Coitus late in pregnancy: Risk of preterm rupture of

amniotic sac membranes

Edem E. Ekwo, MD, MPH: Carol A. Gosselink, PhD: Robert Woolson, PhD,b
Atef Moawad, MD: and Cynthia R. Long, MSb
Chicago, Illinois, and Iowa City, Iowa

OBJECTIVES: Coitus with or without orgasm in late pregnancy is inconsistently associated with preterm
rupture of amniotic sac membranes. We tested the hypothesis that during late pregnancy sexual
behaviors including sexual positioning relate to the occurrence of premature rupture of membranes.
STUDY DESIGN: Women aged 15 to 45 years having preterm premature rupture of membranes, term
premature rupture of membranes, or preterm delivery without premature rupture of membranes were
matched singly by age, race, and parity to control women delivered of term infants. Information about six
sexual activities, obstetric history, cervical infections, smoking during pregnancy, and sociodemographic
information was obtained by face-to-face interview.
RESULTS: Only the male superior position was significantly associated with preterm premature rupture of
membranes (odds ratio 2.40, 95% confidence interval 1.16 to 4.97) and preterm delivery without
premature rupture of membranes (odds ratio 1.82, confidence interval 1.02 to 3.25) after confounding
variables were controlled for. No sexual positioning or sexual activities related significantly to term
premature rupture of membranes.
CONCLUSION: Most sexual positions and activities during late pregnancy are not associated with
adverse pregnancy outcomes. (AM J QBSTET GYNECOI. 1993;168:22-31.)

Key words: Coitus, late pregnancy, premature rupture of membranes

Investigation of risk factors associated with prema-
ture rupture of membranes is important because of the
relationship of premature rupture of membranes to
preterm deliveryl.3 and perinatal infections!-6 A possi-
ble risk factor for premature rupture of membranes is
sexual intercourse during pregnancy. However, results
from previous studies relating sexual behaviors during
pregnancy to premature rupture of membranes are
inconsistent. Sexual intercourse during pregnancy has
been associated with preterm delivery7. 8 and amniotic
fluid infections. 9, 10 Orgasm with or without sexual in-
tercourse also has been reported to relate to prematu~e
rupture of membranes, especially during late pregnan-
cy7, 8 and with a slow fetal heart rate." Yet other studies
have failed to find a relationship between sexual inter-
course and the occurrence of premature rupture of
From the Department of Obstetrics and Gynecology and La Rabida
Children's Hospital and Research Center, University of Chicago
PritzAer School of Medicine,· and the DIViSIOn of Biostatistics, De-
partment of Preventive Medicine, University of Iowa School of Med-
icine.b
Supported fry the United States Public Health Service, Natwnal
Institute of ChIld Health and Human Development grant No.5 R01
HD20361-02.
Received for publicatwn January 28, 1992; revised May 26, 1992;
accepted June 2, 1992.
Reprint requests: Edem E. Ekwo, MD, MPH, La Rabida ChIldren's
Hospital and Research Center, E. 65th St. and Lake MIChIgan,
Chicago, IL 60649.
6/1/39935
membranes. 12• 14 Moreover, some of these studies have
small sample sizes, use inappropriate control groups, or
do not adjust for confounding variables relating sexual
behavior to premature rupture of membranes.
Different positions used by partners during sexual
intercourse and their role in causing premature rupture
of membranes have not been examined. For example,
do couples who use the male superior position late in
pregnancy have increased risk of premature rupture of
membranes as compared with those using the female
superior position? Does achieving organism late in
pregnancy increase the risk for premature rupture of
membranes? The current report is from a matched-pair
case-control study examining factors potentially associ-
ated with premature rupture of membranes, exploring
the hypothesis that sexual behaviors during pregnancy
and use of various positions during coitus relate to the
occurrence of premature rupture of membranes.
Material and methods
Subjects. Those eligible for participation in the study
were female subjects aged 15 to 45 years and giving
birth to infants in the Departments of Obstetrics and
Gynecology at the University of Iowa Hospital and
Clinics (1985 to 1986) and the Pritzker School of
Medicine, University of Chicago (1987 to 1990). Writ-
ten informed consent was obtained from each subject
after the study'S purpose was explained. The study was

22 0002-9378/93 $1.00 + 0.20

Volume 168
Number I . Part 1
approved by the institutional review boards for human
experimentation at both study sites.
Because risk factors for preterm premature rupture
of membranes may differ from those for term prema-
ture rupture of membranes, two study groups were
defined. Also, prematurity itself may constitute a risk
factor for premature rupture of membranes; therefore a
third study group consisting of women who were deliv-
ered preterm without premature rupture of membranes
was included. On the basis of study eligibility criteria,
women were classified within 72 hours of delivery into
three study groups: (1) pre term premature rupture of
membranes if the amniotic sac membranes ruptured at
least 3 hours before the onset of sustained labor at =:; 36
weeks of gestation; (2) preterm delivery without prema-
ture rupture of membranes if delivery occurred at =:; 36
weeks of gestation after the onset of sustained sponta-
neous labor and before rupture of amniotic sac mem-
branes, and (3) term premature rupture of membranes
if delivery occurred at ~ 37 weeks of gestation and the
amniotic sac membranes spontaneously ruptured at
least 3 hours before onset of sustained labor. Control
women were delivered ~ 39 weeks of gestation after
onset of sustained labor before spontaneous or artificial
rupture of amniotic sac membranes occurred. The def-
inition of controls avoided serious selection bias that
would result from including women whose gestational
age was actually =:; 36 weeks but was wrongly classified
as 37 to 38 weeks. Excluding women at 37 to 38 weeks
of gestation could potentially result in selection bias,
but such a selection bias is not as serious as the former
bias. Control women were matched singly to cases by
age (± 1 year), race, and parity (0, 1, 2 to 5, ~ 6). The
diagnosis of premature rupture of membranes was
made by direct observation of discharged fluid from the
vagina on careful speculum examination, a positive
Nitrazine paper test, and positive fernings . Gestational
age was estimated from last menstrual cycle, by ultra-
sonography, or by physical examination of the infact
with the criteria of Dubowitz et al. 15 Eligible mothers
were enrolled only once in the study, irrespective of
whether they had more than one delivery during the
study period. Subjects were excluded from the study for
these reasons: (1) a chronic debilitating disease (e.g.,
cystic fibrosis or chronic heart failure), (2) exposure to
chemotherapy or radiation therapy during pregnancy,
(3) inability to respond to the interview survey, or (4)
multiple births at the index pregnancy.
Interviews. All subjects were interviewed within 72
hours of delivery. Interviews were conducted by an
extensively trained interviewer with 6 years' experience
in interviewing techniques. A structured standardized
questionnaire was used to obtain information in five
primary categories: (1) sociodemographic variables, (2)
gynecologic history, (3) smoking, caffeine consumption,
Coitus late in pregnancy 23
and alcohol or drug use, (4) complications occurring
during the index pregnancy, and (5) sexual history. The
current report focuses on sexual history. Twenty-four
sexual experiences were selected initially, but after ex-
tensive pretesting six of these sexual activity questions
were retained because they were practiced most consis-
tently and frequently by the study population.
The following instructions were read to the subjects
from the questionnaire about their sexual behaviors.
"In this section we are going to ask some questions
about sexual experiences you mayor may not have had.
This is a list of sexual experiences that some people
have. (Subjects were then handed a card listing the
sexual experiences and the response options.) We
would like to know which of these experiences you had.
We are particularly interested in the 6 months before
you were pregnant, the whole time you were pregnant
except for the last month of pregnancy, and during the
last 4 weeks before the membranes ruptured (or you
had your baby). For those you experienced, please
tell me the letter that describes how often this hap-
pened."
The interviewer then read each sexual experience.
Subjects stated the frequencies of their experiences for
periods corresponding to the 6 months before concep-
tion and the time of pregnancy except for the last
month and the last 4 weeks before membrane rupture
or delivery. The six sexual experiences listed on the
response cards were: (1) sexual intercourse with you
lying on top of your partner (female superior), (2)
sexual intercourse with your partner lying on top of you
(male superior), (3) sexual intercourse with both of you
lying side by side, (4) sexual intercourse with vaginal
entry from the rear, (5) orgasm (coming) with or with-
out sexual intercourse, and (6) kissing on the mouth.
The frequences of individual experiences were catego-
rized as follows: never, one or two times a month, three
or four times a month, two or three times a week, four
to six times a week, and daily.
The interviewer recorded responses to each question .
If a subject did not understand a question, the inter-
viewer again read it aloud without further elaboration.
Subjects were informed they could refuse to answer any
part or all of the questions if they felt uncomfortable
with the intimate details of their sexual experiences.
Medical information. Medical data abstracted from
mothers' and infants' charts were used to cross-check
the accuracy of responses obtained during the inter-
view. Information on medical matters from the chart
was always assumed to be more accurate than that
obtained from the mother; the reverse was assumed for
sociodemographic and life-style information.
Abstracted data included obstetric history, medica-
tions taken during pregnancy, complications of preg-
nancy, culture results, and history of infections during
24 Ekwo et al.
pregnancy and the immediate postpartum period (48
hours) for mothers and infants.
Clinical chorioamnionitis was defined by the criteria
of Gibbs et al. 16 and consisted of two or more of the
following: fever ;:: 38° C, maternal and fetal tachycardia,
uterine tenderness, foul odor, and peripheral leukocy-
tosis. Urinary tract infection was documented from
urine culture ;:: 100,000 single species of organisms per
milliliter anytime during the pregnancy. Cervical
Chlamydia trachomatis infection was evidenced by cervical
culture by the standard culture technique. I7 Endocervi-
cal calcium-alginated swabs were placed in sucrose-
phosphate buffer glutamate transport media and im-
mediately kept on wet ice until inoculated within 4
hours of collection on cycloheximide-treated McCoy
cells for recovery of C. trachomatis. A separate endocer-
vical swab was directly inoculated onto a Thayer-Martin
medium for recovery of Neisseria gonorrhoeae.
Data analysis. Sociodemographic variables were an-
alyzed univariately; the p values for the matched-pair X2
test are reported. I8 Sexual experiences were recoded as
dichotomous variables (no = 0, if the woman did not
have the particular experience; yes = 1, if she had the
experience). Conditional logistic regression analyses
with the use of maximum likelihood parameter esti-
mates were used to determine whether sexual experi-
ences for matched case and control pairs differed.
Separate logistic regressions were performed for each
study group on every sexual behavior; the unadjusted
odds ratio and 95% confidence intervals are reported.
The independent effects of variables potentially con-
founding the relationship of sexual intercourse to preg-
nancy outcome, such as marital status, history of having
premature rupture of membranes and delivery in a
previous pregnancy, smoking history, history of any
operation on the cervix, or urinary tract, cervical, or
intraamniotic infection during index pregnancy, were
analyzed in the same manner. Multiple conditional
logistic regression analyses were performed to examine
the independent effects of risk factors and to adjust
simultaneously for such possible confounding effects. 18
The independent variables controlled for in the anal-
ysis were coded as follows: Three levels of household
exposure of the subject to cigarette smoke were created,
the referent group being the household where no one
smoked. These three levels of exposure included house-
holds in which other individuals but not the study
subject smoked, households where the study subject
alone smoked, and those where both the subject and
other household members smoked. Previous experi-
ence with premature rupture of membranes was coded
to two levels indicating whether the women had any
previous pregnancies complicated by either preterm or
term premature rupture of membranes. Women having
no previous experience of premature rupture of mem-
January 1993
Am J Obstet Gynecol
branes served as the referent group. Women having
both previous preterm and term premature rupture of
membranes were too few (n = 13) to form a separate
group and were classified as having preterm premature
rupture of membranes since we hypothesized that a
history of preterm rather than term premature rupture
of membranes would be a more predictive variable in
relation to preterm premature rupture of membranes
in subsequent pregnancy outcome. Previous cervical
surgery, history of urinary tract infection during the
index pregnancy, and presence of chorioamnionitis in
the index pregnancy were each dichotomized. Cervical
infection with chlamydia was coded as positive cul-
ture = 1 and negative culture = O. However, to prevent
women who had no culture or whose results could not
be traced from being eliminated from the analysis, a
dummy variable was constructed to reflect situations in
which no culture was performed (coded as 1) versus
negative culture (coded as 0). When either one of these
two chlamydia variables showed a significant relation-
ship to the outcome, both were retained in the final
model.
Results
During the 4 1/2-year catchment period 1353 mothers
who met the criteria for enrollment as either case or
control were approached. Ninety-nine of these women
refused to participate primarily because they did not
want to take the time to be interviewed. Appropriate
matches could not be found for 78 cases generally
involving older women with high parity or from racial-
ethnic groups that could not be matched. Thus a total
of 588 cases and their matched controls, or 1176
participants, completed the study. Of these, 19 women
refused to answer any of the sexual questions. They and
their respective matches were eliminated from all fur-
ther analysis. These women did not differ from the
participants by mean age, years of education, or parity.
The distribution of the three variables (age, parity,
and race) used for matching cases to controls in each
study group shows that cases and controls were appro-
priately matched (Table I). In the preterm premature
rupture of membranes group the mean maternal age
for cases was 25.1 ± 5.4 compared with 25.2 ± 5.2
years for controls and parity was 1.3 ± 1.4 versus
1.2 ± 1.3 for cases compared with controls. The mean
of the differences between case-control pairs in either
age (- 0.06 ± 0.07, P = 0.44) or parity (0.07 ± 0.05,
P = 0.14) was not statistically different from O. For
preterm delivery without premature rupture of mem-
branes and term premature rupture of membranes
groups, the mean of the differences between case-
control pair's age and parity was similarly not statisti-
cally different from 0, indicating an appropriate match
on these variables. The percentage of nonwhite moth-
Volume 168 Coitus late in pregnancy 25
l\ umber I. Part I

ers was higher for the preterm delivery without prema- Table I. Distribution of matched variables for
ture rupture of membranes group than for the other cases and controls by study group
two groups.
Cases Controls
The percent distribution of sociodemographic vari-
ables for preterm premature rupture of membranes Preterm delzvery WIth premature rupture of membranes
Age (yr)
and preterm delivery without premature rupture of :519 29 (16.2) 23 (12.9)
membranes groups is shown in Table II. Controls were 20-24 57 (31.8) 60 (33.5)
significantly more educated than cases among the pre- 25-29 51 (28.5) 56 (31.3)
~30 42 (23.5) 40 (22.3)
term premature rupture of membranes group, with Parity
31.4% of controls versus 21.8% of controls having some o 63 (35.2) 63 (35.2)
college or more education. A significantly higher per- 1 53 (29.6) 53 (29.6)
2-3 47 (26.3) 52 (29.9)
centage of preterm premature rupture of membranes 4-5 15 (8.4) 10 (5.6)
cases (53.3%) than controls (46.4%) relied on Medicaid ~6 1 (0.5) 1 (0.5)
to cover their pregnancy-related health-care costs. Sig- Race
White 73 (40.8) 73 (40.8)
nificantly more term premature rupture of membranes Nonwhite 106 (59.2) 106 (59.2)
cases than controls were employed outside the home Term deltvery with premature rupture of membranes
(Table III). However, the percentage distribution of Age (yr)
:5 19 43 (20.5) 43 (20.5)
most of the sociodemographic variables for controls 20-24 77 (36.7) 76 (36.2)
and cases was not statistically different. 25-29 50 (23.8) 51 (24.3)
Sexual experiences of cases and controls during the 4 ~30 40 (19.0) 40 (19.0)
Parity
weeks before delivery were examined (Table IV). The 0 108 (51.4) 107 (51.0)
male superior position was reported most frequently by 1 59 (28.1) 59 (28.1)
all case groups and was used by 13% to 31% of the 2-3 38 (18.1) 38 (18.1)
4-5 5 (2.4) 6 (2.8)
women during sexual intercourse. Control subjects ~6 0(0.0) 0(0.0)
most often used either the male superior or side-by-side Race
position during intercourse. From 22% to 33% of case White 88 (41.9) 88 (41.9)
Nonwhite 122 (58.1) 122 (58.1)
and control women achieved orgasm during inter- Preterm delzvery WIthout premature rupture of membranes
course. Age (yr)
The frequencies of sexual experiences throughout :5 19 60 (33.3) 60 (33.3)
20-24 57 (31.7) 58 (32.3)
pregnancy were lower than during the 6 months before 25-29 41 (22.8) 42 (23.4)
conception and continued to decline in the last 4 weeks ~30 22 (12.2) 20 (1Ll)
of gestation. The average number of times per week Parity
o 80 (44.4) 80 (44.4)
cases and controls reported using the male superior 1 49 (27.2) 49 (27.2)
position during sexual intercourse is shown in Table V. 2-3 42 (23.3) 46 (25.6)
The frequency of this most common position declines 4-5 9 (5.1) 5 (2.8)
~6 0(0.0) 0(0.0)
as gestation progresses. Repeated-measures analysis of Race
variance showed no significant differences in frequen- White 41 (22.8) 41 (22.8)
cies between cases and controls in the preterm without Nonwhite 139 (77.2) 139 (77.2)
premature rupture of membranes and term premature
rupture of membranes groups. Significant differences
in average frequency of engaging in coitus with the
male superior position did occur between preterm pre- univariate conditional logistic regression analysis of the
mature rupture of membranes cases and controls relationship between sexual activities and pregnancy
(P = 0.002); however, the frequencies declined in the outcome in the 4 weeks preceding delivery showed that
same manner for cases and controls from 6 months the male superior position (odds ratio 1.84, confidence
before pregnancy to the duration of pregnancy except interval 1.05 to 3.22) and orgasm with or without sexual
for the last month (p = 0.66), and from the duration of intercourse (odds ratio 1. 91, confidence interval 1.12 to
pregnancy except for the last month to the last 4 weeks 3.23) were associated with statistically significant risk of
of pregnancy (p = 0.23). The frequency of couples pre term rupture of amniotic sac membranes (Table VI).
kissing each other should not be affected appreciably by Vaginal entry from the rear and female superior posi-
pregnancy. Indeed, the percentage of women report- tions showed a slight but not statistically significant
ing kissing remained high among case and control trend toward increased risk. The male superior position
groups. was not associated with a statistically increased risk of
Examination of unadjusted odds ratios and 95% term premature rupture of membranes (odds ratio
confidence intervals for each variable by means of 1.59, confidence interval 0.93 to 2.71), although there
 26 Ekwo at al. January 1993
Am J Obstet Gynecol

Table II. Percent distribution of sociodemographic variables for cases and controls at index pregnancy:
Preterm premature rupture of membranes and preterm delivery without premature rupture
of membranes
Preterm premature Preterm delivery without
rupture of membranes premature rupture of membranes

Cases Controls Cases Controls

(n = 179) (n = 179) (n = 180) (n = 180)
Variable (%) (%) Significance * (%) (%) Significance*
Education
< High school 30.7 25.1 P = 0.002 44.4 39.4 P = 0.36
High school 47.5 37.4 32.8 32.8
> High school 21.8 37.4 22.8 27.8
Marital status
Not married 49.2 50.8 P = 0.69 62.8 60.6 P = 0.62
Married 50.8 49.2 37.2 39.4
Household income
~$25,OOO 17.9 18.4 P = 0.63 10.6 13.9 P = 0.44
Refused or do 5.6 3.9 7.2 10.6
not know
$10,000-$24,999 21.2 25.7 21.7 21.1
<$10,000 55.3 51.9 60.6 54.4
Insurance
Self-pay 11.7 19.5 P = 0.03 10.0 11.1 P = 0.70
Medicaid 53.6 46.4 62.8 59.4
Third-party 34.6 43.1 27.2 29.4
Employment
Unemployed 73.2 72.6 P = 0.89 81.7 80.0 P = 0.64
Employed 26.8 27.4 18.3 20.0

*p Value of matched X2 calculated by k x k contingency tables, where k is number of levels of the variable.

Table III. Percent distribution of the pre term delivery without premature rupture of
sociodemographic variables for cases membranes group, however, the male superior position
and controls at index pregnancy: Term proved to be significantly associated with the risk of
premature rupture of membranes pereterm delivery without premature rupture of mem-
branes (odds ratio 2.05, confidence interval 1.20 to
Cases Controls
(n = 210) (n = 210) 3.50). Orgasm was not associated with increased risk for
Variable (%) (%) Significance preterm delivery without premature rupture of mem-
Education branes.
< High school 25.2 24.3 P = 0.84 Univariate analyses of the confounding variables
High school 35.7 34.8 likely to modifY the association of sexual activities with
> High school 39.1 40.9
Marital status pregnancy outcome consisting of preterm premature
Not married 44.3 43.8 P = 0.90 rupture of membranes or preterm delivery without
Married 55.7 56.2 premature rupture of membranes are shown in Table
Household income
VII. Among women with preterm premature rupture of
~$25,OOO 19.5 20.5 P = 0.73
Refused or do 6.2 5.2 membranes, variables with signficant unadjusted odds
not know ratios included previous history of pre term premature
$10,000-$24,999 21.9 25.2
<$10,000 52.4 49.1 rupture of membranes (odds ratio 4.64, confidence
Insurance interval 2.02 to 10.70) or term premature rupture of
Self-pay 19.5 21.9 P = 0.19 membranes (odds ratio 2.58, confidence interval 1.29
Medicaid 47.2 41.9
Third-party 33.3 36.2 to 5.16), urinary tract infection during index pregnancy
Employment (odds ratio 3.08, confidence interval 1.65 to 5.75),
Unemployed 65.2 73.8 P = 0.04 history of cervical surgery (odds ratio 1.83, confidence
Employed 34.8 26.2
interval 1.03 to 3.26), subject alone smoked (odds ratio
*p Value of matched X· calculated by k x k contingency 4.24, confidence interval 1.79 to lO.03), or she and
tables, where k is number of levels of the variable. others in the household smoked (odds ratio 2.06, con-
fidence interval 1.20 to 3.54), or chorioamnionitis dur-
was a trend in that direction. None of the other five ing index pregnancy (odds ratio 8.5, confidence inter-
sexual positions was associated with increased risk of val 1.96 to 36.79). The odds for preterm premature
term premature rupture of membranes, and therefore rupture of membranes of 4.24 when the mother alone
no further analysis of this group was undertaken. For smoked were less than the odds of 2.06 when she and
Volume 168 Coitus late in pregnancy 27
Number 1, Part I

Table IV. Frequency distribution of sexual positions, activities, and orgasm during last 4 weeks
of pregnancy
Study group

Preterm delzvery with Term delivery with Preterm delivery without

premature rupture premature rupture premature rupture
of membranes of membranes of membranes

Cases Controls Cases Controls Cases Controls

(n = 179) (n = 179) (n = 210) (n = 210) (n = 180) (n = 180)
Sexual
actiVity No.
I % No. I % No.
I % No. I % No.
I % No. I %
Male superior
Yes 49 27.4 33 18.4 41 19.5 28 13.3 54 30.0 33 18.3
No 130 72.6 146 81.6 169 80.5 182 86.7 126 70.4 147 81.7
Female superior
Yes 30 16.8 22 12.3 26 12.4 30 14.3 23 12.9 23 12.8
No 149 83.2 157 87.7 184 87.6 180 85.7 157 87.2 157 87.2
Couples lying side by side
Yes 39 21.8 34 19.0 36 17.1 42 20.0 35 19.4 30 16.7
No 140 78.2 145 81.0 174 82.9 168 80.0 145 80.6 150 83.3
Vaginal entry from rear
Yes 25 14.0 19 10.6 20 9.5 23 10.9 20 ILl 19 10.6
No 154 86.0 160 89.4 190 90.5 187 89.1 160 88.9 161 89.4
Orgasm With or without coztus
Yes 58 32.4 39 21.8 52 24.8 49 23.3 52 28.9 55 30.6
No 121 67.6 140 78.2 158 75.2 161 76.7 128 7Ll 125 69.4
Kissing*
Yes 138 77.5 140 78.2 166 79.4 165 78.9 140 77.8 131 72.8
No 40 22.5 39 21.8 43 20.6 44 21.1 40 22.2 49 27.2

*Some responses are missing.

Table V. Distribution of average times per week of male superior position during coitus for 6 months
before pregnancy, throughout pregnancy except for last month, and during last 4 weeks
of pregnancy
Average times per week

Preterm delivery With Preterm delivery Without Term delivery wzth

premature rupture premature rupture premature rupture
Male superior of membranes of membranes of membranes
position
dUring coitus Cases
I Controls Cases I Controls Cases I Controls
During 6 mo before pregnancy 2.24 1.85 2.00 2.16 1.93 1.88
Throughout pregnancy except 1.37 0.88 0.98 1.21 1.05 0.90
for last month
During last 4 wk of pregnancy 0.57 0.30 0.34 0.32 0.18 0.15

others in the household smoked. A majority of the case
(40/63, 63.5%) and control (27/44, 61.4%) mothers
living in households where others smoked were them-
selves light smokers « 10 cigarettes per day). Thus
their total exposure to cigarette smoke could have been
less than that for mothers who were the only smokers in
their households. This no doubt accounts for a lack of
incremental risk for smoking mothers living with other
smokers, compared with mothers who alone smoked.
Preterm premature rupture of membranes cases had
3.33 odds of cervical chlamydia infection, but this was
not significant at the 0.05 level.
Variables significantly associated with preterm deliv-
ery without premature rupture of membranes included
history of previous preterm premature rupture of mem-
branes (odds ratio, 2.83, confidence interval 1.11 to
7.22) or previous cervical surgery (odds ratio 2.50,
confidence interval 1.35 to 4.65), smoking by the sub-
ject and other household members (odds ratio 2.35,
confidence interval 1.31 to 4.21), and cervical chlamy-
dia infection during pregnancy (odds ratio 3.67, confi-
dence interval 1.02 to 13.14). Chorioamnionitis was not
a significant risk factor and was excluded from subse-
quent multivariate analysis.
The relationship of sexual intercourse in the male
superior position to preterm premature rupture of
membranes was examined by multiple conditional lo-
gistic regression analysis after confounding variables
28 Ekwo et al. January 1993
Am J Obstet Gynecol

Table VI. Conditional logistic analysis of relationship of sexual activities in last 4 weeks of gestation to
pregnancy outcome
Preterm delivery with Term delivery with Preterm delivery wIthout
premature rupture premature rupture premature rupture
of membranes of membranes of membranes

Sexual activity
Unadjusted
odds ratio
I 95%interval
Confidence Unadjusted
odds ratio
I 95%interval
Confidence Unadjusted
odds ratio
I 95%interval
Confidence

Female superior 1.50 0.80-2.82 0.88 0.41-1.67 1.08 0.51-2.29

Male superior 1.84 1.05-3.22 1.59 0.93-2.71 2.05 1.20-3.50
Couples lying side 1.19 0.71-1.98 0.84 0.48-1.36 1.19 0.71-2.01
by side
Vaginal entry from 1.40 0.72-2.72 0.88 0.43-1.79 1.06 0.55-2.01
rear
Orgasm with or 1.91 1.12-3.23 1.12 0.70-1.79 0.93 0.60-1.41
without inter-
course

Table VII. Conditional logistic analysis of potential confounders of relationship of sexual activities in last
4 weeks of gestation to pregnancy outcome
Preterm delivery WIth Preterm delivery WIthout
premature rupture of membranes premature rupture of membranes

Individual 95% Confidence Individual 95% Confidence

Potential confounder odds ratIO I znterval odds ratio I interval
History of premature rupture of membranes
Preterm 4.64 2.02-10.70 2.83 1.11-7.22
Term 2.58 1.29-5.16 0.99 0.46-2.13
Family history of premature 0.72 0.44-1.20 0.79 0.46-1.37
rupture of membranes
Urinary tract infection 3.08 1.65-5.75 1.30 0.78-2.14
History of cervical surgery 1.83 1.03-3.26 2.50 1.35-4.65
Smoking in household
Others alone smoke 1.06 0.60-1.89 1.76 0.99-3.12
Subject alone smokes 4.24 1.79-10.03 1.47 0.58-3.74
Subject and others smoke 2.06 1.20-3.54 2.35 1.31-4.21
Chlamydia infection
Positive 3.33 0.92-12.11 3.67 1.02-13.14
Not available 1.00 0.56-1.78 0.63 0.39-1.22
Chorioamnionitis 8.50 1.96-36.79 1.00 0.25-3.99

were controlled for (Table VIII). Variables having po-
tentially significant confounding effects at the univari-
ate level were included in the analysis. However, no
other sexual experience variables were included be-
cause they did not further contribute to the fit of the
model. As a consequence of the large number of po-
tentially confounding variables, two models were built
to explore the effects of controlling for infection in the
analysis. With history of urinary tract infection included
in the model, the independent association of the male
superior position to preterm premature rupture of
membranes remained statistically significant (odds ratio
2.63, confidence interval 1.30 to 5.S1). When chlamydia
infection and clinical chorioamnionitis were added to
the model, the association between sexual intercourse
and male superior position was still significant, al-
though the magnitude of the odds ratio decreased to
2.40 (confidence interval 1.16 to 4.97).
The relationship of orgasm with or without sexual
intercourse to preterm premature rupture of mem-
branes shows a trend toward significance after con-
founding variables were controlled for (Table IX). The
odds ratio for the association was 1.92 (confidence
interval 1.02 to 3.61) when urinary tract infection,
previous cervical surgery, and household smoking ex-
posure were included (model 1). However, the relation-
ship between orgasm and preterm premature rupture
of membranes was strong, although no longer signifi-
cant (odds ratio 1.93, confidence interval 0.97 to 3.86)
when chlamydia and chorioamnioftitis were also in-
cluded (model 2). The p values for the relationship of
orgasm to preterm premature rupture of membranes
were 0.04 and 0.06 for models 1 and 2, respectively.
Similarly, a statistically significant association was
found between sexual intercourse in the male superior
position and preterm delivery without premature rup-
Volume 168 Coitus late in pregnancy 29
Jl<umber I, Part I

Table VIII. Conditional multiple logistic regression analysis of relationship of male superior sexual
position to preterm delivery with premature rupture of amniotic sac membranes after confounding
variables are controlled for
Modell Model 2

Adjusted 95% Confidence Adjusted 95% Confidence

Vanable odds ratIO I interval odds ratIO
I interval

Male superior position 2.63 1.30-5.31 2.40 1.16-4.97

Previous premature rupture of membranes
Preterm 7.32 2.70-19.84 7.51 2.67-21.12
Term 3.10 1.34-7.14 3.15 1.33-7.45
Urinary tract infection 4.56 2.13-9.77 5.17 2.24-11.97
Previous cervical surgery 2.48 1.15-5.36 2.02 0.92-4.46
Household smoking
Others alone smoke 1.01 0.51-1.97 0.86 0.42-1.77
Subject alone smokes 7.28 2.50-21.24 6.60 2.18-19.99
Subject and others smoke 2.41 1.27-4.57 2.28 1.15-4.55
Chlamydia culture
Positive 7.53 1.18-48.17
Not available 1.42 0.66-3.03
Chorioamnionitis 8.18 1.65-40.51

Table IX. Conditional multiple logistic regression analysis of relationship of orgasm with or without sexual
intercourse to preterm delivery with premature rupture of amniotic sac membranes after
confounding variables are controlled for
Modell Model 2

1
Adjusted 95% Confidence Adjusted 95% Confidence
Vanable odds ratio I tnterval odds ratIO interval

Orgasm 1.92 1.02-3.61 1.93 0.97-3.86

Previous premature rupture of membranes
Preterm 5.62 2.16-14.64 5.82 2.16-15.69
Term 2.98 1.32-6.79 3.01 1.29-7.03
Urinary tract infection 4.49 2.12-9.51 5.01 2.20-11.44
Previous cervical surgery 2.09 1.00-4.30 1.72 0.79-3.70
Household smoking
Others alone smoke 1.16 0.59-2.27 0.99 0.48-2.06
Subject alone smokes 6.78 2.42-19.02 6.38 2.16-18.86
Subject and others smoke 2.37 1.27-4.46 2.32 1.17-4.60
Chlamydia culture
Positive 8.16 1.29-51.49
Not available 1.43 0.67-3.02
Chorioamnionitis 8.59 1.75-42.05

ture of membranes (Table X). The odds ratio was 1.84
(confidence interval 1.05 to 3.26) without chlamydia
infection (model I) and was 1.82 (confidence interval
1.02 to 3.25) when chlamydia infection was included
(model 2). Hence the relationship remains in both
models.
Comment
Women delivered preterm after premature rupture
of membranes and with preterm delivery without pre-
mature rupture of membranes had a statistically signif-
icant exposure rate as compared with that of their
matched controls for the male superior position during
sexual intercourse in the last 4 weeks of pregnancy.
Women who had term premature rupture of mem-
branes and delivery more often used the male superior
position than did their matched controls but the differ-
ences were not statistically significant. Only women
delivered of preterm infants after premature rupture of
membranes experienced more frequent orgasm with or
without sexual intercourse as compared with control
women during the last 4 weeks of pregnancy.
Even after adjustment for important confounding
covariates such as presence of urinary tract infection
during pregnancy, previous history of premature rup-
ture of membranes, household exposure to cigarette
smoke during pregnancy, chlamydia infection, and
chorioamnionitis, the increased risk of exposure to the
male superior position among women with preterm
premature rupture of membranes and delivery still
30 Ekwo et al. January 1993
Am J Obstet Gynecol

Table X. Conditional multiple logistic regression analysis of relationship of male superior sexual position
to preterm delivery without premature rupture of amniotic sac membranes after confounding
variables are controlled for
Modell Model 2

I I
Adjusted 95% Confidroce Adjusted 95% Confidroce
Variable odds ratio interval odds ratio internal

Male superior position 1.84 1.05-3.26 1.82 1.02-3.25

Previous premature rupture of membranes
Pre~~ 2.M 1.04-7.92 2.60 0.91-7.40
Te~ 0.95 0.41-2.19 0.93 0.40-2.18
Previous cervical surgery 2.76 1.39-5.48 2.93 1.45-5.90
Household smoking
Others alone smoke 1. 70 0.93-3.08 1.57 0.85-2.85
Subject alone smokes 1.35 0.50-3.66 1.43 0.53-3.89
Subject and others smoke 2.23 1.20-4.14 2.27 1.20-4.28
Chlamydia culture
Positive 4.12 1.08-15.76
Not available 0.79 0.42-1.49

remained significant. The association between orgasm
and pre term premature rupture of membranes with
delivery was no longer statistically significant, although
the trend remained strong, after these same confound-
ing variables were controlled for.
Both case and control women reported declines in
their sexual experiences from before pregnancy to 4
weeks before delivery. This decline in sexual experi-
ences during pregnancy is consistent with past re-
search,19-21 although some have reported an increase in
sexual activity during pregnancy.22 The importance of
sexual positioning during intercourse in pregnancy and
its relationship to pregnancy outcome have not been
previously explored. Prior studies have indicated incon-
sistent statistical association between sexual intercourse
and premature rupture of membranes. In a study of
500 women, Pugh and Fernandez2' found an average
time between coitus and admission for delivery to be 52
days but the average time for patients with premature
rupture of membranes was 42 days. They found no
statistical association between premature rupture of
membranes and coitus. Perkins 24 also failed to show
association of coitus with premature rupture of mem-
branes after controlling for the interval between coitus
and labor onset. Naeye and Peters 5 showed no increase
in risk for premature rupture of membranes among
women who had sexual intercourse one or two times
during the month of delivery . In a study from Israel"
no association was found between coitus in the last 3
months of pregnancy and either premature rupture of
membranes or low birth weight. In none of these
studies were sexual positions investigated. Further,
most studies have not differentiated between premature
rupture of membranes at term and in association with
premature delivery. The current study shows no asso-
ciation between sexual position or the frequency of
sexual activity with term premature rupture of mem-
branes and delivery and may explain part of the incon-
sistencies found in previous studies where preterm
premature rupture of membranes was not always differ-
entiated from that at term.
Findings in the current study suggest that several
sexual positions during pregnancy are not associated
with increased risk for premature rupture of mem-
branes. However, the frequently used sexual position
with the male partner in the superior position increases
the risk for preterm rupture of amniotic sac mem-
branes. Because the male superior position is also
associated with increased risk of premature delivery
without premature rupture of membranes, however,
trauma during sexual intercourse alone cannot be in-
voked as a major etiologic factor for preterm premature
rupture of membranes.
Some researchers have found that orgasm with or
without sexual intercourse is associated with premature
rupture of membranes. 25 • 26 Orgasms resulting from
masturbation have been reported to be stronger than
orgasms resulting from sexual intercourse.22 Goodlin et
al. B implied that toward the latter stages of pregnancy
orgasm may produce uterine contractions strong
enough to induce labor, although other researchers
have thought this unlikely. Wagner et al.,' who studied
19 women delivered prematurely matched to control
mothers delivered at term, found that the frequency of
orgasm with or without sexual intercourse was higher
for the premature group than the control group. In the
current study women in the preterm premature rupture
of membranes group more frequently had orgasms
during the last 4 weeks of pregnancy than did controls.
This was not true for either the women giving birth to
preterm infants without premature rupture of mem-
branes or mothers delivered at term after premature
Volume 168
Number 1, Part 1
rupture of membranes. This would indicate that orgasm
may have an indirect relationship to preterm prema-
ture rupture of membranes by propagating nascent
intraamniotic infection, disseminating existing ascend-
ing cervical infections or infectious products. Orgasm
and the resultant uterine contraction are inconsistently
associated with deceleration in fetal heart rate, but their
relationship to onset of labor is enigmatic. II
Why the male superior position should be associated
with an increased risk of premature rupture of mem-
branes and preterm delivery is uncertain. The observed
relationship may not be causal but may reflect the
indirect effects of other, yet unknown factors. A possible
explanation is that the pressure placed on the woman
and the resultant trauma caused by movements may
make this position unsuitable during the later months
of pregnancy. Various cervical infections may play a
role. This is supported by recent studies showing that
vaginal colonization with bacterial flora and the occur-
rence of chorioamnionitis are associated with prema-
ture rupture of membranes and premature delivery.4. 27
Whether bacterial infection of fetal membranes and
chorioamnionitis precede or follow fetal membrane
rupture is uncertain. Amniotic fluid from women with
intact fetal membranes but in premature labor has
been shown to grow vaginal flora, indicating that pri-
mary ascending infection does occur!8 Whether these
events relate to sexual intercourse and the frequency of
sexual experiences is debatable. However, these and
other data indicate that most sexual experiences and
positioning with the exception of the male superior
position are not harmful during pregnancy.
We should also point out that no combinations of
sexual experiences were examined. Therefore it is pos-
sible that some relationships among the sexual posi-
tions used during gestation may influence pregnancy
outcome. We hope to explore these relationships in
future analyses.
In conclusion, there is no consistent evidence that
most sexual positions and activities other than the male
superior position during pregnancy may be harmful.
Our results should be confirmed by subsequent studies
before broad-based recommendations for sexual prac-
tices during pregnancy are made.
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