The postnatal care of women has been relatively neglected in terms of research and health service priorities1,2 and largely mirrors the limited research on women's postnatal health. In the last few decades, most research on women's postnatal health has concentrated on postnatal depression,3–12 but more recently, interest has been extended to include women's physical health—for example, their general health profile,13–19 their urinary and fecal continence problems,20–29 and their sexual health.30–36 The lack of research has meant that little professional information has been available to assist women, their partners, and those providing support on outcomes and expectations in the postnatal period.
One area of postnatal health that has been particularly neglected is the relationship between postnatal depression and sexual health. So far, only four studies have included information on both sexual health and depression.17,18,30,31 However, two of these studies are based on small sample sizes, and the other two include only a limited measure of sexual health. Outside the postnatal period, an association between sexual dysfunction and depression has been recognized37–39 but little researched.38 There is a great need for reliable research in this area to underpin service provision, education, and counseling. Particularly, service-use questions, such as the women's approach to a health care provider for discussion of sexual health problems, need to be addressed.
In this article, we describe the experiences of depressed and nondepressed postnatal women in relation to sexual health. The data our analysis is based on is from a study carried out at St. George's Healthcare NHS in South London. (Findings relating to the full study are available elsewhere.36) The study is a detailed examination of women's sexual health in the postnatal period, and therefore the variety of sexual health outcome measures included in our analysis (eg, feelings about resumption, initiation, sexual practices including oral sex and genital contact, and a range of sexual problems) is unique.
MATERIALS AND METHODS
We studied a series of consecutive primiparous women delivering a live infant at St. George's Hospital in London from July 1 to December 31, 1997. Women delivering preterm births, twins (where both were living), and infants with malformations were included in the study. Primiparous women were selected to avoid confounding effects such as previous postnatal depression or previous obstetric injury. Information about each woman (eg, age, medical history, social circumstances, obstetric details including mode of delivery and type of perineal/genital injury) and her infant (eg, birth weight, gestational age) was collected from computerized birth records. The information in the computerized birth records was detailed and complete.
Postal questionnaires were sent to women 6 months after delivery, in 1-month batches (eg, July deliveries received their first posting in December). Nonresponders were sent two reminder questionnaires at 2-week intervals. Overall data collection lasted from December 1997 to June 1998. The questionnaire inquired about general health, bowel and bladder function, sexual health, and mental health.
The sexual health section of the questionnaire began by asking women if they had resumed sexual intercourse or had attempted to do so. Women who had resumed intercourse and those who had attempted to resume intercourse were considered in one group during the analysis to capture the full range of women's postnatal sexual experiences. Women were classified as experiencing dyspareunia if they answered positively to questions about painful penetration and/or pain during sexual intercourse and/or pain on orgasm.
All women who had resumed (or attempted) sexual intercourse were asked a detailed set of questions about problems experienced (before pregnancy and postnatally), sexual practices (using definitions developed for the National Sexual Attitude and Lifestyles Survey40), frequency of sexual intercourse, satisfaction with sex life, and consultation for postnatal sexual problems. The questionnaire relied on a mixture of recalled information (ie, before pregnancy, postnatal problems in the first 3 months) and contemporaneous information (ie, problems being experienced now). The questionnaire was piloted successfully with 158 primiparous women in 199635 and is available on request.
The ten-item Edinburgh Postnatal Depression Scale (EPDS) was chosen to assist in the identification of women with postnatal depression.41 The measure, designed specifically for postnatal women, asks about depressive symptoms in the past 7 days. The scale has been validated in the community setting for use by a variety of health care providers.9,42–44 The EPDS, which used a threshold of 12 and 13, respectively, has been found to have a sensitivity of 86% and 68%, a specificity of 78% and 96%, and a positive predictive value of 73% and 67%.41 In this study, women were classified as experiencing postnatal depression if they scored 13 on the scale. Postnatal depression was evaluated at 6 months because it is a reliable period at which symptomatology occurs.45 A variety of statistical tests were used to assess the relationship between depression (ie, a EPDS score of 13 or more) and sexual health. Differences between proportions were tested by χ2 tests or Fisher exact test, as appropriate. For paired proportions, the McNemar test was used. The Wilcoxon rank-sum test was used to compare the number of sexual problems before and after pregnancy, and the Mann-Whitney U test was used to compare the numbers of sexual problems in depressed and nondepressed women. P < .05 was considered statistically significant. Analysis was carried out by STATA for Windows (Stata, College Station, TX). Ethical approval for the study was provided by the local research ethics committee.
Of the 796 women included in the study, 484 (61%) returned a questionnaire. There were no significant differences between responders and nonresponders on any obstetric parameter. However, responders were significantly more likely to be married, employed, older, white, and born in the United Kingdom.36 Of the 484 responders, 468 (97%) had a valid EPDS score. Of these, 57 women (12.%) had an EPDS score of 13 or more. Depressed women (ie, with scores of 13 or more) differed significantly from nondepressed women in terms of ethnicity, occupation, and security of accommodation, but were similar in terms of marital status, age, type of delivery, perineal damage incurred, and breast-feeding at 6 months (Table 1).
Of the 468 women with valid EPDS scores, 465 answered the questions on sexual health. Of those, 87% (402) had resumed and 2% (ten) had attempted to resume sexual intercourse. Depressed women were significantly less likely to have resumed (or attempted to resume) than nondepressed women (Table 2). The time of resumption for women with and without postnatal depression appears similar (Figure 1).
Fifty-three women had not resumed sexual intercourse at 6 months postpartum. For 13 women, this was because they had no partner. The other 40 women had partners but had not resumed intercourse. Of these, depressed women most commonly stated loss of libido, lack of interest in sex, tiredness, physical problems, and feeling unattractive as the most common reasons for lack of resumption. Nondepressed women mentioned fear of pregnancy, need for contraception, partner being away or ill, and time spent with the child as additional reasons.
Of the 412 women who had resumed sexual intercourse, depressed women were significantly more likely to report that their partner initiated the resumption of sexual intercourse (Table 2). However, there were no significant differences between depressed and nondepressed women in terms of their evaluation of the frequency or quality of their sex life.
There were some differences in the profile of sexual activities between depressed and nondepressed women (Table 3). Women without depression tended to engage in more varied sexual activities at all points in time; thus, a decrease in the activities at 6 months postpartum is more evident.
Compared with the year before pregnancy, significantly more problems were experienced at 6 months than before pregnancy by both depressed and nondepressed women (P = .002 and P < .001, respectively). At 6 months, however, the median number of problems was higher for depressed women than nondepressed women (a median of two versus a median of one; P = .009). The pattern of sexual problems was similar between the two groups: high levels of problems in the first 3 months, and fewer problems at 6 months but not a decline to prepregnancy levels (Figure 2).
Of the 330 women who reported a postnatal sexual problem, 12.4% (41) reported talking to their doctor about the problem, and 33% (109) discussed it with their partner. However, the majority of women 60% (199) reported that they had not discussed the problem with anyone. There were no significant differences between depressed and nondepressed women in terms of whether they discussed the problem with their doctor (P = .46) or partner (P = .73), or whether they had discussed the problem at all (P = .91).
This article demonstrates that many sexual health changes occur in the postpartum period. By 6 months, a majority of women had resumed or attempted to resume sexual intercourse, but for most of those women, intercourse was less frequent, and for many, it was less satisfying than before pregnancy. Women with postnatal depression followed a similar pattern of resumption than those without depression, with increasing numbers of women engaging in intercourse over each of the consecutive months postpartum. However, depressed women were significantly less likely to have resumed intercourse by 6 months, and of those who had resumed, 25% felt that they had resumed intercourse too soon. A woman's feelings about herself and her life situation may play a great role in this judgment. It is possible that this is a reflection of her changing role as a mother and her relationship with her partner.
Sexual practices also changed in the postpregnancy period. The pattern of change was similar in all women studied, with higher levels of vaginal intercourse, oral sex by either partner, and genital contact during the prepregnancy time and lower levels at 6 months postpartum (except genital contact without intercourse in depressed women). Overall, depressed women engaged in fewer activities. The activity changes, along with a constant amount of genital contact, may represent a replacement of one activity for another. The change in oral sex may be a reflection of the woman's feelings about herself, her changes in her body, and her relationship with her partner.
This study also demonstrates that sexual problems such as vaginal dryness, dyspareunia, and decreased libido commonly exist in women after childbirth. All women studied follow a similar pattern, with high levels of problems reported in the first 3 months after delivery and lower levels at 6 months (but not a decline to prepregnancy baselines). Although the pattern of problems did not differ between depressed and nondepressed women, depressed women reported significantly more problems at each time point. Although this study can demonstrate associations between sexual problems and depression, causality cannot be ascertained. It is possible that the depression causes women to evaluate their health in a more negative manner. Conversely, it is also possible that an increased number of negative sexual health outcomes may contribute to the development of postnatal depression.
Previous studies have demonstrated that postnatal sexual health problems may be related to obstetric experience and/or perineal injury.46–48 Our findings did not find a relationship between obstetric trauma and postnatal depression. This suggests that a more complex interplay may exist between factors such as sexual satisfaction, dyspareunia, and postnatal depression. Further studies on this area should be undertaken to better elucidate this relationship.
We found low rates of consultation with the general practitioners for problems with sexual health, consistent with a previous study,2 but we found that depressed women were no more (or less) likely to consult. Given the increased medicalization of sexual problems,49 the rates of consultation are likely to increase over time. This study provides a basis for clinicians to provide information to women, depressed or not, on the problems they are likely to encounter, which of those may resolve, and when to seek further health care.
Our study achieved a 61% response rate. Ideally, this would have been higher, but given the subject of the questionnaire and the inner-city location of the research, it was an acceptable response rate and comparable to other studies.14,16,46,48,50 From the birth records, it was possible to determine that our nonresponders differed from our responders in terms of age, marital status, ethnicity, country of birth, and occupation. Explanations for this nonresponse are likely to include higher mobility and/or cultural and language differences. However, because three of the variables we had a nonresponse bias on (ethnicity, country of birth, and occupation) were associated with depression in our analysis, we were concerned that depressed women might be underrepresented in our study. Although we cannot fully gauge the extent of this potential bias, we were reassured that the prevalence of depression in our sample was close to that found in other similar studies.4,5,7,17 Part of our study relied on recalled information (ie, sexual problems before pregnancy and the first 3 months), and, as with all retrospective studies, recall bias may be a limitation of this study. However, the focus of the study was on current depression and current sexual problems—information that was collected contemporaneously. Also, because we used a cross-sectional study design and a validated measure in the postnatal period to identify women with postnatal depression, we did not have comparable information about depression in the prepregnancy or antenatal period. Consequently, we do not know what proportion of women with (and without) postnatal depression had previously experienced depression. Additionally, our data did not include factors on partners' feelings and risk for postnatal depression, and therefore, this potentially significant factor could not be assessed. More information on the partner and the partner's role may be elicited in future studies on this subject.
Overall, it is clear from our results that negative sexual health outcomes exist in many women after childbirth and, in common with the few previous studies to include information on both depression and sexual health,17,18,30,31 depressed women are more likely to report sexual health problems or negative outcomes. However, the striking feature of this study is the extent to which both depressed and nondepressed women reported sexual health problems. The high levels of sexual morbidity found in nondepressed women also have a parallel with a few recent studies of women's physical health in the postnatal period.17–19 Depressed women appeared to have a worse sexual health profile in the postnatal period than nondepressed women, and a complex interplay of physical, social, and psychologic factors is likely the cause. On the basis of our findings, however, we would advise health professionals not to assume that postnatal sexual morbidity is simply a product of depressed mental state.
1. Bick D. Postnatal care cannot be ignored. Br J Midwifery 1995;3:411–2.
2. Glazener CMA. Sexual function after childbirth: Women's experiences, persistent morbidity and lack of professional recognition. Br J Obstet Gynaecol 1997;104:330–3.
3. Feggetter G, Cooper P, Gath D. Non-psychotic psychiatric disorders in women one year after childbirth. J Psychosom Res 1981;25:369–72.
4. Kumar R, Robson KM. A prospective study of emotional disorders in childbearing women. Br J Psychiatry 1984;144:35–7.
5. Watson JP, Elliott SA, Rugg AJ. Psychiatric disorders in pregnancy and the first postnatal year. Br J Psychiatry 1984;144:453–62.
6. Cox JL. Postnatal depression: Diagnosis and management. In: Postnatal depression. Edinburgh: Churchill Livingstone, Longman 1986:41–52.
7. Cox JL, Murray D, Chapman G. A controlled study of the onset, duration and prevalence of postnatal depression. Br J Psychiatry 1993;163:27–31.
8. Stamp GE, Williams AS, Crowther CA. Evaluation of antenatal and postnatal support to overcome poastnatal depression: A randomized controlled trial. Birth 1995;22:138–84.
9. Hearn G, Iliff A, Jones I, Kirby A, Ormiston P, Parr P, et al. Postnatal depression in the community. Br J Gen Practice 1998;48:1064–6.
10. Affonso DD, De AK, Horowitz JA. An international study exploring levels of postpartum depressive symptomatology. J Psychosom Res 2000;49:207–16.
11. Beck CT. Predictors of postpartum depression. Nurs Res 2001;50:275–85.
12. Evans J, Heron J, Francomb H. Cohort study of depressed mood during pregnancy and after childbirth. BMJ 2001;323:257–60.
13. MacArthur C, Lewis M, Knox EG. Health after childbirth. London: HMSO, 1991.
14. Bick DE, MacArthur C. The extent, severity and effect of health problems after childbirth. Br J Midwifery 1995;3:27–31.
15. Glazner CMA, Abdalla M, Stroud P, Naji S, Templeton A, Russell IT. Postnatal maternal morbidity: Extent, causes, prevention, and treatment. Br J Obstet Gynaecol 1995;102:282–7.
16. Brown S, Lumley J. Maternal health after childbirth: Results of an Australian population based survey. Br J Obstet Gynaecol 1998;105:156–61.
17. Brown S, Lumley J. Physical health problems after childbirth and maternal depression and six to seven months postpartum. Br J Obstet Gynaecol 2000;107:1194–201.
18. Waterstone M, Wolfe C, Hooper R, Bewley S. Postnatal morbidity after childbirth and severe obstetric morbidity. Br J Obstet Gynaecol 2003;110:128–33.
19. Saurel-Cubizolles MJ, Romito P, Lelong N, Ancel PY. Women's health after childbirth: A longitudinal study in France and Italy. Br J Obstet Gynaecol 2000;107:1202–9.
20. Bek KM, Laurberg S. Risks of anal incontinence from subsequent vaginal delivery after a complete obstetric anal sphincter tear. Br J Obstet Gynaecol 1992;99:724–6.
21. Dimpfl T, Hesse U, Schussler B. Incidence and cause of postpartum urinary stress incontinence. Eur J Obstet Gynecol Reprod Biol 1992;43:29–33.
22. Foldsprang A, Mommsen S, Lam GW. Parity as a correlate of female urinary incontinence prevalence. J Epidemiol Commun Heal 1992;46:595–600.
23. Sultan AH, Kamm MA, Hudson CN. Anal sphincter disruption during vaginal delivery. N Engl J Med 1993;329:1905–11.
24. Deindl FM, Vodusek DB, Hesse CN, Schussler B. Pelvic Floor activity patterns: Comparison of nulliparous continent and parous urinary stress incontinent women—A kinesiological EMG study. Br J Urol 1994;73:413–7.
25. Kamm M. Obstetric damage and faecal incontinence. Lancet 1994;344:730–3.
26. Toglia MR, DeLancey JOL. Anal incontinence and obstetrician-gynaecologist. Obstet Gynecol 1994;84:731–40.
27. Wilson PD, Herbison RM, Herbison GP. Obstetric practice and the prevalence of urinary incontinence three months after delivery. Br J Obstet Gynaecol 1996;103:154–61.
28. Sultan AH, Kamm MA. Faecal incontinence after childbirth. Br J Obstet Gynaecol 1997;104:979–82.
29. MacArthur C, Bick DE, Keighley MRB. Faecal incontinence after childbirth. Br J Obstet Gynaecol 1997;104:46–50.
30. Robson KM, Kumar R. Maternal sexuality during first pregnancy and after childbirth. Br J Obstet Gynaecol 1981;88:882–9.
31. Elliott SA, Watson JP. Sex during prepregnancy and the first postnatal year. J Psychosom Res 1985;29:541–8.
32. Abraham S, Child A, Ferry J, Vissard J, Mira M. Recovery after childbirth: A preliminary prospective study. Med J Aust 1990;152:9–11.
33. von Sydow K. Sexuality during pregnancy and after childbirth: a metacontent analysis of 59 studies. J Psychosomatic Res 1999;47:27–49.
34. Barrett G, Victor CR. Postnatal sexual health. BMJ 1994;309:1584–5.
35. Barrett G, Pendry E, Peacock J, Victor C, Thakar R, Manyonda I. Women's sexuality after childbirth: A pilot study. Arch Sex Behav 1999;28:179–91.
36. Barrett G, Pendry E, Peacock J, Victor C, Thakar R, Manyonda I. Women's sexual health after childbirth. Br J Obstet Gynaecol 2000;107:186–95.
37. Gitlin MJ. Effects of depression and antidepressants on sexual functioning. Bull Menninger Clin 1995;59:232–48.
38. Bartlik B, Kocsis JH, Legere R, Villalus J, Kossoy A, Gelenberg AJ. Sexual dysfunction secondary to depressive disorders. J Gend Specif Med 1999;2:52–60.
39. Phillips RL, Slaughter JR. Depression and sexual desire. Am Fam Physician 2000;62:782–6.
40. Johnson AM, Wadsworth J, Wellings K, Field J. Sexual attitudes and lifestyles. Oxford: Blackwell Science, 1994.
41. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987;150:782–6.
42. Murray L, Carothers AD. The validation of the Edinburgh Postnatal Depression Scale on a community sample. Br J Psychiatry 1990;157:288–90.
43. Cox JL. Using the Edinburgh Postnatal Depression Scale in clinical practice. In: Cox J, Holden J, eds. Perinatal psychiatry: Use and misuse of the Edinburgh Postnatal Depression Scale. London: Gaskwell, 1994:125–43.
44. Green JM, Murray J. The use of the Edinburgh Postnatal Depression Scale in research to explore the relationship between antenatal and postnatal dysphoria. In: Cox J, Holden J, eds. Perinatal psychiatry: Use and misuse of the Edinburgh Postnatal Depression Scale. London: Gaskwell, 1994:180–98.
45. Elkin GD. Women's issues in mental health. In: Introduction to clinical psychiatry. Norwalk, Connecticut: Appleton & Lange 1999:252–3.
46. Signorello LB, Harlow BL, Chekos AK, Repke JT. Postpartum sexual functioning and its relationship to perineal trauma: A retrospective cohort study of primiparous women. Am J Obstet Gynecol 2001;184:181–90.
47. Thompson JF, Roberts CL, Currie M, Ellwood DA. Prevalence and persistence of health problems after childbirth: Associations with parity and method of birth. Birth 2002;29:83–94.
48. Johnson AM, Mercer CH, Erens B, Copas AJ, McManus S, Wellings K, et al. Sexual behaviour in Britain: Partnerships, practices, and HIV risk behaviours. Lancet 2001;358:1835–42.
49. Hart G, Wellings K. Sexual behaviour and its medicalisation: In sickness and in health. BMJ 2002;324:896–900.
© 2003 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.
50. Russell R, Groves P, Taub N, O'Dowd J, Reynolds F. Assessing long term backache after childbirth. BMJ 1993;306:1299–303.