Sexual Health and Midwifery Care

Throughout this paper, I will be looking at a variety of topics related to sexual health and how they influence midwifery care. According to WHO (World Health Organization), “Sexual health is a state of physical, emotional, mental, and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction, or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence” (WHO, 2022).

I will be exploring several aspects of sexual health, with a focus on female sexual health. I will give on my own insight from practical placement experiences, as well as research significant literature. The first theme will explain what sexual health is and female sexuality in different cultures. The second theme is on contraception in relation to midwifery practice and aims to discuss factors that could influence a woman's contraception choices. The third theme is management of STIs/HIV in pregnancy and the importance of this management. Lastly, I will be exploring some of the barriers young people face in relation to seeking sexual health advice. All four themes will relate to midwifery, as sexual health advice is a very important aspect to midwifery.

I will be looking at the freedom of sexual expression in correlation to midwifery practice in this section of the paper. Part of the World Health Organization’s definition of sexual health is “requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence” (WHO, 2022). Highlighting the fact that it is essential for an individual's sexuality to be recognized and not to be discriminated against to achieve good sexual health.

“The female sexual cycle is the foundation of human existence and was likely the focus of awe and ceremony for our ancestors. For example, the onset of fertility with first menstruation are still celebrated in other cultures today” (Buckley, 2010).

Being a midwife, it is essential to acknowledge labor and birth will be part of a woman’s sexual history, as they are sexual beings. More than 85% of midwives surveyed by (Postel, 2013) confirmed that a sexually pleasurable birth experience was possible (Mayberry and Daniel, 2016). In the book ‘Ina May’s Guide to Childbirth’ it also speaks on the importance of sexual contact during labor. Gaskin (2003) highlights the sexual quality of birth, that by actions such as deep kissing and nipple stimulation may help labor and birth to progress. More research that has been carried out shows that breast stimulation causes a release of oxytocin causing the womb to contract (Kavanagh, J. et al., 2005), which also helps labor to progress. Gaskin (2003) promotes parents to enjoy intimacy during labor. A survey was carried where women were interviewed about having experienced orgasms during childbirth. The results showed that 32 out of 151 women had experienced orgasms during childbirth, most of these experiences occurred at homebirths compared to within a clinical setting (Gaskin, 2003) depicting the fact that a very important role as a midwife is being able to establish and create private and intimate environment where women and their partners feel safe in.

Certain cultures have different views about female sexuality which may have an impact on labor and delivery, for example, intercourse during pregnancy is forbidden if the presumed gender of the fetus is 'female', according to an Iranian study, because it may harm the fetus’ hymen. (Shojaa et al., 2009), in comparison to research from Pakistan, which reveals majority of women's beliefs on sexual activity during pregnancy, birth, and postpartum will affect fetus and neonatal health. Because of this, Pakistani women believe in these 'essential' traditions that will ensure a healthy pregnancy and safe birth. As a result, women begin avoiding sexual intercourse as soon as their pregnancy is confirmed in order to avoid unnecessary difficulties (Qamar, 2017). As a midwife whilst caring for any woman, it is important to be aware of her views on female sexuality which may influence her attitude toward labor and birth. Part of a role as a midwife, it is essential to deal with these circumstances with sensitivity and respect. Every woman, regardless of her cultural or religious views should be cared with free from discrimination and treated with dignity.

Contraception is a significant component of sexual health as it offers women control over their bodies and gives them the choice to choose when and how many children they want. The National Institute for Clinical Excellence (NICE, 2019, p.5) highlights the importance of women making an informed decision in regard to contraception that is fitting with their lifestyle. Discussing contraception and sexual health is an important role for midwives.

Throughout this module, I have been able to widen my knowledge on the various forms of contraception available to women and factors that could influence a woman's contraception choices. A variety of factors influence what type of contraception is most appropriate for a woman to take, for example, how it is taken, the duration of the effects and its effect on menstruation. Specific to midwifery, how a woman chooses to feed is also another factor to consider. Being a midwife, we should be aware of the methods of contraception which are available to breastfeeding women, but also need to take a holistic view of the whole situation of a woman. Results showed that contraceptive decision-making is influenced by social factors such as individual, interpersonal, cultural practices, society, and its beliefs (Dombola et al., 2021).

The Faculty of Sexual and Reproductive Health (FSRH, 2020) states: “Maternity services (including services providing antenatal, intrapartum, and postpartum care) should give women opportunities to discuss their fertility intentions, contraception, and preconception planning”. This is a very important role as a midwife as it allows our woman to have a safe place to discuss their contraception choices, which can also create a trusting relationship with our women.

Unfortunately, from my experience on placement in regard to contraceptive advice, I found is very minimal. A response from the FSRH response to the NHS Maternity Review’s online consultation states majority of midwives “referred women on to other healthcare professionals as many felt that they needed more training to confidently discuss contraceptive methods in detail” (FSRH, 2022). My experience of providing contraceptive advice in maternity services supports this statement. From personal experience on placement, I have rarely seen contraceptive advice being given antenatally and postnatally advice about contraception has been very little and not as informative as it should be. This could be because midwives could feel pressured by time and feel there is not enough time to talk in depth about contraception, therefore, “refer women on to other healthcare professionals” and or could be, because “many felt that they needed more training to confidently discuss contraceptive methods in detail”. The Nursing and Midwifery Council standards of proficiency for midwives reinforces the role of the midwife by stating that midwives should demonstrate the ability to offer information and access to resources and services for women and families in regard to sexual and reproductive health and contraception (NMC, 2019). By being able to effectively talk about contraception is essential to high quality midwifery care, and in order to achieve this we must keep up to date with relevant research and information about contraception for our women in our care so they are able to make their own informed choice about which contraceptive method would suit them the most. Effective communication is key and is a skill that all midwives must keep developing further.

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Sexually transmitted infections (STIs) are a major public health concern. STIs are often considered to be stigmatizing and may seriously impact the health and wellbeing of affected individuals, as well as being costly to healthcare services (PHE, 2022). STDs can complicate pregnancy and may have serious effects on both mother and the developing baby. These problems may be seen at birth, while others may not be found until much later (CDC, 2022).

During a woman’s first antenatal appointment, it is the role of the midwife to discuss and share information about infectious diseases in pregnancy and screening for these, such as HIV, syphilis, and hepatitis B (NICE, 2022). A woman with a positive a HIV or STI result will be referred to the sexual health team and her care will then be shared between a midwife and an obstetrician.

Throughout this module I had the chance to learn about the very many different types of STIs, and unfortunately up to 45% of females are susceptible to asymptomatic STIs (Chacko et al., 2004), which may lead to complications for a pregnancy. STIs have been associated with many adverse pregnancy outcomes, such as spontaneous abortion, stillbirth, prematurity, low birth weight and various sequelae in surviving neonates (Bullick et al., 2005).

Chlamydia trachomatis in pregnancy can lead to cervicitis, and cervical discharge with many women are asymptomatic. Chlamydia has been linked with stillbirth, premature delivery, premature rupture of the membranes, and LBW (Bullick et al., 2005). Chlamydia can also affect the neonate, leading to infant pneumonia and ophthalmia neonatorum. 30-50% of infants born to untreated will chlamydia develop chlamydial ON (Beem and Saxon, 1977). This depicting the importance of identifying STIs as early as possible to prevent complications for the pregnancy occurring, therefore is the role of the midwife to be confident in knowledge about STI screening, but also in such a way a woman feels comfortable as it may be a sensitive topic for some women as STI screening can come with stigma associated with it for some.

An example of how powerful stigma can be and how it can affect healthcare is HIV. “A pregnant woman is often the first in the family to be tested for HIV and may be blamed for bringing the virus into the family and may suffer from adverse consequences of her HIV-positive status disclosure” (Turan et al., 2011). During my placement whilst observing in the antenatal clinic, I saw a client who had recently gotten the results that she was HIV positive. The client was extremely anxious due to the facts, she was feared she would be judged within her community, but also feared she would be judged by the people whose care she would be under. This example from my placement highlights the importance of providing attentive and unbiased care to all women. It is essential to treat women with respect and be non-judgment in order to give them a positive pregnancy and birth experience in any circumstance. By not using judgmental tones whilst talking and assuming things may help someone already dealing with internalized stigma feel more comfortable and less uneasy. Whilst communicating to woman, explaining the benefits of treatment and medication regimens, empowering her during their pregnancy, we must remain empathetic and let the woman make her own informed choices.

From this module I have been able to learn about sexual health in regard to young people up to the age of 25 (NICE, 2014), however sexual activity can start much earlier. A survey carried out showed that 50% of adolescents had their 1st sexual relations before age 17, and at least 50% of 1st sexual relations were unprotected by contraception, and half of adolescent pregnancies occur in the 1st 6th months of sexual activity (Pichot and Dayan-lintzer, 1985). This depicting the idea that there is a fear of seeking for advice about contraception from young people, a lack of knowledge about contraception making providing effective sexual health services to young people much harder.

Some research was done as to why young people find it hard seeking sexual health advice, and found that the reasons were that young women reported that embarrassment or fear had made them delay using services. One study showed that fear of examination (49%) and embarrassment (48.7%) were regarded by young people as main barriers to going to a general practitioner (Wilson and Williams, 2008). Young people also tend to worry about service age limit, with younger adolescent females more concerned, that they more likely delay going to the clinic. Males expressed their worries that the services are oriented to women exclusively. Being able to go to a clinic without being seen was also seen as a great importance as there was a fear of other people being outside and creating gossip.

Maintaining professional practice as a midwife requires awareness of the regulations governing confidentiality with any client. Knowing and following the Nursing and Midwifery Code, will ideally help the development of a trusting connection with all of our clients, reducing their fear, and as a result improving the likelihood of them engaging with services they need and getting the correct care that they require.

As a result of young people fearing to engage with sexual health services, in 2019, 16,639 pregnancies were registered among adolescents, down 9% compared to 2018 (UNICEF, 2022). Even with a slight decrease in teenage pregnancies, the figure is still high, meaning for us as midwives caring for young pregnant women may be often and should care for them without any bias.

It is critical role for midwives to understand the responsibility in assisting and empowering young people to make their own sexual health decisions and to support them in making such decisions. Every healthcare professional owes a duty of care to every client, regardless of age.

To conclude, each of the four themes have increased my knowledge of sexual and reproductive health as a whole. I've learned that it is much deeper than just providing services and information about sexual health; it's about understanding the challenges for people, giving them the best care, and encouraging them to take control of their own health and make their own informed decisions in order for them to have a healthy safe sex life. Learning about what sexuality and sexual health can mean to people, how it affects their lives and self-concepts, has helped me build my confidence about discussing sensitive matters as a health care professional. I am more knowledgeable about how different cultures and beliefs have different views on female sexuality during pregnancy, how important discussing contraception with our clients are, more aware of the fears young people have and why in relation to sexual health, and finally more informed of the evidence STIs have to one’s health. This program has broadened my awareness of sexual health, and I am confident that it has made me a better understanding and compassionate student midwife.