Table 3 Studies on both positive and negative postpartum sexual health (or neutral; n = 28)

Alum et al. (2015) [43]

Uganda—Cross-sectional

To assess prevalence and factors associated with early resumption of sexual intercourse among postnatal mothers

374 postpartum women who came for postnatal care or brought their babies for immunization (within 6 months postpartum) to one of three postnatal and immunization clinics of a teaching hospital

Resumption of sex

– 21.6% of participants had resumed sexual intercourse within 6 weeks of childbirth

– Participants who were more likely to have resumed intercourse early included those that: had a high income, had low parity, had ever used contraception, or had a spouse with a high education level

Anzaku and Mikah (2014) [44]

Nigeria—Cross-sectional

To describe the current sexual practices of postpartum women, sexual morbidity, contraceptive prevalence and predictive factors for early postpartum sexual intercourse and associated sexual problems

340 women at a child welfare clinic 14 weeks after childbirth at a teaching hospital in Jos, Nigeria

Resumption of sex, Sexual morbidities

– Episiotomies were present in 19.7% of participants and vaginal lacerations in 29.9%. Most genital tract injuries (77.9%) had healed well; the rest led to complications including infection, chronic pain, and scarring

– 67.6% of participants had resumed sex by 14 weeks after birth. The most prominent reason for resuming intercourse (reported by 77.4% of those who had resumed sex) was request of the husband; other reasons included: convenience (14.8%), advice given by health workers (4.3%), the woman's initiation (2.6%), and cultural demands (0.9%)

– Reasons for not resuming intercourse included: husband's unavailability (reported by 38.2% of those who had not yet resumed), feeling that it was not yet time (21.8%), to prevent pregnancy (16.4%), being unwell (12.7%), uninterest (5.5%), cultural reasons (3.6%), health worker advised not to (1.8%)

– Among those who had resumed coitus, 62.6% experienced one or more sexual morbidity upon commencing intercourse, though only 22.2% of these women were still experiencing the problem(s) when enrolled in the study. Only 5.6% of those with a sexual problem had pursued medical advice or treatment

– Reported sexual problems included: vaginal dryness (16.7% of reported problems), deep dyspareunia (14.9%), vaginal tightness (13.1%), superficial dyspareunia (12.5%), loss of sexual desire (11.9%), vaginal looseness (8.3%), abnormal vaginal discharge (7.1%), vaginal bleeding (4.8%), tiredness (4.8%), and other problems (5.9%)

– In multivariate regression, women that had a vaginal delivery were more likely to have reported one or more sexual problems when resuming sex (OR 3.6, p = 0.01); those who had a vaginal laceration or episiotomy were more likely to experience sexual problem(s) when resuming sex (OR 2.4, p = 0.04)

Asadi et al. (2021) [45]

Iran—Qualitative

To explore the experiences related to postpartum changes in women

23 women who have given birth and healthcare providers (midwives and obstetricians)

Perception of sexual dysfunction

– Postpartum participants described feeling less sexually attractive than in the past, referencing vaginal loosening as a reason, and felt that they were not well-groomed

– Some postpartum participants described a decreased feeling of sexual attractiveness (and subsequent self-confidence) in relation to episiotomy scars and the protrusion of labia minora

– Some postpartum participants reported that their husband's approval of these appearance changes resulted in greater sexual performance and less anxiety

– Postpartum participants also described not enjoying sex because of dyspareunia, as well as due to feelings of burning/dryness, and reported feeling less sexual desire during the postpartum period

Borda et al. (2010) [24]

17 DHS countries—Cross-sectional

To identify factors affecting return to sexual activity and use of modern family planning among women in the extended postpartum period

15 of 17 countries included all women, two included married women only

Resumption of sex

– In all 17 countries, women who were 0–2.9 months postpartum reported the least sexual activity

– In 13 countries, the majority of women 3.0–5.9 months postpartum had resumed sexual activity and over three-quarters of women 9.0–11.9 months postpartum were sexually active

– In 10 countries, exclusive breastfeeding was significantly associated with the woman's resumption of sexual activity, with women currently breastfeeding less likely to have resumed sexual activity at the time of the survey

– In 16 countries, resumption of sexual activity was significantly associated with the return of menses. In 14 of these countries, the odds of having resumed sexual activity among women whose menses had returned was more than double the odds of resumption among those whose menses had not returned

– Having resumed sexual activity was associated with the duration of the postpartum period (with 0–2.9-month period as referent); in all but Zambia, this association was significant for two or more of the postpartum intervals

Dadabhai et al. (2020) [46]

Malawi—Prospective Cohort

To determine time from delivery to resumption of sexual activity and menses by HIV infection status

878 women (460 HIV-uninfected and 418 HIV-infected) who attended at least one follow-up visit

Resumption of sex

– Comparable proportions of HIV-infected and HIV-uninfected women reported sexual activity at each visit (< 6.0% at the 6-week postpartum, increasing to > 82.0% at the 12-month)

– Marital status was the only variable significantly associated with early resumption of sex and this significance remained for both groups after stratifying by HIV infection status

Desgrées-du-Loû and Brou (2005) [47]

Cote d'Ivoire—Qualitative

To understand how couples negotiate the resumption of sexual relations following childbirth, the role of post-partum sexual abstinence, the underlying norms, who makes the decision and what each partner's agency is in the decision

Men (n = 10) and women (n = 23); parent of an already weaned child under the age of five

Resumption of sex, Coercive sex, Fear of STIs/HIV

– One argument for sexual abstinence was breastfeeding-related taboos: most women referenced breastfeeding (specifically the belief that semen should not mix with breastmilk, for the health of the child) as a reason for sexual abstinence; nine women and eight men reported resuming sex only after the complete cessation of breastfeeding

– Another common practice was waiting to resume sex until the child could walk; this practice overlapped with breastfeeding-related taboos, given the idea that the ability to walk suggested resilience and no more need for breastfeeding

– For some, resumption of sex depended on the recuperation of the mother from childbirth; the recuperation period ranged from 5–8 months or until menses returned. This practice was based both on desires to regulate fertility and concern for the mother's health

– Women that spoke to a friend of sister about postpartum abstinence were warned about the risk of the husband's unfaithfulness (if abstinence lasted too long) and the risk of pregnancy (if abstinence was too brief)

– All of the women reported that the resumption of sex was generally initiated by the man; eight women reported feeling pressured to resume sex earlier than they wanted to

– Some women felt that polygynous marriages allowed for longer abstinence, given sexual activity with other wives

– Many women expressed fears of infidelity by their partner and related STI and/or HIV risk

– Women seemed to have some agency regarding the resumption of sex: many postponed resumption a few months following their husband's request; some only agreed to resume sex with protection (condoms were believed to prevent semen mixing with breastmilk); some women moved in with their parents for the first year postpartum and/or avoided spending the night at their partner's house until ready to resume sex

Ezebialu and Eke (2012) [48]

Nigeria—Cross-sectional

To determine the average time for resuming vaginal intercourse during the puerperium, as well as factors that are associated with resumption of coital activity

860 mothers in a postnatal clinic at their first visit postpartum

Resumption of sex, Fear of pain/experienced pain

– By the time of their first postnatal visit, 29.7% of participants had resumed vaginal intercourse. Factors that varied significantly between those who had and had not resumed coitus by their first postnatal visit included: resumption of menses (p < 0.001), place of residence (p = 0.001), HIV status (p = 0.004), having minimal or no education (p = 0.009), mode of delivery (p = 0.039), extremes of age (p = 0.007), and being married (p = 0.002)

– In multivariate analysis, HIV-negative status and the resumption of menses showed strongest associations with resuming sex during the puerperium (p < 0.001)

– Among those who had not yet resumed sex, reported reasons for abstaining included avoiding pregnancy (64.5%), partner unavailable (14.9%), lack of interest (9.1%), fear of pain at the site of episiotomy (2.5%), and no reason (11.6%)

– The most common reasons justifying recommended durations of postpartum abstinence were to allow for the woman's full recovery (39.5%) and for family planning purposes (27.9%)

– Six women reported experiencing pain during sex

Gadisa et al. (2021) [49]

Ethiopia—Cross-sectional

To assess the early resumption of postpartum sexual intercourse and its associated risk factors among married women who visited public hospitals for child immunization services

330 postpartum women, 14 weeks after childbirth, randomly selected

Resumption of sex

– 53.9% resumed sex early (< 6 weeks postpartum); 14% of these resumed sex < 4 weeks postpartum

– 77% reportedly resumed sex at their husband's request

– Factors significantly associated with early resumption of sex included: low income (aOR 0.19), monogamous marriage (aOR 3.78), having practiced sexual intercourse during pregnancy (aOR 4.55), having had a cesarean delivery (aOR 0.06), and using contraception (aOR 3.7)

Glynn et al. (2001)[50]

Multi-country (Cameroon, Zambia, Kenya)—Cross-sectional

To demonstrate if prolonged postpartum sexual abstinence may increase the risk of HIV through an associated increases in male extramarital sexual contacts

From six antenatal clinics: n = 1532 women in Yaoundé, Cameroon; n = 1480 in Kisumu, Kenya; n = 1021 in Ndola, Zambia

Postpartum abstinence

– Postpartum abstinence > 6 months was reported by half of participants in Yaoundé, 17% in Kisumu, and 13% in Ndola; abstinence > 12 months was reported by 23% in Yaoundé, 8% in Kisumu, and 4% in Ndola

– Postpartum abstinence was shorter among married women and similar between polygamous/monogamous across sites

– In Yaoundé, postpartum abstinence duration was strongly associated with HIV seropositivity overall, though when restricting to those who were married to their current partner at time of birth results remained only borderline significant

– In Yaoundé, postpartum abstinence was longer among women with prolonged postpartum amenorrhea

– In Kisumu, postpartum abstinence was not associated with HIV status. In Ndola, postpartum abstinence duration was slightly positively associated with being HIV-positive overall, though not when restricting to married women

Iliyasu et al. (2006) [51]

Nigeria—Cross-sectional

To assess contemporary postpartum beliefs, practices, and health problems of mothers in a typical Hausa rural community

300 mothers with children under five

Resumption of Sex, Perineal pain, Harmful traditional practices

– 76.7% of participants resumed sex 6–11 months after delivery

– Certain postpartum rituals and cultural practices were believed to strengthen the mother and return her stamina (believed by 92.7%), help heal perineal wounds (77.3%), stimulate lactation (81.3%), and aid in the drainage of lochia (66.0%). According to 64% of participants, non-observance of such practices could result in body swelling and, according to 4%, to perineal pain and foul-smelling lochia

– Few participants (8.7%) did not believe that the practices were beneficial. Significantly more women with a formal education (22.5%) did not believe the practices to be beneficial compared to those without any formal education (2.8%; p < 0.01)

– Such commonly practiced rituals included: confinement for 40 days after birth (practiced by 87.7%), confinement beyond 40 days (12.3%), hot ritual baths (86.0%), nursing in heated rooms (84.3%), laying on heated beds (5.3%), eating a gruel dish enriched with salt (82.7%), and eating spicy foods (85.3%)

– Some common postpartum complaints included excessive bleeding (reported by 16.3%) and lower abdominal/perineal pain (56.3%); most women who reported a complaint (66.0%) sought traditional remedies, while 25.0% pursued modern medical care and 9.0% did not utilize any medication

– Nearly half of participants stated that they would continue practices regardless of their harmful effects, 25% felt that the practices should be optional, and 8% supported discontinuation

Iliyasu et al. (2018) [52]

Nigeria—Cross-sectional

To determine the prevalence of postpartum sexual activity, delivery-coitus interval, and their determinants among women who delivered within 12 months of the study and attended the postnatal/family planning and child welfare/immunization clinics at Aminu Kano Teaching Hospital in Kano, Nigeria

317 mothers

attending the postnatal/family planning clinics and

those who brought their children for immunization

Resumption of sex, Vaginal discharge, Vaginal irritation, Lack of libido, Dyspareunia

– 52.1% of participants underwent episiotomies. Genital injuries were present among 15.1%, most commonly vaginal lacerations (70.8%) and perineal tears (25.0%)

– 66.9% had resumed sex by study. The duration of postpartum abstinence ranged from 4–28 weeks (mean = 9.6)

– Among sexually active, primary reasons for resuming sex were husband's demands (67.5%) and own desire (14.6%)

– Among those still abstaining from sex, reasons for abstinence included: the infant being too young (81.0%), avoiding pregnancy (13.3%), lack of interest (2.9%), and being either divorced or widowed (2.9%)

– Most sexually active participants reported experiencing a sexual problem (64.2%) including: dyspareunia (32.5%), diminished sexual desire (31.6%), vaginal dryness/soreness (15.6%), vaginal 'looseness' (15.6%), and discharge (6.1%)

– Fewer than two-thirds of those experiencing a sexual problem sought help; most commonly sought sources of advice were friends, mothers, physicians, and internet

– Reasons referenced for not seeking guidance included feeling shy, problem resolving on its own, cultural/religious factors, and not having a female doctor to ask

– Upon adjusting for confounders, the following characteristics remained significantly associated with having resumed sex: not co-habitating with husband (aOR 0.47, p = 0.001), spontaneous vaginal delivery (aOR 1.10, p = 0.05), infant's age 1–6 months (aOR 1.53, p = 0.02) or 6 + months (aOR 2.10, p = 0.001), having five or more living children (aOR 1.21, p = 0.03), and not having resumed menstruation (aOR 0.34, p = 0.003)

Kinuthia et al. (2017) [53]

Kenya—Prospective Cohort

To characterize frequency and types of sexual behaviors and vaginal practices among HIV-uninfected women during pregnancy and up to 9 months postpartum

1252 pregnant, HIV-uninfected women who attended antenatal care clinics

Resumption of sex, Forced sex, Vaginal washing/

drying

– From 2 to 36 weeks postpartum, the proportion of sexually active women increased from 8% to 701% (p < 0.001) and the proportion of women who reported condomless sex within the past month rose from 6% to 60% (p < 0.001)

– 60.1% reported vaginal washing, and prevalence was stable throughout follow-up. Vaginal washing at 36 weeks postpartum was associated decreased odds of having a partner of unknown HIV status, being a housewife, and longer relationship duration, and increased odds of history of abnormal discharge, later sexual debut, and past-month forced sex

– Proportion of vaginal drying decreased over follow-up, and increased with increasing age

– At 36 weeks postpartum, the odds of condomless sex (vs. protected sex or no sexual activity) in the past month was significantly higher among women who: were older, married, had more lifetime sexual partners, reported past-month forced sex, reported past-month anal sex, were unemployed, had HIV-uninfected partners, and had had more live births

– Earlier resumption of sex after childbirth was associated with: older age, more lifetime sexual partners, partner's age compared to the woman's age, a history of anal sex, being marriage, whereas decreased hazard ratios were observed for having completed primary education or beyond, having had a caesarean section. having a partner with unknown HIV status, and partner circumcision status

Lundberg and Trieu (2011) [54]

Vietnam—Cross-sectional and Qualitative

To describe cultural beliefs and practices related to the postpartum period among Vietnamese women in Ho Chi Minh City

115 Vietnamese women, 95 in the first group and 20 in the second group. A questionnaire was used with the first group and a semi-structured in-depth interview was used with the second group

Resumption of sex, Fear of prolapse, Perineal wounds

– All participants abstained from sexual intercourse with their spouses for the first 3–4 months following childbirth

– Participants believed that engaging in sex too early could negatively impact their health and/or perineal wounds

– Participants also feared the possibility of earlier sex leading to uterine prolapse or pregnancy

– Some participants were not interested in having sex with their spouses because they were very tired from caring for their infants

Maamri et al. (2019) [55]

Tunisia—Cross-sectional

To evaluate the sexual function of a population of women in postpartum, and identify possible particularities and associated factors of the studied population

100 women who gave birth 6 months prior

Resumption of sex, FSFI score items (desire, arousal, lubrication, orgasm, satisfaction and pain), Hypoactive sexual desire, Postpartum sexual practices, Perineal trauma, & Other sexual morbidities

– Among vaginal births, 42/53 had perineal lesions

– The mean duration of postpartum abstinence was 2.1 months

– Among those who underwent a scheduled cesarean section, 45% resumed sex 4–6 weeks after delivery, while 72% of those who had an instrumental vaginal delivery resumed at six months postpartum or later (p = 0.01)

– Reasons for engaging in sexual activity included both partners' pleasure (83%), only the husband's pleasure (13%), and personal pleasure exclusively (5%). Additionally, 10% of participants report having sex due to marital duty and 6% to avoid infidelity by the husband

– Reasons offered for abstaining from sex included fear of pain (32%) and fear of repeat pregnancy (13%). Feeling physically undesirable (37%) and feeling their body had changed (31%) led women to feeling disconnected from their bodies. Other hinderances included excessive fatigue (24%), the presence of a child (50%), and mother's unavailability (60%)

– 79% reported that their relationship changed postpartum

– Hypoactive sexual desire was reported by 31% of participants

– Most women (65%) reported achieving adequate lubrication always, almost always, or usually

– The frequency of reaching orgasm was unaltered after delivery among 58% of participants, reduced for 29%, and rose for 13%

– Sexual satisfaction did not change postpartum for 52% of participants, reduced for 33%, and improved for 15%

– 14% of women reported dyspareunia

Mbekenga et al. (2011) [56]

Tanzania—Qualitative

To explore and describe postpartum experiences of first-time mothers in a Tanzanian, multiethnic, low-income suburb

10 first-time mothers recruited at two RCH clinics in the lower-income areas of Ilala municipality, Dar es Salaam city, Tanzania. They were recruited when bringing their infants for routine examination and vaccination 4–10 weeks after childbirth

Resumption of sex, Episiotomy

– Women expressed uncertainty and a need for information regarding care for episiotomy wounds

– The women reported that reproductive and child health clinics did not provide enough health education, while antenatal clinics provided too much information all at once

– Except for one, all the mothers planned to abstain from intercourse until ceasing breastfeeding (up to 4 years). A common belief is that having sex while still breastfeeding would make the infant ill and hamper their development

– The mothers, however, doubted that their partners’ would be able to abstain from sex for this long; they believed that their partners may have sex with other people and risk contracting HIV. One participant, per an interview excerpt, described feeling strongly that her and her partner need to get HIV tested due to possible infidelity by her partner

Mekonnen (2020) [57]

Ethiopia—Cross-sectional

To assess the early resumption of sexual intercourse after childbirth and associated factors among women in the extended postpartum period in Gondar city, Northwest Ethiopia

634 women of child-bearing age who gave birth within the 12 months preceding the study period in Gondar city, Northwest Ethiopia

Resumption of Sex, Sexual coercion, Painful sex, Sexual desire, Vaginal dryness

– 61.4% of participants had vaginal delivery without an episiotomy/tears, 11.8% had a vaginal delivery with episiotomy/tears, and 6.5% had an instrumental delivery (forceps/vacuum); the remainder had a cesarean section

– At the time of study, 89.7% had resumed sexual intercourse; of these, 26.9% had resumed sex before 6 weeks postpartum

– The most frequent reason for resumption of sex was partner demand (reported by 76.1%)

– Upon resuming sexual intercourse, 69.2% reported having no problems, 15.6% reported pain during sex, 6.0% reported vaginal bleeding/discharge, 5.1% reported a lack of desire, and 4.0% reported vaginal dryness

– 29.7% of those who did experience a problem after resuming sex sought medical advice for their sexual problem

– 28.5% had ever been advised about sexual activity

– In multivariable logistic regression, the following were significantly associated with early resumption of sex: urban residence (aOR 6.12), low parity (aOR 2.26), partner demand as the reason for resuming sex (aOR 2.66), using any family planning (aOR 2.72), and obtaining postnatal care (aOR 1.45)

Nkwabong et al. (2019) [58]

Cameroon—Retrospective cohort

The study enquires whether nursing mothers regularly resume sexual intercourse before the 42nd day postpartum

120 women at their 6-week postpartum check-ups who delivered

between 11/15/2013 & 12/31/2013

Resumption of sex, Perineal tear/pain, STI risk

– 79.1% of the participants had resumed sexual intercourse within the first 6 weeks after childbirth

– Among those who resumed intercourse, 3.2% delivered via cesarean section vs. 56% of those that had not yet resumed sex (p < 0.001). Similarly, vaginal and uncomplicated deliveries both increased the likelihood of having resumed sex before the 6-week postpartum visit (p < 0.001)

– Among those who had resumed intercourse, perineal trauma was present for 12.6% (including four episiotomies and eight perineal tears), vs. 60% of those who had not yet resumed sex (including two  episiotomies and 13 tears) (p < 0.001)

Nolens et al. (2018) [59]

Uganda—Prospective cohort

The aim of this study was to assess how vacuum extraction was experienced by women after its re-introduction in a tertiary referral hospital in sub-Saharan Africa, using women-centered outcomes such as birthing experience satisfaction; pain 1 day after birth; and quality of life, pain and dyspareunia 6 weeks and 6months after birth

Women who gave birth (to a singleton in cephalic presentation) via vacuum extraction or SSCS at the main labor ward of the Mulago National Referral Hospital in Kampala, Uganda. Participants were interviewed at 1 day, 6 weeks, and 6 months after birth

Resumption of sex, Dyspareunia

– At baseline, 90.7% of participants had a known perineal status; of these, 35.9% had an episiotomy, 34.0% had an intact perineum, 29.8% had a first or second degree tear, and 0.8% had a third degree tear

– Women who underwent vacuum extraction, vs. second– stage caesarean section (SSCS), experienced less pain in the first 24 hours following birth (p < 0.001), less vaginal/abdominal pain at 6 weeks postpartum (p < 0.001), and a similar amount of vaginal/abdominal pain at 6 months postpartum (p = 0.05)

– At 6– weeks postpartum, no pain was reported by 76.2% of women who had a vacuum extraction, vs. 55.5% of those that had a SSCS (OR 2.56). Among women that had undergone vacuum extraction, pain scores indicated 'severe' or 'very severe' pain in the last 4 weeks for 3.4%, vs. 17.1% for those that underwent a SSCS (OR 0.17). For 50.0% (vacuum extraction), vs. 73.6% (SSCS), pain had interfered with their daily activities during the preceding 4 weeks (OR 0.36)

-At 6-weeks postpartum, women who underwent vacuum extraction, vs. SCSS, had higher odds of having resumed sex (40.0% vs. 28.3%, OR 1.69, p = 0.01)

Odar et al. (2003) [60]

Uganda—Cross-sectional

To establish the time taken to resume sexual intercourse, the sexual morbidity associated with resumption, and the prevalence of sexual problems encountered by postpartum women attending immunization clinics in Mulago Hospital in Uganda

216 women, 3–6 months postpartum, who had brought their infants to the Mugalo Hospital immunization clinics for vaccination

Resumption of sex, Dyspareunia, Other sexual morbidities

– Among participants, 39.4% had either had an episiotomy or vaginal laceration; 87.2% of the episiotomies healed well while 12.8% became infected

– At the time of the study, 66.4% of participants had resumed having sexual intercourse; 49.3% of these resumed sex during the puerperium. Of those who resumed during the puerperium, 8.5% resumed within the first week after birth. Time to resumption ranged from the first week to the 24th week after birth, with an mean time of 7.87 (± 4.9) weeks

– Advice provided to mothers by health workers at discharge was inconsistent; only some advised to wait 6 or more weeks

– Reasons for resuming sexual activity included: husbands' demands (46%), advise from health workers (7%), convenience (37%), and fulfilling cultural demands (10%)

– Some cultural demands included an expectation for women to resume sexual activity within a week of delivery as to help heal her wounds and bring health to the infant. Some women resumed sex early because "they were entering a new house"

– Reasons for not resuming sex included: not well yet (18%), health advice (37%), not interested (22%), and "husband's way" (23%). Some participants (n = 26) had not resumed sex because they had not been told when it would be safe to do so

– 22.2% of participants experienced significant degrees of morbidity within 6 months of giving birth, including: dyspareunia (62.5%), vaginal discharge (18.8%), vaginal bleeding (15.6%), and tears or bruises (3.1%)

– Early resumption of sex (within 6 weeks) was significantly associated with: having up to a primary-level education (OR 1.53; p = 0.03), having had a vaginal delivery (OR 3.84; p = 0.0005), and having an intact perineum (OR 1.73; p = 0.02)

– Only 19 of the 32 women with morbidities sought help. The women who sought help were generally older (p = 0.01)

– Women who sought help still felt shy to discuss their problems. Most sought advice and/or treatment from less qualified personnel, while the rest administered treatment themselves or reported that the problem ended within 1 day

Osinde et al. (2012) [61]

Uganda—Cross-sectional

To assess the factors associated with resumption of sexual intercourse and use of contraception in the 6-week postpartum period among women attending postnatal care at Kabale Regional Hospital, Kabale, Uganda

131 women who attended the hospital's postnatal clinic

Resumption of sex; Sexual coercion; Perineal wounds

– Among the 131 participants, 58.0% resumed sexual intercourse early (within 6 weeks following childbirth)

– Education level of the spouse was significantly associated with early resumption of intercourse (aOR 0.2; p = 0.05)

– Participants reported spousal pressure and the fear of their spouse leaving them as reasons for resuming intercourse early

– Those who waited at least 8 weeks before resuming intercourse reported the following reasons for waiting: unhealed perineal wounds, the fear of conception, and geographic separation from their spouse

Rezaei et al. (2017) [62]

Iran—Cross-sectional

To evaluate women’s sexual function in the postpartum period in Iran

380 postpartum women attending 10 urban health centers

FSFI score;

Sexual dysfunction was classified by FSFI score of ≤ 28

– 76.3% of participants reported sexual dysfunction

– 79% of those with sexual dysfunction reported a lack of desire

– In multivariate regression, primiparous mothers (aOR 1.96, p = 0.006) and those that exclusively breastfed their infants (aOR 2.47, p = 0.01) were more likely to report sexual dysfunction

Shabangu and Madiba (2019) [63]

Eswatini—Qualitative

To explore the practice of post-partum sexual abstinence in Swazi women and examine how cultural beliefs influence and promote the perpetuation of the practice

15 postpartum women selected via purposive sampling at health facility

Resumption of sex (sexual coercion and HIV transmission risk also mentioned)

– At interview, most women had yet to resume sexual intercourse; most of those that had resumed did so when their infant's age reached 6 months

– Participants overall felt that postpartum sexual abstinence benefited the mother, infant, and spouse. They indicated that abstinence supports the mother's recovery from birth and allows her to adequately care for the infant

– Participants believed that resuming sex early could hinder the infant's health, development, and growth as well as contaminate breastmilk, making it unhealthy for the infant to consume

– Participants also reported being told by older women that early resumption of intercourse could result in their partner's illness and possibly even death

– The baby's gender also influences the duration of abstinence; for boys, the period of abstinence is more relaxed (shorter) due to the higher social value placed on boys

– Participants reported feeling pressure to abstain from sex from family members and in-laws; while in-laws typically enforced abstinence upon married women, abstinence was enforced by the woman's mother among single women

– Women also expressed a lack of control over abstinence; they did not live with their partners during the abstinence period and felt that if they had, then they would have resumed sex early

– Disadvantages of the culturally prescribed period of postpartum abstinence include potential risk of HIV transmission (given the lack of pressure placed on the men to abstain from pursuing sexual relations with other women)

Sheikhi et al. (2020) [64]

Iran—Randomized controlled trial

To determine the effect of sexual health education on sexual function and the time of sexual intercourse resumption in primiparous women referring to the health-care center of Zahedan, Iran

Primiparous women referred to health centers for postnatal care 3–5 days after birth, with healthy perineum or low-grade tears. Randomly assigned to the intervention or control group (n = 47 per group) with posttest at 8 weeks postpartum

Resumption of sex, Perineal status, Sexual desire/arousal, Vaginal lubrication, Orgasm, Sexual satisfaction, Dyspareunia

– 92/94 participants had had an episiotomy; two had grade one or two perineal tears

– In the intervention group, the mean total sexual function (SFI) score increased from 12.7 (pre-intervention) to 17.4 (post-intervention) (p < 0.001); control score decreased slightly

– Intervention and control group post-test scores were significantly different (p < 0.05) for all dimensions of sexual function, including: desire (p = 0.001), arousal (p = 0.009), lubrication (p = 0.001), orgasm (p = 0.001), satisfaction (p = 0.001), and dyspareunia (p = 0.003)

Shirvani et al. (2010) [65]

Iran—Cross-sectional

To investigate the sexual function of mothers at 1 year postpartum and associated factors

490 Iranian women who were recruited randomly at four time periods from childbirth: first 3 months, 4 to 6, 7 to 9 and 10 to 12 months, from January to July 2008

FSFI score items (desire, arousal, lubrication, orgasm, satisfaction and pain)

– The mean duration of postpartum abstinence was 57.17 (± 27.95) days from delivery

– 52.9% abstained from intercourse beyond 45 days postpartum, possibly reflecting the common recommendation in Iran that intercourse be delayed until 6-weeks postpartum

– Reasons for abstaining or delaying sex included: fear of pain (8.6%), having no interest (3.5%), avoiding pregnancy (2.5%), tiredness (2.2%), and bleeding (0.6%)

– While 8.8% of participants reported sexual problem(s) and 40% noticed a reduction in sexual desire from pre-pregnancy to postpartum, only 2.4% of participants spoke to a health professional about their sexual problem(s)

– Mean scores for all domains of sexual function and total sexual function varied significantly across the four postpartum intervals overall

– The following sociodemographic characteristics were significantly correlated with sexual function: postpartum duration (r = 0.17; p = 0.0001), higher maternal age (r = − 0.12; p = 0.006), number of children (r = − 0.09; p = 0.02) and marriage duration (r = − 0.08; p = 0.05)

Sule-Odu et al. (2008) [66]

Nigeria—Prospective cohort

To review the postpartum sexual practices in the community, predominantly inhabited by the Yorubas

371 mothers who had just given birth to singleton babies and previously breastfed at least one child >= 6 months

Resumption of sex

– During the first month following childbirth, 84.6% of participants abstained from sexual intercourse; dropped to 2.1% by the 11th–15th months

– Examined patterns by social class, age, and breastfeeding

Ugwu et al. (2021) [67]

Nigeria—Prospective cohort

To determine the comparative effect of caesarean section and vaginal delivery on female sexual function disorders

Postnatal mothers at two hospitals in Nigeria

The intervention group  of women delivered via caesarean section whereas women in the control group had a vaginal delivery (50 in each group)

Resumption of sex, Sexual Function Disorders

– Among the 48 participants that had a vaginal delivery, the perineum was intact after childbirth for 11, while 19 experienced perineal tearing and/or an episiotomy

– Among those who had a cesarean section, 74.4% resumed intercourse by 6-weeks postpartum, vs. 52.1% of those who had a vaginal delivery (RR = 1.43; p = 0.03)

– Those who had a cesarean section had significantly higher mean scores (p < 0.05) for the following sexual function domains: orgasm, pain, and satisfaction

Zulu (2001) [68]

Malawi—Mixed-methods

To examine ethnic differences in the tradition of postpartum sexual abstinence by comparing its observance and rationale in three culturally different ethnic communities in Malawi, using quantitative and qualitative data collected in those communities

Women's data from the three rural census enumeration areas (n = 273 south; n = 550 central; n = 288 north).

In-depth interviews (IDIs) and focus group discussions (FGDs) conducted with key informants (n = 22 FGDs, n = 61 IDIs)

Resumption of sex

– Quantitative data suggest that postpartum sexual abstinence practices did not change substantially between 1988 and 1998

– Based on 1998 data, at 2 and 4 months postpartum, abstinence is similar in the north and in the south, much lower in the central region. Observed regional variation in postpartum abstinence duration corresponded with regional differences in knowledge of and adherence to customs requiring abstinence while breastfeeding and until after the resumption of menses

– Participants elucidated beliefs related to the infant's nutrition and health in relation to postpartum abstinence. Participants believed that intercourse (via the exposure to semen) can contaminate breastmilk

– Participants from each region studied also expressed that postpartum abstinence protected the male partner's health. It was perceived that postpartum bleeding ends when the mother's reproductive system has "cooled," signifying that she is free from harmful fluids. Participants listed a variety of symptoms men may experience when exposed to reproductive blood, some participants suggesting that the symptoms can resemble those of AIDS and others explaining that the effect can be fatal. These perceived symptoms also included sterility and the gradual loss of sexual prowess. Among participants in the central and southern regions, concerns were also mentioned in relation to abstinence after the postpartum bleeding period

– The recommended duration of postpartum abstinence varied. Most participants from the central region recommended 3 and 6 months, though some indicated that one should abstain until the infant reached a certain level of physical maturity

– Participants in the central and southern regions described various versions of child-strengthening rituals, which were performed before resuming intercourse as to protect the child from harm; participants explained that men too were advised to abstain from intercourse (including with other women) prior to a child-strengthening ritual

– In the north there was a clear and definitive event (i.e. the resumption of menses) believed to indicate that resuming sex was then safe; northern participants believed that menstruation signifies that the woman's body is recovered and physically prepared for another pregnancy. Child-strengthening rituals were also performed in the north prior to resuming intercourse, as to protect the child's health. Participants explained that becoming pregnant before resuming menses and performing the ritual was considered disgraceful and appalling; parents who resume sex before this point were seen as callous and selfish. Older women sometimes judged parents' adherence to abstinence expectations by assessing the child's health