Risk factors for sexual dysfunction during the first year postpartum: A prospective study

To assess the connection of postpartum sexual dysfunction with mode of delivery, amenorrhea, depressive symptoms, and relationship satisfaction.

retrospective data, or inappropriate selection criteria. 2,8 The majority of studies have been cross-sectional or retrospective, and therefore limited in their ability to identify factors in the early postpartum period that are risk factors for sexual dysfunction. 3,8 The rate of cesarean section has been increasing in recent decades, including in Hungary, where 42.02% of deliveries were by cesarean section in 2019. 9 One explanation could be the perception by women that cesarean section preserves the quality of prepregnancy sexual function. However, the literature is inconsistent regarding the connection between the mode of delivery and postpartum sexual dysfunction. According to some studies, mode of delivery is not a risk factor for sexual dysfunction, 5,8,10,11 according to others, it is. [12][13][14] The postpartum period can be considered a vulnerable period of life. 1,2 According to therapists and previous studies, the normality of a couple's sexual function and their satisfaction with the relationship are linked. A high level of relationship satisfaction has been repeatedly reported to be connected with a high level of sexual function, and these two factors seem to vary concurrently. 1,2,15 Another variable affecting postpartum sexual function is depression. Postpartum depression occurs within the first 12 months after delivery, and the prevalence of depressive symptoms ranges widely between 13% and 19% of mothers. 16 Earlier studies have reported that postpartum depression increases the risk for developing sexual dysfunction.
Conversely, the presence of sexual dysfunction may lead to depression. 17,18 These results suggest that relationship dissatisfaction and depressive symptoms are important risk factors for sexual dysfunction in the postpartum period. Therefore, their role should be examined in a prospective study.
Our study sought to investigate the long-term connection between sexual dysfunction and potential risk factors such as mode of delivery, amenorrhea, level of relationship satisfaction, and severity of depressive symptoms at 3, 6, and 12 months after delivery.

| MATERIAL S AND ME THODS
This prospective study was carried out in three obstetric institutes in Budapest, Hungary. Women were personally invited within 3 days postpartum to participate. The invitation period was between June 2018 and August 2019. The purposes, procedures, risks, and benefits of the study, and the data protection regulations, were explained to all participants. The study was designed in accordance with the General Data Protection Regulation and approved by the Semmelweis University Regional and Institutional Committee of Scientific and Research Ethics in May 2018 (SE-REB number: 24/2017). All participants signed an informed consent form before enrolling.
Data were collected using online questionnaires at 3 months (T1), 6 months (T2), and 12 months (T3) postpartum. The SurveyMonkey program-which is a General Data Protection Regulation-compliant survey program specified for market and scientific research surveyswas used for designing the survey, collecting responses, creating the database, and pre-analyzing the results. Links to the questionnaires were sent via e-mail at every time-point. This was followed by a reminder e-mail for participants with no or partial responses 4 days after the initial invitation.
The inclusion criteria stipulated that participants must: (1) be between the ages of 18 and 45 years, (2) have been in the same relationship since at least 6 months before their last pregnancy, and (3) fully complete the questionnaire. Women who: (1) had multiple pregnancies, (2) had preterm deliveries (before the 37th gestational week), (3) gave inconsistent responses in the questionnaires, (4) terminated their relationship, (5) became pregnant, or (6) had an infant with a birth weight under 1500 g or over 4000 g or received long-term treatment in an intensive care unit were excluded from all questionnaires. Additionally, we excluded women from the currentbut not necessarily from the subsequent-questionnaires who had not resumed sexual life since delivery or had not been sexually active in the last 4 weeks. A woman could be in more than one exclusion category.
The sample size was calculated by assuming the prevalence of sexual dysfunction to be 64.3%, 7 where the difference to be detected was a decrease of 20% (to 51.4%) with 95% confidence interval (CI), with the type 1 error set at 5% and the power at 90%. 19 Calculation based on these values produced a minimum sample size of 199.
We invited 729 women to participate in this study. Only 389 completed the questionnaire at T1. Of these 389, 278 completed the questionnaire at T2. Of these 278, 133 completed the questionnaire at T3. At T1, of the 389 women, 46 were not selected because they did not meet the selection criteria, and an additional 50 because of sexual inactivity. At T2, of the 278 women, 44 were not selected because they did not meet the selection criteria at T1 or T2, and an additional 20 because of sexual inactivity. At T3, of the 133 women, 32 were not selected because they did not meet the selection criteria at T1 or T2 or T3, and an additional 6 because of sexual inactivity.
The final sample size was 293 at T1, 214 at T2, and 95 at T3.
Data on sociodemographic characteristics such as maternal age, educational level, and parity were collected in the first questionnaire (T1). Data on the menstrual cycle were collected at all time-points.  is a 19-item survey that reflects women's sexual experience over the previous 4 weeks and assesses six domains of sexual function: desire, arousal, lubrication, orgasm, satisfaction, and pain. The score of each domain is multiplied by a correlation factor. Therefore, the lowest possible score is 2, and the highest is 36. The minimum-maximum subgroup scores are Desire: 1.2-6.0, Arousal: 0-6.0, Lubrication: 0-6.0, Orgasm: 0-6.0, Satisfaction: 0.8-6.0, and Pain: 0-6.0. 20 We used 26.55 as a cut-off score, so a total FSFI score below 26.55 was In a primary analysis, the Pearson chi-square test and the Mann-Whitney U test were used to determine the connection between independent variables and sexual dysfunction.
To obtain more precise estimates of the connection between sexual dysfunction and potential influencing variables, univariate and multivariate logistic regression models were developed. Univariate logistic regression was used to assess the connection between sexual function and those independent variables that were found to be significant in the primary analysis or that we assumed to be connected with sexual dysfunction. Variables that were in significant connection with sexual dysfunction in a univariate regression model were examined in a multivariate regression model. Their connection was adjusted for parity, age, and education level.
The mean age of the participants varied between 31.44 and 31.8 years over the study (Table 1).
Of the 293 T1 participants, 131 (44.70%) participants had sexual dysfunction according to their initial total FSFI scores. This rate decreased over time (T2: 40.18%; T3: 23.15%). Among the FSFI subgroups, the lowest mean scores appeared in the Desire subgroup at T1, T2, and T3. All subgroup mean scores increased over time, except for the Satisfaction scores, which slightly decreased at T2 ( Figure 1).
Mean and median RAS scores were highest at T1, then mildly decreased at T2 and stagnated at T3. Mean and median EPDS scores slightly increased from T1 to T2, then decreased to the T1 level again at T3 (Table 1). Table 2 (Table 3).

| DISCUSS ION
In our study, we longitudinally examined postpartum sexual dysfunction and the effect of potential influencing factors using validated questionnaires.
The proportion of participants who had sexual dysfunction corresponded to the proportions reported in previous studies. [3][4][5][6][7] The proportion of postpartum women with sexual dysfunction is generally high; however, labeling postpartum women as sexually dysfunctional should not be done automatically. The postpartum period can be considered a vulnerable period of life, 1,2 and a time of decreased sexual function, which is mostly transient. 11 Our results showed that the number of women with sexual dysfunction decreased over time.
There were increasing total FSFI and subgroups scores, in line with several previous studies. 10 According to the literature, lack of sexual interest is the most frequently reported sexual dysfunction in the postpartum period. 2,5,14 Likewise, we found the lowest scores in the Desire subgroup among FSFI subgroups at each time-point ( Figure 1). One explanation could be the sleep deprivation because of regular night-time nursing, which is common in the postpartum period, and can be accompanied by lower sexual interest. 3,16 Sexual desire and activity are also higher during ovulation. 24 Therefore, those women who have not menstruated are more likely to suffer from sexual dysfunction, 7 which is in line with our results.
As mentioned before, conflicting results are found in the literature regarding the connection between mode of delivery and sexual dysfunction.
Barrett et al. 13 revealed in their early and highly cited study that after cesarean section women had significantly lower risk of having dyspareunia at 3 months postpartum than women with vaginal delivery; however, they used a cross-sectional study design. 13 McDonald et al, 14 also found a significant connection between sexual dysfunction and mode of delivery at 18 months postpartum. They reported that after having an emergency or elected cesarean section, women had a higher risk of dyspareunia than women who had vaginal delivery with an intact perineum or an unsutured tear.
Examining prospective studies from the last decade, which assess more categories of delivery, there are more consistent results. There is a pressure on women to get into shape soon after delivery, and at 3 months postpartum they might feel weight gain allowed for a short time. We also found a connection between being underweight and sexual dysfunction, which can suggest that for underweight women it might take more time to recover after delivery.
Our results confirm a significant connection between sexual dysfunction and level of relationship satisfaction, which is consistent with previous studies. 1,2,15 One explanation could be that the lower the level of relationship satisfaction, the more likely the woman is to avoid sex as a way of giving feedback about the relationship.
McDonald, et al. 15 found in their longitudinal study that while sexual function seemed to improve over time, women's satisfaction with their relationship decreased in the first 18 months after delivery.
Similarly, in our study we found that although total FSFI scores increased over time, satisfaction decreased at T2, and total median RAS scores slightly decreased within 12 months after delivery. This may suggest that the longer women experience sexual dysfunction, the more they lose the interest of their partner, which can make them insecure about their partner's commitment to their relationship and family. 25 In line with previous studies, in our study the more severe the depressive symptoms, the more likely that the participant suffered from sexual dysfunction at each time-point (Table 3). 17,18,23 The mean EPDS score increased from T1 to T2, and then decreased to T3. This suggests that depressive symptoms such as sleeping difficulties, problems with appetite, and loss of energy can remain unrecognized in the early postpartum period because, according to the consensus, the puerperium is typically beset with similar problems. 16 Significantly higher EPDS scores were found in the Sexual dysfunc-   In conclusion, the present results show that sexual dysfunction is common in the postpartum period, where the most relevant dysfunction is the lack of sexual interest. We confirm that relationship satisfaction and depressive symptoms are risk factors for postpartum sexual dysfunction on a continuous scale: the lower the relationship satisfaction and the more severe the depressive symptoms, the higher the risk of dysfunction. Amenorrhea seems to be a relevant risk factor for sexual dysfunction in the first 6 months postpartum, whereas obesity seems to be a protective factor at 3 months postpartum. According to previous studies and our own data, cesarean section cannot be considered advantageous compared with vaginal birth in order to protect sexual function. To avoid sexual dysfunction, couples may need professional counseling after delivery, especially when risk factors are observed.

CO N FLI C T S O F I NTE R E S T
The authors have no conflicts of interest.

AUTH O R CO NTR I B UTI O N S
KS designed the study, recruited the participants, collect responses, and contributed to planning and performing the analysis.