1415
ORIGINAL RESEARCH Prevalence and Risk Factors of Sexual Dysfunction in Postpartum Australian Women Marjan Khajehei, PhD,* Maryanne Doherty, PhD,* P.J. Matt Tilley, MPsych,* and Kay Sauer, PhD† *Department of Sexology, School of Public Health, Curtin University, Perth, WA, Australia; †Department of Epidemiology and Biostatics, School of Public Health, Curtin University, Perth, WA, Australia DOI: 10.1111/jsm.12901
ABSTRACT
Introduction. Female sexual dysfunction is highly prevalent and reportedly has adverse impacts on quality of life. Although it is prevalent after childbirth, women rarely seek advice or treatment from health care professionals. Aim. The aim of this study was to assess the sexual functioning of Australian women during the first year after childbirth. Methods. Postpartum women who had given birth during the previous 12 months were invited to participate in this cross-sectional study. A multidimensional online questionnaire was designed for this study. This questionnaire included a background section, the Female Sexual Function Index, the Patient Health Questionnaire (PHQ-8), and the Relationship Assessment Scale. Responses from 325 women were analyzed. Results. Almost two-thirds of women (64.3%) reported that they had experienced sexual dysfunction during the first year after childbirth, and almost three-quarters reported they experienced sexual dissatisfaction (70.5 %). The most prevalent types of sexual dysfunction reported by the affected women were sexual desire disorder (81.2%), orgasmic problems (53.5%), and sexual arousal disorder (52.3%). The following were significant risk factors for sexual dysfunction: fortnightly or less frequent sexual activity, not being the initiator of sexual activity with a partner, late resumption of postnatal sexual activity (at 9 or more weeks), the first 5 months after childbirth, primiparity, depression, and relationship dissatisfaction. Conclusion. Sexual satisfaction is important for maintaining quality of life for postpartum women. Health care providers and postpartum women need to be encouraged to include sexual problems in their discussions. Khajehei M, Doherty M, Tilley PJM, and Sauer K. Prevalence and risk factors of sexual dysfunction in postpartum Australian women. J Sex Med 2015;12:1415–1426. Key Words. Childbirth; Sexual Dysfunction; Postpartum Depression; Relationship Satisfaction; Quality of Life
Introduction
T
he World Association for Sexual Health [1] and the World Health Organization stated that sexual health is “. . . a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity . . .” [2]. Sexual activity is an integral part of everyone’s life, and its impairment may have a substantial impact on quality of life [3].
© 2015 International Society for Sexual Medicine
Maintaining meaningful sexual activity after childbirth has been shown to be a key factor in the quality of a couple’s relationship [4]. During and after pregnancy, many factors can affect sexual function in women and can result in changes to their sexual practice, sexual behaviors, and interpersonal relationships. Factors that have been reported include the following: hormonal and physiological changes, physical factors, health issues, and psychological and neurological changes [5,6]. In addition, cultural and ethical issues, reliJ Sex Med 2015;12:1415–1426
1416 gious beliefs, social norms, and myths and fears, as well as the changing structure of women’s roles, have been reported to influence the sexual life of women during and after pregnancy [7,8] and their quality of life [9]. Female sexual dysfunction has been described and widely accepted as an impairment of normal sexual function in women [10]. Sexual dysfunction is specified by the American Psychiatric Association as “a disturbance in the processes that characterize the sexual response cycle or by pain associated with sexual intercourse” [11]. The prevalence of sexual dysfunction among women after childbirth has been reported to vary worldwide from 5% to 35% after caesarean section to 40% to 80% after normal vaginal delivery with an episiotomy [12]. Despite this high prevalence of sexual dysfunction, only a small proportion of women with sexual dysfunction refer to health care professionals to seek advice or treatment for their sexual problems [13–15]. There has been increasing recent interest in assessing the sexual functioning of women after childbirth [16–18]. An integrated search of the literature identified preliminary reports on sexual function in postpartum Australian women [19,20]; however, there is a lack of up-to-date data. Aims
The present study was conducted to measure the prevalence of sexual dysfunction after childbirth among Australian women while addressing the limitations of previous studies. In addition, this study investigated which factors contributed to the sexual dysfunction of the participants. Method
Study Design This study was undertaken as a cross-sectional investigation. Postpartum women who had given birth during the previous 12 months were invited (as described below) to complete the multi-section online questionnaire. Ethics The Human Research Ethics Committee at Curtin University (approval HR171/2011) approved the study protocol. Women provided passive consent by completing and submitting the online questionnaire. Participants Based on previous reports by Brown and Lumley [19,20], which showed that 26% of postpartum J Sex Med 2015;12:1415–1426
Khajehei et al. women in Australia reported sexual dysfunction, the following formula was used. It was then calculated that 295 postpartum women were required to complete the online questionnaire, so that the study would be adequately powered: Z 2 P (1 − P ) n= E 2R Z = 1.96; E = error (precising) = 0.05; P = prevalence of sexual problems = 26% or 0.26 [19,20]. The following inclusion criteria were applied: (i) aged between 16 and 40; (ii) gave birth to a live baby at week 37 or later in pregnancy; (iii) gave birth 0 to 12 months ago; (iv) had a regular sexual partner; (v) not pregnant at the time of the study; and (vi) an Australian resident. The exclusion criteria were as follows: (i) clinically diagnosed with a psychiatric illness; (ii) taking antipsychotic medicine; and (iii) identifying as Aboriginal or Torres Strait Islander. At the beginning of the questionnaire, relevant questions were included that allowed the inclusion and exclusion criteria to be applied.
Recruitment Process Participation in this anonymous study was voluntary. Australian women who had given birth during the past year were recruited through a variety of venues to complete the online questionnaire. For example, the invitation letter was posted on selected Facebook pages. The 123 Submit and Dream submission programs were also used to place the link to the questionnaire on various search engines; advertisements containing a brief description of the research and the link to the study website were printed in community newspapers; flyers were distributed in public places to women who had babies younger than 1 year old; and invitation e-mails were sent to mothers whose babies were in selected childcare centers. Snowball sampling technique was also used, and women passed the website’s link to other women. The questionnaire was available online from May to August 2012, and during this time frame, the required number of participants was acquired. Main Outcome Measures A multidimensional questionnaire was designed and made available, which redirected participants to SurveyMonkey. The questionnaire included an initial section of 37 questions, including 6 questions about demographics, 10 related to obstetric and
1417
Sexual Dysfunction in Postpartum Women Table 1
Score range and factor to calculate each domain’s score
Domain
Question
Factor
Minimum score
Maximum score
Score range
Desire Arousal Lubrication Orgasm Satisfaction Pain
1 and 2 3, 4, 5, and 6 7, 8, 9, and 10 11, 12, and 13 14, 15, and 16 17, 18, and 19
0.6 0.3 0.3 0.4 0.4 0.4
1.2 0 0 0 2 0
6 6 6 6 6 6
1–5 0–5 0–5 0–5 0 (or 1)–5* 0–5
*Range for item 14: 0–5; range for items 15 and 16: 1–5
gynecological history, 6 about the last born baby, 9 related to medical history, and 6 about sexual life. This section was followed by the Female Sexual Function Index (FSFI), the Patient Health Questionnaire (PHQ-8), the Relationship Assessment Scale (RAS), and six open-ended questions about sexuality. The questionnaire was designed to take approximately 20 minutes to complete.
FSFI The FSFI was used to investigate sexual function in postpartum women. The FSFI is a valid questionnaire, and its reliability has been reported in many studies (α = 0.76–0.93) [9,21,22]. The FSFI section of the questionnaire used in this study consisted of 19 multiple-choice questions, and it was designed to collect data on female sexual functioning in the past 4 weeks. Six main domains of sexual function—desire, arousal, lubrication, orgasm, satisfaction, and pain—were assessed [23]. The items were scored using a Likert scale. Questions 1, 2, 15, and 16 were scored from 1 to 5. The other questions had a six-point Likert scale ranging from 0 to 5. The item scores were computed for the six domains of sexual function including desire, arousal, lubrication, orgasm, satisfaction, and pain. Then, each domain score was multiplied by a relative factor to calculate rates for domains of sexual dysfunction (Table 1). The score of the domain of “desire” ranged from 1.2 to 6. For the other five domains, the scores ranged from 0 to 6. If the participants acquired domain scores smaller than 4.28 on desire, 5.08 on arousal, 5.45 on lubrication, 5.05 on orgasm, 5.04 on satisfaction, and 5.51 on pain, they were classified as having difficulties in that domain. To calculate the total score of the FSFI, domains’ scores were computed and a cutoff score of 26 or less was used to identify women with a sexual dysfunction [24,25]. PHQ-8 Symptoms of depression were evaluated by using the PHQ-8, which had eight items and collected
data on current symptoms of depression. Studies that have used the PHQ-8 have reported its high level of reliability (α = 0.90) [26–28]. The items in the PHQ-8 were scored based on a four-point Likert scale scoring system from 0 (not at all) to 3 (nearly every day). Depressive symptoms were recognized as a score of 10 or greater.
RAS The RAS was used to investigate the current level of relationship satisfaction among participants. The RAS has been reported as a valid and reliable measure (α = 0.86–0.91) [29,30] for evaluating relationship satisfaction within any type of partnered relationship and “is not limited to marriage relationships” (p. 145) [29]. It consisted of seven multiple-choice questions, and the items were scored based on a five-point Likert scale. A score equal to or higher than 4 indicated high levels of relationship satisfaction. Data Analysis The quantitative data were downloaded from the SurveyMonkey website to SPSS Advanced Statistics, Release 18.0 (SPSS for Windows, SPSS Inc., Chicago, IL, USA). The data were then cleaned, recoded, labeled, and formatted for analysis. Descriptive statistics were used to summarize the demographic data. The distribution of all variables among women with and without sexual dysfunction was calculated by using the chi-squared (χ2) test (Fisher’s exact test if applicable). The independent samples t-test was used to assess mean scores on the PHQ-8 and the RAS among women with and without sexual dysfunction. Multiple logistic regression analysis (backward Wald) identified the factors that significantly affected the sexual functioning of postpartum women. In this analysis, the dependent variable was measured on a dichotomous scale with mutually exclusive categories (women with sexual dysfunction and women without sexual dysfunction). The independent categorical variables were also J Sex Med 2015;12:1415–1426
1418 Table 2
Khajehei et al. Demographic characteristics of primiparous and multiparous women Parity
Demographic Age 18–20 21–30 31–40 Education Diploma or lower Associate’s degree Bachelor’s degree Master’s degree or higher Career Student No formal occupation Casual work Permanent work Annual income of family Less than $50,000 $50,000+ Ethnicity Australian and New Zealander Other
Primiparous (n = 87)
Multiparous (n = 238)
P value
n
%
n
%
8 48 31
9.2 55.2 35.6
5 122 111
2.1 51.3 46.6
27 16 37 7
31.1 18.4 42.5 8
88 57 62 31
37 23.9 26.1 13
5 27 7 48
5.7 31 8 55.2
21 111 18 88
8.8 46.6 7.6 36.9
30 57
34.5 65.5
80 158
33.6 66.4
0.895
3 47
45.9 53.9
109 129
45.7 54.2
0.558
0.007*
0.096
0.03*
*P < 0.05
dichotomous such as postpartum time period (6–12 months and 0–5 months) and parity (multiparous and primiparous). Differences were considered significant when the P value was less than 0.05 (P < 0.05). Results
A total of 489 responses were received. Data from 164 women were excluded because their responses indicated that they did not meet the inclusion criteria. That is, 67 women resided outside Australia, 8 were not in a relationship, 5 were pregnant, 8 had given birth in week 36 or earlier in pregnancy, 15 reported using antipsychotic medication, 13 reported suffering mental health problems, and 48 did not complete the entire survey. Thus, responses from 325 women were considered for analysis. Nevertheless, the demographics of those who were excluded did not significantly differ from those whose data were analyzed. The mean age of participants was 29.8 with a range of 18 to 40 years. More than half of the women had completed a university degree (64.6%), had no formal occupation (50.5%), and had an annual household income higher than $50,000 (66.2%). Demographic characteristics of the women are shown in Table 2. Greater number of primiparous women than multiparous ones was in the 21–30 age group (55.2% vs. 51.3%, respectively) and had permanent work (55.2% vs. 36.9%). The differences between the two groups were statistically significant (P < 0.05). J Sex Med 2015;12:1415–1426
Two hundred nine women (64.3%) experienced sexual dysfunction after childbirth. There were no significant differences in age group, educational level, occupation, or annual income between women with and without sexual dysfunction (P > 0.05). Among those who experienced sexual dysfunction, sexual desire disorder (81.2%), orgasmic problems (53.5%), and sexual arousal disorder (52.3%) were the most prevalent domains/types of sexual dysfunction reported. In addition, 70.5% of women reported that they had experienced sexual dissatisfaction (Table 3). Lubrication difficulty (43.3%) and sexual pain disorder (39.4%) were less prevalent. Tables 4–6 show the results of the chi-squared tests. The Table 3 data reveal that the sexual dysfunction of postpartum women was not significantly associated with the following factors: parity, Table 3 Distribution of female sexual dysfunction and its domains among postpartum women surveyed online in Australia in 2012
Female sexual dysfunction Domains Sexual desire disorder Sexual arousal disorder Lubrication difficulty Orgasmic problems Sexual dissatisfaction Sexual pain disorder
n
%*
209
64.3
264 170 141 174 229 128
81.2 52.3 43.4 53.5 70.5 39.4
*The percentages do not add to 100 because some women reported more than one disorder
1419
Sexual Dysfunction in Postpartum Women
Table 4 Birth-related factors among postpartum women with and without female sexual dysfunction (FSD) surveyed online in Australia in 2012 Sexual function Factor Parity Primiparous Multiparous Number of children at home 1 child 2+ children Miscarriage or abortion† 0 1 2+ Method of delivery NVD without tears/ episiotomy NVD with tears/ episiotomy Instrumental delivery‡ Caesarean section Birth place Public hospital Private hospital Home Birth center Gender of the baby Boy Girl Two boys (twins) Two girls (twins) Baby’s birth weight Less than 2500 grams 2500–4000 grams More than 4000 grams Breastfeeding No breastfeeding Exclusive breastfeeding Partial breastfeeding Regular menstrual bleeding after childbirth Yes No
With FSD (n = 209)
Without FSD (n = 116)
χ2
n
%
n
%
63 146
30.1 69.9
24 92
20.7 79.3
0.069
91 118
43.5 56.5
36 80
31 69
0.033*
125 52 32
59.8 24.9 15.3
60 26 30
51.7 22.4 25.9
77
36.8
53
45.7
69
33
38
32.8
13 50
6.2 23.9
4 21
3.4 18.1
123 38 43 5
58.9 18.2 20.6 2.4
63 22 26 5
54.3 19 22.4 4.3
101 103 2 3
48.3 49.3 1 1.4
53 60 2 1
45.7 51.7 1.7 0.9
38 139 32
18.9 66.5 15.3
14 89 13
12.1 76.7 11.3
55 90 64
26.3 43.1 30.6
35 32 49
30.2 27.6 42.2
90 119
43.1 56.9
65 51
56 44
0.135
0.298
0.729
0.858
0.158
0.017*
0.026*
*P < 0.05 † Induced termination of pregnancy before week 13 of pregnancy ‡ With ventouse (vacuum) or forceps NVD = normal vaginal delivery
history of miscarriage or abortion, method of delivery, place of birth, gender of the baby, and birth weight of the baby (P > 0.05). However, women with sexual dysfunction were more likely to have only one child at home (P = 0.033), to exclusively breastfeed their babies (P = 0.017), and to lack regular menstrual bleeding after childbirth (P = 0.026) than were women without sexual dysfunction. Table 4 shows that the following factors were not significantly associated with sexual dysfunction after childbirth (P > 0.05): use of hormonal medicines (P = 0.402), use of any particular medicines (P = 0.487), pelvic operations (P = 0.071),
sleep hours in a 24-hour period (P = 0.062), cigarette smoking (P = 0.207), alcohol consumption (P = 0.741), illness during pregnancy (P = 0317), and being clinically diagnosed with postpartum depression (P = 0.227). Women with sexual dysfunction were more likely to have less frequent or no sexual activity than women without sexual dysfunction (P < 0.001) and were also more likely to resume sexual activity later than 9 weeks postpartum (P < 0.001) (Table 6). By contrast, women without sexual dysfunction were more likely than women with sexual dysfunction to be the initiator of sex during partnered sexual activity (P < 0.001). J Sex Med 2015;12:1415–1426
1420
Khajehei et al.
Table 5 Medical history and lifestyle factors among postpartum women with and without female sexual dysfunction (FSD) surveyed online in Australia in 2012 Sexual function Factor Use of hormonal medicines No Yes Use of particular medicines Yes No Pelvic operations Laparoscopy Bladder prolapse repair Ovariectomy None Sleep hours in a 24-hour period 4–6 hours 7–9 hours 10–11 hours Cigarette smoking No smoking Occasional smoking* Regular smoking† Alcohol consumption No alcohol consumption Light drinking Moderate drinking Heavy drinking Illness during pregnancy Yes No Being clinically diagnosed with postnatal depression Yes No
With FSD (n = 209)
Without FSD (n = 116)
χ2
n
%
n
%
194 15
92.8 7.2
104 12
89.7 10.3
12 197
5.7 94.3
9 107
7.8 92.2
1 2
4
— 206
0.5 1 — 98.6
1 111
3.4 — 0.9 95.7
94 112 3
45 53.6 1.4
51 59 6
44 50.9 5.2
187 6 16
89.5 2.9 7.7
107 — 9
92.2 — 7.8
123 78 6 2
58.9 37.3 2.9 1
64 45 6 1
55.2 38.8 5.2 0.9
47 162
22.5 77.5
20 96
17.2 82.8
0.317
31 178
14.8 85.2
11 105
9.5 90.5
0.227
0.402
—
0.487
0.071
0.062
0.207
0.741
*Fewer than 4 days per week † Almost every day
Table 6 reports that vaginal intercourse was the most practiced form of sexual activity among participants in both groups. However, the practice of the following sexual activities was higher among women with sexual dysfunction than women without sexual dysfunction: masturbation together with vaginal sex (12.4% vs. 4.3%, respectively); masturbation together with oral, vaginal, and anal sex (6.2% vs. 4.3%, respectively); masturbation only (1.4% vs. 0.9%, respectively); and anal sex only (0.5% vs. 0%, respectively). The two groups were significantly different in the most practiced form of sexual activities (P = 0.004) (Table 5). There was no significant association between sexual orientation and sexual dysfunction after childbirth (P = 1) (Table 6). However, this comparison may not be reliable because of the smaller number of women in same-sex relationships (16) than in heterosexual relationships (309). More women with sexual dysfunction than women without sexual dysfunction had scores J Sex Med 2015;12:1415–1426
higher than 10 on the PHQ-8, indicating a significant higher rate of depression (30.6% vs. 12.1%, respectively) (P < 0.001) (Table 6). In addition, women with sexual dysfunction were more likely than women without sexual dysfunction to experience relationship dissatisfaction (obtaining scores less than 4 on the RAS) (45.9% vs. 21.6%, respectively) (P < 0.001) (Table 5). These findings were supported by the independent sample t-test results, as shown in Table 6. The mean scores on the RAS and the PHQ-8 showed that women with sexual dysfunction were at a greater risk of relationship dissatisfaction and postnatal depression than women without sexual dysfunction (P < 0.001) (Table 7). Regarding other risk factors, the following were significant risk factors for sexual dysfunction during the first year after childbirth: low frequency of sexual activity (fortnightly or less) (adjusted odds ratio [OR] = 4.041, 95% confidence interval [CI] = 2.199–7.427, P < 0.001), not being the initiator of sex during sexual activity (OR = 3.78,
1421
Sexual Dysfunction in Postpartum Women
Table 6 Elements of sexual life and categorical scores on the PHQ-8 and RAS among postpartum women with and without female sexual dysfunction (FSD) surveyed online in Australia in 2012
Sexual function Sexual life Usual sexual activity
No sexual activity Single method Vaginal sex Masturbation Anal sex Total Mixed method Oral and vaginal sex Masturbation and vaginal sex Masturbation, oral, and vaginal sex Oral, vaginal, and anal sex Masturbation, oral, vaginal, and anal sex Total
With FSD (n = 209)
Without FSD (n = 116)
n
%
n
29 73 3 1 77 29 26 30 5 13 103
13.9 34.9 1.4 0.5 36.8 13.9 12.4 14.4 2.4 6.2 49.3
3 44 1 0 45 24 5 29 5 5 68
2.6 37.9 0.9 0 38.8 20.7 4.3 25 4.3 4.3 58.6
31 1 19 64 44 50
14.8 0.5 9.1 30.6 21.1 23.9
1 5 39 45 15 11
0.9 4.3 33.6 38.8 12.9 9.5
32 49 74 54
15.3 23.4 35.4 25.8
– 41 56 19
– 35.3 48.3 16.4
25 104 54 26
12 49.8 25.8 12.4
14 29 67 6
12.1 25 57.8 5.2
10 199
4.8 95.2
6 110
5.2 94.8
145 64
69.4 30.6
102 14
87.9 12.1
96 113
45.9 54.1
25 91
21.6 78.4
χ2
% 0.004*
ORIGINAL RESEARCH Prevalence and Risk Factors of Sexual Dysfunction in Postpartum Australian Women Marjan Khajehei, PhD,* Maryanne Doherty, PhD,* P.J. Matt Tilley, MPsych,* and Kay Sauer, PhD† *Department of Sexology, School of Public Health, Curtin University, Perth, WA, Australia; †Department of Epidemiology and Biostatics, School of Public Health, Curtin University, Perth, WA, Australia DOI: 10.1111/jsm.12901
ABSTRACT
Introduction. Female sexual dysfunction is highly prevalent and reportedly has adverse impacts on quality of life. Although it is prevalent after childbirth, women rarely seek advice or treatment from health care professionals. Aim. The aim of this study was to assess the sexual functioning of Australian women during the first year after childbirth. Methods. Postpartum women who had given birth during the previous 12 months were invited to participate in this cross-sectional study. A multidimensional online questionnaire was designed for this study. This questionnaire included a background section, the Female Sexual Function Index, the Patient Health Questionnaire (PHQ-8), and the Relationship Assessment Scale. Responses from 325 women were analyzed. Results. Almost two-thirds of women (64.3%) reported that they had experienced sexual dysfunction during the first year after childbirth, and almost three-quarters reported they experienced sexual dissatisfaction (70.5 %). The most prevalent types of sexual dysfunction reported by the affected women were sexual desire disorder (81.2%), orgasmic problems (53.5%), and sexual arousal disorder (52.3%). The following were significant risk factors for sexual dysfunction: fortnightly or less frequent sexual activity, not being the initiator of sexual activity with a partner, late resumption of postnatal sexual activity (at 9 or more weeks), the first 5 months after childbirth, primiparity, depression, and relationship dissatisfaction. Conclusion. Sexual satisfaction is important for maintaining quality of life for postpartum women. Health care providers and postpartum women need to be encouraged to include sexual problems in their discussions. Khajehei M, Doherty M, Tilley PJM, and Sauer K. Prevalence and risk factors of sexual dysfunction in postpartum Australian women. J Sex Med 2015;12:1415–1426. Key Words. Childbirth; Sexual Dysfunction; Postpartum Depression; Relationship Satisfaction; Quality of Life
Introduction
T
he World Association for Sexual Health [1] and the World Health Organization stated that sexual health is “. . . a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity . . .” [2]. Sexual activity is an integral part of everyone’s life, and its impairment may have a substantial impact on quality of life [3].
© 2015 International Society for Sexual Medicine
Maintaining meaningful sexual activity after childbirth has been shown to be a key factor in the quality of a couple’s relationship [4]. During and after pregnancy, many factors can affect sexual function in women and can result in changes to their sexual practice, sexual behaviors, and interpersonal relationships. Factors that have been reported include the following: hormonal and physiological changes, physical factors, health issues, and psychological and neurological changes [5,6]. In addition, cultural and ethical issues, reliJ Sex Med 2015;12:1415–1426
1416 gious beliefs, social norms, and myths and fears, as well as the changing structure of women’s roles, have been reported to influence the sexual life of women during and after pregnancy [7,8] and their quality of life [9]. Female sexual dysfunction has been described and widely accepted as an impairment of normal sexual function in women [10]. Sexual dysfunction is specified by the American Psychiatric Association as “a disturbance in the processes that characterize the sexual response cycle or by pain associated with sexual intercourse” [11]. The prevalence of sexual dysfunction among women after childbirth has been reported to vary worldwide from 5% to 35% after caesarean section to 40% to 80% after normal vaginal delivery with an episiotomy [12]. Despite this high prevalence of sexual dysfunction, only a small proportion of women with sexual dysfunction refer to health care professionals to seek advice or treatment for their sexual problems [13–15]. There has been increasing recent interest in assessing the sexual functioning of women after childbirth [16–18]. An integrated search of the literature identified preliminary reports on sexual function in postpartum Australian women [19,20]; however, there is a lack of up-to-date data. Aims
The present study was conducted to measure the prevalence of sexual dysfunction after childbirth among Australian women while addressing the limitations of previous studies. In addition, this study investigated which factors contributed to the sexual dysfunction of the participants. Method
Study Design This study was undertaken as a cross-sectional investigation. Postpartum women who had given birth during the previous 12 months were invited (as described below) to complete the multi-section online questionnaire. Ethics The Human Research Ethics Committee at Curtin University (approval HR171/2011) approved the study protocol. Women provided passive consent by completing and submitting the online questionnaire. Participants Based on previous reports by Brown and Lumley [19,20], which showed that 26% of postpartum J Sex Med 2015;12:1415–1426
Khajehei et al. women in Australia reported sexual dysfunction, the following formula was used. It was then calculated that 295 postpartum women were required to complete the online questionnaire, so that the study would be adequately powered: Z 2 P (1 − P ) n= E 2R Z = 1.96; E = error (precising) = 0.05; P = prevalence of sexual problems = 26% or 0.26 [19,20]. The following inclusion criteria were applied: (i) aged between 16 and 40; (ii) gave birth to a live baby at week 37 or later in pregnancy; (iii) gave birth 0 to 12 months ago; (iv) had a regular sexual partner; (v) not pregnant at the time of the study; and (vi) an Australian resident. The exclusion criteria were as follows: (i) clinically diagnosed with a psychiatric illness; (ii) taking antipsychotic medicine; and (iii) identifying as Aboriginal or Torres Strait Islander. At the beginning of the questionnaire, relevant questions were included that allowed the inclusion and exclusion criteria to be applied.
Recruitment Process Participation in this anonymous study was voluntary. Australian women who had given birth during the past year were recruited through a variety of venues to complete the online questionnaire. For example, the invitation letter was posted on selected Facebook pages. The 123 Submit and Dream submission programs were also used to place the link to the questionnaire on various search engines; advertisements containing a brief description of the research and the link to the study website were printed in community newspapers; flyers were distributed in public places to women who had babies younger than 1 year old; and invitation e-mails were sent to mothers whose babies were in selected childcare centers. Snowball sampling technique was also used, and women passed the website’s link to other women. The questionnaire was available online from May to August 2012, and during this time frame, the required number of participants was acquired. Main Outcome Measures A multidimensional questionnaire was designed and made available, which redirected participants to SurveyMonkey. The questionnaire included an initial section of 37 questions, including 6 questions about demographics, 10 related to obstetric and
1417
Sexual Dysfunction in Postpartum Women Table 1
Score range and factor to calculate each domain’s score
Domain
Question
Factor
Minimum score
Maximum score
Score range
Desire Arousal Lubrication Orgasm Satisfaction Pain
1 and 2 3, 4, 5, and 6 7, 8, 9, and 10 11, 12, and 13 14, 15, and 16 17, 18, and 19
0.6 0.3 0.3 0.4 0.4 0.4
1.2 0 0 0 2 0
6 6 6 6 6 6
1–5 0–5 0–5 0–5 0 (or 1)–5* 0–5
*Range for item 14: 0–5; range for items 15 and 16: 1–5
gynecological history, 6 about the last born baby, 9 related to medical history, and 6 about sexual life. This section was followed by the Female Sexual Function Index (FSFI), the Patient Health Questionnaire (PHQ-8), the Relationship Assessment Scale (RAS), and six open-ended questions about sexuality. The questionnaire was designed to take approximately 20 minutes to complete.
FSFI The FSFI was used to investigate sexual function in postpartum women. The FSFI is a valid questionnaire, and its reliability has been reported in many studies (α = 0.76–0.93) [9,21,22]. The FSFI section of the questionnaire used in this study consisted of 19 multiple-choice questions, and it was designed to collect data on female sexual functioning in the past 4 weeks. Six main domains of sexual function—desire, arousal, lubrication, orgasm, satisfaction, and pain—were assessed [23]. The items were scored using a Likert scale. Questions 1, 2, 15, and 16 were scored from 1 to 5. The other questions had a six-point Likert scale ranging from 0 to 5. The item scores were computed for the six domains of sexual function including desire, arousal, lubrication, orgasm, satisfaction, and pain. Then, each domain score was multiplied by a relative factor to calculate rates for domains of sexual dysfunction (Table 1). The score of the domain of “desire” ranged from 1.2 to 6. For the other five domains, the scores ranged from 0 to 6. If the participants acquired domain scores smaller than 4.28 on desire, 5.08 on arousal, 5.45 on lubrication, 5.05 on orgasm, 5.04 on satisfaction, and 5.51 on pain, they were classified as having difficulties in that domain. To calculate the total score of the FSFI, domains’ scores were computed and a cutoff score of 26 or less was used to identify women with a sexual dysfunction [24,25]. PHQ-8 Symptoms of depression were evaluated by using the PHQ-8, which had eight items and collected
data on current symptoms of depression. Studies that have used the PHQ-8 have reported its high level of reliability (α = 0.90) [26–28]. The items in the PHQ-8 were scored based on a four-point Likert scale scoring system from 0 (not at all) to 3 (nearly every day). Depressive symptoms were recognized as a score of 10 or greater.
RAS The RAS was used to investigate the current level of relationship satisfaction among participants. The RAS has been reported as a valid and reliable measure (α = 0.86–0.91) [29,30] for evaluating relationship satisfaction within any type of partnered relationship and “is not limited to marriage relationships” (p. 145) [29]. It consisted of seven multiple-choice questions, and the items were scored based on a five-point Likert scale. A score equal to or higher than 4 indicated high levels of relationship satisfaction. Data Analysis The quantitative data were downloaded from the SurveyMonkey website to SPSS Advanced Statistics, Release 18.0 (SPSS for Windows, SPSS Inc., Chicago, IL, USA). The data were then cleaned, recoded, labeled, and formatted for analysis. Descriptive statistics were used to summarize the demographic data. The distribution of all variables among women with and without sexual dysfunction was calculated by using the chi-squared (χ2) test (Fisher’s exact test if applicable). The independent samples t-test was used to assess mean scores on the PHQ-8 and the RAS among women with and without sexual dysfunction. Multiple logistic regression analysis (backward Wald) identified the factors that significantly affected the sexual functioning of postpartum women. In this analysis, the dependent variable was measured on a dichotomous scale with mutually exclusive categories (women with sexual dysfunction and women without sexual dysfunction). The independent categorical variables were also J Sex Med 2015;12:1415–1426
1418 Table 2
Khajehei et al. Demographic characteristics of primiparous and multiparous women Parity
Demographic Age 18–20 21–30 31–40 Education Diploma or lower Associate’s degree Bachelor’s degree Master’s degree or higher Career Student No formal occupation Casual work Permanent work Annual income of family Less than $50,000 $50,000+ Ethnicity Australian and New Zealander Other
Primiparous (n = 87)
Multiparous (n = 238)
P value
n
%
n
%
8 48 31
9.2 55.2 35.6
5 122 111
2.1 51.3 46.6
27 16 37 7
31.1 18.4 42.5 8
88 57 62 31
37 23.9 26.1 13
5 27 7 48
5.7 31 8 55.2
21 111 18 88
8.8 46.6 7.6 36.9
30 57
34.5 65.5
80 158
33.6 66.4
0.895
3 47
45.9 53.9
109 129
45.7 54.2
0.558
0.007*
0.096
0.03*
*P < 0.05
dichotomous such as postpartum time period (6–12 months and 0–5 months) and parity (multiparous and primiparous). Differences were considered significant when the P value was less than 0.05 (P < 0.05). Results
A total of 489 responses were received. Data from 164 women were excluded because their responses indicated that they did not meet the inclusion criteria. That is, 67 women resided outside Australia, 8 were not in a relationship, 5 were pregnant, 8 had given birth in week 36 or earlier in pregnancy, 15 reported using antipsychotic medication, 13 reported suffering mental health problems, and 48 did not complete the entire survey. Thus, responses from 325 women were considered for analysis. Nevertheless, the demographics of those who were excluded did not significantly differ from those whose data were analyzed. The mean age of participants was 29.8 with a range of 18 to 40 years. More than half of the women had completed a university degree (64.6%), had no formal occupation (50.5%), and had an annual household income higher than $50,000 (66.2%). Demographic characteristics of the women are shown in Table 2. Greater number of primiparous women than multiparous ones was in the 21–30 age group (55.2% vs. 51.3%, respectively) and had permanent work (55.2% vs. 36.9%). The differences between the two groups were statistically significant (P < 0.05). J Sex Med 2015;12:1415–1426
Two hundred nine women (64.3%) experienced sexual dysfunction after childbirth. There were no significant differences in age group, educational level, occupation, or annual income between women with and without sexual dysfunction (P > 0.05). Among those who experienced sexual dysfunction, sexual desire disorder (81.2%), orgasmic problems (53.5%), and sexual arousal disorder (52.3%) were the most prevalent domains/types of sexual dysfunction reported. In addition, 70.5% of women reported that they had experienced sexual dissatisfaction (Table 3). Lubrication difficulty (43.3%) and sexual pain disorder (39.4%) were less prevalent. Tables 4–6 show the results of the chi-squared tests. The Table 3 data reveal that the sexual dysfunction of postpartum women was not significantly associated with the following factors: parity, Table 3 Distribution of female sexual dysfunction and its domains among postpartum women surveyed online in Australia in 2012
Female sexual dysfunction Domains Sexual desire disorder Sexual arousal disorder Lubrication difficulty Orgasmic problems Sexual dissatisfaction Sexual pain disorder
n
%*
209
64.3
264 170 141 174 229 128
81.2 52.3 43.4 53.5 70.5 39.4
*The percentages do not add to 100 because some women reported more than one disorder
1419
Sexual Dysfunction in Postpartum Women
Table 4 Birth-related factors among postpartum women with and without female sexual dysfunction (FSD) surveyed online in Australia in 2012 Sexual function Factor Parity Primiparous Multiparous Number of children at home 1 child 2+ children Miscarriage or abortion† 0 1 2+ Method of delivery NVD without tears/ episiotomy NVD with tears/ episiotomy Instrumental delivery‡ Caesarean section Birth place Public hospital Private hospital Home Birth center Gender of the baby Boy Girl Two boys (twins) Two girls (twins) Baby’s birth weight Less than 2500 grams 2500–4000 grams More than 4000 grams Breastfeeding No breastfeeding Exclusive breastfeeding Partial breastfeeding Regular menstrual bleeding after childbirth Yes No
With FSD (n = 209)
Without FSD (n = 116)
χ2
n
%
n
%
63 146
30.1 69.9
24 92
20.7 79.3
0.069
91 118
43.5 56.5
36 80
31 69
0.033*
125 52 32
59.8 24.9 15.3
60 26 30
51.7 22.4 25.9
77
36.8
53
45.7
69
33
38
32.8
13 50
6.2 23.9
4 21
3.4 18.1
123 38 43 5
58.9 18.2 20.6 2.4
63 22 26 5
54.3 19 22.4 4.3
101 103 2 3
48.3 49.3 1 1.4
53 60 2 1
45.7 51.7 1.7 0.9
38 139 32
18.9 66.5 15.3
14 89 13
12.1 76.7 11.3
55 90 64
26.3 43.1 30.6
35 32 49
30.2 27.6 42.2
90 119
43.1 56.9
65 51
56 44
0.135
0.298
0.729
0.858
0.158
0.017*
0.026*
*P < 0.05 † Induced termination of pregnancy before week 13 of pregnancy ‡ With ventouse (vacuum) or forceps NVD = normal vaginal delivery
history of miscarriage or abortion, method of delivery, place of birth, gender of the baby, and birth weight of the baby (P > 0.05). However, women with sexual dysfunction were more likely to have only one child at home (P = 0.033), to exclusively breastfeed their babies (P = 0.017), and to lack regular menstrual bleeding after childbirth (P = 0.026) than were women without sexual dysfunction. Table 4 shows that the following factors were not significantly associated with sexual dysfunction after childbirth (P > 0.05): use of hormonal medicines (P = 0.402), use of any particular medicines (P = 0.487), pelvic operations (P = 0.071),
sleep hours in a 24-hour period (P = 0.062), cigarette smoking (P = 0.207), alcohol consumption (P = 0.741), illness during pregnancy (P = 0317), and being clinically diagnosed with postpartum depression (P = 0.227). Women with sexual dysfunction were more likely to have less frequent or no sexual activity than women without sexual dysfunction (P < 0.001) and were also more likely to resume sexual activity later than 9 weeks postpartum (P < 0.001) (Table 6). By contrast, women without sexual dysfunction were more likely than women with sexual dysfunction to be the initiator of sex during partnered sexual activity (P < 0.001). J Sex Med 2015;12:1415–1426
1420
Khajehei et al.
Table 5 Medical history and lifestyle factors among postpartum women with and without female sexual dysfunction (FSD) surveyed online in Australia in 2012 Sexual function Factor Use of hormonal medicines No Yes Use of particular medicines Yes No Pelvic operations Laparoscopy Bladder prolapse repair Ovariectomy None Sleep hours in a 24-hour period 4–6 hours 7–9 hours 10–11 hours Cigarette smoking No smoking Occasional smoking* Regular smoking† Alcohol consumption No alcohol consumption Light drinking Moderate drinking Heavy drinking Illness during pregnancy Yes No Being clinically diagnosed with postnatal depression Yes No
With FSD (n = 209)
Without FSD (n = 116)
χ2
n
%
n
%
194 15
92.8 7.2
104 12
89.7 10.3
12 197
5.7 94.3
9 107
7.8 92.2
1 2
4
— 206
0.5 1 — 98.6
1 111
3.4 — 0.9 95.7
94 112 3
45 53.6 1.4
51 59 6
44 50.9 5.2
187 6 16
89.5 2.9 7.7
107 — 9
92.2 — 7.8
123 78 6 2
58.9 37.3 2.9 1
64 45 6 1
55.2 38.8 5.2 0.9
47 162
22.5 77.5
20 96
17.2 82.8
0.317
31 178
14.8 85.2
11 105
9.5 90.5
0.227
0.402
—
0.487
0.071
0.062
0.207
0.741
*Fewer than 4 days per week † Almost every day
Table 6 reports that vaginal intercourse was the most practiced form of sexual activity among participants in both groups. However, the practice of the following sexual activities was higher among women with sexual dysfunction than women without sexual dysfunction: masturbation together with vaginal sex (12.4% vs. 4.3%, respectively); masturbation together with oral, vaginal, and anal sex (6.2% vs. 4.3%, respectively); masturbation only (1.4% vs. 0.9%, respectively); and anal sex only (0.5% vs. 0%, respectively). The two groups were significantly different in the most practiced form of sexual activities (P = 0.004) (Table 5). There was no significant association between sexual orientation and sexual dysfunction after childbirth (P = 1) (Table 6). However, this comparison may not be reliable because of the smaller number of women in same-sex relationships (16) than in heterosexual relationships (309). More women with sexual dysfunction than women without sexual dysfunction had scores J Sex Med 2015;12:1415–1426
higher than 10 on the PHQ-8, indicating a significant higher rate of depression (30.6% vs. 12.1%, respectively) (P < 0.001) (Table 6). In addition, women with sexual dysfunction were more likely than women without sexual dysfunction to experience relationship dissatisfaction (obtaining scores less than 4 on the RAS) (45.9% vs. 21.6%, respectively) (P < 0.001) (Table 5). These findings were supported by the independent sample t-test results, as shown in Table 6. The mean scores on the RAS and the PHQ-8 showed that women with sexual dysfunction were at a greater risk of relationship dissatisfaction and postnatal depression than women without sexual dysfunction (P < 0.001) (Table 7). Regarding other risk factors, the following were significant risk factors for sexual dysfunction during the first year after childbirth: low frequency of sexual activity (fortnightly or less) (adjusted odds ratio [OR] = 4.041, 95% confidence interval [CI] = 2.199–7.427, P < 0.001), not being the initiator of sex during sexual activity (OR = 3.78,
1421
Sexual Dysfunction in Postpartum Women
Table 6 Elements of sexual life and categorical scores on the PHQ-8 and RAS among postpartum women with and without female sexual dysfunction (FSD) surveyed online in Australia in 2012
Sexual function Sexual life Usual sexual activity
No sexual activity Single method Vaginal sex Masturbation Anal sex Total Mixed method Oral and vaginal sex Masturbation and vaginal sex Masturbation, oral, and vaginal sex Oral, vaginal, and anal sex Masturbation, oral, vaginal, and anal sex Total
With FSD (n = 209)
Without FSD (n = 116)
n
%
n
29 73 3 1 77 29 26 30 5 13 103
13.9 34.9 1.4 0.5 36.8 13.9 12.4 14.4 2.4 6.2 49.3
3 44 1 0 45 24 5 29 5 5 68
2.6 37.9 0.9 0 38.8 20.7 4.3 25 4.3 4.3 58.6
31 1 19 64 44 50
14.8 0.5 9.1 30.6 21.1 23.9
1 5 39 45 15 11
0.9 4.3 33.6 38.8 12.9 9.5
32 49 74 54
15.3 23.4 35.4 25.8
– 41 56 19
– 35.3 48.3 16.4
25 104 54 26
12 49.8 25.8 12.4
14 29 67 6
12.1 25 57.8 5.2
10 199
4.8 95.2
6 110
5.2 94.8
145 64
69.4 30.6
102 14
87.9 12.1
96 113
45.9 54.1
25 91
21.6 78.4
χ2
% 0.004*
