The birth of a baby brings a range of phy sical, emotional and social changes. A woman's sexual life is also changed (Nyström and Ohrling, 2004). Various researchers have explored how childbirth affects women in relation to sex. In a study by Buhling et al (2006), it was found that 47% (n = 298/636) of women resumed sexual intercourse within 8 weeks after giving birth, while another study reported that about 90% of the 509 participating women were sexually active within half a year after giving birth (Brubaker et al, 2008). More recently, McDonald et al (2015) reported that 98% of women (n = 1211/1239) had resumed vaginal intercourse by 18 months postpartum.
Sexual problems are very common in the postpartum period. Wang et al (2003) reported that 71% of 460 women had some sexual difficulties in the third month after birth. In another study, 83% of 484 women reported some sexual problems at 3 months, and after 6 months this fell to 64% (Barrett et al, 2000). Following childbirth, women may experience a decrease in sexual desire and have problems with arousal and orgasmic disorders. The most common type of postpartum sexual dysfunction is dyspareunia or painful intercourse (Sayasneh and Pendeva, 2010). In their prospective study, McDonald et al (2015) found that, in a sample of 1239 women, dyspareunia was reported by 45% of women at 3 months, 43% at 6 months, 28% at 12 months and 23% at 18 months postpartum. Sexual problems, especially pain, are more common in women after vaginal births (Barrett et al, 2000; Klein et al, 2009), operative vaginal births (Barrett et al, 2000; Signorello et al, 2001; Hicks et al, 2004; Buhling et al, 2006; McDonald et al, 2015), and in women who have suffered extensive perineal tears (Signorello et al, 2001; van Brummen et al, 2006). Some studies have identified episiotomy as a risk factor for pain disorder (Sartore et al, 2004; Ejegård et al, 2008; Sayasneh and Pendeva, 2010; Chang et al, 2011).
Episiotomy is one of the most common interventions during the second stage of labour (Lede et al, 1996). The rate of episiotomy increased during the first half of 20th century (Carroli and Mignini, 2009) because of suggested maternal benefits, which include preservation of the muscle relaxation of the pelvic floor and perineum leading to, among other things, improved sexual function (Lede et al, 1996). Episiotomy rates vary internationally (Graham et al, 2005; EURO-PERISTAT, 2013). In the Czech Republic, in 2013, the rate of episiotomy was 31.5% of all deliveries (Ústav Zdravotnických Informací a Statistiky, 2013). Most studies that investigate the effects of episiotomy on female sexuality have focused on women up to 18 months after childbirth (Sartore et al, 2004; Williams et al, 2007; Ejegård et al, 2008; Sayasneh and Pendeva, 2010; Chang et al, 2011; McDonald et al, 2015). However, there is a dearth of literature exploring whether episiotomy has an effect on female sexuality later.
Aims
The primary aim of the study was to explore the effect of episiotomy on sexual function in women 2–5 years after their last spon taneous birth. The effect of episiotomy was verified for all participating women, and then again only for primi parous women, to verify the result without the potential influence of injuries from a pre vious birth.
The secondary aim was to determine whether age and parity may have an influence on women's sexual function.
Methods
A cross-sectional design was used. Data were collected using the Female Sexual Function Index (FSFI), which has been developed by Rosen et al (2000) as a brief, multidimensional self-report instrument for assessing the key dimensions of sexual function in women. The FSFI has 19 items and assesses female sexual function in six domains:
In four questionnaire items, participants marked their responses on a five-point scale; in the other 15 items, participants marked their responses on a six-point scale, graded according to the degree of functionality of individual sexual areas. Each response was then assigned a value coefficient according to the questionnaire scoring system (i.e. 0.6 for desire, 0.3 for arousal and lubrication, and 0.4 for the other domains). The minimum number of points was 0.0 in four domains, 1.2 in the desire domain and 0.8 in the satisfaction domain. A domain score of 0.0 indicates that no sexual activity was reported during the past month. The maximum number of points in each domain was 6.0. A lower score indicates a less satisfactory outcome in a given domain. The sum of the points from the individual domains gives the total score. The minimum total score was 2.0, maximum 36.0. High reliability (overall test-retest reliability for each domains r = 0.79–0.86, and internal consistency—Cronbach's alpha 0.82 and higher) and psychometric validity (significant mean difference scores between the study and control groups for each of the domains (P < 0.001) of FSFI was verified by Rosen et al (2000).
The questionnaire was supplemented by questions concerning the women's obstetric history. Inclusion criteria were: the last childbirth occurred 2–5 years ago; it was a spontaneous vaginal birth at full term (i.e. at 38–42 weeks of pregnancy) and the woman must have a sexual partner. Women with vacuum-assisted vaginal birth, forceps and caesarean section were excluded. All participants were divided into individual groups according to perineal trauma in last childbirth: episiotomy, intact perineum, a first-degree tear (i.e. with injury of perineal skin), a second-degree tear (i.e. rupture extending to perineal muscles but not involving the anal sphincter), and a third-degree or fourth-degree rupture (i.e. injury to perineum involving the anal sphincter complex and injury to perineum involving the anal sphincter complex and anorectal mucosa).
The study commenced after receiving approval from the Ethics Committee of the University of Ostrava and the signing of informed consent forms by representatives of gynaecological clinics. Data were collected between August–September 2013 from 13 private gynaecological clinics in three regions—Moravian-Silesian region, Olomouc region and Zlin region; since the 1990s, all gynaecological clinics in the Czech Republic have been private. Questionnaires were distributed via employees of surgeries, who were instructed in the principles of data collection. Questionnaires were given to women during routine annual gynaecological examinations. The aim of the study and process of completing the questionnaire were explained by clinic staff and described in the introduction to the questionnaire. Participants agreed to have their responses included in the study. With respect to data sensitivity, questionnaires were placed in envelopes and the completed questionnaires were anonymous.
Data were processed using SPSS version 15. Non-parametric methods (Kruskal–Wallis test, Spearman correlation analysis, Mann–Whitney U test with Bonferroni correction) were used for the analysis. The non-parametric tests were used owing to non-normal distribution of data. The normality of data was verified by a Shapiro–Wilk test. Tests were performed at the significance level of 0.05.
Findings
A total of 600 questionnaires were distributed. The response rate was 41% (n = 246) but 35 questionnaires were excluded (18 were incompletely filled-out and 17 women did not meet the inclusion criteria). The final sample therefore consisted of 211 women.
Descriptive characteristics of all women are presented in Table 1. A total of 112 women had an episiotomy, 43 had intact perineum, 32 had a first-degree tear, 21 had a second-degree tear and three women had third- or fourth-degree rupture. In the primiparous group, there were 69 episiotomies, 21 women had intact perineum, eight had a first-degree tear, and 11 had a second-degree tear. Given the very small number of participants in the group of women with spontaneous third-degree and fourth-degree tears (n = 3), this group was no longer compared with the other groups of participants.
| n = 211 | % | |
|---|---|---|
| Mean age (range) | 30.8 (21–48) | |
| Parity | ||
| First | 112 | 53.1 |
| Second | 89 | 42.2 |
| Third | 10 | 4.7 |
| Perineal tear | ||
| Intact perineum | 43 | 20.4 |
| First-degree perineal tear | 32 | 15.2 |
| Second-degree perineal tear | 21 | 10.0 |
| Third- or fourth-degree perineal tear | 3 | 1.4 |
| Episiotomy | 112 | 53.1 |
The groups differed in individual domains and total score. In the group with second-degree perineal tear, worse results were significantly established in the domains of arousal (P = 0.001), orgasm (P = 0.011) and total score (P = 0.005) in comparison with women with first-degree perineal tear and those who had an episiotomy (Table 2).
| Domains | Intact perineum n = 43 median (range) | First-degree perineal tear n = 32 median (range) | Second-degree perineal tear n = 21 median (range) | Episiotomy n = 112 median (range) | P-value of Kruskal–Wallis test |
|---|---|---|---|---|---|
| Sexual desire | 3.6 (1.2–6.0) | 3.0 (1.2–6.0) | 3.0 (1.2–6.0) | 3.6 (1.2–6.0) | 0.141 |
| Arousal | 3.3 (0.0–6.0) | 4.5 (0.0–6.0) | 3.0 (0.0–4.8) | 4.2 (0.0–6.0) | 0.001 |
| Lubrication | 4.8 (0.0–6.0) | 5.4 (0.0–6.0) | 4.8 (0.0–6.0) | 5.3 (0.0–6.0) | 0.089 |
| Orgasm | 4.4 (0.0–6.0) | 5.6 (0.0–6.0) | 3.6 (0.0–5.6) | 4.8 (0.0–6.0) | 0.011 |
| Satisfaction | 4.8 (1.2–6.0) | 5.6 (1.2–6.0) | 4.4 (1.2–6.0) | 4.8 (1.2–6.0) | 0.059 |
| Pain | 5.2(0.0–6.0) | 5.8 (0.0–6.0) | 4.4 (0.0–6.0) | 5.4 (0.0–6.0) | 0.068 |
| Total score | 26.4 (2.4–36.0) | 30.5 (4.2–34.5) | 22.7 (2.4–30.2) | 28.5 (2.4–36.0) | 0.005 |
Table 3 shows the results of the Mann– Whitney U test with Bonferroni correction. The two groups according to perineal trauma were compared in arousal domain, orgasm and total score. The results show that the women with a second-degree perineal tear had significantly different results than women with a first-degree tear and woman with episiotomy.
| Compared domains | Arousal P-value | Orgasm P-value | Total score P-value |
|---|---|---|---|
| Intact perineum vs first-degree perineal tear | 0.217 | 0.497 | 0.907 |
| Intact perineum vs second-degree perineal tear | 0.847 | > 0.999 | 0.390 |
| Intact perineum vs episiotomy | 0.164 | 0.843 | 0.877 |
| First-degree perineal tear vs second-degree perineal tear | 0.007 | 0.019 | 0.013 |
| First-degree perineal tear vs episiotomy | > 0.999 | > 0.999 | > 0.999 |
| Second-degree perineal tear vs episiotomy | 0.003 | 0.023 | 0.007 |
The median scores for the individual domains are illustrated in a grouped bar graph (Figure 1). The arrows mark the group of participants with a second-degree perineal tear, which had significantly lower median values than the groups of participants with a first-degree perineal tear and episiotomy (marked by an asterisk).
The test was also performed for a group of primiparae (n = 112) to verify whether the results might be influenced by injuries from previous births. Three primiparae had third-degree or fourth-degree perineal tears, so this group was not compared with other groups owing to the small number. In the primiparous group, the women with second-degree perineal tears had the lowest scores for orgasm and total score, similar to the results for all women. However, between the groups of women, no statistically significant difference was found in individual domains, or in total score. This suggests that primiparous women after episiotomy do not differ in sexual function from women without perineal tears or with spontaneous first-degree and second-degree tears (Table 4).
| Domains | Intact perineum n = 21 median (range) | First-degree perineal tear n = 8 median (range) | Second-degree perineal tear n = 11 median (range) | Episiotomy n = 69 median (range) | P-value of Kruskal–Wallis test |
|---|---|---|---|---|---|
| Sexual desire | 3.6 (2.4–6.0) | 3.6 (2.4–5.4) | 3.6 (1.2–6.0) | 3.6 (1.8–6.0) | 0.539 |
| Arousal | 3.3 (0.0–6.0) | 4.4 (0.0–5.1) | 3.6 (1.2–4.8) | 4.5 (0.0–6.0) | 0.155 |
| Lubrication | 5.4 (0.0–6.0) | 4.8 (0.0–6.0) | 5.1 (1.8–6.0) | 5.4 (0.0–6.0) | 0.847 |
| Orgasm | 4.4 (0.0–6.0) | 4.2 (0.0–6.0) | 3.6 (2.4–5.6) | 4.8 (0.0–6.0) | 0.126 |
| Satisfaction | 5.2 (1.2–6.0) | 5.0 (1.2–6.0) | 4.4 (1.6–6.0) | 4.8 (1.2–6.0) | 0.764 |
| Pain | 5.6 (0.0–6.0) | 6.0 (0.0–6.0) | 5.2 (3.6–6.0) | 5.6 (0.0–6.0) | 0.530 |
| Total score | 26.4 (3.6–36.0) | 26.9 (3.6–34.5) | 25.5 (18.4–30.2) | 28.7 (3.6–34.8) | 0.302 |
The secondary aim of this study was to verify whether a woman's age and parity may affect her sexual function. Variables were evaluated considering the total score. No relationship was discovered between participants' age and total score on the FSFI (Spearman's rho = 0.037; P = 0.598). It was found, therefore, that women's age does not affect overall evaluation of their sexual function; nor was it proven that women's sexual function is affected by number of births (Table 5).
| Female Sexual Function Index total score | One birth n = 112 | Two births n = 89 | Three births n = 10 | Kruskal– Wallis test P-value |
|---|---|---|---|---|
| Median (range) | 27.6 (3.6–36.0) | 28.0 (2.4–36.0) | 22.3 (2.4–33.3) | 0.155 |
Discussion
The study aimed to assess whether episiotomy has an effect on women's sexual function. Several studies have assessed the effect of episiotomy on women's sexuality, but have tended to focus on women up to only 3 months (Chang et al, 2011), 6 months (Barrett et al, 2000), 1 year (Williams et al, 2007; Fauconnier et al, 2012) or 18 months after birth (McDonald et al, 2015).
In a prospective follow-up study, Chang et al (2011) investigated the effect of episiotomy on perineal pain and sexual dysfunction up to 3 months postpartum in 243 women (55 women with episiotomy and 188 without episiotomy). In the first, second and sixth week postpartum, women who received an episiotomy reported a higher incidence of perineal pain compared to those who did not, but the groups did not differ in overall assessment of female sexual function. However, spontaneous tears (from the first to fourth degree) occurred in both groups, which may have affected the results. A cross-sectional study by Barrett et al (2000) reported that birth injuries (intact perineum, first-to third-degree perineal tears, episiotomy, labial tears and vaginal tears) did not have an influence on the incidence of dyspareunia in 364 primiparous women 3 months after birth, and 400 primiparous women 6 months after birth. The major risk factor for dyspareunia was found to be vaginal tears; the current study did not observe this type of birth injury. Fauconnier et al (2012) focused on 254 women 1 year after birth and the incidence of dyspareunia. Their study included 482 women. It was found that pain during sexual intercourse was not affected by perineal trauma (episiotomy, perineal tears and intact perineum). In contrast, Williams et al (2007) established that women with intact perineum had a lower incidence of sexual problems and dyspareunia 1 year after birth than women with episiotomy or spontaneous tears. However, women with spontaneous perineal tears did not differ from women who had an episiotomy.
‘Female sexuality is multidimensional and includes biological, psychological, socio-economic and spiritual components’
A prospective study by McDonald et al (2015) found that sutured tears or episiotomy increased the occurrence of dyspareunia in comparison to intact perineum or unsutured tear at 6 months after birth (odds ratio 2.32), but not at 18 months after birth. This study included 1211 women. Mean while, Ejegård et al (2008) found that primiparae with episiotomy (n = 110) reported a higher frequency of dyspareunia and insufficient lubrication than the control group (n = 153 women without episiotomy) 12–18 months after birth. However, there may be a distortion in this study's results because both groups (study and control) contained women with first- and second-degree perineal tears. The authors found that episiotomy, second-degree perineal laceration and history of dyspareunia were risk factors for dyspareunia 12–18 months after birth.
The aim of the current study was to establish whether episiotomy has an effect on sexual function in women 2–5 years after a vaginal birth. It was discovered that participants with a second-degree perineal tear tended to have the lowest score for arousal, orgasm and total score on the Female Sexual Function Index, while women with first-degree tears and episiotomies tended to have higher scores in these domains. In the primiparae group, no significant difference was found in individual domains or total score; women with second-degree perineal tears had the lowest score for orgasm but the total score was similar to all women. The reason for this is not clear and requires further research.
Female sexuality is multidimensional and includes biological, psychological, socioeconomic and spiritual components (Bernhard, 2002).
Based on the results obtained in this study, it can be suggested that multiparous women's sexual functions are influenced more by other variables, among which may be their relationship with their partner; age of their older child(ren); living conditions; and a breastfed infant's biological rhythm. Shirvani et al (2010) confirmed the effect of other variables. They found that a less satisfactory sex life was associated with higher maternal age, marriage duration and number of children. Women with a medical condition or an unwell baby were found to have less satisfactory sexuality than healthy women. In an Iranian cross-sectional study of 564 women (331 primiparae and 233 multiparae), 3–6 months after birth libido decreased (Makkii and Yazdi, 2012). The frequency of anorgasmia and vaginal dryness before and after birth were the same in primiparous and multiparous women. In a study by Williams et al (2007), older mothers had a higher incidence of dyspareunia 1 year after birth than younger women. However, the current study found no relationship between the participants' parity, age and sexual function.
Limitations
This study has several limitations. Firstly, it only achieved a 41% response rate. One reason for this may be the sensitive subject of the study.
Secondly, the study was performed in private gynaecological clinics in three of 14 regions of the Czech Republic, so the results may be influenced by geographical area and the social conditions in these regions.
The third limitation was the small size of the sample. Each group contained a different number of respondents and one group (third- and fourth-degree perineal tears) contained only three respondents, so was not compared with the other groups. The small number of respondents in this group may be the result of the low incidence of these injuries during labour. The analyses for primiparous women showed no significant differences between the four perineal trauma groups. The score for orgasm and total score were lowest in women with second-degree perineal tears. However, the first-degree and second-degree perineal tear groups were quite small, which may have affected the significance of the comparisons.
The statistics in this study are from 2013, which is time-limited. The authors recommend that the study be repeated for a larger number of primiparous women for a more definitive answer to the question of whether the findings for all women are also true for primiparous women.
Conclusion
This study did not give definitive results re gard ing the effects of episiotomy on female sexual function. However, women with second-degree perineal tears tended to have lower scores for arousal, orgasm and total score than women with first-degree perineal tears or episiotomy. An asso ci ation between participants' age, number of births and overall evaluation of female sexuality was not established. Based on the results obtained, it may be suggested that multiparous women's sexuality is affected by variables that were not explored in this research.