BJOG 2000,107(2), pp.

186-195

Women’s sexual health after childbirth

*Geraldine Barrett Lecturer (Medical Sociology), *Elizabeth Pendry Research Assistant, *Janet Peacock Senior
Lecturer (Medical Statistics), “Christina Victor Reader (Health Services Research), **Ranee Thakar Research Fellow
(Obstetrics and Gynaecology), **Isaac Manyonda Consultant (Obstetrics and Gynaecology)
*St George’sHospital Medical School, London; * *St George’sHealth Care Trust, London

Objective To investigate the impact of childbirth on the sexual health of primiparous women and iden-
tify factors associated with dyspareunia.
Design Cross-sectional study using obstetric records, and postal survey six months after delivery.
Setting Department of Obstetrics and Gynaecology, St George’s Hospital, London.
Population All primiparous women (n = 796) delivered of a live birth in a six month period.
Methods Quantitative analysis of obstetric and survey data.
Main outcome measures Self reported sexual behaviour and sexual problems (e.g. vaginal dryness,
painful penetration, pain during sexual intercourse, pain on orgasm, vaginal tightness, vaginal
looseness, bleedinghrritation after sex, and loss of sexual desire); consultation for postnatal sexual
problems.
Results Of the 484 respondents (61% response rate), 89% had resumed sexual activity within six
months of the birth. Sexual morbidity increased significantly after the birth: in the first three months
after delivery 83% of women experienced sexual problems, declining to 64% at six months, although
not reaching pre-pregnancy levels of 38% . Dyspareunia in the first three months after delivery was,
after adjustment, significantly associated with vaginal deliveries (P = 0.01) and previous experience
of dyspareunia (P = 0.03). At six months the association with type of delivery was not significant (P =
0.4); only experience of dyspareunia before pregnancy (P < 0.0001) and current breastfeeding were
significant (P = 0-0006). Only 15% of women who had a postnatal sexual problem reported dis-
cussing it with a health professional.
Conclusions Sexual health problems were very common after childbirth, suggesting potentially high
levels of unmet need.

INTRODUCTION in a certain area2s-27,or met the entry criteria for a ran-

Women’s mental health in the postnatal period has been
researched e~tensivelyl-~. More recently, studies have
demonstrated that women also experience physical
problems, and urinary and faecal incontinence after
childbirth&”. However, women’s sexual health after
birth remains under-researched, in particular the experi-
ence of dyspareunia and other sexual problems.
The few reported studies of postnatal sexual health
have had limitations, either with the sample or the extent
to which sexual health was examined. For example,
some studies have volunteer samplesz0-23or only have
included women who meet certain criteria, such as
women with e p i s i o t ~ m i e svaginal
~ ~ , deliveriesz5,women
with adequate English, a stable relationship, and living
Correspondence: Ms G. Barrett, Sexual Health Programme,
Health Promotion Research Unit, Department of Public Health
and Policy, London School of Hygiene and Tropical Medicine,
Keppel Street, London WClE 7HT, UK.
domised controlled trial2*-”. Two well conducted stud-
ies used large unselected samples to examine women’s
general postnatal health; these studies included ques-
tions on postnatal sexual health, but the questions were
limited’.”.
Despite the limitations of available studies, general
trends emerge: childbirth brings about a change in the
sexual relationship; perineal pain and dyspareunia are
common experiences for postnatal and
there is generally a decrease in the frequency of sexual
i n t e r c o ~ r s e ~ ~ . ~ ~and
.” the woman’s sexual
desireZ0,24,27,28,”,~S . Hormonal effects associated with
breastfeeding appear to be associated with vaginal dry-
ness and/or loss of although this finding
is not consistent across all s t ~ d i e s ~ ~ , ~ ~ .
There is evidence for a positive association between
levels of dyspareunidperineal pain and perineal damage
(in particular, episiotomy)22~23~.2s*z* and assisted vaginal
d e l i ~ e r y ~ ~ .Such
~ ~ * evidence
”. is relevant to the debate
about women’s choice of elective caesarean section as

186 0 RCOG 2000 BJOG


preferred mode of delivery3g4z.Parity is also important
because primiparous women have higher rates of epi-
siotomy and assisted delivery than multiparous
womenz3,4145 and report higher levels of dyspareunia
and perineal painz3*28.
There is a lack of information about consultation for
postnatal sexual problems and information provided by
health professionals on this subject. It appears that while
the majority of women discuss contraception with a
health professional, they rarely discuss sexual inter-
c ~ u r s e * ~and
~ ~even
’ , when they feel a need for help with
a sexual problem, only a minority seek it3*.
In this study we describe the nature of women’s sex-
ual health after childbirth and focus on the factors asso-
ciated with dy spareunia.
METHODS
We studied a series of consecutive primiparous women
giving birth to a live infant at a London teaching hospital
between 1 July and 31 December 1997. Three women
were excluded from the sample: one because she died
some months after the birth; one because of the infant’s
subsequent death; and one because one of her twins was
stillborn. The final sample included 796 women with
surviving infants. All preterm births, twins (where both
were alive), and infants with malformations were
included. Primiparous women were chosen to avoid the
confounding effects of a previous birth. A six month
cohort of women was chosen because of administrative
convenience and funding constraints (this study was
funded in-house). We expected the six month period to
provide approximately 750 primiparous women. In our
pilot study the proportions of women reporting dyspare-
unia varied significantly prior to pregnancy (22%), in the
first three months (58%), and at approximately six
months after birth (26%). However, the sample size was
insufficient to perform multifactorial analyses on dys-
pareunia. We estimated that the current study size would
give at least 100 women with dyspareunia at six months,
and so would be large enough do such analyses and thus
explore factors related to dyspareunia.
Information about each woman (e.g. age, social cir-
cumstances, medical history, obstetric details) and her
infant (e.g. birthweight, gestational age) was collected
from the computerised birth records. All antenatal and
peripartum data in the hospital are entered onto com-
puter by trained midwives, and all midwives receive
training on how to use the system and enter the data.
There is also a midwife in overall charge of the data sys-
tem who regularly validates the data entered. Overall,
the information in the computerised birth records is
detailed and has a high level of completeness.
Postal questionnaires were also sent to women six
months after delivery. The questionnaires were sent out
QRCOG2000 BJOG 107,186-195
WOMEN’S SEXUAL HEALTH AFTER CHILDBIRTH 187
in one month batches in the sixth month after delivery
(for example, July deliveries received their first posting
in December, August deliveries in January erc). Nonre-
sponders in each batch were sent two reminder ques-
tionnaires, at two week intervals. Most women in the
final sample responded to either the first of second mail-
ing; very little was gained by the third mailing. Overall,
data collection lasted from December 1997 to early June
1998.
The questionnaire enquired about general health,
bowel and bladder function, sexual health and mental
health&, but only the findings relating to sexual health
are reported in this paper. Our other findings will be
reported elsewhere, as appropriate.
In the questionnaire women were asked if they had
resumed sexual intercourse or had attempted to do so.
All women who had resumed (or attempted) sexual
intercourse were asked a detailed set of questions about
problems experienced (prior to pregnancy and postna-
tally), sexual practices (using the definitions developed
for the National Sexual Attitudes and Lifestyles Sur-
~ e y ~frequency
~), of sexual intercourse, satisfaction with
sex life, and consultation for postnatal sexual problems.
With the exception of the questions on sexual practices,
all other areas of postnatal health that we included in the
questionnaire have been identified as areas of potential
change by previous studiesz0-”.All women were asked
about the information they received on postnatal health
before the birth and any information, help or advice they
received from health professionals after the birth.
Women were asked to recall information (e.g. problems
before pregnancy, problems in the first three months
after delivery, whether they had gone for their six week
check etc), but also included contemporaneous ques-
tions (e.g. the postnatal problems they were experienc-
ing now). The questionnaire was piloted successfully
with 158 primiparous women in 199648and is available
on request.
Women were classified as experiencing dyspareunia
if they answered positively to questions about ‘painful
penetration’ and/or ‘pain during sexual intercourse’
andor ‘pain on orgasm’.
Differences between proportions were tested using x2
tests. For paired proportions McNemar’s test was used
(an exact binomial test was used in instances where dis-
cordant pairs were c 10)’ and for three related propor-
tions Cochran’s Q test was used.
Logistic regression was used to investigate factors
associated with dyspareunia in the postnatal period. Two
models were fitted: one for dyspareunia reported in the
first three months after delivery and one for dyspareunia
at six months after delivery, Variables significantly
related (P < 0-05) to dyspareunia in the unifactorial
analyses were put into the models. Variables were
entered simultaneously in each model. Results of the
188 G . B A R R E T T E T AL.

logistic regression analyses are presented as odds ratios
and 95% confidence intervals. Analyses were carried
out using SPSS for Windows and ethical approval for
this study was given by the Local Research Ethics Com-
mittee.
RESULTS
Of the 796 women, 484 (61%) returned a questionnaire.
Of the 312 nonresponders,at least six refused because the
questionnairewas too personal (we know this from letters
and telephone calls from the women), and at least 45
women (6% of total sample) never received the question-
naire as our mailings were returned by the Post Office.
There were no differencesbetween responders and nonre-
sponders in any obstetric feature. However, responders
and nonresponders were significantly different with
respect to age, ethnicity, occupation, marital status, and
birthplace; responders were more likely to be older,
white, employed, married, and born in the UK (Table 1).
Resumption of sexual intercourse
Of the responders, 86% (415/480) had resumed sexual
intercourse since the birth of their child, and 2%
(10/480) had attempted to resume, although they had
not achieved penetrative sexual intercourse. Sexual
intercourse had not been resumed by 55 women (11%)
since the birth of their child. For 15 women, this was
because they had no partner. The other 40 women had
partners, but had not resumed intercourse. Reasons
given by women included: tirednesdlack of energy (n =
14 women), physical problems, such as unhealed per-
ineum (n = 9), loss of libido (n = S), need for contracep-
tion (n = 3), feeling unattractive to partner (n = 2), and
partner ill or working away (n = 2). Table 2 shows when
women resumed sexual intercourse.
The sexual relationship
The nature of sexual practices changed after the birth,
with the main change being a decline in oral sex by both
the women and their partners (Table 3). Of the women
who had resumed or attempted to resume sexual inter-
course, 67% (282/420) reported that sexual intercourse
was less frequent than before their pregnancy. Only 5%
(2 1/420) said that sexual intercourse was more frequent.
Assessment of quality of sex life was more variable with

Table 1. Characteristics of responders and nonresponders. Values are given as % (n).

_____

Responders Nonresponders
(n = 484) ( n = 312) P

Age (years) < 0.0001; x2 = 30; df = 4

15-19 9 (42) 14 (44)
20-24 14 (67) 24 (75)
25-29 31 (150) 32 (100)
30-34 32 (157) 22 (69)
2 35 14 (68) 8 (24)
Marital status 0.0009; x2 = 11; df = 1
Married 61 (294) 49 (152)
Single' 39 (190) 51 (160)
Ethnicity < 0.0001;x2 = 34; df = 2
White 71 (344) 51 (159)
Black 18 (86) 33 (103)
Asian 11 (54) 16 (50)
Employment at time
of booking appointment+ < O~OOO1;x2 = 43; df = 3
Employed 76 (363) 54 (166)
Unemployed 11 (53) 25 (76)
Student 5 (22) 9 (28)
Housewife 8 (38) 11 (35)
Birthplace of woman* < 0.0001; x2 = 16; df = 1
UK 72 (347) 58 (1 80)
Outside UK 28 (135) 42 ( 128)

No significant differences were found on any of the following variables: type of delivery, perineavgenital damage, number of infants,
birthweight of infant, preterm birth, induction of labour, artificial rupture of membranes, use of syntocinon, any type of pain relief, length of
labour, previous miscarriages, terminations, fertility treatment prior to pregnancy, or smoking.
*Includes divorcedlseparated.
'Employment status not known for eight responders and seven nonresponders.
*Placeof birth not known for two responders and four nonresponders.

0 RCOG 2000 BJOG 107.186-195

 WOMEN’S SEXUAL HEALTH AFTER CHILDBIRTH 189

Table 2. Resumption of sexual intercourse. dyspareunia and other sexual problems in the postnatal
period. In the year before pregnancy, 62% of women
When sexual intercourse was resumed
(or attempted, if not yet resumed) n (%) [cumulative%]
(25 1/403) reported not experiencing any sexual prob-
lems, as defined in Table 4. In the first three months
Weeks 1-3 47 (10) [lo] after delivery, this figure had dropped to 17%
Weeks 4-6 107 (22) [32] (61/363), and by six months after delivery it had risen
Weeks 7-8 142 (30) [62] to 36% (146/403).
Month 3 89 (19) [81]
Month 4 30 (6) [871
Month 5 8 (2) [891 Factors associated with dyspareunia
Month 6 2 (< 1) [891
Not resumed In the unifactorial analysis, dyspareunia experienced
No partner 15 (3) ~921 during the first three months after birth was significantly
Other reason 40 (8) [loo]
TOTAL 480 (100) [loo] associated with type of delivery, perineal damage, and
having experienced dyspareunia before pregnancy
(Table 5). In the multifactorial analysis, only type of

38% (157/416) describing it as ‘less good’, 47%

(194/416) saying it was ‘about the same’, 10% (42/416)
saying it had improved, and 6% (23/416) saying they Table 3. Nature of sexual activity before and after pregnancy.
did not know. Values are given as % (n).

Sexual Sexual
Problems with sexual intercourse activities in activities
year prior to since the
Compared with the year before pregnancy, problems Sexual activity* pregnancy birth P’
such as pain, lack of vaginal lubrication, and loss of
sexual desire all increased significantly in the first Vaginal intercourse 99 (386) 98 (379) 0.04’
three months after delivery; these problems declined Oral sex by woman 71 (277) 58 (225) < 0@001
Oral sex by partner 72 (278) 52 (203) < 0.0001
by six months but not to pre-pregnancy levels Anal sex 6 (25) 3 (10) 0.002
(Table 4). Dyspareunia (as defined by experience of Genital contact not
painful penetration and/or pain during sexual inter- involving intercourse 71 (276) 69 (269) 0.2
course and/or pain on orgasm) was particularly com-
mon: 12% (48/403) had experienced dyspareunia in *Question answered by 91% (388/425) of women who had resumed
sexual activity.
the year before pregnancy, compared with 62% ‘McNemar’s test.
(22Y364) in the first three months after birth and 3 1% *Exact binomial test carried out because there were only nine
(123/403) at six months. Figure 1 shows the pattern of discordant pairs.

Table 4. Problems experienced with sexual intercourse. Values are given as % (n).

Ever experienced in first

Ever experienced in year 3 months after birth Experiencing this
prior to pregnancy (n = see individual problem now
Problem* (n = 403) denominators)+ (n = 403) PI

Lack of vaginal lubrication 46 (169/368) 26 (106) < O~OoO1

Painful penetration 55 (200/364) 27 (110) < 0~0001
Pain during sexual intercourse 45 (162/363) 20 (80) < 0.000 1
Pain on orgasm 3 (11/364) 2 (9) 0.004
Difficulty reaching orgasm 33 (121/369) 23 (91) < 0~0001
Vaginal tightness 33 (120/365) 20 (80) < 0~0001
Vaginal loosenessflack of muscle tone 20 (72/365) 12 (49) < O~OoO1
Bleeding or irritation after sex 15 (54/363) 6 (23) < 0~0001
Loss of sexual desire 53 (204/385) 37 (150) < 0~0001

*Question answered by 95% (403/425) of women who had resumed sexual activity
+Ofthe 403 women who answered the question, not all answered the section ‘in first 3 months’. Individual denominators are given for each
problem in the ‘in first 3 months’ column.
iCochran’s Q test; relates to women who gave information at each time point (i.e. denominator in ‘in first three months’ column).

0 RCOG 2000 BJOG 107,186-195

190 G. B A R R E T T E T A L

70

60

50

c 40

s3
a,

u-

'0

30

20

10

Fig. 1.Sexual problems.

I
Prior

-+- dyspareunia; -.- I

3 months
I
6 months

lack of vaginal lubrication; -A- difficulty reaching orgasm; -x- vaginal tightness;
-*- vaginal looseness; -0- bleedinghitation after sex; -+- loss of sexual desire.

delivery and history of pre-pregnancy dyspareunia
remained significant (Table 6).
Dyspareunia at six months was significantly associated
with breastfeeding and a history of pre-pregnancy dys-
pareunia in both the unifactorial and multifactorial analy-
ses (Tables 6 and 7).The association of dyspareunia with
type of delivery was not significant at six months in either
the unifactorial or multifactorial analyses; the proportion
and odds ratio for forcepdventouse deliveries were still
raised, but the confidence interval straddled one. Figure 2
illustrates the pattern of dyspareunia by delivery (cae-
sarean section is presented as one category).
Breastfeeding and contraception
Sixty percent of women (289/483)reported fully breast-
feeding in the first six weeks, 23% (1 10/483)reported
mixing breast and bottle, and 17% (84/483)reported
bottle feeding only. Rates of breastfeeding then
dropped. Thirty-seven percent of women (1 80/482)
reported fully breastfeeding at around three months,
21% (103/482)reported mixing breast and bottle, and
41% (199/482)reported bottle feeding only. By six
months 42% of women (282/482)reported breastfeed-
ing (full or partial). There was no association between
type of delivery and breastfeeding in first six weeks
(df = 6, P = 0.2), at three months (df = 6, P = 0.3), or at
six months (df = 3,P = 0.9).
Of the women who had resumed (or attempted to
resume) sexual intercourse, 82% (3501425) reported
using a method of contraception. Four women were
pregnant again. Of the 350 women using contraception,
45% (n = 156)were using hormonal contraception (pre-
dominantly the pill), 43% (n = 151) were using con-
doms, 2% (n = 6)were using an intrauterine device, 3%
(n = 12) were using the diaphragm, and 7% (n = 25)
were using safe period or withdrawal methods. There
was no association between method of contraception
and dyspareunia at three months (df = 3,P = O-S),or at
six months (df = 3,P = 0.8).
Health services and postnatal sexual health
Twenty-eight percent of women (1 341476) said some-
one talked to them about sex after childbirth before the
birth of their child. These conversations were predomi-
nantly with antenatal teachers, midwives, family or
friends.

0 RCOG 2000 BJOG 107,186-195

 WOMEN’S SEXUAL HEALTH AFTER CHILDBIRTH 191

Table 5. Factors associated with the experienceof dyspareunia in After the birth of their child, 69% of women
the first three months after delivery. (332/480) said that a health professional talked to them
about resuming sex after childbirth. These discussions
Unadjusted
odds ratio were predominantly with general practitioners, mid-
Factor % (n) 95% CI P wives, and health visitors and predominantly related to
contraception. Ninety-six percent of women (3 14/328)
Type of delivery < 0~0001 reported that contraception was discussed with them.
Vaginal unassisted 62 (108/174) 1.00 Only 29% (94/328) reported that the right time to
Forceps/ventouse 78 (78/100) 2.17 (1.23-3.81) resume intercourse was discussed, and only 18%
Caesarean (+ labour) 41 (23/56) 0.43 (0.23479)
Caesarean (no labour) 47 (16/34)
(60/328) were advised about possible changes or prob-
0.54 (0.26-1.14)
Perinedother genital lems they might experience.
damage 0.006 Ninety-one percent of women (436/481) reported
Intact perineum 49 (61/124) 1.0 attending the six week postnatal check. During the
1st degree tear 68 (19/28) 2.18 (0.92-5.19) check, 62% (266/429) had a vaginal examination, and
2nd degree tear 61 (35/57) 1.64 (0.87-3.11) 45% (189/420) were asked about problems with their
3rd degree tear 64 (7/11) 1.80 (0.50-6.49) perineudvagina. Nine percent (n = 41) reported that
Episiotomy 73 (87/119) 2.81 (1,64480)
they had wanted to ask something but felt they could
Labial tears 50 (8/16) 1.03 (0.362.93)
Vaginal tears 89 (8/9) 8.24 (1.00-67.72) not. The main topics these women wanted to ask about
Experienced dyspareunia were sexual matters (particularly pain and other prob-
in year prior to pregnancy 0.03 lems) and problems with urinary and faecal continence.
Yes 78 (31/40) 2.31 (1.06-5.01) Of the 337 women who reported a postnatal sexual
No 60 (194/324) 1.o problem, as defined in Table 4, 15% (n = 49) reported
discussing it with a health professional, usually a general
No significant differences were found on any of the following
practitioner. Help varied from ‘none’ (n = 9), through
variables: age, marital status, ethnicity, birth place of woman,
induced labour, artificial rupture of membranes, any type of pain ‘advice and reassurance’ or some form of treatment (e. g.
relief, syntocinon used during labour, length of labour, birthweight oestrogen pessaries or vaginal lubricant), to referral to
of infant, gestations, sex of infant, and breastfeeding around three secondary services (n = 9). The vast majority did not dis-
months. cuss their problem(s) with a health professional.

Table 6. Logistic regression analysis of factors associated with dyspareunia in the postnatal period. Values are given as adjusted OR (95%
CI)*. NA = not applicable to model.

Experiencing dyspareunia in Experiencing dyspareunia at

Factor first three months (n = 364) P six months (n = 400) P

Experienced dyspareunia in year

prior to pregnancy 0.03 < 0.0001
Yes 2.44 (1.09-5.46) 4.97 (2.57-9.60)
No 1.0 1.o
Type of delivery 0.01 0.4
Vaginal unassisted 1.00 1.o
Forceps/ventouse 2.41 (1.24-4.69) 1.38 (0.74-2.57)
Caesarean (+ labour) 0.42 (0.18-1@0) 1.91 (0.69-5.28)
Caesarean (no labour) 0.52 (0.20-1.38) 1.19 (0.37-3.78)
PerineaVother genital damage 0.6 0.7
Intact perineum 1.0 1.o
1st degree tear 1.20 (0.42-3.46) 2.26 (0.68-7.53)
2nd degree tear 0.83 (0.34-2.00) 2.17 (0.80-5.88)
3rd degree tear 0.52 (0.12-2.36) 1.87 (0.38-9.12)
Episiotomy 0.97(0.41-2.31) 2.21 (0.83-5.91)
Labial tears 0.62 (0.19-2.03) 2.18 (0.57-8.38)
Vaginal tears 4.3 1 (0.48-38.92) 3.84 (0.81-18.33)
Breastfeeding at six months 0.0006
Yes NA 2.25 (1.42-3.57)
No NA 1.o

*Each odds ratio adjusted for other variables in model.

These were the women for whom full data were available.

0 RCOG 2000 BJOG 107,186-195

192 G . B A R R E T T ET AL.

Table 7. Factors associated with the experience of dyspareunia six months after delivery.

Factor % (4 Unadjusted odds ratio (95% CI) P

Type of delivery 0.3

Vaginal unassisted 30 (59/198) 1.oo
Forcepslventouse 37 (39/106) 1.38 (0.84-2.27)
Caesarean (+ labour) 28 ( 17/60) 0.94 (0.50-1.78)
Caesarean (no labour) 21 (8/38) 0.63 (0.27-1.46)
PerineaVother genital damage 0.3
Intact perineum 24 (32/135) 1.o
1st degree tear 28 (8/29) 1.21 (0.49-3-00)
2nd degree tear 31 (22f71) 1.43 (0.75-2.72)
3rd degree tear 33 (4/12) 1.59 (0.45-5.64)
Episiotomy 36 (47/129) 1.83 (1.07-3.12)
Labial tears 29 (5/17) 1.33 (04-4.05)
Vaginal tears 50 (5/10) 3.19 (0.87-11.71)
Experienced dyspareunia in year prior to pregnancy < 0~0001
Yes 60 (29/48) 4.22 (2-26-7.88)
No 27 (94/354) 1.o
Breastfeeding at six months 0.001
Yes 40 (65/164) 2.02 (1.31-3.10)
No 25 (58/236) 1.o

No significant differences were found on any of the following variables: age, marital status, ethnicity, birth place of woman, induced labour,
artificial rupture of membranes, any type of pain relief, syntocinon used during labour, length of labour, birthweight of infant, gestation or sex
of infant.

DISCUSSION women who had not experienced dy spareunia before

Our study showed that primiparous women experienced
high levels of sexual morbidity after childbirth, with
dyspareunia, vaginal dryness and loss of libido being
very common. The level of reported sexual problems
was very consistent: high levels of problems were
reported in the first three months after delivery, which
then declined by six months but not to pre-pregnancy
levels.
Our findings on frequency and assessment of quality
of sexual intercourse were similar to those reported in
previous s t ~ d i e s ~ ' ,The
~ ~ pattern
, ~ ~ , ~of~ sexual
. practices
altered in the postnatal period, although remained
broadly similar to that of the wider population of
women in this age group47.
We were surprised at how few factors influenced the
occurrence of dyspareunia in the postnatal period. Type
of delivery and perineal damage were associated with
higher rates of postnatal dyspareunia, as indicated in
previous s t ~ d i e s ~ ~ .but ~ ~neither
, ~ ~ , of
~ ~these
, ~ ~factors
, resumed sexual intercourse. Thus the six week check
were significant by six months. Since dyspareunia is
cited as one of the reasons why women might opt for an
elective caesarean section as preferred mode of
d e l i ~ e r y ~our
~ . finding
~, is especially relevant in coun-
selling women in the antenatal period about mode of
delivery.
Women who experienced dyspareunia before preg-
nancy had over a fourfold chance of experiencing dys-
pareunia six months after the birth, compared with
having a baby. These women are a small group but may
have specific needs; they could be identified antenatally
and offered appropriate help and advice.
The association of dy spareunia with breastfeeding
has been documented before21.22 and is most likely to be
due to the changed hormonal profile of women36,associ-
ated loss of libido31,34,36
and vaginal dryness21,22. New
mothers could be alerted to this side effect and given
appropriate advice regarding use of vaginal lubricants
and oestrogen pessaries if necessary, while being reas-
sured about the benefits of breastfeeding.
Health professionals take it for granted that women
will resume sexual intercourse following delivery,
hence they discuss contraception. However, they do not
seem to be concerned about the quality of women's sex-
ual health, since this issue is rarely discussed. The
explanation may lie in the fact that at the six week
check, where issues of contraception are usually dis-
cussed, approximately 60% of women will not have
may be too early to discover chronic We
also found low rates of consultation for problems with
sexual intercourse (similar to a previous study31),and of
the women who consulted, not all were helped. This
suggests that advice and treatment relating to postnatal
sexual health could be vastly improved. Our data pro-
vide at least some basis on which health professionals
might reconsider the information they impart to women
before and after childbirth, whether or not women are

0 RCOG 2000 BJOG 107,186-195


80 I
70 -
60 -
s 50 -
-E
0
8 40 -
30 -
20 -
0' I I
Prior
Fig. 2. Dyspareunia by type of delivery. -+vaginal unassisted; -tforcepslventouse; -A-caesarean.
symptomatic. For example, in the antenatal period
women might be counselled on both choice of mode of
delivery and what they might expect in terms of sexual
health outcome, and after delivery they could be given
advice on how to deal with any problems they experi-
ence, an idea of when various problems are likely to
resolve, and an indication of when to seek further medi-
cal help.
Limitations
Our study achieved a 61% response rate. Ideally, this
would have been higher, but given the subject of the
questionnaireand the inner-city location of the research,
it was an acceptable response rate and comparable to
other ~tudies~.~.~'.
Also, it was possible from our birth
records to establish whether there was a non-response
bias. In fact, we had lower levels of response from
women who were younger, single, Asian or Black, born
outside the UK or not in full time employment. Explana-
tions for this nonresponse are likely to include higher
mobility andor cultural and language differences. It is
also possible that women experiencing postnatal sexual
problems were more likely to reply, but we think this is
0 RCOG 2000 BJOG 107,186-195
WOMEN'S SEXUAL HEALTH AFTER CHILDBIRTH 193
I
3 months 6 months
unlikely to be a major bias. Our questionnaire asked
about other areas of postnatal health; therefore, applying
the same logic, women with higher rates of other prob-
lems (e.g. back pain, urinary incontinence, depression)
might be more likely to reply, thus diluting the effect on
postnatal sexual problems. We were also reassured by
the fact that none of the variables on which we had
response biases were in any way related to dyspareunia
in our analyses.
Another possible limitation of our study is that we
asked women to recall information from before their
pregnancy and the early months of the postnatal period.
Ideally, we would ask women about their experiences
prospectively,but this is virtually impossible; for exam-
ple, women would need to be identified and recruited
before they became pregnant, retained in the study, and
followed up over the years. Comparison of our current
findings with the findings from our pilot carried
out in 1996, offers reassurance as the results from the
two surveys are remarkably similar, and therefore sug-
gests that the findings have external validity.
We carried out a large number of statistical tests on
our data (e.g. the analyses for Table 5 and Table 7
included 40 tests), and there is the possibility of a Type 1
194 G . BARRETT ET AL.
error. However, we think this is unlikely as significant P
values are generally very small. Applying the Bonfer-
roni correction did not substantially alter our findings.
For example, using the Bonferroni correction to Table 5
and Table 7 (i.e. P < 0.05/40 = P < 0.00125) would mean
that three tests were significant rather than five, and the
Bonferroni correction is known to be overconservative.
In fact, in our study we were surprised at how few fac-
tors were related to dyspareunia.
Our study provides new data on postnatal sexual
health in women, although the picture remains incom-
plete as the male perspective is not included. To date,
there are no reports on male perspectives of postnatal
sexual health. The current practice of encouraging the
father’s presence at the birth may well influence postna-
tal sexuality and warrants further research as postnatal
sex life depends on the couple, not just the woman.
CONCLUSION
Childbirth in primiparous women is associated with a
high prevalence of postnatal sexual morbidity; over
80% of women in our study experienced at least one
postnatal sexual problem in the first three months after
birth, and two-thirds were still experiencing problems at
six months. Despite the high frequency of problems,
only a minority of women receive information about
sexual health, and rates of consultation for problems
with sexual intercourse are low. Our study suggests
there may be high levels of unmet need which postnatal
care services do not currently address. We also exam-
ined factors associated with dyspareunia in the postnatal
period and found that in the first three months after
birth, dyspareunia was significantly associated with
vaginal deliveries. At six months there was some evi-
dence of an association but it was not significant. These
findings contribute to the debate about provision of
elective caesarean section at the request of the woman,
as dyspareunia is often cited as a reason why women
might opt for this mode of delivery.
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