Women’s sexual health six months after a severe maternal morbidity event*

Objective: to investigate female sexual function in women six months postpartum and to compare sexual function among women who had and who did not have severe maternal morbidity (SMM). Method: a cross-sectional study conducted with 110 women in the postpartum period, with and without SMM. Two instruments were used, one for the characterization of sociodemographic and obstetric variables and the Female Sexual Function Index (FSFI) for sexual function. Univariate, bivariate and regression model analyses were performed. Results: FSFI scores showed 44.5% of female sexual dysfunction, of which 48.7% were among women who had SMM and 42.0% among those who had not. There were significant differences between age (P=0.013) and duration of pregnancy (P<0.001) between women with or without SMM. Among the cases of SMM, hypertensive disorders were the most frequent (83%). An association was obtained between some domains of the FSFI and the following variables: orgasm and self-reported skin color, satisfaction and length of relationship, and pain and SMM. Conclusion: white women have greater difficulty in reaching orgasm when compared to non-white women and women with more than 120 months of relationship feel more dissatisfied with sexual health than women with less time in a relationship. Women who have had some type of SMM have more dyspareunia when compared to women who have not had SMM.


Introduction
Severe Maternal Morbidity (SMM) is characterized as an event of severe morbidity in women during pregnancy, childbirth, or 42 days postpartum. Classified as a potential life-threatening condition, it is defined by some specific criteria, such as hemorrhagic disorders; hypertensive disorders; other systemic diseases, such as endometritis, pulmonary edema; and some severity indicators such as blood transfusion and admission to the Intensive Care Unit (ICU) (1) .
SMM is currently a development indicator and, as it is more prevalent than maternal mortality, its monitoring is a strategy for preventing and combating maternal mortality (2) . Similar behavior to the maternal mortality ratio, SMM is higher in low-and middle-income countries when compared to high income countries (3) .
However, the magnitude of SMM is unknown; it is estimated that its occurrence is increasing over the years and that there are 20 to 30 SMM events for each maternal death (4) . These events, whether acute or chronic, cause sequelae that can compromise life activities prior to obstetric complications. Recent data estimates 27 million SMM episodes annually worldwide (5) .
The results of research using the criteria established by the WHO point to Africa as the continent with the highest global prevalence of SMM (5) , whose ratio ranges from 8/1000 live births (LBs) in Rwanda (6) to 88.6/1000lb in Somalia (7) . In Asia, SMM ranges from 3.8/1000 LBs in Nepal (8) to 120/1000 LBs in India (9) . Latin America and the Caribbean have the most disparate data on the world scenery, with the lowest SMM rate in Argentina being 2.62/1000 LBs and the highest in Peru at 34.92/1000 LBs (10) . Brazil is in a median position, with a prevalence of 10.21/1000 LBs (11) . In developed countries, the studies found vary in method and definition used; however, these have the lowest data in the world, ranging from 3/1000 LBs in Ireland to 7.3/1000 LBs in the United States (5) .
Although several studies have been developed on how SMM affects women's quality of life (10) , we find few studies in our search on the consequences of SMM on the sexual health of surviving women (12)(13) .
A study carried out in Asia with women who had SMM showed that most of them had difficulty in having orgasms and had reports of pain during sexual intercourse (14) . Another study, conducted in Africa, found a prevalence of dyspareunia among women exposed or not to SMM but there were no significant differences (13) . Based on the long-term consequences of SMM on women's health, it is questioned in this article, whether women who have had SMM have more somatic complaints related to sexual function than women who have not had an episode of SMM. Ribeirão Preto is home to the 13 th Regional Health Department (Departamento Regional de Saúde, DRS XIII) of the state of São Paulo, a regional health reference for 26 municipalities, covering an estimated population of 1,300,000 inhabitants. In this context, CRSMRP-MATER is a regional reference for gynecological and obstetric cases of medium complexity and performs about one third of usual risk and medium risk births of the Brazilian Public Health System (Sistema Único de Saúde, SUS). In this institution, participants were recruited who did not suffer injuries during pregnancy, delivery or immediate postpartum. HCFMRP/USP is a tertiary care hospital, a regional reference center for health, serving days after discharge. This instrument was developed in the United States, validated and adapted for Brazil (16) .

Method
The questionnaire contains 19 questions, which assess the sexual activity in the last four weeks, divided into six domains: desire, arousal, lubrication, orgasm, satisfaction and pain, where each one has a score and the total score refers to the sum of the scores multiplied by their respective factor. If the total value is less than or equal to 26.55, it indicates that the participant has some type of sexual dysfunction (16) .
The data were stored in a spreadsheet structured in Microsoft Excel, with double entry to validate the data entered and ensure reliability in the compilation.
To verify the association between the variables, the  (1) .

Results
Of the 110 women who participated in the study, 41 had SMM and 69 did not have any problems during the pregnant-puerperal cycle. Table 1  Among the cases of SMM, hypertensive disorders were the most frequent (83%), with severe hypertension and severe pre-eclampsia, the most incident diagnoses (Table 2).
Rev. Latino-Am. Enfermagem 2020;28:e3293.   Table 3 shows the comparison of each domain and the total FSFI score between women with and without SMM. From the analysis of the data of the participants in this study, no association was found between the occurrence of female sexual dysfunction and SMM.
When analyzing the domains that make up the FSFI, there was an association between the presence of SMM and pain during sexual intercourse, regardless of age, length of relationship, income, self-reported skin color, parity and type of delivery (Table 4).

Discussion
In this study, there were statistically significant differences between the age (P= 0.013) and duration of pregnancy (P<0.001) variables between women with or without SMM. However, in addition to these two variables, the characterization of these women shows similarities with several studies, both in our country and abroad. These data agree with a study carried out in the state of Sergipe (17) , women, using FSFI, and found no association between groups; however, the score obtained indicated dysfunction both in the group of women with morbidity and in the control group (13) .
From the Inflated Beta regression analysis, the present study found a significant association between some FSFI domains and some women's variables: orgasm and self-reported skin color, satisfaction and length of relationship, and pain and SMM, corroborating data from a study that found association between sexual dysfunction and skin color, demonstrating that non-white women find it easier to reach orgasm when compared to white women (12) . With regard to dyspareunia, our study found that women who suffered some type of injury during pregnancy, childbirth or postpartum had higher rates of pain during sexual intercourse when compared to women who went through a pregnancy without any type of injury. This result agrees with a research carried out in Campinas which revealed that maternal morbidity is directly associated with a higher frequency of dyspareunia after delivery (15) .
As for the limitations of this study, it is considered that, as it is a cross-sectional study, a characteristic limitation is the fact that the data are collected at only one point in the lives of these women. Thus, there is no way to state that women who scored less than 26.55 did not previously have any type of sexual dysfunction. In a prospective cohort study, data would be collected at various times and there would be a follow-up of the sexual life of these women. In this context, the importance of the nurse's approach to the topic in women's routine consultations is emphasized.
It must be considered that sexuality is still a subject whose approach generates discomfort. In this sense, despite having their privacy preserved, many women may have felt shy at the time of the interview, which may have interfered with the results. Another limitation lies in the fact that the instrument used was designed to be applied to women without any type of health problem. As far as we know, there is no specific instrument in the literature to assess the sexual health of women who have had an event of severe maternal morbidity.

Conclusion
Our study showed that white women have greater difficulty in reaching orgasm when compared to nonwhite women and that women with more than 120 months of relationship feel more dissatisfied with sexual health than women with less time in relationship.
However, women who had some type of SMM have more dyspareunia when compared to women who did not have any type of injury during pregnancy, childbirth or postpartum.
We understand that these findings show that women's sexual health should be better assessed in routine consultations and that SMM may have an influence on the sexual response after delivery. Thus, we hope that our results will stimulate further studies with a view to a better approach to female sexual health and the prevention of problems during pregnancy, childbirth or postpartum.