Retrospective comparison of sexual function outcomes postpartum based on FSFI score after episiotomy, normal vaginal delivery, and cesarean section

Authors

Abstract

Aim The aim is to determine sexual function according to the female sexual function index score after normal vaginal birth with episiotomy and after birth with cesarean section, and to reveal its importance in the decision of birth method and to examine the effects of demographic characteristics on sexual function.
Methods In this study, 18-45 year-old women with a minimum of 6 months and a maximum of 1 year postpartum who applied to our clinic, 89 women had a normal vaginal birth with episiotomy (Group 1), and 89 women had a cesarean section (Group 2) were evaluated.
Results When the total sexual function scores (desire, arousal, lubrication, satisfaction, and orgasm) were compared between group 1 and group 2, no statistically significant difference was detected in terms of the degree of sexual dysfunction, but the total scores calculated for both groups were observed in favor of postpartum sexual dysfunction. It was found that age, body mass index, marriage duration, gravida, parity, and number of children did not affect sexual function and Female Sexual Function Index (FSFI) score.
Conclusion When birth methods are compared, there is no difference in terms of sexual function between episiotomy and vaginal birth and cesarean birth in the period from the 6th month to the 1st year postpartum, but both birth methods cause sexual dysfunction. When the whole group is looked at, demographic characteristics can be said to affect sexual function.

Keywords

Introduction

According to the World Health Organization (WHO), sexuality consists of a combination of physical, emotional, intellectual, and social aspects that enrich personality, communication, and love.¹ While sexuality, which lasts throughout human life, is affected by both physiological and psychological factors, the most important factor affecting sexuality is the socio-cultural environment in which the person lives and the attitude and approach of the culture in which the person lives towards sexuality.²
Although sexuality in women is a symbol of desirability, body image, and childbearing ability, it also includes intellectual and emotional components. Sexuality is not static and is experienced with different qualities at different times. In women, the processes starting with menarche and extending through pregnancy and the postpartum period greatly affect the quality of sexual life. Pregnancy and the postpartum period are the periods when female sexuality is experienced at its most subdued due to the endocrinological, psycho-social, and physical changes experienced by the woman.³
The resumption of sexual activity in the postpartum period depends on the psychological readiness of both parents, especially the mother, and on the woman’s physical recovery. While adapting to physical changes, women are also affected by psychological factors such as performance anxiety, insomnia, and stress related to motherhood. Additionally, postpartum maternal and fetal complications influence the timing of resuming sexual activity. In a study conducted by Rathfish et al. in 2010, it was observed that the rates of decreased sexual desire, inability to achieve orgasm, sexual dissatisfaction, and dyspareunia were increased in women who had vaginal deliveries with perineal trauma and episiotomy. According to this study, at least one of the following problems was observed to be significantly more frequent in the postpartum period: decreased sexual desire, difficulty with vaginal stimulation, difficulty with lubrication, difficulty experiencing orgasm, pain during intercourse, and lack of enjoyment from sexual intercourse.⁴ In a study conducted by Barret et al., it was reported that dyspareunia, vaginal dryness, difficulty achieving orgasm, vaginal laxity, sexual aversion, genital pain, postcoital bleeding, and decreased amount of sexual intercourse occurred in the first 3 months after childbirth.⁵
In our country, the time for resuming sexual intercourse postpartum is culturally accepted as the sixth week, and studies report that a large proportion of women have had sexual intercourse in the sixth week.⁶ According to the 2013 Turkey Population and Health Survey (TNSA), the rate of women who did not start sexual intercourse postpartum was 13.0% in the first 3 months, while this rate was reported as 7.0% in the 6th-7th month. In the study conducted by Barret et al., it was reported that 90.0% of patients had sexual life for 6 weeks, but 64.0% of patients experienced problems.⁵
Providing effective counseling during this period requires that healthcare professionals have sufficient knowledge of postpartum sexual problems. The key is identifying these problems and referring patients for appropriate treatment. Improving sexual quality of life in the postpartum period is closely linked to overall quality of life. In this study, we aimed to compare sexual function outcomes after episiotomy, vaginal delivery, and cesarean section using the Female Sexual Function Index score; to evaluate the effect of delivery method on postpartum sexual function; and to assess the impact of demographic characteristics on sexual function.

Materials and Methods

Study Design and Data CollectionThis study was designed as a survey of women who had vaginal episiotomy and those who had cesarean section. The sample size was calculated using the G*Power Version 3.1.6 program. Assuming a difference of at least 0.5 in the mean effect size between Group 1 and Group 2, the sample size was calculated as 176 individuals with 95% power and an alpha significance level of 0.05.
Using the Female Sexual Function Index (FSFI), the sexual function and demographic data of women who had vaginal deliveries via episiotomy and those who had cesarean deliveries were compared.
In our study, we evaluated 89 women aged 18-45 who had either episiotomy followed by vaginal delivery (Group 1) or 89 women who had cesarean section (Group 2), and who had given birth between August 1, 2022, and February 1, 2023, at the Obstetrics and Gynecology Clinic of Şişli Hamidiye Etfal Training and Research Hospital, Health Sciences University. The postpartum period was between 6 months and 1 year. Patients who gave birth at our hospital were identified by scanning the hospital's electronic data system. FSFI and demographic questionnaires were administered. Subsequently, the responses obtained from these questionnaires were analyzed.
Two groups were evaluated across six separate categories: desire, arousal, lubrication, orgasm, satisfaction, and pain. Sexual function and the effects of demographic characteristics on the two groups were compared using FSFI scores. Inclusion criteria included having given birth via episiotomy or cesarean section at our hospital's obstetrics and gynecology clinic, being between 18 and 45 years of age, having passed a minimum of 6 months and a maximum of 1 year postpartum, and having complete access to information in our hospital's electronic system. Exclusion criteria included those with a history of sexual dysfunction such as vaginismus, those with marital or family problems, those who gave birth in adolescence, those who gave birth prematurely, those who underwent cerclage, those with a history of high-risk pregnancies such as placenta previa, those who received IVF treatment, those with a history of multiple pregnancies, those with psychiatric illnesses, those with children with anomalies, and those with systemic diseases or medications that could cause sexual dysfunction.
Two forms were used to collect the necessary data for the research. The first form was a demographic information form designed to determine the socio-demographic characteristics of the women included in the study, and the second form was the Female Sexual Function Index (FSFI), used to assess the sexual function of the women. Informed consent was obtained from all patients who participated in the survey by having them sign an informed consent form.
Female Sexual Function Scale (FSFI)The FSFI is a 19-item questionnaire used to measure female sexual function, examining sexual function under 6 subheadings: desire, arousal, lubrication, orgasm, satisfaction, and pain.⁷ Each item is scored from 0 to 5. Sexual desire or interest level is measured in questions 1 and 2 (score range, 1-5); arousal level, confidence, and satisfaction in questions 3-6 (score range, 0-5); lubrication frequency, difficulty, and ability to maintain intercourse in questions 7-10 (score range, 0-5); orgasm frequency, difficulty, and satisfaction in questions 11-13 (score range, 0-5); satisfaction rate with partner, level of satisfaction in intercourse and in overall sexual life in questions 14-16 (score range, 0-5); Pain or discomfort during vaginal penetration, the presence of pain, and the level of pain during and following vaginal penetration are addressed and evaluated in questions 17-19 (score range, 0-5). Accordingly, the highest possible raw score on the scale is 95.0, and the lowest possible raw score is 4.0.
Ethical ApprovalThis study was approved by the Ethics Committee of Sisli Hamidiye Training and Research Hospital (Date: 2023-08-29, No: 4076).
Statistical Analysis
Statistical analysis was performed using SPSS 23.0 for Windows. Descriptive statistics were presented as number and percentage for categorical variables, and as mean, standard deviation, minimum, maximum, and median for numerical variables. Proportions in independent groups were compared using the Chi-Square Test. When the normal distribution condition was not met for comparisons of numerical variables between two independent groups, the Mann-Whitney U test was used. When the parametric test condition was not met for relationships between numerical variables, Spearman Correlation Analysis was used. Determinant factors were examined using Linear Regression Analysis. The statistical significance level was accepted as p ˂ 0.05.
Reporting GuidelinesThis study was reported in accordance with the STROBE guidelines.

Results

The study evaluated a total of 89 patients who had vaginal deliveries with episiotomy and 89 patients who had cesarean deliveries. No statistically significant differences were found between Group 1 and Group 2 in terms of age, duration of marriage, mean gravidity, body mass index (BMI), and mean parity (p = 0.645, p = 0.447, p = 0.328). No statistically significant differences were found between the two groups in terms of demographic characteristics (The detailed data are provided in Supplementary Table 1). In the entire study group, the percentage of patients with an FSFI score below 26.55, indicating a high risk for sexual dysfunction, was found to be 61.2%. The percentage of patients with sexual dysfunction was 62.9% in Group 1 and 59.6% in Group 2. No significant difference was found between the two groups (p = 0.644) (Table 1). Among the characteristics of the study group, there were statistically significant differences in the rates of cases with FSFI scores below 26.55 and sexual dysfunction based on education level, employment status, and income level (p = 0.005, p = 0.042, p = 0.021). Those with university and postgraduate education had higher FSFI scores compared to those with primary, secondary, and high school education. Employed individuals had statistically significantly higher FSFI scores than unemployed individuals, and those with high income levels had significantly higher FSFI scores than those with low to medium income levels (The detailed data are provided in Supplementary Table 2). The total FSFI score was 22.1 ± 9.2 in Group 1 and 23.4 ± 8.2 in Group 2. The total scores calculated for both groups favored postpartum sexual dysfunction. However, when comparing the total sexual function scores for the two groups, no statistically significant difference was found (p = 0.481). When considering subgroups, no significant difference was found between the two groups (The detailed data are provided in Supplementary Table 3). No statistically significant relationship was found between the FSFI score subcategories and age, duration of marriage, gravidity, parity, and number of children. A statistically significant weak positive correlation was found between sexual desire score and BMI (p = 0.002, r = 0.236). A statistically significant weak positive correlation was found between sexual arousal score and income level (p = 0.043, r = 0.152). Lubrication, orgasm, pain/discomfort, and total score were found to be statistically significantly associated with education level (p = 0.046, r = 0.150; p = 0.023, r = 0.170; p = 0.041, r = 0.153; p = 0.006, r = 0.207) (The detailed data are provided in Supplementary Table 4). When comparing subgroups between smokers and non-smokers, no statistically significant difference was found in sexual function index scores. Pain/discomfort scores were statistically significantly higher in alcohol users compared to non-users (p = 0.042). No statistically significant differences were found in other sexual function index scores in cases of alcohol use (The detailed data are provided in Supplementary Table 5).

Discussion

This study found no statistically significant difference in total FSFI scores and subscales between women who had vaginal deliveries via episiotomy and those who had cesarean deliveries, between the 6th month and the 1st year postpartum. However, the low total FSFI scores in both groups, indicating postpartum sexual dysfunction, suggest that the postpartum period has a negative impact on women's sexual function, regardless of the mode of delivery.
The literature shows heterogeneous results regarding the effect of delivery method on postpartum sexual function. While some studies report that vaginal delivery with episiotomy has negative effects on sexual function, other studies have found no significant difference between cesarean and vaginal delivery.^8,9 The FSFI-based studies of Baytur et al. and Barrett et al. show that the delivery method is not a determinant of sexual function, similar to our findings.^5,10 In contrast, some researchers, such as Barbara et al., have reported lower sexual function scores in operative vaginal delivery.¹¹ These contradictory results can be attributed to the fact that female sexual dysfunction is a multidimensional process resulting from the interaction of many biological, psychological, hormonal, and sociocultural factors.
In our study, it was found that education level, employment status, and income level had a significant effect on sexual functions. There are studies in the literature that have found similar results to our study. A study by İncesu in 2004 showed that sexual problems occurred as the education level decreased.¹² Studies by Singh et al. in 2009, Chedraui et al. in 2012, and Llaneza et al. in 2011 showed that the prevalence of postpartum sexual dysfunction was higher in women with low education levels compared to the group with high education levels.^13,14,15 This situation shows that postpartum sexual dysfunction cannot be explained solely by obstetric and demographic parameters. The increase in FSFI scores with increasing education and income levels may be related to access to information, health awareness, and stronger communication between partners.
When the FSFI subscales were examined, no difference was observed depending on the delivery method in terms of desire, arousal, lubrication, orgasm, satisfaction, and pain scores. Furthermore, a statistically significant weak positive correlation was found between sexual desire score and BMI, a weak positive correlation between sexual arousal score and income level, and a weak positive statistically significant correlation between lubrication, orgasm, pain/discomfort, and total score and education level. Contrary to our findings, there are differing opinions in the literature regarding the relationship between the number of births and the FSFI score subscales. A study by Witting et al. on 2081 women showed that nulliparous women have more difficulty achieving orgasm and have a higher prevalence of dyspareunia compared to multiparous women.¹⁶ However, another study comparing women who had four or more births with those who had fewer, conducted on 491 women, found that the level of desire decreased with the number of children. A prospective cohort study by Lagaert et al. showed that multiparous women experienced less pain during intercourse than primiparous women.¹⁷ The findings in our study suggest that the surgical trauma of cesarean section and the effects on perineal structures during vaginal delivery may lead to similar levels of changes in sexual function through different mechanisms.
In the postpartum period, sociodemographic and psychosocial factors appear to be more influential than the delivery method in determining women’s sexual function. Therefore, sexual function expectations should not be the sole criterion in choosing a delivery method, and women should be provided with holistic counseling and support during the postpartum period.

Limitations

This study has several limitations. First, its retrospective design limits the ability to establish causal relationships. Second, the relatively small sample size may have reduced statistical power, particularly in subgroup analyses. Third, the absence of pre-pregnancy FSFI data prevented comparison of sexual function before and after pregnancy. In addition, as FSFI scores are self-reported, respondent bias cannot be excluded. Finally, important factors such as psychological status, postpartum depression, and breastfeeding duration were not assessed. Therefore, these findings should be supported by larger, prospective studies.

Conclusion

This study reveals no significant difference in postpartum sexual function between episiotomy-assisted vaginal delivery and cesarean delivery. The high frequency of sexual dysfunction in both delivery methods indicates that postpartum sexual health is affected independently of the delivery method. Our findings emphasize that sexual function expectations should not be the determining factor in the decision-making process regarding the delivery method, and highlight the importance of addressing women's sexual health in the postpartum period with a routine, holistic approach that takes sociodemographic factors into account.

Declarations

Abbreviations

BMI: Body mass index
FSFI: Female Sexual Function Index
G*Power: Statistical Power Analysis Program
IVF: In vitro fertilization
SPSS: Statistical Package for the Social Sciences
STROBE: Strengthening the Reporting of Observational Studies in Epidemiology
TNSA: Turkey Population and Health Survey
WHO: World Health Organization

References

1. World Health Organization. Defining sexual health. Published 2015. Accessed December 29, 2022. https://www.who.int/teams/sexual-and-reproductive-health-and-research/key-areas-of-work/sexual-health/defining-sexual-health
   PubMed Google Scholar
2. Bancroft J. Models of human sexuality: the role of theory. In: Human Sexuality and Its Problems. 3rd ed. Elsevier Health Sciences; 2009:5-19.
   PubMed Google Scholar
3. Olsson A, Lundqvist M, Faxelid E, Nissen E. Women's thoughts about sexual life after childbirth: focus group discussions with women after childbirth. Scand J Caring Sci. 2005;19(4):381-387. doi:10.1111/j.1471-6712.2005.00357.x
   Article PubMed Google Scholar
4. Aydın Beşen M, Rathfısch G. Doğumda perineal travma ve onarımı: kanıt temelli yaklaşımlar [Perineal trauma and repair during childbirth: evidence-based approaches]. Gazi Sağlık Bil. 2019;4(3):1-11.
   PubMed Google Scholar
5. Barrett G, Peacock J, Victor CR, Manyonda I. Cesarean section and postnatal sexual health. Birth. 2005;32(4):306-311. doi:10.1111/j.0730-7659.2005.00388.x
   Article PubMed Google Scholar
6. Banaei M, Kariman N, Ozgoli G, et al. Prevalence of postpartum dyspareunia: a systematic review and meta-analysis. Int J Gynaecol Obstet. 2021;153(1):14-24. doi:10.1002/ijgo.13523
   Article PubMed Google Scholar
7. Shindel AW, Goldstein I. Sexual function and dysfunction in the female. In: Wein AJ, Kavoussi LR, Partin AW, Peters CA, eds. Campbell-Walsh Urology. 11th ed. Elsevier; 2016:749-764
   PubMed Google Scholar
8. Botros SM, Abramov Y, Miller JJ, et al. Effect of parity on sexual function: an identical twin study. Obstet Gynecol. 2006;107(4):765-770. doi:10.1097/01.AOG.0000207677.03235.76
   Article PubMed Google Scholar
9. Buhling KJ, Schmidt S, Robinson JN, et al. Rate of dyspareunia after delivery in primiparae according to mode of delivery. Eur J Obstet Gynecol Reprod Biol. 2006;124(1):42-46. doi:10.1016/j.ejogrb.2005.04.008
   Article PubMed Google Scholar
10. Baytur YB, Deveci A, Uyar Y, Ozcakir HT, Kizilkaya S, Caglar H. Mode of delivery and pelvic floor muscle strength and sexual function after childbirth. Int J Gynaecol Obstet. 2005;88(3):276-280. doi:10.1016/j.ijgo.2004.12.019
    Article PubMed Google Scholar
11. Barbara G, Pifarotti P, Facchin F, et al. Impact of mode of delivery on female postpartum sexual functioning: spontaneous vaginal delivery and operative vaginal delivery vs. cesarean section. J Sex Med. 2016;13(3):393-401. doi:10.1016/j.jsxm.2016.01.004
    Article PubMed Google Scholar
12. İncesu C. Cinsel işlevler ve cinsel işlev bozuklukları [Sexual functions and sexual dysfunction]. Turk J Clin Psychiatry. 2004;7(suppl 3):3-13.
    PubMed Google Scholar
13. Singh JC, Tharyan P, Kekre NS, et al. Prevalence and risk factors for female sexual dysfunction in women attending a medical clinic in south India. J Postgrad Med. 2009;55(2):113-120. doi:10.4103/0022-3859.52842
    Article PubMed Google Scholar
14. Chedraui P, Pérez-López FR, Sánchez H, et al. Assessment of sexual function of mid-aged Ecuadorian women with the 6-item Female Sexual Function Index. Maturitas. 2012;71(4):407-412. doi:10.1016/j.maturitas.2012.01.013
    Article PubMed Google Scholar
15. Llaneza P, Fernández-Iñarrea JM, Arnott B, Portilla-Garcia MP, Chedraui P, Perez-Lopez FR. Sexual function assessment in postmenopausal women with the 14-item changes in sexual functioning questionnaire. J Sex Med. 2011;8(8):2144-2151. doi:10.1111/j.1743-6109.2011.02309.x
    Article PubMed Google Scholar
16. Witting K, Santtila P, Alanko K, et al. Female sexual function and its associations with number of children, pregnancy, and relationship satisfaction. J Sex Marital Ther. 2008;34(2):89-106. doi:10.1080/00926230701636163
    Article PubMed Google Scholar
17. Lagaert L, Weyers S, Van Kerrebroeck H, et al. Postpartum dyspareunia and sexual functioning: a prospective cohort study. Eur J Contracept Reprod Health Care. 2017;22(3):200-206. doi:10.1080/13625187.2017.1315938
    PubMed Google Scholar

Additional Information

Publisher’s Note
Bayrakol MP remains neutral with regard to jurisdictional and institutional claims.

Rights and Permissions

Creative Commons License

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC 4.0). To view a copy of the license, visit https://creativecommons.org/licenses/by-nc/4.0/

View full license details →

About This Article

Received:

February 6, 2026

Accepted:

March 31, 2026

Published Online:

April 1, 2026