Discourse on women’s sexual health after birth is gaining momentum across diverse disciplines, for example, midwifery, obstetric, sexology and psychology disciplines [1,2,3,4,5]. This increased interest and body of research in perinatal sexual health, however, is not evidenced in sexual health policy [6, 7] or maternity care policy [8, 9], although data demonstrating that women are not prepared for changes to their sexual health after birth [10], are available. Lack of knowledge and preparation for sexual health issues postpartum can be distressing for women, and their partner, while also negatively impacting on their ability to adapt to their new role as mothers [10,11,12]. Postpartum sexual health is challenging to theoretically define but cannot be separated from sexuality and sexual function, and is thought to be influenced by labour and birth events [13]. Attributes of good postpartum sexual health include; sexual desire, resumption of sexual intercourse after birth, pain free sex and orgasm.
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 [38,39,40]. 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.