Prevalence of and risk factors associated with sexual health issues in primiparous women at 6 and 12 months postpartum; a longitudinal prospective cohort study (the MAMMI study)

Study design

A longitudinal prospective cohort study was conducted, evaluating sexual health issues self-reported by women, at 6 and 12 months postpartum, recruited to the MAMMI study from one large urban maternity hospital in Ireland. Surveys, providing the study data, were returned between February 2012 and July 2015 (see http://mammi.ie/surveys.php for downloadable copies of the MAMMI surveys).

Sample

Women were eligible to take part if they were nulliparous (no previous live birth or pregnancy ending in stillbirth), aged 18 years or over and had sufficient English to complete the surveys. No additional exclusion criteria were applied. Midwives and midwifery students offered eligible women the study invitation pack at women’s first antenatal appointment, which takes place usually between 12 and 16 weeks gestation, and all women who accepted the study information were telephoned within 1–2 weeks of their booking visit. The purpose of this call was to offer women additional information on the study, answer questions, and determine their interest in taking part. Women were regarded as recruited to the study when they returned the completed consent form and Survey 1.

Ethical approval

Ethical approval for the study was granted by the Faculty of Health Sciences Research Ethics Committee, Trinity College Dublin and the Research Ethics Committee of the participating hospital study site.

Characteristics of the study participants

Women included in this study report (n = 1477) all gave birth between August 2012 and end of July 2014. Of these 1477 women who were recruited in early pregnancy, 1408 were eligible for follow-up. For those 69 women not available for follow-up, reasons included, gave birth elsewhere, withdrew at Survey 1, experienced a late miscarriage or stillbirth, and no consent provided. Subsequent 2, 3, 4 and 5 survey return rates were 1180 (84%) 1094 (80%), 1027 (77%) and 971 (74%), respectively. To determine, accurately, any changes over time only data from women who returned all five surveys (n = 866, 59%) and consented to having their hospital records accessed (n = 832, 56%) were included in these analyses (Fig. 1).

Where it was possible to do so, study data were compared to data in the Irish National Perinatal Statistics Report for 2013 [29]. This allowed for an assessment of the national representativeness of the study participants. The National Perinatal Statistics Report is produced annually and collates data (hereafter referred to as national data) on the obstetric and social characteristics of every woman who gave birth in Ireland in the year preceding the report. Comparative assessments demonstrated that the study sample had proportionately fewer women under 24 years of age and more 30–34 and 35–39 year old women when compared to national statistics (30–39 years: 70.1% in the MAMMI study versus 52.5% in the national data). Greater than two-thirds (n = 566, 68.1%) of women in the MAMMI study are Irish with just over a quarter (n = 216, 25.9%) born in another European country. The five most common countries of birth after Ireland were; Poland (n = 58, 7%), United Kingdom (n = 45, 5.4%), France (n = 13, 1.6%), Germany (n = 12, 1.5%) and Romania (n = 12, 1.5%). Seventy-one percent of participants had a university degree or higher (n = 588, 70.6%). No data were available for this item from the National Perinatal Statistics Report; however, the Central Statistics Office reports a national rate of women aged 25–34 with a third level qualification in Ireland of 55.3% in 2014 [30].

Prevalence of self-reported sexual health issues over time

Table 2 presents the number and proportion of women who experienced sexual health issues pre-pregnancy, in early pregnancy and at 6 and 12 months postpartum. The prevalence of loss of interest in sexual activity was considerably elevated 6 months postpartum (46.3%) and remained significantly so at 12 months postpartum compared to pre-pregnancy levels (39.8% versus 33% p < 0.001). The proportion of women reporting dyspareunia at 6 months was significantly higher than those who experienced it pre-pregnancy (37.5% versus 29.3%, p < 0.001). Contrastingly, this was significantly lower than pre-pregnancy levels at 12 months postpartum (20.5% versus 29.3% p < 0.001). Six months postpartum 43% of women reported a lack of vaginal lubrication compared to 36.6% pre-pregnancy (p = 0.002). This decreased to 35.4% 12 months after birth (p = 0.761). Pregnancy and birth appeared to resolve difficulties women experienced with orgasm, as, pre-pregnancy, 34.1% of women experienced difficulty achieving orgasm and 19.7% were unable to achieve orgasm. The prevalence of these sexual health issues were significantly less, however at 12 months after birth (23.5% (p < 0.001) and 13.8% (p = 0.001), respectively). Figure 2 illustrates the prevalence of sexual health issues experienced by women at the different time points.

	Pre pregnancy n (%)	Early pregnancy n (%)	6 months pp. n (%)	12 months pp. n (%)
Lack of vaginal lubrication m = 174	241/658 (36.6)	167/658 (25.4)	283/658 (43)	233/658 (35.4)
Pain during sexual intercourse m = 203	184/629 (29.3)	155/629 (24.6)	236/629 (37.5)	129/629 (20.5)
Difficulty reaching orgasm m = 236	203/596 (34.1)	156/596 (26.2)	183/596 (30.7)	140/596 (23.5)
Unable to reach orgasm m = 254	114/578 (19.7)	98/578 (17)	90/578 (15.6)	80/578 (13.8)
Vaginal tightness m = 216	138/616 (22.4)	130/616 (21.1)	200/616 (32.5)	107/616 (17.4)
Vaginal looseness / lack of muscle tone m = 243	10/589 (1.7)	10/589 (1.7)	79/589 (13.4)	53/589 (9)
Loss of interest in sexual activity compared with before pregnancy m = 187	216/654 (33)	349/654 (53.4)	303/654 (46.3)	260/654 (39.8)

m missing responses; pp. postpartum

Univariate logistic regression analysis

Multivariable logistic regression analysis

Key findings

This study provides a further body of evidence demonstrating that women experience considerable sexual health issues after pregnancy and childbirth, and adds to the discourse on women’s sexual health after birth from a maternity (midwifery and obstetric) perspective. Almost half of the women included in this study reported sexual health issues 6 months postpartum with more than 40% doing so 12 months after birth. A loss of interest in sexual activity was the most commonly reported issue (46.3% at 6 months and 39.8% at 12 months). This is somewhat less than that reported in the Australian Maternal Health Study (60.3% at 6 and 51.3% at 12 months) [1] and more than that reported by Barrett and colleagues at 6 months postpartum (37%) [17]. Information relating to sexual health issues that was sought in these 3 studies were almost identical; however, there is a 15-year interval from data collection in our study and that of Barrett and colleagues. It is, therefore, possible that over the past 15 years women have become more comfortable and confident in recognising sexual health issues, possibly as a result of the increased interest in the social media, weekender magazines and in other media which discuss women’s sexual lives after birth [31, 32]. Experiencing a loss of interest in sexual activity during the first year after birth is relatively common, which suggests that altered desire for sex is a normal part of adapting to motherhood and new roles of both parents in the household. If viewed through the adaptation lens, one is left with questions around the appropriateness of including lack of sexual activity as an indicator of ‘sexual dysfunction’ in the DSM-5 definition of sexual dysfunctions [33], especially for this cohort of postpartum women. The high rate of reported loss of interest in sexual activity also points to the need for women and their partners to be forewarned of this potential change, as a routine part of perinatal care. By so doing much of the stress and anxiety identified by women interviewed by Olsson [10] and guilt reported by women in Woolhouse and colleague’s study [11] around intimacy would be reduced.

In our study 37.5% of women experienced dyspareunia 6 months after birth, compared to 43.4% reported in the Maternal Health Study [1] and 31% in Barrett et al.’s (2000) study [17]. Our findings demonstrate that events that occur during labour and birth influence the extent with which women report dyspareunia 6 months after birth. The likelihood of women experiencing dyspareunia at 6 months was substantially higher in women whose birth was vacuum-assisted, had 2nd degree tears, 3rd degree tears and episiotomies compared to those who had a spontaneous vaginal birth and an intact perineum; although, when all other factors were considered, 3rd degree tears, only, along with pre-existing dyspareunia and breastfeeding emerged as significant factors for dyspareunia at 6 months postpartum. Our univariate results reflect the findings from previous studies which also report an association with episiotomy and poor sexual health outcomes [15], instrumental birth and dyspareunia [19, 34]. In addition, it raises questions about the rates of obstetric intervention experienced by women in Ireland. In our study 20.7% of women experienced a vacuum-assisted birth, similar to a national rate of 21.2% [29], double the rate of 10.4% in the Maternal Health Study in Australia [34] and much higher than the 5% in the nulliparous sample used by Connolly and colleagues [35]. Our high rate of vacuum-assisted birth could be related to the equally high uptake of epidural anaesthesia in Irish maternity settings, as 78% of women in this study used epidural analgesia (similar to the 72% of nulliparous women at the research site), and a 2011 Cochrane review identified that epidural analgesia increased the risk of an instrumental birth [36]. The association between episiotomy and persistent dyspareunia up to 12 months was found in our study, although it did not emerge as a risk factor for dyspareunia in multivariable analysis. In our study 36.1% of women had an episiotomy, while this may appear elevated it is worth noting that 33% of women had an instrumental birth which is commonly associated with an episiotomy. Our high rate of episiotomy (36.1%) compares poorly, internationally, where 16% of women in the Maternal Health Study had an episiotomy [34] and 14% in Connolly’s research [35]. This finding does not necessarily suggest there is routine use of episiotomy but rather poses concern over the high rate of epidural uptake, consequent instrumental births, perineal trauma and associated long term dyspareunia.

Little has been published on the influence of breastfeeding on postpartum sexual health, with many studies choosing to focus on breastfeeding as a means of contraception [37] or the influence of breastfeeding on resumption of sexual activity and frequency of sexual activity [38–40]. In our study, breastfeeding, in association with other related factors, remained significantly present for all three of the outcomes of dyspareunia, a lack of vaginal lubrication and a loss of interest in sexual activity 6 months postpartum. This finding highlights the potential for cognitive dissonance to occur. Cognitive dissonance occurs when people experience inconsistency between cognitions or between cognitions and behaviour [41]. In a professional or practice context that emphasises women-centred care and disclosure, and a policy context that promotes breastfeeding, there is potential for internal conflict to arise. Practitioners may struggle with the professional imperative to inform women of the impact of breastfeeding on sexual activity, dyspareunia and vaginal lubrication at the same time as fearing a decrease in women’s willingness to breastfeed if impact is known. However, information regarding breastfeeding needs to take account of these findings, if care is to be ‘woman-centred’ as opposed to ‘breast-feeding centred’ [42]. Without this information women may blame themselves for their loss of sexual interest, or struggle alone without information on the array of vaginal lubricants available to alleviate vaginal dryness.

Little attention has been given to pre-existing dyspareunia and its influence on sexual health after birth to date, however two studies found a similar association between pre-existing dyspareunia and experiencing sexual health issues after birth [17, 34]. In our study 29.3% of women experienced dyspareunia in the 12 months before becoming pregnant, and this, with other significantly related factors (e.g. 3rd degree tears and breastfeeding at 6 months and age > 35 years at 12 months) contributed to dyspareunia 6 and 12 months after birth. The majority of women do not seek professional support for postpartum sexual health issues, 15% in Barrett et al.’s study spoke to a health professional [17] and 24% in the Australian study were asked directly by a health professional about their sexual health postpartum [1]. This corresponds to conclusions from qualitative studies that demonstrated that women find it difficult to bring up sexual health issues with health professionals [10, 11, 43] and this occurs at a time when women have direct contact with a variety of health professionals during the postpartum period. Therefore it is very likely that women do not seek help for dyspareunia experienced before pregnancy as there may be limited contact with health services. The antenatal period, a time when women have frequent consultations with health professionals appears to be an ideal opportunity to ask them about their sexual health and discuss any problems, such as pain during sexual intercourse, they may be experiencing. It is potentially an ideal time to refer women to the most appropriate professional for help, be it the women’s health physiotherapist attached to the maternity services, sexual health therapist or couples therapy. However, previous studies of healthcare professionals have shown that many lack competence and confidence in their abilities to help with sexual problems [44], which may be why so many women had not been asked. Managing dyspareunia during pregnancy will go some way to reducing the identified association between pre-pregnancy dyspareunia and a lack of vaginal lubrication and a loss of interest in sexual activity seen in this study. Similarly, it is probable that persistent postpartum dyspareunia at 6 and 12 months would be reduced if managed antenatally or at the very least women should be asked about sexual health issues, and would then know where to seek appropriate help.

This study is unique in its investigation of an association between perception of body image and sexual health issues after birth. In this study women with a poor perception of their body images 6 and 12 months postpartum were more likely to experience a lack of vaginal lubrication (in the context of being overweight, obese, breastfeeding and pre-existing dyspareunia) and a loss of interest in sexual activity (in the context of breastfeeding and pre-existing dyspareunia). The complex nature of the concept of postpartum body image and its influence on postpartum sexual health is poorly researched, and this led the first author of this paper to carry out qualitative one-to-one semi-structured interviews with some of the women who completed the survey and identified themselves as experiencing sexual health problems. Analysis of these data is in progress and will be reported at a later date.

Strengths and limitations

The strengths of this study include the recruitment of a large sample of nulliparous women in early pregnancy, regular follow-up and a high retention rate to 12 months postpartum. The frequency of follow-up reduces the likelihood of recall bias and provides reliable data on changes to women’s sexual health over time following birth. Some findings in our study are similar to other comparable studies. This strengthens the argument for introducing sexual health to antenatal and postnatal care pathways well beyond the traditional 6 week postnatal assessment.

A number of potential limitations have been identified that may influence the data. The study sample is from one maternity unit in Ireland, which is not entirely representative of a national sample. The survey did not include definitions of concepts such as lack of vaginal lubrication, hence they are open to individual interpretation on meaning. The association of breastfeeding and sexual health issues may be questionable as Ireland has a low breastfeeding continuation rate; for example, in a national study of infant feeding in Ireland, only 19% (n = 347) of women were exclusively breastfeeding at 3–4 months postpartum [45]. Data on other factors such as medications (e.g., psychotropic drugs) that may affect interest in sexual activity [46] were not collected. A further limitation is the lack of data on the sexual orientation of women in our study, thus it was not possible to identify if there was any difference between women in same sex relationships and those in opposite sex relationships.