Women s sexual health after childbirth

Transcription

1 B JOG 2000,107(2), pp Women s sexual health after childbirth *Geraldine Barrett Lecturer (Medical Sociology), *Elizabeth Pendry Research Assistant, *Janet Peacock Senior Lecturer (Medical Statistics), Christina Victor Reader (Health Services Research), **Ranee Thakar Research Fellow (Obstetrics and Gynaecology), **Isaac Manyonda Consultant (Obstetrics and Gynaecology) *St George s Hospital Medical School, London; * *St George s Health Care Trust, London Objective To investigate the impact of childbirth on the sexual health of primiparous women and identify factors associated with dyspareunia. Design Setting Population Cross-sectional study using obstetric records, and postal survey six months after delivery. Department of Obstetrics and Gynaecology, St George s Hospital, London. All primiparous women (n = 796) delivered of a live birth in a six month period. Methods Quantitative analysis of obstetric and survey data. Main outcome measures Self reported sexual behaviour and sexual problems (e.g. vaginal dryness, painful penetration, pain during sexual intercourse, pain on orgasm, vaginal tightness, vaginal looseness, bleedinghrritation after sex, and loss of sexual desire); consultation for postnatal sexual problems. Results Of the 484 respondents (61% response rate), 89% had resumed sexual activity within six months of the birth. Sexual morbidity increased significantly after the birth: in the first three months after delivery 83% of women experienced sexual problems, declining to 64% at six months, although not reaching pre-pregnancy levels of 38%. Dyspareunia in the first three months after delivery was, after adjustment, significantly associated with vaginal deliveries (P = 0.01) and previous experience of dyspareunia (P = 0.03). At six months the association with type of delivery was not significant (P = 0.4); only experience of dyspareunia before pregnancy (P < ) and current breastfeeding were significant (P = ). Only 15% of women who had a postnatal sexual problem reported discussing it with a health professional. Conclusions Sexual health problems were very common after childbirth, suggesting potentially high levels of unmet need. INTRODUCTION Women s mental health in the postnatal period has been researched e~tensivelyl-~. More recently, studies have demonstrated that women also experience physical problems, and urinary and faecal incontinence after childbirth&. However, women s sexual health after birth remains under-researched, in particular the experience of dyspareunia and other sexual problems. The few reported studies of postnatal sexual health have had limitations, either with the sample or the extent to which sexual health was examined. For example, some studies have volunteer samplesz0-23 or only have included women who meet certain criteria, such as women with episiot~mies~~, vaginal deliveriesz5, women with adequate English, a stable relationship, and living Correspondence: Ms G. Barrett, Sexual Health Programme, Health Promotion Research Unit, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London WClE 7HT, UK. in a certain area2s-27, or met the entry criteria for a randomised controlled trial2*-. Two well conducted studies used large unselected samples to examine women s general postnatal health; these studies included questions on postnatal sexual health, but the questions were limited.. Despite the limitations of available studies, general trends emerge: childbirth brings about a change in the sexual relationship; perineal pain and dyspareunia are common experiences for postnatal and there is generally a decrease in the frequency of sexual interco~rse~~.~~. and the woman s sexual desirez0,24,27,28,,~s. Hormonal effects associated with breastfeeding appear to be associated with vaginal dryness and/or loss of although this finding is not consistent across all st~dies~~,~~. There is evidence for a positive association between levels of dyspareunidperineal pain and perineal damage (in particular, episiotomy)22~23~.2s*z* and assisted vaginal deli~ery~~.~~*. Such evidence is relevant to the debate about women s choice of elective caesarean section as RCOG 2000 BJOG

2 WOMEN S SEXUAL HEALTH AFTER CHILDBIRTH 187 preferred mode of delivery3g4z. Parity is also important because primiparous women have higher rates of episiotomy and assisted delivery than multiparous womenz3,4145 and report higher levels of dyspareunia and perineal painz3*28. There is a lack of information about consultation for postnatal sexual problems and information provided by health professionals on this subject. It appears that while the majority of women discuss contraception with a health professional, they rarely discuss sexual interc~urse*~~~, and even when they feel a need for help with a sexual problem, only a minority seek it3*. In this study we describe the nature of women s sexual health after childbirth and focus on the factors associated with dy spareunia. METHODS We studied a series of consecutive primiparous women giving birth to a live infant at a London teaching hospital between 1 July and 31 December Three women were excluded from the sample: one because she died some months after the birth; one because of the infant s subsequent death; and one because one of her twins was stillborn. The final sample included 796 women with surviving infants. All preterm births, twins (where both were alive), and infants with malformations were included. Primiparous women were chosen to avoid the confounding effects of a previous birth. A six month cohort of women was chosen because of administrative convenience and funding constraints (this study was funded in-house). We expected the six month period to provide approximately 750 primiparous women. In our pilot study the proportions of women reporting dyspareunia varied significantly prior to pregnancy (22%), in the first three months (58%), and at approximately six months after birth (26%). However, the sample size was insufficient to perform multifactorial analyses on dyspareunia. We estimated that the current study size would give at least 100 women with dyspareunia at six months, and so would be large enough do such analyses and thus explore factors related to dyspareunia. Information about each woman (e.g. age, social circumstances, medical history, obstetric details) and her infant (e.g. birthweight, gestational age) was collected from the computerised birth records. All antenatal and peripartum data in the hospital are entered onto computer by trained midwives, and all midwives receive training on how to use the system and enter the data. There is also a midwife in overall charge of the data system who regularly validates the data entered. Overall, the information in the computerised birth records is detailed and has a high level of completeness. Postal questionnaires were also sent to women six months after delivery. The questionnaires were sent out in one month batches in the sixth month after delivery (for example, July deliveries received their first posting in December, August deliveries in January erc). Nonresponders in each batch were sent two reminder questionnaires, at two week intervals. Most women in the final sample responded to either the first of second mailing; very little was gained by the third mailing. Overall, data collection lasted from December 1997 to early June The questionnaire enquired about general health, bowel and bladder function, sexual health and mental health&, but only the findings relating to sexual health are reported in this paper. Our other findings will be reported elsewhere, as appropriate. In the questionnaire women were asked if they had resumed sexual intercourse or had attempted to do so. All women who had resumed (or attempted) sexual intercourse were asked a detailed set of questions about problems experienced (prior to pregnancy and postnatally), sexual practices (using the definitions developed for the National Sexual Attitudes and Lifestyles Sur- ~ey~~), frequency of sexual intercourse, satisfaction with sex life, and consultation for postnatal sexual problems. With the exception of the questions on sexual practices, all other areas of postnatal health that we included in the questionnaire have been identified as areas of potential change by previous studiesz0-. All women were asked about the information they received on postnatal health before the birth and any information, help or advice they received from health professionals after the birth. Women were asked to recall information (e.g. problems before pregnancy, problems in the first three months after delivery, whether they had gone for their six week check etc), but also included contemporaneous questions (e.g. the postnatal problems they were experiencing now). The questionnaire was piloted successfully with 158 primiparous women in and is available on request. Women were classified as experiencing dyspareunia if they answered positively to questions about painful penetration and/or pain during sexual intercourse andor pain on orgasm. Differences between proportions were tested using x2 tests. For paired proportions McNemar s test was used (an exact binomial test was used in instances where discordant pairs were c 10) and for three related proportions Cochran s Q test was used. Logistic regression was used to investigate factors associated with dyspareunia in the postnatal period. Two models were fitted: one for dyspareunia reported in the first three months after delivery and one for dyspareunia at six months after delivery, Variables significantly related (P < 0-05) to dyspareunia in the unifactorial analyses were put into the models. Variables were entered simultaneously in each model. Results of the QRCOG2000 BJOG 107,

3 188 G. BARRETT ET AL. logistic regression analyses are presented as odds ratios and 95% confidence intervals. Analyses were carried out using SPSS for Windows and ethical approval for this study was given by the Local Research Ethics Committee. RESULTS Of the 796 women, 484 (61%) returned a questionnaire. Of the 312 nonresponders, at least six refused because the questionnaire was too personal (we know this from letters and telephone calls from the women), and at least 45 women (6% of total sample) never received the questionnaire as our mailings were returned by the Post Office. There were no differences between responders and nonresponders in any obstetric feature. However, responders and nonresponders were significantly different with respect to age, ethnicity, occupation, marital status, and birthplace; responders were more likely to be older, white, employed, married, and born in the UK (Table 1). Resumption of sexual intercourse Of the responders, 86% (415/480) had resumed sexual intercourse since the birth of their child, and 2% (10/480) had attempted to resume, although they had not achieved penetrative sexual intercourse. Sexual intercourse had not been resumed by 55 women (1 1 %) since the birth of their child. For 15 women, this was because they had no partner. The other 40 women had partners, but had not resumed intercourse. Reasons given by women included: tirednesdlack of energy (n = 14 women), physical problems, such as unhealed perineum (n = 9), loss of libido (n = S), need for contraception (n = 3), feeling unattractive to partner (n = 2), and partner ill or working away (n = 2). Table 2 shows when women resumed sexual intercourse. The sexual relationship The nature of sexual practices changed after the birth, with the main change being a decline in oral sex by both the women and their partners (Table 3). Of the women who had resumed or attempted to resume sexual intercourse, 67% (282/420) reported that sexual intercourse was less frequent than before their pregnancy. Only 5% (2 1/420) said that sexual intercourse was more frequent. Assessment of quality of sex life was more variable with Table 1. Characteristics of responders and nonresponders. Values are given as % (n). Responders Nonresponders (n = 484) (n = 312) P Age (years) < ; x2 = 30; df = (42) 14 (44) (67) 24 (75) (150) 32 (100) (157) 22 (69) (68) 8 (24) Marital status ; x2 = 11; df = 1 Married 61 (294) 49 (152) Single' 39 (190) 51 (160) Ethnicity White 71 (344) 51 (159) Black 18 (86) 33 (103) Asian 11 (54) 16 (50) < ; x2 = 34; df = 2 Employment at time of booking appointment+ < O~OOO1; x2 = 43; df = 3 Employed 76 (363) 54 (166) Unemployed 11 (53) 25 (76) Student 5 (22) 9 (28) Housewife 8 (38) 11 (35) Birthplace of woman* UK 72 (347) 58 (180) < ; x2 = 16; df = 1 Outside UK 28 (135) 42 ( 128) No significant differences were found on any of the following variables: type of delivery, perineavgenital damage, number of infants, birthweight of infant, preterm birth, induction of labour, artificial rupture of membranes, use of syntocinon, any type of pain relief, length of labour, previous miscarriages, terminations, fertility treatment prior to pregnancy, or smoking. *Includes divorcedlseparated. 'Employment status not known for eight responders and seven nonresponders. *Place of birth not known for two responders and four nonresponders. 0 RCOG 2000 BJOG

4 WOMEN S SEXUAL HEALTH AFTER CHILDBIRTH 189 Table 2. Resumption of sexual intercourse. When sexual intercourse was resumed (or attempted, if not yet resumed) Weeks 1-3 Weeks 4-6 Weeks 7-8 Month 3 Month 4 Month 5 Month 6 Not resumed No partner Other reason TOTAL n (%) [cumulative%] 47 (10) [lo] 107 (22) [32] 142 (30) [62] 89 (19) [81] 30 (6) [871 8 (2) [891 2 (< 1) [ (3) ~ (8) [loo] 480 (100) [loo] 38% (157/416) describing it as less good, 47% (194/416) saying it was about the same, 10% (42/416) saying it had improved, and 6% (23/416) saying they did not know. Problems with sexual intercourse Compared with the year before pregnancy, problems such as pain, lack of vaginal lubrication, and loss of sexual desire all increased significantly in the first three months after delivery; these problems declined by six months but not to pre-pregnancy levels (Table 4). Dyspareunia (as defined by experience of painful penetration and/or pain during sexual intercourse and/or pain on orgasm) was particularly common: 12% (48/403) had experienced dyspareunia in the year before pregnancy, compared with 62% (22Y364) in the first three months after birth and 3 1 % (123/403) at six months. Figure 1 shows the pattern of dyspareunia and other sexual problems in the postnatal period. In the year before pregnancy, 62% of women (25 1/403) reported not experiencing any sexual problems, as defined in Table 4. In the first three months after delivery, this figure had dropped to 17% (61/363), and by six months after delivery it had risen to 36% (146/403). Factors associated with dyspareunia In the unifactorial analysis, dyspareunia experienced during the first three months after birth was significantly associated with type of delivery, perineal damage, and having experienced dyspareunia before pregnancy (Table 5). In the multifactorial analysis, only type of Table 3. Nature of sexual activity before and after pregnancy. Values are given as % (n). Sexual Sexual activities in activities year prior to since the Sexual activity* pregnancy birth P Vaginal intercourse 99 (386) 98 (379) 0.04 Oral sex by woman 71 (277) 58 (225) < 0@001 Oral sex by partner 72 (278) 52 (203) < Anal sex 6 (25) 3 (10) Genital contact not involving intercourse 71 (276) 69 (269) 0.2 *Question answered by 91% (388/425) of women who had resumed sexual activity. McNemar s test. *Exact binomial test carried out because there were only nine discordant pairs. Table 4. Problems experienced with sexual intercourse. Values are given as % (n). Problem* Ever experienced in first Ever experienced in year 3 months after birth Experiencing this prior to pregnancy (n = see individual problem now (n = 403) denominators)+ (n = 403) PI Lack of vaginal lubrication Painful penetration Pain during sexual intercourse Pain on orgasm Difficulty reaching orgasm Vaginal tightness Vaginal loosenessflack of muscle tone Bleeding or irritation after sex Loss of sexual desire 46 (169/368) 55 (200/364) 45 (162/363) 3 (11/364) 33 (121/369) 33 (120/365) 20 (72/365) 15 (54/363) 53 (204/385) 26 (106) 27 (110) 20 (80) 2 (9) 23 (91) 20 (80) 12 (49) 6 (23) 37 (150) < O~OoO1 < < O~OoO1 *Question answered by 95% (403/425) of women who had resumed sexual activity +Of the 403 women who answered the question, not all answered the section in first 3 months. Individual denominators are given for each problem in the in first 3 months column. icochran s Q test; relates to women who gave information at each time point (i.e. denominator in in first three months column).

5 190 G. BARRETT ET AL a, s c 40 3 u- ' Fig. 1. Sexual problems. -+- dyspareunia; -.- I I I Prior 3 months 6 months lack of vaginal lubrication; -A- difficulty reaching orgasm; -x- vaginal tightness; -*- vaginal looseness; -0- bleedinghitation after sex; -+- loss of sexual desire. delivery and history of pre-pregnancy dyspareunia remained significant (Table 6). Dyspareunia at six months was significantly associated with breastfeeding and a history of pre-pregnancy dyspareunia in both the unifactorial and multifactorial analyses (Tables 6 and 7). The association of dyspareunia with type of delivery was not significant at six months in either the unifactorial or multifactorial analyses; the proportion and odds ratio for forcepdventouse deliveries were still raised, but the confidence interval straddled one. Figure 2 illustrates the pattern of dyspareunia by delivery (caesarean section is presented as one category). Breastfeeding and contraception Sixty percent of women (289/483) reported fully breastfeeding in the first six weeks, 23% (1 10/483) reported mixing breast and bottle, and 17% (84/483) reported bottle feeding only. Rates of breastfeeding then dropped. Thirty-seven percent of women (180/482) reported fully breastfeeding at around three months, 21% (103/482) reported mixing breast and bottle, and 41% (199/482) reported bottle feeding only. By six months 42% of women (282/482) reported breastfeed- ing (full or partial). There was no association between type of delivery and breastfeeding in first six weeks (df = 6, P = 0.2), at three months (df = 6, P = 0.3), or at six months (df = 3, P = 0.9). Of the women who had resumed (or attempted to resume) sexual intercourse, 82% ( ) reported using a method of contraception. Four women were pregnant again. Of the 350 women using contraception, 45% (n = 156) were using hormonal contraception (predominantly the pill), 43% (n = 151) were using condoms, 2% (n = 6) were using an intrauterine device, 3% (n = 12) were using the diaphragm, and 7% (n = 25) were using safe period or withdrawal methods. There was no association between method of contraception and dyspareunia at three months (df = 3, P = O-S), or at six months (df = 3, P = 0.8). Health services and postnatal sexual health Twenty-eight percent of women ( ) said someone talked to them about sex after childbirth before the birth of their child. These conversations were predominantly with antenatal teachers, midwives, family or friends.

6 WOMEN S SEXUAL HEALTH AFTER CHILDBIRTH 191 Table 5. Factors associated with the experience of dyspareunia in the first three months after delivery. Factor % (n) Type of delivery Vaginal unassisted 62 (108/174) Forceps/ventouse 78 (78/100) Caesarean (+ labour) 41 (23/56) Caesarean (no labour) 47 (16/34) Perinedother genital damage Intact perineum 49 (61/124) 1 st degree tear 68 (19/28) 2nd degree tear 61 (35/57) 3rd degree tear 64 (7/11) Episiotomy 73 (87/119) Labial tears 50 (8/16) Vaginal tears 89 (8/9) Experienced dyspareunia in year prior to pregnancy Yes 78 (31/40) No 60 (194/324) Unadjusted odds ratio 95% CI P ( ) 0.43 ( ) 0.54 ( ) ( ) 1.64 ( ) 1.80 ( ) 2.81 (1,64480) 1.03 ( ) 8.24 ( ) 2.31 ( ) 1.o 0.03 No significant differences were found on any of the following variables: age, marital status, ethnicity, birth place of woman, induced labour, artificial rupture of membranes, any type of pain relief, syntocinon used during labour, length of labour, birthweight of infant, gestations, sex of infant, and breastfeeding around three months. After the birth of their child, 69% of women (332/480) said that a health professional talked to them about resuming sex after childbirth. These discussions were predominantly with general practitioners, midwives, and health visitors and predominantly related to contraception. Ninety-six percent of women (3 14/328) reported that contraception was discussed with them. Only 29% (94/328) reported that the right time to resume intercourse was discussed, and only 18% (60/328) were advised about possible changes or problems they might experience. Ninety-one percent of women (436/48 1) reported attending the six week postnatal check. During the check, 62% (266/429) had a vaginal examination, and 45% (189/420) were asked about problems with their perineudvagina. Nine percent (n = 41) reported that they had wanted to ask something but felt they could not. The main topics these women wanted to ask about were sexual matters (particularly pain and other problems) and problems with urinary and faecal continence. Of the 337 women who reported a postnatal sexual problem, as defined in Table 4, 15% (n = 49) reported discussing it with a health professional, usually a general practitioner. Help varied from none (n = 9), through advice and reassurance or some form of treatment (e. g. oestrogen pessaries or vaginal lubricant), to referral to secondary services (n = 9). The vast majority did not discuss their problem(s) with a health professional. Table 6. Logistic regression analysis of factors associated with dyspareunia in the postnatal period. Values are given as adjusted OR (95% CI)*. NA = not applicable to model. Factor Experiencing dyspareunia in Experiencing dyspareunia at first three months (n = 364) P six months (n = 400) P Experienced dyspareunia in year prior to pregnancy Yes No Type of delivery Vaginal unassisted Forceps/ventouse Caesarean (+ labour) Caesarean (no labour) PerineaVother genital damage Intact perineum 1st degree tear 2nd degree tear 3rd degree tear Episiotomy Labial tears Vaginal tears Breastfeeding at six months Yes No 2.44 ( ) ( ) 0.42 (0.18-1@0) 0.52 ( ) ( ) 0.83 ( ) 0.52 ( ) 0.97 ( ) 0.62 ( ) ( ) NA NA ( ) 1.o 1.o 1.38 ( ) 1.91 ( ) 1.19 ( ) 1.o 2.26 ( ) 2.17 ( ) 1.87 ( ) 2.21 ( ) 2.18 ( ) 3.84 ( ) 2.25 ( ) 1.o < *Each odds ratio adjusted for other variables in model. These were the women for whom full data were available.

7 192 G. BARRETT ET AL. Table 7. Factors associated with the experience of dyspareunia six months after delivery. Factor % (4 Unadjusted odds ratio (95% CI) P Type of delivery 0.3 Vaginal unassisted 30 (59/198) 1.oo Forcepslventouse 37 (39/106) 1.38 ( ) Caesarean (+ labour) 28 ( 17/60) 0.94 ( ) Caesarean (no labour) 21 (8/38) 0.63 ( ) PerineaVother genital damage 0.3 Intact perineum 24 (32/135) 1.o 1 st degree tear 28 (8/29) 1.21 ( ) 2nd degree tear 31 (22f71) 1.43 ( ) 3rd degree tear 33 (4/12) 1.59 ( ) Episiotomy 36 (47/129) 1.83 ( ) Labial tears 29 (5/17) 1.33 ( ) Vaginal tears 50 (5/10) 3.19 ( ) Experienced dyspareunia in year prior to pregnancy Yes 60 (29/48) 4.22 ( ) No 27 (94/354) 1.o Breastfeeding at six months Yes 40 (65/164) 2.02 ( ) No 25 (58/236) 1.o No significant differences were found on any of the following variables: age, marital status, ethnicity, birth place of woman, induced labour, artificial rupture of membranes, any type of pain relief, syntocinon used during labour, length of labour, birthweight of infant, gestation or sex of infant. DISCUSSION Our study showed that primiparous women experienced high levels of sexual morbidity after childbirth, with dyspareunia, vaginal dryness and loss of libido being very common. The level of reported sexual problems was very consistent: high levels of problems were reported in the first three months after delivery, which then declined by six months but not to pre-pregnancy levels. Our findings on frequency and assessment of quality of sexual intercourse were similar to those reported in previous st~dies~',~~,~~,~~. The pattern of sexual practices altered in the postnatal period, although remained broadly similar to that of the wider population of women in this age group47. We were surprised at how few factors influenced the occurrence of dy spareunia in the postnatal period. Type of delivery and perineal damage were associated with higher rates of postnatal dyspareunia, as indicated in previous st~dies~~.~~,~~,~~,~~, but neither of these factors were significant by six months. Since dyspareunia is cited as one of the reasons why women might opt for an elective caesarean section as preferred mode of deli~ery~~.~, our finding is especially relevant in counselling women in the antenatal period about mode of delivery. Women who experienced dy spareunia before pregnancy had over a fourfold chance of experiencing dyspareunia six months after the birth, compared with women who had not experienced dy spareunia before having a baby. These women are a small group but may have specific needs; they could be identified antenatally and offered appropriate help and advice. The association of dy spareunia with breastfeeding has been documented before21.22 and is most likely to be due to the changed hormonal profile of women36, associated loss of libido31,34,36 and vaginal dryness21,22. New mothers could be alerted to this side effect and given appropriate advice regarding use of vaginal lubricants and oestrogen pessaries if necessary, while being reassured about the benefits of breastfeeding. Health professionals take it for granted that women will resume sexual intercourse following delivery, hence they discuss contraception. However, they do not seem to be concerned about the quality of women's sexual health, since this issue is rarely discussed. The explanation may lie in the fact that at the six week check, where issues of contraception are usually discussed, approximately 60% of women will not have resumed sexual intercourse. Thus the six week check may be too early to discover chronic We also found low rates of consultation for problems with sexual intercourse (similar to a previous study31), and of the women who consulted, not all were helped. This suggests that advice and treatment relating to postnatal sexual health could be vastly improved. Our data provide at least some basis on which health professionals might reconsider the information they impart to women before and after childbirth, whether or not women are

8 WOMEN'S SEXUAL HEALTH AFTER CHILDBIRTH 193 I s E ' I I I Prior 3 months 6 months Fig. 2. Dyspareunia by type of delivery. -+ vaginal unassisted; -t forcepslventouse; -A- caesarean. symptomatic. For example, in the antenatal period women might be counselled on both choice of mode of delivery and what they might expect in terms of sexual health outcome, and after delivery they could be given advice on how to deal with any problems they experience, an idea of when various problems are likely to resolve, and an indication of when to seek further medical help. Limitations Our study achieved a 61% response rate. Ideally, this would have been higher, but given the subject of the questionnaire and the inner-city location of the research, it was an acceptable response rate and comparable to other ~tudies~.~.~'. Also, it was possible from our birth records to establish whether there was a non-response bias. In fact, we had lower levels of response from women who were younger, single, Asian or Black, born outside the UK or not in full time employment. Explanations for this nonresponse are likely to include higher mobility andor cultural and language differences. It is also possible that women experiencing postnatal sexual problems were more likely to reply, but we think this is unlikely to be a major bias. Our questionnaire asked about other areas of postnatal health; therefore, applying the same logic, women with higher rates of other problems (e.g. back pain, urinary incontinence, depression) might be more likely to reply, thus diluting the effect on postnatal sexual problems. We were also reassured by the fact that none of the variables on which we had response biases were in any way related to dyspareunia in our analyses. Another possible limitation of our study is that we asked women to recall information from before their pregnancy and the early months of the postnatal period. Ideally, we would ask women about their experiences prospectively, but this is virtually impossible; for example, women would need to be identified and recruited before they became pregnant, retained in the study, and followed up over the years. Comparison of our current findings with the findings from our pilot carried out in 1996, offers reassurance as the results from the two surveys are remarkably similar, and therefore suggests that the findings have external validity. We carried out a large number of statistical tests on our data (e.g. the analyses for Table 5 and Table 7 included 40 tests), and there is the possibility of a Type 1

9 194 G. BARRETT ET AL. error. However, we think this is unlikely as significant P values are generally very small. Applying the Bonferroni correction did not substantially alter our findings. For example, using the Bonferroni correction to Table 5 and Table 7 (i.e. P < 0.05/40 = P < ) would mean that three tests were significant rather than five, and the Bonferroni correction is known to be overconservative. In fact, in our study we were surprised at how few factors were related to dyspareunia. Our study provides new data on postnatal sexual health in women, although the picture remains incomplete as the male perspective is not included. To date, there are no reports on male perspectives of postnatal sexual health. The current practice of encouraging the father s presence at the birth may well influence postnatal sexuality and warrants further research as postnatal sex life depends on the couple, not just the woman. CONCLUSION Childbirth in primiparous women is associated with a high prevalence of postnatal sexual morbidity; over 80% of women in our study experienced at least one postnatal sexual problem in the first three months after birth, and two-thirds were still experiencing problems at six months. Despite the high frequency of problems, only a minority of women receive information about sexual health, and rates of consultation for problems with sexual intercourse are low. Our study suggests there may be high levels of unmet need which postnatal care services do not currently address. We also examined factors associated with dyspareunia in the postnatal period and found that in the first three months after birth, dyspareunia was significantly associated with vaginal deliveries. At six months there was some evidence of an association but it was not significant. These findings contribute to the debate about provision of elective caesarean section at the request of the woman, as dyspareunia is often cited as a reason why women might opt for this mode of delivery. References 1 Feggetter G, Cooper P, Gath D. Non-psychotic psychiatric disorders in women one year after childbirth. J Psychosom Res 1981; 25: Kumar R, Robson KM. A prospective study of emotional disorders in childbearing women. Br Jfsychiatry 1984; 144: Watson JP, Elliott SA, Rugg AJ, Brough DI. Psychiatric disorder in pregnancy and the first postnatal year. Br J Psychiatry 1984; 144: Cox JL. Postnatal Depression. Edinburgh: Churchill Livingstone, Cox JL, Murray D, Chapman G. A controlled study of the onset, duration and prevalence of postnatal depression. Br J fsychiarry 1993; 163: MacArthur C, Lewis M, Knox EG. Health After Childbirth. London: HMSO, Bick DE, MacArthur C. The extent, seventy and effect of health problems after childbirth. Br JMidwifery 1995; 3: Glazener CMA, Abdalla M, Stroud P, Naji S, Templeton A, Russell IT. Postnatal maternal morbidity: extent, causes, prevention and treatment. BrJ Obstet Gynaecoll995; 102: Brown S, Lumley J. Maternal health after childbirth: results of an Australian population based survey. Br J Obstet Gynaecol1998; 105: Bek KM, Laurberg S. Risks of anal incontinence from subsequent vaginal delivery after a complete obstetric anal sphincter tear. Br J Obstet Gynaecol1992; 99: Dimpfl T, Hesse U, Schussler B. Incidence and cause of postpartum urinary stress incontinence. Eur J Dbstet Gynecol Reprod Biol 1992; 43: Foldsprang A, Mommsen S, Lam GW, Elving L. Panty as a correlate of adult female urinary incontinence prevalence. JEpidemiol Community Health 1992; 46: Sultan AH, Kamm MA, Hudson CN, Chir M, Thomas JM, Bartram CI. Anal sphincter disruption during vaginal delivery. N Engl J Med 1993; 329: Deindl FM, Vodusek DB, Hesse U, Schussler B. Pelvic floor activity patterns: comparison of nulliparous continent and parous urinary stress incontinent women. A kinesiological EMG study. Br J Urol 1994; 73: Kamm M. Obstetric damage and faecal incontinence. Lancet 1994; 344: Toglia MR, DeLancey JOL. Anal incontinence and obstetriciangynaecologist. Obstet Gynecol1994; 84: Wilson PD, Herbison RM, Herbison GP. Obstetric practice and the prevalence of urinary incontinence three months after delivery. Br J Obstet Gynaecol1996; 103: Sultan AH, Kamm MA. Faecal incontinence after childbirth. Br J Obstet Gynaecoll997; 104: MacArthur C, Bick DE, Keighley MRB. Faecal incontinence after childbirth. Br J Obstef Gynaecoll997; 104: Scott-Heyes G. Marital adaptation during pregnancy and after childbirth. J Reprod Infant Psychology 1983; 1: Barrett G, Victor CR. Postnatal sexual health. BMJ 1994; 309: Barrett G, Victor CR. Postnatal sexual health. Br J Gen Pract 1996; 46: Barrett G, Victor CR. Incidence of postnatal dyspareunia. Br J Sexual Med 1996; 23: Reading AE, Sledmere CM, Cox DN, Campbell S. How women view postepisiotomy pain. BMJ 1982; 284: Abraham S, Child A, Ferry J, Vizzard J, Mira M. Recovery after childbirth: a preliminary prospective study. Med JAust 1990; 152: Kumar R, Brant HA, Robson KM. Childbearing and maternal sexuality: a prospective survey of 119 primiparae. J Psychosom Res 1981; 25: Elliott SA, Watson JP. Sex during pregnancy and the first postnatal year. J Psychosom Res 1985; 29: Klein MC, Gauthier RJ, Robbins JM et al. Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation. Am J Obstet Gynecol1994; 71: Sleep J, Grant A, Garcia J, Elbourne D, Spencer J, Chalmers I. West Berkshire perineal management trial. BMJ 1984; Sleep J, Grant A. West Berkshire perineal management trial: three year follow up. BMJ 1987; 295: Glazener CMA. Sexual function after childbirth: women s experiences, persistent morbidity and lack of professional recognition. Br J Obstet Gynaecol1997; 104: Bex PJ, Hofmeyr GJ. Perineal management during childbirth and subsequent dyspareunia. Clin Exp Obstet Gynecol1987; 14: Frohlich EP, Herz C, Van der Menve FJ, Van Tonder DM, Booysen JPM, Becker PJ. Sexuality during pregnancy and early puerperium and its perception by pregnant and puerperal woman. J Psychosom Obstet Gynaecoll990; 11: Alder EM, Bancroft J. Sexual behaviour of lactating women: a preliminary communication. J Reprod Infant Psycho1 1983; 1: Ellis DJ, Hewat RJ. Mother s postpartum perceptions of spousal relationships. J Obstet Gynecol Neonatal Nurs 1985; MarcNApril: Alder EM, Cook A, Davidson D, West C, Bancroft J. Hormones, mood and sexuality in lactating women. Br J Psychiatry 1986; 148:

10 WOMEN S SEXUAL HEALTH AFTER CHILDBIRTH Masters WH, Johnson VE. Humn Sexual Response. London: Churchill, Bustan MA, Tomi NF, Faiwalla MF, Manav V. Maternal sexuality during pregnancy and after childbirth in Muslim Kuwaiti women. Arch SexBehav 1995; 24: Sultan AH, Stanton SL. Preserving the pelvic floor and perineum during childbirth4lective caesarean section? Br J Obstet Gynuecol 1996; 103: Al-Mufti R, McCarthy A, Fisk NM. Obstetricians personal choice and mode of delivery. Lancet 1996; 347: Paterson-Brown S. Should doctors perform an elective caesarean section on request? Yes, as long as the woman is fully informed. BMJ 1998; 317: Amu 0, Rajendran S, Bolaji II. Should doctors perform an caesarean section on request? Maternal choice alone should not determine method of delivery. BMJ 1998; 317: Turner M, Finn M. Obstetric outcome should be analysed by parity. BMJ 1993; 306: Turner M, Casey C. Rates of episiotomy: data on parity are not given. BMJ 1995; 310: Stratton JF, Gordon H, Logue M. Rates of episiotomy: conclusions and validity of data cannot be. judged. BMJ 1995; Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987; 150: Johnson AM, Wadsworth J, Wellings K, Field J. Sexual Altitudes and Lifestyles. Oxford: Blackwell Science, Barrett G, Pendry E, Peacock J, Victor CR, Thakar R, Manyonda I. Women s sexuality after childbirth: a pilot study. Arch Sex Behav 1999; 28: Bick DE, MacArthur C. Identifying morbidity in postpartum women. Mod Midwife 1994; 4: Russell R, Groves P, Taub N, O Dowd J, Reynolds F. Assessing long term backache after childbirth. BMJ 1993: 306: Accepted 4 October 1999