Background: Many women are not prepared for changes to their sexual health after childbirth. The aim of this paper is to report on the prevalence of and the potential risk factors (pre-pregnancy dyspareunia, mode of birth, perineal trauma and breastfeeding) for sexual health issues (dyspareunia, lack of vaginal lubrication and a loss of interest in sexual activity) at 6 and 12 months postpartum. Methods: A longitudinal cohort study of 832 first-time mothers who were recruited in early pregnancy and returned postnatal surveys at 3, 6, 9 and 12 months postpartum were assessed for sexual health issues and associated risk factors. Results: Nearly half of the women (46.3%) reported a lack of interest in sexual activity, 43% experienced a lack of vaginal lubrication and 37.5% of included women had dyspareunia 6 months after birth. On univariate analysis, vacuum-assisted birth, 2nd degree perineal tears, 3rd degree perineal tears and episiotomy were all associated with dyspareunia 6 months postpartum, but, of these only 3rd degree tears, in association with breastfeeding and pre-existing dyspareunia, remained significant on multivariable analysis. Breastfeeding, in combination, with other significant factors, was associated with dyspareunia, a lack of vaginal lubrication and a loss of interest in sexual activity 6 months postpartum, and, dissatisfaction with body image emerged as a significant factor associated with lack of interest in sexual activity at 12 months postpartum. Pre-pregnancy dyspareunia and breastfeeding emerged as common factors associated with all three outcomes of dyspareunia, a lack of vaginal lubrication and a loss of interest in sexual activity at 6 months postpartum. Conclusion: Breastfeeding and pre-existing dyspareunia are associated with sexual health issues at 6 months postpartum. Pre-existing dyspareunia is associated with a lack of vaginal lubrication at 12 months postpartum and breastfeeding is associated with dissatisfaction with body image. Preparing women and their partners during the antenatal period and advising on simple measures, such as use of lubrication to avoid or minimise sexual health issues, could potentially remove stress, anxiety and fears regarding intimacy after birth. Introducing the topic of pre-existing sexual health issues antenatally may facilitate appropriate support, treatment or counselling for women. Keywords: Sexual health postpartum, Prevalence, Dyspareunia, Sexual activity, Perineal trauma, Breastfeeding, Regression analysis * Correspondence: firstname.lastname@example.org School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. O’Malley et al. BMC Pregnancy and Childbirth (2018) 18:196 Page 2 of 13 Background via self-reported questionnaires in early pregnancy and at Discourse on women’s sexual health after birth is gaining 3, 6, 9 and 12 months postpartum, and from hospital re- momentum across diverse disciplines, for example, midwif- cords, so that changes over time might be evaluated. ery, obstetric, sexology and psychology disciplines [1–5]. Women received the study information, consent form and This increased interest and body of research in perinatal Survey 1 on their first visit (the booking visit) to the hos- sexual health, however, is not evidenced in sexual health pital. Those who completed and returned Survey 1 and policy [6, 7] or maternity care policy [8, 9], although data the consent form were sent Surveys 2 to 5 by post demonstrating that women are not prepared for changes with a stamped addressed envelope provided for re- to their sexual health after birth , are available. Lack of turn,at3,6,9 and 12 monthspostpartum, respect- knowledge and preparation for sexual health issues post- ively, unless they indicated, during this time, that they partum can be distressing for women, and their partner, wished to withdraw from the study. At time of ana- while also negatively impacting on their ability to adapt to lysis, a total of 2764 women joined the study, repre- their new role as mothers [10–12]. Postpartum sexual senting 38% of all those who were invited to take health is challenging to theoretically define but cannot be part (n = 7348) and future plans involve following this separated from sexuality and sexual function, and is cohort of women up to 5 years postpartum. thought to be influenced by labour and birth events . In this paper we report on the prevalence of sexual Attributes of good postpartum sexual health include; sex- health issues (i.e., dyspareunia, lack of vaginal lubrication, ual desire, resumption of sexual intercourse after birth, a loss of interest in sexual activity) and the potential fac- pain free sex and orgasm. Several studies to date have fo- tors (pre-pregnancy dyspareunia, mode of birth, perineal cused on factors such as timing of resumption of sexual trauma, and breastfeeding) that might be associated with intercourse [4, 14] and frequency of sexual inter- these at 6 and 12 months postpartum in a cohort of 832 course [15, 16] and are often limited to the first 3 to women from one study site (site 1) who completed all 5 6 months postpartum [17–20]. Others, in measuring MAMMI study surveys between February 2012 and women’s postpartum sexual health tend to do so with July 2015. Limiting to this site was necessary as data instruments not validated for use in a postpartum collection and entry in sites 2 and 3 was ongoing at population; for example, the Female Sexual Function the time of the analysis and complete data were only Index [21–23], the Arizona Sexual Experience Scale available from site 1.  and the Golombok Rust Inventory of Sexual Sat- isfaction . Furthermore, health professionals them- Methods selves have identified a lack of expertise on advising Study design women about potential changes to sexual health after A longitudinal prospective cohort study was conducted, birth . Studying women’s sexual health for a lengthy evaluating sexual health issues self-reported by women, at 6 period of time postpartum, for example, up to 1 year post- and 12 months postpartum, recruited to the MAMMI partum, from the perspectives of women themselves study from one large urban maternity hospital in Ireland. (i.e. self-report) is paramount so as to gain a deeper Surveys, providing the study data, were returned between understanding of potential sexual health issues affect- February 2012 and July 2015 (see http://mammi.ie/surveys. ing women, insight into any issues that may persist php for downloadable copies of the MAMMI surveys). or worsen over time and an understanding of factors that are associated with emergent issues. Gaining an Sample understanding of issues can assist healthcare profes- Women were eligible to take part if they were nullipar- sionals plan healthcare practices or interventions to ous (no previous live birth or pregnancy ending in still- address these, and, in doing so, positively impact the birth), aged 18 years or over and had sufficient English sexual health of women who give birth. to complete the surveys. No additional exclusion criteria The Maternal health And Maternal Morbidity in were applied. Midwives and midwifery students offered Ireland (MAMMI) study, launched in February 2012 eligible women the study invitation pack at women’s first (www.mammi.ie) is a longitudinal cohort study investi- antenatal appointment, which takes place usually be- gating the existence, extent and prevalence of an array tween 12 and 16 weeks gestation, and all women who of morbidities (mental health issues, sexual health issues, accepted the study information were telephoned within urinary incontinence, faecal incontinence, pelvic girdle 1–2 weeks of their booking visit. The purpose of this call pain, etc.) in nulliparous women antenatally and up to was to offer women additional information on the study, 1 year postpartum across three maternity units in answer questions, and determine their interest in taking Ireland. The survey was launched in the three maternity part. Women were regarded as recruited to the study units on a rolling basis; February 2012 (site 1), September when they returned the completed consent form and 2013 (site 2) and August 2015 (site 3). Data were collected Survey 1. O’Malley et al. BMC Pregnancy and Childbirth (2018) 18:196 Page 3 of 13 Ethical approval Statistical analysis Ethical approval for the study was granted by the Faculty Data were analysed using IBM SPSS (version 23). Fre- of Health Sciences Research Ethics Committee, Trinity quencies and descriptive statistics were used to present College Dublin and the Research Ethics Committee of prevalence rates of sexual health issues in the year be- the participating hospital study site. fore this pregnancy, in early pregnancy and at 6 and 12 months postpartum. To determine if there was any statistically significant change over time in sexual health Data collection and outcomes measures issues, McNemar’s Chi-squared test for differences in cor- TheMAMMI studysurveys areA4booklets of approxi- related proportions was calculated . mately 60 pages in length, taking 40–50 min to complete. Univariate and multivariable logistic regression analyses, All surveys sought information on sexual health issues, using Odds Ratio (OR) and 95% Confidence Intervals (CI) within adiscretesurveysection,and women’sdemograph- were used to assess associations between pre-pregnancy ics (e.g. age, relationship status, employment status, highest dyspareunia, mode of birth, perineal trauma and breast- level of education) were additionally collected in Survey 1. feeding, and, dyspareunia, a lack of vaginal lubrication and The surveys were developed from surveys used in a similar alossofinterest in sexual activityat 6and12 months. cohort study, the Maternal Health Study, in Melbourne, These three sexual health issues were chosen for the ana- Australia , and were subsequently assessed for face val- lyses as they are the more commonly reported of all sexual idity (with 15 women), content validity (with 18 experts), health issues. The multivariable logistic regression analysis tested for reliability using the test-retest method (with 11 model included the variables; age, pre pregnancy body mass women) (Cohen’s Kappa co-efficient 0.87 to 1.0), piloted index (BMI) and level of education. The Omnibus Test of (with a sample of 33 women) and modified accordingly for Model Coefficients and the Hosmer and Lemeshow Test useinanIrish maternitypopulationwithpermissionfrom supported the models used. The Maternal Health study team. Specific information that related to sexual health morbidity centred on issues such as Results the occurrence of a lack of vaginal lubrication, dyspareunia Characteristics of the study participants (pain during sexual intercourse), difficulty in reaching Women included in this study report (n = 1477) all gave orgasm, inability to reach orgasm, vaginal tightness, birth between August 2012 and end of July 2014. Of vaginal looseness and a loss of interest in sexual ac- these 1477 women who were recruited in early preg- tivity.InSurvey1womenwereasked to report on nancy, 1408 were eligible for follow-up. For those 69 these symptoms, if any, in the previous 12 months women not available for follow-up, reasons included, and since becoming pregnant. In the four postpartum gave birth elsewhere, withdrew at Survey 1, experienced surveys women were again asked to self-report on a late miscarriage or stillbirth, and no consent provided. any of these issues for the 3 months preceding their Subsequent 2, 3, 4 and 5 survey return rates were 1180 3, 6, 9 and 12 months postpartum time-frames. (84%) 1094 (80%), 1027 (77%) and 971 (74%), respect- Data on mode of birth, perineal trauma and birth events ively. To determine, accurately, any changes over time were collected from the hospital records using a detailed only data from women who returned all five surveys pre-designed data extraction form and in the first postpar- (n = 866, 59%) and consented to having their hospital tum (3 month) survey. Mode of birth was classified into 5 records accessed (n = 832, 56%) were included in these categories; spontaneous vaginal birth, vacuum birth, for- analyses (Fig. 1). ceps birth (including failed vacuum birth), emergency cae- Where it was possible to do so, study data were com- sarean section (CS) (included failed forceps birth) and pared to data in the Irish National Perinatal Statistics elective CS (includes elective CS in labour). Grades of Report for 2013 . This allowed for an assessment of perineal trauma were classified into 6 categories; intact the national representativeness of the study participants. perineum (includes women who had a CS), 1st degree tear The National Perinatal Statistics Report is produced an- (includes women who had both sutured and unsutured nually and collates data (hereafter referred to as national 1st degree tears), 2nd degree tears, episiotomy (includes data) on the obstetric and social characteristics of every women who had an extended episiotomy), 3rd degree woman who gave birth in Ireland in the year preceding tears and labial and vaginal wall lacerations. Breastfeeding the report. Comparative assessments demonstrated that at each time point was ascertained through one question the study sample had proportionately fewer women under ‘Are you still breastfeeding your baby or giving expressed 24 years of age and more 30–34 and 35–39 year old breastmilk’? Women were also asked to rate their satisfac- women when compared to national statistics (30–39 years: tion with their body image at each time point, indicating if 70.1% in the MAMMI study versus 52.5% in the national they were ‘always satisfied’, ‘sometimes satisfied’ or ‘never data). Greater than two-thirds (n = 566, 68.1%) of women satisfied’ with their body image. in the MAMMI study are Irish with just over a quarter O’Malley et al. BMC Pregnancy and Childbirth (2018) 18:196 Page 4 of 13 (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 Statis- tics 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 . Women in the MAMMI study were under represented in terms of spontaneous vaginal birth (35.6% versus 45.5% nationally), over represented for forceps births (12% versus 5.6% nationally) and representative for caesarean section rates (31.6% versus 27.2% nationally). One third (n =301, 36.1%) of study participants had an episiotomy compared to nearly half (n = 1187, 46.3%) of nulliparous women at the hospital site in 2013. The study sample were represen- tative in all other categories of perineal trauma compared to the research site. Table 1 presents the characteristics of the MAMMI study sample. 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 postpar- tum 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 com- pared 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 experi- enced 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), respect- ively). Figure 2 illustrates the prevalence of sexual health issues experienced by women at the different time points. Univariate logistic regression analysis Mode of birth as a risk factor for postpartum sexual health issues Six months postpartum, vacuum-assisted birth was sig- Fig. 1 Analytical sample nificantly associated with dyspareunia (OR 1.6, 95% CI 1.1–2.4), elective CS was associated with a reduced odds (n = 216, 25.9%) born in another European country. The of experiencing dyspareunia (OR 0.5, 95% CI 0.3–0.9), five most common countries of birth after Ireland were; and an emergency CS was protective of experiencing a Poland (n = 58, 7%), United Kingdom (n = 45, 5.4%), France loss of interest in sexual activity 6 months postpartum; O’Malley et al. BMC Pregnancy and Childbirth (2018) 18:196 Page 5 of 13 Table 1 Characteristics of study participants these associations did not persist to 12 months postpar- tum. There was no significant association between Characteristics of study participants Study participants vacuum-assisted birth and an increased lack of vaginal n% lubrication at 6 (OR 1.3, 95% CI 0.9–2.0) and 12 months Age Up to 24 41 4.9 postpartum (OR 1.3, 95% CI 0.9–1.9) (Table 3). 25 to 29 179 21.5 30 to 34 376 45.2 Perineal trauma as a risk factor for postpartum sexual 35 to 39 207 24.9 health issues 40 and over 29 3.5 Compared to women with an intact perineum, women who had 2nd degree perineal tears (OR 1.6, 95% CI 1.0–2.3), Place of birth Irish 566 68.1 episiotomy (OR 1.7, 95% CI 1.2–2.5) or 3rd degree perineal Europe (excluding Ireland 171 20.5 and UK) tears (OR 3.7, 95% CI 1.5–9.3), were significantly more likely to experience dyspareunia at 6 months postpartum. UK 45 5.4 This association persisted to 12 months for both episioto- America 17 2 mies and 3rd degree perineal tears (Table 4). At 6 months Asia 10 1.2 postpartum a loss of interest in sexual activity was associ- Africa 8 0.9 ated with both 2nd and 3rd degree perineal tears (Table 4). Australia 3 0.4 Missing 12 1.4 Breastfeeding as a risk factor for postpartum sexual health issues Highest level of School - second level 89 10.7 education When data on women who were breastfeeding and not Apprenticeship 75 9.1 breastfeeding were compared, the results showed that Certificate or Diploma 77 9.3 women who were breastfeeding were significantly more Undergraduate degree 254 30.5 likely to experience dyspareunia (OR 1.9, 95% CI 1.3–2.6), Postgraduate degree 334 40.1 a lack of vaginal lubrication (OR 1.7, 95% CI 1.2–2.3) Missing 3 0.3 and a loss of interest in sexual activity (OR 1.7, 95% CI 1.3–2.3) 6 months postpartum. This association was not Mode of birth Spontaneous vaginal birth 296 35.6 significant at 12 months postpartum, likely due, perhaps, Vacuum birth 172 20.7 to the low numbers still breastfeeding 12 months after Forceps birth 101 12 birth. It is noteworthy that for those breastfeeding, the Elective Caesarean Section 74 8.9 ORs for dyspareunia, a lack of vaginal lubrication and a Emergency Caesarean Section 189 22.7 loss of interest in sexual activity were all greater than 1.0 Perineal trauma Intact 268 32.2 at 12 months postpartum, although none reached a level of significance (Table 5). 1st degree tear 43 5.2 2nd degree tear 168 20.2 Pre-pregnancy dyspareunia as a risk factor for postpartum 3rd degree tear 26 3.1 sexual health issues Episiotomy 301 36.1 Women who reported pre-pregnancy dyspareunia were sig- Labial/vaginal wall tears 26 3.1 nificantly more likely to report several postpartum sexual includes participants who had a CS health issues including dyspareunia at 6 and 12 months post- partum, a lack of vaginal lubrication at 6 and 12 months and Table 2 Prevalence of self-reported sexual health issues pre pregnancy, in early pregnancy and at 6 and 12 months postpartum 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 216/654 (33) 349/654 (53.4) 303/654 (46.3) 260/654 (39.8) before pregnancy m = 187 m missing responses; pp. postpartum O’Malley et al. BMC Pregnancy and Childbirth (2018) 18:196 Page 6 of 13 Fig. 2 Self-reported sexual health issues; pre pregnancy, in early pregnancy, 6 and 12 months postpartum a loss of interest in sexual activity at 6 and 12 months post- 1.8–3.6), and this association was even more pro- partum compared to those who did not report it (Table 6). nounced at 12 months (AOR 3.8, 95% CI 2.5–5.8). Breastfeeding and a 3rd degree perineal tear were both Multivariable logistic regression analysis associated with experiencing dyspareunia 6 months after Dyspareunia at 6 and 12 months postpartum birth. Having a vacuum-assisted birth was not a signifi- Pre-existing dyspareunia was strongly associated with cantly associated risk factor for dyspareunia 6 months dyspareunia (over two and half times more likely) at postpartum (AOR 1.7, 95% CI 0.9–2.7). Compared to 6 months postpartum (Adjusted OR (AOR) 2.6, 95% CI women aged 18–29 years, women aged ≥30 years were Table 3 Mode of birth as a risk factor for sexual health issues at 6 and 12 months postpartum 6 months postpartum 12 months postpartum n/total % Unadjusted OR 95% CI p value n/total % Unadjusted OR 95% CI p value Dyspareunia Spontaneous vaginal birth 108/279 38.7 1.0 (ref.) 60/280 21.4 1.0 (ref.) Vacuum birth 83/163 50.9 1.6 1.1–2.4 0.013* 47/164 28.7 1.5 0.9–2.3 0.086 Forceps birth 30/89 33.7 0.8 0.5–1.3 0.397 18/96 18.8 0.8 0.4–1.5 0.577 Elective CS 16/66 24.2 0.5 0.3–0.9 0.03* 10/64 15.6 0.7 0.3–1.4 0.3 Emergency CS 61/181 33.7 0.8 0.5–1.2 0.277 31/181 17.1 0.8 0.5–1.2 0.258 Lack of vaginal lubrication Spontaneous vaginal birth 122/285 42.8 1.0 (ref.) 93/286 32.5 1.0 (ref.) Vacuum birth 83/166 50 1.3 0.9–2.0 0.139 63/164 33 1.3 0.9–1.9 0.206 Forceps birth 36/92 39.1 0.9 0.5–1.4 0.535 33/96 34.4 1.1 0.7–1.8 0.738 Elective CS 22/65 33.8 0.7 0.4–1.2 0.187 20/64 31.3 0.9 0.5–1.7 0.845 Emergency CS 77/181 42.5 1.0 0.7–1.4 0.955 69/185 37.3 1.2 0.8–1.8 0.287 Loss of interest in sexual activity Spontaneous vaginal birth 145/285 50.9 1.0 (ref.) 112/286 39.2 1.0 (ref.) Vacuum birth 88/165 53.3 1.1 0.7–1.6 0.615 69/165 41.8 1.1 0.8–1.6 0.579 Forceps birth 40/95 42.1 0.7 0.4–1.2 0.139 40/96 41.7 1.1 0.7–1.8 0.664 Elective CS 25/67 37.3 0.6 0.3–1.0 0.047 29/65 44.6 1.2 0.7–2.1 0.419 Emergency CS 73/181 40.3 0.6 0.4–0.9 0.027* 63/179 35.2 0.8 0.6–1.2 0.391 *indicates statistical signficance at p < 0.05 O’Malley et al. BMC Pregnancy and Childbirth (2018) 18:196 Page 7 of 13 Table 4 Perineal trauma as a risk factor for sexual health issues at 6 and 12 months postpartum 6 months postpartum 12 months postpartum n/total % Unadjusted OR 95% CI p value n/total % Unadjusted OR 95% CI p value Dyspareunia Intact 77/252 30.6 1.0 (ref.) 40/250 16 1.0 (ref.) 1st degree tear 11/39 28.2 0.9 0.4–1.9 0.766 7/40 17.5 1.1 0.5–2.7 0.811 2nd degree tear 66/161 41 1.6 1.0–2.3 0.03* 35/158 22.2 1.5 0.9–2.5 0.119 3rd degree tear 13/21 61.9 3.7 1.5–9.3 0.005* 8/25 32 2.5 1.0–6.1 0.05* Episiotomy 121/281 43.1 1.7 1.2–2.5 0.003* 69/288 24 1.6 1.1–2.6 0.023* Labial or vaginal wall tear 10/24 41.7 1.6 0.7–3.8 0.267 7/24 29.2 2.1 0.8–5.6 0.109 Lack of vaginal lubrication Intact 101/251 40.2 1.0 (ref.) 91/254 35.8 1.0 (ref.) 1st degree tear 16/39 41 1.0 0.5–2.1 0.926 14/42 33.3 0.89 0.5–1.8 0.754 2nd degree tear 72/163 44.2 1.2 0.8–1.8 0.428 57/162 35.2 1.0 0.6–1.5 0.894 3rd degree tear 12/23 52.2 1.6 0.7–3.8 0.269 9/24 37.5 1.0 0.4–2.6 0.87 Episiotomy 128/288 44.4 1.2 0.8–1.7 0.325 97/289 33.6 0.9 0.6–1.3 0.58 Labial or vaginal wall tear 11/25 44 1.2 0.5–2.7 0.715 10/24 41.7 1.3 0.5–3.0 0.57 Loss of interest in sexual activity Intact 103/253 40.7 1.0 (ref.) 94/249 37.8 1.0 (ref.) 1st degree tear 17/41 41.5 1.0 0.5–2.0 0.928 19/42 45.2 1.4 0.7–2.6 0.358 2nd degree tear 88/163 54 1.7 1.1–2.5 0.008* 69/162 42.6 1.2 0.8–1.8 0.327 3rd degree tear 15/24 62.5 2.4 1.0–5.8 0.044* 9/25 36 0.9 0.4–2.2 0.863 Episiotomy 138/288 47.9 1.3 0.9–1.9 0.093 114/289 39.4 1.1 0.8–1.5 0.687 Labial or vaginal wall tear 10/24 41.7 1.0 0.4–2.4 0.927 8/24 33.3 0.8 0.3–2.0 0.67 *indicates statistical signficance at p < 0.05 less likely to experience dyspareunia at 6 and 12 months. association between a vacuum-assisted birth and an in- This was most pronounced at 12 months for women creased lack of vaginal lubrication at 12 months was ≥35 years of age (Table 7). also found (Table 8). Lack of vaginal lubrication at 6 and 12 months postpartum Loss of interest in sexual activity at 6 and 12 months Pre-existing dyspareunia was strongly associated with a postpartum lack of vaginal lubrication at 6 months (AOR 1.6, 95% Breastfeeding at 6 months and 12 months postpartum CI 1.1–2.2) and the association persisted to 12 months were associated with experiencing a loss of interest in postpartum (AOR 1.7, 95% CI 1.2–2.5). Breastfeeding, sexual activity at these time-points (AOR 2.2, 95% CI being sometimes satisfied with one’s body image and 1.6–3.0 and AOR 1.6, 95% CI 1.0–2.1, respectively). Be- never satisfied with one’s body image were all associated ing sometimes satisfied and never satisfied with one’s with a lack of vaginal lubrication 6 months postpartum. body image was a risk factor for a loss of interest in sex- Compared to ideal weight women, being overweight or ual activity 6 months after birth. This association per- obese was protective of experiencing a lack of vaginal sisted for women who were never satisfied with their lubrication 6 months after birth. A non-significant body image to 12 months postpartum (AOR 3.6, 95% CI Table 5 Breastfeeding as a risk factor for sexual health issues at 6 and 12 months postpartum 6 months postpartum 12 months postpartum n/total % Unadjusted OR 95% CI p value n/total % Unadjusted OR 95% CI p value Dyspareunia 139/292 47.6 1.9 1.3–2.6 < 0.001* 33/133 24.8 1.2 0.7–1.8 0.477 Lack of vaginal lubrication 159/295 52.9 1.7 1.2–2.3 0.001* 55/135 40.7 1.3 0.9–1.9 0.221 Loss of interest in sexual activity 168/298 56.4 1.7 1.3–2.3 0.001* 62/135 45.9 1.4 1.0–2.1 0.064 *indicates statistical signficance at p < 0.05 O’Malley et al. BMC Pregnancy and Childbirth (2018) 18:196 Page 8 of 13 Table 6 Pre-existing dyspareunia as a risk factor for sexual health issues 6 and 12 months postpartum 6 months postpartum 12 months postpartum n/total % Unadjusted OR 95% CI p value n/total % Unadjusted OR 95% CI p value Dyspareunia 126/234 53.8 2.5 1.8–3.5 < 0.001* 85/235 36.2 3.2 2.3–4.6 < 0.001* Lack of vaginal lubrication 123/242 50.8 1.6 1.1–2.1 0.004* 106/237 44.7 1.8 1.3–2.5 < 0.001* Loss of interest in sexual activity 127/242 52.5 1.4 1.0–1.9 0.025* 110/237 46.4 1.5 1.1–2.0 0.01* *indicates statistical signficance at p < 0.05 1.9–6.7). Compared with women without degree-level midwifery, obstetric, sexology and psychology disciplines educational qualifications, women who had a postgradu- [1–5]. This increased interest and body of research in peri- ate qualification were more likely to experience a loss of natal sexual health, however, is not evidenced in sexual interest in sexual activity 6 months after birth (AOR 1.5, health policy [6, 7] or maternity care policy [8, 9], although 95% CI 1.0–2.3) (Table 9). data demonstrating that women are not prepared for changes to their sexual health after birth , are available. Discussion Lack of knowledge and preparation for sexual health issues Discourse on women’s sexual health after birth is gaining postpartum can be distressing for women, and their part- momentum across diverse disciplines, for example, ner, while also negatively impacting on their ability to adapt Table 7 Multivariable logistic regression of dyspareunia at 6 and 12 months postpartum Associated factors 6/12 postpartum 12/12 postpartum Total n = 748 Total n = 585 OR 95% CI p value OR 95% CI p value Age Groups 18–29 years 1.0 (ref.) 1.0 (ref.) 30–34 years 0.7 0.4–1.0 0.059 0.7 0.4–1.2 0.222 35+ years 0.7 0.4–1.0 0.096 0.4 0.2–0.8 0.009* BMI Groups Ideal 1.0 (ref.) 1.0 (ref.) Overweight 1.0 0.6–1.6 0.947 0.9 0.5–1.7 0.773 Obese 1.1 0.6–1.8 0.841 0.8 0.4–1.7 0.545 Underweight 1.4 0.7–2.7 0.325 1.4 0.6–3.4 0.387 Unknown BMI 0.7 0.3–1.4 0.366 0.9 0.4–2.5 0.926 Highest level of education No degree 1.0 (ref.) 1.0 (ref.) Primary degree 1.4 0.9–2.1 0.11 1.3 0.7–2.3 0.35 Postgrad qualification 1.1 0.7–1.6 0.698 1.3 0.8–2.3 0.283 Pre-existing dyspareunia Yes 2.6 1.8–3.6 < 0.001* 3.8 2.5–5.8 < 0.001* Mode of birth SVB 1.0 (ref.) 1.0 (ref.) Vacuum birth 1.7 0.9–2.7 0.053 1.5 0.7–2.8 0.225 Forceps birth 0.7 0.3–1.4 0.384 0.8 0.3–1.8 0.611 Elective CS 0.7 0.3–1.7 0.491 1.9 0.6–5.7 0.255 Emergency CS 1.1 0.6–2.2 0.605 1.537 0.6–3.7 0.344 Perineal trauma Intact 1.0 (ref.) 1.0 (ref.) 2nd degree 1.6 0.8–3.1 0.133 1.4 0.5–3.4 0.466 3rd degree 4.1 1.3–12.3 0.013* 2.7 0.7–10.1 0.143 Episiotomy 1.4 0.7–2.7 0.336 1.5 0.6–3.6 0.374 Still breastfeeding Yes 1.9 1.3–2.7 < 0.001* 1.1 0.7–1.9 0.56 Perception of body image Always satisfied 1.0 (ref.) 1.0 (ref.) 0.993 Sometimes satisfied 0.9 0.6–1.5 0.96 1.0 0.6–1.7 0.941 Never satisfied 1.4 0.8–2.4 0.211 1.0 0.5–2.2 0.905 includes 1st degree tears and vaginal wall and labial tears *indicates statistical signficance at p < 0.05 O’Malley et al. BMC Pregnancy and Childbirth (2018) 18:196 Page 9 of 13 Table 8 Multivariable logistic regression of lack of vaginal lubrication at 6 and 12 months postpartum Associated factors 6/12 postpartum 12/12 postpartum Total n = 758 Total n = 591 OR 95% CI p value OR 95% CI p value Age Groups 18–29 years 1.0 (ref.) 1.0 (ref.) 30–34 years 0.9 0.7–1.4 0.994 0.8 0.5–1.3 0.383 35+ years 0.9 0.6–1.4 0.799 0.7 0.4–1.1 0.149 BMI Groups Ideal 1.0 (ref.) 1.0 (ref.) Overweight 0.5 0.3–0.8 0.003* 0.7 0.3–1.1 0.129 Obese 0.5 0.3–1.0 0.038* 0.6 0.3–1.2 0.148 Underweight 1.5 0.8–2.9 0.226 1.8 0.9–3.7 0.117 Unknown BMI 0.6 0.3–1.2 0.182 0.9 0.4–2.0 0.896 Highest level of education No degree 1.0 (ref.) 1.0 (ref.) Primary degree 1.0 0.6–1.5 0.985 1.0 0.6–1.7 0.862 Postgrad qualification 1.1 0.8–1.7 0.496 1.2 0.8–2.0 0.332 Pre-existing dyspareunia Yes 1.6 1.1–2.2 0.005* 1.7 1.2–2.5 0.004* Mode of birth SVB 1.0 (ref.) 1.0 (ref.) Vacuum birth 1.4 0.9–2.4 0.145 1.7 1.0–3.0 0.062 Forceps birth 1.0 0.6–1.9 0.932 1.4 0.7–2.9 0.308 Elective CS 0.7 0.3–1.5 0.339 1.2 0.5–2.9 0.677 Emergency CS 0.9 0.5–1.7 0.874 1.3 0.6–2.7 0.405 Perineal trauma Intact 1.0 (ref.) 1.0 (ref.) 2nd degree 1.0 0.5–1.8 0.963 1.0 0.5–2.0 0.945 3rd degree 1.4 0.5–3.7 0.55 1.2 0.4–3.8 0.787 Episiotomy 0.8 0.4–1.5 0.449 0.7 0.3–1.4 0.325 Still breastfeeding Yes 2.1 1.5–2.9 < 0.001* 1.3 0.8–1.9 0.27 Perception of body image Always satisfied 1.0 (ref.) 1.0 (ref.) Sometimes satisfied 1.8 1.2–2.8 0.005* 1.2 0.7–1.9 0.444 Never satisfied 2.4 1.4–4.0 0.001* 1.5 0.8–2.8 0.233 includes 1st degree tears and vaginal wall and labial tears *indicates statistical signficance at p < 0.05 to their new role as mothers [10–12]. Postpartum sexual issue (46.3% at 6 months and 39.8% at 12 months). This health is challenging to theoretically define but cannot be is somewhat less than that reported in the Australian separated from sexuality and sexual function, and is Maternal Health Study (60.3% at 6 and 51.3% at thought to be influenced by labour and birth events . 12 months)  and more than that reported by Barrett Attributes of good postpartum sexual health include; sex- and colleagues at 6 months postpartum (37%) . In- ual desire, resumption of sexual intercourse after birth, formation relating to sexual health issues that was pain free sex and orgasm. sought in these 3 studies were almost identical; however, there is a 15-year interval from data collection in our Key findings study and that of Barrett and colleagues. It is, therefore, This study provides a further body of evidence demon- possible that over the past 15 years women have become strating that women experience considerable sexual more comfortable and confident in recognising sexual health issues after pregnancy and childbirth, and adds to health issues, possibly as a result of the increased inter- the discourse on women’s sexual health after birth from est in the social media, weekender magazines and in a maternity (midwifery and obstetric) perspective. Al- other media which discuss women’s sexual lives after most half of the women included in this study reported birth [31, 32]. Experiencing a loss of interest in sexual sexual health issues 6 months postpartum with more activity during the first year after birth is relatively com- than 40% doing so 12 months after birth. A loss of inter- mon, which suggests that altered desire for sex is a nor- est in sexual activity was the most commonly reported mal part of adapting to motherhood and new roles of O’Malley et al. BMC Pregnancy and Childbirth (2018) 18:196 Page 10 of 13 Table 9 Multivariable logistic regression of loss of interest in sexual activity at 6 and 12 months postpartum Associated factors 6/12 postpartum 12/12 postpartum Total n = 762 Total n = 588 OR 95% CI p value OR 95% CI p value Age Groups 18–29 years 1.0(ref.) 1.0(ref.) 30–34 years 0.8 0.6–1.2 0.396 1.0 0.7–1.6 0.836 35+ years 0.8 0.5–1.3 0.436 1.2 0.7–2.0 0.441 BMI Groups Ideal 1.0(ref.) 1.0(ref.) Overweight 0.9 0.6–1.4 0.562 0.7 0.4–1.3 0.276 Obese 1.6 1.0–2.8 0.07 0.8 0.4–1.5 0.42 Underweight 0.9 0.5–1.9 0.982 0.9 0.4–2.0 0.882 Unknown BMI 0.7 0.4–1.4 0.337 0.9 0.4–2.1 0.931 Highest level of education No degree 1.0(ref.) 1.0(ref.) Primary degree 1.0 0.7–1.5 0.916 1.3 0.8–2.0 0.326 Postgrad qualification 1.5 1.0–2.3 0.021* 1.3 0.8–2.0 0.249 Pre-existing dyspareunia Yes 1.4 1.0–1.9 0.05* 1.3 0.9–1.9 0.127 Mode of birth SVB 1.0(ref.) 1.0(ref.) Vacuum birth 1.1 0.7–1.8 0.686 1.4 0.8–2.4 0.235 Forceps birth 0.7 0.4–1.3 0.244 1.3 0.6–2.5 0.489 Elective CS 0.7 0.4–1.6 0.446 1.0 0.4–2.2 0.933 Emergency CS 0.8 0.4–1.5 0.464 0.7 0.3–1.3 0.266 Perineal trauma Intact 1.0(ref.) 1.0(ref.) 2nd degree 1.6 0.9–2.9 0.125 1.0 0.5–2.0 0.941 3rd degree 2.6 0.9–7.2 0.065 0.9 0.3–2.8 0.853 Episiotomy 1.2 0.6–2.3 0.595 0.7 0.3–1.4 0.272 Still breastfeeding Yes 2.2 1.6–3.0 < 0.001* 1.6 1.0–2.4 0.029* Perception of body image Always satisfied 1.0(ref.) 1.0(ref.) Sometimes satisfied 1.6 1.0–2.4 0.035* 1.5 0.9–2.3 0.082 Never satisfied 2.8 1.6–4.6 < 0.001* 3.6 1.9–6.7 < 0.001* includes 1st degree tears and vaginal wall and labial tears *indicates statistical signficance at p < 0.05 both parents in the household. If viewed through the with which women report dyspareunia 6 months after adaptation lens, one is left with questions around the ap- birth. The likelihood of women experiencing dyspar- propriateness of including lack of sexual activity as an eunia at 6 months was substantially higher in women indicator of ‘sexual dysfunction’ in the DSM-5 definition whose birth was vacuum-assisted, had 2nd degree tears, of sexual dysfunctions , especially for this cohort of 3rd degree tears and episiotomies compared to those postpartum women. The high rate of reported loss of who had a spontaneous vaginal birth and an intact peri- interest in sexual activity also points to the need for neum; although, when all other factors were considered, women and their partners to be forewarned of this po- 3rd degree tears, only, along with pre-existing dyspar- tential change, as a routine part of perinatal care. By so eunia and breastfeeding emerged as significant factors doing much of the stress and anxiety identified by for dyspareunia at 6 months postpartum. Our univariate women interviewed by Olsson  and guilt reported by results reflect the findings from previous studies which women in Woolhouse and colleague’s study  around also report an association with episiotomy and poor sex- intimacy would be reduced. ual health outcomes , instrumental birth and dyspar- In our study 37.5% of women experienced dyspareunia eunia [19, 34]. In addition, it raises questions about the 6 months after birth, compared to 43.4% reported in the rates of obstetric intervention experienced by women in Maternal Health Study  and 31% in Barrett et al.’s Ireland. In our study 20.7% of women experienced a (2000) study . Our findings demonstrate that events vacuum-assisted birth, similar to a national rate of 21.2% that occur during labour and birth influence the extent , double the rate of 10.4% in the Maternal Health O’Malley et al. BMC Pregnancy and Childbirth (2018) 18:196 Page 11 of 13 Study in Australia  and much higher than the 5% in between pre-existing dyspareunia and experiencing sex- the nulliparous sample used by Connolly and colleagues ual health issues after birth [17, 34]. In our study 29.3% of . Our high rate of vacuum-assisted birth could be re- women experienced dyspareunia in the 12 months before lated to the equally high uptake of epidural anaesthesia becoming pregnant, and this, with other significantly re- in Irish maternity settings, as 78% of women in this lated factors (e.g. 3rd degree tears and breastfeeding at study used epidural analgesia (similar to the 72% of nul- 6 months and age > 35 years at 12 months) contributed to liparous women at the research site), and a 2011 Cochrane dyspareunia 6 and 12 months after birth. The majority of review identified that epidural analgesia increased the risk women do not seek professional support for postpartum of an instrumental birth . The association between sexual health issues, 15% in Barrett et al.’s study spoke to a episiotomy and persistent dyspareunia up to 12 months health professional  and 24% in the Australian study was found in our study, although it did not emerge as a were asked directly by a health professional about their risk factor for dyspareunia in multivariable analysis. In our sexual health postpartum . This corresponds to conclu- study 36.1% of women had an episiotomy, while this may sions from qualitative studies that demonstrated that appear elevated it is worth noting that 33% of women had women find it difficult to bring up sexual health issues an instrumental birth which is commonly associated with with health professionals [10, 11, 43] and this occurs at a an episiotomy. Our high rate of episiotomy (36.1%) com- time when women have direct contact with a variety of pares poorly, internationally, where 16% of women in the health professionals during the postpartum period. There- Maternal Health Study had an episiotomy  and 14% in fore it is very likely that women do not seek help for dys- Connolly’sresearch. This finding does not necessarily pareunia experienced before pregnancy as there may be suggest there is routine use of episiotomy but rather poses limited contact with health services. The antenatal period, concern over the high rate of epidural uptake, consequent a time when women have frequent consultations with instrumental births, perineal trauma and associated long health professionals appears to be an ideal opportunity to term dyspareunia. ask them about their sexual health and discuss any prob- Little has been published on the influence of breast- lems, such as pain during sexual intercourse, they may be feeding on postpartum sexual health, with many studies experiencing. It is potentially an ideal time to refer women choosing to focus on breastfeeding as a means of contra- to the most appropriate professional for help, be it the ception  or the influence of breastfeeding on re- women’s health physiotherapist attached to the maternity sumption of sexual activity and frequency of sexual services, sexual health therapist or couples therapy. How- activity [38–40]. In our study, breastfeeding, in associ- ever, previous studies of healthcare professionals have ation with other related factors, remained significantly shown that many lack competence and confidence in their present for all three of the outcomes of dyspareunia, a abilities to help with sexual problems , which may be lack of vaginal lubrication and a loss of interest in sexual why so many women had not been asked. Managing dys- activity 6 months postpartum. This finding highlights pareunia during pregnancy will go some way to reducing the potential for cognitive dissonance to occur. Cogni- the identified association between pre-pregnancy dyspar- tive dissonance occurs when people experience incon- eunia and a lack of vaginal lubrication and a loss of interest sistency between cognitions or between cognitions and in sexual activity seen in this study. Similarly, it is probable behaviour . In a professional or practice context that that persistent postpartum dyspareunia at 6 and 12 months emphasises women-centred care and disclosure, and a would be reduced if managed antenatally or at the very policy context that promotes breastfeeding, there is po- least women should be asked about sexual health issues, tential for internal conflict to arise. Practitioners may and would then know where to seek appropriate help. struggle with the professional imperative to inform This study is unique in its investigation of an associ- women of the impact of breastfeeding on sexual activity, ation between perception of body image and sexual dyspareunia and vaginal lubrication at the same time as health issues after birth. In this study women with a fearing a decrease in women’s willingness to breast- poor perception of their body images 6 and 12 months feed if impact is known. However, information regarding postpartum were more likely to experience a lack of va- breastfeeding needs to take account of these findings, if ginal lubrication (in the context of being overweight, care is to be ‘woman-centred’ as opposed to ‘breast-feed- obese, breastfeeding and pre-existing dyspareunia) and a ing centred’ . Without this information women may loss of interest in sexual activity (in the context of blame themselves for their loss of sexual interest, or strug- breastfeeding and pre-existing dyspareunia). The com- gle alone without information on the array of vaginal lu- plex nature of the concept of postpartum body image bricants available to alleviate vaginal dryness. and its influence on postpartum sexual health is poorly Little attention has been given to pre-existing dyspar- researched, and this led the first author of this paper to eunia and its influence on sexual health after birth to carry out qualitative one-to-one semi-structured inter- date, however two studies found a similar association views with some of the women who completed the O’Malley et al. BMC Pregnancy and Childbirth (2018) 18:196 Page 12 of 13 survey and identified themselves as experiencing sexual Abbreviations AOR: Adjusted Odds Ratio; BMI: Body Mass Index; CI: Confidence Interval; health problems. Analysis of these data is in progress CS: Caesarean Section; MAMMI: Maternal health And Maternal Morbidity in and will be reported at a later date. Ireland; OR: Odds ratio; PP: Postpartum; SPSS: Statistical Package for the Social Sciences Strengths and limitations Acknowledgements The strengths of this study include the recruitment of a We are grateful to all of the women who participated in the MAMMI study, large sample of nulliparous women in early pregnancy, the midwives and midwifery students who recruited women to the study and to other members of the MAMMI research team who have contributed regular follow-up and a high retention rate to 12 months to data collection and data management. postpartum. The frequency of follow-up reduces the likeli- hood of recall bias and provides reliable data on changes Funding This research was funded by a Health Research Board Healthcare Professional to women’s sexual health over time following birth. Some Fellowship grant awarded to Deirdre O’Malley (HRB HPF/2013/477-Begley). findings in our study are similar to other comparable stud- The funders had no role in the design of the study and collection, analysis, ies. This strengthens the argument for introducing sexual and interpretation of data and in writing the manuscript. health to antenatal and postnatal care pathways well be- Availability of data and materials yond the traditional 6 week postnatal assessment. The data supporting our findings are contained within the manuscript. A number of potential limitations have been identified Previous presentations reporting results on sexual health and other maternal that may influence the data. The study sample is from one morbidities are available for viewing on the MAMMI study website; www.mammi.ie. The corresponding author may be contacted for further maternity unit in Ireland, which is not entirely representa- information or clarifications relating to the data. tive of a national sample. The survey did not include defi- nitions of concepts such as lack of vaginal lubrication, Authors’ contributions DOM planned and conducted the analyses, interpreted data and contributed hence they are open to individual interpretation on to writing the paper. VS and AH supervised the analysis, contributed to meaning. The association of breastfeeding and sexual interpretation of data and reviewed and commented on all drafts of the health issues may be questionable as Ireland has a low paper. DD wrote the study protocol and took primary responsibility for the design and conduct of the MAMMI study, in conjunction with CB. CB was breastfeeding continuation rate; for example, in a national original supervisor to DOM and is the grant holder for this research. All study of infant feeding in Ireland, only 19% (n =347) of authors have approved the final draft of the paper prior to submission. women were exclusively breastfeeding at 3–4months postpartum . Data on other factors such as medica- Ethics approval and consent to participate The research ethics committees of the Faculty of Health Sciences Trinity tions (e.g., psychotropic drugs) that may affect interest in College Dublin and the Rotunda hospital Dublin approved the study. Written sexual activity  were not collected. A further limitation consent was obtained, and only women who returned a completed signed is the lack of data on the sexual orientation of women in consent form were included in this study. our study, thus it was not possible to identify if there was Competing interests any difference between women in same sex relationships Valerie Smith is a member of the BMC Pregnancy and Childbirth Editorial and those in opposite sex relationships. Board. All remaining authors declare that they have no competing interests. Conclusion Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in The findings from this large prospective cohort study of published maps and institutional affiliations. nulliparous demonstrates that women experience consider- able sexual health issues after pregnancy and childbirth. Author details Health Research Board, Research Fellow, School of Nursing and Midwifery, Dyspareunia, lack of vaginal lubrication and loss of interest Trinity College Dublin, Dublin, Ireland. School of Nursing and Midwifery, in sexual activity at 6 months postpartum were all signifi- Trinity College Dublin, Dublin, Ireland. Institute of Health and Care Sciences, cantly associated with pre-existing dyspareunia and breast- The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. feeding. 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“My last article couldn't be possible without the platform @deepdyve that makes journal papers cheaper.”@JoseServera