Sexual function in primiparous women: a prospective study

From 1 October 2014 to 1 October 2017, nulliparous women registering for maternity health care in Region Örebro County, Sweden, were invited by their midwife to participate in the prospective observational study, POPRACT (Pelvic flOor in PRegnancy And ChildbirTh). Exclusion criteria were insufficient knowledge of Swedish and a gestational age > 16 weeks + 6 days. Web-based questionnaires were mailed to the women included in the study in early pregnancy, in late pregnancy (these data were not utilized in the present study), at 8 weeks postpartum and at 12 months postpartum. The questionnaires covered patients’ characteristics (i.e., education, weight, height and smoking habits), self-reported health, breastfeeding and whether they were sexually active or not. Sexually active women were asked about sexual dysfunction.

The results from the part of the POPRACT study on risk factors for perineal and vaginal tears were recently published [13].

The primary outcome measures were sexual activity (“yes” or “no”) and sexual function, measured at early pregnancy and 12 months postpartum. The secondary outcome was sexual activity at 8 weeks postpartum.

Sexual function was measured using the Swedish translation of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) [14]. The PISQ-12 consists of 12 questions, asking the participants to consider their sexual function during the last 6 months, and was validated in 2003 [15]. The maximum score is 48 points; a higher score indicates better sexual function, and there is no cutoff value for dysfunction [15]. The PISQ-12 was scored taking into consideration the errata published by Rogers [16]. The following answers to the PISQ-12 sub-questions were dichotomized as “dysfunction”: the answers “seldom” and “never” for questions 1–4; the answers “always,” “usually” and “sometimes” for questions 5–11; the answers “much less intense” and “less intense” for question 12 (see Appendix Table 6). This categorization has previously been used for questions about pain [8, 9] and sexual desire [8].

When calculating each participant’s total PISQ-12 score, the mean value of the participant’s answered items was used to fill missing values in cases of up to two missing values. Questionnaires with more than two missing questions were excluded from the analysis of the total PISQ-12 score [15].

Since the PISQ-12 questions refer to the last 6 months, we analyzed PISQ-12 scores only at early pregnancy and at 12 months postpartum, and not for 8 weeks postpartum. Distributions of the answers to PISQ-12 from early pregnancy, 8 weeks and 12 months postpartum are presented in Appendix.

Obstetric variables were collected from a local laceration protocol or Obstetrix, a widely used obstetric journal system in Sweden. Use of the local laceration protocol has been validated [17]. A more detailed description of data collection from a local laceration protocol and from Obstetrix has been published [13].

The variables were categorized as follows: Delivery mode was grouped into: spontaneous vaginal, vaginal with vacuum extraction or cesarean section. Perineal tears were categorized in three groups: no laceration or first-degree laceration, second-degree laceration or OASI, in accordance with the Royal College of Obstetricians and Gynecologists classification [18]. Episiotomies were automatically recorded as a second-degree perineal tear, except in the case of OASI, when the perineal laceration diagnosis remained unchanged. Vaginal tears were categorized as either low or high, depending on whether the tear was limited to or extended above the distal third of the vagina, following the ICD-10 classification [19]. Self-reported health with a 5-point Likert scale was dichotomized as either good (“excellent,” “very good” and “good”) or poor (“fairly good” and “bad”). Body mass index (BMI) in early pregnancy was grouped into < 18.5, 18.5–24.9, 25.0–29.9 and > 30.0. Education was classified into elementary school, high school or university. Age was dichotomized at ≥ 35 years.

Data collected from the questionnaires were stored in the cloud-based tool esMaker 3.0 (Entergate AB, Sweden) in accordance with the General Data Protection Regulation of the European Union.

Participation was voluntary, and exiting the study was possible at all times. Ethical approval was obtained from the Regional Ethical Review Board in Stockholm (registration number 2014/124–32).

In early pregnancy, 797 (98.0%) of the participants were sexually active; this number decreased to 502 (66.7%) at 8 weeks postpartum and then rose to 631 (90.0%) at 12 months postpartum (see Appendix Table 6). Table 3 presents the associations between demographic and obstetric factors and sexual inactivity. In the adjusted model, the only statistically significant associations with sexual inactivity in early pregnancy were age ≥ 35 years and poor self-reported health compared with good health. Second-degree perineal tear, OASI and current breastfeeding were associated with a statistically significant increased risk for sexual inactivity at 8 weeks postpartum. At 12 months postpartum, second-degree perineal tear, current breastfeeding and age ≥ 35 years were statistically significantly associated with higher risk of sexual inactivity. High school education, compared with elementary school education, showed a statistically significant raised risk for sexual inactivity at 12 months, but not in early pregnancy or at 8 weeks postpartum. Compared with non-smokers, smokers showed a lower likelihood of sexual inactivity in early pregnancy and at 12 months postpartum.

Table 6 in the Appendix presents the frequency of answers to each sub-question, and Table A2 presents the change in dysfunction for each sub-question. Table 4 presents the mean and SD for the total PISQ-12 score and the difference in the total PISQ-12 score at early pregnancy and at 12 months postpartum by exposure measures. In early pregnancy, a statistically significant difference in lower sexual function was observed for poor self-reported health; this difference remained significant at 12 months postpartum and after adjustments were made for other variables. At 12 months postpartum, in the adjusted model, the difference in sexual function as associated with OASI compared with no or first-degree perineal tear became greater than in early pregnancy, although the association was not statistically significant.

For question 4 in the questionnaire, “Are you satisfied with the variety of sexual activities?,” poor self-reported health in early pregnancy was the only statistically significant risk factor for being unsatisfied with the variety of sexual activities at 12 months postpartum, when adjusted for smoking, self-reported health in early pregnancy, delivery mode and degree of perineal tear (data not shown).

In early pregnancy, 18.2% of the women suffered from dyspareunia, as measured by question 5; at 12 months postpartum, this had increased to 29.8% (see Appendix Table 6). Table 5 presents risk factors for dyspareunia. After adjustment, a statistically significant higher risk for dyspareunia was observed for second-degree perineal tear and OASI compared with women without injury or with first-degree tear, respectively. Compared with vaginal delivery without vacuum extraction, delivery with vacuum extraction showed a statistically significant association in the unadjusted model; however, after the adjustment, the odds ratio (OR) declined and this association was no longer statistically significant. To explore whether this change was due to an over-adjustment of other factors naturally associated with vacuum extraction, an alternative adjusted analysis was performed that excluded perineal tear, high vaginal tear, episiotomy and the mode of delivery start. In this alternative model, vacuum extraction remained significant at 12 months postpartum, with an adjusted OR of 1.63 (95% CI 1.01, 2.63).

Our finding that the great majority of studied women resumed sexual activity after childbirth within 12 months postpartum is similar to other findings [11, 20]. Notably, we did not find the mode of delivery [21] or episiotomy [8, 11] to affect sexual activity at 12 months postpartum. We found that second-degree perineal tear and OASI were associated with less sexual activity at 8 weeks postpartum, although only second-degree perineal tear remained significant at 12 months postpartum. Our results support previous findings that OASI is associated with less sexual activity at 6 months postpartum. Anglès-Acedo found that 98% of women with spontaneous vaginal delivery without OASI are sexually active, in contrast to 77% of women with OASI [3]. In addition, Brubaker found that 94% of women without OASI were sexually active compared with 88% of women with OASI [8]. Rådestad et al. found OASI to extend the time to first sexual intercourse; however, as in our study, no difference was seen at 12 months postpartum, at which point 96% of the studied women had been sexually active [11]. Similar to our results at 12 months postpartum, Leeman et al. found that the great majority of studied women, 87%, resumed sexual activity at 6 months postpartum with no difference between tear groups. Leeman et al. combined second-degree perineal tear and OASI when analyzing [22]. Buhling et al. investigated the time to first sexual intercourse until 8 weeks postpartum and found no difference among delivery mode or the degree of perineal tear; however, their data consisted of deliveries taking place in 1997–1999 [21], and diagnostic procedures and the handling of tears might have been different at that time.

We found higher maternal age to affect the time taken to resume sexual activity, consistent with Rådestad et al. who found that an age > 35 years was a risk factor for being sexually inactive at 12 months postpartum [11]. An age of 36 years or older has been described as a risk factor for waiting an average of 2.5 weeks longer to resume sexual activity compared with an age < 25 years [4]. In our study, we only obtained data on sexual activity at two time points after childbirth, namely, at 8 weeks and 12 months postpartum. In contrast, Brubaker et al. dichotomized age at 30 years and found no age difference in the resumption of sexual activity at 6 months postpartum [8].

Our finding that a high school education was associated with sexual inactivity at 12 months postpartum is somewhat surprising and is inconsistent with previous studies; Brubaker et al. found no association between level of education and sexual inactivity [8].

In general, the decrease in sexual function from early pregnancy to 12 months postpartum was small. Poor self-reported health in early pregnancy was found to be the only statistically significant risk factor for a decreased total PISQ-12 score at 12 months postpartum. Consistent with our finding, Brubaker et al. studied the PISQ-12 score at 6 months postpartum and did not find age, dichotomized at 30 years, to affect the total PISQ-12 score, although their mean value (scoring 39 ± 4) was similar to ours [8].

Unlike our expectation that OASI would be a risk factor for decreased sexual function postpartum, the association between OASI and decreased sexual function did not reach statistical significance. Two smaller studies at 6 months postpartum also found no association between OASI and the total PISQ-12 score in primiparous women [8] or in a mixed group of primiparous and multiparas women [3]. Furthermore, we did not find delivery mode to affect sexual function, which aligns with previous findings [1, 23]. Current breastfeeding had no impact on the total PISQ-12 score in our study, whereas Anglès-Acedo et al. found a negative association at 6 months postpartum. However, their study was not restricted to primiparous women [3].

Question 4 regarding satisfaction with the variety of sexual activities was difficult to analyze because few women scored for dysfunction. It is unclear whether the participants answered strictly about their satisfaction with the variety of activities (i.e., different types of sex) or whether their answers referred more generally to their satisfaction with their sexual life. We think that information about the latter would be of even greater importance. Olsson et al. arranged focus group discussions with women after childbirth and found that women wanted to sleep and have time for themselves, as well as not feeling comfortable with their body changes after pregnancy and delivery [12]. Interviews with fathers post-delivery also found that sleep had a higher priority than sex and that the fathers considered general closeness and caring as a part of their current sexuality [24].

Our finding that dyspareunia affects 30% of primiparous women at 12 months postpartum aligns with the results from previous studies [7, 8]. Statistically significant risk factors were second-degree perineal tear and OASI, which aligns with the findings of Leeman et al., who found perineal tear or OASI to be a statistically significant risk factor for dyspareunia 6 months postpartum [22]. Others have also found evidence of dyspareunia due to OASI [21, 22].

Our findings show overall good sexual function, and responses indicating sexual dysfunction were rare in each sub-question. Poor self-reported health in early pregnancy was a statistically significant risk factor for sexual inactivity in early pregnancy and for scoring lower in the total PISQ-12 in early pregnancy. Moreover, health in early pregnancy affected sexual function at 12 months postpartum, but did not affect the probability of being sexually active postpartum. To the best of our knowledge, there is little research on self-reported health and sexual function during pregnancy and after childbirth. Schytt et al. found poor self-reported health to improve during pregnancy, decline 2 months after childbirth and increase again at 1 year postpartum. Increased poor self-reported health was also seen in the partners at 1 year post-delivery [25]. Stepanikova et al. found that good self-reported health in pregnancy correlated with fewer maternal health problems at 6 months, 18 months and even 3 years after childbirth [26]. Our findings might reveal some of the complex origins of sexual function and its interplay with the psychological aspect, extending beyond this study. It is not well understood how long obstetric outcomes influence sexual function beyond 1 year. We suggest further research on sexual function postpartum, preferably considering new parents’ expectations of alteration of sexual activity after childbirth.

The strength of this prospective study is the availability of early pregnancy data, which were unavailable or collected retrospectively in previous studies [8, 9], increasing the risk of recall bias. Furthermore, limiting the sample to primiparous women avoided the risk of impact from previous deliveries.

The PISQ-12 questions were administered only to women who answered “yes” to the question “Are you sexually active?” There was no definition of what “sexually active” might entail, so the woman’s own interpretation of sexual activity was decisive. Since being sexually active is a subjective judgment we believe this to be appropriate. The International Urogynecological Association (IUGA) modified the PISQ score and in 2013 validated the PISQ IUGA-Revised (PISQ-IR). The use of PISQ-IR would have given us more complete information about sexual activity and reasons not to be sexually active and there would be the benefit of gender-neutral questions [27], but as far as we know a Swedish translation of the PISQ-IR has not been validated.

Since the PISQ-12 requests participants to consider the last 6 months, we analyzed PISQ-12 scoring at the early pregnancy and 12 months postpartum, not including 8 weeks postpartum, since answers from this period would mainly reflect the late pregnancy period, which was not the focus of our study. The PISQ-12 is validated for heterosexual women with a partner [15]; however, as far as we know, it has not been validated for pregnant women. Although aware of this, we used the questionnaire for women in early pregnancy, as the questionnaire characteristics of pelvic floor dysfunction suited the overall project (the POPRACT study) well. It is possible that women in early pregnancy might suffer from, for example, nausea and tiredness affecting sexual function, although the participants were asked to consider the past 6 months when answering. Another limitation might be the inclusion criteria of understanding Swedish; we might have missed cultural differences in sexuality and expectations of life after childbirth.

It is not clear whether findings of dysfunction 12 months postpartum could be considered irreversible, although tissue healing and remodeling has probably stopped. However, psychological, social and partner-related factors certainly continue to change beyond 1 year after childbirth.

We calculated PISQ-12 scoring by the errata [16] published in 2004. Some recent studies [9] have calculated based on the original PISQ-12 validation [15] published in 2003; consequently, it is crucial that studies clearly present their methods when using the PISQ-12.