Epidemiology

DOI: 10.1111/1471-0528.12166
www.bjog.org

Does method of birth make a difference to when

women resume sex after childbirth?
EA McDonald, SJ Brown
Healthy Mothers Healthy Families Research Group, Murdoch Childrens Research Institute, Melbourne, Australia
Correspondence: E McDonald, Healthy Mothers Healthy Families Research Group, Murdoch Childrens Research Institute, The Royal Childrens
Hospital, Flemington Road, Parkville, Victoria, Australia 3052. Email ellie.mcdonald@mcri.edu.au
Accepted 20 November 2012. Published Online 27 February 2013.

Objective To investigate the timing of resumption of vaginal

sex and assess associations with method of birth, perineal trauma

and other obstetric and social factors.
Design Prospective pregnancy cohort study of nulliparous women.
Setting Melbourne, Australia.
Sample A total of 1507 nulliparous women recruited in early

pregnancy (  24 weeks).
Method Women were recruited from six public hospitals. Data

from hospital records and self-administered questionnaires at

recruitment and 3, 6 and 12 months postpartum were analysed
using univariable and multivariable logistic regression.
Main outcome measure Resumption of vaginal sex.
Results Sexual activity was resumed earlier than vaginal sex, with
53% resuming sexual activity by 6 weeks postpartum, and 41%
attempting vaginal sex. By 8 weeks a majority of women had

attempted vaginal sex (65%), increasing to 78% by 12 weeks, and

94% by 6 months. Compared with women who had a
spontaneous vaginal birth with an intact perineum, women who
had a spontaneous vaginal birth with an episiotomy (adjusted
odds ratio 3.43, 95% confidence interval 1.96.2) or sutured
perineal tear (adjusted odds ratio 3.18, 95% confidence interval
2.14.9) were more likely not to have resumed vaginal sex by
6 weeks postpartum. Similarly, women who had an assisted
vaginal birth or caesarean section had raised odds of delaying
resumption of sex.
Conclusions Most women having a first birth do not resume

vaginal sex until later than 6 weeks postpartum. Women who

have an operative vaginal birth, caesarean section or perineal tear
or episiotomy appear to delay longer.
Keywords Method of birth, perineal trauma, pregnancy cohort,
resumption of sex.

Please cite this paper as: McDonald E, Brown S. Does method of birth make a difference to when women resume sex after childbirth?. BJOG 2013;120:823
830.

Introduction
The resumption of sex after childbirth is a concern for
many women and their partners, and a recommended discussion topic in postnatal care.13 Yet, obstetric and midwifery clinical textbooks generally contain minimal
information about the impact of pregnancy and childbirth
on resumption of sex. The third edition of a classic obstetric text book published in 1997 suggests that coitus is often
resumed within 23 weeks with an intact perineum, and at
48 weeks or later with an episiotomy or perineal repair.4
Myles Textbook for Midwives states that women should be
pain free and have been able to resume intercourse without
pain by 6 weeks postpartum, but acknowledges that this is
sometimes not the case.5 The author of a recent compendium of obstetric evidence-based guidelines concludes that
there is insufficient evidence regarding the resumption of

sex after childbirth to inform the advice that health professionals give to women about this issue.6 This is largely
because of the limitations of existing studies, most of which
are cross-sectional, and therefore subject to recall bias.7
Few studies distinguish between nulliparous and multiparous women, and most lack sufficient sample size to assess
associations with method of birth and degree of perineal
trauma.
This paper draws on data collected in the Maternal
Health Study, a large multicentre prospective nulliparous
cohort study that was designed to assess the natural history
of maternal morbidity during pregnancy and after a first
birth. Primary outcomes included urinary incontinence,
faecal incontinence, persisting perineal pain and other sexual health problems. Data were collected via self-administered questionnaires in early pregnancy, and at 3, 6 and
12 months postpartum, and included questions regarding

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McDonald Brown

resumption of sexual activity. The objectives of this paper

are: (i) to investigate the timing of resumption of vaginal
sex in this prospective nulliparous cohort, and (ii) to assess
associations between resumption of vaginal sex and social
and obstetric characteristics of study participants, in particularmethod of birth and degree of perineal trauma.

Methods
Sample
Women were recruited to the study between 1 April 2003
and 31 December 2005 from six metropolitan public hospitals in Melbourne, Australia with a mix of high-risk and
low-risk perinatal services. Eligibility criteria were:
 18 years, nulliparous (i.e. no previous live births or pregnancies ending in a stillbirth), sufficient English language
fluency to complete self-administered questionnaires and
telephone interviews, and estimated gestation of
 24 weeks at enrolment (according to ultrasound or date
of last menstrual period). Following their booking visit, all
eligible women were mailed an invitation package by participating hospitals. Study staff also made regular visits to
antenatal booking clinics at two participating hospitals, and
to childbirth education classes at one of the other study
sites, to distribute information packages to women eligible
to take part in the study. The invitation package included
the baseline questionnaire, an information sheet about the
study, a consent form and a separate sheet for providing
contact details. The invitation was followed up by a single
mailed reminder postcard. We were prevented from following up non-responders by telephone by Australian privacy
legislation and the conditions of our ethics approval.
Women were invited to return the consent papers, contact
information and completed questionnaire in a reply-paid
envelope. This paper draws on data collected in the baseline
questionnaire and follow-up questionnaires completed at 3,
6 and 12 months postpartum, and on data abstracted from
hospital medical records for women giving written consent.

Measures and definitions

Questionnaires were B5 booklets approximately 40 pages in
length, which focused on the assessment of a range of common maternal physical and psychological health problems,
including sexual health issues using previously validated
standardised questions where possible. Questions regarding
resumption of sexual activity, vaginal sex and postnatal sexual health problems drew on the study reported by Barrett
et al.,8 and were included in each postpartum questionnaire. Sexual activity was defined as any form of sexual
contact which may or may not include vaginal sex.
Data on labour and birth events were abstracted from
hospital medical records using a detailed data abstraction
protocol, and were also collected in the first postnatal fol-

824

low-up questionnaire at 3 months postpartum. There was a

high level of congruity between medical record data and
womens own accounts of method of birth and other
obstetric events.9,10 Data from questionnaires have been
used to categorise method of birth and degree of perineal
trauma in the current paper as they provided more complete data for these variables. Medical record data gave
more precise information about perineal trauma, and timing of caesarean section in first-stage or second-stage
labour. Data on method of birth and degree of perineal
trauma were combined to provide a single measure of perineal trauma stratified by method of birth.
Maternal depressive symptoms were assessed at
3 months postpartum using the Edinburgh Postnatal
Depression Scale (EPDS), a 10-item scale that has good
sensitivity and specificity for identifying probable clinical
depression in community samples.11 Scores  13 on the
EPDS are indicative of probable major depression. Twelvemonth period prevalence of intimate partner abuse was
assessed using the short version of the Composite Abuse
Scale, a validated instrument comprising 18 items of
actions by an intimate partner that constitute emotional or
physical abuse.12,13
Tiredness in the first 3 months postpartum was assessed
using a symptom checklist that asked about the experience
of common maternal physical health problems. Specifically,
women were asked Since the birth have you ever experienced extreme tiredness or exhaustion? Pre-given
response categories were: never, rarely, occasionally or
often. Responses were dichotomised into symptoms
reported as often or occasionally versus rarely or never.
Method of infant feeding was assessed based on
responses to a series of questions about whether women
had ever breastfed their baby, the type of feeds the baby
was having at the time of completing the 3-month questionnaire, and for women who started to breastfeed but
had stopped, how old their baby was when they stopped
(number of completed weeks). No distinction was made
between exclusive, predominant or complimentary breastfeeding. Babies having some formula feeds and some
breast-milk feeds were categorised as breastfed for the purposes of analysis.
Data on sociodemographic characteristics such as maternal age, education and relationship status were collected in
the baseline questionnaire and the questionnaire at
3 months postpartum.

Analysis
Data were analysed using STATA version 12.14 The proportion (and cumulative proportion) of women resuming sexual activity and vaginal sex at given intervals after
childbirth were calculated based on the proportions of
women reporting resumption of sex divided by the total

2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2013 RCOG

Method of birth and resumption of sex

number of women with data available. Sociodemographic

and other factors associated with nonresumption of vaginal
sex including maternal depressive symptoms, intimate partner violence in the first 12 months postpartum, tiredness
and method of infant feeding were investigated using logistic regression. Multivariable logistic regression was used to
examine the association between method of birth and perineal trauma (exposures of main interest) and resumption
of sex (primary outcome), taking into account potential
confounders, including maternal age, relationship status
and site of recruitment to account for possible cluster
effects.

Results
Sample
A total of 1537 women enrolled in the study. Thirty
women were excluded after enrolment due to miscarriage
(12), insufficient fluency in English (11), multiparity (5),
or termination of pregnancy for fetal abnormality (2), leaving a final sample of 1507 women. We are unable to determine a precise response fraction. Over 6000 information
packages were distributed, but some were mailed to women
who had already received a questionnaire and information
package at a booking visit. It is also likely that some were
incorrectly addressed or sent to women who were ineligible
(e.g. multiparous). Based on the assumption that 8090%
of invitations were sent to eligible women with a correct
mailing address, we conservatively estimate the overall
response fraction to be in the range of 2831%.
The mean gestation of study participants at the time of
enrolment was 15.0 weeks (SD 3.1, range 624 weeks).
Social and reproductive characteristics of participants were
compared with routinely collected data for women giving
birth at Victorian public hospitals in the study period.
Compared with all women  18 years giving birth to their
first child at public hospitals in Victoria during the 30month period of recruitment, study participants were representative in relation to method of birth and infant birthweight, but under-represented young women (1824 years,
15.5% versus 29.9%) and women born overseas from a
non-English-speaking background (16.2% versus 21.0%).
Further information regarding sociodemographic and
reproductive characteristics of the sample and representativeness of study participants compared with other women
giving birth at study hospitals and other Victorian public
hospitals in the same time period is available in a previous
paper.15

Resumption of sexual contact and vaginal sex

postpartum
Table 1 shows the number, proportion and cumulative
proportion of women to resume sexual activity and vaginal

Table 1. Resumption of sexual activity and vaginal sex postpartum

(n = 1305)
Timing

 4 weeks
56 weeks
78 weeks
912 weeks
4 months (1317 weeks)
5 months (1821 weeks)
6 months (2226 weeks)
79 months (2739 weeks)
1012 months
(4052 weeks)
Not resumed by 12
months

Sexual activity
n (%)
[cumulative%]
365 (28.0)
327 (25.0)
266 (20.4)
170 (13.0)
74 (5.7)
21 (1.6)
23 (1.8)
22 (1.7)
8 (0.6)

[28.0]
[53.0]
[73.4]
[86.4]
[92.1]
[93.7]
[95.5]
[97.2]
[97.8]

29 (2.2) [100.0]

Vaginal sex
n (%)
[cumulative%]
199 (15.2)
342 (26.2)
310 (23.8)
169 (13.0)
156 (12.0)
36 (2.8)
11 (0.8)
27 (2.0)
11 (0.8)

[15.2]
[41.4]
[65.2]
[78.2]
[90.2]
[93.0]
[93.8]
[95.8]
[96.6]

44 (3.4) [100.0]

sex in the first 12 months postpartum. Sexual activity was

resumed earlier than vaginal sex, with 53% resuming some
form of sexual activity by 6 weeks postpartum, and 41%
attempting vaginal sex. By 8 weeks a majority of women
had attempted vaginal sex (65%), with this figure increasing to 78% by 12 weeks postpartum, and 94% by 6 months
postpartum.

Factors associated with resumption of vaginal sex

Table 2 shows analyses assessing the association between
non-resumption of vaginal sex at two time-points (6 weeks
and 3 months postpartum) and maternal sociodemographic, obstetric and postnatal characteristics, including scores
on the EPDS and the Composite Abuse Scale. The odds
ratios shown in the Table are based on the odds of not
resuming sex at each time-point. Compared with women
aged 3034 years, younger women (1824 years) were significantly less likely not to have resumed vaginal sex by
6 weeks postpartum. Women who had a birth assisted with
forceps and those who had an episiotomy or sutured tear
were more likely not to have resumed vaginal sex compared with women who had a spontaneous vaginal birth
and intact perineum, respectively. Breastfeeding and
extreme tiredness since the birth were also associated with
not resuming vaginal sex by 6 weeks postpartum, as was
being single, separated or divorced.
At 3 months postpartum, women were more likely not
to have resumed vaginal sex if they were older
(  35 years); single, separated or divorced; had had an episiotomy, or had experienced extreme tiredness since the
birth. Compared with women who had degree-level qualifications, women who had not completed year 12 were sig-

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825

McDonald Brown

Table 2. Resumption of vaginal sex at or by 6 weeks postpartum and 3 months postpartum by background, obstetric and postnatal variables
Total*

Resumed vaginal sex by 6 weeks

postpartum
n

Maternal age at birth (years)

3034
376
150
1824
148
93
2529
529
201
35+
252
97
Relationship status
Married/de facto
1248
525
Divorced/separated/single
56
15
Qualification
University degree
622
238
Certificate/diploma
337
149
Year 12
238
100
<Year 12
101
51
Method of birth
Spontaneous vaginal
634
263
Forceps
140
45
Vacuum extraction
140
57
Caesarean, no labour
128
61
Caesarean, laboured
263
115
Perineal trauma
Intact perineum
539
270
Unsutured tear
68
35
Sutured tear
402
141
Episiotomy
293
94
Any breastfeeding at 6 weeks
No
165
87
Yes
1072
424
Any breastfeeding at 3 months
No
265
na
Yes
972
Extreme tiredness since birth
No
432
198
Yes
861
338
EPDS at 3 months
No
1211
na
Yes
89
Any type of abuse birth 12 m postpartum
No
1082
451
Yes
216
90

OR

95% CI

OR

95% CI

39.9
62.8
38.0
38.5

1.0 (ref)
0.39
1.08
1.06

0.30.6
0.81.4
0.81.5

305
131
404
180

81.1
88.5
76.4
71.4

1.0 (ref)
0.56
1.33
1.72

0.31.0
1.01.8
1.22.5

42.1
26.8

1.0 (ref)
1.99

1.13.6

991
28

79.4
50.0

1.0 (ref)
3.86

2.26.6

38.3
44.2
42.0
50.5

1.0 (ref)
0.78
0.86
0.61

0.61.0
0.61.2
0.40.9

471
264
190
90

75.7
78.3
79.8
89.1

1.0 (ref)
0.86
0.79
0.38

0.61.2
0.61.1
0.20.7

41.5
32.1
40.7
47.7
43.7

1.0 (ref)
1.50
1.03
0.78
0.91

1.02.2
0.71.5
0.51.1
0.71.2

496
112
103
96
213

78.2
80.0
73.6
75.0
81.0

1.0 (ref)
0.90
1.29
1.20
0.84

0.61.4
0.92.0
0.81.9
0.61.2

50.1
51.5
35.1
32.1

1.0 (ref)
0.95
1.86
2.13

0.61.6
1.42.4
1.62.9

437
57
314
211

81.1
83.8
78.1
72.0

1.0 (ref)
0.83
1.20
1.67

0.41.6
0.91.7
1.22.3

52.7
39.6

1.0 (ref)
1.71

na

na

1.22.4

na

na

na

na

45.8
39.3

1.0 (ref)
1.31

1.01.7

na

na

na

41.7
41.7

1.0 (ref)
1.00

nificantly less likely not to have resumed vaginal sex. There

was a weak association between resumption of vaginal sex
and depressive symptoms (EPDS  13), with data showing
a moderate effect bordering on statistical significance.
There was no association between exposure to intimate
partner abuse as assessed by the Composite Abuse Scale
and timing of resumption of vaginal sex.

826

Resumed vaginal sex by 3 months

postpartum

0.71.4

na

221
749

83.4
77.1

1.0 (ref)
1.26

0.91.7

354
658

81.9
76.4

1.0 (ref)
1.40

1.11.9

955
64

78.9
71.9

1.0 (ref)
1.46

0.92.4

843
175

77.9
81.0

1.0 (ref)
0.83

0.61.2

Impact of method of birth and perineal trauma

To investigate the contribution of method of birth and perineal trauma to timing of resumption of vaginal sex, we
combined data from these two variables to create a composite variable. Table 3 shows the proportions of women
who had resumed vaginal sex by 6 weeks and 3, 6 and
12 months postpartum by degree of perineal trauma (intact

2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2013 RCOG

Method of birth and resumption of sex

Table 3. Relationship between method of birth, perineal trauma

and resumption of vaginal sex (n = 1302)
Method of
birth and
perineal
trauma

Total
n

Table 4. Multivariable regression analysis assessing the relationship

between resumption of vaginal sex by 6 weeks postpartum and
method of birth and perineal trauma (n = 1281)

Resumed vaginal sex by (%):

6
weeks

3
months

6
months

12
months

Method of birth
and perineal
trauma

Total

Resumed vaginal sex by

6 weeks postpartum
n

Spontaneous vaginal birth

Intact perineum
142
60.6
Unsutured tear
64
50.0
Sutured tear
337
34.7
Episiotomy
91
30.8
Vaginal birth forceps
Intact
2
100.0
Unsutured tear
2
50.0
Sutured tear
24
33.3
Episiotomy
112
30.4
Vaginal birth vacuum extraction
Intact
11
72.7
Unsutured tear
2
100.0
Sutured tear
39
41.0
Episiotomy
88
35.2
Caesarean section
No labour intact
128
47.7
perineum
Laboured intact
256
44.1
perineum
Laboured sutured
2
0.0
tear
Laboured
2
50.0
episiotomy

86.6
82.8
78.0
62.6

97.9
93.8
93.5
93.4

98.6
96.9
95.6
96.7

100.0
100.0
87.5
77.7

100.0
100.0
95.8
96.4

100.0
100.0
100.0
97.3

72.7
100.0
71.8
73.9

90.9
100.0
92.3
90.9

90.9
100.0
92.3
95.5

75.0

88.3

89.1

81.3

94.5

96.9

100.0

100.0

100.0

100.0

100.0

100.0

perineum/unsutured tear/sutured tear/episiotomy) within

strata for method of birth. The pattern of association
between degree of perineal trauma and non-resumption of
vaginal sex at 6 weeks and 3 months postpartum is similar
across unassisted and assisted vaginal delivery methods,
with women who had an intact perineum more likely to
have resumed sex than women who sustained a perineal
tear or episiotomy.
To obtain a more precise estimate of the association
between method of birth, perineal trauma and resumption
of sex, we developed a multivariable logistic regression
model with the composite variable for method of birth and
degree of perineal trauma as the exposure of main interest
and resumption of sex at 6 weeks postpartum as the outcome variable. The small subgroups of women who sustained perineal trauma before caesarean section or who
gave birth assisted by forceps or vacuum extraction without
sustaining perineal trauma were excluded from the model.
Other variables included in the model (shown in Table 4)
were maternal age (included for a priori reasons), relationship status, infant feeding method and extreme tiredness in
the first 3 months after the birth (all of which were associ-

Spontaneous vaginal birth

Intact perineum
142
86 60.6
Unsutured tear
64
32 50.0
Sutured tear
337
117 34.7
Episiotomy
91
28 30.8
Vaginal birth with forceps
Sutured tear
24
8 33.3
Episiotomy
112
34 30.4
Vaginal birth with vacuum extraction
Sutured tear
39
16 41.0
Episiotomy
88
31 35.2
Caesarean section
No labour intact
128
61 47.7
perineum
Laboured intact
256
113 44.1
perineum
Maternal age (years)
3034
376
150 39.9
1824
148
93 62.8
2529
529
201 38.0
35+
252
97 38.5
Relationship status
Married/de facto
1248
525 42.1
Divorced/separated/
56
15 26.8
single
Qualification
University degree
622
238 38.3
Certificate/diploma
337
149 44.2
Year 12
238
100 42.0
<Year 12
101
51 50.5
Any breast feeding at 6 weeks
No
165
87 52.7
Yes
1072
424 39.3
Extreme tiredness since birth
No
432
198 45.8
Yes
861
338 39.3

Adjusted
OR*

95% CI

1.0 (ref)
1.39
3.18
3.43

0.72.6
2.14.9
1.96.2

4.60
3.46

1.613.6
2.06.0

2.38
2.86

1.15.2
1.65.2

1.71

1.02.9

1.99

1.33.1

1.0 (ref)
0.44
1.13
1.16

0.30.7
0.81.5
0.81.7

ne**

ne

1.0 (ref)
0.94
0.98
0.82

0.71.3
0.71.4
0.51.3

1.0 (ref)
1.25

1.12.3

1.0 (ref)
1.25

1.01.6

*Adjusted for maternal age, marital status, qualification category,

breastfeeding at 6 weeks postpartum, extreme tiredness in the first
3 months postpartum and delivery hospital.
**Not estimated, small numbers in cells.

ated with timing of resumption of vaginal sex in univariable analyses). The site of recruitment was included in the
model to account for potential cluster effects. Table 4
shows the adjusted odds ratios within strata compared with
the reference category of spontaneous vaginal birth with an
intact perineum. The results confirm effects associated with

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McDonald Brown

degree of perineal trauma within strata of vaginal delivery

types. Women who had a spontaneous vaginal birth or
birth assisted by forceps or vacuum extraction and sustained a sutured tear or episiotomy were more likely not to
resume vaginal sex by 6 weeks postpartum compared with
women who experienced a spontaneous vaginal birth with
an intact perineum. The small group of women who had
an unsutured tear were slightly more likely not to resume
vaginal sex by 6 weeks, but the effect was modest and of
borderline statistical significance. Women who gave birth
by caesarean section were included in the model even
though the numbers of women who sustained perineal
trauma were too small for inclusion in the modelling analyses. Compared with the reference category of women who
had a spontaneous vaginal birth and intact perineum,
women who had a caesarean section had raised odds of not
resuming vaginal sex by 6 weeks postpartum, irrespective
of the timing of caesarean section (before or after commencing labour) that were not explained by maternal age
and other variables included in the model.

Discussion
Main findings
The most important finding of this study is the wide
time interval over which women resume vaginal sex after
a first birth. The common assumption that most women
will resume sex by 6 weeks postpartum is out of step
with the choices made by many women and their partners. Many factors will influence these decisions. It is
possible that some couples delay resumption of sex until
after the 6-week check-up on the grounds of waiting to
check that everything is back to normal. This may
explain the relatively large number of women who
resumed vaginal sex around 78 weeks postpartum. The
study findings provide evidence that both method of birth
and degree of perineal trauma also play a role, with caesarean birth or operative vaginal birth more likely to be
associated with a delay in resumption of vaginal sex compared with vaginal birth with an intact perineum. In
modern obstetric practice, only a small proportion of
women having a first baby will achieve a vaginal birth
with no attendant perineal trauma. In this large multicentre study, the proportion was around 10%. Hence, for the
vast majority of women and their partners, it is reasonable to anticipate a delay in resuming vaginal sex related
to the events of labour and birth.
Young women (<25 years) tended to resume vaginal sex
earlier than older women. Women who were single,
divorced or separated were more likely to resume sex later
than women living with a partner. Apart from maternal
age and relationship status, sociodemographic characteristics appeared to play little role in womens decisions about

828

timing of resumption of vaginal sex. Other factors associated at a univariable level with a delay in resumption of
vaginal sex were breastfeeding and extreme tiredness.
Exhaustion is a common experience in the first year after
childbirth,1619 and was frequently commented on by study
participants as a factor influencing their sex lives in the
year after the birth (data not shown). Radestadt et al.20
have previously reported an association between breastfeeding and delayed resumption of sex citing hormonal changes
and lack of vaginal lubrication as potentially contributing
to this finding. It is possible that tiredness contributes to
the association with breastfeeding, but our results showing
an association between breastfeeding and timing of
resumption of sex, adjusting for a range of other factors
including tiredness, suggest that lactation may make an
independent contribution to the timing of resumption of
vaginal sex after childbirth.
Women who scored  13 on the EPDS at 3 months
postpartum did not appear to be any more likely to delay
resumption of vaginal sex than women scoring below this
cut-off, although the results bordering on statistical significance and modest effect size would suggest a weak association. Other studies have shown associations between
maternal depression and sexual health problems21 and
delay in resumption of sex.22

Strengths and limitations

Strengths include: prospective data collection with intensive
follow up to 12 months postpartum, limited attrition, and
very few missing data for primary outcomes and exposures
of main interest. Ascertainment of method of birth and
degree of perineal trauma drew on data from medical
records and on womens own accounts of labour and birth
events. As with all studies there are also limitations. Ascertainment of timing of resumption was based on combining
data from questionnaires at 3, 6 and 12 months postpartum, which may have introduced some recall bias, although
our study involves more frequent assessment than most
other studies. Women were recruited from hospitals with a
mix of women at high and low risk of obstetric complications, but the sample cannot be considered to be truly population-based. We were able to quantify the extent of
selection bias by comparing study participants with women
who gave birth in the study period drawing on routinely
collected data. These showed that the sample was representative in relation to method of birth and infant birthweight,
but that women who are socially disadvantaged, for example younger women, and women born overseas of nonEnglish speaking backgrounds, are under-represented.
While this can be expected to influence prevalence estimates, and may for example, have biased estimates for
resumption of sex towards a greater delay in resumption
than may be true for the total population, recent studies

2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2013 RCOG

Method of birth and resumption of sex

examining exposureoutcome associations in studies with

low response fractions suggest that our findings showing
associations between obstetric events and delay in resumption of vaginal sex should be considered robust.23 Assessment of infant feeding method and duration of
breastfeeding via questionnaire at 3 months postpartum
may have resulted in some misclassification. Similarly, we
did not have data on intimate partner violence that was
specific to the first 3 months. It is possible that our results
may mask effects that were present during this period.
Other studies have shown that women experiencing intimate partner violence may suffer major health consequences as a result of being forced to have sex.24

Contribution to authorship
EM conducted the analyses and wrote the paper. SB wrote
the study protocol, took primary responsibility for the
design and conduct of the study, contributed to analysis
and interpretation of data and contributed to writing the
paper. Both authors have approved the final draft of the
paper for publication.

Details of ethics approval

This study was approved by the following human research
ethics committees: La Trobe University (2002/38); Royal
Womens Hospital, Melbourne (2002/23); Southern Health,
Melbourne (2002-099B); Angliss Hospital, Melbourne
(2002), Royal Childrens Hospital, Melbourne (27056A).

Interpretation
The timing of resumption of vaginal sex is only one dimension of sexuality after childbirth, but it is very common for
women to want information about when sexual activity may
be safely and comfortably resumed, and what to expect in
relation to the impact of childbirth on their sexual relationship. Having more reliable information to guide clinical
practice is important for a number of reasons. First and foremost, it can help dispel myths about what is normal (or
abnormal) in the postnatal period. The fact that most
women had not resumed vaginal sex by 6 weeks postpartum
means that it is normal for couples to delay resumption of
sex until after this time. This is useful information for couples to know before their baby is born, and may help to
reduce the feelings of anxiety and guilt about not resuming
sexual activity sooner.25 Second, having more reliable evidence enables clinicians to tailor information to womens
circumstances. It may help women who have had a caesarean
section, operative vaginal birth and/or an episiotomy or perineal tear to be counselled to anticipate ways in which this
might affect their sexual relationship.

Conclusion
The Maternal Health Study is the first large multicentre,
prospective pregnancy cohort study to provide robust evidence regarding the association of method of birth, perineal trauma and the timing of resumption of vaginal sex
after a first birth. The findings show that most women do
not resume vaginal sex until later than 6 weeks postpartum, and that women having an operative vaginal birth,
caesarean section and/or perineal tear or episiotomy are
likely to delay resumption of vaginal sex for longer. The
study provides important new evidence to guide information given to women and their partners about what to
expect after childbirth.

Disclosure of interests
None disclosed.

Funding
This research was supported by project grants from the
Australian National Health and Medical Research Council
(ID191222 and ID433006 Melbourne, Australia); a VicHealth Public Health Research Fellowship (200206) and a
National Health and Medical Research Council Career
Development Fellowship (ID491205, 200811) awarded to
SB; and the Victorian Governments Operational Infrastructure Support Programme.

Acknowledgements
We are grateful to members of the Maternal Health Study
research team who have contributed to data collection and
coding (Maggie Flood, Deirdre Gartland, Ann Krastev,
Renee Paxton, Susan Perlen, Martine Spaull, Hannah
Woolhouse), and to Deirdre Gartland and Hannah Woolhouse for reviewing and commenting on the manuscript
before submission. &

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