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Arch Sex Behav

DOI 10.1007/s10508-016-0818-z

ORIGINAL PAPER

Sexual Risk and Intravaginal Practice Behavior Changes During


Pregnancy
Chloe A. Teasdale1,2 Elaine J. Abrams1,2 Mary Ann Chiasson2,3 Jessica Justman1,2
Kelly Blanchard4 Heidi E. Jones5

Received: 11 February 2016 / Revised: 11 July 2016 / Accepted: 19 July 2016


 Springer Science+Business Media New York 2016

Abstract Data suggest that pregnant women in some settings some high-risk sexual behaviors but increased the risk of sex
have high prevalence of HIV and other sexually transmitted without a condom.
infections (STI). We examined changes in sexual risk behaviors
and intravaginal practices during pregnancy that may contribute Keywords Sexual risk behaviors  Pregnancy 
to HIV and STI incidence using data from the Methods for Intravaginal practices
Improved Reproductive Health in Africa study conducted in
South Africa and Zimbabwe 20032006. We used a crossover
design and modified Poisson regression to compare behaviors Introduction
among HIV negative women 1845 years during pregnant and
non-pregnant periods. Among the 4802 women\45 years at Epidemiologic data suggest that pregnant women, particularly
enrollment, 483 (10.1 %) had a pregnancy and were included young pregnant women and those in resource-limited settings,
in the analysis. Compared to non-pregnant periods, pregnancy have high prevalence of sexually transmitted infections (STI),
was associated with fewer than 3 sex acts per week (adjusted risk including HIV (Berggren & Patchen, 2011; Chico et al., 2012;
ratio [ARR] 0.89; 95 % CI 0.790.99) but more sex acts without Kurewa et al., 2010; Moodley et al., 2015). STIs cause consid-
condoms (ARR 1.32; 95 % CI 1.151.51). Pregnancy was also erable morbidity in women, with infections potentially leading
associated with decreased reporting of other sexual risk behav- to infertility and other adverse health outcomes, including mor-
iors including any anal sex, multiple sexual partners, and/or tality in the case of HIV (Mullick, Watson-Jones, Beksinska, &
sex in exchange for drugs or money. Women also reported less Mabey, 2005; Paavonen & Eggert-Kruse, 1999). STIs can also
intravaginal wiping during pregnancy (ARR 0.84; 95 % CI cause complications during pregnancy includingpreterm deliv-
0.760.93). We found pregnancy decreased sexual activity and ery and premature rupture of membranes which can be life
threatening for both pregnant women and infants (Mullick et al.,
2005).In addition, certain infectionscan be transmittedto infants
causing congenital defects such as blindness and developmental
& Chloe A. Teasdale disabilities,andsomeinfectionscanbefatal(James& Kimberlin,
ct116@columbia.edu
2015; Mullick et al., 2005).
1
International Center for AIDS Care and Treatment Programs Sexual risk behaviors have been studied in order to identify
(ICAP), Mailman School of Public Health, Columbia which are most strongly associated with STI incidence and
University, 722 W 168th Street, Room 1319, New York, prevalence in women. Sexual risk behaviors found to be asso-
NY 10032, USA
ciated with STI transmission include sex without a condom
2
Department of Epidemiology, Mailman School of Public (unprotected sex), frequency of sex, concurrent sexual part-
Health, Columbia University, New York, NY, USA
nerships, number of lifetime sex partners, transactional orex-
3
Public Health Solutions, New York, NY, USA changesex (for shelter, money, or drugs), and unprotected anal
4
Ibis Reproductive Health, Cambridge, MA, USA sex (Chersich & Rees, 2008; Kaestle, Halpern, Miller, & Ford,
5
Department of Epidemiology, Hunter College, City University 2005; Mylonas, 2012; Op de Coul et al., 2011; Shain et al., 1999).
of New York School of Public Health, New York, NY, USA These data are important for understanding STI acquisition in

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Arch Sex Behav

women; however, there have been few examinations of whether intravaginal practices more often when they have transac-
sexual risk behaviors change during pregnancy, particularly in tional sex (Lees et al., 2014) which could increase STI risk if
low resource settings where STI prevalence is high. transactional sex partners are more likely to be infected with
Existing studies on sexual behaviors of pregnant women STIs or if transactional sex involves more risky behaviors.
have found that coital frequency tendsto decline over the course There are few studies describing intravaginal practices among
of pregnancy with the least amount of intercourse reported in pregnant women. In a cross-sectional study of pregnant women in
the third trimester generally (Bartellas, Crane, Daley, Bennett, Cote dIvoire, 97 % reported douching before antenatal medical
& Hutchens, 2000; Pauleta, Pereira, & Graca, 2010; Senkum- visits and 98 % reported douching as a common practice (La
wong, Chaovisitsaree, Rugpao, Chandrawongse, & Yanunto, Ruche et al., 1999). Data on other types of intravaginal practices
2006). Data from a cross-sectional survey of women in Malawi have not been reported among pregnant women. Given the lim-
found that pregnant women reported less sex than non-pregnant ited data on intravaginal practices during pregnancy and their
women and a decline in frequency of intercourse over the course potential as a risk factor for STI acquisition, it is critical to
of the pregnancy (Keating et al., 2012). A study from South describe the frequency of these behaviors among pregnant
Africa showed relatively high rates of sexual activity in late women and to document how intravaginal practices change
pregnancy but less frequent sex in the postpartum period. In during pregnancy.
the South African study, 67 % of women 2430 weeks gestation We conducted a secondary analysis of data from a randomized
reported sexual activity in the previous week, whereas only 49 % clinical trial to measure the association between pregnancy status
reported recent sexual activity at 3 months postpartum (Villar- and self-reported sexual behaviors and intravaginal practices
Loubet et al., 2013). among women with documented pregnancies during follow-up.
Available data are inconsistent with regard to how pregnancy
impacts sexual risk behaviors known to be associated with STI
acquisition. Sex without a condom was more frequently repor- Method
ted by pregnant women compared to non-pregnant women in
several studies (Gray et al., 2005; Morrison et al., 2007; Mugo Participants
et al., 2011; Reid et al., 2010); however, other risk behaviors
associated with STI transmission appear less common among We examined the association between pregnancy and sexual
pregnant women including concurrent sexual partnerships and risk behaviors and vaginal practices using a crossover design
transactional sex (Gray et al., 2005; Morrison et al., 2007; Reid comparing self-reported data by the same group of women prior
et al., 2010). There are few data on the sexual risk behaviors of to and during pregnancy. The data come from the Methods for
male partners of pregnant women which is also a critical fac- Improved Reproductive Health in Africa (MIRA) study, an
tor in womens STI acquisition. Pregnant women in Malawi open-label randomized controlled trial of the diaphragm and
reported greater fear of male partner infidelity compared to lubricant gel for prevention of HIV infection in women which
non-pregnant women (Keating et al., 2012). However, in studies has been previously described (Padian et al., 2007). The MIRA
with data collected from male partners, men in South Africa and trial was approved by institutional review boards in the U.S.,
Uganda were not more likely to report additional sex partners South Africa, and Zimbabwe (ClinicalTrials.gov: NCT00121
when their female partners were pregnant (Gray et al., 2005; 459), and the current analysis was exempt from additional ethics
Villar-Loubet et al., 2013). review as a secondary analysis of de-identified data.
Inadditiontosexualriskbehaviors,intravaginalpracticeshave During MIRA study follow-up, which ranged from 12 to 24
been identified as a potentially important mechanism for STI months, participants attended quarterly visits and received rou-
acquisition. Intravaginal practices include a broad array of tine STI and HIV testing, and risk reduction counseling includ-
behaviors such as douching or cleaning the vagina which may ing unlimited condoms. At each visit, participants reported sex-
be done for hygienic reasons or for pregnancy prevention, as ual activity, contraceptive and condom use, and intravaginal
well as practices aimed at altering the vagina, such as inserting practices in the previous 3 months through clinician-adminis-
absorbent materials to tighten or dry the vagina (Lees et al., tered interviews and audio computer-assisted self-interview-
2014; Myer, Kuhn, Stein, Wright, & Denny, 2005). Intravagi- ing (ACASI). Women who became pregnant during follow-up
nal practices have been studied as a potential causal factor in continued in the study during and after pregnancy.
womens STI risk, most notably HIV (Joesoef et al., 1996; Lees Pregnancy status was assessed at all quarterly study visits
et al., 2014; Low et al., 2011; Myer et al., 2005; Scholes et al., through laboratory (urine) pregnancy testing. Knowledge of
1998). It is not fully understood how intravaginal practices pregnancy was assessed at each quarterly follow-up visit through
increase STI risk; it may be through abrasions to vaginal tissue a clinical questionnaire which included asking women whether
or through alteration of the vaginal pH level which causes bac- they had been pregnant at any time prior to the visit and on what
terial vaginosis (Low et al., 2011; Rottingen, Cameron, & Gar- date they knew of the pregnancy. Women who became pregnant
nett, 2001). Some studies have shown that women engage in reported the date when they first knew of the pregnancy and

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resolution of pregnancies, including deliveries, miscarriages, included frequency of vaginal sex acts per week with/without
and terminations. To examine whether sexual risk behaviors a condom, number of vaginal sex partners, transactional sex,
and vaginal practices changed in response to pregnancy, only and any anal intercourse. In addition to examining the individual
follow-up time after the date a woman knew of a pregnancy measures, a dichotomoushigh-risk sexvariable was created
was considered as pregnant follow-up time for the analysis. indicating any report of the following: vaginal sex without a con-
For the analysis, a woman was considered pregnant in the inter- dom, exchange sex, anal sex (with or without condoms), two or
val preceding a visit if she had a positive urine pregnancy test at more sex partners, and having had a new sex partner. Women
the visit and had knowledge of the pregnancy prior to the visit. also reported on male sexual partner behaviors at enrollment,
In addition, women were also considered pregnant at a visit if it including HIV-positive status, partners away from home for
occurred within 6 weeks of a reported birth as women were preg- more than month, suspecting or knowing a partner had other
nant for the majority of that visit interval. sex partners, and use of alcohol or drugs before sex. A variable
Visit intervals with women who had negative pregnancy tests was created indicating male partners who werehigh riskat
were considered non-pregnant, including those with reports of enrollment using these variables. At follow-up visits, women
miscarriages and terminations since the last visit. Visit intervals reported whether they knew or suspected male partners of having
were also considered non-pregnant for women who had posi- other partners and abuse by partners.
tive pregnancy tests but no knowledge of the pregnancy. Visits Self-reported data on intravaginal practices were also col-
that occurred more than 6 weeks after a reported delivery were lected at all quarterly follow-up visits and were classified into
excluded from the analysis as data suggest that sexual behav- three categories: intravaginal washing (inside the vagina),wip-
iorsmaychangeinthepostpartumperiod(DeSchachtetal.,2014). ing, or insertion of products not related to menstruation. Fre-
Visits that occurred during a pregnancy were further classified quency of the three types of intravaginal practices was assessed
according to the estimated gestational age of the fetus at the visit using categories for reported daily, weekly, monthly, or none,
based on the first date women reported knowing of a pregnancy, and a summary variable was created indicating any of the three
first positive pregnancy test, or the delivery date (last menstrual intravaginal practices.
period date was not available). Given that we did not have precise
gestational age measuresandthatpreviousstudieshavesuggested Statistical Analysis
that sexual behaviors change in the third trimester (Bartellas et al.,
2000; Pauletaet al., 2010), gestational age was estimated in weeks Descriptive statistics (chi-squared tests for categorical variables
and then visits were grouped by trimester with visits in the first and Wilcoxon tests for continuous variables) were used to com-
28 weeks of pregnancy considered to be first/second trimester pare demographic characteristics and frequency of reported sex-
and visits after 28 weeks and up to 6 weeks postpartum as third ual behaviors and intravaginal practices at enrollment comparing
trimester. women included in the analysis who had pregnancies to women
We restricted the analysis to women 1845 years of age who who did not have a pregnancy during follow-up. Next, the fre-
had at least one visit with a laboratory positive pregnancy test with quency of sexual behaviors and intravaginal practices reported at
prior knowledge of the pregnancy and then examined non-preg- study visits prior to and during pregnancies among women
nant visits prior to the pregnancy and visits during pregnancy. To included in the analysis was examined. To compare the fre-
be included, women had to have at least one non-pregnant visit at quency of reported sexual risk behaviors and intravaginal prac-
most 6 months prior to the first pregnant visit. Only scheduled tices, logistic regression models fitted with generalized estimat-
quarterly follow-up visits with both pregnancy testing and self- ing equations (GEE) with an exchangeable correlation matrix
reported behavior data were examined. Visits after HIV diagnosis were used to estimate robust standard errors (for continuous vari-
for women who seroconverted and visits more than 6 months ables, linear regression with GEE was used). The same analysis
apart were excluded (follow-up time was truncated at the last was conducted to examine the association between sexual behav-
visit before a 6-month gap) in order to ensure comparisons iors and intravaginal practices according to gestational age. A
between pregnant and non-pregnant visits were in close prox- further analysis measured change across two visits for each
imity. For women with two pregnancies during follow-up, only woman, the visit just prior to the pregnancy, and the first visit
visits prior to and during the first pregnancy were included. during the pregnancy, using McNemars test for paired cate-
gorical data. Finally, modified Poisson regression models (to
Measures correct variance estimates for repeated measures per partic-
ipant) were fitted to estimate the risk ratio of sexual risk behav-
Sexual Risk Behaviors and Intravaginal Practices iors and intravaginal practices at pregnant and non-pregnant
visits (Zou, 2004). Multivariable models were adjusted for age,
Women were asked via ACASI about their sexual behavior in the study randomization arm, and location. All statistical proce-
previous 3 months at enrollment and quarterly visits. Reports dures were conducted using SAS 9.3 (SAS Institute, Cary, NC).

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Table 1 Characteristics at enrollment by pregnancy status during follow-up, N = 4313


Characteristics at enrollment Total Women with no pregnancies Women in analysis p value
N % N % N %

4313 100.0 3830 88.8 483 11.2


Study location
Harare 2155 50.0 1881 49.1 274 56.7 .01
Durban 1289 29.9 1165 30.4 124 25.7
Johannesburg 869 20.2 784 20.5 85 17.6
Age
Median age (range) 27 (1845) 27 (1845) 24 (1844) \.001
1824 1635 37.9 1388 36.3 247 51.1 \.001
2534 1751 40.6 1552 40.5 199 41.2
C35 927 21.5 890 23.2 37 7.7
Completed high school (11-year school) 2263 51.5 1987 51.9 276 57.1 .03
Paid employment 985 22.8 888 23.2 97 20.1 .13
Married 2546 61.3 2250 58.8 296 61.3 .29
Lives with male partner 2928 67.9 2591 67.7 337 69.8 .42
Previous pregnancy 3956 91.7 3536 92.3 258 87.0 \.001
Using hormonal contraception (oral/injectable) 2719 63.0 2446 63.9 273 56.5 \.01
Regular sexual partner 1763 40.9 1577 41.2 186 38.5 .37
Two or more sexual partners 357 8.3 312 8.2 45 9.3 \.01
Three or more sex acts per week 2317 53.7 2079 54.3 238 49.3 .10
Condom use (male or female) at last sex 3040 70.5 2701 70.5 339 70.2 .88
Sex without a condom past 3 months 2931 68.1 2610 68.3 321 66.5 .40
Exchange for money or drugs past 3 months 344 8.0 306 8.0 38 7.9 .92
High-risk sexa 1002 23.2 879 23.0 123 25.5 .22
Partner older[5 years 1694 41.1 1502 41.1 192 40.9 .21
Partner tested HIV-positive 150 3.5 136 3.6 14 2.9 .45
Partner away from home[2 months 472 10.9 425 11.1 47 9.7 .37
Suspects/knows male partner concurrency 1302 30.3 1164 30.5 138 28.6 .39
Physical or verbal abuse 789 33.3 715 33.3 74 33.0 .94
Partner high riskb 2685 62.2 2386 62.3 299 61.9 .87
Intravaginal washing
Daily 2632 61.2 2331 61.1 301 62.3 .54
Weekly 623 14.5 562 14.7 61 12.6
Monthly or less 299 7.0 268 7.0 31 6.4
None 747 17.4 657 17.2 90 18.6
Intravaginal wiping
Daily 1741 40.5 1546 40.5 195 40.4 .50
Weekly 418 9.7 362 9.5 56 11.6
Monthly or less 267 6.2 237 6.2 30 6.2
None 1875 43.6 1673 43.8 202 41.8
Intravaginal insertion (non-menstruation related)
Daily 560 13.0 502 13.2 58 12.0 .87
Weekly 144 3.4 126 3.3 18 373.0
Monthly or less 178 4.1 158 4.1 20 4.1
None 3415 79.5 3028 79.4 387 80.1
Diaphragm arm 2132 49.4 1901 49.6 231 47.8 .45
Positive for STI (enrollment)
Chlamydia 187 4.3 159 4.2 28 5.8 .09

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Table 1 continued
Characteristics at enrollment Total Women with no pregnancies Women in analysis p value
N % N % N %

Gonorrhea 33 0.8 30 0.8 3 0.6 .70


Trichomoniasis 157 3.6 137 3.6 20 4.1 .53
HSV-2 2492 57.8 2257 59.0 235 48.7 \.001
a
High-risk sex: (any of the following) C2 partners, exchange sex, anal sex, and use of alcohol and/or drugs before sex
b
High-risk partner: (any of the following) HIV-infected, away[1 month from home, suspected or known to have other sexual partners, and use of
alcohol and/or drugs before sex

Table 2 Risk behaviors reported at 2540 follow-up visits and association with pregnancy status, N = 483 women (unadjusted odds ratios)
Reported behaviors at follow-up Frequency of report Frequency of report Frequency of report Odds ratio pregnant versus
at all visits at non-pregnant at pregnant visits non-pregnant periods
visits
N % N % N % OR 95 % CI p value

2540 100.0 1636 64.4 904 35.6


Any vaginal sex since last visit 2409 94.8 1560 95.4 849 93.9 0.87 0.631.20 .40
Vaginal sex frequency per week
Mean (range) 3.6 (010) 3.8 (010) 3.4 (010) 0.74 0.640.85 \.001
C3 times per week 1607 69.4 1022 71.2 585 66.5 0.80 0.690.93 \.01
Condom use at last sex 1654 68.7 1103 70.7 551 64.9 0.81 0.680.96 .02
Unprotected sex (any report) 1646 68.3 1018 65.3 628 74.0 1.42 1.191.70 \.01
Anal sex since last visit 136 5.4 104 6.4 32 3.5 0.54 0.370.80 \.01
Sex in exchange for money or drugs 79 3.3 56 3.6 23 2.7 0.80 0.581.11 .18
C2 male sex partners since last visit 156 6.5 130 8.3 26 3.1 0.32 0.210.49 \.001
New sex partner 264 10.9 188 12.0 76 9.0 0.69 0.540.88 \.01
Suspects/knows male partner concurrency 573 23.7 384 24.5 189 22.3 0.89 0.751.05 .16
High-risk sexa 431 17.0 316 19.3 115 12.7 0.59 0.470.72 \.001
Intravaginal washing
Daily 1424 56.1 914 55.9 510 56.4 0.84 0.740.96 .01
Weekly 306 12.1 200 12.2 106 11.7 0.87 0.721.11 .17
Monthly or less 224 8.8 162 9.9 62 6.9 0.72 0.580.92 \.01
None (ref) 586 23.1 360 22.0 226 25.0 1.00
Any 1954 76.9 1276 78.0 678 75.0 0.82 0.710.94 \.01
Intravaginal wiping
Daily 795 31.3 543 33.2 525 27.9 0.70 0.610.80 \.0001
Weekly 158 6.2 113 6.9 45 5.0 0.64 0.500.83 \.01
Monthly or less 117 4.6 82 5.0 35 3.9 0.63 0.460.86 \.01
None (ref) 1470 57.9 898 54.9 572 63.3 1.00
Any 1070 42.1 738 45.1 332 36.7 0.66 0.590.75 \.0001
Intravaginal insertion (non-menstruation related)
Daily 173 6.8 118 7.2 55 6.1 0.76 0.571.01 .06
Weekly 50 2.0 35 2.1 15 1.7 0.71 0.411.22 .22
Monthly or less 75 3.0 54 3.3 21 2.3 0.71 0.481.06 .09
None (ref) 2242 88.3 1429 87.4 813 89.9 1.00
Any 298 11.7 207 12.7 91 10.1 0.74 0.590.93 .02
a
High-risk sex: (any of the following) C 2 partners, exchange sex, anal sex, and use of alcohol and/or drugs before sex

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Fig. 1 Risk behaviors reported at two follow-up visits for each woman: last non-pregnant and first pregnant visit, N = 483

Results having other sexual partners. Intravaginal washing and wiping


wereboth commonly reported at enrollment by all women; more
Among 4948 women included in the MIRA trial final analysis, than 60 % of women in both groups reported any intravaginal
4802 were 1845 years of age; 3830 (79.8 %) had no pregnan- washing and 40 % reported intravaginal wiping. Significantly,
cies during follow-up; and 662 (13.8 %) had laboratory-con- more women who did not have pregnancies during follow-up
firmed and known pregnancies [the remaining 310 (6.5 %) were serological positive for HSV-2 at enrollment (p\.0001).
women had either only self-reported pregnancies or laboratory- Theanalysisincludes2540visitscompletedbythe483women
confirmed pregnancies but no visits with prior knowledge of the with pregnancies, 1636 (64.4 %) non-pregnant visits, and 904
pregnancy]. Among all women with laboratory-confirmed and (35.6 %) visits during pregnancies (Table 2). Median time
known pregnancies, 483 (73.0 %) were included in the analysis; between visits was 91 days (interquartile range [IQR] 9095),
179 (27.0 %) were excluded for lacking a non-pregnant follow- follow-up time per woman was 15 months (IQR 1221), and
up visits at most 6 months prior to the first pregnant visit. median number of visits per woman was 5 (range 28); 3 (range
Compared to women with no pregnancies, women included 17) during pregnancies; and 2 (range 14) during non-preg-
in the analysis were younger; median age 24 years (range 18 nant periods.
44 years) for those with pregnancies compared to 27 years (range Regardless of pregnancy status, women reported sexual activity
1845) for women with no pregnancies (p\.0001) (Table 1). at almost all visits; however, women were less likely to report three
Pregnant and non-pregnant women did not differ by marital or more sex acts per week when they were pregnant, odds ratio
status or cohabitation with male partners. More than 70 % of (OR) = 0.80, 95 % CI [0.69, 0.93] (Table 2). During pregnancy,
women in both groups reported using condoms at the last sex women were more likely to report last sex without a condom
act, but an equal proportion reported at least one sex act in the (OR = 0.81, 95 % CI[0.68,0.96])and anysexwithout a condom in
last 3 months without condoms (Table 1). Male partner charac- the past 3 months (OR = 1.42, 95 % CI [1.19, 1.70]). There were
teristics did not differ by group, and roughly, 30 % of women in lower reports of other risk behaviors during pregnancy including
both groups reported knowing or suspecting male partners of anal sex, having two or more sexual partners and having had a new

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Table 3 Association between pregnancy status and reported risk behaviors and intravaginal practices at follow-up visits, N = 483 women, 2540 visits
(modified Poisson risk regression)
Risk behavior Univariable Adjusted
RR 95 % CI p value RR 95 % CI p value

Any vaginal sex since last visit 0.80 0.641.00 0.05 0.84 0.671.05 .12
Vaginal sex C3 times per week 0.88 0.800.99 0.03 0.89 0.790.99 .04
Condom use (male or female) at last sex 0.85 0.750.96 0.01 0.82 0.720.93 \.01
Unprotected sex (any report) 1.30 1.141.49 \0.01 1.32 1.151.51 \.001
Anal sex since last visit 0.68 0.510.90 0.01 0.67 0.510.89 .01
Sex in exchange for money or drugs 0.84 0.611.17 0.30 0.83 0.601.15 .27
C2 male sex partners since last visit 0.55 0.390.77 \0.01 0.47 0.320.69 \.01
New sex partner 0.84 0.691.02 0.07 0.81 0.670.98 .03
Suspects/knows male partner concurrency 0.92 0.801.06 0.21 0.89 0.781.02 .10
High-risk sexa 0.75 0.640.88 \0.01 0.74 0.630.86 \.01
Intravaginal washing
Daily 0.94 0.81.1 0.29 0.94 0.841.06 .32
Weekly 0.92 0.81.1 0.36 0.91 0.751.10 .33
Monthly or less 0.73 0.60.9 0.01 0.74 0.580.94 \.01
None (ref) 1.00 1.00
Any 0.92 0.81.0 0.14 0.92 0.821.03 .15
Intravaginal wiping
Daily 0.85 0.80.9 \0.01 0.85 0.760.95 .01
Weekly 0.76 0.61.0 0.04 0.76 0.590.99 .04
Monthly or less 0.80 0.61.1 0.13 0.81 0.611.07 .14
None (ref) 1.00 1.00
Any 0.92 0.80.9 \0.01 0.84 0.760.93 \.01
Intravaginal insertion (non-menstruation related)
Daily 0.93 0.81.2 0.52 0.93 0.751.15 .49
Weekly 0.87 0.51.4 0.57 0.87 0.541.40 .57
Monthly or less 0.79 0.61.1 0.12 0.78 0.581.06 .12
None (ref) 1.00 1.00
Any 0.87 0.71.0 0.12 0.87 0.731.04 0.11
a
High-risk sex: (any of the following) C2 partners, exchange sex, anal sex, and use of alcohol and/or drugs before sex

sexual partner in the past 3 months (Table 2). Overall, during preg- Comparingsexual riskbehaviorsreportedbywomenatthelast
nancy, women were less likely to report high-risk sex (OR = 0.59, non-pregnant visit and the first pregnant visit, 15.7 % of women
95 % CI [0.47, 0.72]) and were significantly less likely to report who reported sex without a condom at the pregnant visit had not
intravaginalwashing,wiping,orinsertionofproducts;oddsofdaily reportedsexwithoutacondomattheprecedingnon-pregnantvisit
intravaginal wiping during pregnancy were 30 % lower (OR = (p\.05, Fig. 1). A significant proportion of women also changed
0.66, 95 % CI [0.590.75]) compared to non-pregnant periods. from reporting some high-risk sex prior to pregnancy, but none
Of the 904 pregnant visits included in the analysis, 492 (54.4 %) once they were pregnant (p\.01). Women also appeared to
were estimated to have occurred during the first/second trimester decrease intravaginal wiping (p = .05) once they were preg-
and 412 (45.6 %) occurred during the third trimester (data not nant with a significant proportion changing from reporting this
shown). Compared to visits earlier in pregnancy, during the third behavior prior to pregnancy but not reporting it at the first preg-
trimester women reported less sex between visits, OR 0.39, 95 % nant visit.
CI[0.220.72],andfewerreportedthree ormore sexactsperweek, In multivariable Poisson models, pregnancy was associated with
OR = 0.59, 95 % CI [0.47, 0.73]. During the third trimester, less frequent sex, adjusted risk ratio (ARR) sex C3 times per week
women were more likely to report sex without a condom com- 0.89, 95 % CI [0.790.99], less reported condom use at last sex,
paredto visitsearlierinpregnancy. Nodifferenceswereobserved ARR = 0.82, 95 % CI [0.72, 0.93], and more reported unprotected
in sexual risk behaviors between early and late pregnancy, nor for sex,ARR = 1.32,95 %CI[1.15,1.51](Table 3).Overallpregnancy
intravaginal practices. was also associated with less high-risk sex, ARR = 0.74, 95 % CI

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[0.630.86].Pregnancywasnot associatedwithlowerriskofintrav- Thisstudy isoneofonlyafewexaminingintravaginal practices


aginal washing or insertion of materials but was found to decrease among pregnant women and one of the only studies to measure the
the risk of intravaginal wiping on a daily and weekly basis; preg- impact of pregnancy on these behaviors. Intravaginal practices are
nancy was associated with 26 % lower risk of any intravaginal considered important modifiable risk factors for STI acquisition,
wiping, ARR = 0.84, 95 % CI [0.760.93]. particularlyHIV,andhavealsobeenassociatedwithincreasedrisk
of ectopic pregnancy (Cottrell,2010). The decrease in intravaginal
wiping we observed could be a result of less sexual activity during
pregnancy or reduced frequency of exchange sex which has been
Discussion found to be positively associated with intravaginal practices (Lees
et al., 2014). It is also possible that the reduction in intravaginal
This analysis examined changes in self-reported sexual behaviors practices during pregnancy was a result of a general decline in
and intravaginal practices during pregnancy in order to under- these behaviors observed during the trial among participants
stand pregnancys impact on important factors associated with as reported by van der Straten et al. (2010). These data provide
STI acquisition. We found that pregnancy tended to lead to a important new information, and further study of intravaginal
decrease sexual activity, particularly in the third trimester. We practices during pregnancy is warranted given their role in
also observed that vaginal sex without condoms was reported STI acquisition and potential impact on pregnancy outcomes.
more frequently during pregnancy compared to non-pregnant In addition to providing additional information about sexual
periods; however, other sexual risk behaviors were reported less behaviors of pregnant women and, as noted above, novel data on
frequently during pregnancy, including anal sex, concurrent sex- intravaginal practices among pregnant women, to our knowl-
ual relationships, new sex partners, and intravaginal wiping. edge, this is one of the only studies to date comparing these
Our findings that sexual activity decreased, that sex without behaviors prior to and during pregnancy in the same women.
a condom was more common, and that other sexual risk behav- A major strength of the analysis was the crossover design which
iors, such as anal sex and having multiple concurrent sexual allowed women to serve as their own controls. This approach is
partnerships, occurred less frequently during pregnancy are con- unique for studies in this area and has advantages over the more
sistent with previous studies from resource-limited settings typical approach of comparing sexual risk behaviors of women
(Gray et al., 2005; Keating et al., 2012; Morrison et al., 2007; who are pregnant to other women who are not pregnant, which
Mugo et al., 2011; Reid et al., 2010; Villar-Loubet et al., 2013) has the potential for uncontrolled or residual confounding result-
and highlight the complexities of understanding risk factors for ing from non-comparability of women who do and those who do
STIs, including HIV, during pregnancy. Lower frequency of sex- not have pregnancies during follow-up. In addition, we had a
ual activity and fewer additional sexual partners should confer robust sample of over 480 women with both pregnant and non-
lower risk of STI acquisition; however, lower rates of condom pregnant follow-up time in data from a randomized clinical trial
useamongpregnant women couldincreaseexposuretoSTIs,and with rigorous follow-up and data collection procedures.
risk could be further increased if male partners have concurrent This study had several important limitations including potential
relationships during pregnancy. Changes in behaviors of male bias in the reporting of sexual behaviors, which have been shown to
partner of pregnant women have only been measured in a small be unreliable markers of risk (Fenton, Johnson, McManus, &
number of studies focused on HIV risk, none of which have Erens, 2001; Minnis et al., 2009; Minnis, van der Straten, Gerdts,
shown increases in partner concurrency during pregnancy (Gray & Padian, 2010; Weinhardt, Forsyth, Carey, Jaworski, & Dur-
et al., 2005; Villar-Loubet et al., 2013). ant, 1998). A recent review of studies using biological validation
At more than 60 % of all follow-up visits, women reported use of self-reported HIV risk behaviors estimated that on average
of condoms at the last sex act, including during pregnancy; how- about 38 % of participants over report condom use (Zimmer-
ever, sex without a condom at any time between visits was also man, Morisky, Harrison, & Mark, 2014). It is not clear whether
reported frequently (over 68 % of follow-up visits) regardless pregnancy has an impact on this reporting bias, and we cannot
of pregnancy status. The women in this analysis were enrolled know whether condom use actually declined during pregnancy
in an HIV prevention trial and were counseled at all study visits, or whether there were systematic differences in reporting based
including those during pregnancy, to use condoms for HIV and on pregnancy status. In addition, we considered visits to have
STIprevention.Despitecounseling,mostwomenreportedunpro- occurred during a pregnancy only when woman knew about the
tected sex at visits with increased reporting during pregnancy pregnancy prior to the visit and it is possible that some women
which poses risks of their own health and the health of their may not have accurately reported when they knew about preg-
child. These data suggest that pregnant women may need more nancies. We also did not have data on last menstrual period, and
support to understand the continued risk of STIs during preg- thus, approximate gestational age was used. A final limitation of
nancy and suggest that interventions are needed to improve con- the data was not having information reported directly by male
sistent condom use among pregnant women. partners.

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Arch Sex Behav

Conclusion cohort study in Southern Mozambique. Journal of the International


AIDS Society, 17, 18808. doi:10.7448/IAS.17.1.18808.
Fenton, K. A., Johnson, A. M., McManus, S., & Erens, B. (2001). Measuring
In this study, women reduced condom usage during pregnancy sexual behaviour: Methodological challenges in survey research. Sex-
which could increase their risk of HIV and other STI acquisi- ually Transmitted Infections, 77(2), 8492.
tion, but also reduced other high-risk sexual behaviors and intra- Gray, R. H., Li, X., Kigozi, G., Serwadda, D., Brahmbhatt, H., Wabwire-
vaginal wiping which could decrease risk. In settings with high Mangen, F., Wawer, M. J. (2005). Increased risk of incident HIV
during pregnancy in Rakai, Uganda: A prospective study. Lancet,
STI and HIV prevalence, interventions to increase condom 366(9492), 11821188. doi:10.1016/S0140-6736(05)67481-8.
usage during pregnancy may be warranted. James, S. H., & Kimberlin, D. W. (2015). Neonatal herpes simplex virus
infection: Epidemiology and treatment. Clinics in Perinatology, 42(1),
Acknowledgments We are grateful to the participants in the MIRA study, 4759. doi:10.1016/j.clp.2014.10.005.
as well as the study staff and investigators, for generously providing us with Joesoef, M. R., Sumampouw, H., Linnan, M., Schmid, S., Idajadi, A., & St
their data. Louis, M. E. (1996). Douching and sexually transmitted diseases in
pregnant women in Surabaya, Indonesia. American Journal of
Funding The analysis presented here was a secondary analysis that did Obstetrics and Gynecology, 174(1 Pt 1), 115119.
not receive funding. Details regarding funding for the MIRA trial have Kaestle, C. E., Halpern, C. T., Miller, W. C., & Ford, C. A. (2005). Young
been previously published (Padian et al., 2007). age at first sexual intercourse and sexually transmitted infections in
adolescents and young adults. American Journal of Epidemiology,
161(8), 774780. doi:10.1093/aje/kwi095.
Keating, M. A., Hamela, G., Miller, W. C., Moses, A., Hoffman, I. F., &
Compliance with Ethical Standards
Hosseinipour, M. C. (2012). High HIV incidence and sexual behavior
change among pregnant women in Lilongwe, Malawi: Implications
Conflict of Interest None of the authors have conflicts of interest related
for the risk of HIV acquisition. PLoS ONE, 7(6), e39109. doi:10.1371/
to this analysis.
journal.pone.0039109.
Kurewa, N. E., Mapingure, M. P., Munjoma, M. W., Chirenje, M. Z.,
Ethical Approval The analysis presented here was a secondary analysis of
Rusakaniko, S., & Stray-Pedersen, B. (2010). The burden and risk
the MIRA trial which was approved by institutional review boards in the U.S.,
factors of sexually transmitted infections and reproductive tract
South Africa, and Zimbabwe (ClinicalTrials.gov: NCT00121459). The
Infections among pregnant women in Zimbabwe. BMC Infectious
current analysis was exempt from additional ethics review as a secondary
Diseases, 10, 127. doi:10.1186/1471-2334-10-127.
analysis of de-identified data.
La Ruche, G., Messou, N., Ali-Napo, L., Noba, V., Faye-Kette, H., Combe,
P., Msellati, P. (1999). Vaginal douching: Association with lower
Human and Animal Rights No animals or human subjects were involved
genital tract infections in African pregnant women. Sexually Transmit-
with this analysis; all data from the original study were de-identified prior to
ted Diseases, 26(4), 191196.
this analysis. Lees, S., Zalwango, F., Andrew, B., Vandepitte, J., Seeley, J., Hayes, R. J., &
Francis, S. C. (2014). Understanding motives for intravaginal practices
Informed consent Details regarding the informed consent process have amongst Tanzanian and Ugandan women at high risk of HIV infection:
been published previously (Padian et al., 2007). The embodiment of social and cultural norms and well-being. Social
Science and Medicine, 102, 165173. doi:10.1016/j.socscimed.2013.
12.005.
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