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The Relationship Between Mode of Delivery and Sexual Health Outcomes after
Childbirth

Article  in  Journal of Sexual Medicine · April 2015

DOI: 10.1111/jsm.12883 · Source: PubMed

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 1

The Relationship Between Mode of Delivery and Sexual Health

Outcomes after Childbirth

Alexandre Faisal-Cury, MD, PhD,* Paulo Rossi Menezes, PhD,* Julieta Quayle, PhD,*
Alicia Matijasevich, MD, PhD,* and Simone Grilo Diniz, MD, PhD†
*Preventive Medicine Department, University of São Paulo, São Paulo, Brazil; †Maternal and Child Health Department,
University of São Paulo, São Paulo, Brazil

DOI: 10.1111/jsm.12883

ABSTRACT

Introduction: Several factors are implicated in the women’s sexuality after childbirth. Nevertheless, there is con-
flicting evidence about the influence of mode of delivery (MD)
Aim: To prospectively evaluate the relationship between MD and sexual health outcomes after childbirth
Methods: A prospective cohort study conducted between May 2005 and March 2007 included 831 pregnant women
recruited from primary care clinics of the public sector in São Paulo, Brazil. The exposure variable was MD:
uncomplicated vaginal delivery (spontaneous vaginal delivery without episiotomy or any kind of perineal laceration);
complicated vaginal delivery (either forceps or normal, with episiotomy or any kind of perineal laceration) and
cesarean delivery. Socio-demographic and obstetric data were obtained through a questionnaire applied during the
antenatal and postnatal period. Crude and adjusted risk ratios, with 95% confidence intervals, were calculated using
Poisson regression to examine the associations between MD and sexual health outcomes.
Main Outcome Measures: The three main sexual health outcomes were later resumption of sexual life, self-
perception of decline of sexual life (DSL), and presence of sexual desire.
Results: One hundred and forty-one women (21.9%) resumed sexual life 3 or more months after delivery. Although
87.1% of women had desire, DSL occurred in 21.1% of the cohort. No associations were found between MD and
sexual health outcomes.
Conclusions: Women’s sexuality after childbirth were not influenced by the type of delivery. Efforts to improve the
treatment of sexual problems after childbirth should focus beyond MD. Faisal-Cury A, Menezes PR, Quayle J,
Matijasevich A, and Diniz SG. The relationship between mode of delivery and sexual health outcomes after
childbirth. J Sex Med **;**:**–**.
Key Words. Mode of Delivery; Sexual Functioning; Childbirth; Postpartum Depression

Introduction marital conflicts, depression, and economic strains

[4]. There is conflicting evidence about the role of

C hildbirth and the postpartum period repre-

sent a major life transition and usually has a
substantial impact on the sexual adjustment for
both mothers and fathers [1] [2]. Not all women
adapt well to the psychological and biological
changes, and two-thirds experience significant
worsening in sexual functioning 6 months after
childbirth [3]. A variety of reasons has been impli-
cated for the deterioration of sexual life including
mode of delivery (MD) on sexual health outcomes.
In a retrospective cohort study of 626 pregnant
women over a 6-month period after childbirth,
Signorello et al. [5] found that women who deliv-
ered with an intact perineum were significantly
more likely to report better sexual outcomes. Klein
et al. [6] found that women without perineal
trauma had a greater chance of resuming sexual
intercourse by 6 weeks postpartum in comparison

© 2015 International Society for Sexual Medicine J Sex Med **;**:**–**

2 Faisal-Cury et al.
with women with perineal trauma. A recent study
of 1,507 nulliparous women found that most
women having a first birth did not resume vaginal
sex until later than 6 weeks postpartum. Moreover,
women who had an operative vaginal birth, caesar-
ean section, or perineal tear or episiotomy appear
to delay longer to resume sexual life [7]. In con-
trast, studies about resumption of sexual life, per-
formed at 7 and 12 weeks after delivery, found that
sexual activity was not influenced by the degree of
perineal laceration [8,9].
Possible reasons for the association between
later resumption of sexual life and perineal trauma
include pudendal neuropathy, perineal pain and/or
dyspareunia, and poor maternal health [10].
Pudendal nerve trauma has been demonstrated
after vaginal delivery [11,12]. Dyspareunia is
reported by 41–67% of women 2–3 months after
childbirth [3,5,13,14]. Perineal pain typically
resolves by 3 months after delivery, although dys-
pareunia takes somewhat longer to resolve [13].
Finally, poor health outcomes may impact sexual
function among women with severe obstetrical
morbidity [15]. Nevertheless, there is scarce as
well conflicting evidence regarding the effect of
MD on sexual function in the period beyond the
first year [16].
In a longitudinal cohort study, Ejegård et al.
evaluated the long-term sexual effects of episi-
otomy and perineal laceration [17]. They stated
that episiotomy may affect women’s sexual life
during the second year postpartum with more
frequent pain and vaginal dryness at intercourse.
Moreover, other obstetrical factors and pain
history may also influence the propensity for dys-
pareunia. Van Brummen et al. in a prospective
cohort study with 377 nulliparous women evalu-
ated the factors that determine sexual activity and
satisfaction with the sexual relationship 1 year after
the first delivery. They found that women were
five times less likely to be sexually active after a
third/fourth degree anal sphincter tear as com-
pared with women with an intact perineum [18].
On the other hand, studies report that sexual
dysfunction occurs postnatally but performance
returns to prepregnancy levels within 1 year after
delivery [19]. There is inconsistent evidence of
chronic dyspareunia after severe lacerations or
operative delivery. Most studies suggest no differ-
ence after the first 6 [20], 12 [21], or even 36
months [22]. Similar conclusion has been reached
in relation to the long-lasting effects of cesarean
delivery on sexuality. In the Breech Trial, planned
cesarean section was not associated with substan-
J Sex Med **;**:**–**
tially better or worse sexual outcomes for women 2
years after the birth compared with planned
vaginal delivery [23]. Another study with 276 iden-
tical twin pairs demonstrated that childbirth was
associated with decreased sexual function among
parous twins. However, MD was not found to be
associated with altered sexual function in the 29
pairs discordant for MD. The authors stated that
childbirth appears to have a lasting impact on
sexual function, due to psychological more than
physical factors, well beyond the postpartum
period [24].
The purpose of the present study is to evaluate
prospectively, up to 18 months after delivery, the
association between MD and sexual health out-
comes after childbirth, namely later resumption
of sexual life, presence of sexual desire, and self-
report of sexual life decline.
Methods
Study Design and Sample
This was a prospective cohort study, conducted
between May 2005 and March 2007, with 831
pregnant women recruited from primary care
clinics of the public sector in three administrative
districts in the Western area of the city of São
Paulo, Brazil. The study area comprised a hetero-
geneous population of approximately 400,000,
where people with high, medium, and low income
live near each other. Private health care is usually
only accessible for women from the middle and
upper middle classes. The public primary care
clinics offer free antenatal care for all women
living in their catchment areas. Antenatal care is
offered regularly, typically once a month, generally
starting as soon as the woman seeks a pregnancy
test at one of these clinics. Women followed in
these clinics are at low obstetrical risk. High-risk
pregnancies are referred to regional hospitals
for prenatal care. There were two public hospitals
in the study area, providing approximately
2,000 deliveries per year. After childbirth, the
primary care clinics continue to provide clinical
and gynecological care including contraception,
breastfeeding orientation, and cervical smear.
Pregnant women between 20 and 30 weeks of
pregnancy, whose conception occurred naturally,
aged 16 years or older and with singleton pregnan-
cies, who were receiving antenatal care in primary
care clinics in the study area, were considered eli-
gible for this study. Pregnant women with a history
of psychosis were excluded. Postpartum women
were interviewed at home (mean time of interview
Mode of Delivery and Sexuality after Childbirth
after delivery: 11.1 months, standard deviation
[SD]: 2.3 months, range 6–18 months). Further
details of the study sample have been described
elsewhere [25].
Instruments
Main Exposure Variable
Main exposure variable was mode of delivery. Data
on method of birth and degree of perineal trauma
were combined to provide a single variable. Three
categories were used: uncomplicated spontaneous
vaginal delivery (UVD) (without episiotomy or
any kind of perineal laceration); complicated
vaginal delivery (CVD) (either forceps or normal,
with episiotomy or any kind of perineal lacera-
tion); and cesarean delivery (CD). Data about type
of delivery were extracted from medical charts.
Main Outcome Variable
Two sexual health outcomes were evaluated by
direct questions. Time of resumption of sexual
activity was ascertained through a single question
to the mother (“Have you resumed your sexual life
(intercourse) after childbirth?”). If the answer was
yes, they were asked how many months after deliv-
ery this happened. According to the answers given
by women who restarted sexual life after child-
birth, two groups were formed: earlier resumption
(1–2 months after delivery) and later resumption
(3 or more months after delivery). Self-evaluation
of sexual life was ascertained through questions to
the mother. One question was about the presence
of desire (“At the moment, do you feel desire
to have a sexual life?”). The other question was
about decline of sexual life (DSL) after childbirth
(“Considering your sexual life before pregnancy,
how would you describe your present sexual life:
improved, the same, worsened?”). The question
focused on the sexuality with a partner. According
to the answers, two groups were formed: women
who answered “improved” or “the same” were
classified as “no decline” in sexual life; and women
who answered “worsened” were classified as
“decline” in sexual life.
Questionnaire
Sociodemographic and economic characteristics
as well as obstetric information were obtained
through a structured detailed questionnaire that
was applied during the antenatal assessment.
The information obtained included age, years of
schooling, marital status, and skin color. Socioeco-
nomic indicators were “assets score” (in tertiles)
and “monthly family income per capita” (0–59,
3
60–113, and 114–810 USD). Household assets
measured included electricity, plumbing, com-
puter, television, cable television, bathroom,
telephone, and refrigerator. An “asset-based score
(AS)” was created using principal component
analysis. The primary component was used to gen-
erate tertiles. Monthly family income per capita
was defined as the monthly family income divided
by the number of adults and children living in
the house. Number of previous pregnancies was
recorded. Current obstetric data included gesta-
tional age, birth weight, and Apgar score at 5
minutes of life. Obstetric complications in the last
pregnancy (yes/no) was defined by the presence of
a gestational age less than 37 weeks, a newborn
weight under 2,500 grams, or a 5-minute Apgar
score less than 7. In the postpartum period,
breastfeeding was evaluated and defined as feeding
the baby with breast milk, regardless of supple-
menting with other food. Breastfeeding length
was ascertained through a single question to the
mother: “How long have you breastfed?”. A vari-
able (yes–no) for “breastfeeding more than 4
months” was created. The presence of antenatal
and postnatal depression was assessed with the
Self-Report Questionnaire (SRQ-20), which was
developed for screening common mental disorders
in patients treated in primary care settings [26].
The SRQ-20 was validated in primary care
centers in Brazil, with 85% sensitivity and 80%
specificity [27]. The SRQ-20 has good psychomet-
ric properties for diagnosing antenatal and postna-
tal depression, performing even better than others
instruments specifically designed for this purpose
[28]. The optimal cut-off point for the SRQ-20
was set at 7/8 for the present study. Body mass
index (BMI) was assessed after delivery, and par-
ticipants were classified in three groups: under-
weight (below 19.9), normal weight (20–25.0), and
overweight or obese (above 25.0). The presence of
a health problem after childbirth was defined as
any consultation with a physician that has led to
any kind of surgery or hospitalization for treat-
ment. Timing of interviews was divided in three
groups: group 1: up to 8 months (99 participants;
14.1%); group 2: from 9 to 12 months (408 par-
ticipants; 58.3%), and group 3: from 13 to 18
months (193 participants; 27.6%).
Procedures
During the study period, trained research assis-
tants went to the primary care clinics and
approached all pregnant women. Eligible women
were invited to participate. Those who agreed
J Sex Med **;**:**–**
4 Faisal-Cury et al.
signed an informed consent form and were inter-
viewed between 20 and 30 weeks of pregnancy.
The same group of research assistants interviewed
these women at home after childbirth. Participants
then answered the SRQ-20 and the questionnaire
with questions about sexual patterns and health
conditions. The Ethics Committee of the Univer-
sity of São Paulo, School of Medicine, approved
the research project.
Statistical Analysis
The proportion of women reporting a decline in
sexual life, presence of sexual desire, and later
resumption of sexual life after childbirth was
calculated. Crude and adjusted risk ratios (RRs)
with 95% confidence intervals (95% CIs) were
estimated using Poisson regression with robust
variance to examine the associations between
later sexual resumption, sexual desire, and decline
in sexual life after childbirth with MD. In the
adjusted analyses, we examined the effects of MD
on these three sexual health outcomes accounting
for potential confounders. To be included as
potential confounders, variables had to be associ-
ated with MD and outcomes with a P level of <0.2.
Statistical associations were assessed with Wald
tests. A P value of <0.05 was considered statisti-
cally significant. Statistical analyses were per-
formed using STATA version 12 (StataCorp,
College Station, TX, USA).
Results
Eight hundred and sixty-eight eligible pregnant
women were identified, and 831 (95.7%) women
were included in the study during the antenatal
care period. Of these, 701 (84.4%) women were
re-assessed during the postnatal period. Among
701 postpartum women, 644 (91.8%) had resumed
sexual activity in the postpartum period and were
included in this study. Participants had a mean age
of 25 years (range 16–44) and most were living
with a partner (78.1%). In addition, 46.5% had
completed 9 years of education. Regarding to the
family income, 30.6% had a family per capita
monthly income below US$ 60.00. According
to the MD, 333 (51.7%), 105 (16.3%), and 206
(31.9%) were UVD, CVD, and CD, respectively.
Among the reasons for performing a cesarean
section were intrapartum bleeding (3.5%); acute
fetal distress (10.2%); one previous cesarean deliv-
ery (10.6%); blood pressure disturbances (19.6%);
and meconium stain (21.2%). Breech presentation
(3.9%) and two or more previous cesarean deliv-
J Sex Med **;**:**–**
eries (3.9%) were common reasons for performing
a primary cesarean delivery. Women who had
resumed sexual activity were of similar age but
were more educated, had higher family income,
and had less symptoms of depression and anxiety
than the group of 184 women who did not return
after delivery or did not resume sexual activity in
the postpartum period.
One hundred and forty-one women (21.9%)
resumed sexual life 3 or more months after deliv-
ery. The mean time for the beginning of sexual
activity in the postpartum period was 2.1 months
(range 1–12). Although the majority of women
(87.1%) answered they had sexual desire, 136
women (21.1%) were classified as having a decline
in sexual life after childbirth.
In the bivariate analysis, MD was not associated
with any sexual health outcomes (Table 1).
Married women restarted sexual life after delivery
later than not married (single) women. In regard to
the other sexual health outcomes, DSL was asso-
ciated with unmarried status, older women’s age,
antenatal depression, postnatal depression, and
health problems whereas the presence of sexual
desire was associated with higher asset-based
score, higher familiar per capita monthly income,
more than 9 years of education, white skin color,
unmarried status, first pregnancy, antenatal and
postnatal depression (Table 1).
After adjustment for potential confounders the
lack of association between MD and later resump-
tion of sexual life, DSL and sexual desire remained
unchanged (Table 2).
Discussion
Our prospective cohort study showed that MD is
not associated with different sexual health out-
comes, including later resumption of sexual life,
desire, and self-perception of sexual life decline
after childbirth. Although one in five women com-
plained of deterioration in sexual life after preg-
nancy, there is no relationship between MD and
this type of sexual problem. Moreover, sexual
desire and later resumption of sexual life after
delivery were not associated with MD.
In agreement with our results, a review of
studies about sexuality during pregnancy and post-
partum confirmed that intercourse is resumed, on
average, 6–8 weeks after birth in Europe and the
United States. Before the sixth week postpartum,
only 9–17% of the couples practice intercourse,
in the sixth week 50–62%, in the second month
66–94%, in the third month 88–95%, in the
Mode of Delivery and Sexuality after Childbirth 5

Table 1 Socioeconomic, demographic, and other health-related characteristics of the sample, according to the sexual
health outcomes
Later sexual Decline of Presence of
resumption sexual life sexual desire
N N (%) P level N (%) P level N (%) P level

Mode of delivery 0.85 0.09 0.07

UVD 333 73 (22.0) 76 (22.9) 282 (84.9)
CVD 105 25 (23.6) 14 (13.2) 99 (93.4)
CD 206 43 (20.8) 46 (22.3) 180 (87.4)
Asset score (tertiles) 0.67 0.08 0.008
First 204 49 (24.0) 52 (25.5) 167 (81.8)
Second 256 54 (21.1) 54 (21.1) 224 (87.5)
Third 184 38 (20.6) 30 (16.3) 170 (92.4)
Family per capita monthly income (USD) 0.87 0.87 0.002
0–59 195 44 (22.5) 42 (21.5) 156 (80.0)
60–113 218 48 (22.0) 46 (21.1) 196 (89.9)
114–810 224 46 (20.5) 44 (19.6) 205 (90.6)
Years of education (y) 0.35 0.08 0.001
1–4 108 23 (21.3) 31 (28.7) 85 (78.7)
5–9 192 49 (25.5) 39 (20.3) 162 (84.4)
>9 342 69 (20.2) 64 (18.7) 313 (91.5)
Skin color 0.38 0.96 0.03
White 304 62 (20.4) 64 (21.0) 274 (90.1)
Black/mixed/other 340 79 (23.2) 72 (21.2) 287 (84.4)
Marriage status 0.04 0.04 0.04
Unmarried 141 21 (14.9) 55 (39.0) 130 (92.2)
Married 503 115 (22.8) 86 (17.1) 431 (85.7)
Mother’s age 0.36 0.03 0.62
16–19 131 24 (18.3) 18 (13.7) 117 (89.3)
20–29 359 78 (21.7) 77 (21.4) 309 (86.1)
30–44 154 39 (35.3) 41 (26.6) 135 (87.6)
Obstetric complications 0.67 0.68 0.87
No 524 113 (21.5) 109 (20.8) 457 (87.2)
Yes 120 28 (23.3) 27 (22.5) 104 (86.7)
Number of pregnancies 0.79 0.13 0.006
1 222 52 (23.4) 40 (18.0) 205 (92.3)
2 198 42 (21.2) 39 (19.7) 172 (86.8)
3 or more 224 47 (21.0) 57 (25.4) 184 (82.1)
Breastfeeding (in months) 0.32 0.79 0.28
0–4 200 39 (19.5) 41 (20.5) 170 (85.0)
>5 444 102 (23.0) 95 (21.4) 391 (88.0)
BMI (kg/m2) 0.18 0.51 0.07
200–250 326 81(24.8) 63 (19.3) 292 (89.5)
154–199 41 8 (19.5) 10 (24.4) 32 (78.0)
251–414 277 52 (18.7) 63 (22.7) 237 (85.5)
Postnatal depression 0.15 0.000 0.000
No 465 95 (20.4) 60 (12.9) 430 (92.4)
Yes 179 46 (25.7) 76 (42.4) 131 (73.2)
Antenatal depression 0.76 0.02 0.001
No 445 96 (21.5) 83 (18.6) 401 (90.1)
Yes 199 45 (22.6) 53 (26.6) 160 (80.4)
Health problems 0.47 0.003 0.62
No 569 122 (21.4) 109 (19.1) 500 (87.8)
Yes 63 16 (25.4) 22 (34.9) 54 (85.7)
Timing of interview (months) 0.054 0.16 0.88
6–8 91 19 (20.9) 16 (17.6) 79 (86.8)
9–12 380 73 (19.2) 75 (19.7) 337 (88.7)
13–18 173 49 (28.3) 145 (26.0) 153 (88.4)

seventh month 95–100%, and in the thirteenth
month 97% of the couples [29]. Wide variations
have also been found in a prospective cohort with
570 pregnant women interviewed in four occa-
sions, starting at the second trimester of pregnancy
and ending at 12 months after birth. Although
19% of the couples resume intercourse within
the first month after birth, 19% did not resume
sexual life until 4 months after birth. In this study,
women reported that they resumed intercourse, on
average, 7 weeks postpartum [1]. In Brazil, there is
no formal recommendation regarding the time to

J Sex Med **;**:**–**

6 Faisal-Cury et al.
Table 2 Crude and adjusted associations of type of delivery with the sexual health outcomes
Later sexual resumption
Crude Adjusted*
RR/95% CI RR/95% CI
Type of delivery P = 0.73 P = 0.88
UVD 1.0 1.0
CVD 1.07 (0.72:1.59) 1.01(0.68:1.50)
CD 0.95 (0.68:1.32) 1.02 (0.74:.1.42)
*Marriage status, women’s body mass index (BMI).
†Marriage status, mother’s age, years of education, asset score, number of pregnancies, antenatal depression, health problem.
‡Monthly family income per capita, skin color, years of education, asset score, number of pregnancies, antenatal depression.
resume sexual life after delivery, and it remains the
woman’s choice.
There is little agreement about the impact of
MD on the resumption of sexual activity following
childbirth. We did not find an association between
vaginal delivery with episiotomy/perineal lacera-
tion or cesarean delivery with later resumption of
sexual life. In accordance with the present study
results, Hartmann et al. [30] reported that episi-
otomy did not affect the postpartum sexual func-
tions of the women, and Rogers et al. [31] reported
that spontaneous perineal trauma was not associ-
ated with sexual dysfunction. Klein et al. [32]
reported similar results as well.
Other studies suggest that assisted vaginal deliv-
ery and cesarean section may delay sexual activity
after childbirth. A recent prospective pregnancy
cohort study of 1,507 nulliparous women found
that 53% and 65% of women had resumed vaginal
sex by 6 and 8 weeks, respectively, and women who
had an operative vaginal birth, caesarean section or
perineal tear or episiotomy appear to delay longer
[7]. Differences may be explained by the distinct
socio-demographic characteristics of the sample
and by the obstetric procedures used in each study.
Women in the Australian study were married,
older, and more educated than women in our
study. Moreover, we have higher rates of cesarean
delivery and spontaneous vaginal delivery.
The timing of resumption of vaginal sex is only
one dimension of sexuality after childbirth. It may be
more important to evaluate the impact of MD on
other aspects of women’s sexual health such as sexual
desire and pleasure. Regarding to the long-term
effects of MD on sexual functioning studies suggest
that there is no significant difference at 12–18
months after childbirth between women who deliv-
ered vaginally without episiotomy, heavy perineal
laceration, operative interventions, and women who
underwent elective cesarean section [32]. This is in
line with the results of a large population-based
study with 2,490 pregnant women in Sweden. Tears
J Sex Med **;**:**–**
Decline of sexual life Presence of sexual desire
Crude Adjusted† Crude Adjusted‡
RR/95% CI RR/95% CI RR/95% CI RR/95% CI
P = 0.04 P = 0.08 P = 0.08 P = 0.08
1.0 1.0 1.0 1.0
0.57 (0.34:0.98) 0.62 (0.37:1.06) 1.07 (0.99:1.16) 1.00 (0.92:1.08)
0.97 (0.70:1.34) 0.88 (0.63:1.24) 1.03 (0.96:1.11) 0.99 (0.92:1.07)
in the vagina, perineum, and rectum were all associ-
ated with not resuming sexual life at 3 and 6 months
after childbirth. No statistical differences were
found at 12-month follow-up [33]. In our study, we
did not find any difference in relation to the presence
of desire and self-perception of DSL after childbirth.
It seems that an occasional decline in sexual desire in
the postpartum period [34,35] may improve with
time. Moreover, desire as well as pleasure is influ-
enced by other important life issues such as body
image, mother’s mental health, and marital relation-
ship [36]. For example, breastfeeding has been asso-
ciated with a delay in resumption of sexual activity
[37] and reports of a lack of sexual desire [1,38].
Depression has also been implicated in the sexual
dysfunction after childbirth. In a previous publica-
tion, we have shown that postpartum women with
symptoms of depression/anxiety have more than
three times higher risk of reporting DSL after
childbirth compared with women without these
symptoms [39]. Morof et al. [40] evaluated the
sexual health experiences of both depressed and
nondepressed women. They found that women who
were depressed were less likely to have resumed
intercourse by 6 months postpartum, engaged in less
varied sexual activities and were more likely to report
sexual problems than nondepressed women. In the
present study, the lack of association between MD
and sexual health outcomes did not change after
controlling for breastfeeding, antenatal, postnatal
depression, timing of interview in months (and other
covariates).
The lack of association between MD and sexual
functioning may be explained by the psychologi-
cal, behavioral, and cultural factors that influence
sexuality after childbirth. Postpartum female
sexual function is likely to be impacted by transi-
tion to role as a mother, changes in body image,
marital satisfaction, mood, fatigue, and anxiety or
apprehension regarding the infant’s well-being
[41]. Serati et al. [42] have stated that sexual func-
tion is dependent on many mechanisms associated
Mode of Delivery and Sexuality after Childbirth
more with psychological than organic factors.
According to Abdool [36], female sexual desire and
orgasmic disorders are a complex subject as they
encompass components of a subjective experience.
Although hormonal changes and peripartum trau-
matic events may be part of this, it seems from the
literature that it is short lived and self-limiting.
Despite the fact that the MD is not associated
with sexual health outcomes, sexual dysfunction
was quite frequent among our sample. DSL after
childbirth may have a negative impact on several
domains of women’s life. Therefore, health pro-
fessionals should address sexuality concerns as an
essential component in the practice standards
during and beyond the postpartum period. It has
been stated that healthcare workers need to be
aware of this silent suffering, as sexual morbidity
can have a detrimental effect on a women’s quality
of life, as well on her social, physical, and emo-
tional well-being [36].
Our study has some strengths, including a pro-
spective evaluation of sexual functioning up to
18 months after delivery and the representative
nature of our sample of pregnant women attending
antenatal care in primary care units in the city of
São Paulo, a large urban center in a middle-
income country. Additionally, in relation to our
exposure variable, MD, data were retrieved mostly
from public teaching hospital charts. In these hos-
pitals, the quality of medical data is good.
Our study also has some limitations. First, the
assessment of our three sexual health outcomes
was based on a direct question, and we did not
include questions about dyspareunia and subjec-
tive reasons for sexual life decline. Moreover, we
cannot exclude the risk for recall bias considering
the fact that many women may not feel comfort-
able or eager to report sexual problems. In this
case, estimates would possibly be biased toward
the null hypothesis. Some misclassification may
have occurred regarding to the lower rate of CVD
(16.3%). Although it may be explained by the
characteristic of both obstetric facilities, medical
teaching schools that praise normal delivery
(without episiotomy), it is known that perineal lac-
erations grade 1 are frequently omitted by the
nurses or doctors. Second, we have complete data
about sexual life for 77% (644 of 831) of the origi-
nal sample of pregnant women. Third, as a result
of the high incidence of female sexual dysfunction
in the nonpregnant female population, it would be
important to include assessment of sexual behavior
before and during pregnancy. Lastly, our results
were obtained from low income women attended
7
in the public sector and cannot be generalized to
other groups of postpartum women.
Conclusion
In this study, the MD had no impact on different
sexual health outcomes, namely later resumption of
sexual life, presence of sexual desire, and decline of
sexual life after birth. Spontaneous uncomplicated
or complicated vaginal delivery and cesarean deliv-
ery had the same impact on sexuality evaluated up
to 18 months after childbirth. Nevertheless, decline
of sexual life is a relatively common occurrence
after delivery, and efforts to recognize and treat this
problem should not focus only on MD.
Acknowledgments
The study was funded by FAPESP (2003/08553-7).
PRM was partially funded by the CNPq-Brazil.
AFC received postdoctoral fellowships from the
CNPq-Brazil and FAPESP (2005/04572-2).
Corresponding Author: Alexandre Faisal-Cury, MD,
PhD, Departamento de Medicina Preventiva,
Faculdade de Medicina, Universidade de São Paulo, Av.
Dr. Arnaldo 455, São Paulo, SP CEP 01246-903, Brazil.
Tel: 55-11-99362007; Fax: 55-11-36838196; E-mail:
lim39@usp.br; faisal@ip2.com.br
Conflict of Interest: The author(s) report no conflicts of
interest.
Statement of Authorship
Category 1
(a) Conception and Design
Alexandre Faisal-Cury; Paulo Rossi Menezes
(b) Acquisition of Data
Alexandre Faisal-Cury; Paulo Rossi Menezes
(c) Analysis and Interpretation of Data
Alexandre Faisal-Cury; Alicia Matijasevich; Julieta
Quayle, Simone Grilo Diniz
Category 2
(a) Drafting the Article
Alexandre Faisal-Cury; Alicia Matijasevich; Julieta
Quayle, Simone Grilo Diniz
(b) Revising It for Intellectual Content
Alexandre Faisal-Cury; Paulo Rossi Menezes, Alicia
Matijasevich; Julieta Quayle, Simone Grilo Diniz
Category 3
(a) Final Approval of the Completed Article
Alexandre Faisal-Cury; Paulo Rossi Menezes; Alicia
Matijasevich; Julieta Quayle, Simone Grilo Diniz
J Sex Med **;**:**–**
8 Faisal-Cury et al.
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