The present study provided a detailed analysis of the discourses on prolonged sexual abstinence after childbirth in a low-income Tanzanian suburb. The dominant and socially desirable discourse in this study setting delineated sexual abstinence as a means of protecting the infant from a perceived illness called kubemenda. As a dominant discourse
, this limited what people could say. Stereotypic gender relations, with male dominance and female submission, were normative and depicted as essential for controlling sexuality to ensure family health and avoid the social implications of non-adherence to sexual abstinence. The medical discourse with aspects such as contraceptives, HIV, and the use of health care services, was less prominent. Other co-existing and conflicting discourses delineated abstinence as being against natural human sexuality, and resulting in practices that could endanger family relationships and health. This is especially problematic in the era of HIV/AIDS. Nevertheless, modern discourses were interspersed among traditional ones.
The promotion of child health through birth spacing is the main reason for observing abstinence in Tanzania
[9, 28], Ghana
, Ivory Coast
[11, 19], and Nigeria
. In the present study however, abstinence was observed mainly to avoid kubemenda. The viewpoint that condoms prevent pregnancy but could not always protect the child from kubemenda supports this argument. However, as reported from Malawi
, the participants in the present study often referred to modern couples as having the possibility to use condoms and other modern contraceptives to protect the child and/or avoid further pregnancy. The variety of explanations of how kubemenda occurred and was prevented could possibly be explained by the multitude of ethnic and cultural backgrounds among the population in Ilala and the FGDs. However, in all the FGDs, there appeared to be genuine worry about resuming sex after childbirth, although opinions on the duration of abstinence differed. The low usage of modern contraceptives among married women, 34% in Tanzania and 30% of women in the reproductive age in Dar es Salaam
, is problematic. The reluctance to use contraceptives could possibly reflect parents’ fear of sexual resumption that might result in a new pregnancy sooner than desired, in addition to having little awareness of, and poor access to, contraceptive methods.
In contrast, in other instances, condoms were also described as an acceptable strategy for avoiding kubemenda during the postpartum period. This is because condoms were believed to prevent sperm from possible poisoning breast milk. The higher awareness and acceptability of condoms compared to other modern contraceptives seen in the present study results indicate the importance of raising awareness of and improving access to a variety of contraceptive methods to enable informed choice among men and women.
There are no medical reasons for refraining from vaginal intercourse after childbirth once the woman’s discharge has ceased and any wounds have healed
, which generally happens 4–6 weeks after delivery. Establishing this knowledge in communities could facilitate women’s and men’s informed choices on the timing of the resumption of sex postpartum. Health workers have a responsibility for providing this knowledge, particularly to first-time parents, and information and the provision of modern contraceptives have the potential to diminish tensions related to sexuality after childbirth.
Prolonged sexual abstinence of up to two and a half years was described as being the predominant behaviour in both the olden days and at present, suggesting a reiteration of the discourse across generations, and illustrating the role of discourse in the production and reproduction of social practices in societies
. However, these results should be interpreted with caution, as what people say in a group discussion does not necessarily accord with how they behave in real life. In a group discussion, the expression of views is likely to adhere to socially acceptable norms in a particular social context, and this is supported by findings from the Tanzania health survey
, where the median length of postpartum abstinence was only 3.8 months.
An imbalance in the power relations between men and women in sexual relationships was highlighted, and this corroborated other work on dominant male sexuality
[1, 7, 31]. Men were accorded more power and fewer restrictions on sexual matters than were women, who were burdened with more responsibilities and blamed if expectations were not met. The differences in the way men and women were positioned in relation to sexuality illustrated ‘power determines whose pleasure is given priority and when, how, and with whom sex takes place’
, page 2. As men were presumed ‘weak’ and having an uncontrollable sexual desire, they were privileged to continued sex life, whereas, women were restrained from the possibility of enjoying and meeting their sexual needs. This reflected the traditional feminine and masculine stereotypes prevalent both in Tanzania
 and globally
. These concepts encourage, perpetuate, and normalise infidelity in men, and reproduce gender inequalities with negative implications for family health, such as contraction of STIs and family breakups. Nevertheless, these stereotypic ideas require cautious consideration, as other, less prominent, patterns were highlighted. Quantitative studies are needed to explore the distribution of these perceptions and practices in the broader study population. Furthermore, females participated in upholding male dominance discourses, a factor that has been previously described
, indicating how deeply these ideas are embedded in the participants’ culture and, as such, are regarded as normative.
Whereas men were positioned as ‘weak’ in abstaining from sex, women were expected to curb the problem by providing sex to avoid risking HIV/STIs, and to protect their marriage, even if this happens against their will. Women in this position lacked the right to decide when to have sex (‘lack of bedroom power’) page 167. Female submission to male sexual dominance is a social expectation
. However, in Ilala, this problem was compounded by women’s economic dependence, as they were expected to disregard their partners’ infidelity so as not to be deprived of basic needs such as food. Thus, achieving equal gender-power relations is unrealistic if women are not economically empowered. Obtaining positive relationships among couples and practices that promote family health requires economically independent women and general sexuality education covering gender dimensions, in which maternal and child health services are important stakeholders.
Different moral standards related to sexual activity after childbirth were used to determine who were good mothers and women and good fathers and men, a fact that supported previous findings
[6, 31]. For instance, women having extramarital sex were labelled as deviant and irresponsible, whereas, for men, the same behaviour was socially tolerable and even expected. Similar differences in moral standards in this area are described by mothers
 and fathers
 suggests ‘deviant’ women might be tired of repression, and find ways of expressing and meeting their sexual urge by adopting positions to take control of their lives. This could be an alternative interpretation of the findings in the present study.
Sexuality as a socially constructed phenomenon can be controlled and channelled in directions where it does least harm
. The tensions in the discourse in the present study indicated a possible opening for introducing interventions aimed at promoting family health after childbirth. Interventions in the form of dialogue between couples, community members in general, and health care providers would create a forum for discussing different discourses, the tensions created, and their relation to various practices that are important for family health after childbirth. Further, the dialogue would act as a forum for the provision of health information and discussion on gendered norms relating to sexuality during the childbearing period. Increasing the awareness of gendered feminine and masculine notions that can compromise the health of the families is important for enabling couples to make informed choices in relation to sexuality, and for creating opportunities for health workers to reflect on their own perspectives and uncertainties as part of both the traditional and medical discourses.
The discourses indicated a strong link between perceptions on sexual behaviour and ideas about the qualities that make a good parent. This could be an asset and a motivating factor for change towards promoting healthier lifestyles during the childbearing period. Change could be promoted by creating awareness of how previous discourses that might have supported health in other times and settings could now lead to ill health, due to changed circumstances, such as the abandonment of organised polygamy and the high prevalence of HIV; and of new possibilities, such as condoms, oral contraceptives and increased knowledge about sexual relations. One of the challenges would be discussing and questioning the perceived direct link between sexual activity and ill health in infants, in the face of the strong popular belief in kubemenda. The existence of discourses contradicting the dominant discourse of abstinence could be used to motivate discussions and interventions for influencing a positive change towards healthy behaviour.
To understand both sexual relations after childbirth and the tension resulting from conflicting discourses in connection to kubemenda and sexuality, participants relied on traditional discourses, and only partly on medical discourses. However, this depended on specific contexts and individual situations and preferences. In accordance with previous studies on mothers
 and fathers
, if the worries outlined in the discourses were not addressed, they could have negative health implications for both the baby and the parents. The increased risk of contracting HIV/STIs in the case of multiple sex partners was considered a threat, as was disagreements between the couple over sexual abstinence. Furthermore, common childhood illnesses might be confused with kubemenda, implying the child might be denied health care and taken to traditional healers instead. In the worst scenario, parents might decide to stop breastfeeding prematurely to be able to have sex, contrary to professional advice. However, participants in the present study did not describe this as an option. Premature mixed feeding or weaning increases the risk of diarrhoea, infections, malnutrition, and slow development in infants
, which could be interpreted as kubemenda from a layman’s perspective.
Although emotional health problems were not explored or mentioned in the FGDs, these problems, especially depression, are internationally described as frequent among women and men, in general, and during the postpartum period in particular
[36–38]. From the results of the present study, the worries, relational problems, violence, and ill health indicate a possibility of the development of emotional problems. There are few studies on emotional health after childbirth in Tanzania
, and further studies are thus needed to explore the frequency and character of depression among parents during the childbearing years.
Currently in Tanzania, the health care system pays little attention to maternal or family health after childbirth, including sexual matters
. In the present study, health workers were said to be active in reinforcing traditional discourses, which implies a lack of expertise on sexual matters after childbirth. Health care providers should inform, and discuss sex resumption and related problems after childbirth, with the parents. Midwives and other health care providers are in a better position to intervene if provided the opportunity, in the form of guidelines, content and skills, for sexual education after childbirth. A crucial contribution would be putting the Tanzanian national policy
 for postpartum health care visits into practice.
Descriptions of the participants’ characteristics, setting, along with some illustrative quotes, were provided to help in the assessment of the transferability of the results from the present study to other contexts. One limitation of this study was the design, which did not allow ethnic differences to be discerned, although 29 ethnics groups, out of about 130 existing in Tanzania, were represented, and the FGD groups comprised a mixture of participants with different ethnic backgrounds. Furthermore, the study did not include first-time parents with higher educational levels and higher socioeconomic status. Their inclusion could have generated different perspectives.