Archives of Sexual Behavior, Vol. 28, No. 2, 1999
Women’s Sexuality After Childbirth: A Pilot Study
Geraldine Barrett, B.A., M.Sc.,1,3Elizabeth Pendry, B.Sc.,1Janet Peacock,
B.Sc., M.Sc., Ph.D.,1Christina Victor, B.A., M.Phil., Ph.D., HonMFPHM,1
Ranee Thakar, MRCOG,2and Isaac Manyonda, B.Sc., Ph.D., MRCOG2
A pilot study was carried out investigating women’s sexual health in the postnatal
period. Postal questionnaires were sent to a cohort of 158 primiparous women
approximately 7 months after delivery. Women who had resumed sexual inter-
course were asked a detailed set of questions about problems experienced, sexual
practices, frequency of intercourse, satisfaction with sex life, and consultation for
postnatal sexual problems. All women were asked about the information they re-
ceivedon postnatal health prior tothe birth and any information or help and advice
they received from health professionals on the subject after the birth. Ninety-eight
women (62%) responded. Women experienced signi®cant levels of morbidity in
the postnatal period; 3 months after delivery 58% experienced dyspareunia, 39%
experienced vaginal dryness, and 44% suffered loss of sexual desire. These ®g-
ures had reduced to 26, 22, and 35%, respectively, by the time of answering the
questionnaire (approximately 8 to 9 months after delivery). Compared to before
pregnancy, there was a decrease in frequency and satisfaction with sexual inter-
course, although sexual practices changed little. Of the 67 women who reported
a postnatal sexual problem, only 19% discussed this with a health professional.
Conversations with health professionals in routine postnatal health contacts were
mainly about contraception, and only rarely discussed problems with intercourse.
KEY WORDS: postnatal; sexuality; dyspareunia; childbirth.
Women’s mental health in the postnatal period has been extensively re-
searched for many years (Feggetter et al., 1981; Watson et al., 1984; Cox, 1986).
1St George’s Hospital Medical School, London, England.
2St George’s Health Care Trust, London, England.
3To whom correspondence should be addressed at Health Promotion Research Unit, London School
of Hygiene and Tropical Medicine, London WC 1E 7HT, England.
0004-0002/99/0400-0179$16.00 /0 C ° 1999 Plenum Publishing Corporation
180Barrett et al.
More recently, studies have demonstrated that women also experience a range of
physical problems after birth (MacArthur et al., 1991; Bick and MacArthur, 1995;
Glazener et al., 1995) and there has been increasing recognition of urinary and
fecal incontinence as sequelae of childbirth (Dimp¯ et al., 1992; Foldsprang et al.,
1992; Deindl et al., 1994; Kamm, 1994; Toglia and DeLancey, 1994; Wilson et al.,
1996; Bek and Laurberg, 1992; Sultan et al., 1993; MacArthur et al., 1997; Sultan
and Kamm, 1997). However, one area which remains underresearched is women’s
sexual health after childbirth, in particular the experience of dyspareunia and other
Studies of postnatal sexual health have been carried out and variably reported
®ndings on the timing of resumption of sexual intercourse, frequency of sexual
intercourse, experience of perineal pain and/or dyspareunia, levels of sexual desire
or responsiveness, and sexual enjoyment or satisfaction with sex. There are also
a number of commentaries written from either a personal or professional view-
point (Bailey, 1989; Riley, 1989; Tobert, 1990; Van Wert, 1991; Hanmer, 1991;
Hulme, 1993). Overall, these show that childbirth brings about a change in the
sexual relationship; perineal pain and dyspareunia are common experiences for
postnatal women (Kumar et al., 1981; Reading et al., 1982; Bex and Hofmeyr,
1987; Abraham et al., 1990; Klein et al., 1994; Barrett and Victor, 1996a, 1996b;
Glazener, 1997), and there is generally a decrease in the frequency of sexual in-
tercourse (Kumar et al., 1981; Elliott and Watson, 1985; Frohlich et al., 1990),
the woman’s sexual desire (Reading et al., 1982; Alder and Bancroft, 1983; Scott-
Heyes, 1983; Elliott and Watson, 1985; Ellis and Hewat, 1985; Glazener, 1997),
and satisfaction with the sexual relationship (Kumar et al., 1981; Reading et al.,
1982; Moss etal.,1986; Frohlich et al., 1990; Klein et al., 1994; Barrett and Victor,
1994). Some studies also provide evidence of vaginal dryness and/or loss of libido
linked to the hormonal changes of breastfeeding (Alder and Bancroft, 1983; Alder
et al., 1986; Barrett and Victor,1994, 1996a; Glazener,1997), although this ®nding
is not consistent acrossallstudies (MastersandJohnson, 1966; Bustan etal.,1995).
There is evidence for a positive association between levels of dyspareu-
nia/perineal pain and perineal damage (in particular, episiotomy) (Abraham et al.,
1990; Klein et al., 1994; Barrett and Victor, 1996a, 1996b) and assisted vaginal
delivery (Abraham et al., 1990; Barrett and Victor, 1996b; Glazener, 1997). Parity
is also an important factor because primiparous women have higher rates of epi-
siotomy and assisted delivery than multiparous women (Turner and Finn, 1993;
Turner and Casey,1995; Stratton et al., 1995; Barrett,1996b) andreport higher lev-
els of dyspareunia and perineal pain (Klein et al., 1994; Barrett and Victor, 1996b).
In the British system of health care, new mothers are currently visited at
home by a midwife every day for the ®rst 10 days after birth. They are then seen
regularly by a health visitor, have a postnatal examination at 6 weeks by a General
Practitioner or hospital doctor, and attend child health clinics or their General
Practice for the baby’s immunizations and developmental checks. In theory, this
should provide ample opportunity for a woman to raise concerns about her own
Women’s Sexuality After Childbirth181
health. However, very few studies have presented information about consultations
for postnatal sexual problems or information received on this subject from health
professionals. Barrett and Victor (1996b) and Glazener (1997) reported that the
majority of women discussed contraception with a health professional but rarely
discussed sexual intercourse. Even when women felt a need for help or advice with
a sexual problem, only a minority sought it (Glazener, 1997) and in Barrett and
Victor’s (1996a, 1996b) study, there was evidence from the survey comments of
long-term untreated morbidity.
There are a number of limitations with the recent studies on postnatal sex-
ual health. Some studies have volunteer samples (Scott-Heyes, 1983; Barrett and
Victor, 1994, 1996a, 1996b) or have only included women who meet certain cri-
teria, e.g., women with episiotomies (Reading et al., 1982), vaginal deliveries
(Abraham et al., 1990), women with adequate English, a stable relationship, living
in a certain area, and at a certain stage of pregnancy at time of recruitment (Kumar
et al., 1981; Elliott and Watson, 1985; Abraham et al., 1990). Klein et al.’s (1994)
study was based on a secondary analysis of data from a randomized controlled trial
of restrictive versus liberal policy on episiotomy, and therefore women included
in the analysis were those who met the entry criteria to the trial. Glazener’s (1997)
study was a further analysis of a survey of women’s general postnatal health using
an unselected sample of women (Glazener et al., 1995), but had a limited number
of questions on postnatal sexual health.
To investigate women’s postnatal sexual health more fully, a large-scale study
is needed with detailed information on obstetric parameters, physical and mental
health, postnatal sexual behavior, and contacts with health services. This paper
represents the ®rst stage in that process and presents the ®ndings relating to sexual
health from a pilot questionnaire administered to an unselected sample of primi-
A cohort of 158 consecutive primiparous women delivering a live birth at a
London teaching hospital between 1 February and 7 March 1996 were identi®ed.
Primiparous women were chosen to avoid the confounding effects of a previous
birth. Information about each woman (i.e., age, social circumstances, medical
history, details of delivery, and other obstetric factors) and her infant (i.e., sex,
birth weight, gestational age, whether transferred to neonatal intensive care) was
collected from birth records. Postal questionnaires were sent to the women ap-
proximately 7 months after their delivery. Nonresponders were sent two reminder
Women were asked if they had resumed sexual intercourse or had attempted
to resume. All women who had resumed or attempted to resume sexual intercourse
were asked a detailed set of questions about problems experienced (e.g., pain dur-
ing sexual intercourse, painful penetration, loss of libido, vaginal dryness), sexual
182Barrett et al.
practices (using the de®nitions developed for the National Sexual Attitudes and
Lifestyles Survey; Johnson et al., 1994), frequency of sexual intercourse, satisfac-
tion with sex life, and consultation for postnatal sexual problems. With the excep-
tion of the questions on sexual practices, all other areas of postnatal health have
been indicated as areas of potential change by previous studies (see Introduction).
All women were asked about the information they received on postnatal health
prior to the birth and any information or help and advice they received from health
professionals on the subject after the birth. The questionnaire consisted mainly of
closed questions (with tick box answers), but also included four open questions,
and allowed spacefor elaboration/explanation on anumber of the closed questions.
The questionnairealso asked women for information on generalhealth, bowel
and bladder function, and mental health (using the Edinburgh Postnatal Depression
Scale; Cox et al., 1987), however these ®ndings are not presented in this paper.
The questionnaire is available on request from the authors.
Women were classi®ed as experiencing dyspareunia if they answered posi-
tively to questions about ªpainful penetrationº and/or ªpain during sexual inter-
courseº and/or ªpain on orgasm.º
Differencesbetweenproportions weretestedusing chi-square tests.For paired
proportions McNemar’s test was used, and for three-related proportions Cochran’s
Q test was used. The analysis was carried out using SPSS for Windows.
Ethical approval for this study was given by the Local Research Ethics
Of the 158 women sampled, 98 (62%) returned a questionnaire. Of the 60
nonresponders, 14 (9% of the total sample) had changed address and so never re-
ceivedthe questionnaire.There wereno signi®cantdifferences between responders
and nonresponders with regard to age, marital status, or any obstetric parameter.
However, Table I shows that responders and nonresponders were signi®cantly dif-
ferent with respect to ethnicity and employment status, with the major differences
appearing to be that responders were more likely to be White and employed than
The sociodemographic and obstetric characteristics of women returning the
questionnaire are shown in Table II. Most women (85%) were answering the
questionnaire 8 or 9 months after the delivery (range 7±12 months). (The women
answering at 7, 10, 11, and 12 months did not give markedly different answers to
the women at 8 and 9 months, however numbers were small.)
Healing of Stitches
Seventy-six women reported having stitches for a caesarean section or per-
ineal damage. Of these, 32% said their stitches had healed and were comfortable
Women’s Sexuality After Childbirth183
Table I. Comparison of Responders with Nonresponders
Employment at time of
v2(3)= 12 0.007
Type of delivery
v2(1)= 1 0.7
in under 2 weeks, 26% reported 3±4 weeks, and 30% reported 5 or more weeks.
Eight women (5 of whom had caesarean sections) said their stitches had healed
but were still not comfortable.
Resumption of Sexual Intercourse
Seventy-eight women (80%) had resumed sexual intercourse since the birth
of their child, and 8 women (8%) had attempted to resume, although they had not
achieved full sexual intercourse. Table III shows when women resumed sexual
184Barrett et al.
Table II. Sociodemographic and Obstetric Data of 98 Women
Type of delivery
Assisted vaginal (e.g., ventouse/forceps)
Pain relief used during delivery
(categories are not mutually exclusive)
1st-degree tear (of opening of vagina)
2nd-degree tear (into perineum)
3rd-degree tear (extending into rectal muscle)
Episiotomy (surgical incision of perineum)
Posterior vaginal wall tear (with intact perineum)
aIn women, the perineum is the bridge of muscle and ®brous tissue
between the vagina and anus
Table III. Resumption of Sexual Intercourse
When sexual intercourse was
resumed (or attempted, if
not yet resumed)
Not resumed-no partner
Not resumed-other reason
Women’s Sexuality After Childbirth185
intercourse (or attempted it, if not yet resumed). Eleven women had not resumed
sexual intercourse since the birth of their child. For 5 women,this was becausethey
had no partner. The other 6 women did have partners, however 3 explained that
they and their partners were either too tired or too busy and the other 3 said their
partners had lost interest in them sexually.
Twenty-three women(28%)saidthattheirpartnerhadinitiated theresumption
of the sexual relationship; 68% said the decision was mutual; only 5% said they
initiated the resumption themselves. Three quarters of the women felt that the
timing of the resumption was ªabout right.º
Problems with Sexual Intercourse
Problems such as pain, lack of vaginal lubrication, vaginal looseness/lack of
muscle tone, and dif®culty reaching orgasm increased signi®cantly in the ®rst 3
months after birth, declining to prepregnancy levels later in the postnatal period
(Table IV). Dyspareunia (using the de®nition outlined in the Method section)
was particularly common: Prior to pregnancy 22% had at sometime experienced
dyspareunia; in the ®rst 3 months after the birth 58% experienced it; and ªnowº it
was currently experienced by 26%. Loss of sexual desire followed the same pattern
Table IV. Problems Experienced with Sexual Intercourse
prior to becoming
Ever experienced in
®rst three months
Lack of vaginal
Pain during sexual
Pain on orgasm
lack of muscle tone
irritation after sex
242039 312218 110.005
0.0218 1527 212016
13 1144353529 32 <0.0001
4335 2016 4033
aTested on the 79 women available at each time point.
186Barrett et al.
Table V. Nature of Sexual Activity Before and After Pregnancy (N= 78)
in year prior
since the birth
Oral sex by woman
Oral sex by partner
Genital contact not
of increased prevalence in the ®rst 3 months after birth, but remained at higher
than prepregnancy levels later in the postnatal period. Vaginal infection appeared
to be the only problem that did not increase after childbirth.
Of the 67 women who reported a postnatal sexual problem, 19% said they
discussed the problem with a health professional. For half the women, infection
was the main reason for consulting. Other women discussed dyspareunia, lack of
vaginal lubrication, or loss of libido.
The Sexual Relationship
Overall, sexual practices in the postnatal period were similar to prepregnancy
(Table V). The only practice which had declined signi®cantly was oral sex by the
Nearly two thirds of the women said that sexual intercourse was now less
frequent (Table VI). Assessment of quality of sex life was more variable with a
third of women describing it as ªless goodº and two thirds saying it was ªim-
provedº or ªabout the same.º Over half the women perceived their partner to
be ªvery satis®edº or ªsomewhat satis®edº with the sexual relationship. How-
ever, a third also perceived their partner to be ªsomewhat dissatis®edº or ªvery
Health Services and Postnatal Sexual Health
After the birth of their child, 59% of women said that a health professional
talked tothem about resuming sexafterchildbirth. These discussions werepredom-
inantly with midwives, General Practitioners, hospital doctors, and health visitors.
Ninety-three percent of these women reported that these conversations were about
contraception, 35% said they discussed the right time to resume, and 11% said they
were advised about possible changes or problems they might experience. Before
Women’s Sexuality After Childbirth 187
Table VI. Perception and Satisfaction with Postnatal Sexual Activity
Frequency of sexual intercourse
About the same
Can’t say/don’t know
Quality of sex life
Can’t say/don’t know
Perception of partner’s satisfaction with sexual relationship
Neither satis®ed nor dissatis®ed
Can’t say/don’t know
the birth, 30% of women said someone talked to them about sex after childbirth.
These conversations were predominantly with antenatal teachers, midwives, fam-
ily, or friends.
Eighty-®ve women (88%) attended their 6-week postnatal check. Of those,
64% had a vaginal examination, and 31% were asked about problems with their
perineum/vagina. Ten women (11%) said they wanted to ask something but felt
they could not. These topics included urinary incontinence, pain in rectum and
loss of bowel control, sexual matters (e.g., loss of woman’s or partner’s interest,
resuming sex), and bad dreams/reaction to birth. Two women complained that the
check was too quick and impersonal.
The results of our pilot study indicate that childbirth brings about a change
in the sexual relationship. Nearly two thirds of women reported a decline in the
frequency of sexual intercourse. Other studies have also shown a decline in the
frequency of sexualintercourse (e.g., Kumaretal., 1981; Elliott and Watson, 1985;
Frohlich et al., 1990; Barrett, 1995) but it is not possible to make direct compari-
sons because of the differences between studies in sampling, timing, and types
of question. Our study showed that women also experienced signi®cant levels of
sexual morbidity in the postnatal period, with experiences of dyspareunia, vaginal
dryness, and loss of libido being common. High levels of sexual morbidity have
also beenshown by other studies (Reading etal.,1982; Abraham et al., 1990; Klein
et al., 1994; Barrett and Victor, 1996b; Glazener, 1997), however, it is dif®cult to
188 Barrett et al.
compare their prevalence and incidence rates with this study because morbidity
has been assessed in a variety of ways and at different points in time.
Women assessed the quality of their sex life somewhat variably: Approxi-
mately a third believed it to be ªless good,º over a third thought it was ªabout
the sameº and under a quarter felt it had ªimproved.º In the study of National
Childbirth Trust women, the same question was asked, with primiparous women
making somewhat more negative replies (58% reported ªless good,º 23% ªabout
the same,º and 13% ªimproved,º Barrett, 1995). Other studies have looked at qual-
ity of, and satisfaction with, the sexual relationship in different ways. In Kumar
et al.’s (1981) study 26% of primiparous women reported little or no pleasure in
sexual intercourse 3 months after the birth, with this ®gure declining to 15% at
1 year. In Elliott and Watson’s (1985) study, 30% of women reported at 3 months
postnatal that they were not satis®ed with their sex life, and at 12 months this
®gure was still as high as 24%. These studies suggest that for a sizable minority
of women negative changes to the sexual relationship do not resolve in the imme-
diate postnatal period, if at all. Satisfaction with the sexual relationship was not
associated with repertoire of sexual practices, which changed little in the postnatal
period compared to before pregnancy.
Women were asked to assess their partner’s satisfaction with the sexual re-
lationship: 59% assessed their partner as satis®ed with the relationship, but also
just under a third assessed them to be dissatis®ed. This is only the women’s as-
sessment and it would have been more valid to ask their partner’s directly, how-
ever it was not possible to do this within the time constraints of the pilot. Elliott
and Watson (1985) interviewed both men and women in their study and showed
that women slightly underestimated their husband’s concern about their decline
in sexual responsiveness. Lack of sexual responsiveness by men can also be a
problem postnatally. In our study three women reported that they had not re-
sumed sexual intercourse because their partners had lost interest in them sexually
(two of the couples were married, one was cohabiting). Other studies have re-
ported similar ®ndings: Elliott and Watson reported that a year after birth 3% of
women were ªvery much botheredº by the decreased sexual responsiveness of
their partner; in Glazener’s (1997) study, 2% of women reported that their part-
ners were not interested in them sexually; and in the National Childbirth Trust
survey 2% also reported this, with some women attributing the problem to the fact
their partners had witnessed the birth (Barrett, 1995). To investigate this aspect of
postnatal sexual relationships further research with new fathers would need to be
This study con®rms previous ®ndings regarding low rates of consultation
for problems with sexual intercourse and the dominance of contraception as the
subject of discussion with health professionals in the postnatal period (Barrett and
Victor, 1996a, 1996b; Glazener,1997). At the 6-week check only a third of women
were asked about problems with their perineum and vagina, however, given that
Women’s Sexuality After Childbirth 189
under a third of women had resumed sexual intercourse by this time, the 6-week
check is too early to discover chronic problems. The inability of the 6-week check
to assess persistent problems with sexual functioning has been highlighted before
(Reading et al., 1982; Bick and MacArthur, 1995; Barrett and Victor, 1996b). Bick
and MacArthur (1994) recommended that a checklist of symptoms is asked about
at the 6-week check with longer term follow-ups (e.g., 3 months, 6 months) for
women with chronic symptoms, or alternatively, they suggest that all women are
seen routinely at a later date (e.g., 3 months or 6 months).
The primary aim of this pilot study was to discover whether the postal ques-
tionnaire we had designed was an appropriate and acceptable methodology for
researching postnatal sexual health in an unselected sample of women. Other stud-
ies have employed questionnaires in this ®eld (Reading et al., 1982; Elliott and
Watson, 1985; Abraham et al., 1990; Barrett and Victor, 1996a, 1996b; Glazener,
1997), however most have not included questions at the same level of detail and
sensitivity and/or have been administered to nonrandom samples. We examined
sexual practices, perceptions of the sexual relationship, and contact with health
care providers regarding sexual matters, as well as areas of morbidity such as
The questions on sexual behavior were well completed and appeared well un-
derstood. Only sevenwomen commentedthatsomequestions wereªabit personalº
or ªsensitive,º and only two of these women refused to answer the questions on
sexual behavior. Our experience echoes that of Johnson et al. (1994) who demon-
strated that it was possible to ask a random sample of the population detailed
questions about sexual behavior in a questionnaire and interview format. Simi-
larly, Glazener’s (1997) study of postnatal women, found that response rates to
questions about sensitive topics were as high for questions about other topics.
One limitation of this pilot study is the small sample. This meant we were
not able to carry out analyses that allowed us to assessthe contribution of different
factors (e.g., extent of perineal damage, type of delivery, breastfeeding, postnatal
depression) on dyspareunia and other sexual health outcomes. In a full-scale study,
more sophisticated analyses will be possible, allowing us to examine relationships
between obstetric parameters, breastfeeding, physical morbidity, depression, and
poor sexual health outcomes. With more data it will be possible to draw ®rmer
conclusions and make recommendations about changes in health care practice
required to meet postnatal women’s needs. Our pilot study indicates that there is
a wide research agenda.
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