DOES METHOD OF BIRTH MAKE A

DIFFERENCE TO WHEN WOMEN

RESUME SEX AFTER CHILDBIRTH?
EA McDonald, SJ Brown

Complied: Jessica Gabriana K (11.2014.150)

Preceptor: dr. Doddy F.P. Gultom, SpOG, MKes

Introduction

The resumption of sex after childbirth is

a concern for many women and their
partners, and a recommended discussion
topic in postnatal care.
Yet, theres still minimal information
about the impact of pregnancy and
childbirth on resumption of sex.

Introduction

Myles Textbook for Midwives states that

women should be pain free and have
been able to resume intercourse without
pain by 6 weeks postpartum.
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.

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.

Methods of the study

Design

Prospective pregnancy
nulliparous women

Setting

Melbourne, Australia

cohort

study

of

Methods of the study

Sample

A total of 1507 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:

Women 18 years, nulliparous (i.e no previous live births

or pregnancies ending in a stillbirth)
sufficient English language fluency to complete selfadministered questionnaires and telephone interviews
estimated gestation of 24 weeks at enrolment (according
to ultrasound or date of last menstrual period)

Methods of the study

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.
The invitation package included the baseline
questionnaire, an information sheet about the
study, a consent form and a separate sheet for
providing contact details.

Methods of the study

Women were invited to return the consent

papers, contact information and completed
questionnaire.
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.

Methods of the study

Measures and Definitions

Questionnaires were B5 booklets which focused

on the assessment of a range of common
maternal physical and psychological health
problems, including sexual health issues.
Questions regarding resumption of sexual activity,
vaginal sex and postnatal sexual health problems
were included in each postpartum questionnaire.
Sexual activity was defined as any form of
sexual contact which may or may not
include vaginal sex.

Methods of the study

Measures and Definitions

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.

Methods of the study

Common maternal physical and psychological

health problems

Maternal depressive symptoms were assessed at

3 months postpartum using the Edinburgh Postnatal
Depression Scale (EPDS), a 10-item scale, which are
scores 13 on the EPDS are indicative of probable
major depression.
Twelve month 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.

Methods of the study

Common maternal
health problems

physical

and

psychological

Tiredness in the first 3 months postpartum was

assessed using a symptom checklist that asked about
the experience of common maternal physical health
problems.
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 3month questionnaire, and for women who started to
breastfeed but had stopped, how old their baby was
when they stopped (number of completed weeks).

Methods of the study

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.

Methods of the study

Analysis

Data were analysed using STATA version 12

The 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
number of women with data available.
Sociodemographic and other factors associated
with nonresumption of vaginal sex maternal
depressive symptoms, intimate partner violence
in the first 12 months postpartum, tiredness and
method of infant feeding were investigated
using logistic regression.

Methods of the study

Analysis

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).

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.

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).

Results
Resumption
postpartum

of

sexual

contact

and

vaginal

sex

Table 1 shows the number, proportion and cumulative

proportion of women to resume sexual activity and
vaginal 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%)
78% by 12 weeks postpartum
94% by 6 months postpartum.

Table 1. Resumption of sexual activity

and vaginal sex postpartum (n =
1305)
Timing

4 weeks

Sexual activity
n (%)
[cumulative
%]

Vaginal sex
n (%)
[cumulative %]

365 (28.0) [28.0]

199 (15.2) [15.2]

56 weeks

327 (25.0)
[53.0]

342 (26.2) [41.4]

78 weeks

266 (20.4) [73.4]

310 (23.8) [65.2]

912 weeks
4 months (1317 weeks)
5 months (1821 weeks)
6 months (2226
weeks)
79 months (2739 weeks)
1012 months (4052

170 (13.0) [86.4]

74 (5.7) [92.1]
21 (1.6) [93.7]
23 (1.8) [95.5]
22 (1.7) [97.2]
8 (0.6) [97.8]

169 (13.0) [78.2]

156 (12.0) [90.2]
36 (2.8) [93.0]
11 (0.8) [93.8]
27 (2.0) [95.8]
11 (0.8) [96.6]

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

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

Results

Factors associated with resumption of

vaginal sex

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.

Results
Factors associated with resumption of vaginal sex

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.

women who had not completed year 12 were significantly

less likely not to have resumed vaginal sex.

Results

Factors associated with resumption of

vaginal sex

There was a weak association between

resumption of vaginal sex and depressive
symptoms
There was no association between exposure to
intimate partner abuse as assessed by the
Composite Abuse Scale and timing of
resumption of vaginal sex.

Results
Table 3. Relationship between
method of birth, perineal trauma
and resumption of vaginal sex
(n= 1302)

Impact of method of birth and

perineal trauma

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
perineum/unsutured
tear/sutured
tear/episiotomy)
within strata for method of
birth.

Results

Impact of method of birth and perineal trauma

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.

Results
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)

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 associated with
timing of resumption of vaginal
sex in univariable analyses).

Results

Impact of method of birth and perineal trauma

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.
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.

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.
Yet, 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.

Discussion

Main findings

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 com pared with
vaginal birth with an intact perineum.
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.

Discussion

Main findings

Other factors associated with a delay in

resumption
of
vaginal
sex
were
breastfeeding and extreme tiredness.
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.

Discussion

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.

Discussion

Strengths and 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.
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 populationbased.

Discussion

Strengths and limitations

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.

Discussion

Interpretation

The timing of resumption of vaginal sex is

only one dimension of sexuality after
childbirth.
Yet, 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.

Discussion

Interpretation

First and foremost, it can help dispel myths about

what is normal (or abnormal) in the postnatal period.
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.
Second, 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.
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.