Sexual Function of Women in Six Month Period after Spontaneous Delivery

Dwi Ajeng Rembulan1, Dwiana Ocviyanti1, I Putu Gede Kayika1

1

Department of Obstetrics and Gynecology, Faculty of Medicine University of Indonesia

Cipto Mangunkusumo National Hospital, Jakarta, Indonesia

Abstract
Introduction: Sexual dysfunction is experienced by 22-86% women after giving birth. The
reasons to delay resuming sexual intercourse is due to anxiety about perineal pain, bleeding,
and fatigue. Sexual dysfunction is usually unnoticed either by patients or clinicians. This
study was conducted to assess sexual dysfunction in women during six months period after
spontaneous delivery.
Methods: This was a cross-sectional study using female sexual function index (FSFI)
questionnaires which were distributed among 47 subjects during period

of September-

December 2012. Each individual results was assessed for general sexual dysfunction and per
domain sexual dysfunction. Subjects characteristics were analyzed bivariately with sexual
dysfunction prevalence.
Results: During six months after spontaneous delivery, 44 subjects (93.6%) had restarted to
do sexual activity. Out of 47 subjects, 27 (57.5%) suffered from sexual dysfunction. P value
for bivariate analysis between patients age group, education level, parity, perineal rupture,
breastfeeding and sexual dysfunction status were respectively 0.064; 0.437; 0.836; 0.761;
0.723.
Conclusion: There was no significant difference between various variables analyzed and
sexual dysfunction, either general or per domain, in six months period after spontaneous
delivery.
Keywords: sexual dysfunction, domain, six months period, spontaneous delivery
Abstrak
Pendahuluan: Disfungsi seksual dialami oleh 22-86% perempuan pada periode
pascapersalinan. Alasan yang dikemukakan untuk menunda hubungan seksual adalah
kekhawatiran mengenai nyeri perineum, perdarahan, dan kelelahan. Disfungsi seksual
seringkali tidak disadari, baik oleh pasien maupun oleh klinisi. Penelitian ini dilakukan untuk
menilai disfungsi seksual perempuan dalam waktu enam bulan setelah melahirkan spontan.

Metode: Penelitian ini merupakan studi potong lintang menggunakan kuesioner female
sexual function index (FSFI) yang didistribusikan di antara 47 responden dalam periode
September-Desember 2012. Tiap hasil individu digunakan untuk menilai disfungsi seksual
secara umum dan disfungsi seksual per domain. Karakteristik responden kemudian dianalisis
bivariat dengan disfungsi seksual.
Hasil: Dalam enam bulan setelah persalinan spontan, 44 responden (93,6%) telah memulai
kembali aktivitas seksual. Dari 47 responden, 27 (57,5%) menderita disfungsi seksual. Nilai p
untuk analisis bivariaat antara kelompok usia, tingkat pendidikan, paritas, derajat ruptur
perineum, status menyusui dan disfungsi seksual secara berturut-turut, yaitu: 0,064; 0,437;
0,836; 0,761; 0,723.
Kesimpulan: Tidak ada perbedaan bermakna antara berbagai variabel yang dianalisis dengan
disfungsi seksual, baik secara umum maupun per domain, dalam periode enam bulan
pascapersalinan spontan.
Kata kunci: disfungsi seksual, domain, periode enam bulan, persalinan spontan
Introduction
Women sexual dysfunction is a complex entity in diagnosis, classification, and
management.1,2 Prior studies claimed that sexual dysfunction is experienced by 22-50%
women generally3,4 and 22-86% women in postpartum period. 5,6 Almost 90% of women
become sexually active in less than six months. 7 The ones who delay to do sexual intercourse
said that the delay are due to anxiety about perineal pain, bleeding, and fatigue. 8 Vaginal
delivery is overshadowed by more risk of sexual dysfunction due to higher prevalence of
birth canal rupture which then affects pelvic floor muscle function and eventually leads to
sexual dysfunction.9
Sexual dysfunction problem is usually unnoticed either by patients or clinicians.
However, it actually makes a big impact in family life. Barret et al 7 found that 60%
postpartum patients felt there were sexual dysfuctions, but there were only 15% who
discussed those with physicians. Meanwhile, Oboro and Tabowei 10 stated that 68%
postpartum women needed help in sexual dysfunction problem. However, there were only
12% of them who consulted with physicians. In the other side, physicians actually had less
concern about this problem compared to other postpartum disturbances, such as uterus
involution, perineal and abdominal incision wound healing, or breast milk production.11,12

There has been no data of postpartum sexual dysfunction prevalence and related
factors in Indonesia or Jakarta yet. This study was conducted to assess sexual function, sexual
dysfunction prevalence, and related factors in women during six months period after delivery.
Methods
This study was cross sectional study using female sexual function index (FSFI)
questionnaires which were distributed among 47 subjects during period September-December
in 2012. Questionnaire data were filled using consecutive sampling method, either by home
visits or by phone calls. All subjects were women who previously had undergone pervaginam
spontaneous delivery during last sixth months in obstetry and gynecology emergency unit,
Cipto Mangunkusumo National Hospital, Jakarta. The subjects and their husbands signed
informed consents which were given by the researcher.
General and per domain sexual dysfunction. For each individual results, there were two
parameters analyzed: general sexual dysfunction and per domain sexual dysfunction. General
sexual dysfunction was determined if the total score from questionnaire 26.55. 13
Meanwhile, per domain sexual dysfunction consisted of: motivation, lubrication, orgasm,
satisfaction, and pain. Each domain were assessed using table 1.Domain score resulted from
individual score in each domain which was multiplied with multiply factor in each domain.
Domain sexual dysfunction could be stated when subjects didnt reach domain score of 50%.
Score zero (0) was given when subject hadnt done sexual activity during last one month.14
Table 1. Female sexual function index (FSFI) scoring system.
Domain
Motivation
Generation
Lubrication
Orgasm
Satisfaction
Pain
Full Score

Question

Score Range Multiply

Number
1,2
3,4,5,6
7,8,9,10
11,12,13
14,15,16
17,18,19

1-5
0-5
0-5
0-5
0 (atau 1) -5
0-5

Factor
0.6
0.3
0.3
0.4
0.4
0.4

Minimum Maximu

Score of 50%

Score
1.2
0.0
0.0
0.0
0.8
0.0
2.0

3.6
3.6
3.6
3.6
2.4 or 3.6
3.6
21.6

m Score
6.0
6.0
6.0
6.0
6.0
6.0
36.0

Statistical analysis. Categorical data were presented as number and percent. Descriptive data
was presented generally for all subjects. The categorical independent data then were analyzed
using bivariat analysis, either using chi-square (if fulfilled the requirement of chi-square test)

or fisher exact test to get relative risk (RR) value and 95% confidence interval (CI).
Multivariate analysis would be done with logistic regression enter method if there had been
variables with p value less than 0.10. This study was reported to and had already approved by
Medical ResearchEthical Committee, Faculty of Medicine University of Indonesia, with
number: 601/PT02.FK/ETIK/2012.
Results
Subjects characteristics. Subjects age range from 17 to 45 years old with median of 30
years old. Most of subjects (70%) had medium education level, were multipara (57.4%),
suffered from grade II perineal rupture (51%), and still breastfed their babies (78.7%).
Table 2. Subject characteristics.
Characteristics
Age (median, IQR) (years)
Age group (n, %)
Age < 20 years
Age 20-30 years
Age 31-40 years
Age >40 years
Education level (n, %)
Low education level
Medium education level
High education level
Parity (n, %)
Primipara
Multipara
Grande multipara
Grade of perineal rupture (n, %)
Grade 0
Grade I
Grade II
Grade III
Grade IV
Breasfeeding status (n, %)
Breastfeeding
Non-breastfeeding

Subjects (n = 47)
30.00 (25.00-33.00)
3 (6.4)
25 (53.2)
16 (34.0)
3 (6.4)
8 (17.0)
33 (70.2)
6 (12.8)
18 (38.3)
27 (57.4)
2 (4.3)
14 (29.8)
6 (12.8)
24 (51.1)
3 (6.4)
0 (0.0)
37 (78,7)
10 (21,3)

Sexual dysfunction. In this study was found that during six months after spontaneous
delivery, 44 subjects (93,6%) had restarted to do sexual activity, with 45 subjects (95.7%)
stated that their spouses were the ones who asked to do it first. Based on the restart time of
sexual intercourse, 28 subjects (63.6%) started between 40 days and 3 months after delivery,

14 subjects (31.8%) started between 3 and 6 months after delivery. There were only 2
subjects (4.6%) who restarted earlier (less than 40 days after delivery). Among subjects
which had already begun to do sexual intercourse, there were 9 (20.9%) who felt disturbances
in sexual intercourse when compared to condition before delivery. The most common
problem found were pain (66.7%). However, there were only 2 people who consulted
physicians. Meanwhile, 3 subjects (6.4%) which hadnt begun to do sexual intercourse until 6
months after delivery complained fatigue, pain, and lack of motivation. Three of them didnt
consult physicians as well.
Out of 47 subjects, 20 had normal sexual function, meanwhile the rest suffered from
sexual dysfunction in six month period after spontaneous delivery (Table 3). Per domain
sexual dysfunctions were described in table 4.
Table 3. Sexual function in six months period after spontaneous delivery
Sexual Function
Normal
Sexual dysfunction
1 domain dysfunction
2 domain dysfunction
3 domain dysfunction
4 domain dysfunction
5 domain dysfunction
6 domain dysfunction

Value
20
27
10
7
4
3
1
4

(%)
(42.5)
(57.5)
(21.3)
(14.9)
(8.5)
(6.4)
(2.1)
(8.5)

Table 4. Per domain sexual dysfunction in six months period after spontaneous delivery
Dysfunctio
Domain
Motivation
Generation
Lubrication
Orgasm
Satisfaction
Pain

Normal
22
32
38
33
40
36

(%)
(46.8)
(68.1)
(80.9)
(70.2)
(85.1)
(76.6)

n
25
15
9
14
7
11

(%)
(53.2)
(31.9)
(19.1)
(29.8)
(14.9)
(23.4)

There was no significant difference between various variables analyzed andsexual

dysfunction in six months period after spontaneous delivery (Table 5). Further, each domains
was analyzed bivariately, however, there were no significances between each domains and
independent variables.

Table 5. Relationship between sexual dysfunction in six months period after delivery with
various variables.

Variables
Patients Age
<20 years*
20-30 years*
31-40 years+
>40 years+
Education Level
Low
Medium*
High*
Parity
Primipara
Multipara (2-4)*
Grande multipara (5)*
Perineal Rupture

Sexual Function
Dysfunction
Normal
n
%
n
%

RR

95%CI

2
11
11
3

66.7
44.0
68.8
100.0

1
14
5
0

33.3
56.0
31.3
0.0

0.064

1.587

0.982-2.565

6
19
2

75.0
57.6
33.3

2
14
4

25.0
42.4
66.7

0.437

0.718

0.438-1.177

10
15
2

55.6
55.6
100.0

8
12
0

44.4
44.4
0.0

0.836

1.055

0.631-1.764

57.1
66.7
58.3
33.3

6
2
10
2

42.9
33.3
41.7
66.7

0.761

0.926

0.566-1.514

59.5
50.0

15
5

40.5
50.0

0.723

1.189

0.606-2.334

Grade
0*
8
I*
4
II+
14
III+
1
Breastfeeding Status
Breastfeeding
22
Non-breastfeeding
5
*
merged as one group for statistic necessity
+

merged as one group for statistic necessity

Multivariate analysis was done for sexual generation domain. Variables assessed were
age group and education level. However, both variables didnt reach significance in
multivariate analysis (p>0.05).
Discussion
There were 93.6% subjects who had restarted their sexual activities with their spouses
which are in accordance with Barret7, in which there were 89% subjects who had begun back
their sexual activities during six months after delivery.There were two subjects (4.6%) who
began their activities very early (less than 40 days after delivery). However, there were three
subjects who hadnt begun their sexual activities at all. The reason given were fatigue, pain,
and lack of motivitation. They didnt discuss and consult their problems with physicians. That

fact supports that women sexual dysfunction is often neglected and not detected, not only by
physician, but also by patients themselves.3
The number of sexual dysfunction in six months after spontaneous delivery (57.5%)
was higher than results from Odar et al15, which was 22%. This difference could result from
different method used in each studies. This study used female sexual function index (FSFI), a
standardized and validated questionnaire; meanwhile Odar et al assessed sexual dysfunction
based only on patients complaints. If this study used patients complaints as assessment
basis, there would have been only 9 subjects (20.9%) who felt problem in sexual activity post
delivery. It showed us that most women didnt realize their own problem unless assessed with
sensitive objective tool.
There were five subjects who suffered from dysfunction in motivation domain, but
still had total score more than 26.55 so that they were not included in sexual dysfunction
category. It was in accordance with Basson sexual response which described that in women,
the motivation didnt have to progress before sexual stimulation all the time. When a woman
got involved in sexual activity, she could be stimulated and experience sexual motivation. 16
Therefore, dysfunction in motivation domain not always ends as general sexual dysfunction.
Pain is the most experienced problems, which were stated by 6 of 9 subjects (66.7%)
who experienced problem in sexual activity. From further interpretation was found that 5 out
of 6 of them had history of perineal rupture. FSFI assessment gave information that those five
experienced sexual dysfunction, but not in pain domain. Instead, they suffered from sexual
motivation dysfunction. The difference could be caused by pain perception which was
different in respondents, even though pain complaint was proven decreasing subjects sexual
motivation. Sexual motivation dysfunction was also the most experienced by subjects
(53.2%). Lack of motivation also became main problem complained by subjects in other
studies.17,18,19,20,21
Through descriptive data, sexual dysfunction in six month period after delivery
seemed to be more prevalent in age group > 40 years old (100%), medium education level
(66.7%), grande multipara (100%), grade II perineal rupture (66.7%), and breasfeeding
women (64.9%). However, in bivariate analysis, those factors werent statistically significant
(p>0.05) to cause sexual dysfunction, not also generally, but also per domain. It could be
caused by less number of sample compared to other researches.
Age was found to be not significant in affecting sexual dysfunction, while actually
there were several anatomical changes, such as: shortening and losing elasticity of vagina,
decreased lubrication from cervix and vaginal wall.22In bivariate analysis for sexual

generation dysfuction domain, age factor was pretty close to significance (p = 0,061; RR =
2,211; 95%CI 0,943-5,188). The fact supported that there were decreased response for sexual
stimulation in women age > 40 years old so that causing sexual generation dysfunction. In the
next study, it is suggested to use bigger sample to analyze this relation.
Fajewonyomi23 found that sexual dysfunction was more prevalent in women with
higher education level due to their higher awareness about health problem and their being
more open in discussing sexual problem. However, it was found otherwise in this study, with
no significance between sexual dysfunction and education level.
The number of parity and grade of perineal rupture were previously thought as
affecting factors of sexual dysfunction because it related closely with hip base muscles
function which eventually lead to post delivery sexual dysfunction. 21,24 The result showed that
the number of sexual dysfunction was higher in grander multipara (100%), however, the same
result couldnt be gotten in association with grade of perineal rupture. The sexual dysfunction
was more prevalent in grade I (66.7%) and II (58.3%) perineal rupture, compared to
previously suggested grade III (33.3%). Therefore, perineal rupture didnt relate directly with
sexual dysfunction, but also affected by associating factors to perineal rupture wound healing,
such as suture, nutrition, and hygiene in wound treatment.
In subjects who had breastfed until six months after delivery, there were 64.9% of
sexual dysfunction. Breastfeeding was one of the factors which affected post delivery sexual
dysfunction. High level of prolactin caused lower level of estrogen, progesteron, and
androgen which further caused decreased vaginal secretion and depressive mood. Eventually,
those would lead to sexual pain and lack of motivation to sexual activity.25,26,27
Conclusion
This study identified that almost all subjects (93.6%) started back their sexual activity
in period six months after delivery. Meanwhile, the after delivery sexual dysfunction
prevalence in National Hospital Cipto Mangunkusumo was 57.5%. Most of them didnt
realize there were problem in their sexual activity and didnt discuss it with physicians. The
subjects characteristics (consisting age, education level, parity, and breastfeeding status)
didnt have significance relation with sexual dysfunction and each domains.
Acknowledgment
The author would like to thank specially to dr. Ardeno Kristianto and dr. Anwar Fuady
for their help in statistic analysis and interpreting the results.

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