The intercourse during pregnancy has many advantages: harmony in the couple, good outcome of pregnancy and childbirth [1]. Sexual practice during pregnancy is strongly influenced by beliefs, cultures and religions [2]. Ethnological studies show the diversity of beliefs and sexual practices of couples during pregnancy. In Africa, i.e. in the Azanda tribe in the Democratic Republic of Congo, the sperm is considered as an important factor in the growth of the fetus [3]. Among the Dogon in Mali, it is necessary to have sex with the expectant mother for the child growth [4]. On the contrary, for the Ewe in Togo, the husband who transgressed the prohibition of sexual intercourse during pregnancy might cause a miscarriage or a stillbirth child [5]. In Burkina Faso, i.e. in the Samo’s tribe, sperm would turn into blood and nourish the bloodstream of the future child: so repeated sexual intercourse during the first 7 months of pregnancy is advice. Ouagadougou city is the political and economic capital of Burkina Faso and is mainly inhabited by the Mossi. In this city, traditional beliefs on sexuality are intertwined with those of the common monotheistic religions (Islam and Christianity). Data on sexuality during pregnancy are rare in the literature. Specifically in the Mossi’s area in Burkina Faso, no study was conducted on the issue. In view of this, our study aimed to analyse the opinions, attitudes and practices of women regarding sexuality during pregnancy. As for, the results will help health care providers to direct communication during prenatal consultations in order to ensure better sexual fulfilment during pregnancy.

This study was a cross-sectional survey. It involved ten health centres in Ouagadougou city. Data collection was prospective and covered the period from 1^st July to 31^st August, 2014. The sample size was calculated using the following formula:

N=Z² × p × (1-p)/c²

N=Sample size

Z=value corresponding to a given confidence level (1.96 for a confidence level of 95% corresponding to the value typically used).

p=percentage of the primary indicator, expressed in decimals.

We assigned the p value of 0.85, because a previous study in Bobo Dioulasso, the second city of Burkina Faso, found a prevalence of 85% of women reporting to have sex during pregnancy [6].

c=standard error expressed as a decimal (0.05).

We had an estimated sample size N=196 case minimum.

This size was corrected by a final size as follows:

Nc=N × g × (1+nonresponse)

g is the factor related to the cluster effect which in our case equals 2.

The factor related to nonresponse was estimated at 5%. We then obtained a final minimum size or corrected size of 412 cases. The 2- degree sampling was the one we adopted. All five districts in Ouagadougou were taken into account. We conducted a simple random sampling of 02 health centers per district. In fact, pregnant women consulting in these health centers for antenatal care during the study period were systematically recruited by order of consultation until the number required by the clinic was attained. The number of pregnant women surveyed by the health center was proportional to the number of expected pregnancies in 2014. A healthy pregnancy was the inclusion criteria. One deaf and dumb pregnant woman was excluded. Three pregnant women refused to participate in the study because they wanted to return quickly to their workplaces (Figure 1).

Figure 1: Flow chart of participants included in the analysis.

An individual written questionnaire with closed and open questions was used.

A preliminary test was carried out at 25 health centers (not selected for the survey) to assess the reaction of respondents and to adjust survey tools. Data were collected by five investigators who have been previously trained to understand the questionnaire.

Those five investigators were sent in different health centers involved in the investigation. A room or a space closed to the antenatal care (ANC) consulting was provided for the purpose of the survey. At the end of the ANC, the pregnant woman was led by midwives to investigators who were conducting the administration of the questionnaire after she had agreed to participate. This procedure was followed until the required number of pregnant women by the health center is attained. The pregnant women were interviewed in a room that guarantees confidentiality. In addition, they were informed of the anonymous nature of the collection of data. The open questions were processed manually. The parametric Student test was used to compare the weekly average number of intercourse before and during pregnancy. Microsoft Excel 2007 software was used to develop graphics. The administration of the questionnaire was carried out with the consent of the respondent who was informed of the context of the study. The anonymity of the questionnaire and the confidentiality of the data collected were also assured. After she had filled in the questionnaire, we provided her answers to questions about sexuality during pregnancy.

About 412 pregnant women were interviewed in the 10 selected health centers. All completed questionnaire sheets were exploitable.

Characteristics of pregnant women

Pregnant women who were married represented 97.3% of the sample. Those who had not attended school were rated at 32.3% of cases (Table 1).

Table 1: Characteristics of pregnant women (n=412).

Opinions of pregnant women about sex during pregnancy

For 31.3% (129/412) of clients, sexuality was taboo and discussing about it is uncomfortable. Among 398 pregnant respondents, 94.2% believed it is possible to have sex during pregnancy and 29.4% (121/412) believed that sex had a negative impact on pregnancy. The consequences cited by the women are given in Table 2.

Table 2: Frequencies of the possible consequences of sexual intercourse during pregnancy cited by the pregnant women (n=412).

Pregnant women attitudes to discussion about sex during pregnancy

Among the pregnant women surveyed, 383 (93%) said they were willing to discuss the subject of sexuality during prenatal consultations. The time at which the topic of sexuality should be discussed during pregnancy is presented in Figure 2. The subject of sexuality was said to be discussed by 20.9% of pregnant women during their current pregnancy. In 14.8% of cases (61/412), the initiative to discuss about sexuality came from the care providers. However, 6.1% (25/412) of pregnant women had the initiative to talk about the issue.

Among the women who asked for information about sexuality, 24 (96.0%) indicated what their questions were about: nine (09) had asked if it was possible to continue sex during pregnancy; six (06) asked when they should stop sex; four (04) needed advice about sex during pregnancy; and also four (04) would like to know about the risks of sex during pregnancy (Figure 2).

Figure 2: Suitable period to discuss about sexuality during pregnancy.

Sexual practices of women before and during pregnancy

The change in sex drive with the occurrence of pregnancy is summarized in Table 3. In 90.0% (371/412) of cases, the women reported having sex during the index pregnancy. The reasons for maintaining sex during pregnancy are given in Table 4. Forty-one pregnant women (9.96%) had stopped sexual intercourse during pregnancy. Among those 41 pregnant, the reasons given for the interruption of sexual intercourse were: lack of sexual desire (46.3%) fear of hurting the fetus (41.5%), physical discomfort (24.4%), the risk of miscarriage (22.0%) and non-motivated spouse (17.1%).

Table 3: Sexual desire during pregnancy compared to the Pre-pregnancy period [Note: All pregnant women could give an answer regarding the first trimester. Those who were in the 2^nd or 3^rd trimester could give an answer regarding the second trimester. Only those who were in the 3^rd trimester could give an answer regarding the same trimester].

Table 4: Frequency of reasons to have sex during pregnancy (n=371).

The mean number of intercourse per week during pregnancy was 1.1 ± 0.4 with a range of 0 to 6. Before pregnancy, the mean number was 2.4 ± 0.5 with a range of 0.1 (sex every four weeks) and 7 (p<0.001).

We asked pregnant women to compare the frequency of sex they use to have before pregnancy and the two weeks preceding the survey. They reported a decrease in the frequency at 78.0% (39/50) in the 1^st quarter; 35.7% (66/185) and 69.5% (123/177) respectively in the 2^nd and 3^rd trimester. Among the pregnant women who use to have sexual intercourse, 76.3% and 68.9% respectively mentioned a decrease in the frequency of orgasm in the 1^st and 3^rd trimesters (Tables 3 and 4).

The survey was only about pregnant women. It would also be interesting to investigate in parallel health professionals to know their opinions about the subject. The non-inclusion of spouses in the investigation has constituted a limitation because this has not allowed matching men’s responses with the women’s about sex during pregnancy. Our study is not totally immune to bias due it nature being an opinions and practices survey. Indeed, poor understanding of the issues, the discomfort experienced when talking about sexuality, the false statements provided just to satisfy the investigator constituted possible bias. Creating confidence in the respondents and explaining the purpose of the study could help reduce these potential biases.

Sexuality was considered as a taboo subject by 31.3% pregnant women. This result is significantly lower than those of Lobna et al. in Tunisie [7] who recorded 81.8%. This result gap could be explained by the cultural difference between the women of Burkina Faso and those of Tunisia.

The vast majority of pregnant women (94.2%) thought it is possible to have sex during pregnancy. This result goes in line with other authors [6,8,9]. However, this result is greater than Lobna et al. in Tunisia (82%) [7]. In fact, an favorable evolution in people’s opinions in Sub-Sahara African societies can explain these high rates, since in the past, sex during pregnancy and in the postpartum period was not a common practice in african societies [8].

Nevertheless, 29.4% of pregnant women thought that sex had a negative impact on pregnancy. This result is similar to that of Dao et al. in Bobo-Dioulasso (30.5%) [6]. According to the results of the survey, pregnant women averred that the consequences of sexual intercourse during pregnancy could be miscarriages (19.9%), preterm delivery (8.3%), infection (6.3%), bleeding (3.2%) and pain to the fetus (2.4%). These beliefs are also found in other studies. Indeed, in the study of Kouakou et al. [8], miscarriage, vaginal bleeding and infection were cited respectively by 60.9%, 7.8% and 5.9% pregnant women as being complications of sexual intercourse during the pregnancy. Other authors such as Naim et al. [10], Bartella et al. [11] and Wing et al. [12] had made the same observation. These results reflect the existence of erroneous beliefs of women about the possible adverse consequences of intercourse during pregnancy.

However, these beliefs are contrary to scientific knowledge. In fact, no study so far has shown danger of the sexual intercourse on a normal pregnancy. The study of Sayle et al. [13] showed that sex did not increase the risk of preterm delivery. As for pregnancy-term, the sexual act would facilitate the induction of labor and its smooth outcome [1,14]. The majority of women (93%) thought it was important to talk about sexuality during antenatal visit especially in the 1^st trimester of pregnancy (70.1%).

The way the antenatal consultation is conducted in Burkina Faso does not meet the pregnant women expectations. Indeed, the ANC focused mostly on physical health of the mother and fetus, but not the overall wellbeing of the mother-child couple and even paid attention less to the welfare of the father. Besides the heavy workload of health workers, due to the high number of attendants, reduces the consultation duration. In addition, sexuality is not mentioned on the check-list to be discussed during the refocused ANC in Burkina Faso. This constitutes a violation of the right for pregnant women to have appropriate information about a safe sexual fulfillment during pregnancy. Besides, according to the results of our study, a small portion of pregnant women (6.1%) said to have requested information on sexuality during pregnancy. These results are lesser than those of Jarlier C France [15] who reported 15%. This difference could be explained by the fact that in the Burkinabe society, women often have no word in decision making as for their sexual and reproductive lives.

All women would like to know whether they could continue or not sexual intercourse during pregnancy and without any risk. In this regard, only three women who have requested information were not satisfied. This result is assuring and shows that health professionals provide appropriate answers to their clients. The majority of pregnant women (93.9%) did not ask information and this let us assume that for some of them it seemed obvious that sexuality changed as pregnancy progress. In the opposite, 44.7% of pregnant women who had concerns about sexuality dared not ask questions to the health worker due to the matter of bashfulness. So, it was the role of health workers to put the pregnant women at ease so that they could provide the necessary information about their sex fulfillment during pregnancy. In our study, the number of pregnant women who described a decrease in their sexual desire throughout pregnancy was the most numerous. This decrease was said to be more significant in the first and third trimester and was rated at 74.5% and 66.7% respectively. For the second trimester only 38.4% reported that their sexual desire had decreased, whereas 42.1% found their sexual desire increased. It is important to mention here that the results of the present study are consistent with those found in the literature in general. Indeed, most studies have shown variations in sexual desire during the course of pregnancy. For instance, Master and Jonhson [16] found a reduction in sexual desire in 1^st and 2^nd trimesters, and an increase in the 3^rd trimester. Other studies have also shown a decrease in sexual desire as the pregnancy progresses [12,17-19]. In our study, pregnant women who kept sex gave the following reasons: for my pleasure and satisfaction of the spouse (in 58.49% of cases), for marital duty (in 41.8% of cases), to avoid the infidelity of spouse (in 14.7% of cases), for the pleasure of the spouse (in 25.4% cases), to facilitate childbirth (in 21.3% of cases). Similar reasons were found in other studies to justify keeping sex during pregnancy [6,8]. In our study, we noticed a significant reduction in the frequency of intercourse and orgasm. The 1^st and 3^rd quarter were the periods when the orgasm was less frequent. In fact, compared to the period before pregnancy, 78.0% of pregnant women reported a decrease in frequency of sexual intercourse with orgasm in the 1^st trimester and 69.5% in the third trimester. These two trimesters are indeed difficult times. In the 1^st trimester, the minor ailments of pregnancy such as nausea and vomiting, gastric embarrassment make uncomfortable the pregnancy. This discomfort may negatively influence libido. As for the third trimester of pregnancy, the accentuation of physical changes and anguish associated with childbirth which approaches may explain the decreased of the libido and the frequency of sexual intercourse of pregnant women. The health system must to consider these realities and help couples for a fulfilled sexuality during pregnancy. For this, as in Ciccone’s model [20], a partnership between couples and health workers can improve the sex during pregnancy. This good partnership requires a good training of health workers about sexuality and a good environment for focused counselling [21-24].

Most pregnant women said to maintain sexual activity. However, we found a decrease in sexual desire and frequency of sexual intercourse where erroneous beliefs about adverse effect of sexuality during pregnancy were approved. A good communication about sexuality during the antenatal visit, involving spouses should be encouraged. The subject of sexuality during pregnancy should be included in the guide book of ANC.