A scoping review on women's sexual health in the postpartum ...

Wood et al. Reproductive Health (2022) 19:112 https://doi.org/10.1186/s12978-022-01399-6

REVIEW

A scoping review on women’s sexual health in the postpartum period: opportunities for research and practice within low-and middle-income countriesShannon N. Wood1* , Alexandria Pigott1, Haley L. Thomas1, Chloe Wood2 and Linnea A. Zimmerman1

Abstract

Background: Women’s sexual health is generally defined and explored solely in relation to reproductive capacity, and often omits elements of sexual function and/or dysfunction. Concerted focus is given to women’s health during pregnancy; however, women’s sexual health is largely neglected after childbirth. This scoping review explored how the sexual health of postpartum women has been defined, measured, and researched in low- and middle-income countries (LMICs).

Methods: Articles eligible for review were those that investigated women’s sexual health during the first 12 months postpartum and were conducted among women aged 15–49 in LMICs. Eligibility was further restricted to stud-ies that were published within the last 20 years (2001–2021). The initial PubMed search identified 812 articles, but upon further eligibility review, 97 remained. At this time, the decision was made to focus this review only on articles addressing sexual function and/or dysfunction, which yielded 46 articles. Key article characteristics were described and analyzed by outcome.

Results: Of the final included articles, five studies focused on positive sexual health, 13 on negative sexual health, and the remaining 28 on both positive and negative sexual health or without specified directionality. The most com-mon outcome examined was resumption of sex after childbirth. Most studies occurred within sub-Saharan Africa (n = 27), with geographic spread throughout the Middle East (n = 10), Asia (n = 5), North Africa (n = 3), and cross-geography (n = 1); notably, all five studies on positive sexual health were conducted in Iran. Negative sexual health outcomes included vaginismus, dyspareunia, episiotomy, perineal tears, prolapse, infection, obstetric fistula, female genital cutting, postnatal pain, uterine prolapse, coercion to resume sex, sexual violence, and loss of sexual desire/arousal. Most studies were quantitative, though eight qualitative studies elucidated the difficulties women endured in receiving information specific to sexual health and hesitance in seeking help for sexual morbidities in the postpartum period.

Conclusions: Overall, the evidence base surrounding women’s sexual health in the postpartum period within LMICs remains limited, with most studies focusing solely on the timing of resumption of sex. Integration of sexual health

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*Correspondence: [email protected] Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USAFull list of author information is available at the end of the article

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of 34Wood et al. Reproductive Health (2022) 19:112

IntroductionWomen’s health is often framed in relation to reproduc-tive capacity, with less attention on the wide spectrum of health outcomes that are both unique to women or disproportionately impact women [1, 2]. The sexual and reproductive health (SRH) field has been largely criti-cized for underemphasis on the “S” in SRH, where these critiques highlight underinvestment in and lack of poli-cies surrounding women’s sexual health [3, 4]. Sexual health, or “the positive and respectful approach to sexual relationships, including pleasurable and safe sexual expe-riences, free from coercion, discrimination, or violence” [5], is a cornerstone of Sustainable Development Goal-5 [6], however, indicators notably center around infringe-ments on sexual rights, including sexual violence, child marriage, and female genital cutting (FGC), rather than addressing positive outcomes, such as voluntary resump-tion of sex or sexual pleasure.

Pregnancy and childbirth are profound physical and psychological transition periods for women, and vast literature has documented the impact of pregnancy on women’s sexual health, including the necessity of sexual health counseling during antenatal care visits and childbirth classes [7, 8]. Further, a number of stud-ies from high-income countries, including systematic reviews, have explored specific sexual function or dys-function outcomes during the postpartum period [9–11]. These studies reveal the high prevalence of sexual morbidities, such as dyspareunia, incontinence, lack of desire, and change in sensations of pleasures following childbirth, as well need for effective interventions and

counseling strategies to navigate them [9–11]. Addi-tionally, the effects of psychological changes within the postpartum period must be considered, as postnatal depression affects as many as one in five women and can have a profound impact on sexual desire and the perception of sexual pleasure [7]. Despite the research supporting interventions, postpartum sexual health care remains regionalized, under-funded, and without policy support, even within high-income countries.

In low- and middle-income countries (LMICs), many women deliver at home or in facilities that are ill-equipped for obstetric emergencies [12], placing them at increased risk of both short- and long-term deliv-ery complications [13, 14], including sexual health morbidities [15]. Antenatal and postnatal care are key intervention points for sexual health education and counseling; however, coverage of these services varies substantially, both within and across LMIC contexts [7, 16, 17] Moreover, recent efforts to estimate the cover-age of quality services have found substantial gaps [16, 17]. Postnatal care, which consistently has lower cov-erage than antenatal care [18, 19], focuses largely on life-threatening danger signs to the child, with mater-nal health often limited to counseling on postpartum contraceptive use to prevent short interval pregnancies. Given these gaps in care, much less is known about the prevalence of postpartum sexual health complications and/or practices to mitigate dysfunctions and promote positive sexual health within LMICs.

Against this backdrop, the present study aims to syn-thesize the current literature on women’s sexual health

counseling into postnatal care and nonjudgmental service provision can help women navigate these bodily changes and ultimately improve their sexual health.

Plain language summary

Women’s sexual health is often studied in relation to reproductive health and childbearing. While reproductive health during pregnancy and immediately after is well documented, it remains unclear how women’s sexual health is addressed, particularly within low- and middle-income countries. The aim of this review is to understand how researchers have measured, defined, and examined postpartum sexual health. In October 2021, we searched PubMed database with the following criteria: published in the last 20 years; conducted in a low- or middle-income context; examined sexual function and/or dysfunction among women aged 15–49 within 1 year after childbirth. From this inclusion criteria, we identified 46 relevant articles. Most studies were conducted in sub-Saharan Africa. Only five stud-ies focused exclusively on positive sexual health, and the majority of studies examined the resumption of sex after childbirth. Multiple qualitative studies described women’s reluctance to seek help for postpartum sexual health issues and highlighted the difficulties they faced in receiving information specific to sexual health. Overall, the evidence base surrounding women’s sexual health after childbirth within low- and middle-income contexts is limited. Future research should examine sexual health beyond resumption of sex after childbirth and explore barriers to help-seeking for women experiencing sexual health issues. Further exploration of positive sexual health is needed across contexts.

Keywords: Sexual health, Postpartum, Sexual function, Sexual dysfunction


in the postpartum period, with a focus on research spe-cific to sexual function and dysfunction among women living in LMICs. Findings can inform research and practice guidelines within LMICs.

MethodsScoping review proceduresA scoping review was conducted to identify and sum-marize studies from LMICs, as described by Arksey and Malley [20], Levac, Colquhoun and O’Brien [21], and the PRISMA Extension for Scoping Reviews [22]. First, a search strategy was developed with the assistance of library informationists (Additional file 1: Table S1). This search was conducted within PubMed in October 26, 2021, with identified references imported into Covidence, a systematic literature review management program. Titles and abstracts of each reference were screened by one Masters-level researcher, with questions flagged for the first author. Full-text articles were then reviewed by two Masters-level researchers to determine final eligi-bility. Throughout the review process, eligibility criteria were discussed with the entire authorship team and any disputes resolved via discussion. All decisions were docu-mented within Covidence software.

Studies were eligible for inclusion if they were peer-reviewed, English-language articles, published within the past twenty years (2001 to 2021), and explored women’s sexual health in the postpartum period. Initially, the team adopted a broad definition of sexual health—in line with the World Health Organization’s definition and exam-ples—which included wide-ranging topics such as sexual expression, relationships, pleasure, sexually transmitted infections (STIs), sexual dysfunction, sexual violence, and harmful sexual practices [23]. Given the vast, well-documented literature on postpartum contraception, family planning, and return to fertility, the team chose to not include these terms within the search. During the full-text review of the literature, the team identified 97 articles that met the initial review criteria; of note, this initial review included topics such as human immuno-deficiency virus (HIV), sexually transmitted infections (STIs), reproductive cancers, fistula, reproductive tract infections (RTIs), uterine prolapse, FGC, sexual violence, sexual function, and sexual dysfunction. To allow for a more focused discussion while ensuring comprehensive coverage of positive and negative sexual health outcomes, the research team chose to narrow the inclusion criteria and focus solely on sexual function and/or dysfunction (defined further below); many of the initial topics were also included if the article concurrently discussed sexual function/dysfunction. Future work aims to explore the myriad of additional sexual health needs of women in the postpartum period.

Final inclusion criteria:

• Studies that examined women’s sexual health during the postpartum period.

• For the purpose of this scoping review, the post-partum period was defined as one year after deliv-ery.

• To allow for a comprehensive lens of sexual health and be in line with the World Health Organiza-tion’s definition, sexual health included both nega-tive and positive experiences; this review focuses on sexual function (including resumption of sex-ual activity, sexual pleasure, sexual satisfaction, arousal, intimacy, orgasm) and sexual dysfunction (including dyspareunia, sexual violence, sexual coercion)

• Studies focused on women of childbearing age (ages 15–49)

• Studies published in English• Studies conducted in low or low-middle economies,

as defined by the World Bank lending groups (2021–2022 classification)

• Studies published within the last 20 years (between 2001 and 2021)

Final exclusion criteria

• Studies that were not conducted with women less than one year postpartum (i.e., studies with only male partners or service providers)

• Studies not specific to sexual health, and specifically sexual function/dysfunction, as defined within the inclusion criteria

• Studies specific to rapid repeat pregnancy, unin-tended pregnancy, abortion, postpartum family plan-ning, contraceptive side-effects, or postpartum fertil-ity, including studies that examined sexual abstinence only in relation to fertility and family planning

• Literature reviews, case reports, study protocols, and grey literature

• Studies focused on morbidities experienced before or after, rather than during, the postpartum period

• Studies that focused on the perspectives of men and men’s sexual activity within the postpartum period

• Studies that focus on highly specific subgroups, such as HIV positive women only

Data extractionThe search yielded 812 results, all of which were screened via title and abstract review. Of these, 241 progressed to a


full-text review. Based on the initially broad inclusion cri-teria, 97 articles were eligible for inclusion. After further restricting the inclusion criteria to only studies involving sexual function and/or dysfunction, only 46 articles were eligible and included (Fig. 1). Key characteristics of each article (author, year, objective, population, study design, sexual health topic, results) were described in Microsoft Excel tables by two Masters-level researchers and con-solidated with input by the lead author; extracted data and study characteristics were then analyzed by positive sexual health (i.e., sexual function), negative sexual health (i.e., sexual dysfunction), and studies that reported both positive and negative sexual health or approached sexual health from a neutral perspective, which often exam-ined resumption of sex as an outcome without indica-tion of whether this outcome was viewed positively or negatively.

ResultsThe final inclusion and exclusion criteria yielded 46 articles (Tables 1, 2, 3). Of these 46 articles, five studies focused on positive sexual health, 13 studies on negative sexual health, and the remaining 28 on both positive and negative sexual health or without specified directionality. The most common outcome examined was resumption of sex after childbirth. The majority of studies occurred within sub-Saharan Africa (n = 27), with additional geo-graphic spread throughout the Middle East (n = 10), Asia (n = 5), and North Africa (n = 3); one study analyzed data from 17 Demographic and Health Surveys (DHS) [24]. Most studies were quantitative, including prospec-tive cohort, cross-sectional, and clinical trial designs; however, eight studies solely or supplementally collected qualitative data.

Positive sexual healthFive studies examined positive sexual health during the postpartum period with outcomes including libido, satis-faction, stimulation, orgasm, pelvic floor muscle strength, sexual self-efficacy, female sexual function (measured via the Female Sexual Function Index (FSFI)), and intimacy [25–29] (Table 1). Notably, all five studies were con-ducted within the Islamic Republic of Iran and largely within the context of interventions or utilizing com-parison groups. Specifically, Golmakani et al. examined the impact of a pelvic floor muscle exercise program on pelvic floor strength and sexual self-efficacy and found significant increases in both outcomes within the inter-vention compared to the control group [26]. Zamani et al. examined the effectiveness of sexual health counseling and found increased sexual satisfaction among interven-tion participants [29]. Two additional studies examined sexual function in relation to infant feeding practices,

with mixed results [25, 27]. Additionally, Nezhad and Goodarzi examined intimacy and sexuality within the context of partnerships and found that having a high level of intimacy could potentially buffer against negative effects of low sexual satisfaction on overall marital satis-faction [28].

Negative sexual healthThirteen studies explored negative sexual health out-comes, including vaginismus, dyspareunia, episiotomy, perineal tears, prolapse, infection, obstetric fistula, female genital cutting, postnatal pain, uterine prolapse, coercion to resume sex, sexual violence, and loss of sex-ual desire/arousal [30–42] (Table 2).

Dyspareunia, or painful intercourse, was one of the most examined negative sexual health outcomes for post-partum women. In Nigeria, Adanikin found that over one in three women reported dyspareunia within six months after delivery [31]. Similarly, in Ethiopia, approximately one in five women reported sexual morbidities upon resuming intercourse in the postpartum period, and dys-pareunia was the most common morbidity reported [37]. In Pakistan, dyspareunia was examined in relation to epi-siotomy, where dyspareunia was more prevalent among episiotomy patients than those without (69% vs. 12%) [36]. Further, in Nigeria, Oboro and Tabowei found that painful intercourse decreased throughout the postpar-tum period, with approximately 55% of women reporting painful intercourse at 6-weeks postpartum and dropping to less than 20% at 6-months postpartum; dyspareunia at 3-months postpartum was significantly more likely among women who had perineal trauma or reported pre-pregnancy dyspareunia [40].

Resumption of sex, if explored in relation to coercive or forced sex, was also included within negative sexual health outcomes. Postpartum sexual abstinence was largely practiced across settings (though length of time depended on cultural factors); however, not all women who resumed sex did so on their own accord. Specifically, in Ethiopia, among the 20% of women who had resumed sex within 6-weeks postpartum (and prior to the end of the 40 day sexual abstinence period largely observed within Ethiopia), half reported being pressured by their husband to resume intercourse [37].

While our search only uncovered three qualitative studies specific to negative sexual health, these studies were helpful for elucidating cultural beliefs and concerns surrounding sexual health in the postpartum period. In Cambodia, White explored Khmer women’s beliefs sur-rounding sex, specifically that resuming sex too soon after delivery, either by choice or by force, could cause physical health symptoms [42]. In Mozambique, women with fistula reported no sexual activity since onset, with


Fig. 1 Flow diagram of scoping review process


Tabl

e 1

Stud

ies

on p

ositi

ve p

ostp

artu

m s

exua

l hea

lth (n

= 5

)

Aut

hor (

Year

)Lo

catio

n an

d st

udy

desi

gnO

bjec

tive(

s)St

udy

popu

latio

nSp

ecifi

c to

pic(

s)Ke

y re

sults

Anh

aran

et a

l. (2

015)

[25]

Iran—

Cro

ss-s

ectio

nal

To a

sses

s po

stpa

rtum

sex

ual

func

tion

in m

othe

rs u

sing

dif-

fere

nt in

fant

feed

ing

met

hods

366

wom

en re

ferr

ed to

hea

lth

cent

ers

in M

ashh

ad; w

omen

w

ho w

ere

rece

ivin

g po

stpa

rtum

ca

re, c

hild

gro

wth

mon

itorin

g,

imm

uniz

atio

n, a

nd fa

mily

pla

n-ni

ng c

ouns

elin

g 4

mon

ths

afte

r ch

ildbi

rth

Libi

do, S

atis

fact

ion,

stim

ulat

ion,

O

rgas

m–

The

mea

n to

tal s

core

of s

exua

l fu

nctio

n va

ried

sign

ifica

ntly

be

twee

n gr

oups

par

ticip

atin

g in

di

ffere

nt in

fant

feed

ing

met

hods

(p

= 0

.04)

– Th

e ex

clus

ive

brea

stfe

edin

g gr

oup

had

the

high

est m

ean

scor

e fo

r tot

al s

exua

l fun

ctio

n, fo

l-lo

wed

by

the

brea

stfe

edin

g pl

us

com

plem

enta

ry fe

edin

g gr

oup,

th

en b

y fo

rmul

a on

ly, a

nd la

stly

by

bre

astfe

edin

g pl

us fo

rmul

a–

The

four

gro

ups

wer

e al

so

sign

ifica

ntly

diff

eren

t in

term

s of

m

ean

lubr

icat

ion

(p =

0.0

1) a

nd

satis

fact

ion

scor

es (p

= 0

.01)

; the

y w

ere

not s

igni

fican

tly d

iffer

ent i

n te

rms

of d

esire

, aro

usal

, org

asm

, or

pai

n m

ean

scor

es

Gol

mak

ani e

t al.

(201

5) [2

6]Ira

n—C

linic

al T

rial

To d

efine

the

effec

ts o

f an

8-w

eek

pelv

ic fl

oor m

uscl

e ex

erci

se p

rogr

am o

n se

xual

sel

f-effi

cacy

in p

rimip

arou

s w

omen

af

ter c

hild

birt

h

79 p

rimip

arou

s w

omen

who

w

ere

refe

rred

to h

ealth

car

e ce

nter

s in

Mas

hhad

, Ira

n in

20

13, 8

wee

ks a

fter

del

iver

y, to

re

ceiv

e he

alth

car

e se

rvic

es

Pelv

ic fl

oor m

uscl

e st

reng

th,

Sexu

al s

elf-

effica

cy–

Pelv

ic fl

oor s

tren

gth

incr

ease

d si

gnifi

cant

ly a

mon

g th

e in

terv

en-

tion

grou

p on

ly a

t 4 a

nd 8

wee

ks

afte

r exe

rcis

es (p

< 0

.001

)–

Pelv

ic fl

oor m

uscl

e sc

ores

at

8 w

eeks

wer

e si

gnifi

cant

ly d

if-fe

rent

bet

wee

n th

e co

ntro

l and

in

terv

entio

n gr

oups

(p <

0.0

01)

– Se

xual

sel

f-effi

cacy

sco

res

incr

ease

d si

gnifi

cant

ly fo

r bot

h th

e in

terv

entio

n (p

< 0

.001

) and

co

ntro

l (p =

0.0

01) g

roup

s at

4

and

8 w

eeks

aft

er th

e st

udy.

Se

xual

sel

f-effi

cacy

sco

res

at

8 w

eeks

wer

e si

gnifi

cant

ly d

if-fe

rent

bet

wee

n th

e co

ntro

l and

in

terv

entio

n gr

oups

(p =

0.0

01)


Tabl

e 1

(con

tinue

d)

Aut

hor (

Year

)Lo

catio

n an

d st

udy

desi

gnO

bjec

tive(

s)St

udy

popu

latio

nSp

ecifi

c to

pic(

s)Ke

y re

sults

Mirz

aei e

t al.

(202

1) [2

7]Ira

n—C

ross

-sec

tiona

lTo

ass

ess

the

impa

ct o

f CO

VID

-19

on

psyc

holo

gica

l hea

lth, s

ex-

ual f

unct

ion,

and

qua

lity

of li

fe

(QoL

) in

Irani

an p

regn

ant a

nd

lact

atin

g w

omen

and

com

pare

th

e re

sults

with

non

-pre

gnan

t/no

n-la

ctat

ing

wom

en

604

preg

nant

and

lact

atin

g w

omen

and

non

-pre

gnan

t/no

n-la

ctat

ing

wom

en;

May

–Jun

e 20

20

FSFI

sco

re it

ems

(des

ire, a

rous

al,

lubr

icat

ion,

org

asm

, sat

isfa

ctio

n,

and

pain

)

– W

hen

com

parin

g pr

egna

nt a

nd

lact

atin

g w

omen

, Fem

ale

Sexu

al

Func

tion

Inde

x (F

SFI)

scor

es d

id

not d

iffer

sig

nific

antly

for a

ny

sexu

al fu

nctio

n do

mai

n. T

otal

FSF

I sc

ores

for p

regn

ant a

nd la

ctat

ing

wom

en w

ere

near

ly e

quiv

alen

t–

Whe

n co

mpa

ring

lact

atin

g w

omen

with

thos

e ne

ither

lact

at-

ing

nor p

regn

ant,

FSFI

sco

res

for

the

follo

win

g do

mai

ns d

iffer

ed

sign

ifica

ntly

: des

ire (p

< 0

.001

), ar

ousa

l (p

< 0

.001

), or

gasm

(p

= 0

.007

), an

d pa

in (p

< 0

.001

)–

The

tota

l FSF

I sco

re fo

r lac

tatin

g w

omen

was

sig

nific

antly

low

er

than

for t

hose

nei

ther

lact

atin

g no

r pre

gnan

t (22

.72

and

26.1

9 re

spec

tivel

y; p

< 0

.001

)–

Am

ong

the

lact

atin

g an

d pr

eg-

nant

wom

en, 3

7% re

port

sex

ual

dysf

unct

ion

rela

ted

to lu

bric

atio

n,

com

pare

d to

54%

of w

omen

ne

ither

pre

gnan

t nor

lact

atin

g (p

< 0

.001

)


Tabl

e 1

(con

tinue

d)

Aut

hor (

Year

)Lo

catio

n an

d st

udy

desi

gnO

bjec

tive(

s)St

udy

popu

latio

nSp

ecifi

c to

pic(

s)Ke

y re

sults

Nez

had

& G

ooda

rzi (

2011

) [28

]Ira

n—C

ross

-sec

tiona

lTo

gai

n in

sigh

t reg

ardi

ng th

e pe

rcep

tions

of i

ntim

acy

and

sexu

ality

hel

d by

pos

tpar

tum

co

uple

s, an

d th

e re

latio

nshi

ps

of p

erce

ived

sex

ualit

y, a

nd

intim

acy

leve

ls o

n po

stpa

rtum

m

arita

l sat

isfa

ctio

n

128

post

part

um m

arrie

d co

u-pl

es o

f Ahv

az, I

ran

(6–3

6 w

eeks

po

stpa

rtum

) obt

aine

d th

roug

h cl

uste

r ran

dom

sam

plin

g w

ith

the

help

of c

hild

birt

h ce

nter

s

Sexu

ality

, Sex

ual s

atis

fact

ion,

In

timac

y–

Mos

t (91

%) o

f the

fem

ale

par-

ticip

ants

repo

rted

that

they

felt

heal

ed b

y 8

wee

ks a

fter

del

iver

y–

Gen

der w

as s

igni

fican

tly

asso

ciat

ed w

ith s

exua

lity,

with

th

e m

ale

part

icip

ants

repo

rtin

g a

high

er le

vel o

f sex

ualit

y th

an

the

fem

ale

part

icip

ants

, but

was

no

t sig

nific

antly

ass

ocia

ted

with

se

xual

sat

isfa

ctio

n, in

timac

y, o

r m

arita

l sat

isfa

ctio

n–

Am

ong

part

icip

ants

, whe

n to

tal

intim

acy

and

sexu

al s

atis

fact

ion

are

both

hig

h, m

arita

l sat

isfa

ctio

n w

as a

lso

high

for 1

00%

of p

artic

i-pa

nts,

vs. 6

8% w

hen

intim

acy

was

hi

gh a

nd s

exua

l sat

isfa

ctio

n w

as

low

(p =

0.0

06).

Am

ong

part

ici-

pant

s w

ith lo

w to

tal i

ntim

acy

and

high

sex

ual s

atis

fact

ion,

mar

ital

satis

fact

ion

was

stil

l hig

h–

Thes

e co

rrel

atio

ns w

ere

iden

ti-fie

d in

bot

h co

uple

and

indi

vidu

al

data

and

sug

gest

that

hav

ing

a hi

gh le

vel o

f int

imac

y m

ay b

uffer

th

e ne

gativ

e eff

ect t

hat l

ow

sexu

al s

atis

fact

ion

can

have

on

mar

ital s

atis

fact

ion

– Re

sults

als

o in

dica

te th

at-

wom

en’s

satis

fact

ion

with

thei

r ap

pear

ance

is p

ositi

vely

cor

-re

late

d w

ith s

exua

lity

(p <

0.0

01)

and

that

fatig

ue a

nd s

exua

lity

are

nega

tivel

y co

rrel

ated

(p <

0.0

01)

Zam

ani e

t al.

(201

9) [2

9]Ira

n—C

linic

al T

rial

To in

vest

igat

e th

e eff

ectiv

enes

s of

sex

ual h

ealth

cou

nsel

ing

on

wom

an’s

sexu

al s

atis

fact

ion

in

the

post

part

um p

erio

d

80 Ir

ania

n po

stna

tal w

omen

(a

ged

18–3

5) w

ho a

tten

ded

heal

th-c

are

cent

ers

3 m

onth

s to

1

year

aft

er c

hild

birt

h in

Mas

h-ha

d, Ir

an in

201

6

Sexu

al s

atis

fact

ion

– A

t bas

elin

e, s

exua

l sat

isfa

ctio

n sc

ores

did

not

diff

er s

igni

fican

tly

betw

een

the

inte

rven

tion

grou

p an

d co

ntro

l gro

up 8

wee

ks a

fter

th

e in

terv

entio

n; h

owev

er, s

exua

l sa

tisfa

ctio

n w

as s

igni

fican

tly

high

er in

the

inte

rven

tion

grou

p (p

= 0

.03)

– Pr

e- a

nd p

ost-

test

sex

ual s

atis

-fa

ctio

n sc

ores

diff

ered

sig

nifi-

cant

ly in

the

inte

rven

tion

grou

p on

ly (p

< 0

.001

)


one woman reporting that her husband had used her “handicap” to justify taking an additional wife [33].

Across studies/settings, many women reported sexual health morbidities following pregnancy and childbirth, however, help-seeking or participation within interven-tions was minimal. In Tunisia, Achour et al. reported that while women experienced vaginismus symptoms fol-lowing delivery, 60% did not feel that sex was important compared to motherhood, and no women completed the pelvic floor training program nor sought counseling from the sexologist [30]. Moreover, some studies reported that women did not feel comfortable discussing sexual health issues or felt providers were poorly equipped to handle matters surrounding sexual health. In Nigeria, while 98% of women in the study reported receiving counseling on contraception, only 29% reported discussions surround-ing sexual health [40]. Similarly, in Iran, women felt their sexual health needs during the postpartum period were often neglected by healthcare providers [39].

Additional findings included associations between RTIs and uterine prolapse and postpartum depression [41], a cross-sectional examination of abnormal vaginal discharges in Zambian women [38], perineal tearing and postpartum complications related to FGC in Ethiopia [35], and perineal tearing and genital prolapse in Bang-ladesh [34].

Positive and negative (or neutral) sexual healthStudies that examined both positive and negative sexual health outcomes or examined women’s health within the postpartum period from a neutral perspective are out-lined within Table 3 [24, 43–68] (n = 28). Of note, the majority of studies within this group explore prevalence or corelates of resumption of sex, with little discussion of the positive or negative impact of the timing of sexual activity within the postpartum period [24, 43, 46, 48–50, 53, 54, 58, 61, 66, 67]. In a multi-country DHS study, resumption of sex was related to the return of a woman’s menses [24], and this practice was corroborated via qual-itative data from Cote d’Ivoire [47] and Malawi [68]. In Cote d’Ivoire, Tanzania, Eswatini, and Malawi, postpar-tum sexual abstinence was further described in relation to breastfeeding or child developmental benchmarks, specifically the child being of age to walk [47, 56, 63, 68].

Multiple studies linked resumption of sexual activity to their husband’s sexual needs or demands [44, 52, 55, 57, 63]. A qualitative study in Cote d’Ivoire depicted this pressure on women to resume sex—while some women felt that polygynous marriages were useful in allowing for long abstinence periods, others expressed fear of infidel-ity and related STI risks [47]. In one study from Kenya, increased odds of resumption of sex was associated with past-month forced sex [53].

Few studies explored specific cultural practices, with-standing timing of resumption of sex, in relation to wom-en’s sexual health. In northern Nigeria, women reported a number of postpartum practices, including postpartum abstinence periods inclusive of confinement for 40 days after birth or longer, hot ritual baths, nursing in heated rooms, laying on heated beds, and consuming specific foods [51]. In Malawi, substantial regional variation per-sisted in cultural practices, however, need for postpar-tum abstinence was described in relation to healing the mother, partner, and child, with early resumption linked to numerous health complications [68].

Notably, within qualitative data, women described feel-ing less sexually attractive during the postpartum period and felt that decreased self-confidence impacted their sexual health and desire; however, they also indicated that partner acceptance of their body changes helped improve their anxiety surrounding sex [45]. Some women simply stated that they were too tired to engage in sex [54].

Within the studies on both negative and positive sex-ual health, women similarly reported difficulty seeking help or discussing sex with healthcare providers [44]. In one Nigerian study, fewer than two thirds of postpar-tum women sought help for the sexual morbidities they were experiencing, and prominent reasons for not seek-ing health included feeling shy, the problem resolving on its own, cultural or religious factors, and not having a female doctor to ask [52]. In Tanzania, women described that too much health education was provided at once during antenatal care, and felt that some of this informa-tion should be spread throughout postpartum care visits [56]. In Uganda, women noted that the advice provided by health workers at discharge was inconsistent, leaving them unsure of when to resume sexual activity and how to navigate associated health and safety risks [60].

DiscussionWhile our search yielded 46 studies examining sexual health in the postpartum period within LMICs, only five of these studies focused exclusively on positive sex-ual health. Rather, sexual health was generally framed within the context of delivery complications (episioto-mies, prolapse, fistula) or morbidities that continued into the postpartum period. Moreover, the vast majority of studies were conducted in sub-Saharan Africa—while this number of articles was nearly three-fold those from other geographies, many of these studies only examined the prevalence or correlates of sexual resumption. Over-all, the evidence base surrounding women’s sexual health in the postpartum period within LMICs remains limited in comparison to higher income countries and high-lights a need to explore a broader range of sexual health


Tabl

e 2

Stud

ies

on n

egat

ive

post

part

um s

exua

l hea

lth (n

= 1

3)

Aut

hor (

Year

)Lo

catio

n an

d st

udy

desi

gnO

bjec

tive(

s)St

udy

popu

latio

nSp

ecifi

c to

pic(

s)Ke

y re

sults

Ach

our e

t al.

(201

9) [3

0]Tu

nisi

a—Pr

ospe

ctiv

e Co

hort

To in

vest

igat

e th

e ps

ycho

so-

mat

ic im

pact

of v

agin

ism

us in

pr

egna

nt w

omen

and

eva

luat

e th

e qu

ality

of t

heir

ther

apeu

tic

care

in T

unis

ia

20 p

regn

ant f

emal

es w

ith d

iag-

nose

d va

gini

smus

at t

he ti

me

they

pre

sent

ed a

t an

emer

-ge

ncy

depa

rtm

ent,

follo

wed

in

to th

e po

stpa

rtum

per

iod

Vagi

nism

us–

Am

ong

part

icip

ants

who

had

a

vagi

nal d

eliv

ery,

75%

con

side

red

thei

r vag

inis

mus

to b

e cu

red

fol-

low

ing

deliv

ery;

n =

4, h

owev

er,

expe

rienc

ed a

ggra

vate

d va

gini

smus

sy

mpt

oms

follo

win

g th

eir v

agin

al

deliv

ery

– Th

ough

reco

mm

ende

d, n

o pa

rtic

ipan

ts to

ok p

art i

n pe

lvic

floo

r tr

aini

ng p

ostp

artu

m. S

imila

rly, a

ll pa

rtic

ipan

ts w

ere

dire

cted

tow

ards

a

sexo

logi

st fo

r pos

tpar

tum

follo

w-

up fo

r the

ir va

gini

smus

, but

non

e pu

rsue

d: 2

0% w

ere

unin

tere

sted

in

reso

lvin

g th

eir v

agin

ism

us w

hile

60

% re

fere

nced

that

thei

r sex

ual

life

was

of m

inim

al im

port

ance

co

mpa

red

to m

othe

rhoo

d–

70%

repo

rted

feel

ing

mis

unde

r-st

ood

by th

eir h

ealth

pro

vide

rs

durin

g pr

egna

ncy

Ada

niki

n et

al.

(201

5) [3

1]N

iger

ia—

Pros

pect

ive

Coho

rtTo

det

erm

ine

the

hist

ory

of

resu

mpt

ion

of in

terc

ours

e af

ter c

hild

birt

h an

d as

soci

ated

co

ntra

cept

ive

prac

tices

am

ong

wom

en in

the

sout

hwes

t re

gion

of N

iger

ia

181

wom

en w

ith li

ve b

irths

w

ho d

eliv

ered

in a

n O

BGYN

te

achi

ng h

ospi

tal i

n A

do-

Ekiti

—in

terv

iew

ed w

eekl

y un

til

6-m

onth

s po

stpa

rtum

Resu

mpt

ion

of s

ex, D

ys-

pare

unia

– 27

.6%

of p

artic

ipan

ts h

ad

resu

med

sex

ual i

nter

cour

se w

ithin

6

wee

ks o

f chi

ldbi

rth,

63.

3% w

ithin

3

mon

ths,

and

70.2

% w

ithin

6 m

onth

s–

The

perio

d pr

eval

ence

of

dysp

areu

nia

with

in 6

mon

ths

of

deliv

ery

was

36.

2%–

Whi

le 7

8.4%

of p

artic

ipan

ts w

ho

had

had

a va

gina

l del

iver

y re

sum

ed

sexu

al in

terc

ours

e w

ithin

6 m

onth

s of

chi

ldbi

rth,

sig

nific

antly

few

er

(59.

2%) o

f tho

se w

ho h

ad h

ad a

ca

esar

ean

sect

ion

had

resu

med

by

this

tim

e–

Resu

mpt

ion

of s

exua

l int

erco

urse

w

as n

ot a

ssoc

iate

d w

ith p

erin

eal

inju

ry o

r exp

erie

nce

of d

yspa

reun

ia


Tabl

e 2

(con

tinue

d)

Aut

hor (

Year

)Lo

catio

n an

d st

udy

desi

gnO

bjec

tive(

s)St

udy

popu

latio

nSp

ecifi

c to

pic(

s)Ke

y re

sults

Ass

arag

et a

l. (2

013)

[32]

Mor

occo

—C

ross

-sec

tiona

lTo

mea

sure

and

iden

tify

the

caus

es o

f pos

tpar

tum

mor

bid-

ity 6

wee

ks a

fter

del

iver

y an

d to

co

mpa

re w

omen

’s pe

rcep

-tio

n of

thei

r hea

lth d

urin

g th

is p

erio

d to

thei

r med

ical

di

agno

ses

All

wom

en a

ged

18 to

49

in

the

Al M

assi

ra d

istr

ict w

ho h

ad

deliv

ered

bet

wee

n D

ecem

ber

2010

and

Mar

ch 2

012

in th

e de

liver

y ho

use,

hos

pita

l mat

er-

nity

war

ds, o

r priv

ate

clin

ics

(n =

121

0)

Epis

ioto

my,

Pro

laps

e, In

fec-

tions

– 4

4% e

xpre

ssed

one

or m

ore

com

plai

nts

at th

eir p

ostp

artu

m

cons

ulta

tion.

Of t

hose

with

a c

om-

plai

nt, 9

1% d

id n

ot c

onsu

lt w

ith a

ph

ysic

ian

abou

t the

ir co

mpl

aint

(s)

– Th

e m

ost f

requ

ent c

ompl

aint

re

port

ed d

urin

g a

post

part

um

cons

ulta

tion

was

men

tal d

istr

ess,

follo

wed

by

geni

tal i

nfec

tions

(in

clud

ing

vagi

nal d

isch

arge

and

/or

leak

ing)

, and

bre

ast p

robl

ems

– A

dditi

onal

ly, 1

0% o

f par

ticip

ants

re

port

ed o

ther

gyn

ecol

ogic

al a

nd

obst

etric

com

plai

nts

(incl

udin

g ut

erin

e pr

olap

se, s

exua

l pro

blem

s, an

d in

fect

ed e

pisi

otom

y). L

astly

, 2%

of

par

ticip

ants

repo

rted

bur

ning

du

ring

urin

atio

n an

d 1%

repo

rted

ur

inar

y le

akag

e–

A h

ighe

r pre

vale

nce

of p

ostp

ar-

tum

com

plai

nts

was

iden

tified

am

ong

wom

en a

ged

30 a

nd a

bove

, em

ploy

ed w

omen

, wom

en th

at h

ad

deliv

ered

in th

e pr

ivat

e se

ctor

or a

t ho

me,

and

wom

en w

ith c

ompl

ica-

tions

dur

ing

deliv

ery

Boen

e et

al.

(202

0) [3

3]M

ozam

biqu

e—Q

ualit

ativ

eTo

des

crib

e w

omen

’s ex

peri-

ence

s of

ant

enat

al, p

artu

m a

nd

post

-par

tum

car

e in

sou

ther

n M

ozam

biqu

e, a

nd to

pin

poin

t th

ose

expe

rienc

es th

at a

re

uniq

ue to

wom

en w

ith fi

stul

a

14 w

omen

with

a p

ositi

ve d

iag-

nosi

s of

fist

ula

and

an e

qual

nu

mbe

r with

out,

betw

een

the

ages

of 1

6 an

d 49

Obs

tetr

ic fi

stul

a–

Am

ong

the

14 p

artic

ipan

ts w

ith a

fis

tula

dia

gnos

is, s

ix w

ere

repo

rtin

g on

thei

r firs

t birt

h, n

ine

repo

rted

ly

had

a ca

esar

ean

deliv

ery,

and

10

had

a st

illbi

rth

– M

ost w

omen

with

an

obst

etric

fis

tula

repo

rted

not

hav

ing

had

sex

sinc

e its

ons

et–

One

wom

an re

port

ed th

at h

er

husb

and

had

just

ified

taki

ng a

se

cond

wife

bec

ause

of h

er fi

stul

a,

whi

ch h

e vi

ewed

as

a ha

ndic

ap


Tabl

e 2

(con

tinue

d)

Aut

hor (

Year

)Lo

catio

n an

d st

udy

desi

gnO

bjec

tive(

s)St

udy

popu

latio

nSp

ecifi

c to

pic(

s)Ke

y re

sults

Ferd

ous

et a

l. (2

012)

[34]

Bang

lade

sh—

Pros

pect

ive

Coho

rtTo

inve

stig

ate

the

asso

cia-

tion

of p

ostp

artu

m m

ater

-na

l mor

bidi

ties/

disa

bilit

ies

with

var

ious

acu

te o

bste

tric

co

mpl

icat

ions

aris

ing

durin

g pr

egna

ncy

or d

eliv

ery,

and

with

so

ciod

emog

raph

ics

and

othe

r ke

y ch

arac

teris

tics

of w

omen

at

del

iver

y

N =

103

7 w

omen

with

four

cat

-eg

orie

s of

del

iver

ies:

unco

m-

plic

ated

nor

mal

vag

inal

birt

h,

thos

e w

ho s

uffer

ed a

per

inat

al

deat

h, th

ose

who

had

sev

ere

or le

ss s

ever

e co

mpl

icat

ions

du

ring

preg

nanc

y or

del

iver

y,

or th

ose

who

had

a C

-sec

tion

but n

o re

cord

ed m

ater

nal

indi

catio

n

Prol

apse

, Fis

tula

, Inf

ectio

n,

Perin

eal t

ear

– Se

xual

hea

lth o

utco

mes

var

ied

sign

ifica

ntly

by

the

pres

ence

/typ

e of

del

iver

y co

mpl

icat

ion,

incl

udin

g pe

rinea

l tea

r (p

< 0

.001

), cl

ini-

cally

dia

gnos

ed g

enita

l inf

ectio

n (p

= 0

.04)

, and

ute

rine

prol

apse

(p

< 0

.001

)–

Part

icip

ants

who

exp

erie

nced

de

liver

y co

mpl

icat

ions

, com

pare

d to

thos

e w

ho d

id n

ot, w

ere

less

lik

ely

to e

xper

ienc

e ge

nita

l pro

laps

e or

per

inea

l tea

ring

– Pa

rtic

ipan

ts w

ith a

per

inat

al

deat

h, c

ompa

red

to th

ose

with

an

unco

mpl

icat

ed b

irth,

wer

e m

ore

likel

y to

be

diag

nose

d w

ith a

gen

ital

infe

ctio

n an

d le

ss li

kely

to e

xper

i-en

ce g

enita

l pro

laps

e–

Part

icip

ants

that

had

a c

esar

ean

sect

ion,

com

pare

d to

thos

e w

ith a

n un

com

plic

ated

birt

h, w

ere

less

like

ly

to e

xper

ienc

e ge

nita

l pro

laps

e–

Perin

eal t

earin

g w

as m

ore

prev

alen

t am

ong

wom

en o

ver 3

0,

amon

g w

omen

with

par

ity o

ver

four

, am

ong

wom

en in

the

poor

est

wea

lth q

uint

ile, a

mon

g w

omen

w

ho d

eliv

ered

at h

ome,

and

am

ong

wom

en th

at h

ad a

vag

inal

del

iver

y–

Prol

apse

was

mor

e lik

ely

to o

ccur

am

ong

wom

en a

ged

20–2

9 an

d 30

+ v

s. w

omen

und

er 2

0, a

nd

amon

g w

omen

with

par

ity o

f 2–4

an

d 4 +

vs.

parit

y of

1. P

rola

pse

was

less

like

ly a

mon

g w

omen

who

ha

d a

cesa

rean

sec

tion

vs. v

agin

al

deliv

ery

– Pe

rinea

l tea

ring

was

mor

e lik

ely

to

occu

r am

ong:

wom

en a

ged

30 +

vs.

wom

en a

ged

< 2

0; w

omen

who

de

liver

ed a

t hom

e vs

. in

a ho

spita

l; an

d w

omen

with

per

inat

al d

eath

vs.

a liv

e ba

by–

Gen

ital i

nfec

tion

was

mor

e lik

ely

to o

ccur

am

ong

wom

en w

ith

perin

atal

dea

th


Tabl

e 2

(con

tinue

d)

Aut

hor (

Year

)Lo

catio

n an

d st

udy

desi

gnO

bjec

tive(

s)St

udy

popu

latio

nSp

ecifi

c to

pic(

s)Ke

y re

sults

Gud

u an

d A

bdul

ahi (

2017

) [35

]Et

hiop

ia—

Pro

spec

tive

Coho

rtTo

ass

ess

labo

r, de

liver

y, a

nd

post

part

um c

ompl

icat

ions

in

nul

lipar

ous

wom

en w

ith

FGM

/C a

nd e

valu

ate

the

attit

ude

of m

othe

rs to

war

ds

elim

inat

ion

of F

GM

288

nulli

paro

usw

omen

out

of 1

,125

mot

hers

ad

mitt

ed fo

r lab

or a

ndde

liver

y in

the

stud

y pe

riod

FGM

/FG

C, I

nfec

tion

– Th

ere

was

a 9

1.7%

pre

vale

nce

of

fem

ale

geni

tal c

uttin

g (F

GM

/C).

Of

thos

e w

ho h

ad e

xper

ienc

ed F

GM

/C,

7.6%

had

Typ

e-II

FGM

/C, w

hile

92

.4%

had

Typ

e-III

. The

age

at w

hich

pa

rtic

ipan

ts e

xper

ienc

ed F

GM

/C

rang

ed fr

om 2

–9 y

ears

old

– 90

.3%

of p

artic

ipan

ts b

elie

ved

FGM

/C to

neg

ativ

ely

impa

ct la

bor

and

deliv

ery.

All

part

icip

ants

who

un

derw

ent F

GM

/C w

ere

fear

ful

abou

t pro

blem

s th

at m

ay a

rise

durin

g la

bor o

r del

iver

y as

a re

sult

of th

e FG

M/C

– A

nter

ior e

pisi

otom

y w

as n

eede

d to

faci

litat

e de

liver

y fo

r 83.

0% o

f pa

rtic

ipan

ts, a

ll of

who

m h

ad ty

pe-

III F

GM

/C–

In to

tal,

29.0

% o

f par

ticip

ants

ex

perie

nced

spo

ntan

eous

per

inea

l te

arin

g (3

1.1%

with

FG

M/C

; 8.3

%

with

out)

– Po

stpa

rtum

com

plic

atio

ns

occu

rred

in 3

9% o

f par

ticip

ants

(2

5.7%

pos

tpar

tum

hem

orrh

age,

24

% g

enita

l inf

ectio

n, a

nd 1

2%

psyc

holo

gica

l dis

turb

ance

)–

Post

part

um h

emor

rhag

e w

as p

re-

sent

in 2

7% o

f wom

en w

ith F

GM

/C

and

8% o

f tho

se w

ithou

t FG

M/C

– Po

stpa

rtum

infe

ctio

n w

as p

rese

nt

in 1

4% o

f wom

en w

ith F

GM

/C a

nd

4% o

f tho

se w

ithou

t FG

M/C

Isla

m e

t al.

(201

3) [3

6]Pa

kist

an—

Rand

omiz

ed e

xper

i-m

ent

To a

sses

s th

e m

orbi

dity

from

ep

isio

tom

y10

0 pa

tient

s w

ho w

ere

give

n a

med

iola

tera

l epi

siot

omy

(gro

up

I) an

d an

equ

al n

umbe

r (gr

oup

II) w

ho d

eliv

ered

with

out

epis

ioto

my

Perin

eal t

earin

g, V

agin

al

lace

ratio

ns, P

ostn

atal

pa

in, D

yspa

reun

ia, U

terin

e pr

olap

se

– A

mon

g pa

tient

s w

ith e

pisi

otom

y,

69%

repo

rted

pos

tnat

al p

ain,

vs.

12%

with

out e

pisi

otom

y. S

imila

rly,

69%

of t

he e

pisi

otom

y gr

oup

repo

rted

dys

pare

unia

, vs.

12%

from

w

ithou

t epi

siot

omy

grou

p–

No

sign

ifica

nt d

iffer

ence

s in

pre

s-su

re, i

ncon

tinen

ce, o

r ute

rine

pro-

laps

e be

twee

n th

ose

who

rece

ived

ep

isio

tom

y an

d th

ose

who

did

not


Tabl

e 2

(con

tinue

d)

Aut

hor (

Year

)Lo

catio

n an

d st

udy

desi

gnO

bjec

tive(

s)St

udy

popu

latio

nSp

ecifi

c to

pic(

s)Ke

y re

sults

Jam

bola

et a

l. (2

020)

[37]

Ethi

opia

—C

ross

-sec

tiona

lTo

ass

ess

the

early

resu

mp-

tion

of s

exua

l int

erco

urse

(i.e

., be

fore

6 w

eeks

pos

tpar

tum

) an

d as

soci

ated

fact

ors

amon

g po

stpa

rtum

wom

en a

tten

ding

pu

blic

hea

lth in

stitu

tions

in

Wes

tern

Eth

iopi

a

509

post

part

um w

omen

w

ho c

ame

for p

ostn

atal

car

e or

bro

ught

thei

r bab

ies

for

imm

uniz

atio

n to

one

of t

he

part

icip

atin

g pu

blic

faci

litie

s 6

wee

ks a

fter

chi

ldbi

rth

Resu

mpt

ion

of s

ex, S

exua

l M

orbi

ditie

s, Co

erci

ve s

ex/

pres

sure

to re

sum

e

– 20

.2%

of p

artic

ipan

ts re

sum

ed

inte

rcou

rse

durin

g th

e fir

st 6

wee

ks

post

part

um. O

f tho

se w

ho re

sum

ed

sex

durin

g th

e pu

erpe

rium

, 46.

6%

repo

rted

bei

ng p

ress

ured

by

thei

r hu

sban

d to

resu

me

inte

rcou

rse

– Fe

w p

artic

ipan

ts (1

6.9%

) had

re

ceiv

ed g

uida

nce

or in

form

atio

n ab

out i

nter

cour

se d

urin

g th

e po

st-

part

um p

erio

d–

Am

ong

the

sexu

ally

act

ive

part

ici-

pant

s, 22

.4%

repo

rted

one

or m

ore

sexu

al m

orbi

ditie

s or

pro

blem

s up

on re

sum

ing

inte

rcou

rse.

Pro

b-le

ms

incl

uded

dys

pare

unia

(41.

7%),

vagi

nal d

ryne

ss (2

7.1%

), re

duce

d se

xual

des

ire (1

0.4%

), va

gina

l bl

eedi

ng (8

.3%

), ab

norm

al v

agin

al

disc

harg

e (6

.3%

), an

d va

gina

l tig

ht-

ness

(6.5

%)

– W

omen

who

resu

med

sex

ear

ly

used

con

trac

eptio

n le

ss fr

eque

ntly

th

an th

ose

who

resu

med

aft

er

6 w

eeks

pos

tpar

tum

(41.

8% v

s. 71

.2%

)–

Am

ong

thos

e w

ho h

ad n

ot y

et

resu

med

sex

ual a

ctiv

ity, r

easo

ns fo

r ab

stin

ence

incl

uded

: fee

ling

it w

as

not y

et a

ccep

tabl

e to

resu

me,

the

husb

and

bein

g un

avai

labl

e, a

void

-in

g pr

egna

ncy,

feel

ing

unw

ell,

reli-

giou

s re

ason

s, be

ing

unin

tere

sted

, an

d ad

vice

from

a h

ealth

wor

ker

– In

mul

tivar

iabl

e an

alys

is, t

he

likel

ihoo

d of

hav

ing

resu

med

se

xual

inte

rcou

rse

was

sig

nific

antly

as

soci

ated

with

: the

mot

her h

avin

g so

me

seco

ndar

y-le

vel e

duca

tion

(aO

R 0.

22),

low

par

ity (a

OR

3.52

), th

e hu

sban

d ha

ving

som

e el

emen

tary

-le

vel (

aOR

0.23

) or s

econ

dary

-leve

l (a

OR

0.25

) edu

catio

n, n

orm

al

vagi

nal d

eliv

ery

(aO

R 5.

44),

havi

ng

a m

ale

infa

nt (a

OR

1.94

), w

ant-

ing

anot

her c

hild

(aO

R 5.

71),

and

bein

g pr

essu

red

by th

e hu

sban

d to

re

sum

e se

x (a

OR

9.89

)


Tabl

e 2

(con

tinue

d)

Aut

hor (

Year

)Lo

catio

n an

d st

udy

desi

gnO

bjec

tive(

s)St

udy

popu

latio

nSp

ecifi

c to

pic(

s)Ke

y re

sults

Lagr

o et

al.

(200

3) [3

8]Za

mbi

a—C

ross

-sec

tiona

lTo

kno

w if

wom

en e

xper

ienc

ed

heal

th p

robl

ems

afte

r chi

ld-

birt

h, th

e sp

ecifi

c pr

oble

ms

they

exp

erie

nced

, and

if th

ey

did

anyt

hing

abo

ut th

em

Wom

en w

ho a

tten

ded

the

hos-

pita

l with

in th

ree

mon

ths

afte

r de

liver

y of

a li

ve o

r stil

lbor

n ba

by w

ith a

ges

tatio

nal a

ge o

f m

ore

than

22

wee

ks o

r wei

gh-

ing

mor

e th

an 5

00 g

Resu

mpt

ion

of s

ex, g

enita

l tr

act i

nfec

tions

, Bre

akdo

wn

of e

pisi

otom

y/pe

rinea

l te

ar, V

ario

us s

exua

l hea

lth

sym

ptom

s

– 2

7% o

f par

ticip

ants

(bet

wee

n 6

wee

ks a

nd 3

mon

ths

post

part

um)

had

resu

med

sex

ual i

nter

cour

se;

90%

had

don

e so

with

in 2

mon

ths

afte

r del

iver

y–

Vagi

nal d

isch

arge

was

repo

rted

by

31%

of p

artic

ipan

ts a

nd a

bnor

mal

va

gina

l ble

edin

g by

7%

; 21

part

ici-

pant

s se

emed

hea

lthy,

but

upo

n ph

ysic

al e

xam

inat

ion

reve

aled

"pus

-lik

e" d

isch

arge

or t

he b

reak

dow

n of

th

eir p

erin

eal t

ear/

epis

ioto

my

– A

mon

g pa

rtic

ipan

ts fo

r who

m

high

vag

inal

sw

ab re

sults

wer

e av

aila

ble,

17%

had

abn

orm

al re

sults

. Th

e co

mbi

natio

n of

the

follo

win

g sy

mpt

oms

(9%

of a

ll pa

rtic

ipan

ts)

was

pre

dict

ive

of a

pue

rper

al in

fec-

tion:

low

er a

bdom

inal

pai

n, b

adly

sm

ellin

g di

scha

rge,

and

feve

r–

Am

ong

wom

en w

ho u

nder

wen

t a

vagi

nal s

wab

, phy

sica

l exa

min

atio

ns

indi

cate

d va

gina

l dis

char

ge a

mon

g 21

% a

nd te

nder

ute

rus

amon

g 10

%

Naz

ari e

t al.

(202

1) [3

9]Ira

n—C

ross

-sec

tiona

l and

Q

ualit

ativ

eTo

det

erm

ine

the

educ

a-tio

nal n

eeds

of m

othe

rs a

fter

ch

ildbi

rth

Qua

ntita

tive:

250

pre

gnan

t m

othe

rs in

the

third

trim

este

r, in

the

first

48

hour

s af

ter d

eliv

-er

y, in

the

first

6 m

onth

s af

ter

deliv

ery,

and

in th

e se

cond

6

mon

ths

afte

r del

iver

y w

ho

wer

e re

ferr

ed to

five

hea

lth

cent

ers

in B

ojno

urd

to re

ceiv

e m

idw

ifery

car

eQ

ualit

ativ

e pr

egna

nt w

omen

an

d po

stpa

rtum

wom

en u

p to

yea

r aft

er d

eliv

ery,

thei

r sp

ouse

s an

d ke

y in

form

ants

Gen

eral

sex

ual h

ealth

– Q

ualit

ativ

e th

emes

hig

hlig

ht

that

sex

ual h

ealth

nee

ds d

urin

g th

e po

stpa

rtum

per

iod

wer

e of

ten

negl

ecte

d. O

ne p

artic

ipan

t, 37

yea

rs

old

and

2 m

onth

s af

ter d

eliv

ery,

di

scus

sed

her e

xper

ienc

e of

vag

inal

dr

ynes

s, no

ting

that

she

trie

d bu

t "c

ould

not

hav

e se

x" a

nd u

tiliz

ed

ineff

ectiv

e oi

ntm

ent

– In

corr

ect b

elie

fs a

nd li

mite

d aw

aren

ess

wer

e fu

rthe

r obs

tacl

es to

m

eetin

g se

xual

hea

lth n

eeds

. Som

e pa

rtic

ipan

ts, f

or e

xam

ple,

bel

ieve

d th

at h

avin

g se

x du

ring

preg

nanc

y co

uld

nega

tivel

y im

pact

the

fetu

s–

The

mea

n ed

ucat

iona

l nee

d sc

ores

for t

he a

rea

of s

exua

l hea

lth

wer

e no

t sta

tistic

ally

diff

eren

t be

twee

n th

e fo

ur p

erio

ds s

tudi

ed

(pre

gnan

cy, 4

8 ho

urs

afte

r del

iver

y,

the

first

6 m

onth

s po

stpa

rtum

, and

th

e se

cond

6 m

onth

s po

stpa

rtum

; p =

0.1

2)


Tabl

e 2

(con

tinue

d)

Aut

hor (

Year

)Lo

catio

n an

d st

udy

desi

gnO

bjec

tive(

s)St

udy

popu

latio

nSp

ecifi

c to

pic(

s)Ke

y re

sults

Obo

ro &

Tab

owei

(200

2) [4

0]N

iger

ia—

Pane

l stu

dyTh

is s

tudy

add

ress

es th

e po

st-

nata

l sex

ual h

ealth

of N

iger

ian

wom

en

122

mar

ried

prim

ipar

as a

t the

Kw

ale

Zona

l Hos

pita

ls, D

elta

St

ate

of N

iger

ia

Loss

of s

exua

l des

ire, L

ack

of

vagi

nal l

ubric

atio

n, L

ack

of

vagi

nal m

uscl

e to

ne, V

agin

al

tight

ness

, Pai

nful

pen

etra

-tio

n, P

ainf

ul in

terc

ours

e,

Diffi

culty

ach

ievi

ng o

rgas

m,

Irrita

tion

or b

leed

ing

afte

r se

x, C

oita

l fre

quen

cy,

Sexu

al s

atis

fact

ion,

Typ

e of

in

terc

ours

e

– Re

port

ed s

exua

l pro

blem

s at

6

wee

ks, 3

mon

ths,

6 m

onth

s po

st-

part

um, r

espe

ctiv

ely:

– Lo

ss o

f sex

ual d

esire

: 61%

, 40%

, 26

%–

Lack

of v

agin

al lu

bric

atio

n: 5

1%,

29%

, 13%

– La

ck o

f vag

inal

mus

cle

tone

: 22%

, 17

%, 1

0%–

Vagi

nal t

ight

ness

: 33%

, 21%

, 11%

– Pa

infu

l pen

etra

tion:

47%

, 30%

, 21

%–

Pain

ful i

nter

cour

se: 5

5%, 3

4%, 1

9%–

Diffi

culty

ach

ievi

ng o

rgas

m: 4

1%,

27%

, 15%

– Irr

itatio

n or

ble

edin

g af

ter s

ex:

19%

, 9%

, 6%

– Fo

llow

ing

child

birt

h, 7

7% o

f w

omen

repo

rted

a d

ecre

ase

in

coita

l fre

quen

cy a

nd 3

7% re

port

ed

dim

inis

hed

sexu

al s

atis

fact

ion.

Fol

-lo

win

g ch

ildbi

rth,

the

vagi

nal r

oute

be

cam

e le

ss fr

eque

ntly

em

ploy

ed

durin

g in

terc

ours

e (9

3% v

s. 10

0%

pre-

child

birt

h, p

= 0

.004

)–

Follo

win

g ch

ildbi

rth,

sex

ual d

ys-

func

tion

over

all g

ener

ally

incr

ease

d (4

7% v

s. 21

% p

re-c

hild

birt

h,

p <

0.0

01)

– A

fter

com

plet

ing

the

ques

tion-

naire

at 6

wee

ks p

ostp

artu

m, 4

7 w

omen

initi

ated

dis

cuss

ion

of

sexu

al m

atte

rs–

Dys

pare

unia

at 3

mon

ths

post

part

um w

as s

igni

fican

tly m

ore

likel

y am

ong

wom

en w

ho: p

erin

eal

trau

ma

(aO

R 2.

00) a

nd p

re-p

reg-

nanc

y dy

spar

euni

a (a

OR

2.36

)–

Whi

le 6

8% o

r par

ticip

ants

felt

the

need

for a

ssis

tanc

e w

ith p

ostp

ar-

tum

sex

ual d

ysfu

nctio

n, o

nly

12%

so

ught

out

hel

p fro

m h

ealth

care

pr

ofes

sion

als

– Th

ough

pos

tnat

al c

linic

hea

lth

prof

essi

onal

s re

port

edly

dis

cuss

ed

cont

race

ptio

n w

ith 9

8% o

f the

w

omen

, sex

ual h

ealth

was

onl

y di

scus

sed

with

29%


Tabl

e 2

(con

tinue

d)

Aut

hor (

Year

)Lo

catio

n an

d st

udy

desi

gnO

bjec

tive(

s)St

udy

popu

latio

nSp

ecifi

c to

pic(

s)Ke

y re

sults

Surk

an e

t al.

(201

7) [4

1]Ba

ngla

desh

—Pr

ospe

ctiv

e Co

hort

To p

rovi

de a

n in

itial

est

imat

e of

th

e m

agni

tude

of d

epre

ssiv

e sy

mpt

oms

amon

g w

omen

in

the

first

yea

r pos

tpar

tum

, ide

n-tif

y ris

k fa

ctor

s an

d sp

ecifi

cally

to

est

imat

e st

reng

th o

f ass

ocia

-tio

ns b

etw

een

seve

ral h

ealth

co

nditi

ons

follo

win

g ch

ildbi

rth

and

depr

essi

ve s

ympt

oms

39,4

34 m

arrie

d w

omen

(age

s 13

–44)

in 1

9 ru

ral a

dmin

istr

a-tiv

e un

ions

in a

djac

ent d

istr

icts

of

Gai

band

ha a

nd R

angp

ur in

no

rthw

est B

angl

ades

h w

ho

part

icip

ated

, dur

ing

preg

nanc

y an

d th

e ea

rly p

ostp

artu

m

perio

d, in

the

JiVitA

-1 tr

ial a

nd

gave

birt

h to

sin

glet

ons

RTI,

Ute

rine

prol

apse

– W

hen

adju

stin

g on

ly fo

r soc

iode

-m

ogra

phic

var

iabl

es, e

xper

ienc

ing

a re

prod

uctiv

e tr

act i

nfec

tion

(RTI

) (R

R =

1.2

9; p

< 0

.001

) or u

terin

e pr

o-la

pse

(RR =

1.4

6; p

< 0

.001

) at t

hree

m

onth

s po

stpa

rtum

incr

ease

d ris

k fo

r hig

h de

pres

sive

sym

ptom

atol

-og

y at

6 m

onth

s–

Whe

n fu

lly a

djus

ting

for a

ll m

ater

-na

l illn

esse

s, ex

perie

ncin

g an

RTI

at

thre

e m

onth

s po

stpa

rtum

doe

s no

t sig

nific

antly

incr

ease

the

risk

for

high

dep

ress

ive

sym

ptom

atol

ogy

at s

ix m

onth

s (R

R =

0.9

0; p

= 0

.21)

, th

ough

exp

erie

ncin

g ut

erin

e pr

o-la

pse

at th

ree

mon

ths

still

incr

ease

d th

e ris

k fo

r hig

h de

pres

sive

sym

p-to

mat

olog

y at

6 m

onth

s (R

R =

1.2

0;

p =

0.0

1)

Whi

te (2

004)

[42]

Cam

bodi

a–Q

ualit

ativ

eTo

det

ail t

he s

peci

fic b

elie

fs o

f Kh

mer

wom

en in

Cam

bodi

a re

gard

ing

post

part

um, t

he ta

x-on

omie

s th

ey u

se to

des

crib

e po

stpa

rtum

con

ditio

ns, a

nd

the

prac

tices

they

follo

w to

pr

even

t sic

knes

s an

d de

ath

11 F

GD

s w

ith 8

8 w

omen

of

child

bear

ing

age

and

in-d

epth

in

terv

iew

s w

ith 2

1 w

omen

and

20

birt

h at

tend

ants

. The

chi

ld-

bear

ing

age

wom

en in

clud

ed

wer

e et

hnic

ally

Khm

er, K

hmer

-sp

eaki

ng, h

ad g

iven

birt

h w

ithin

the

last

thre

e ye

ars,

and

lived

in th

e ric

e-gr

owin

g ba

sin

of th

e M

ekon

g an

d To

nle

Sap

Rive

rs

Resu

mpt

ion

of s

ex, S

exua

l co

erci

on/v

iole

nce,

Infe

ctio

n–

Resu

min

g se

x to

o so

on w

as

seen

as

the

trig

ger f

or o

ne ty

pe o

f to

as (p

ostp

artu

m il

lnes

s/m

orbi

di-

ties)

ass

ocia

ted

with

sym

ptom

s of

w

eakn

ess,

palp

itatio

ns, a

bdom

inal

cr

amps

/pai

ns, w

eigh

t los

s, an

d po

or

appe

tite

– To

as d

amne

yk m

ore

typi

cally

ass

o-ci

ated

with

the

wom

an re

sum

ing

sexu

al in

terc

ours

e (o

ften

by

forc

e)

befo

re s

he fe

lt re

ady,

as

oppo

sed

to

mer

ely

resu

min

g in

terc

ours

e du

ring

"imm

atur

e sa

wsa

ye" (

the

cultu

rally

un

ders

tood

per

iod

of p

ostp

artu

m

reco

very

)–

The

prim

ary

sym

ptom

ass

ocia

ted

with

toas

dam

neyk

was

thin

-ne

ss. O

ther

ass

ocia

ted

sym

ptom

s in

clud

ed d

ry s

kin,

inso

mni

a, a

bu

rnin

g se

nsat

ion

in e

xtre

miti

es,

abdo

min

al c

ram

ping

, bac

kbon

e st

iffne

ss, a

nd "h

otne

ss in

the

body

." To

as d

amne

yk w

as tr

eate

d in

va

rious

way

s, in

clud

ing

burn

ing

the

coup

le’s

pubi

c ha

ir, a

ddin

g it

to ri

ce

win

e, a

nd d

rinki

ng th

e co

ncoc

-tio

n; c

onsu

min

g th

e w

ater

use

d to

cl

eans

e th

e m

ale

part

ner’s

pen

is;

and

othe

r tra

ditio

nal m

edic

ines


Tabl

e 3

Stud

ies

on b

oth

posi

tive

and

nega

tive

post

part

um s

exua

l hea

lth (o

r neu

tral

; n =

28)

Aut

hor (

Year

)Lo

catio

n an

d st

udy

desi

gnO

bjec

tive(

s)St

udy

popu

latio

nSp

ecifi

c to

pic(

s)Ke

y re

sults

Alu

m e

t al.

(201

5) [4

3]U

gand

a—C

ross

-sec

tiona

lTo

ass

ess

prev

alen

ce a

nd fa

ctor

s as

soci

ated

with

ear

ly re

sum

ptio

n of

se

xual

inte

rcou

rse

amon

g po

stna

tal

mot

hers

374

post

part

um w

omen

who

cam

e fo

r pos

tnat

al c

are

or b

roug

ht th

eir

babi

es fo

r im

mun

izat

ion

(with

in

6 m

onth

s po

stpa

rtum

) to

one

of

thre

e po

stna

tal a

nd im

mun

izat

ion

clin

ics

of a

teac

hing

hos

pita

l

Resu

mpt

ion

of s

ex–

21.6

% o

f par

ticip

ants

had

resu

med

sex

ual i

nter

cour

se

with

in 6

wee

ks o

f chi

ldbi

rth

– Pa

rtic

ipan

ts w

ho w

ere

mor

e lik

ely

to h

ave

resu

med

inte

r-co

urse

ear

ly in

clud

ed th

ose

that

: had

a h

igh

inco

me,

had

low

pa

rity,

had

eve

r use

d co

ntra

cept

ion,

or h

ad a

spo

use

with

a

high

edu

catio

n le

vel

Anz

aku

and

Mik

ah (2

014)

[44]

Nig

eria

—C

ross

-sec

tiona

lTo

des

crib

e th

e cu

rren

t sex

ual

prac

tices

of p

ostp

artu

m w

omen

, se

xual

mor

bidi

ty, c

ontr

acep

tive

prev

alen

ce a

nd p

redi

ctiv

e fa

c-to

rs fo

r ear

ly p

ostp

artu

m s

exua

l in

terc

ours

e an

d as

soci

ated

sex

ual

prob

lem

s

340

wom

en a

t a c

hild

wel

fare

clin

ic

14 w

eeks

aft

er c

hild

birt

h at

a te

ach-

ing

hosp

ital i

n Jo

s, N

iger

ia

Resu

mpt

ion

of s

ex,

Sexu

al m

orbi

ditie

s–

Epis

ioto

mie

s w

ere

pres

ent i

n 19

.7%

of p

artic

ipan

ts a

nd

vagi

nal l

acer

atio

ns in

29.

9%. M

ost g

enita

l tra

ct in

jurie

s (7

7.9%

) ha

d he

aled

wel

l; th

e re

st le

d to

com

plic

atio

ns in

clud

ing

infe

c-tio

n, c

hron

ic p

ain,

and

sca

rrin

g–

67.6

% o

f par

ticip

ants

had

resu

med

sex

by

14 w

eeks

aft

er

birt

h. T

he m

ost p

rom

inen

t rea

son

for r

esum

ing

inte

rcou

rse

(repo

rted

by

77.4

% o

f tho

se w

ho h

ad re

sum

ed s

ex) w

as

requ

est o

f the

hus

band

; oth

er re

ason

s in

clud

ed: c

onve

nien

ce

(14.

8%),

advi

ce g

iven

by

heal

th w

orke

rs (4

.3%

), th

e w

oman

’s in

itiat

ion

(2.6

%),

and

cultu

ral d

eman

ds (0

.9%

)–

Reas

ons

for n

ot re

sum

ing

inte

rcou

rse

incl

uded

: hus

band

’s un

avai

labi

lity

(repo

rted

by

38.2

% o

f tho

se w

ho h

ad n

ot y

et

resu

med

), fe

elin

g th

at it

was

not

yet

tim

e (2

1.8%

), to

pre

vent

pr

egna

ncy

(16.

4%),

bein

g un

wel

l (12

.7%

), un

inte

rest

(5.5

%),

cultu

ral r

easo

ns (3

.6%

), he

alth

wor

ker a

dvis

ed n

ot to

(1.8

%)

– A

mon

g th

ose

who

had

resu

med

coi

tus,

62.6

% e

xper

ienc

ed

one

or m

ore

sexu

al m

orbi

dity

upo

n co

mm

enci

ng in

terc

ours

e,

thou

gh o

nly

22.2

% o

f the

se w

omen

wer

e st

ill e

xper

ienc

ing

the

prob

lem

(s) w

hen

enro

lled

in th

e st

udy.

Onl

y 5.

6% o

f th

ose

with

a s

exua

l pro

blem

had

pur

sued

med

ical

adv

ice

or

trea

tmen

t–

Repo

rted

sex

ual p

robl

ems

incl

uded

: vag

inal

dry

ness

(16.

7%

of re

port

ed p

robl

ems)

, dee

p dy

spar

euni

a (1

4.9%

), va

gina

l tig

htne

ss (1

3.1%

), su

perfi

cial

dys

pare

unia

(12.

5%),

loss

of

sexu

al d

esire

(11.

9%),

vagi

nal l

oose

ness

(8.3

%),

abno

rmal

va

gina

l dis

char

ge (7

.1%

), va

gina

l ble

edin

g (4

.8%

), tir

edne

ss

(4.8

%),

and

othe

r pro

blem

s (5

.9%

)–

In m

ultiv

aria

te re

gres

sion

, wom

en th

at h

ad a

vag

inal

de

liver

y w

ere

mor

e lik

ely

to h

ave

repo

rted

one

or m

ore

sexu

al p

robl

ems

whe

n re

sum

ing

sex

(OR

3.6,

p =

0.0

1); t

hose

w

ho h

ad a

vag

inal

lace

ratio

n or

epi

siot

omy

wer

e m

ore

likel

y to

exp

erie

nce

sexu

al p

robl

em(s

) whe

n re

sum

ing

sex

(OR

2.4,

p =

0.0

4)


Tabl

e 3

(con

tinue

d)

Aut

hor (

Year

)Lo

catio

n an

d st

udy

desi

gnO

bjec

tive(

s)St

udy

popu

latio

nSp

ecifi

c to

pic(

s)Ke

y re

sults

Asa

di e

t al.

(202

1) [4

5]Ira

n—Q

ualit

ativ

eTo

exp

lore

the

expe

rienc

es re

late

d to

pos

tpar

tum

cha

nges

in w

omen

23 w

omen

who

hav

e gi

ven

birt

h an

d he

alth

care

pro

vide

rs (m

idw

ives

an

d ob

stet

ricia

ns)

Perc

eptio

n of

sex

ual

dysf

unct

ion

– Po

stpa

rtum

par

ticip

ants

des

crib

ed fe

elin

g le

ss s

exua

lly

attr

activ

e th

an in

the

past

, ref

eren

cing

vag

inal

loos

enin

g as

a

reas

on, a

nd fe

lt th

at th

ey w

ere

not w

ell-g

room

ed–

Som

e po

stpa

rtum

par

ticip

ants

des

crib

ed a

dec

reas

ed fe

el-

ing

of s

exua

l att

ract

iven

ess

(and

sub

sequ

ent s

elf-

confi

denc

e)

in re

latio

n to

epi

siot

omy

scar

s an

d th

e pr

otru

sion

of l

abia

m

inor

a–

Som

e po

stpa

rtum

par

ticip

ants

repo

rted

that

thei

r hus

-ba

nd’s

appr

oval

of t

hese

app

eara

nce

chan

ges

resu

lted

in

grea

ter s

exua

l per

form

ance

and

less

anx

iety

– Po

stpa

rtum

par

ticip

ants

als

o de

scrib

ed n

ot e

njoy

ing

sex

beca

use

of d

yspa

reun

ia, a

s w

ell a

s du

e to

feel

ings

of b

urni

ng/

dryn

ess,

and

repo

rted

feel

ing

less

sex

ual d

esire

dur

ing

the

post

part

um p

erio

d

Bord

a et

al.

(201

0) [2

4]17

DH

S co

untr

ies—

Cro

ss-

sect

iona

lTo

iden

tify

fact

ors

affec

ting

retu

rn

to s

exua

l act

ivity

and

use

of m

od-

ern

fam

ily p

lann

ing

amon

g w

omen

in

the

exte

nded

pos

tpar

tum

per

iod

15 o

f 17

coun

trie

s in

clud

ed a

ll w

omen

, tw

o in

clud

ed m

arrie

d w

omen

onl

y

Resu

mpt

ion

of s

ex–

In a

ll 17

cou

ntrie

s, w

omen

who

wer

e 0–

2.9

mon

ths

post

-pa

rtum

repo

rted

the

leas

t sex

ual a

ctiv

ity–

In 1

3 co

untr

ies,

the

maj

ority

of w

omen

3.0

–5.9

mon

ths

post

part

um h

ad re

sum

ed s

exua

l act

ivity

and

ove

r thr

ee-

quar

ters

of w

omen

9.0

–11.

9 m

onth

s po

stpa

rtum

wer

e se

xual

ly a

ctiv

e–

In 1

0 co

untr

ies,

excl

usiv

e br

east

feed

ing

was

sig

nific

antly

as

soci

ated

with

the

wom

an’s

resu

mpt

ion

of s

exua

l act

ivity

, w

ith w

omen

cur

rent

ly b

reas

tfeed

ing

less

like

ly to

hav

e re

sum

ed s

exua

l act

ivity

at t

he ti

me

of th

e su

rvey

– In

16

coun

trie

s, re

sum

ptio

n of

sex

ual a

ctiv

ity w

as s

igni

fi-ca

ntly

ass

ocia

ted

with

the

retu

rn o

f men

ses.

In 1

4 of

thes

e co

untr

ies,

the

odds

of h

avin

g re

sum

ed s

exua

l act

ivity

am

ong

wom

en w

hose

men

ses

had

retu

rned

was

mor

e th

an d

oubl

e th

e od

ds o

f res

umpt

ion

amon

g th

ose

who

se m

ense

s ha

d no

t ret

urne

d–

Hav

ing

resu

med

sex

ual a

ctiv

ity w

as a

ssoc

iate

d w

ith th

e du

ratio

n of

the

post

part

um p

erio

d (w

ith 0

–2.9

-mon

th p

erio

d as

refe

rent

); in

all

but Z

ambi

a, th

is a

ssoc

iatio

n w

as s

igni

fican

t fo

r tw

o or

mor

e of

the

post

part

um in

terv

als

Dad

abha

i et a

l. (2

020)

[46]

Mal

awi—

Pros

pect

ive

Coho

rtTo

det

erm

ine

time

from

del

iver

y to

re

sum

ptio

n of

sex

ual a

ctiv

ity a

nd

men

ses

by H

IV in

fect

ion

stat

us

878

wom

en (4

60 H

IV-u

ninf

ecte

d an

d 41

8 H

IV-in

fect

ed) w

ho

atte

nded

at l

east

one

follo

w-u

p vi

sit

Resu

mpt

ion

of s

ex–

Com

para

ble

prop

ortio

ns o

f HIV

-infe

cted

and

HIV

-uni

n-fe

cted

wom

en re

port

ed s

exua

l act

ivity

at e

ach

visi

t (<

6.0

%

at th

e 6-

wee

k po

stpa

rtum

, inc

reas

ing

to >

82.

0% a

t the

12

-mon

th)

– M

arita

l sta

tus

was

the

only

var

iabl

e si

gnifi

cant

ly a

ssoc

iate

d w

ith e

arly

resu

mpt

ion

of s

ex a

nd th

is s

igni

fican

ce re

mai

ned

for b

oth

grou

ps a

fter

str

atify

ing

by H

IV in

fect

ion

stat

us


Tabl

e 3

(con

tinue

d)

Aut

hor (

Year

)Lo

catio

n an

d st

udy

desi

gnO

bjec

tive(

s)St

udy

popu

latio

nSp

ecifi

c to

pic(

s)Ke

y re

sults

Des

grée

s-du

-Loû

and

Bro

u (2

005)

[47]

Cote

d’Iv

oire

—Q

ualit

ativ

eTo

und

erst

and

how

cou

ples

neg

oti-

ate

the

resu

mpt

ion

of s

exua

l rel

a-tio

ns fo

llow

ing

child

birt

h, th

e ro

le

of p

ost-

part

um s

exua

l abs

tinen

ce,

the

unde

rlyin

g no

rms,

who

mak

es

the

deci

sion

and

wha

t eac

h pa

rt-

ner’s

age

ncy

is in

the

deci

sion

Men

(n =

10)

and

wom

en (n

= 2

3);

pare

nt o

f an

alre

ady

wea

ned

child

un

der t

he a

ge o

f five

Resu

mpt

ion

of s

ex,

Coer

cive

sex

, Fea

r of

STIs

/HIV

– O

ne a

rgum

ent f

or s

exua

l abs

tinen

ce w

as b

reas

tfeed

ing-

rela

ted

tabo

os: m

ost w

omen

refe

renc

ed b

reas

tfeed

ing

(spe

-ci

fical

ly th

e be

lief t

hat s

emen

sho

uld

not m

ix w

ith b

reas

tmilk

, fo

r the

hea

lth o

f the

chi

ld) a

s a

reas

on fo

r sex

ual a

bstin

ence

; ni

ne w

omen

and

eig

ht m

en re

port

ed re

sum

ing

sex

only

aft

er

the

com

plet

e ce

ssat

ion

of b

reas

tfeed

ing

– A

noth

er c

omm

on p

ract

ice

was

wai

ting

to re

sum

e se

x un

til

the

child

cou

ld w

alk;

this

pra

ctic

e ov

erla

pped

with

bre

ast-

feed

ing-

rela

ted

tabo

os, g

iven

the

idea

that

the

abili

ty to

wal

k su

gges

ted

resi

lienc

e an

d no

mor

e ne

ed fo

r bre

astfe

edin

g–

For s

ome,

resu

mpt

ion

of s

ex d

epen

ded

on th

e re

cupe

ra-

tion

of th

e m

othe

r fro

m c

hild

birt

h; th

e re

cupe

ratio

n pe

riod

rang

ed fr

om 5

–8 m

onth

s or

unt

il m

ense

s re

turn

ed. T

his

prac

tice

was

bas

ed b

oth

on d

esire

s to

regu

late

fert

ility

and

co

ncer

n fo

r the

mot

her’s

hea

lth–

Wom

en th

at s

poke

to a

frie

nd o

f sis

ter a

bout

pos

tpar

tum

ab

stin

ence

wer

e w

arne

d ab

out t

he ri

sk o

f the

hus

band

’s un

faith

fuln

ess

(if a

bstin

ence

last

ed to

o lo

ng) a

nd th

e ris

k of

pr

egna

ncy

(if a

bstin

ence

was

too

brie

f)–

All

of th

e w

omen

repo

rted

that

the

resu

mpt

ion

of s

ex w

as

gene

rally

initi

ated

by

the

man

; eig

ht w

omen

repo

rted

feel

ing

pres

sure

d to

resu

me

sex

earli

er th

an th

ey w

ante

d to

– So

me

wom

en fe

lt th

at p

olyg

ynou

s m

arria

ges

allo

wed

for

long

er a

bstin

ence

, giv

en s

exua

l act

ivity

with

oth

er w

ives

– M

any

wom

en e

xpre

ssed

fear

s of

infid

elity

by

thei

r par

tner

an

d re

late

d ST

I and

/or H

IV ri

sk–

Wom

en s

eem

ed to

hav

e so

me

agen

cy re

gard

ing

the

resu

mpt

ion

of s

ex: m

any

post

pone

d re

sum

ptio

n a

few

m

onth

s fo

llow

ing

thei

r hus

band

’s re

ques

t; so

me

only

agr

eed

to re

sum

e se

x w

ith p

rote

ctio

n (c

ondo

ms

wer

e be

lieve

d to

pr

even

t sem

en m

ixin

g w

ith b

reas

tmilk

); so

me

wom

en m

oved

in

with

thei

r par

ents

for t

he fi

rst y

ear p

ostp

artu

m a

nd/o

r av

oide

d sp

endi

ng th

e ni

ght a

t the

ir pa

rtne

r’s h

ouse

unt

il re

ady

to re

sum

e se

x


Tabl

e 3

(con

tinue

d)

Aut

hor (

Year

)Lo

catio

n an

d st

udy

desi

gnO

bjec

tive(

s)St

udy

popu

latio

nSp

ecifi

c to

pic(

s)Ke

y re

sults

Ezeb

ialu

and

Eke

(201

2) [4

8]N

iger

ia—

Cro

ss-s

ectio

nal

To d

eter

min

e th

e av

erag

e tim

e fo

r res

umin

g va

gina

l int

erco

urse

du

ring

the

puer

periu

m, a

s w

ell a

s fa

ctor

s th

at a

re a

ssoc

iate

d w

ith

resu

mpt

ion

of c

oita

l act

ivity

860

mot

hers

in a

pos

tnat

al c

linic

at

thei

r firs

t vis

it po

stpa

rtum

Resu

mpt

ion

of s

ex,

Fear

of p

ain/

expe

ri-en

ced

pain

– By

the

time

of th

eir fi

rst p

ostn

atal

vis

it, 2

9.7%

of p

artic

i-pa

nts

had

resu

med

vag

inal

inte

rcou

rse.

Fac

tors

that

var

ied

sign

ifica

ntly

bet

wee

n th

ose

who

had

and

had

not

resu

med

co

itus

by th

eir fi

rst p

ostn

atal

vis

it in

clud

ed: r

esum

ptio

n of

m

ense

s (p

< 0

.001

), pl

ace

of re

side

nce

(p =

0.0

01),

HIV

sta

tus

(p =

0.0

04),

havi

ng m

inim

al o

r no

educ

atio

n (p

= 0

.009

), m

ode

of d

eliv

ery

(p =

0.0

39),

extr

emes

of a

ge (p

= 0

.007

), an

d be

ing

mar

ried

(p =

0.0

02)

– In

mul

tivar

iate

ana

lysi

s, H

IV-n

egat

ive

stat

us a

nd th

e re

sum

ptio

n of

men

ses

show

ed s

tron

gest

ass

ocia

tions

with

re

sum

ing

sex

durin

g th

e pu

erpe

rium

(p <

0.0

01)

– A

mon

g th

ose

who

had

not

yet

resu

med

sex

, rep

orte

d re

ason

s fo

r abs

tain

ing

incl

uded

avo

idin

g pr

egna

ncy

(64.

5%),

part

ner u

nava

ilabl

e (1

4.9%

), la

ck o

f int

eres

t (9.

1%),

fear

of p

ain

at th

e si

te o

f epi

siot

omy

(2.5

%),

and

no re

ason

(11.

6%)

– Th

e m

ost c

omm

on re

ason

s ju

stify

ing

reco

mm

ende

d du

ratio

ns o

f pos

tpar

tum

abs

tinen

ce w

ere

to a

llow

for

the

wom

an’s

full

reco

very

(39.

5%) a

nd fo

r fam

ily p

lann

ing

purp

oses

(27.

9%)

– Si

x w

omen

repo

rted

exp

erie

ncin

g pa

in d

urin

g se

x

Gad

isa

et a

l. (2

021)

[49]

Ethi

opia

—C

ross

-sec

tiona

lTo

ass

ess

the

early

resu

mpt

ion

of

post

part

um s

exua

l int

erco

urse

and

its

ass

ocia

ted

risk

fact

ors

amon

g m

arrie

d w

omen

who

vis

ited

publ

ic

hosp

itals

for c

hild

imm

uniz

atio

n se

rvic

es

330

post

part

um w

omen

, 14

wee

ks

afte

r chi

ldbi

rth,

rand

omly

sel

ecte

dRe

sum

ptio

n of

sex

– 53

.9%

resu

med

sex

ear

ly (<

6 w

eeks

pos

tpar

tum

); 14

% o

f th

ese

resu

med

sex

< 4

wee

ks p

ostp

artu

m–

77%

repo

rted

ly re

sum

ed s

ex a

t the

ir hu

sban

d’s

requ

est

– Fa

ctor

s si

gnifi

cant

ly a

ssoc

iate

d w

ith e

arly

resu

mpt

ion

of

sex

incl

uded

: low

inco

me

(aO

R 0.

19),

mon

ogam

ous

mar

riage

(a

OR

3.78

), ha

ving

pra

ctic

ed s

exua

l int

erco

urse

dur

ing

preg

-na

ncy

(aO

R 4.

55),

havi

ng h

ad a

ces

area

n de

liver

y (a

OR

0.06

), an

d us

ing

cont

race

ptio

n (a

OR

3.7)

Gly

nn e

t al.

(200

1)[5

0]M

ulti-

coun

try

(Cam

eroo

n,

Zam

bia,

Ken

ya)—

Cro

ss-

sect

iona

l

To d

emon

stra

te if

pro

long

ed

post

part

um s

exua

l abs

tinen

ce m

ay

incr

ease

the

risk

of H

IV th

roug

h an

ass

ocia

ted

incr

ease

s in

mal

e ex

tram

arita

l sex

ual c

onta

cts

From

six

ant

enat

al c

linic

s: n =

153

2 w

omen

in Y

aoun

dé, C

amer

oon;

n =

148

0 in

Kis

umu,

Ken

ya;

n =

102

1 in

Ndo

la, Z

ambi

a

Post

part

um a

bsti-

nenc

e–

Post

part

um a

bstin

ence

> 6

mon

ths

was

repo

rted

by

half

of

part

icip

ants

in Y

aoun

dé, 1

7% in

Kis

umu,

and

13%

in N

dola

; ab

stin

ence

> 1

2 m

onth

s w

as re

port

ed b

y 23

% in

Yao

undé

, 8%

in

Kis

umu,

and

4%

in N

dola

– Po

stpa

rtum

abs

tinen

ce w

as s

hort

er a

mon

g m

arrie

d w

omen

an

d si

mila

r bet

wee

n po

lyga

mou

s/m

onog

amou

s ac

ross

site

s–

In Y

aoun

dé, p

ostp

artu

m a

bstin

ence

dur

atio

n w

as s

tron

gly

asso

ciat

ed w

ith H

IV s

erop

ositi

vity

ove

rall,

thou

gh w

hen

rest

rictin

g to

thos

e w

ho w

ere

mar

ried

to th

eir c

urre

nt p

artn

er

at ti

me

of b

irth

resu

lts re

mai

ned

only

bor

derli

ne s

igni

fican

t–

In Y

aoun

dé, p

ostp

artu

m a

bstin

ence

was

long

er a

mon

g w

omen

with

pro

long

ed p

ostp

artu

m a

men

orrh

ea–

In K

isum

u, p

ostp

artu

m a

bstin

ence

was

not

ass

ocia

ted

with

H

IV s

tatu

s. In

Ndo

la, p

ostp

artu

m a

bstin

ence

dur

atio

n w

as

slig

htly

pos

itive

ly a

ssoc

iate

d w

ith b

eing

HIV

-pos

itive

ove

rall,

th

ough

not

whe

n re

stric

ting

to m

arrie

d w

omen


Tabl

e 3

(con

tinue

d)

Aut

hor (

Year

)Lo

catio

n an

d st

udy

desi

gnO

bjec

tive(

s)St

udy

popu

latio

nSp

ecifi

c to

pic(

s)Ke

y re

sults

Iliya

su e

t al.

(200

6) [5

1]N

iger

ia—

Cro

ss-s

ectio

nal

To a

sses

s co

ntem

pora

ry p

ostp

ar-

tum

bel

iefs

, pra

ctic

es, a

nd h

ealth

pr

oble

ms

of m

othe

rs in

a ty

pica

l H

ausa

rura

l com

mun

ity

300

mot

hers

with

chi

ldre

n un

der

five

Resu

mpt

ion

of

Sex,

Per

inea

l pai

n,

Har

mfu

l tra

ditio

nal

prac

tices

– 7

6.7%

of p

artic

ipan

ts re

sum

ed s

ex 6

–11

mon

ths

afte

r de

liver

y–

Cert

ain

post

part

um ri

tual

s an

d cu

ltura

l pra

ctic

es w

ere

belie

ved

to s

tren

gthe

n th

e m

othe

r and

retu

rn h

er s

tam

ina

(bel

ieve

d by

92.

7%),

help

hea

l per

inea

l wou

nds

(77.

3%),

stim

ulat

e la

ctat

ion

(81.

3%),

and

aid

in th

e dr

aina

ge o

f loc

hia

(66.

0%).

Acc

ordi

ng to

64%

of p

artic

ipan

ts, n

on-o

bser

vanc

e of

su

ch p

ract

ices

cou

ld re

sult

in b

ody

swel

ling

and,

acc

ordi

ng to

4%

, to

perin

eal p

ain

and

foul

-sm

ellin

g lo

chia

– Fe

w p

artic

ipan

ts (8

.7%

) did

not

bel

ieve

that

the

prac

tices

w

ere

bene

ficia

l. Si

gnifi

cant

ly m

ore

wom

en w

ith a

form

al

educ

atio

n (2

2.5%

) did

not

bel

ieve

the

prac

tices

to b

e be

nefi-

cial

com

pare

d to

thos

e w

ithou

t any

form

al e

duca

tion

(2.8

%;

p <

0.0

1)–

Such

com

mon

ly p

ract

iced

ritu

als

incl

uded

: con

finem

ent f

or

40 d

ays

afte

r birt

h (p

ract

iced

by

87.7

%),

confi

nem

ent b

eyon

d 40

day

s (1

2.3%

), ho

t ritu

al b

aths

(86.

0%),

nurs

ing

in h

eate

d ro

oms

(84.

3%),

layi

ng o

n he

ated

bed

s (5

.3%

), ea

ting

a gr

uel

dish

enr

iche

d w

ith s

alt (

82.7

%),

and

eatin

g sp

icy

food

s (8

5.3%

)–

Som

e co

mm

on p

ostp

artu

m c

ompl

aint

s in

clud

ed e

xces

sive

bl

eedi

ng (r

epor

ted

by 1

6.3%

) and

low

er a

bdom

inal

/per

inea

l pa

in (5

6.3%

); m

ost w

omen

who

repo

rted

a c

ompl

aint

(66.

0%)

soug

ht tr

aditi

onal

rem

edie

s, w

hile

25.

0% p

ursu

ed m

oder

n m

edic

al c

are

and

9.0%

did

not

util

ize

any

med

icat

ion

– N

early

hal

f of p

artic

ipan

ts s

tate

d th

at th

ey w

ould

con

tinue

pr

actic

es re

gard

less

of t

heir

harm

ful e

ffect

s, 25

% fe

lt th

at th

e pr

actic

es s

houl

d be

opt

iona

l, an

d 8%

sup

port

ed d

isco

ntin

u-at

ion


Tabl

e 3

(con

tinue

d)

Aut

hor (

Year

)Lo

catio

n an

d st

udy

desi

gnO

bjec

tive(

s)St

udy

popu

latio

nSp

ecifi

c to

pic(

s)Ke

y re

sults

Iliya

su e

t al.

(201

8) [5

2]N

iger

ia—

Cro

ss-s

ectio

nal

To d

eter

min

e th

e pr

eval

ence

of

pos

tpar

tum

sex

ual a

ctiv

ity,

deliv

ery-

coitu

s in

terv

al, a

nd th

eir

dete

rmin

ants

am

ong

wom

en w

ho

deliv

ered

with

in 1

2 m

onth

s of

the

stud

y an

d at

tend

ed th

e po

stna

tal/

fam

ily p

lann

ing

and

child

wel

fare

/im

mun

izat

ion

clin

ics

at A

min

u Ka

no T

each

ing

Hos

pita

l in

Kano

, N

iger

ia

317

mot

hers

atte

ndin

g th

e po

stna

tal/f

amily

pl

anni

ng c

linic

s an

dth

ose

who

bro

ught

thei

r chi

ldre

n fo

r im

mun

izat

ion

Resu

mpt

ion

of s

ex,

Vagi

nal d

isch

arge

, Va

gina

l irr

itatio

n,

Lack

of l

ibid

o,

Dys

pare

unia

– 52

.1%

of p

artic

ipan

ts u

nder

wen

t epi

siot

omie

s. G

enita

l in

jurie

s w

ere

pres

ent a

mon

g 15

.1%

, mos

t com

mon

ly v

agin

al

lace

ratio

ns (7

0.8%

) and

per

inea

l tea

rs (2

5.0%

)–

66.9

% h

ad re

sum

ed s

ex b

y st

udy.

The

dur

atio

n of

pos

tpar

-tu

m a

bstin

ence

rang

ed fr

om 4

–28

wee

ks (m

ean =

9.6

)–

Am

ong

sexu

ally

act

ive,

prim

ary

reas

ons

for r

esum

ing

sex

wer

e hu

sban

d’s

dem

ands

(67.

5%) a

nd o

wn

desi

re (1

4.6%

)–

Am

ong

thos

e st

ill a

bsta

inin

g fro

m s

ex, r

easo

ns fo

r abs

ti-ne

nce

incl

uded

: the

infa

nt b

eing

too

youn

g (8

1.0%

), av

oidi

ng

preg

nanc

y (1

3.3%

), la

ck o

f int

eres

t (2.

9%),

and

bein

g ei

ther

di

vorc

ed o

r wid

owed

(2.9

%)

– M

ost s

exua

lly a

ctiv

e pa

rtic

ipan

ts re

port

ed e

xper

ienc

ing

a se

xual

pro

blem

(64.

2%) i

nclu

ding

: dys

pare

unia

(32.

5%),

dim

inis

hed

sexu

al d

esire

(31.

6%),

vagi

nal d

ryne

ss/s

oren

ess

(15.

6%),

vagi

nal ’

loos

enes

s’ (1

5.6%

), an

d di

scha

rge

(6.1

%)

– Fe

wer

than

two-

third

s of

thos

e ex

perie

ncin

g a

sexu

al p

rob-

lem

sou

ght h

elp;

mos

t com

mon

ly s

ough

t sou

rces

of a

dvic

e w

ere

frien

ds, m

othe

rs, p

hysi

cian

s, an

d in

tern

et–

Reas

ons

refe

renc

ed fo

r not

see

king

gui

danc

e in

clud

ed

feel

ing

shy,

pro

blem

reso

lvin

g on

its

own,

cul

tura

l/rel

igio

us

fact

ors,

and

not h

avin

g a

fem

ale

doct

or to

ask

– U

pon

adju

stin

g fo

r con

foun

ders

, the

follo

win

g ch

arac

teris

-tic

s re

mai

ned

sign

ifica

ntly

ass

ocia

ted

with

hav

ing

resu

med

se

x: n

ot c

o-ha

bita

ting

with

hus

band

(aO

R 0.

47, p

= 0

.001

), sp

onta

neou

s va

gina

l del

iver

y (a

OR

1.10

, p =

0.0

5), i

nfan

t’s

age

1–6

mon

ths

(aO

R 1.

53, p

= 0

.02)

or 6

+ m

onth

s (a

OR

2.10

, p =

0.0

01),

havi

ng fi

ve o

r mor

e liv

ing

child

ren

(aO

R 1.

21,

p =

0.0

3), a

nd n

ot h

avin

g re

sum

ed m

enst

ruat

ion

(aO

R 0.

34,

p =

0.0

03)


Tabl

e 3

(con

tinue

d)

Aut

hor (

Year

)Lo

catio

n an

d st

udy

desi

gnO

bjec

tive(

s)St

udy

popu

latio

nSp

ecifi

c to

pic(

s)Ke

y re

sults

Kinu

thia

et a

l. (2

017)

[53]

Keny

a—Pr

ospe

ctiv

e Co

hort

To c

hara

cter

ize

frequ

ency

and

ty

pes

of s

exua

l beh

avio

rs a

nd v

agi-

nal p

ract

ices

am

ong

HIV

-uni

nfec

ted

wom

en d

urin

g pr

egna

ncy

and

up

to 9

mon

ths

post

part

um

1252

pre

gnan

t, H

IV-u

ninf

ecte

d w

omen

who

att

ende

d an

tena

tal

care

clin

ics

Resu

mpt

ion

of s

ex,

Forc

ed s

ex, V

agin

al

was

hing

/dr

ying

– Fr

om 2

to 3

6 w

eeks

pos

tpar

tum

, the

pro

port

ion

of s

exua

lly

activ

e w

omen

incr

ease

d fro

m 8

% to

701

% (p

< 0

.001

) and

the

prop

ortio

n of

wom

en w

ho re

port

ed c

ondo

mle

ss s

ex w

ithin

th

e pa

st m

onth

rose

from

6%

to 6

0% (p

< 0

.001

)–

60.1

% re

port

ed v

agin

al w

ashi

ng, a

nd p

reva

lenc

e w

as s

tabl

e th

roug

hout

follo

w-u

p. V

agin

al w

ashi

ng a

t 36

wee

ks p

ostp

ar-

tum

was

ass

ocia

ted

decr

ease

d od

ds o

f hav

ing

a pa

rtne

r of

unkn

own

HIV

sta

tus,

bein

g a

hous

ewife

, and

long

er re

latio

n-sh

ip d

urat

ion,

and

incr

ease

d od

ds o

f his

tory

of a

bnor

mal

di

scha

rge,

late

r sex

ual d

ebut

, and

pas

t-m

onth

forc

ed s

ex–

Pro

port

ion

of v

agin

al d

ryin

g de

crea

sed

over

follo

w-u

p, a

nd

incr

ease

d w

ith in

crea

sing

age

– A

t 36

wee

ks p

ostp

artu

m, t

he o

dds

of c

ondo

mle

ss s

ex (v

s. pr

otec

ted

sex

or n

o se

xual

act

ivity

) in

the

past

mon

th w

as

sign

ifica

ntly

hig

her a

mon

g w

omen

who

: wer

e ol

der,

mar

ried,

ha

d m

ore

lifet

ime

sexu

al p

artn

ers,

repo

rted

pas

t-m

onth

fo

rced

sex

, rep

orte

d pa

st-m

onth

ana

l sex

, wer

e un

empl

oyed

, ha

d H

IV-u

ninf

ecte

d pa

rtne

rs, a

nd h

ad h

ad m

ore

live

birt

hs–

Earli

er re

sum

ptio

n of

sex

aft

er c

hild

birt

h w

as a

ssoc

iate

d w

ith: o

lder

age

, mor

e lif

etim

e se

xual

par

tner

s, pa

rtne

r’s a

ge

com

pare

d to

the

wom

an’s

age,

a h

isto

ry o

f ana

l sex

, bei

ng

mar

riage

, whe

reas

dec

reas

ed h

azar

d ra

tios

wer

e ob

serv

ed

for h

avin

g co

mpl

eted

prim

ary

educ

atio

n or

bey

ond,

hav

ing

had

a ca

esar

ean

sect

ion.

hav

ing

a pa

rtne

r with

unk

now

n H

IV

stat

us, a

nd p

artn

er c

ircum

cisi

on s

tatu

s

Lund

berg

and

Trie

u (2

011)

[54]

Viet

nam

—C

ross

-sec

tiona

l an

d Q

ualit

ativ

eTo

des

crib

e cu

ltura

l bel

iefs

and

pr

actic

es re

late

d to

the

post

part

um

perio

d am

ong

Viet

nam

ese

wom

en

in H

o C

hi M

inh

City

115

Viet

nam

ese

wom

en, 9

5 in

the

first

gro

up a

nd 2

0 in

the

seco

nd

grou

p. A

que

stio

nnai

re w

as u

sed

with

the

first

gro

up a

nd a

sem

i-st

ruct

ured

in-d

epth

inte

rvie

w w

as

used

with

the

seco

nd g

roup

Resu

mpt

ion

of s

ex,

Fear

of p

rola

pse,

Pe

rinea

l wou

nds

– A

ll pa

rtic

ipan

ts a

bsta

ined

from

sex

ual i

nter

cour

se w

ith th

eir

spou

ses

for t

he fi

rst 3

–4 m

onth

s fo

llow

ing

child

birt

h–

Part

icip

ants

bel

ieve

d th

at e

ngag

ing

in s

ex to

o ea

rly c

ould

ne

gativ

ely

impa

ct th

eir h

ealth

and

/or p

erin

eal w

ound

s–

Part

icip

ants

als

o fe

ared

the

poss

ibili

ty o

f ear

lier s

ex le

adin

g to

ute

rine

prol

apse

or p

regn

ancy

– So

me

part

icip

ants

wer

e no

t int

eres

ted

in h

avin

g se

x w

ith

thei

r spo

uses

bec

ause

they

wer

e ve

ry ti

red

from

car

ing

for

thei

r inf

ants


Tabl

e 3

(con

tinue

d)

Aut

hor (

Year

)Lo

catio

n an

d st

udy

desi

gnO

bjec

tive(

s)St

udy

popu

latio

nSp

ecifi

c to

pic(

s)Ke

y re

sults

Maa

mri

et a

l. (2

019)

[55]

Tuni

sia—

Cro

ss-s

ectio

nal

To e

valu

ate

the

sexu

al fu

nctio

n of

a p

opul

atio

n of

wom

en in

po

stpa

rtum

, and

iden

tify

poss

ible

pa

rtic

ular

ities

and

ass

ocia

ted

fac-

tors

of t

he s

tudi

ed p

opul

atio

n

100

wom

en w

ho g

ave

birt

h 6

mon

ths

prio

rRe

sum

ptio

n of

sex

, FS

FI s

core

item

s (d

esire

, aro

usal

, lu

bric

atio

n, o

rgas

m,

satis

fact

ion

and

pain

), H

ypoa

c-tiv

e se

xual

des

ire,

Post

part

um s

exua

l pr

actic

es, P

erin

eal

trau

ma,

& O

ther

se

xual

mor

bidi

ties

– A

mon

g va

gina

l birt

hs, 4

2/53

had

per

inea

l les

ions

– Th

e m

ean

dura

tion

of p

ostp

artu

m a

bstin

ence

was

2.

1 m

onth

s–

Am

ong

thos

e w

ho u

nder

wen

t a s

ched

uled

ces

area

n se

c-tio

n, 4

5% re

sum

ed s

ex 4

–6 w

eeks

aft

er d

eliv

ery,

whi

le 7

2% o

f th

ose

who

had

an

inst

rum

enta

l vag

inal

del

iver

y re

sum

ed a

t si

x m

onth

s po

stpa

rtum

or l

ater

(p =

0.0

1)–

Reas

ons

for e

ngag

ing

in s

exua

l act

ivity

incl

uded

bot

h pa

rtne

rs’ p

leas

ure

(83%

), on

ly th

e hu

sban

d’s

plea

sure

(13%

), an

d pe

rson

al p

leas

ure

excl

usiv

ely

(5%

). A

dditi

onal

ly, 1

0% o

f pa

rtic

ipan

ts re

port

hav

ing

sex

due

to m

arita

l dut

y an

d 6%

to

avoi

d in

fidel

ity b

y th

e hu

sban

d–

Reas

ons

offer

ed fo

r abs

tain

ing

from

sex

incl

uded

fear

of

pain

(32%

) and

fear

of r

epea

t pre

gnan

cy (1

3%).

Feel

ing

phys

i-ca

lly u

ndes

irabl

e (3

7%) a

nd fe

elin

g th

eir b

ody

had

chan

ged

(31%

) led

wom

en to

feel

ing

disc

onne

cted

from

thei

r bod

ies.

Oth

er h

inde

ranc

es in

clud

ed e

xces

sive

fatig

ue (2

4%),

the

pres

-en

ce o

f a c

hild

(50%

), an

d m

othe

r’s u

nava

ilabi

lity

(60%

)–

79%

repo

rted

that

thei

r rel

atio

nshi

p ch

ange

d po

stpa

rtum

– H

ypoa

ctiv

e se

xual

des

ire w

as re

port

ed b

y 31

% o

f par

tici-

pant

s–

Mos

t wom

en (6

5%) r

epor

ted

achi

evin

g ad

equa

te lu

bric

a-tio

n al

way

s, al

mos

t alw

ays,

or u

sual

ly–

The

frequ

ency

of r

each

ing

orga

sm w

as u

nalte

red

afte

r de

liver

y am

ong

58%

of p

artic

ipan

ts, r

educ

ed fo

r 29%

, and

ro

se fo

r 13%

– Se

xual

sat

isfa

ctio

n di

d no

t cha

nge

post

part

um fo

r 52%

of

part

icip

ants

, red

uced

for 3

3%, a

nd im

prov

ed fo

r 15%

– 14

% o

f wom

en re

port

ed d

yspa

reun

ia

Mbe

keng

a et

al.

(201

1) [5

6]Ta

nzan

ia—

Qua

litat

ive

To e

xplo

re a

nd d

escr

ibe

post

-pa

rtum

exp

erie

nces

of fi

rst-

time

mot

hers

in a

Tan

zani

an, m

ultie

thni

c,

low

-inco

me

subu

rb

10 fi

rst-

time

mot

hers

recr

uite

d at

tw

o RC

H c

linic

s in

the

low

er-

inco

me

area

s of

Ilal

a m

unic

ipal

ity,

Dar

es

Sala

am c

ity, T

anza

nia.

The

y w

ere

recr

uite

d w

hen

brin

ging

thei

r in

fant

s fo

r rou

tine

exam

inat

ion

and

vacc

inat

ion

4–10

wee

ks a

fter

ch

ildbi

rth

Resu

mpt

ion

of s

ex,

Epis

ioto

my

– W

omen

exp

ress

ed u

ncer

tain

ty a

nd a

nee

d fo

r inf

orm

atio

n re

gard

ing

care

for e

pisi

otom

y w

ound

s–

The

wom

en re

port

ed th

at re

prod

uctiv

e an

d ch

ild h

ealth

cl

inic

s di

d no

t pro

vide

eno

ugh

heal

th e

duca

tion,

whi

le a

nte-

nata

l clin

ics

prov

ided

too

muc

h in

form

atio

n al

l at o

nce

– Ex

cept

for o

ne, a

ll th

e m

othe

rs p

lann

ed to

abs

tain

from

in

terc

ours

e un

til c

easi

ng b

reas

tfeed

ing

(up

to 4

yea

rs).

A

com

mon

bel

ief i

s th

at h

avin

g se

x w

hile

stil

l bre

astfe

edin

g w

ould

mak

e th

e in

fant

ill a

nd h

ampe

r the

ir de

velo

pmen

t–

The

mot

hers

, how

ever

, dou

bted

that

thei

r par

tner

s’ w

ould

be

abl

e to

abs

tain

from

sex

for t

his

long

; the

y be

lieve

d th

at

thei

r par

tner

s m

ay h

ave

sex

with

oth

er p

eopl

e an

d ris

k co

ntra

ctin

g H

IV. O

ne p

artic

ipan

t, pe

r an

inte

rvie

w e

xcer

pt,

desc

ribed

feel

ing

stro

ngly

that

her

and

her

par

tner

nee

d to

ge

t HIV

test

ed d

ue to

pos

sibl

e in

fidel

ity b

y he

r par

tner


Tabl

e 3

(con

tinue

d)

Aut

hor (

Year

)Lo

catio

n an

d st

udy

desi

gnO

bjec

tive(

s)St

udy

popu

latio

nSp

ecifi

c to

pic(

s)Ke

y re

sults

Mek

onne

n (2

020)

[57]

Ethi

opia

—C

ross

-sec

tiona

lTo

ass

ess

the

early

resu

mp-

tion

of s

exua

l int

erco

urse

aft

er

child

birt

h an

d as

soci

ated

fact

ors

amon

g w

omen

in th

e ex

tend

ed

post

part

um p

erio

d in

Gon

dar c

ity,

Nor

thw

est E

thio

pia

634

wom

en o

f chi

ld-b

earin

g ag

e w

ho g

ave

birt

h w

ithin

the

12 m

onth

s pr

eced

ing

the

stud

y pe

riod

in G

onda

r city

, Nor

thw

est

Ethi

opia

Resu

mpt

ion

of S

ex,

Sexu

al c

oerc

ion,

Pa

infu

l sex

, Sex

ual

desi

re, V

agin

al

dryn

ess

– 61

.4%

of p

artic

ipan

ts h

ad v

agin

al d

eliv

ery

with

out a

n ep

isio

tom

y/te

ars,

11.8

% h

ad a

vag

inal

del

iver

y w

ith e

pisi

-ot

omy/

tear

s, an

d 6.

5% h

ad a

n in

stru

men

tal d

eliv

ery

(forc

eps/

vacu

um);

the

rem

aind

er h

ad a

ces

area

n se

ctio

n–

At t

he ti

me

of s

tudy

, 89.

7% h

ad re

sum

ed s

exua

l int

erco

urse

; of

thes

e, 2

6.9%

had

resu

med

sex

bef

ore

6 w

eeks

pos

tpar

tum

– Th

e m

ost f

requ

ent r

easo

n fo

r res

umpt

ion

of s

ex w

as p

artn

er

dem

and

(repo

rted

by

76.1

%)

– U

pon

resu

min

g se

xual

inte

rcou

rse,

69.

2% re

port

ed h

avin

g no

pro

blem

s, 15

.6%

repo

rted

pai

n du

ring

sex,

6.0

% re

port

ed

vagi

nal b

leed

ing/

disc

harg

e, 5

.1%

repo

rted

a la

ck o

f des

ire,

and

4.0%

repo

rted

vag

inal

dry

ness

– 29

.7%

of t

hose

who

did

exp

erie

nce

a pr

oble

m a

fter

resu

m-

ing

sex

soug

ht m

edic

al a

dvic

e fo

r the

ir se

xual

pro

blem

– 28

.5%

had

eve

r bee

n ad

vise

d ab

out s

exua

l act

ivity

– In

mul

tivar

iabl

e lo

gist

ic re

gres

sion

, the

follo

win

g w

ere

sign

ifica

ntly

ass

ocia

ted

with

ear

ly re

sum

ptio

n of

sex

: urb

an

resi

denc

e (a

OR

6.12

), lo

w p

arity

(aO

R 2.

26),

part

ner d

eman

d as

th

e re

ason

for r

esum

ing

sex

(aO

R 2.

66),

usin

g an

y fa

mily

pla

n-ni

ng (a

OR

2.72

), an

d ob

tain

ing

post

nata

l car

e (a

OR

1.45

)

Nkw

abon

g et

al.

(201

9) [5

8]Ca

mer

oon—

Retr

ospe

ctiv

e co

hort

The

stud

y en

quire

s w

heth

er

nurs

ing

mot

hers

regu

larly

resu

me

sexu

al in

terc

ours

e be

fore

the

42nd

da

y po

stpa

rtum

120

wom

en a

t the

ir 6-

wee

k po

st-

part

um c

heck

-ups

who

del

iver

edbe

twee

n 11

/15/

2013

& 1

2/31

/201

3

Resu

mpt

ion

of s

ex,

Perin

eal t

ear/

pain

, ST

I ris

k

– 79

.1%

of t

he p

artic

ipan

ts h

ad re

sum

ed s

exua

l int

erco

urse

w

ithin

the

first

6 w

eeks

aft

er c

hild

birt

h–

Am

ong

thos

e w

ho re

sum

ed in

terc

ours

e, 3

.2%

del

iver

ed v

ia

cesa

rean

sec

tion

vs. 5

6% o

f tho

se th

at h

ad n

ot y

et re

sum

ed

sex

(p <

0.0

01).

Sim

ilarly

, vag

inal

and

unc

ompl

icat

ed d

eliv

erie

s bo

th in

crea

sed

the

likel

ihoo

d of

hav

ing

resu

med

sex

bef

ore

the

6-w

eek

post

part

um v

isit

(p <

0.0

01)

– A

mon

g th

ose

who

had

resu

med

inte

rcou

rse,

per

inea

l tr

aum

a w

as p

rese

nt fo

r 12.

6% (i

nclu

ding

four

epi

siot

omie

s an

d ei

ght p

erin

eal t

ears

), vs

. 60%

of t

hose

who

had

not

yet

re

sum

ed s

ex (i

nclu

ding

two

epi

siot

omie

s an

d 13

tear

s)

(p <

0.0

01)


Tabl

e 3

(con

tinue

d)

Aut

hor (

Year

)Lo

catio

n an

d st

udy

desi

gnO

bjec

tive(

s)St

udy

popu

latio

nSp

ecifi

c to

pic(

s)Ke

y re

sults

Nol

ens

et a

l. (2

018)

[59]

Uga

nda—

Pros

pect

ive

coho

rtTh

e ai

m o

f thi

s st

udy

was

to a

sses

s ho

w v

acuu

m e

xtra

ctio

n w

as

expe

rienc

ed b

y w

omen

aft

er it

s re

-intr

oduc

tion

in a

tert

iary

refe

rral

ho

spita

l in

sub-

Saha

ran

Afri

ca,

usin

g w

omen

-cen

tere

d ou

tcom

es

such

as

birt

hing

exp

erie

nce

satis

-fa

ctio

n; p

ain

1 da

y af

ter b

irth;

and

qu

ality

of l

ife, p

ain

and

dysp

areu

nia

6

wee

ks a

nd 6

mon

ths

afte

r birt

h

Wom

en w

ho g

ave

birt

h (t

o a

sing

leto

n in

cep

halic

pre

sent

a-tio

n) v

ia v

acuu

m e

xtra

ctio

n or

SS

CS

at th

e m

ain

labo

r war

d of

the

Mul

ago

Nat

iona

l Ref

erra

l Hos

pita

l in

Kam

pala

, Uga

nda.

Par

ticip

ants

wer

e in

terv

iew

ed a

t 1 d

ay, 6

wee

ks, a

nd

6 m

onth

s af

ter b

irth

Resu

mpt

ion

of s

ex,

Dys

pare

unia

– A

t bas

elin

e, 9

0.7%

of p

artic

ipan

ts h

ad a

kno

wn

perin

eal

stat

us; o

f the

se, 3

5.9%

had

an

epis

ioto

my,

34.

0% h

ad a

n in

tact

pe

rineu

m, 2

9.8%

had

a fi

rst o

r sec

ond

degr

ee te

ar, a

nd 0

.8%

ha

d a

third

deg

ree

tear

– W

omen

who

und

erw

ent v

acuu

m e

xtra

ctio

n, v

s. se

cond

– st

age

caes

area

n se

ctio

n (S

SCS)

, exp

erie

nced

less

pai

n in

the

first

24

hour

s fo

llow

ing

birt

h (p

< 0

.001

), le

ss v

agin

al/a

bdom

i-na

l pai

n at

6 w

eeks

pos

tpar

tum

(p <

0.0

01),

and

a si

mila

r am

ount

of v

agin

al/a

bdom

inal

pai

n at

6 m

onth

s po

stpa

rtum

(p

= 0

.05)

– A

t 6–

wee

ks p

ostp

artu

m, n

o pa

in w

as re

port

ed b

y 76

.2%

of

wom

en w

ho h

ad a

vac

uum

ext

ract

ion,

vs.

55.5

% o

f tho

se th

at

had

a SS

CS

(OR

2.56

). A

mon

g w

omen

that

had

und

ergo

ne

vacu

um e

xtra

ctio

n, p

ain

scor

es in

dica

ted

’seve

re’ o

r ’ve

ry

seve

re’ p

ain

in th

e la

st 4

wee

ks fo

r 3.4

%, v

s. 17

.1%

for t

hose

th

at u

nder

wen

t a S

SCS

(OR

0.17

). Fo

r 50.

0% (v

acuu

m e

xtra

c-tio

n), v

s. 73

.6%

(SSC

S), p

ain

had

inte

rfer

ed w

ith th

eir d

aily

ac

tiviti

es d

urin

g th

e pr

eced

ing

4 w

eeks

(OR

0.36

)-A

t 6-w

eeks

pos

tpar

tum

, wom

en w

ho u

nder

wen

t vac

uum

ex

trac

tion,

vs.

SCSS

, had

hig

her o

dds

of h

avin

g re

sum

ed s

ex

(40.

0% v

s. 28

.3%

, OR

1.69

, p =

0.0

1)


Tabl

e 3

(con

tinue

d)

Aut

hor (

Year

)Lo

catio

n an

d st

udy

desi

gnO

bjec

tive(

s)St

udy

popu

latio

nSp

ecifi

c to

pic(

s)Ke

y re

sults

Oda

r et a

l. (2

003)

[60]

Uga

nda—

Cro

ss-s

ectio

nal

To e

stab

lish

the

time

take

n to

re

sum

e se

xual

inte

rcou

rse,

the

sexu

al m

orbi

dity

ass

ocia

ted

with

re

sum

ptio

n, a

nd th

e pr

eval

ence

of

sex

ual p

robl

ems

enco

unte

red

by p

ostp

artu

m w

omen

att

endi

ng

imm

uniz

atio

n cl

inic

s in

Mul

ago

Hos

pita

l in

Uga

nda

216

wom

en, 3

–6 m

onth

s po

stpa

r-tu

m, w

ho h

ad b

roug

ht th

eir i

nfan

ts

to th

e M

ugal

o H

ospi

tal i

mm

uniz

a-tio

n cl

inic

s fo

r vac

cina

tion

Resu

mpt

ion

of s

ex,

Dys

pare

unia

, Oth

er

sexu

al m

orbi

ditie

s

– A

mon

g pa

rtic

ipan

ts, 3

9.4%

had

eith

er h

ad a

n ep

isio

tom

y or

vag

inal

lace

ratio

n; 8

7.2%

of t

he e

pisi

otom

ies

heal

ed w

ell

whi

le 1

2.8%

bec

ame

infe

cted

– A

t the

tim

e of

the

stud

y, 6

6.4%

of p

artic

ipan

ts h

ad re

sum

ed

havi

ng s

exua

l int

erco

urse

; 49.

3% o

f the

se re

sum

ed s

ex d

urin

g th

e pu

erpe

rium

. Of t

hose

who

resu

med

dur

ing

the

puer

-pe

rium

, 8.5

% re

sum

ed w

ithin

the

first

wee

k af

ter b

irth.

Tim

e to

resu

mpt

ion

rang

ed fr

om th

e fir

st w

eek

to th

e 24

th w

eek

afte

r birt

h, w

ith a

n m

ean

time

of 7

.87

(± 4

.9) w

eeks

– A

dvic

e pr

ovid

ed to

mot

hers

by

heal

th w

orke

rs a

t dis

char

ge

was

inco

nsis

tent

; onl

y so

me

advi

sed

to w

ait 6

or m

ore

wee

ks–

Reas

ons

for r

esum

ing

sexu

al a

ctiv

ity in

clud

ed: h

usba

nds’

dem

ands

(46%

), ad

vise

from

hea

lth w

orke

rs (7

%),

conv

eni-

ence

(37%

), an

d fu

lfilli

ng c

ultu

ral d

eman

ds (1

0%)

– So

me

cultu

ral d

eman

ds in

clud

ed a

n ex

pect

atio

n fo

r w

omen

to re

sum

e se

xual

act

ivity

with

in a

wee

k of

del

iver

y as

to

hel

p he

al h

er w

ound

s an

d br

ing

heal

th to

the

infa

nt. S

ome

wom

en re

sum

ed s

ex e

arly

bec

ause

"the

y w

ere

ente

ring

a ne

w h

ouse

"–

Reas

ons

for n

ot re

sum

ing

sex

incl

uded

: not

wel

l yet

(18%

), he

alth

adv

ice

(37%

), no

t int

eres

ted

(22%

), an

d "h

usba

nd’s

way

" (23

%).

Som

e pa

rtic

ipan

ts (n

= 2

6) h

ad n

ot re

sum

ed s

ex

beca

use

they

had

not

bee

n to

ld w

hen

it w

ould

be

safe

to

do s

o–

22.2

% o

f par

ticip

ants

exp

erie

nced

sig

nific

ant d

egre

es o

f m

orbi

dity

with

in 6

mon

ths

of g

ivin

g bi

rth,

incl

udin

g: d

ys-

pare

unia

(62.

5%),

vagi

nal d

isch

arge

(18.

8%),

vagi

nal b

leed

ing

(15.

6%),

and

tear

s or

bru

ises

(3.1

%)

– Ea

rly re

sum

ptio

n of

sex

(with

in 6

wee

ks) w

as s

igni

fican

tly

asso

ciat

ed w

ith: h

avin

g up

to a

prim

ary-

leve

l edu

catio

n (O

R 1.

53; p

= 0

.03)

, hav

ing

had

a va

gina

l del

iver

y (O

R 3.

84;

p =

0.0

005)

, and

hav

ing

an in

tact

per

ineu

m (O

R 1.

73; p

= 0

.02)

– O

nly

19 o

f the

32

wom

en w

ith m

orbi

ditie

s so

ught

hel

p. T

he

wom

en w

ho s

ough

t hel

p w

ere

gene

rally

old

er (p

= 0

.01)

– W

omen

who

sou

ght h

elp

still

felt

shy

to d

iscu

ss th

eir

prob

lem

s. M

ost s

ough

t adv

ice

and/

or tr

eatm

ent f

rom

less

qu

alifi

ed p

erso

nnel

, whi

le th

e re

st a

dmin

iste

red

trea

tmen

t th

emse

lves

or r

epor

ted

that

the

prob

lem

end

ed w

ithin

1 d

ay


Tabl

e 3

(con

tinue

d)

Aut

hor (

Year

)Lo

catio

n an

d st

udy

desi

gnO

bjec

tive(

s)St

udy

popu

latio

nSp

ecifi

c to

pic(

s)Ke

y re

sults

Osi

nde

et a

l. (2

012)

[61]

Uga

nda—

Cro

ss-s

ectio

nal

To a

sses

s th

e fa

ctor

s as

soci

ated

w

ith re

sum

ptio

n of

sex

ual i

nter

-co

urse

and

use

of c

ontr

acep

tion

in th

e 6-

wee

k po

stpa

rtum

per

iod

amon

g w

omen

att

endi

ng p

ostn

atal

ca

re a

t Kab

ale

Regi

onal

Hos

pita

l, Ka

bale

, Uga

nda

131

wom

en w

ho a

tten

ded

the

hosp

ital’s

pos

tnat

al c

linic

Resu

mpt

ion

of s

ex;

Sexu

al c

oerc

ion;

Pe

rinea

l wou

nds

– A

mon

g th

e 13

1 pa

rtic

ipan

ts, 5

8.0%

resu

med

sex

ual i

nter

-co

urse

ear

ly (w

ithin

6 w

eeks

follo

win

g ch

ildbi

rth)

– Ed

ucat

ion

leve

l of t

he s

pous

e w

as s

igni

fican

tly a

ssoc

iate

d w

ith e

arly

resu

mpt

ion

of in

terc

ours

e (a

OR

0.2;

p =

0.0

5)–

Part

icip

ants

repo

rted

spo

usal

pre

ssur

e an

d th

e fe

ar o

f the

ir sp

ouse

leav

ing

them

as

reas

ons

for r

esum

ing

inte

rcou

rse

early

– Th

ose

who

wai

ted

at le

ast 8

wee

ks b

efor

e re

sum

ing

inte

r-co

urse

repo

rted

the

follo

win

g re

ason

s fo

r wai

ting:

unh

eale

d pe

rinea

l wou

nds,

the

fear

of c

once

ptio

n, a

nd g

eogr

aphi

c se

para

tion

from

thei

r spo

use

Reza

ei e

t al.

(201

7) [6

2]Ira

n—C

ross

-sec

tiona

lTo

eva

luat

e w

omen

’s se

xual

func

-tio

n in

the

post

part

um p

erio

d in

Ira

n

380

post

part

um w

omen

att

endi

ng

10 u

rban

hea

lth c

ente

rsFS

FI s

core

;Se

xual

dys

func

tion

was

cla

ssifi

ed b

y FS

FI s

core

of ≤

28

– 76

.3%

of p

artic

ipan

ts re

port

ed s

exua

l dys

func

tion

– 79

% o

f tho

se w

ith s

exua

l dys

func

tion

repo

rted

a la

ck o

f de

sire

– In

mul

tivar

iate

regr

essi

on, p

rimip

arou

s m

othe

rs (a

OR

1.96

, p =

0.0

06) a

nd th

ose

that

exc

lusi

vely

bre

astfe

d th

eir i

nfan

ts

(aO

R 2.

47, p

= 0

.01)

wer

e m

ore

likel

y to

repo

rt s

exua

l dys

func

-tio

n

Shab

angu

and

Mad

iba

(201

9)

[63]

Esw

atin

i—Q

ualit

ativ

eTo

exp

lore

the

prac

tice

of p

ost-

part

um s

exua

l abs

tinen

ce in

Sw

azi

wom

en a

nd e

xam

ine

how

cul

tura

l be

liefs

influ

ence

and

pro

mot

e th

e pe

rpet

uatio

n of

the

prac

tice

15 p

ostp

artu

m w

omen

sel

ecte

d vi

a pu

rpos

ive

sam

plin

g at

hea

lth

faci

lity

Resu

mpt

ion

of s

ex

(sex

ual c

oerc

ion

and

HIV

tran

smis

sion

risk

al

so m

entio

ned)

– A

t int

ervi

ew, m

ost w

omen

had

yet

to re

sum

e se

xual

inte

r-co

urse

; mos

t of t

hose

that

had

resu

med

did

so

whe

n th

eir

infa

nt’s

age

reac

hed

6 m

onth

s–

Part

icip

ants

ove

rall

felt

that

pos

tpar

tum

sex

ual a

bstin

ence

be

nefit

ed th

e m

othe

r, in

fant

, and

spo

use.

The

y in

dica

ted

that

ab

stin

ence

sup

port

s th

e m

othe

r’s re

cove

ry fr

om b

irth

and

allo

ws

her t

o ad

equa

tely

car

e fo

r the

infa

nt–

Part

icip

ants

bel

ieve

d th

at re

sum

ing

sex

early

cou

ld h

inde

r th

e in

fant

’s he

alth

, dev

elop

men

t, an

d gr

owth

as

wel

l as

cont

amin

ate

brea

stm

ilk, m

akin

g it

unhe

alth

y fo

r the

infa

nt

to c

onsu

me

– Pa

rtic

ipan

ts a

lso

repo

rted

bei

ng to

ld b

y ol

der w

omen

that

ea

rly re

sum

ptio

n of

inte

rcou

rse

coul

d re

sult

in th

eir p

artn

er’s

illne

ss a

nd p

ossi

bly

even

dea

th–

The

baby

’s ge

nder

als

o in

fluen

ces

the

dura

tion

of a

bsti-

nenc

e; fo

r boy

s, th

e pe

riod

of a

bstin

ence

is m

ore

rela

xed

(sho

rter

) due

to th

e hi

gher

soc

ial v

alue

pla

ced

on b

oys

– Pa

rtic

ipan

ts re

port

ed fe

elin

g pr

essu

re to

abs

tain

from

sex

fro

m fa

mily

mem

bers

and

in-la

ws;

whi

le in

-law

s ty

pica

lly

enfo

rced

abs

tinen

ce u

pon

mar

ried

wom

en, a

bstin

ence

was

en

forc

ed b

y th

e w

oman

’s m

othe

r am

ong

sing

le w

omen

– W

omen

als

o ex

pres

sed

a la

ck o

f con

trol

ove

r abs

tinen

ce;

they

did

not

live

with

thei

r par

tner

s du

ring

the

abst

inen

ce

perio

d an

d fe

lt th

at if

they

had

, the

n th

ey w

ould

hav

e re

sum

ed s

ex e

arly

– D

isad

vant

ages

of t

he c

ultu

rally

pre

scrib

ed p

erio

d of

pos

t-pa

rtum

abs

tinen

ce in

clud

e po

tent

ial r

isk

of H

IV tr

ansm

issi

on

(giv

en th

e la

ck o

f pre

ssur

e pl

aced

on

the

men

to a

bsta

in fr

om

purs

uing

sex

ual r

elat

ions

with

oth

er w

omen

)


Tabl

e 3

(con

tinue

d)

Aut

hor (

Year

)Lo

catio

n an

d st

udy

desi

gnO

bjec

tive(

s)St

udy

popu

latio

nSp

ecifi

c to

pic(

s)Ke

y re

sults

Shei

khi e

t al.

(202

0) [6

4]Ira

n—Ra

ndom

ized

con

trol

led

tria

lTo

det

erm

ine

the

effec

t of s

exua

l he

alth

edu

catio

n on

sex

ual f

unc-

tion

and

the

time

of s

exua

l int

er-

cour

se re

sum

ptio

n in

prim

ipar

ous

wom

en re

ferr

ing

to th

e he

alth

-car

e ce

nter

of Z

ahed

an, I

ran

Prim

ipar

ous

wom

en re

ferr

ed to

he

alth

cen

ters

for p

ostn

atal

car

e 3–

5 da

ys a

fter

birt

h, w

ith h

ealth

y pe

rineu

m o

r low

-gra

de te

ars.

Rand

omly

ass

igne

d to

the

inte

rven

-tio

n or

con

trol

gro

up (n

= 4

7 pe

r gr

oup)

with

pos

ttes

t at 8

wee

ks

post

part

um

Resu

mpt

ion

of s

ex, P

erin

eal

stat

us, S

exua

l des

ire/

arou

sal, V

agin

al

lubr

icat

ion,

Org

asm

, Se

xual

sat

isfa

ctio

n,

Dys

pare

unia

– 92

/94

part

icip

ants

had

had

an

epis

ioto

my;

two

had

grad

e on

e or

two

perin

eal t

ears

– In

the

inte

rven

tion

grou

p, th

e m

ean

tota

l sex

ual f

unct

ion

(SFI

) sco

re in

crea

sed

from

12.

7 (p

re-in

terv

entio

n) to

17.

4 (p

ost-

inte

rven

tion)

(p <

0.0

01);

cont

rol s

core

dec

reas

ed

slig

htly

– In

terv

entio

n an

d co

ntro

l gro

up p

ost-

test

sco

res

wer

e si

gnifi

cant

ly d

iffer

ent (

p <

0.0

5) fo

r all

dim

ensi

ons

of s

exua

l fu

nctio

n, in

clud

ing:

des

ire (p

= 0

.001

), ar

ousa

l (p =

0.0

09),

lubr

icat

ion

(p =

0.0

01),

orga

sm (p

= 0

.001

), sa

tisfa

ctio

n (p

= 0

.001

), an

d dy

spar

euni

a (p

= 0

.003

)

Shirv

ani e

t al.

(201

0) [6

5]Ira

n—C

ross

-sec

tiona

lTo

inve

stig

ate

the

sexu

al fu

nctio

n of

mot

hers

at

1 ye

ar p

ostp

artu

m

and

asso

ciat

ed fa

ctor

s

490

Irani

an w

omen

who

wer

e re

crui

ted

rand

omly

at f

our t

ime

perio

ds fr

om c

hild

birt

h: fi

rst

3 m

onth

s, 4

to 6

, 7 to

9 a

nd 1

0 to

12

mon

ths,

from

Janu

ary

to Ju

ly

2008

FSFI

sco

re it

ems

(des

ire, a

rous

al,

lubr

icat

ion,

org

asm

, sa

tisfa

ctio

n an

d pa

in)

– Th

e m

ean

dura

tion

of p

ostp

artu

m a

bstin

ence

was

57.

17

(± 2

7.95

) day

s fro

m d

eliv

ery

– 52

.9%

abs

tain

ed fr

om in

terc

ours

e be

yond

45

days

pos

tpar

-tu

m, p

ossi

bly

refle

ctin

g th

e co

mm

on re

com

men

datio

n in

Ira

n th

at in

terc

ours

e be

del

ayed

unt

il 6-

wee

ks p

ostp

artu

m–

Reas

ons

for a

bsta

inin

g or

del

ayin

g se

x in

clud

ed: f

ear o

f pai

n (8

.6%

), ha

ving

no

inte

rest

(3.5

%),

avoi

ding

pre

gnan

cy (2

.5%

), tir

edne

ss (2

.2%

), an

d bl

eedi

ng (0

.6%

)–

Whi

le 8

.8%

of p

artic

ipan

ts re

port

ed s

exua

l pro

blem

(s) a

nd

40%

not

iced

a re

duct

ion

in s

exua

l des

ire fr

om p

re-p

regn

ancy

to

pos

tpar

tum

, onl

y 2.

4% o

f par

ticip

ants

spo

ke to

a h

ealth

pr

ofes

sion

al a

bout

thei

r sex

ual p

robl

em(s

)–

Mea

n sc

ores

for a

ll do

mai

ns o

f sex

ual f

unct

ion

and

tota

l se

xual

func

tion

varie

d si

gnifi

cant

ly a

cros

s th

e fo

ur p

ostp

ar-

tum

inte

rval

s ov

eral

l–

The

follo

win

g so

ciod

emog

raph

ic c

hara

cter

istic

s w

ere

sign

ifica

ntly

cor

rela

ted

with

sex

ual f

unct

ion:

pos

tpar

tum

du

ratio

n (r =

0.1

7; p

= 0

.000

1), h

ighe

r mat

erna

l age

(r =

−

0.12

; p =

0.0

06),

num

ber o

f chi

ldre

n (r =

− 0

.09;

p =

0.0

2) a

nd

mar

riage

dur

atio

n (r =

− 0

.08;

p =

0.0

5)

Sule

-Odu

et a

l. (2

008)

[66]

Nig

eria

—Pr

ospe

ctiv

e co

hort

To re

view

the

post

part

um

sexu

al p

ract

ices

in th

e co

mm

unity

, pr

edom

inan

tly in

habi

ted

by th

e Yo

ruba

s

371

mot

hers

who

had

just

giv

en

birt

h to

sin

glet

on b

abie

s an

d pr

evio

usly

bre

astfe

d at

leas

t one

ch

ild >=

6 m

onth

s

Resu

mpt

ion

of s

ex–

Dur

ing

the

first

mon

th fo

llow

ing

child

birt

h, 8

4.6%

of p

artic

i-pa

nts

abst

aine

d fro

m s

exua

l int

erco

urse

; dro

pped

to 2

.1%

by

the

11th

–15t

h m

onth

s–

Exam

ined

pat

tern

s by

soc

ial c

lass

, age

, and

bre

astfe

edin

g

Ugw

u et

al.

(202

1) [6

7]N

iger

ia—

Pros

pect

ive

coho

rtTo

det

erm

ine

the

com

para

tive

effec

t of c

aesa

rean

sec

tion

and

vagi

nal d

eliv

ery

on fe

mal

e se

xual

fu

nctio

n di

sord

ers

Post

nata

l mot

hers

at t

wo

hosp

itals

in

Nig

eria

The

inte

rven

tion

grou

p o

f wom

en

deliv

ered

via

cae

sare

an s

ectio

n w

here

as w

omen

in th

e co

ntro

l gr

oup

had

a va

gina

l del

iver

y (5

0 in

ea

ch g

roup

)

Resu

mpt

ion

of s

ex,

Sexu

al F

unct

ion

Dis

orde

rs

– A

mon

g th

e 48

par

ticip

ants

that

had

a v

agin

al d

eliv

ery,

the

perin

eum

was

inta

ct a

fter

chi

ldbi

rth

for 1

1, w

hile

19

expe

ri-en

ced

perin

eal t

earin

g an

d/or

an

epis

ioto

my

– A

mon

g th

ose

who

had

a c

esar

ean

sect

ion,

74.

4% re

sum

ed

inte

rcou

rse

by 6

-wee

ks p

ostp

artu

m, v

s. 52

.1%

of t

hose

who

ha

d a

vagi

nal d

eliv

ery

(RR =

1.4

3; p

= 0

.03)

– Th

ose

who

had

a c

esar

ean

sect

ion

had

sign

ifica

ntly

hig

her

mea

n sc

ores

(p <

0.0

5) fo

r the

follo

win

g se

xual

func

tion

dom

ains

: org

asm

, pai

n, a

nd s

atis

fact

ion


Tabl

e 3

(con

tinue

d)

Aut

hor (

Year

)Lo

catio

n an

d st

udy

desi

gnO

bjec

tive(

s)St

udy

popu

latio

nSp

ecifi

c to

pic(

s)Ke

y re

sults

Zulu

(200

1) [6

8]M

alaw

i—M

ixed

-met

hods

To e

xam

ine

ethn

ic d

iffer

ence

s in

th

e tr

aditi

on o

f pos

tpar

tum

sex

ual

abst

inen

ce b

y co

mpa

ring

its o

bser

-va

nce

and

ratio

nale

in th

ree

cultu

r-al

ly d

iffer

ent e

thni

c co

mm

uniti

es

in M

alaw

i, us

ing

quan

titat

ive

and

qual

itativ

e da

ta c

olle

cted

in th

ose

com

mun

ities

Wom

en’s

data

from

the

thre

e ru

ral

cens

us e

num

erat

ion

area

s (n

= 2

73

sout

h; n

= 5

50 c

entr

al; n

= 2

88

nort

h).

In-d

epth

inte

rvie

ws

(IDIs

) and

focu

s gr

oup

disc

ussi

ons

(FG

Ds)

con

-du

cted

with

key

info

rman

ts (n

= 2

2 FG

Ds,

n =

61

IDIs

)

Resu

mpt

ion

of s

ex–

Qua

ntita

tive

data

sug

gest

that

pos

tpar

tum

sex

ual a

bsti-

nenc

e pr

actic

es d

id n

ot c

hang

e su

bsta

ntia

lly b

etw

een

1988

an

d 19

98–

Base

d on

199

8 da

ta, a

t 2

and

4 m

onth

s po

stpa

rtum

, ab

stin

ence

is s

imila

r in

the

nort

h an

d in

the

sout

h, m

uch

low

er in

the

cent

ral r

egio

n. O

bser

ved

regi

onal

var

iatio

n in

po

stpa

rtum

abs

tinen

ce d

urat

ion

corr

espo

nded

with

regi

onal

di

ffere

nces

in k

now

ledg

e of

and

adh

eren

ce to

cus

tom

s re

quiri

ng a

bstin

ence

whi

le b

reas

tfeed

ing

and

until

aft

er th

e re

sum

ptio

n of

men

ses

– Pa

rtic

ipan

ts e

luci

date

d be

liefs

rela

ted

to th

e in

fant

’s nu

triti

on a

nd h

ealth

in re

latio

n to

pos

tpar

tum

abs

tinen

ce.

Part

icip

ants

bel

ieve

d th

at in

terc

ours

e (v

ia th

e ex

posu

re to

se

men

) can

con

tam

inat

e br

east

milk

– Pa

rtic

ipan

ts fr

om e

ach

regi

on s

tudi

ed a

lso

expr

esse

d th

at

post

part

um a

bstin

ence

pro

tect

ed th

e m

ale

part

ner’s

hea

lth.

It w

as p

erce

ived

that

pos

tpar

tum

ble

edin

g en

ds w

hen

the

mot

her’s

repr

oduc

tive

syst

em h

as "c

oole

d," s

igni

fyin

g th

at

she

is fr

ee fr

om h

arm

ful fl

uids

. Par

ticip

ants

list

ed a

var

iety

of

sym

ptom

s m

en m

ay e

xper

ienc

e w

hen

expo

sed

to re

prod

uc-

tive

bloo

d, s

ome

part

icip

ants

sug

gest

ing

that

the

sym

ptom

s ca

n re

sem

ble

thos

e of

AID

S an

d ot

hers

exp

lain

ing

that

the

effec

t can

be

fata

l. The

se p

erce

ived

sym

ptom

s al

so in

clud

ed

ster

ility

and

the

grad

ual l

oss

of s

exua

l pro

wes

s. A

mon

g pa

rtic

ipan

ts in

the

cent

ral a

nd s

outh

ern

regi

ons,

conc

erns

w

ere

also

men

tione

d in

rela

tion

to a

bstin

ence

aft

er th

e po

stpa

rtum

ble

edin

g pe

riod

– Th

e re

com

men

ded

dura

tion

of p

ostp

artu

m a

bstin

ence

va

ried.

Mos

t par

ticip

ants

from

the

cent

ral r

egio

n re

com

-m

ende

d 3

and

6 m

onth

s, th

ough

som

e in

dica

ted

that

one

sh

ould

abs

tain

unt

il th

e in

fant

reac

hed

a ce

rtai

n le

vel o

f ph

ysic

al m

atur

ity–

Part

icip

ants

in th

e ce

ntra

l and

sou

ther

n re

gion

s de

scrib

ed

vario

us v

ersi

ons

of c

hild

-str

engt

heni

ng ri

tual

s, w

hich

wer

e pe

rfor

med

bef

ore

resu

min

g in

terc

ours

e as

to p

rote

ct th

e ch

ild fr

om h

arm

; par

ticip

ants

exp

lain

ed th

at m

en to

o w

ere

advi

sed

to a

bsta

in fr

om in

terc

ours

e (in

clud

ing

with

oth

er

wom

en) p

rior t

o a

child

-str

engt

heni

ng ri

tual

– In

the

nort

h th

ere

was

a c

lear

and

defi

nitiv

e ev

ent (

i.e. t

he

resu

mpt

ion

of m

ense

s) b

elie

ved

to in

dica

te th

at re

sum

ing

sex

was

then

saf

e; n

orth

ern

part

icip

ants

bel

ieve

d th

at m

en-

stru

atio

n si

gnifi

es th

at th

e w

oman

’s bo

dy is

reco

vere

d an

d ph

ysic

ally

pre

pare

d fo

r ano

ther

pre

gnan

cy. C

hild

-str

engt

hen-

ing

ritua

ls w

ere

also

per

form

ed in

the

nort

h pr

ior t

o re

sum

ing

inte

rcou

rse,

as

to p

rote

ct th

e ch

ild’s

heal

th. P

artic

ipan

ts

expl

aine

d th

at b

ecom

ing

preg

nant

bef

ore

resu

min

g m

ense

s an

d pe

rfor

min

g th

e rit

ual w

as c

onsi

dere

d di

sgra

cefu

l and

ap

palli

ng; p

aren

ts w

ho re

sum

e se

x be

fore

this

poi

nt w

ere

seen

as

callo

us a

nd s

elfis

h. O

lder

wom

en s

omet

imes

judg

ed

pare

nts’

adhe

renc

e to

abs

tinen

ce e

xpec

tatio

ns b

y as

sess

ing

the

child

’s he

alth


outcomes, including those surrounding positive sexual health.

This review highlights a clear need for increased sexual health education for postpartum women within LMICs. Prior global literature has highlighted a lack of education on positive sexual health, which is influenced by access to sexuality education, including knowledge of risks/vul-nerabilities, access to sexual health care, and affirmative environments to promote positive sexual health [6]. Spe-cifically, our results found that when women experienced sexual health morbidities within the postpartum period, they were hesitant to seek help from providers, both because they felt embarrassed and because they felt pro-viders were poorly equipped to handle issues surround-ing women’s sexual health. Further, many women were unclear about the recommended timing surrounding safe resumption of sex, and instead turned to cultural prac-tices, which were largely enforced by family members. Sexual health education, including guidance surrounding care-seeking for potential sexual health morbidities that could occur, must be included within postnatal care ser-vices to ensure that women are able to resume sex when they feel the time is right for themselves and their rela-tionships. Additionally, normalization of sexual health dysfunction, particularly at a time when women’s bodies are undergoing massive physical and hormonal changes, can help women feel less embarrassed and stigmatized. Clear guidelines for healthcare providers on how to inte-grate sexual health education into postpartum proto-cols are necessary, alongside the expansion of accessible postpartum care services far into the postpartum period given delays in resumption of sexual activity and recogni-tion of associated dysfunctions.

While maternal health services are rapidly expanding within LMICs, attention is shifting to not only ensure provision of services, but to also assess the quality of such services [16]. Current quality of care assessments, however, do not include sexual health counseling and to date, the majority have focused on content of antenatal services, with little attention to quality of postnatal care services [69]. Without data to examine receipt and con-tent of sexual health education and counseling as part of antenatal and/or postnatal care services, the research and practice field does not have a clear sense of when and how sexual health is addressed. Future work must seek to close this data gap given the profound impact these data will have on shaping clinical practice guidelines and in turn, monitoring quality of care.

Strengths of this study include a rigorously imple-mented scoping protocol, utilization of library informa-tionists in developing and revising the search strategy, and focus on an understudied topic inclusive of both positive and negative sexual health outcomes; however,

this study is not without limitations. Namely, this scoping review includes many studies with small samples or lim-ited measures for sexual health in the postpartum period. The majority of studies included were cross-sectional in nature, limiting conclusions surrounding temporal-ity of associations. Further, some studies did not define inclusion criteria surrounding timing within postpartum period, and thus were not included within the current scoping review as we could not assess whether the find-ings were specific to one year postpartum. Methodologic rigor was not assessed as part of this review given the large number of articles retained within our final crite-ria. Lastly, as our search strategy purposively did not examine women’s sexual health in relation to fertility and contraception, it is possible that some articles which also explored women’s sexual health in the postpartum period more broadly may have been missed by our search.

ConclusionIn conclusion, we urge future research to examine sexual health beyond the resumption of sex after childbirth and to explore barriers to help-seeking for women experienc-ing sexual health morbidities in the postpartum period. Further exploration of positive women’s sexual health is needed, inclusive of factors that may promote positive sexual health within the postpartum period. Ultimately, both the expansion of indicators surrounding positive sexual health and prioritization of women’s sexual health within global development priorities, such as the SDGs, can ensure that the full range of women’s health needs are not only addressed, but also valued, regardless of context.

AbbreviationsDHS: Demographic and Health Surveys; FGC: Female genital cutting; FSFI: Female Sexual Function Index; HIV: Human immunodeficiency virus; LMIC: Low- and middle-income country; RTI: Reproductive tract infection; SRH: Sexual and reproductive health; STI: Sexually transmitted infection.

Supplementary InformationThe online version contains supplementary material available at https:// doi. org/ 10. 1186/ s12978- 022- 01399-6.

Additional file 1: Table S1. PubMed MeSH Terms

AcknowledgementsWe thank the Welch Medical Library informationists for their assistance in set-ting our scoping review search terms.

Author contributionsSNW conceptualized the manuscript, guided inclusion exclusion/criteria, and drafted the manuscript. AP conducted the initial search, abstract/title review, and full text review, and compiled results tables. HLT conducted full text review and compiled results tables. CW and LAZ provided input into the eligibility criteria and scoping review process and assisted in drafting the manuscript. All authors read and approved the final manuscript.

https://doi.org/10.1186/s12978-022-01399-6

https://doi.org/10.1186/s12978-022-01399-6


FundingNo funding to disclose.

Availability of data and materialsOriginal articles reviewed in this manuscript are available on PubMed.

Declarations

Ethics approval and consent to participateNot applicable.

Consent for publicationNot applicable.

Competing interestsThe authors declare they have no competing interests.

Author details1 Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. 2 Department of Obstetrics and Gynecology, Creighton University School of Medicine Phoe-nix, Phoenix, AZ, USA.

Received: 21 December 2021 Accepted: 1 April 2022

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