General gynaecology
DOI: 10.1111/1471-0528.13263 www.bjog.org
Dyspareunia and childbirth: a prospective cohort study EA McDonald,a D Gartland,a R Small,b SJ Browna,c a Healthy Mothers Healthy Families Research Group, Murdoch Childrens Research Institute, Melbourne, Vic., Australia b The Judith Lumley Centre, La Trobe University, Melbourne, Vic., Australia c General Practice and Primary Health Care Academic Centre, The University of Melbourne, Melbourne, Vic., Australia Correspondence: EA McDonald, Healthy Mothers Healthy Families Research Group, Murdoch Childrens Research Institute, The Royal Children’s Hospital, Flemington Road, Parkville, Vic. 3052, Australia. Email [email protected]
Accepted 15 November 2014. Published Online 21 January 2015.
Objective To investigate the relationship between mode of
delivery, perineal trauma and dyspareunia. Design Prospective cohort study. Setting Six maternity hospitals in Melbourne, Australia. Sample A total of 1507 nulliparous women recruited in the first
and second trimesters of pregnancy. Method Data from baseline and postnatal questionnaires (3, 6, 12
and 18 months) were analysed using univariable and multivariable logistic regression. Main outcome measure Study-designed self-report measure of
dyspareunia at 18 months postpartum. Results In all, 1244/1507 (83%) women completed the baseline
and all four postpartum questionnaires; 1211/1237 (98%) had resumed vaginal intercourse by 18 months postpartum, with 289/ 1211 (24%) women reporting dyspareunia. Compared with women who had a spontaneous vaginal delivery with an intact
perineum or unsutured tear, women who had an emergency caesarean section (adjusted odds ratio [aOR] 2.41, 95% confidence interval [95% CI] 1.4–4.0; P = 0.001), vacuum extraction (aOR 2.28, 95% CI 1.3–4.1; P = 0.005) or elective caesarean section (aOR 1.71, 95% CI 0.9–3.2; P = 0.087) had increased odds of reporting dyspareunia at 18 months postpartum, adjusting for maternal age and other potential confounders. Conclusions Obstetric intervention is associated with persisting
dyspareunia. Greater recognition and increased understanding of the roles of mode of delivery and perineal trauma in contributing to postpartum maternal morbidities, and ways to prevent postpartum dyspareunia where possible, are warranted. Keywords Cohort studies, delivery obstetric, dyspareunia, pain, perineum, postpartum period, prospective studies, sexual intercourse. Linked article This article is commented on by C Sakala, p. 680 in this issue. To view this mini commentary visit http://dx.doi.org/ 10.1111/1471-0528.13264.
Please cite this paper as: McDonald EA, Gartland D, Small R, Brown SJ. Dyspareunia and childbirth: a prospective cohort study. BJOG 2015;122:672–679.
Introduction The relationship between obstetric risk factors including mode of delivery and perineal trauma and dyspareunia is not well characterised or understood.1–7 Previous studies have suffered from several methodological limitations including cross-sectional study design,1–3,5,6 limited power to assess associations with obstetric risk factors1–7 and lack of long-term follow up.1–7 Inferences drawn from the existing literature are limited by the failure of the studies to consider prepregnancy dyspareunia2–7 and a range of postpartum factors, such as breastfeeding and intimate partner abuse, that may confound associations.2–6 This study draws on data collected in the Maternal Health Study, an Australian multicentre, prospective
672
nulliparous pregnancy cohort study.8 The primary objective of this paper was to investigate the contribution of obstetric risk factors, including mode of delivery and perineal trauma, to postpartum dyspareunia. In addition, we aimed to assess the influence of potential confounders, including breastfeeding, maternal fatigue, maternal depression and intimate partner abuse.
Methods Sample and participants Details regarding study eligibility and exclusion criteria and recruitment methods are available in a published study protocol.8 Briefly, women were recruited to the study between April 2003 and December 2005 from six metropolitan public
ª 2015 Royal College of Obstetricians and Gynaecologists
Dyspareunia and childbirth
maternity hospitals in Melbourne, Australia. We recruited nulliparous women, aged over 18 years, in the first and second trimesters of pregnancy. Women with poor English language literacy were excluded.
Measures and definitions At recruitment, participants were asked to complete a baseline questionnaire recording demographic and social characteristics, including age, country of birth and socioeconomic status, and baseline measures of common maternal morbidities, including dyspareunia before and during pregnancy.1 Follow-up questionnaires were administered at 3, 6, 12 and 18 months postpartum. Data regarding the mode of delivery and degree of perineal trauma were collected in the 3-month postpartum questionnaire and abstracted from medical records for a subset of women. There was a high degree of congruity between women’s own accounts of mode of delivery and other obstetric events and data abstracted from medical records.9,10 Follow-up questionnaires included study-designed questions regarding sexual health and dyspareunia drawing on questions included in the Australian Longitudinal Women’s Health Study11 and a study by Barrett et al.1 assessing women’s health after childbirth. Study questionnaires also included validated measures of maternal depressive symptoms (Edinburgh Postnatal Depression Scale)12 and intimate partner abuse (Composite Abuse Scale),13,14 and single item measures assessing maternal fatigue15 and infant feeding.16 Pretesting of the questionnaires, paying particular attention to study-designed questions, was undertaken with a pilot sample of women recruited through participating hospitals. The baseline Maternal Health Study questionnaire is available on the study website.17 Postnatal questionnaires can be made available by contacting the authors.
Statistical analysis Data were analysed using STATA version 13 (StataCorp., College Station, TX, USA).18 Sample representativeness was assessed by comparing data on social and obstetric characteristics of participants with routinely collected perinatal data for nulliparous women giving birth in the study period at the six participating hospitals, and at all public maternity hospitals in Victoria. Analyses presented in the paper are restricted to women who completed the baseline questionnaire and all follow-up questionnaires. The proportions of women resuming vaginal sex by 3, 6 and 12 months postpartum were calculated based on the proportion of women reporting resumption of sex divided by the total number of women with valid responses at each time point. The period prevalence of dyspareunia at 6 and 18 months postpartum was calculated based on the
ª 2015 Royal College of Obstetricians and Gynaecologists
proportions of women reporting symptoms divided by the total number of women who had resumed vaginal sex and had data available for the relevant period. Pain on first vaginal sex is reported separately. Risk factors for postpartum dyspareunia were investigated using univariable and multivariable logistic regression. Logistic regression modelling was used to examine the association between mode of delivery and perineal trauma (exposures of main interest) and dyspareunia at 18 months postpartum (primary outcome), taking into account potential confounders. Maternal age was included in modelling analyses for a priori reasons. Other variables were included based on associations that were observed in univariable analyses at 6 and/or 18 months postpartum. Data are presented as crude or adjusted odds ratios (ORs) with 95% confidence intervals (95% CI). Ethical approval for the study was provided by La Trobe University (2002/38); Royal Children’s Hospital, Melbourne (27056A); Royal Women’s Hospital, Melbourne (2002/23); Southern Health, Melbourne (2002-099B); and Angliss Hospital, Melbourne (2002).
Results Participants A total of 1507 women enrolled in the study. The mean gestation of study participants at the time of enrolment was 15.0 weeks (range 6–24 weeks). We were unable to determine a precise response fraction, but conservatively estimate that the response was between 1507/5400 (28%) and 1507/4800 (31%). The follow-up response fractions were 1431/1507 (95%), 1400/1507 (93%), 1387/1507 (92%), 1326/1507 (88%) at 3, 6, 12 and 18 months postpartum, respectively. In all, 1211/1239 (98%) participants were sexually active at 18 months postpartum. Study participants were representative in relation to obstetric characteristics including mode of delivery and perineal trauma (see Table 1). Women born overseas in countries where English is not the first language, and younger women were under-represented. Further information regarding sociodemographic and reproductive characteristics of the sample and representativeness of study participants is available in previous papers.10,19 The 1244/1507 (83%) women who completed all four follow-up questionnaires comprise the sample for the analyses in this paper (Figure 1).
Birth outcomes A total of 609/1244 (49.0%) women had a spontaneous vaginal birth, two-thirds of whom (411/609, 67.5%) sustained a sutured tear and/or episiotomy; 134/1244 (10.8%) had an operative vaginal birth assisted by vacuum extraction and 133/1244 (10.7%) gave birth assisted by forceps.
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Table 1. Social characteristics of participants in the Maternal Health Study compared with Victorian Perinatal Data Collection Unit data Maternal Health Study participants (n = 1507)
Maternal age at birth of first child 18–24 years 25–29 years 30–34 years 35–39 years ≥40 years Relationship status* Married Unmarried Country of birth* Australia Overseas—English speaking Overseas—non-English speaking background Mode of delivery* Caesarean—no labour Caesarean—laboured Spontaneous vaginal birth Vaginal breech birth Vaginal with forceps Vaginal with vacuum extraction Perineal trauma** Intact perineum Unsutured laceration Sutured laceration Episiotomy Episiotomy and tear
Nulliparous women ≥18 years giving birth in Victorian public hospitals 1/7/03 to 31/12/05 (n = 40 905)
Nulliparous women ≥18 years giving birth in the six participating Victorian hospitals 1/7/03 to 31/12/05 (n = 13 803)
n
%
n
%
n
%
212 437 580 236 42
14.1 29.0 38.4 15.7 2.8
12 216 13 802 10 740 3552 595
29.8 33.7 26.3 8.7 1.5
3813 4645 3769 1319 257
27.6 33.7 27.3 9.6 1.9
914 593
60.7 39.3
22 790 17 932
56.0 44.0
8300 5469
60.3 39.7
1115 141 243
74.4 9.4 16.2
29 791 2109 8738
73.3 5.2 21.5
8603 905 4267
62.5 6.6 30.9
140 292 695 5 150 149
9.8 20.4 48.6 0.3 10.5 10.4
3750 7665 20 785 182 3915 4603
9.2 18.7 50.8 0.4 9.6 11.3
1237 2587 7000 95 1426 1457
9.0 18.7 50.7 0.7 10.3 10.6
595 72 439 228 93
41.7 5.0 30.8 16.0 6.5
19 805 n/a 11 074 9068 958
48.4 n/a 27.1 22.2 2.3
6296 n/a 4221 3089 197
45.6 n/a 30.6 22.4 1.4
*Denominators vary due to missing values. **Data collected by the Perinatal Data Collection Unit on perineal trauma does not include information regarding unsutured lacerations or nonperineal lacerations, e.g. vaginal wall tears.
The majority of these women sustained a sutured tear and/ or episiotomy (124/134, 92.5% and 129/133, 97.0%, respectively). In all, 120/1244 (9.7%) were delivered by elective caesarean section and 248/1244 (19.9%) were delivered by emergency caesarean section.
Dyspareunia following childbirth By 3 months postpartum, 970/1239 (78.3%) had resumed vaginal intercourse; 1165/1239 (94.0%) by 6 months postpartum, 1202/1239 (97.0%) by 12 months postpartum and 1211/1239 (97.7%) by 18 months postpartum. Most of the women who had resumed sex by 12 months postpartum experienced pain during first vaginal sex after childbirth (961/1122, 85.7%). Dyspareunia was reported by 431/964
674
(44.7%) women at 3 months postpartum, 496/1144 (43.4%) women at 6 months postpartum, 333/1184 (28.1%) women at 12 months postpartum and 289/1236 (23.4%) women at 18 months postpartum. Of the 496 women who reported dyspareunia at 6 months postpartum, one-third (162/496, 32.7%) reported persisting dyspareunia at 18 months postpartum. In all, 338/1234 (27.4%) women reported dyspareunia in the year prior to the index pregnancy.
Associations with dyspareunia The unadjusted odds of dyspareunia at 18 months postpartum were higher in women who gave birth by vacuum extraction (OR 2.01, 95% CI 1.2–3.5; P = 0.013),
ª 2015 Royal College of Obstetricians and Gynaecologists
Dyspareunia and childbirth
Q1: 1507 eligible participants 13 Withdrew
Q2: 1494 participants 1431 completed (95.0% of 1507 participants) 5 Withdrew 3 lost to follow up Q3: 1486 participants 1400 completed (92.9% of 1507 participants) 16 Withdrew 6 lost to follow up Q4: 1464 participants 1357 completed (90.0% of 1507 participants) 6 Withdrew 6 lost to follow up Q5: 1452 participants 1327 completed (88.1% of 1507 participants)
Figure 1. Maternal Health Study participation flowchart to 18 months postpartum.
emergency caesarean section (OR 2.04, 95% CI 1.3–3.3; P = 0.004) or elective caesarean section (OR 1.65, 95% CI 0.9–2.9; P = 0.090) compared with women who had a spontaneous vaginal birth with an intact perineum. Younger women (OR 1.58, 95% CI 1.0–2.5; P = 0.057), women who experienced dyspareunia before the index pregnancy (OR 2.18, 95% CI 1.6–2.9; P = 0.000), women who reported intimate partner abuse from birth to 12 months postpartum (OR 1.84, 95% CI 1.3–2.6; P = 0.001), women who reported fatigue at 18 months postpartum (OR 1.65, 95% CI 1.2–2.3; P = 0.002) and women who reported depressive symptoms at 18 months postpartum (OR 1.97, 95% CI 1.3–3.0; P = 0.002) also had increased odds of reporting dyspareunia at 18 months postpartum. To obtain more precise estimates of the association between mode of delivery and dyspareunia at 18 months postpartum, we developed a multivariable logistic regression model (Table 2). A composite variable combining data on mode of delivery and perineal trauma was the exposure of main interest. Maternal age was included in the model for a priori reasons based on previous research showing that younger women are more likely to experience dyspareunia.20,21 Dyspareunia before pregnancy, maternal depression, maternal fatigue and intimate partner abuse were included because of the significant associations with dyspareunia at 6 and/or 18 months postpartum noted in univariable analyses. Women who gave birth by emergency caesarean section or vacuum extraction and those who reported prepregnancy dyspareunia had greater than a twofold increase in adjusted odds of persisting dyspareunia at 18 months postpartum compared with women who had a spontaneous vaginal birth with an intact perineum after adjusting for
ª 2015 Royal College of Obstetricians and Gynaecologists
other variables in the model. Elective caesarean section was also associated with increased odds of dyspareunia at 18 months postpartum, although the confidence interval suggests borderline statistical significance. Similar patterns of association were found between dyspareunia at 6 months postpartum, mode of delivery, perineal trauma and other maternal and postnatal factors (Table 3). Women who had an operative vaginal delivery (with forceps or vacuum extraction) had greater than a three-fold increase in adjusted odds of dyspareunia at 6 months postpartum. Emergency caesarean section and vaginal birth with a sutured tear and/or episiotomy were associated with a two-fold increase in odds of dyspareunia after taking into account other factors in the model. Women who had an elective caesarean section did not have raised odds of reporting dyspareunia at 6 months postpartum. Prepregnancy dyspareunia was associated with a two-fold increase in odds of dyspareunia at both 6 and 18 months postpartum. Observed associations with obstetric intervention in multivariable models were stronger than associations with postnatal factors, including maternal depressive symptoms, fatigue and intimate partner abuse.
Discussion Main findings Almost all women experience some pain during sexual intercourse following childbirth. Our findings show that the extent to which women report dyspareunia at 6 and 18 months postpartum is influenced by events during labour and birth. The odds of dyspareunia at 18 months were substantially higher in women who delivered by
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Table 2. Adjusted odds of dyspareunia at 18 months postpartum associated with mode of delivery, perineal trauma and other risk factors* Dyspareunia at 18 months postpartum No n (%) Mode of delivery and perineal trauma Spontaneous vaginal birth Intact perineum/unsutured tear Sutured tear/episiotomy Caesarean section (intact perineum) Elective Emergency Forceps (sutured tear/episiotomy) Vacuum extraction (sutured tear/episiotomy) Prepregnancy dyspareunia No Yes Maternal age at index birth 30–34 years 18–24 years 25–29 years 35+ years Highest educational qualification University degree Certificate/diploma Year 12
DOI: 10.1111/1471-0528.13263 www.bjog.org
Dyspareunia and childbirth: a prospective cohort study EA McDonald,a D Gartland,a R Small,b SJ Browna,c a Healthy Mothers Healthy Families Research Group, Murdoch Childrens Research Institute, Melbourne, Vic., Australia b The Judith Lumley Centre, La Trobe University, Melbourne, Vic., Australia c General Practice and Primary Health Care Academic Centre, The University of Melbourne, Melbourne, Vic., Australia Correspondence: EA McDonald, Healthy Mothers Healthy Families Research Group, Murdoch Childrens Research Institute, The Royal Children’s Hospital, Flemington Road, Parkville, Vic. 3052, Australia. Email [email protected]
Accepted 15 November 2014. Published Online 21 January 2015.
Objective To investigate the relationship between mode of
delivery, perineal trauma and dyspareunia. Design Prospective cohort study. Setting Six maternity hospitals in Melbourne, Australia. Sample A total of 1507 nulliparous women recruited in the first
and second trimesters of pregnancy. Method Data from baseline and postnatal questionnaires (3, 6, 12
and 18 months) were analysed using univariable and multivariable logistic regression. Main outcome measure Study-designed self-report measure of
dyspareunia at 18 months postpartum. Results In all, 1244/1507 (83%) women completed the baseline
and all four postpartum questionnaires; 1211/1237 (98%) had resumed vaginal intercourse by 18 months postpartum, with 289/ 1211 (24%) women reporting dyspareunia. Compared with women who had a spontaneous vaginal delivery with an intact
perineum or unsutured tear, women who had an emergency caesarean section (adjusted odds ratio [aOR] 2.41, 95% confidence interval [95% CI] 1.4–4.0; P = 0.001), vacuum extraction (aOR 2.28, 95% CI 1.3–4.1; P = 0.005) or elective caesarean section (aOR 1.71, 95% CI 0.9–3.2; P = 0.087) had increased odds of reporting dyspareunia at 18 months postpartum, adjusting for maternal age and other potential confounders. Conclusions Obstetric intervention is associated with persisting
dyspareunia. Greater recognition and increased understanding of the roles of mode of delivery and perineal trauma in contributing to postpartum maternal morbidities, and ways to prevent postpartum dyspareunia where possible, are warranted. Keywords Cohort studies, delivery obstetric, dyspareunia, pain, perineum, postpartum period, prospective studies, sexual intercourse. Linked article This article is commented on by C Sakala, p. 680 in this issue. To view this mini commentary visit http://dx.doi.org/ 10.1111/1471-0528.13264.
Please cite this paper as: McDonald EA, Gartland D, Small R, Brown SJ. Dyspareunia and childbirth: a prospective cohort study. BJOG 2015;122:672–679.
Introduction The relationship between obstetric risk factors including mode of delivery and perineal trauma and dyspareunia is not well characterised or understood.1–7 Previous studies have suffered from several methodological limitations including cross-sectional study design,1–3,5,6 limited power to assess associations with obstetric risk factors1–7 and lack of long-term follow up.1–7 Inferences drawn from the existing literature are limited by the failure of the studies to consider prepregnancy dyspareunia2–7 and a range of postpartum factors, such as breastfeeding and intimate partner abuse, that may confound associations.2–6 This study draws on data collected in the Maternal Health Study, an Australian multicentre, prospective
672
nulliparous pregnancy cohort study.8 The primary objective of this paper was to investigate the contribution of obstetric risk factors, including mode of delivery and perineal trauma, to postpartum dyspareunia. In addition, we aimed to assess the influence of potential confounders, including breastfeeding, maternal fatigue, maternal depression and intimate partner abuse.
Methods Sample and participants Details regarding study eligibility and exclusion criteria and recruitment methods are available in a published study protocol.8 Briefly, women were recruited to the study between April 2003 and December 2005 from six metropolitan public
ª 2015 Royal College of Obstetricians and Gynaecologists
Dyspareunia and childbirth
maternity hospitals in Melbourne, Australia. We recruited nulliparous women, aged over 18 years, in the first and second trimesters of pregnancy. Women with poor English language literacy were excluded.
Measures and definitions At recruitment, participants were asked to complete a baseline questionnaire recording demographic and social characteristics, including age, country of birth and socioeconomic status, and baseline measures of common maternal morbidities, including dyspareunia before and during pregnancy.1 Follow-up questionnaires were administered at 3, 6, 12 and 18 months postpartum. Data regarding the mode of delivery and degree of perineal trauma were collected in the 3-month postpartum questionnaire and abstracted from medical records for a subset of women. There was a high degree of congruity between women’s own accounts of mode of delivery and other obstetric events and data abstracted from medical records.9,10 Follow-up questionnaires included study-designed questions regarding sexual health and dyspareunia drawing on questions included in the Australian Longitudinal Women’s Health Study11 and a study by Barrett et al.1 assessing women’s health after childbirth. Study questionnaires also included validated measures of maternal depressive symptoms (Edinburgh Postnatal Depression Scale)12 and intimate partner abuse (Composite Abuse Scale),13,14 and single item measures assessing maternal fatigue15 and infant feeding.16 Pretesting of the questionnaires, paying particular attention to study-designed questions, was undertaken with a pilot sample of women recruited through participating hospitals. The baseline Maternal Health Study questionnaire is available on the study website.17 Postnatal questionnaires can be made available by contacting the authors.
Statistical analysis Data were analysed using STATA version 13 (StataCorp., College Station, TX, USA).18 Sample representativeness was assessed by comparing data on social and obstetric characteristics of participants with routinely collected perinatal data for nulliparous women giving birth in the study period at the six participating hospitals, and at all public maternity hospitals in Victoria. Analyses presented in the paper are restricted to women who completed the baseline questionnaire and all follow-up questionnaires. The proportions of women resuming vaginal sex by 3, 6 and 12 months postpartum were calculated based on the proportion of women reporting resumption of sex divided by the total number of women with valid responses at each time point. The period prevalence of dyspareunia at 6 and 18 months postpartum was calculated based on the
ª 2015 Royal College of Obstetricians and Gynaecologists
proportions of women reporting symptoms divided by the total number of women who had resumed vaginal sex and had data available for the relevant period. Pain on first vaginal sex is reported separately. Risk factors for postpartum dyspareunia were investigated using univariable and multivariable logistic regression. Logistic regression modelling was used to examine the association between mode of delivery and perineal trauma (exposures of main interest) and dyspareunia at 18 months postpartum (primary outcome), taking into account potential confounders. Maternal age was included in modelling analyses for a priori reasons. Other variables were included based on associations that were observed in univariable analyses at 6 and/or 18 months postpartum. Data are presented as crude or adjusted odds ratios (ORs) with 95% confidence intervals (95% CI). Ethical approval for the study was provided by La Trobe University (2002/38); Royal Children’s Hospital, Melbourne (27056A); Royal Women’s Hospital, Melbourne (2002/23); Southern Health, Melbourne (2002-099B); and Angliss Hospital, Melbourne (2002).
Results Participants A total of 1507 women enrolled in the study. The mean gestation of study participants at the time of enrolment was 15.0 weeks (range 6–24 weeks). We were unable to determine a precise response fraction, but conservatively estimate that the response was between 1507/5400 (28%) and 1507/4800 (31%). The follow-up response fractions were 1431/1507 (95%), 1400/1507 (93%), 1387/1507 (92%), 1326/1507 (88%) at 3, 6, 12 and 18 months postpartum, respectively. In all, 1211/1239 (98%) participants were sexually active at 18 months postpartum. Study participants were representative in relation to obstetric characteristics including mode of delivery and perineal trauma (see Table 1). Women born overseas in countries where English is not the first language, and younger women were under-represented. Further information regarding sociodemographic and reproductive characteristics of the sample and representativeness of study participants is available in previous papers.10,19 The 1244/1507 (83%) women who completed all four follow-up questionnaires comprise the sample for the analyses in this paper (Figure 1).
Birth outcomes A total of 609/1244 (49.0%) women had a spontaneous vaginal birth, two-thirds of whom (411/609, 67.5%) sustained a sutured tear and/or episiotomy; 134/1244 (10.8%) had an operative vaginal birth assisted by vacuum extraction and 133/1244 (10.7%) gave birth assisted by forceps.
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Table 1. Social characteristics of participants in the Maternal Health Study compared with Victorian Perinatal Data Collection Unit data Maternal Health Study participants (n = 1507)
Maternal age at birth of first child 18–24 years 25–29 years 30–34 years 35–39 years ≥40 years Relationship status* Married Unmarried Country of birth* Australia Overseas—English speaking Overseas—non-English speaking background Mode of delivery* Caesarean—no labour Caesarean—laboured Spontaneous vaginal birth Vaginal breech birth Vaginal with forceps Vaginal with vacuum extraction Perineal trauma** Intact perineum Unsutured laceration Sutured laceration Episiotomy Episiotomy and tear
Nulliparous women ≥18 years giving birth in Victorian public hospitals 1/7/03 to 31/12/05 (n = 40 905)
Nulliparous women ≥18 years giving birth in the six participating Victorian hospitals 1/7/03 to 31/12/05 (n = 13 803)
n
%
n
%
n
%
212 437 580 236 42
14.1 29.0 38.4 15.7 2.8
12 216 13 802 10 740 3552 595
29.8 33.7 26.3 8.7 1.5
3813 4645 3769 1319 257
27.6 33.7 27.3 9.6 1.9
914 593
60.7 39.3
22 790 17 932
56.0 44.0
8300 5469
60.3 39.7
1115 141 243
74.4 9.4 16.2
29 791 2109 8738
73.3 5.2 21.5
8603 905 4267
62.5 6.6 30.9
140 292 695 5 150 149
9.8 20.4 48.6 0.3 10.5 10.4
3750 7665 20 785 182 3915 4603
9.2 18.7 50.8 0.4 9.6 11.3
1237 2587 7000 95 1426 1457
9.0 18.7 50.7 0.7 10.3 10.6
595 72 439 228 93
41.7 5.0 30.8 16.0 6.5
19 805 n/a 11 074 9068 958
48.4 n/a 27.1 22.2 2.3
6296 n/a 4221 3089 197
45.6 n/a 30.6 22.4 1.4
*Denominators vary due to missing values. **Data collected by the Perinatal Data Collection Unit on perineal trauma does not include information regarding unsutured lacerations or nonperineal lacerations, e.g. vaginal wall tears.
The majority of these women sustained a sutured tear and/ or episiotomy (124/134, 92.5% and 129/133, 97.0%, respectively). In all, 120/1244 (9.7%) were delivered by elective caesarean section and 248/1244 (19.9%) were delivered by emergency caesarean section.
Dyspareunia following childbirth By 3 months postpartum, 970/1239 (78.3%) had resumed vaginal intercourse; 1165/1239 (94.0%) by 6 months postpartum, 1202/1239 (97.0%) by 12 months postpartum and 1211/1239 (97.7%) by 18 months postpartum. Most of the women who had resumed sex by 12 months postpartum experienced pain during first vaginal sex after childbirth (961/1122, 85.7%). Dyspareunia was reported by 431/964
674
(44.7%) women at 3 months postpartum, 496/1144 (43.4%) women at 6 months postpartum, 333/1184 (28.1%) women at 12 months postpartum and 289/1236 (23.4%) women at 18 months postpartum. Of the 496 women who reported dyspareunia at 6 months postpartum, one-third (162/496, 32.7%) reported persisting dyspareunia at 18 months postpartum. In all, 338/1234 (27.4%) women reported dyspareunia in the year prior to the index pregnancy.
Associations with dyspareunia The unadjusted odds of dyspareunia at 18 months postpartum were higher in women who gave birth by vacuum extraction (OR 2.01, 95% CI 1.2–3.5; P = 0.013),
ª 2015 Royal College of Obstetricians and Gynaecologists
Dyspareunia and childbirth
Q1: 1507 eligible participants 13 Withdrew
Q2: 1494 participants 1431 completed (95.0% of 1507 participants) 5 Withdrew 3 lost to follow up Q3: 1486 participants 1400 completed (92.9% of 1507 participants) 16 Withdrew 6 lost to follow up Q4: 1464 participants 1357 completed (90.0% of 1507 participants) 6 Withdrew 6 lost to follow up Q5: 1452 participants 1327 completed (88.1% of 1507 participants)
Figure 1. Maternal Health Study participation flowchart to 18 months postpartum.
emergency caesarean section (OR 2.04, 95% CI 1.3–3.3; P = 0.004) or elective caesarean section (OR 1.65, 95% CI 0.9–2.9; P = 0.090) compared with women who had a spontaneous vaginal birth with an intact perineum. Younger women (OR 1.58, 95% CI 1.0–2.5; P = 0.057), women who experienced dyspareunia before the index pregnancy (OR 2.18, 95% CI 1.6–2.9; P = 0.000), women who reported intimate partner abuse from birth to 12 months postpartum (OR 1.84, 95% CI 1.3–2.6; P = 0.001), women who reported fatigue at 18 months postpartum (OR 1.65, 95% CI 1.2–2.3; P = 0.002) and women who reported depressive symptoms at 18 months postpartum (OR 1.97, 95% CI 1.3–3.0; P = 0.002) also had increased odds of reporting dyspareunia at 18 months postpartum. To obtain more precise estimates of the association between mode of delivery and dyspareunia at 18 months postpartum, we developed a multivariable logistic regression model (Table 2). A composite variable combining data on mode of delivery and perineal trauma was the exposure of main interest. Maternal age was included in the model for a priori reasons based on previous research showing that younger women are more likely to experience dyspareunia.20,21 Dyspareunia before pregnancy, maternal depression, maternal fatigue and intimate partner abuse were included because of the significant associations with dyspareunia at 6 and/or 18 months postpartum noted in univariable analyses. Women who gave birth by emergency caesarean section or vacuum extraction and those who reported prepregnancy dyspareunia had greater than a twofold increase in adjusted odds of persisting dyspareunia at 18 months postpartum compared with women who had a spontaneous vaginal birth with an intact perineum after adjusting for
ª 2015 Royal College of Obstetricians and Gynaecologists
other variables in the model. Elective caesarean section was also associated with increased odds of dyspareunia at 18 months postpartum, although the confidence interval suggests borderline statistical significance. Similar patterns of association were found between dyspareunia at 6 months postpartum, mode of delivery, perineal trauma and other maternal and postnatal factors (Table 3). Women who had an operative vaginal delivery (with forceps or vacuum extraction) had greater than a three-fold increase in adjusted odds of dyspareunia at 6 months postpartum. Emergency caesarean section and vaginal birth with a sutured tear and/or episiotomy were associated with a two-fold increase in odds of dyspareunia after taking into account other factors in the model. Women who had an elective caesarean section did not have raised odds of reporting dyspareunia at 6 months postpartum. Prepregnancy dyspareunia was associated with a two-fold increase in odds of dyspareunia at both 6 and 18 months postpartum. Observed associations with obstetric intervention in multivariable models were stronger than associations with postnatal factors, including maternal depressive symptoms, fatigue and intimate partner abuse.
Discussion Main findings Almost all women experience some pain during sexual intercourse following childbirth. Our findings show that the extent to which women report dyspareunia at 6 and 18 months postpartum is influenced by events during labour and birth. The odds of dyspareunia at 18 months were substantially higher in women who delivered by
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Table 2. Adjusted odds of dyspareunia at 18 months postpartum associated with mode of delivery, perineal trauma and other risk factors* Dyspareunia at 18 months postpartum No n (%) Mode of delivery and perineal trauma Spontaneous vaginal birth Intact perineum/unsutured tear Sutured tear/episiotomy Caesarean section (intact perineum) Elective Emergency Forceps (sutured tear/episiotomy) Vacuum extraction (sutured tear/episiotomy) Prepregnancy dyspareunia No Yes Maternal age at index birth 30–34 years 18–24 years 25–29 years 35+ years Highest educational qualification University degree Certificate/diploma Year 12
