key: cord-0765002-nxvfq95n
authors: Karakas, Latife A.; Azemi, Asli; Simsek, Seda Y.; Akilli, Huseyin; Esin, Sertac
title: Risk factors for sexual dysfunction in pregnant women during the COVID‐19 pandemic
date: 2020-12-23
journal: Int J Gynaecol Obstet
DOI: 10.1002/ijgo.13462
sha: 1f02405d7a11f95e89559082ffd068891d9da7e6
doc_id: 765002
cord_uid: nxvfq95n

OBJECTIVE: To evaluate the level of sexual function during the COVID‐19 pandemic in pregnant women followed up in Baskent University Faculty of Medicine, Turkey, using the Female Sexual Function Index (FSFI). METHODS: An observational analysis was performed on pregnant women who were not infected with COVID‐19. A total of 135 pregnant women (group 1), 45 of whom were in the first trimester, 45 in the second trimester, and 45 in the third trimester, and 45 healthy women who were not pregnant (group 2), were included in the study. The FSFI was used to assess sexual dysfunction status. RESULTS: A total of 118 (87.4%) pregnant participants and 31 (68.9%) non‐pregnant participants were diagnosed as having sexual dysfunction according to the FSFI. When comparing groups 1 and 2, FSFI scores were significantly lower in group 1 (p = 0.002). It was also found that women who had university degrees, were multiparous, and in the third trimester were more likely to develop sexual dysfunction (p = 0.030, p = 0.029, and p = 0.001, respectively). FSFI scores were found to be significantly higher in planned pregnancies than in unplanned pregnancies (p = 0.001). CONCLUSION: The sexual function of uninfected pregnant women decreased during the COVID‐19 pandemic, negatively influenced by restrictive social distancing measures.

The WHO announced COVID-19 as a global pandemic in March 2020. 1 The first case of the virus, which rapidly spread around the world, was first reported in Turkey on March 11, 2020. Isolation policies during the pandemic, changes in daily routine, restrictions on personal activities, and uncertainty of the future affected people's quality of life and sex life. 2, 3 A study on the effect of social isolation on sexual dysfunction in the general population in the UK in March 2020 demonstrated that the prevalence of sexual activity was below 40%. 4 Previous studies have stated that great disasters cause increased anxiety and negatively affect sexual function. [5] [6] [7] During the COVID-19 pandemic, pregnant women face an increased risk of hospitalization and increased concern. 8 Pregnancy is one of the periods when sexual dysfunction is most common among women. [9] [10] [11] However, to the authors' current understanding, it is believed that there are no published studies evaluating the sexual function of pregnant women.

Nowadays, although sexual activity is not the only cause of concern, it is believed that information regarding sexual dysfunction in pregnant women must also be recorded when establishing surveillance systems for the COVID-19 pandemic. The aim of the present | 227 KARAKAS et Al. study was to compare the levels of sexual function of pregnant women and non-pregnant women during the COVID-19 pandemic using the Female Sexual Function Index (FSFI), and to determine the factors affecting the changes in sexual function in pregnant women.

The present prospective study was performed between July and August 2020, during the COVID-19 pandemic (1 month after the restrictive policies were issued) in Baskent University Hospital, Turkey. Ethical approval was obtained from the university's Clinical Research Ethics Committee (Project no. KA20/274). A total of 135 healthy pregnant female volunteers, 45 of whom were in the first trimester (<13 weeks of pregnancy), 45 in the second trimester (13-26 weeks of pregnancy), and 45 in the third trimester (>26 weeks of pregnancy), who were admitted for their antenatal follow-ups, were included in the study. A total of 45 healthy non-pregnant female volunteers were enrolled as the control group. All women included in the study were aged 20-40 years, sexually active, and had been living together with their partner for 3 months before their enrollment in the study. Pregnant women with complications such as bleeding, risk of miscarriage, placenta previa, risk of preterm delivery, psychological or psychiatric co-morbidities, women with high-risk pregnancies who were abstaining from sexual intercourse, and women with chronic pelvic pain, deep endometriosis, neurogenic bladder, urinary incontinence, and a history of gynecologic or oncologic disease were excluded from the study. Patients who tested positive for COVID -19 or who were living with someone suspected of having COVID-19

were also excluded from the study.

Written consent from each participant was obtained and the participants were invited to complete the questionnaire, which com- When the study was planned, the sample size was calculated using G*Power 3.0.10 software (Franz Faul, Universität Kiel, Kiel, Germany). If an effect size of 0.25 was desired, according to one-way analysis of variance (ANOVA), it was found that at least 180 participants (at least 45 participants in each group) must be included in the study to test the statistical significance of the differences between the groups (control, first trimester, second trimester, third trimester) with 80% power and 5% alpha.

Data were analyzed using the SPSS 24.0 software package (IBM Corp., Armonk, NY, USA). The variables were investigated using the Kolmogorov-Smirnov or Shapiro-Wilk test to determine whether they were normally distributed. Continuous data were analyzed using descriptive statistics including mean, standard deviation, frequencies, and percentages. The inferential statistics tests used were the independent t-test for continuous data, and the independent χ 2 test and Fisher exact test for categorical data. P < 0.050 was considered statistically significant. For non-normally-distributed variables, descriptive analyses are presented using median values.

Kruskal-Wallis tests were conducted to compare these parameters.

The Mann-Whitney U test was performed to test the significance of pairwise differences using Bonferroni correction to adjust for multiple comparisons. An overall 5% type-I error level was used to infer statistical significance.

The questionnaire was administered to 204 volunteers. A total of 180 healthy women who met the study criteria were included in the study. Of these women, 147 (81.7%) were university graduates and 119 (66.1%) were employed.

Of the participants, 135 were pregnant (group 1) and 45 were non-pregnant (group 2). The demographic data and descriptive characteristics of the groups are presented in Table 1 . There was no significant difference between the groups in terms of patient characteristics.

The median FSFI score was 22.2 ± 7.2 (range 2-33.4) in the study population. By using the cutoff FSFI score of 26.55, 118 (87.4%) pregnant women and 31 (68.9%) non-pregnant women were diagnosed as having sexual dysfunction. The mean score of each FSFI domain in all cohorts and comparisons between pregnant and non-pregnant women in terms of each FSFI domain are shown in Table 2 . When groups 1 and 2 were compared, it was found that FSFI scores were significantly lower in group 1 (p = 0.002).

The median score of each FSFI domain between women in the first, second, and third trimesters is summarized in Table 3 . It was determined that women in the third trimester had significantly lower scores in each FSFI domain than women in the early stages of gestation (p < 0.050).

The relationship between the presence of sexual dysfunction and demographic variables in pregnancy is demonstrated in Table 4 .

It was found that women who had university degrees, are multiparous, and in the third trimester were more likely to develop sexual dysfunction (p = 0.030, p = 0.029, and p = 0.001, respectively). FSFI scores were observed to be significantly higher in planned pregnancies than in unplanned pregnancies (p = 0.001).

In the present study, the prevalence of sexual dysfunction in pregnant women during the COVID-19 pandemic was 87.4%. It was found that sexual dysfunction as diagnosed using the FSFI was higher in pregnant women compared with non-pregnant women.

Being a university graduate, multiparous, and having an unplanned pregnancy were found to be associated with low FSFI scores in pregnant women. When trimesters were compared, it was determined that FSFI scores decreased as the trimester increased. It is believed that this is the first study in the literature to analyze the change in sexual function in pregnant women during the COVID-19 pandemic.

A study from China showed that the COVID-19 pandemic caused higher levels of stress, anxiety, and depression in women than in men. 14 In an Italian study that evaluated the FSFI scores of 89 women and excluded pregnant women, it was found that FSFI scores had decreased compared with the pre-COVID-19 period. 15 Sexual dysfunction during the COVID-19 period was attributed to the acute stress caused by the isolation policies issued by the government and the difficulty of adapting to new daily life practices.

Before the COVID-19 pandemic, various studies in the literature found that the prevalence of sexual dysfunction among pregnant women was in the range of 37%-94%, with different scoring systems and cutoff points of the FSFI. 10, 11, [16] [17] [18] Kucukdurmaz et al. 17 conducted a cross-sectional prospective study among 207 Turkish pregnant women in 2016 using the FSFI with a cutoff value similar to that in the present study, and they reported the prevalence of sexual dysfunction as 87%. It is believed that the power analysis performed when planning the present study may enable it to be evaluated comparatively with the study by Kucukdurmaz et al. 16 When the demographic characteristics of the study groups were compared, it was found that 18% of the women in the study by Kucukdurmaz et al were university graduates, whereas the majority of the population in the present study were pregnant women with university degrees. In addition, it was found that having a university degree was a factor that increased sexual dysfunction in the pregnant women During the COVID-19 pandemic, Schiavi et al. 15 found that the FSFI scores of multiparous women were low. Similarly, in the present study, it was found that multiparity was a factor that increased sexual dysfunction. It can be presumed that the pregnant women's increased anxiety regarding the child she cares for at home as well as the anxiety regarding the well-being of herself and the fetus could be a factor.

Before the COVID-19 pandemic, there were many studies in the literature demonstrating that sexual function decreased in pregnant women, especially in the third trimester. 9, 10, [17] [18] [19] In the present study, dysfunction was detected in all pregnant women in the second and third trimesters. In addition, it was found that FSFI scores were significantly lower in women who had not planned to get pregnant compared with women with planned pregnancies. The significantly increased sexual dysfunction in the later months of pregnancy might be due to the increasing anxiety of women who would give birth at a time when the world is dominated by COVID-19 infection. An unplanned pregnancy may activate the mechanism of guilt due to the spontaneity of pregnancy and decrease sexual function in women.

Nevertheless, it must be emphasized that because there are limited normative data on the sexual function of pregnant women, the results of the present study may not be directly comparable with the literature.

The major limitation of the present study was that the participants were recruited from a single antenatal clinic and therefore might not be representative of all pregnant women in the popula- situation and there are no scientific data on how the pandemic will affect the sexual lives of pregnant women in the coming months or years. It is believed that the effects of the COVID-19 pandemic and sexual dysfunction can be prevented using online courses that pregnant women can attend with their partners, which could have positive effects on the psychological and physiological development of pregnant women.

The authors have no conflicts of interest.

LAK was responsible for the planning, conducting, interpretation of data, and manuscript writing. AA, HA, and SYS were responsible for data analysis and acquisition. SE was responsible for designing, interpretation of data, and revising the manuscript.

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