Table 2 Studies on negative postpartum sexual health (n = 13)

Achour et al. (2019) [30]

Tunisia—Prospective Cohort

To investigate the psychosomatic impact of vaginismus in pregnant women and evaluate the quality of their therapeutic care in Tunisia

20 pregnant females with diagnosed vaginismus at the time they presented at an emergency department, followed into the postpartum period

Vaginismus

– Among participants who had a vaginal delivery, 75% considered their vaginismus to be cured following delivery; n = 4, however, experienced aggravated vaginismus symptoms following their vaginal delivery

– Though recommended, no participants took part in pelvic floor training postpartum. Similarly, all participants were directed towards a sexologist for postpartum follow-up for their vaginismus, but none pursued: 20% were uninterested in resolving their vaginismus while 60% referenced that their sexual life was of minimal importance compared to motherhood

– 70% reported feeling misunderstood by their health providers during pregnancy

Adanikin et al. (2015) [31]

Nigeria—Prospective Cohort

To determine the history of resumption of intercourse after childbirth and associated contraceptive practices among women in the southwest region of Nigeria

181 women with live births who delivered in an OBGYN teaching hospital in Ado-Ekiti—interviewed weekly until 6-months postpartum

Resumption of sex, Dyspareunia

– 27.6% of participants had resumed sexual intercourse within 6 weeks of childbirth, 63.3% within 3 months, and 70.2% within 6 months

– The period prevalence of dyspareunia within 6 months of delivery was 36.2%

– While 78.4% of participants who had had a vaginal delivery resumed sexual intercourse within 6 months of childbirth, significantly fewer (59.2%) of those who had had a caesarean section had resumed by this time

– Resumption of sexual intercourse was not associated with perineal injury or experience of dyspareunia

Assarag et al. (2013) [32]

Morocco—Cross-sectional

To measure and identify the causes of postpartum morbidity 6 weeks after delivery and to compare women’s perception of their health during this period to their medical diagnoses

All women aged 18 to 49 in the Al Massira district who had delivered between December 2010 and March 2012 in the delivery house, hospital maternity wards, or private clinics (n = 1210)

Episiotomy, Prolapse, Infections

– 44% expressed one or more complaints at their postpartum consultation. Of those with a complaint, 91% did not consult with a physician about their complaint(s)

– The most frequent complaint reported during a postpartum consultation was mental distress, followed by genital infections (including vaginal discharge and/or leaking), and breast problems

– Additionally, 10% of participants reported other gynecological and obstetric complaints (including uterine prolapse, sexual problems, and infected episiotomy). Lastly, 2% of participants reported burning during urination and 1% reported urinary leakage

– A higher prevalence of postpartum complaints was identified among women aged 30 and above, employed women, women that had delivered in the private sector or at home, and women with complications during delivery

Boene et al. (2020) [33]

Mozambique—Qualitative

To describe women’s experiences of antenatal, partum and post-partum care in southern Mozambique, and to pinpoint those experiences that are unique to women with fistula

14 women with a positive diagnosis of fistula and an equal number without, between the ages of 16 and 49

Obstetric fistula

– Among the 14 participants with a fistula diagnosis, six were reporting on their first birth, nine reportedly had a caesarean delivery, and 10 had a stillbirth

– Most women with an obstetric fistula reported not having had sex since its onset

– One woman reported that her husband had justified taking a second wife because of her fistula, which he viewed as a handicap

Ferdous et al. (2012) [34]

Bangladesh—Prospective Cohort

To investigate the association of postpartum maternal morbidities/disabilities with various acute obstetric complications arising during pregnancy or delivery, and with sociodemographics and other key characteristics of women at delivery

N = 1037 women with four categories of deliveries: uncomplicated normal vaginal birth, those who suffered a perinatal death, those who had severe or less severe complications during pregnancy or delivery, or those who had a C-section but no recorded maternal indication

Prolapse, Fistula, Infection, Perineal tear

– Sexual health outcomes varied significantly by the presence/type of delivery complication, including perineal tear (p < 0.001), clinically diagnosed genital infection (p = 0.04), and uterine prolapse (p < 0.001)

– Participants who experienced delivery complications, compared to those who did not, were less likely to experience genital prolapse or perineal tearing

– Participants with a perinatal death, compared to those with an uncomplicated birth, were more likely to be diagnosed with a genital infection and less likely to experience genital prolapse

– Participants that had a cesarean section, compared to those with an uncomplicated birth, were less likely to experience genital prolapse

– Perineal tearing was more prevalent among women over 30, among women with parity over four, among women in the poorest wealth quintile, among women who delivered at home, and among women that had a vaginal delivery

– Prolapse was more likely to occur among women aged 20–29 and 30 + vs. women under 20, and among women with parity of 2–4 and 4 + vs. parity of 1. Prolapse was less likely among women who had a cesarean section vs. vaginal delivery

– Perineal tearing was more likely to occur among: women aged 30 + vs. women aged < 20; women who delivered at home vs. in a hospital; and women with perinatal death vs. a live baby

– Genital infection was more likely to occur among women with perinatal death

Gudu and Abdulahi (2017) [35]

Ethiopia— Prospective Cohort

To assess labor, delivery, and postpartum complications in nulliparous women with FGM/C and evaluate the attitude of mothers towards elimination of FGM

288 nulliparous

women out of 1,125 mothers admitted for labor and

delivery in the study period

FGM/FGC, Infection

– There was a 91.7% prevalence of female genital cutting (FGM/C). Of those who had experienced FGM/C, 7.6% had Type-II FGM/C, while 92.4% had Type-III. The age at which participants experienced FGM/C ranged from 2–9 years old

– 90.3% of participants believed FGM/C to negatively impact labor and delivery. All participants who underwent FGM/C were fearful about problems that may arise during labor or delivery as a result of the FGM/C

– Anterior episiotomy was needed to facilitate delivery for 83.0% of participants, all of whom had type-III FGM/C

– In total, 29.0% of participants experienced spontaneous perineal tearing (31.1% with FGM/C; 8.3% without)

– Postpartum complications occurred in 39% of participants (25.7% postpartum hemorrhage, 24% genital infection, and 12% psychological disturbance)

– Postpartum hemorrhage was present in 27% of women with FGM/C and 8% of those without FGM/C

– Postpartum infection was present in 14% of women with FGM/C and 4% of those without FGM/C

Islam et al. (2013) [36]

Pakistan—Randomized experiment

To assess the morbidity from episiotomy

100 patients who were given a mediolateral episiotomy (group I) and an equal number (group II) who delivered without episiotomy

Perineal tearing, Vaginal lacerations, Postnatal pain, Dyspareunia, Uterine prolapse

– Among patients with episiotomy, 69% reported postnatal pain, vs. 12% without episiotomy. Similarly, 69% of the episiotomy group reported dyspareunia, vs. 12% from without episiotomy group

– No significant differences in pressure, incontinence, or uterine prolapse between those who received episiotomy and those who did not

Jambola et al. (2020) [37]

Ethiopia—Cross-sectional

To assess the early resumption of sexual intercourse (i.e., before 6 weeks postpartum) and associated factors among postpartum women attending public health institutions in Western Ethiopia

509 postpartum women who came for postnatal care or brought their babies for immunization to one of the participating public facilities 6 weeks after childbirth

Resumption of sex, Sexual Morbidities, Coercive sex/pressure to resume

– 20.2% of participants resumed intercourse during the first 6 weeks postpartum. Of those who resumed sex during the puerperium, 46.6% reported being pressured by their husband to resume intercourse

– Few participants (16.9%) had received guidance or information about intercourse during the postpartum period

– Among the sexually active participants, 22.4% reported one or more sexual morbidities or problems upon resuming intercourse. Problems included dyspareunia (41.7%), vaginal dryness (27.1%), reduced sexual desire (10.4%), vaginal bleeding (8.3%), abnormal vaginal discharge (6.3%), and vaginal tightness (6.5%)

– Women who resumed sex early used contraception less frequently than those who resumed after 6 weeks postpartum (41.8% vs. 71.2%)

– Among those who had not yet resumed sexual activity, reasons for abstinence included: feeling it was not yet acceptable to resume, the husband being unavailable, avoiding pregnancy, feeling unwell, religious reasons, being uninterested, and advice from a health worker

– In multivariable analysis, the likelihood of having resumed sexual intercourse was significantly associated with: the mother having some secondary-level education (aOR 0.22), low parity (aOR 3.52), the husband having some elementary-level (aOR 0.23) or secondary-level (aOR 0.25) education, normal vaginal delivery (aOR 5.44), having a male infant (aOR 1.94), wanting another child (aOR 5.71), and being pressured by the husband to resume sex (aOR 9.89)

Lagro et al. (2003) [38]

Zambia—Cross-sectional

To know if women experienced health problems after childbirth, the specific problems they experienced, and if they did anything about them

Women who attended the hospital within three months after delivery of a live or stillborn baby with a gestational age of more than 22 weeks or weighing more than 500 g

Resumption of sex, genital tract infections, Breakdown of episiotomy/perineal tear, Various sexual health symptoms

– 27% of participants (between 6 weeks and 3 months postpartum) had resumed sexual intercourse; 90% had done so within 2 months after delivery

– Vaginal discharge was reported by 31% of participants and abnormal vaginal bleeding by 7%; 21 participants seemed healthy, but upon physical examination revealed "pus-like" discharge or the breakdown of their perineal tear/episiotomy

– Among participants for whom high vaginal swab results were available, 17% had abnormal results. The combination of the following symptoms (9% of all participants) was predictive of a puerperal infection: lower abdominal pain, badly smelling discharge, and fever

– Among women who underwent a vaginal swab, physical examinations indicated vaginal discharge among 21% and tender uterus among 10%

Nazari et al. (2021) [39]

Iran—Cross-sectional and Qualitative

To determine the educational needs of mothers after childbirth

Quantitative: 250 pregnant mothers in the third trimester, in the first 48 hours after delivery, in the first 6 months after delivery, and in the second 6 months after delivery who were referred to five health centers in Bojnourd to receive midwifery care

Qualitative pregnant women and postpartum women up to  year after delivery, their spouses and key informants

General sexual health

– Qualitative themes highlight that sexual health needs during the postpartum period were often neglected. One participant, 37 years old and 2 months after delivery, discussed her experience of vaginal dryness, noting that she tried but "could not have sex" and utilized ineffective ointment

– Incorrect beliefs and limited awareness were further obstacles to meeting sexual health needs. Some participants, for example, believed that having sex during pregnancy could negatively impact the fetus

– The mean educational need scores for the area of sexual health were not statistically different between the four periods studied (pregnancy, 48 hours after delivery, the first 6 months postpartum, and the second 6 months postpartum; p = 0.12)

Oboro & Tabowei (2002) [40]

Nigeria—Panel study

This study addresses the postnatal sexual health of Nigerian women

122 married primiparas at the Kwale Zonal Hospitals, Delta State of Nigeria

Loss of sexual desire, Lack of vaginal lubrication, Lack of vaginal muscle tone, Vaginal tightness, Painful penetration, Painful intercourse, Difficulty achieving orgasm, Irritation or bleeding after sex, Coital frequency, Sexual satisfaction, Type of intercourse

– Reported sexual problems at 6 weeks, 3 months, 6 months postpartum, respectively:

– Loss of sexual desire: 61%, 40%, 26%

– Lack of vaginal lubrication: 51%, 29%, 13%

– Lack of vaginal muscle tone: 22%, 17%, 10%

– Vaginal tightness: 33%, 21%, 11%

– Painful penetration: 47%, 30%, 21%

– Painful intercourse: 55%, 34%, 19%

– Difficulty achieving orgasm: 41%, 27%, 15%

– Irritation or bleeding after sex: 19%, 9%, 6%

– Following childbirth, 77% of women reported a decrease in coital frequency and 37% reported diminished sexual satisfaction. Following childbirth, the vaginal route became less frequently employed during intercourse (93% vs. 100% pre-childbirth, p = 0.004)

– Following childbirth, sexual dysfunction overall generally increased (47% vs. 21% pre-childbirth, p < 0.001)

– After completing the questionnaire at 6 weeks postpartum, 47 women initiated discussion of sexual matters

– Dyspareunia at 3 months postpartum was significantly more likely among women who: perineal trauma (aOR 2.00) and pre-pregnancy dyspareunia (aOR 2.36)

– While 68% or participants felt the need for assistance with postpartum sexual dysfunction, only 12% sought out help from healthcare professionals

– Though postnatal clinic health professionals reportedly discussed contraception with 98% of the women, sexual health was only discussed with 29%

Surkan et al. (2017) [41]

Bangladesh—Prospective Cohort

To provide an initial estimate of the magnitude of depressive symptoms among women in the first year postpartum, identify risk factors and specifically to estimate strength of associations between several health conditions following childbirth and depressive symptoms

39,434 married women (ages 13–44) in 19 rural administrative unions in adjacent districts of Gaibandha and Rangpur in northwest Bangladesh who participated, during pregnancy and the early postpartum period, in the JiVitA-1 trial and gave birth to singletons

RTI, Uterine prolapse

– When adjusting only for sociodemographic variables, experiencing a reproductive tract infection (RTI) (RR = 1.29; p < 0.001) or uterine prolapse (RR = 1.46; p < 0.001) at three months postpartum increased risk for high depressive symptomatology at 6 months

– When fully adjusting for all maternal illnesses, experiencing an RTI at three months postpartum does not significantly increase the risk for high depressive symptomatology at six months (RR = 0.90; p = 0.21), though experiencing uterine prolapse at three months still increased the risk for high depressive symptomatology at 6 months (RR = 1.20; p = 0.01)

White (2004) [42]

Cambodia–Qualitative

To detail the specific beliefs of Khmer women in Cambodia regarding postpartum, the taxonomies they use to describe postpartum conditions, and the practices they follow to prevent sickness and death

11 FGDs with 88 women of childbearing age and in-depth interviews with 21 women and 20 birth attendants. The childbearing age women included were ethnically Khmer, Khmer-speaking, had given birth within the last three years, and lived in the rice-growing basin of the Mekong and Tonle Sap Rivers

Resumption of sex, Sexual coercion/violence, Infection

– Resuming sex too soon was seen as the trigger for one type of toas (postpartum illness/morbidities) associated with symptoms of weakness, palpitations, abdominal cramps/pains, weight loss, and poor appetite

– Toas damneyk more typically associated with the woman resuming sexual intercourse (often by force) before she felt ready, as opposed to merely resuming intercourse during "immature sawsaye" (the culturally understood period of postpartum recovery)

– The primary symptom associated with toas damneyk was thinness. Other associated symptoms included dry skin, insomnia, a burning sensation in extremities, abdominal cramping, backbone stiffness, and "hotness in the body." Toas damneyk was treated in various ways, including burning the couple's pubic hair, adding it to rice wine, and drinking the concoction; consuming the water used to cleanse the male partner's penis; and other traditional medicines