to pre-pregnancy pain experience during intercourse (p<0.05)(Table 3).It has been reported in the literature that sexuality before pregnancy has an influence on postpartum sexual life (24).In a study by Karaçam and Çalışır (24), women with a history of dyspareunia before pregnancy had an increased possibility of postpartum dyspareunia.In the current study, the women who experience pain during sexual intercourse prepregnancy were found to postpone returning to sexual intercourse at the postpartum period.

Knowledge about Postpartum Sexual Life
In the present study, 67% of the women were found to know that restriction of sexual intercourses is related to protection against infections.67.2% of the women accepted that sexuality is needed, but that 49.5% of the women did not have a positive attitude to masturbation.According to some Islamic sources, extramarital sexuality and masturbation are banned, but that marital sexuality is encouraged due to its reproductive function (4,8,20).Similar effects of Islam are also observed in the Turkish society.Since the present study was performed on married women, the women accepted importance of marital and did not make any comments about masturbation since they considered it embarrassing (39.5%) or had negative thoughts about it due to Islamic effects (35%).In a study by Kısa et al. (10) on couples preparing to get married, 37.2% of the women identified sexuality with reproduction and did not consider it as women's need and that 64.1% of the women had a negative judgement about masturbation.Although the present study and Kısa et al.'s study were carried out in different regions of Turkey, their results are quite similar.

Knowledge about Breastfeeding and Sexuality
In the present study, 53.2% of the women thought that breastfeeding could decrease sexual desire.Forty-four-point two percent of the women did not have knowledge of vaginal dryness and pain during sexual intercourse during lactation.Sixty-five percent of the women accepted importance of breasts for sexual life.Sixty-three-point eight percent of the women thought that breastfeeding could not make a woman sexually satisfied.This can be explained by the belief that motherhood and breastfeeding are sacred in Turkish society.But breasts play an important part in sexual arousal and sexual responses (11).In a study by Avery et al. (18), 32.2% of the women did not consider breasts as sexual objects during lactation, 59.4% of the women commented that they did not have sexual stimulation in the suckling activity and 42.4% of the breastfeeding women thought that breastfeeding decreased sexual desire.The results of the present study are similar to those reported by Avery et al.The only difference was about importance of breasts in terms of sexual life.It can be suggested that Turkish women have more awareness about the fact that breasts do not lose their sexual importance during lactation.

Knowledge about Postpartum Family Planning Methods and Sexuality
In the present study, 92.8% of the women believed the necessity of postpartum family planning and 39,5% of the women thought that contraceptive use could increase the frequency of sexual intercourses.It is recommended that there should be minimum two-year-intervals between pregnancies for better maternal and neonatal outcomes in future pregnancies (25).According to TDHS-2013 (22), 98.7% of the women participating in the study and 99.7% of the married women knew about at least one modern family planning method.In addition, the rate of prior use of modern family planning methods was 76.7% among the married women.In a study by Bilgili and Vural (26), 70% of the women having a baby aged 0-6 months did not receive education about family planning in the postpartum period, 44% of the women said they did not use family planning methods since they thought that breastfeeding prevented conception while they were lactating.The findings of the present study about necessity of postpartum family planning and having correct information about family planning was more favorable than those reported by Bilgili and Vural (26).It seems that postpartum family planning use are influenced by traditions and experiences.

Beliefs about Postpartum Sexual Life and Motherhood
In the current study, 61.8% of the women believed that sexuality does not lose its importance in the postpartum period and 61.8% of the women thought that women are not deprived of their attractiveness in the postpartum period.These beliefs were found to be significantly related to time to return to sexual life in the postpartum period (p<0.05).Sexuality is a basic need and is also necessary and important after giving birth (12,27).Body image has an influence on women's perceptions of womanhood and in turn affects sexual life.Perceived attractiveness is closely related to sexuality (11) Women's perceptions of attractiveness may change after giving birth.Lindblom et al. (28) evaluated perceived body image in postpartum women by using open-ended questions.Although the women mentioned a few positive changes, they usually had negative perceptions of postpartum changes and reported these changes to affect their sexual life.Salim et al. (29) also found in their qualitative study that the women had negative perceptions of postpartum changes, which affected their sexual life.Consistent with the literature (28,29), the present study showed that perceived attractiveness of the women could affect their sexual life.However, the women had more positive attitudes towards importance of postpartum sexuality and body image.
Twenty-nine percent of the women thought that sexuality was a type of duty and that sexual needs of women were disregarded.Eighty-six percent of the women reported that talking to their spouses about their sexual needs could not be considered embarrassing.These two findings seem to be conflicting.This can be explained by dynamics of a marriage in Islamic culture.According to Islam, the sexual role of women is to satisfy sexual needs of men and is directed towards maintenance of reproduction and marital sexuality is encouraged.In addition, having a sexual intercourse with a woman is considered as a mitzvah for men (4,21).In Yangın's (30) study, 38% of the women considered sexuality as a duty in their marital relationship, compatible with the present study.
In the current study, 74.8% of the women commented that anal intercourse was a sin, 66.8% of the women did not approve of oral intercourse and noted that masturbation was a sin and 39.5% of the women had no idea about anal intercourse, oral intercourse and masturbation.These findings were conflicting with the literature.Hipp et al. (31) found that return to postpartum sexual life was in the form of oral intercourse and masturbation.In addition, van Anders et al. (19) evaluated sexual experiences of postpartum women's spouses and reported that the sexual activity which the spouses took pleasure from was oral intercourse.However, in the present study, the rate of women having a negative attitude to or having no idea about oral/anal intercourse and masturbation, considered as sensitive and private, was quite high.In a study by Yangın and Eroğlu (32), all the women noted that anal intercourse was a sin and 11.5% of the women said that a request for anal intercourse from their spouses was a reason for getting divorced, which is consistent with the present study.It seems that culture and religions have remarkable effects on sexual dynamics.

Beliefs about Breastfeeding and Sexuality
In the present study, 72.5% of the women believed that breastfeeding did not prevent conception.Eighty-nine-point five percent of the women thought that they could have a sexual intercourse during lactation and 75.8% of the women thought that having a sexual intercourse did not cause transmission of any diseases to their babies during lactation.Forty-two-point five percent of the women thought that discharge of milk through breasts was not disgusting during a sexual intercourse.Twenty-six percent of the women reported that watching a woman who is breastfeeding can be a sexual stimulus for a man.In a study by Avery et al. (18), 47.5% of the women found leaking of the milk from the breasts in the breastfeeding period was disgusting, 60.3% of the women thought that breastfeeding did not affect sexuality of men, but 27% of the women thought that breastfeeding could sexually stimulate their spouses, which is consistent with the finding of the present study.

Other Beliefs about Sexual Life
In the current study, 36.5% of the women believed that sharing their bedroom with their babies could affect their sexual life.Salim et al. (29) found that there could be some life changes and that an adaptation to motherhood roles is experienced.They added that these changes and experiences can affect sexual life, which is congruent with the results of the current study.
Fifty point-two percent of the women believed that presence of a person who helped with the housework or infant care could have a negative impact on sexual life.Sexual life is confidential and associated with privacy (3).Yangın (30) reported that presence of another person, which could destroy privacy, other family members' sleeping in a room, which allows them to hear couples' voices, could affect sexual lives of couples and reduce sexual desire and satisfaction, which is consistent with the results of the present study.

CONCLUSION
Beliefs and knowledge about sexuality affect not only perceived sexuality and sexual life throughout life but also sexual life related dynamics in the postpartum period.Since motherhood and breastfeeding are affected by cultural and religious values in the postpartum period, it becomes important to evaluate beliefs and knowledge about sexuality.Therefore, it is essential that cultural and religious values and dynamics of societies should be taken into account in evaluation of beliefs and knowledge about sexuality.
The present study has shown that the participants do not have sufficient knowledge and various beliefs about time to return to sexual life, the relation between perceived motherhood and sexuality and breastfeeding.Knowledge and beliefs about sexuality influence postpartum sexual life, time to return to sexual life, perceived motherhood and its

Table 2 :
Distribution of Women by Histories on Sexual Life and Status of Information Receival *Multiple answers marked

Table 4 :
Distribution of Women's Responses to Postpartum Sexual Information Expressions (N=400)