- Email: [email protected]
Mode of delivery and pain during intercourse in the postpartum period: Findings from a developing country
Sexual & Reproductive Healthcare 6 (2015) 44–47
Contents lists available at ScienceDirect
Sexual & Reproductive Healthcare j o u r n a l h o m e p a g e : w w w. s r h c j o u r n a l . o r g
Mode of delivery and pain during intercourse in the postpartum period: Findings from a developing country Tamar Kabakian-Khasholian a, Alexandra Ataya a, Rawan Shayboub a, Faysal El-Kak a,b,* a Health Promotion Community Health Department, WHO Collaborating Center for Health Promotion, Behavioral Sciences, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon b Department of Obstetrics and Gynecology, American University of Beirut Medical Center
A R T I C L E
I N F O
Article history: Received 29 October 2013 Revised 3 September 2014 Accepted 23 September 2014 Keywords: Postpartum health Sexual health Cesarean section Lebanon
A B S T R A C T
Objective: This study examines the association of the reporting of pain during intercourse in the postpartum period with mode of delivery, and describes women’s reports of pain during intercourse and their health care seeking behavior over a period of 40 days–6 months postpartum. Methods: A cross-sectional study recruited women in their 2nd and 3rd trimester of pregnancy from private obstetric clinics affiliated with 18 hospitals in two regions of Lebanon. Face-to-face interviews using a structured questionnaire were conducted at the women’s homes from 40 days to 6 months postpartum. Verbal, informed consent was obtained from all women participating in the study before the interview. Results: In a sample of 238 women, 67% reported experiencing pain during intercourse postpartum and 72.3% did not seek care. Women having a cesarean delivery (1.96; CI (1.29–2.63)), who were primiparous (OR = 2.44; CI (2.05–2.83)) and residing in the Mount Lebanon region (OR = 1.25; CI (1.09–1.40)) were significantly more likely to report pain during intercourse postpartum. Conclusions: Cesarean births may increase the chances of reporting of pain during intercourse postpartum among primiparous women. Given that the increasing cesarean section rates worldwide are perceived to be protective of women’s sexual health, prenatal and postpartum care need to address women’s sexual health problems. © 2014 Elsevier B.V. All rights reserved.
Introduction Sexual health in the postpartum period is an important concern for mothers and, despite some research efforts pointing to changes in sexual relationships postpartum and to the commonality of experiencing pain during intercourse [1–4], the extent of these problems and their underlying contributing factors remain largely understudied, especially in developing country settings. The literature reveals a significant proportion of women reporting discomfort and/or pain during intercourse in different postpartum periods [1,5–8]. Some studies indicate the persistence of pain during intercourse throughout the first year postpartum and beyond. Reports from Scotland [2], Sweden [8] and Italy [9] show that 19.7%, 10.7% and 16.2% of women respectively reported pain during intercourse or difficulty in having sexual intercourse up to 1 year and 18 months postpartum. Furthermore, information about the health care seeking behavior of women for sexual health problems is scarce
* Corresponding author. American University of Beirut, Health Promotion and Community Health Department, WHO Collaborating Center for Health Promotion and Behavioral Sciences, Faculty of Health Sciences, Riad El Solh 1107 2020, PO Box 11-0246, Beirut, Lebanon. Tel.: +961 1 350000 ext.4672/4660. E-mail address: [email protected], please cc: [email protected] (F. El-Kak). http://dx.doi.org/10.1016/j.srhc.2014.09.007 1877-5756/© 2014 Elsevier B.V. All rights reserved.
in the literature, except in a few reports [3,10] indicating that women rarely seek care for this problem and rarely discuss it with a health professional. Despite the presence of a limited number of studies looking at sexual dysfunction related to cesarean section [11] it is presumed that cesarean sections protect women from perineal trauma therefore from sexual dysfunctions. This argument has been used as a perceived benefit for elective cesarean sections in contexts of increased patient autonomy. There is a certain consistency in the literature suggesting an association between assisted vaginal delivery and sexual dysfunction including pain during intercourse [2,3,10,12,13]. Nevertheless, reported associations between pain during intercourse and cesarean deliveries remains largely inconclusive [10]. In Glazener’s study with Scottish women [2] no difference in reporting of pain during intercourse was found between those having spontaneous vaginal delivery and cesarean delivery. Similar findings are reported from a multicenter, international controlled trial on breech presentation at term [7]. A study among primiparous women in England reported that cesarean deliveries were protective against pain during intercourse at 3 months postpartum compared to vaginal birth; however, these differences between the groups disappeared over the long-term. In contrast, a cohort analysis from a randomized controlled trial found that pain during intercourse was more common among women who had
T. Kabakian-Khasholian et al./Sexual & Reproductive Healthcare 6 (2015) 44–47
cesarean births compared to those having vaginal births [14]. Similarly, Goetsch [15] has reported a substantial proportion of women (29%) who had a cesarean delivery to be suffering from pain during intercourse in the postpartum period. Other studies looking into different factors associated with pain during intercourse in the postpartum period point to a consistent association with parity, with the complaints being more common in primiparous than in multiparous women [8,16,17]. Although our knowledge about the scope and persistence of sexual health problems in the postpartum period is improving, it is mainly based on studies from Western countries and much research is needed from different regions of the world to reveal the extent of this problem and to inform practice in ways to improve women’s postpartum quality of life. This needs to be considered, especially in view of the dramatic increase in the rate of cesarean sections in many developing countries including Lebanon, where reported rates are exceeding 40% of births [18], and the use of postpartum care services remains unsatisfactory (51% only, in Lebanon [19]). The current study examines the association of reporting of pain during intercourse in the postpartum period with the mode of delivery and describes women’s reports of pain during intercourse and their health care seeking behavior over a period of 40 days–6 months postpartum. Materials and methods Study design and study population A cross-sectional study was undertaken with the aim of exploring women’s postpartum health problems. Women in their 2nd or 3rd trimester of pregnancy were recruited from private obstetrics clinics affiliated with 18 private hospitals in two regions of Lebanon: Mount Lebanon and the South. A total of 269 women had completed the postpartum interview. A sub-sample of 238 women is used for analysis in this paper, excluding 30 women reporting not having resumed sexual intercourse after childbirth by the time of the interview and one refusal to answer the question related to pain during intercourse. Data collection method and tools Four trained field workers contacted women and solicited verbal and informed consent following which the baseline interview was filled over the phone. Following their birth, these interviewers visited the women at home to complete a structured questionnaire over a period from 40 days up to 6 months postpartum. The instruments used in this study consisted of structured questionnaires developed in Arabic by the study team based on previous research conducted by the same researchers [20] and with input from clinicians regarding postpartum morbidity. The questionnaires were pilot-tested for the comprehension of the wording used, cultural sensitivity and ease of administration. The baseline interview included women’s contact information, their socio-demographic profile and an assessment of their expectations with childbirth. The postpartum home interview assessed postpartum morbidity, including pain during intercourse, where women were asked to respond to a checklist of common symptoms and conditions indicating whether they had suffered from any of the mentioned conditions anytime during the postpartum period. The care taken for each reported condition and the onset of the problem were also recorded. Data analysis Data were entered and analyzed using the SPSS software. Reporting of pain during intercourse was considered as the outcome
45
Table 1 Proportion of women experiencing pain during intercourse postpartum, the onset of the reported problem and women’s health care seeking behavior (n = 238).
Proportion reporting pain during intercourse Time of reporting in the postpartum period 6 weeks–2 months 2–3 months 4–6 months Onset Before or during pregnancy Postpartum Health care seeking behavior Visited a physician Visited other care providers Asked advice from family/friends Home remedies Did nothing Other
N
%
159
66.8
28 83 47
17.7 52.5 29.8
23 135
14.6 85.4
31 2 3 2 115 6
19.5 1.3 1.9 1.3 72.3 3.7
for this analysis. Mode of delivery was considered the main predictor for reporting of pain during intercourse; other predictors were parity, educational level, occupational status, age, region of residence and experiencing complications during pregnancy or birth. The chi-square statistics with continuity correction was used to compare proportions. The multivariate analysis was conducted using stepwise logistic regression to assess the relationship between reporting of pain during intercourse and mode of delivery. The independent variables found to be statistically significant or those that are considered as confounders were added to the regression analysis. Two-sided significance tests were used throughout all analyses. Odds ratios with 95% confidence interval and p-value of 0.05 were used to indicate statistically significant associations. Ethical considerations The study protocol was approved by the Institutional Review Board of the American University of Beirut. Verbal, informed consent was obtained from all women participating in the study at all stages of contact. Results In our sample of 238 women, the average age was 28 years, 58.8% were multiparas and 65% received at least a high school level education. The proportion giving birth with a cesarean section was 43.7%. Table 1 shows that 66.8% of women reported pain during intercourse sometime between 6 weeks and 6 months postpartum, with 52.5% of the women in our sample reporting this problem between 2 and 4 months postpartum and 29.8% reporting it between 4 and 6 months postpartum. The onset of the problem was the postpartum period for 85.4% of women. Among those who reported pain during intercourse in the postpartum period, 72.3% did not take any action to remedy their problem and only 19.5% reported visiting a physician. There were no significant associations between the independent variables considered for this analysis, such as age, parity, education and region of residence. Table 2 shows the adjusted odds ratios for reporting of pain during intercourse in the postpartum period. Primiparous women (OR = 2.44; CI (2.05–2.83)) those from the Mount Lebanon region (OR = 1.25; CI (1.09–1.40)), and those having had a cesarean delivery (1.96; CI (1.29–2.63)) were significantly more likely to report pain during intercourse in the postpartum period.
46
T. Kabakian-Khasholian et al./Sexual & Reproductive Healthcare 6 (2015) 44–47
Table 2 Adjusted OR and 95% confidence intervals for the relationship of pain during intercourse with mode of delivery and other background characteristics. Characteristics Maternal age (years) < 28 > 28 Parity Multipara Primipara Education Less than high school High school level or beyond Region South Lebanon Mount Lebanon Mode of delivery Vaginal Cesarean
N
Adjusted OR
113 125
1.00 0.95
0.47–1.42
140 98
1.00 2.44
2.05–2.83
83 155
1.00 1.07
0.89–1.25
113 125
1.00 1.25
1.09–1.40
134 104
1.00 1.96
1.29–2.63
The high prevalence of the problem in the latter postpartum periods (beyond 2 months) might indicate the consequence of the pressures of parenting and postpartum adjustment on sexual health.
95% CI
Women’s reluctance to seek care
X2 = 35.32; p-value = 0.000. −2 log likelihood = 267.190.
Despite the problem being widespread, women were reluctant to seek care. Sexual health problems in general are considered a taboo in the Lebanese context. This might restrict women’s health care seeking behavior, especially considering the difficulties in communication between health care providers and women regarding sexual health issues [24] and the major deficiencies in postpartum care offered in Lebanon [25]. Studies looking into sexual health postpartum did not assess women’s health care seeking behavior. One study by Glazener [2] reports that during the 6-week postpartum check, problems with intercourse were mentioned less often than other postpartum health problems in a sample of women in Scotland. Painful intercourse in the postpartum period and parity
Discussion Our findings indicate that cesarean sections and first deliveries increase the odds of experiencing pain during intercourse in the postpartum period. In our sample of women, reporting of pain during intercourse in the postpartum period was very common, whereas health care was not sought for the vast majority of these women. Cesarean section not protective against painful intercourse in the postpartum period In our sample, women who delivered by cesarean section were more likely to experience pain during intercourse postpartum. Similar findings are reported by Klein et al. [14] where women undergoing cesarean section were more likely to report pain during intercourse than those having a vaginal delivery with intact perineum. It is not possible from our data to ascertain the extent of perineal injury and therefore difficult to make comparisons per se. In this regard, it is important to note that studies indicating the protective factor of cesarean sections on sexual health problems also point to wearing of that protection beyond 3 months postpartum [13]. Complications of cesarean section may result in poor overall postpartum maternal health therefore affecting sexual health in general. Since cesarean section is believed to be protective against perineal injury and is thus one of the reasons why women would opt for it as a mode of delivery [21] and in the light of inconsistent findings from the literature, counseling of women on this issue during the antenatal period should be encouraged. The burden of painful intercourse in the postpartum period Our findings indicate that a high proportion of women suffer from pain during intercourse in the postpartum period, specifically in the period between 2 and 4 months postpartum and the vast majority of the women are experiencing this problem for the first time after giving birth. It is to be noted that, in this sample, women have reported more physical and psychological health problems in the period 4–6 months postpartum than in the period 2–4 months postpartum [22]. This finding is supported by previous studies [5,6,8] with 41%–67% of women reporting suffering from pain during intercourse by 3 months postpartum [3,6,23]. Barrett et al. [3] reported that 62% of women experienced pain during intercourse in the first three months and 31% at six months postpartum in contrast to only 12% experiencing it in the year prior to pregnancy.
Our data show that primiparous women were most likely to experience pain during intercourse postpartum. This finding is highly consistent with the literature [1,8,17] and could be due to the difficulties primiparous women face in adjusting to the postpartum period that could be related to their lack of experience and unrealistic expectations. The fact that women from the Mount Lebanon region were more likely to report pain during intercourse postpartum compared to those from the South, could be explained by differences in expectations or in reporting of this problem between different regions in Lebanon. Although there were slightly higher rates of cesarean section among women from the Mount Lebanon region compared to the South, the effect of the region on reporting of pain during intercourse postpartum remained significant after adjustment. Our sample included more rural regions from the South than from Mount Lebanon. This observed difference can be a reflection of the cultural differences of perceiving and reporting illhealth rather than worse health status as well as in shaping women’s expectations in this regard. Study limitations Our study is the first from Arab countries and among the very few from the developing world reporting on sexual health problems of postpartum women. There are, however, some limitations that should be noted. Since the study aimed at assessing postpartum health in general, the whole array of sexual health problems was not covered. The data also do not include a differentiation between emergency and elective cesarean sections. Another limitation might be the fact that the study population was recruited from private clinics. Despite the fact that private care is utilized by the majority of the Lebanese population, the findings may not be generalizable to the 10–20% of women using public centers to receive antenatal care. Conclusion Our findings show that cesarean births for primiparous women increase the chance of experiencing pain during intercourse in the postpartum period. This suggests that advice and treatment for sexual health problems can be vastly improved by revisiting the organization and delivery of antenatal and postpartum services. In contexts where antenatal care is used more often than postpartum care services, there is a lost opportunity with regard to the information that can be shared with women about the postpartum period especially considering that the six week postpartum
T. Kabakian-Khasholian et al./Sexual & Reproductive Healthcare 6 (2015) 44–47
checkup may be too early for women to discover sexual health problems. There is a need to broaden the research on postpartum sexual morbidity in developing country settings by further exploring the determinants of pain during intercourse including mode of delivery and by expanding our understanding of women’s interpretation of that experience. This will inform and shape culturally sensitive maternal health service provision in response to women’s experiences of ill-health in the postpartum period. References [1] Brown S, Lumley J. Maternal health after childbirth: results of an Australian population based study. Br J Obstet Gynaecol 1998;105:156–61. [2] Glazener CM. Sexual function after childbirth: women’s experiences, persistent morbidity and lack of professional recognition. Br J Obstet Gynaecol 1997;104:330–5. [3] 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. [4] Kennedy CM, Turcea AM, Bradley CS. Prevalence of vulvar and vaginal symptoms during pregnancy and the puerperium. Int J Gynecol Obstet 2009;105:236–9. [5] Connolly AM, Thorp J, Pahel L. Effects of pregnancy and childbirth on postpartum sexual function: a longitudinal prospective study. Int Urogynecol J Pelvic Floor Dysfunct 2005;16:263–7. [6] 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;184:881–8. [7] Hannah ME, Hannah WJ, Hodnett ED, Chalmers B, Kung R, Willian A. Outcomes at 3 months after planned cesarean vs planned vaginal delivery for breech presentation at term. The international randomized term breech trial. JAMA 2002;287:1822–31. [8] Schytt E, Lindmark G, Waldenstrom U. Physical symptoms after childbirth: prevalence and associations with self-rated health. Br J Obstet Gynaecol 2005;112:210–17. [9] Bertozzi S, Londero AP, Fruscalzo A, Driul L, Delneri C, Calcagno A, et al. Impact of episiotomy on pelvic floor disorders and their influence on women’s wellness after the sixth month postpartum: a retrospective study. BMC Womens Health 2011;11:12.
47
[10] Baytur YB, Deveci A, Uyar Y, Ozcakir HT, Kizilaya S, Caglar H. Mode of delivery and pelvic floor muscle strength and sexual function after childbirth. Int J Gynecol Obstet 2005;88:276–80. [11] Abdool Z, Thakar R, Sultan AH. Postpartum female sexual function. Eur J obstet Gynecol Reprod Biol 2009;145:133–7. [12] Safarninejad M, Kolahi A, Hosseini L. The effect of the mode of delivery on the quality of life, sexual function and sexual satisfaction in primiparous women and their husbands. J Sex Med 2009;6:1645–67. [13] Barrett G, Peacock J, Victor C, Manyonda I. Cesarean section and postnatal sexual health. Birth 2005;32:306–11. [14] Klein MC, Kaczorowski J, Firoz T, Hubinette M, Jorgensen S, Gauthier R. A comparison of urinary and sexual outcomes in women experiencing vaginal and caesarean births. J Obstet Gynaecol Can 2005;27:332–9. [15] Goetsch M. Postpartum dyspareunia. An unexplored problem. J Reprod Med 1994;4:963–8. [16] Brown S, Lumley J. Physical health problems after childbirth and maternal depression at six to seven months postpartum. Br J Obstet Gynaecol 2000;107:1194–201. [17] 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. [18] DeJong J, Akik C, El Kak F, Osman H, El-Jardali F. The safety and quality of childbirth in the context of health systems: mapping maternal health provision in Lebanon. Midwifery 2010;26:549–57. [19] Tutelian M, Khayyat M, Abdel Monem A. Lebanon Family Health Survey 2004. Principal Report. The Republic of Lebanon, The Central administration of Statistics and The Pan Arab Project for Family Health. 2007. [20] Kabakian-Khasholian T, Campbell OMR. Impact of written information on women’s use of postpartum services: a randomized controlled trial. Acta Obstet Gynecol Scand 2007;86(7):793–8. [21] Sultan AH, Stanton SL. Preserving the pelvic floor and perineum during childbirth-elective caesarean section? Br J Obstet Gynaecol 1996;103:731–4. [22] Kabakian-Khasholian T, Shayboub R, Attaya A. Health after childbirth: patterns of reported postpartum morbidity from Lebanon. Women Birth 2014;27:15–20. [23] Clarkson J, Newton C, Bick D. Achieving sustainable quality in maternity services: using audit of incontinence and dyspareunia to identify shortfalls in meeting standards. BMC Pregnancy Childbirth 2001;1(4):1293–6. [24] El-Kak F, Jurdi R, Kaddour A, Zurayk H. Gender and sexual health in clinical practice in Lebanon. Int J Gynaecol Obstet 2004;87(3):260–6. [25] Kabakian-Khasholian T, Jurdi R, El-Kak F. What is happening during the postnatal visit? Health Care Women Int 2006;27(9):839–47.
Contents lists available at ScienceDirect
Sexual & Reproductive Healthcare j o u r n a l h o m e p a g e : w w w. s r h c j o u r n a l . o r g
Mode of delivery and pain during intercourse in the postpartum period: Findings from a developing country Tamar Kabakian-Khasholian a, Alexandra Ataya a, Rawan Shayboub a, Faysal El-Kak a,b,* a Health Promotion Community Health Department, WHO Collaborating Center for Health Promotion, Behavioral Sciences, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon b Department of Obstetrics and Gynecology, American University of Beirut Medical Center
A R T I C L E
I N F O
Article history: Received 29 October 2013 Revised 3 September 2014 Accepted 23 September 2014 Keywords: Postpartum health Sexual health Cesarean section Lebanon
A B S T R A C T
Objective: This study examines the association of the reporting of pain during intercourse in the postpartum period with mode of delivery, and describes women’s reports of pain during intercourse and their health care seeking behavior over a period of 40 days–6 months postpartum. Methods: A cross-sectional study recruited women in their 2nd and 3rd trimester of pregnancy from private obstetric clinics affiliated with 18 hospitals in two regions of Lebanon. Face-to-face interviews using a structured questionnaire were conducted at the women’s homes from 40 days to 6 months postpartum. Verbal, informed consent was obtained from all women participating in the study before the interview. Results: In a sample of 238 women, 67% reported experiencing pain during intercourse postpartum and 72.3% did not seek care. Women having a cesarean delivery (1.96; CI (1.29–2.63)), who were primiparous (OR = 2.44; CI (2.05–2.83)) and residing in the Mount Lebanon region (OR = 1.25; CI (1.09–1.40)) were significantly more likely to report pain during intercourse postpartum. Conclusions: Cesarean births may increase the chances of reporting of pain during intercourse postpartum among primiparous women. Given that the increasing cesarean section rates worldwide are perceived to be protective of women’s sexual health, prenatal and postpartum care need to address women’s sexual health problems. © 2014 Elsevier B.V. All rights reserved.
Introduction Sexual health in the postpartum period is an important concern for mothers and, despite some research efforts pointing to changes in sexual relationships postpartum and to the commonality of experiencing pain during intercourse [1–4], the extent of these problems and their underlying contributing factors remain largely understudied, especially in developing country settings. The literature reveals a significant proportion of women reporting discomfort and/or pain during intercourse in different postpartum periods [1,5–8]. Some studies indicate the persistence of pain during intercourse throughout the first year postpartum and beyond. Reports from Scotland [2], Sweden [8] and Italy [9] show that 19.7%, 10.7% and 16.2% of women respectively reported pain during intercourse or difficulty in having sexual intercourse up to 1 year and 18 months postpartum. Furthermore, information about the health care seeking behavior of women for sexual health problems is scarce
* Corresponding author. American University of Beirut, Health Promotion and Community Health Department, WHO Collaborating Center for Health Promotion and Behavioral Sciences, Faculty of Health Sciences, Riad El Solh 1107 2020, PO Box 11-0246, Beirut, Lebanon. Tel.: +961 1 350000 ext.4672/4660. E-mail address: [email protected], please cc: [email protected] (F. El-Kak). http://dx.doi.org/10.1016/j.srhc.2014.09.007 1877-5756/© 2014 Elsevier B.V. All rights reserved.
in the literature, except in a few reports [3,10] indicating that women rarely seek care for this problem and rarely discuss it with a health professional. Despite the presence of a limited number of studies looking at sexual dysfunction related to cesarean section [11] it is presumed that cesarean sections protect women from perineal trauma therefore from sexual dysfunctions. This argument has been used as a perceived benefit for elective cesarean sections in contexts of increased patient autonomy. There is a certain consistency in the literature suggesting an association between assisted vaginal delivery and sexual dysfunction including pain during intercourse [2,3,10,12,13]. Nevertheless, reported associations between pain during intercourse and cesarean deliveries remains largely inconclusive [10]. In Glazener’s study with Scottish women [2] no difference in reporting of pain during intercourse was found between those having spontaneous vaginal delivery and cesarean delivery. Similar findings are reported from a multicenter, international controlled trial on breech presentation at term [7]. A study among primiparous women in England reported that cesarean deliveries were protective against pain during intercourse at 3 months postpartum compared to vaginal birth; however, these differences between the groups disappeared over the long-term. In contrast, a cohort analysis from a randomized controlled trial found that pain during intercourse was more common among women who had
T. Kabakian-Khasholian et al./Sexual & Reproductive Healthcare 6 (2015) 44–47
cesarean births compared to those having vaginal births [14]. Similarly, Goetsch [15] has reported a substantial proportion of women (29%) who had a cesarean delivery to be suffering from pain during intercourse in the postpartum period. Other studies looking into different factors associated with pain during intercourse in the postpartum period point to a consistent association with parity, with the complaints being more common in primiparous than in multiparous women [8,16,17]. Although our knowledge about the scope and persistence of sexual health problems in the postpartum period is improving, it is mainly based on studies from Western countries and much research is needed from different regions of the world to reveal the extent of this problem and to inform practice in ways to improve women’s postpartum quality of life. This needs to be considered, especially in view of the dramatic increase in the rate of cesarean sections in many developing countries including Lebanon, where reported rates are exceeding 40% of births [18], and the use of postpartum care services remains unsatisfactory (51% only, in Lebanon [19]). The current study examines the association of reporting of pain during intercourse in the postpartum period with the mode of delivery and describes women’s reports of pain during intercourse and their health care seeking behavior over a period of 40 days–6 months postpartum. Materials and methods Study design and study population A cross-sectional study was undertaken with the aim of exploring women’s postpartum health problems. Women in their 2nd or 3rd trimester of pregnancy were recruited from private obstetrics clinics affiliated with 18 private hospitals in two regions of Lebanon: Mount Lebanon and the South. A total of 269 women had completed the postpartum interview. A sub-sample of 238 women is used for analysis in this paper, excluding 30 women reporting not having resumed sexual intercourse after childbirth by the time of the interview and one refusal to answer the question related to pain during intercourse. Data collection method and tools Four trained field workers contacted women and solicited verbal and informed consent following which the baseline interview was filled over the phone. Following their birth, these interviewers visited the women at home to complete a structured questionnaire over a period from 40 days up to 6 months postpartum. The instruments used in this study consisted of structured questionnaires developed in Arabic by the study team based on previous research conducted by the same researchers [20] and with input from clinicians regarding postpartum morbidity. The questionnaires were pilot-tested for the comprehension of the wording used, cultural sensitivity and ease of administration. The baseline interview included women’s contact information, their socio-demographic profile and an assessment of their expectations with childbirth. The postpartum home interview assessed postpartum morbidity, including pain during intercourse, where women were asked to respond to a checklist of common symptoms and conditions indicating whether they had suffered from any of the mentioned conditions anytime during the postpartum period. The care taken for each reported condition and the onset of the problem were also recorded. Data analysis Data were entered and analyzed using the SPSS software. Reporting of pain during intercourse was considered as the outcome
45
Table 1 Proportion of women experiencing pain during intercourse postpartum, the onset of the reported problem and women’s health care seeking behavior (n = 238).
Proportion reporting pain during intercourse Time of reporting in the postpartum period 6 weeks–2 months 2–3 months 4–6 months Onset Before or during pregnancy Postpartum Health care seeking behavior Visited a physician Visited other care providers Asked advice from family/friends Home remedies Did nothing Other
N
%
159
66.8
28 83 47
17.7 52.5 29.8
23 135
14.6 85.4
31 2 3 2 115 6
19.5 1.3 1.9 1.3 72.3 3.7
for this analysis. Mode of delivery was considered the main predictor for reporting of pain during intercourse; other predictors were parity, educational level, occupational status, age, region of residence and experiencing complications during pregnancy or birth. The chi-square statistics with continuity correction was used to compare proportions. The multivariate analysis was conducted using stepwise logistic regression to assess the relationship between reporting of pain during intercourse and mode of delivery. The independent variables found to be statistically significant or those that are considered as confounders were added to the regression analysis. Two-sided significance tests were used throughout all analyses. Odds ratios with 95% confidence interval and p-value of 0.05 were used to indicate statistically significant associations. Ethical considerations The study protocol was approved by the Institutional Review Board of the American University of Beirut. Verbal, informed consent was obtained from all women participating in the study at all stages of contact. Results In our sample of 238 women, the average age was 28 years, 58.8% were multiparas and 65% received at least a high school level education. The proportion giving birth with a cesarean section was 43.7%. Table 1 shows that 66.8% of women reported pain during intercourse sometime between 6 weeks and 6 months postpartum, with 52.5% of the women in our sample reporting this problem between 2 and 4 months postpartum and 29.8% reporting it between 4 and 6 months postpartum. The onset of the problem was the postpartum period for 85.4% of women. Among those who reported pain during intercourse in the postpartum period, 72.3% did not take any action to remedy their problem and only 19.5% reported visiting a physician. There were no significant associations between the independent variables considered for this analysis, such as age, parity, education and region of residence. Table 2 shows the adjusted odds ratios for reporting of pain during intercourse in the postpartum period. Primiparous women (OR = 2.44; CI (2.05–2.83)) those from the Mount Lebanon region (OR = 1.25; CI (1.09–1.40)), and those having had a cesarean delivery (1.96; CI (1.29–2.63)) were significantly more likely to report pain during intercourse in the postpartum period.
46
T. Kabakian-Khasholian et al./Sexual & Reproductive Healthcare 6 (2015) 44–47
Table 2 Adjusted OR and 95% confidence intervals for the relationship of pain during intercourse with mode of delivery and other background characteristics. Characteristics Maternal age (years) < 28 > 28 Parity Multipara Primipara Education Less than high school High school level or beyond Region South Lebanon Mount Lebanon Mode of delivery Vaginal Cesarean
N
Adjusted OR
113 125
1.00 0.95
0.47–1.42
140 98
1.00 2.44
2.05–2.83
83 155
1.00 1.07
0.89–1.25
113 125
1.00 1.25
1.09–1.40
134 104
1.00 1.96
1.29–2.63
The high prevalence of the problem in the latter postpartum periods (beyond 2 months) might indicate the consequence of the pressures of parenting and postpartum adjustment on sexual health.
95% CI
Women’s reluctance to seek care
X2 = 35.32; p-value = 0.000. −2 log likelihood = 267.190.
Despite the problem being widespread, women were reluctant to seek care. Sexual health problems in general are considered a taboo in the Lebanese context. This might restrict women’s health care seeking behavior, especially considering the difficulties in communication between health care providers and women regarding sexual health issues [24] and the major deficiencies in postpartum care offered in Lebanon [25]. Studies looking into sexual health postpartum did not assess women’s health care seeking behavior. One study by Glazener [2] reports that during the 6-week postpartum check, problems with intercourse were mentioned less often than other postpartum health problems in a sample of women in Scotland. Painful intercourse in the postpartum period and parity
Discussion Our findings indicate that cesarean sections and first deliveries increase the odds of experiencing pain during intercourse in the postpartum period. In our sample of women, reporting of pain during intercourse in the postpartum period was very common, whereas health care was not sought for the vast majority of these women. Cesarean section not protective against painful intercourse in the postpartum period In our sample, women who delivered by cesarean section were more likely to experience pain during intercourse postpartum. Similar findings are reported by Klein et al. [14] where women undergoing cesarean section were more likely to report pain during intercourse than those having a vaginal delivery with intact perineum. It is not possible from our data to ascertain the extent of perineal injury and therefore difficult to make comparisons per se. In this regard, it is important to note that studies indicating the protective factor of cesarean sections on sexual health problems also point to wearing of that protection beyond 3 months postpartum [13]. Complications of cesarean section may result in poor overall postpartum maternal health therefore affecting sexual health in general. Since cesarean section is believed to be protective against perineal injury and is thus one of the reasons why women would opt for it as a mode of delivery [21] and in the light of inconsistent findings from the literature, counseling of women on this issue during the antenatal period should be encouraged. The burden of painful intercourse in the postpartum period Our findings indicate that a high proportion of women suffer from pain during intercourse in the postpartum period, specifically in the period between 2 and 4 months postpartum and the vast majority of the women are experiencing this problem for the first time after giving birth. It is to be noted that, in this sample, women have reported more physical and psychological health problems in the period 4–6 months postpartum than in the period 2–4 months postpartum [22]. This finding is supported by previous studies [5,6,8] with 41%–67% of women reporting suffering from pain during intercourse by 3 months postpartum [3,6,23]. Barrett et al. [3] reported that 62% of women experienced pain during intercourse in the first three months and 31% at six months postpartum in contrast to only 12% experiencing it in the year prior to pregnancy.
Our data show that primiparous women were most likely to experience pain during intercourse postpartum. This finding is highly consistent with the literature [1,8,17] and could be due to the difficulties primiparous women face in adjusting to the postpartum period that could be related to their lack of experience and unrealistic expectations. The fact that women from the Mount Lebanon region were more likely to report pain during intercourse postpartum compared to those from the South, could be explained by differences in expectations or in reporting of this problem between different regions in Lebanon. Although there were slightly higher rates of cesarean section among women from the Mount Lebanon region compared to the South, the effect of the region on reporting of pain during intercourse postpartum remained significant after adjustment. Our sample included more rural regions from the South than from Mount Lebanon. This observed difference can be a reflection of the cultural differences of perceiving and reporting illhealth rather than worse health status as well as in shaping women’s expectations in this regard. Study limitations Our study is the first from Arab countries and among the very few from the developing world reporting on sexual health problems of postpartum women. There are, however, some limitations that should be noted. Since the study aimed at assessing postpartum health in general, the whole array of sexual health problems was not covered. The data also do not include a differentiation between emergency and elective cesarean sections. Another limitation might be the fact that the study population was recruited from private clinics. Despite the fact that private care is utilized by the majority of the Lebanese population, the findings may not be generalizable to the 10–20% of women using public centers to receive antenatal care. Conclusion Our findings show that cesarean births for primiparous women increase the chance of experiencing pain during intercourse in the postpartum period. This suggests that advice and treatment for sexual health problems can be vastly improved by revisiting the organization and delivery of antenatal and postpartum services. In contexts where antenatal care is used more often than postpartum care services, there is a lost opportunity with regard to the information that can be shared with women about the postpartum period especially considering that the six week postpartum
T. Kabakian-Khasholian et al./Sexual & Reproductive Healthcare 6 (2015) 44–47
checkup may be too early for women to discover sexual health problems. There is a need to broaden the research on postpartum sexual morbidity in developing country settings by further exploring the determinants of pain during intercourse including mode of delivery and by expanding our understanding of women’s interpretation of that experience. This will inform and shape culturally sensitive maternal health service provision in response to women’s experiences of ill-health in the postpartum period. References [1] Brown S, Lumley J. Maternal health after childbirth: results of an Australian population based study. Br J Obstet Gynaecol 1998;105:156–61. [2] Glazener CM. Sexual function after childbirth: women’s experiences, persistent morbidity and lack of professional recognition. Br J Obstet Gynaecol 1997;104:330–5. [3] 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. [4] Kennedy CM, Turcea AM, Bradley CS. Prevalence of vulvar and vaginal symptoms during pregnancy and the puerperium. Int J Gynecol Obstet 2009;105:236–9. [5] Connolly AM, Thorp J, Pahel L. Effects of pregnancy and childbirth on postpartum sexual function: a longitudinal prospective study. Int Urogynecol J Pelvic Floor Dysfunct 2005;16:263–7. [6] 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;184:881–8. [7] Hannah ME, Hannah WJ, Hodnett ED, Chalmers B, Kung R, Willian A. Outcomes at 3 months after planned cesarean vs planned vaginal delivery for breech presentation at term. The international randomized term breech trial. JAMA 2002;287:1822–31. [8] Schytt E, Lindmark G, Waldenstrom U. Physical symptoms after childbirth: prevalence and associations with self-rated health. Br J Obstet Gynaecol 2005;112:210–17. [9] Bertozzi S, Londero AP, Fruscalzo A, Driul L, Delneri C, Calcagno A, et al. Impact of episiotomy on pelvic floor disorders and their influence on women’s wellness after the sixth month postpartum: a retrospective study. BMC Womens Health 2011;11:12.
47
[10] Baytur YB, Deveci A, Uyar Y, Ozcakir HT, Kizilaya S, Caglar H. Mode of delivery and pelvic floor muscle strength and sexual function after childbirth. Int J Gynecol Obstet 2005;88:276–80. [11] Abdool Z, Thakar R, Sultan AH. Postpartum female sexual function. Eur J obstet Gynecol Reprod Biol 2009;145:133–7. [12] Safarninejad M, Kolahi A, Hosseini L. The effect of the mode of delivery on the quality of life, sexual function and sexual satisfaction in primiparous women and their husbands. J Sex Med 2009;6:1645–67. [13] Barrett G, Peacock J, Victor C, Manyonda I. Cesarean section and postnatal sexual health. Birth 2005;32:306–11. [14] Klein MC, Kaczorowski J, Firoz T, Hubinette M, Jorgensen S, Gauthier R. A comparison of urinary and sexual outcomes in women experiencing vaginal and caesarean births. J Obstet Gynaecol Can 2005;27:332–9. [15] Goetsch M. Postpartum dyspareunia. An unexplored problem. J Reprod Med 1994;4:963–8. [16] Brown S, Lumley J. Physical health problems after childbirth and maternal depression at six to seven months postpartum. Br J Obstet Gynaecol 2000;107:1194–201. [17] 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. [18] DeJong J, Akik C, El Kak F, Osman H, El-Jardali F. The safety and quality of childbirth in the context of health systems: mapping maternal health provision in Lebanon. Midwifery 2010;26:549–57. [19] Tutelian M, Khayyat M, Abdel Monem A. Lebanon Family Health Survey 2004. Principal Report. The Republic of Lebanon, The Central administration of Statistics and The Pan Arab Project for Family Health. 2007. [20] Kabakian-Khasholian T, Campbell OMR. Impact of written information on women’s use of postpartum services: a randomized controlled trial. Acta Obstet Gynecol Scand 2007;86(7):793–8. [21] Sultan AH, Stanton SL. Preserving the pelvic floor and perineum during childbirth-elective caesarean section? Br J Obstet Gynaecol 1996;103:731–4. [22] Kabakian-Khasholian T, Shayboub R, Attaya A. Health after childbirth: patterns of reported postpartum morbidity from Lebanon. Women Birth 2014;27:15–20. [23] Clarkson J, Newton C, Bick D. Achieving sustainable quality in maternity services: using audit of incontinence and dyspareunia to identify shortfalls in meeting standards. BMC Pregnancy Childbirth 2001;1(4):1293–6. [24] El-Kak F, Jurdi R, Kaddour A, Zurayk H. Gender and sexual health in clinical practice in Lebanon. Int J Gynaecol Obstet 2004;87(3):260–6. [25] Kabakian-Khasholian T, Jurdi R, El-Kak F. What is happening during the postnatal visit? Health Care Women Int 2006;27(9):839–47.