DOI: 10.1111/1471-0528.

13263 General gynaecology

www.bjog.org

Dyspareunia and childbirth: a prospective cohort

study
EA McDonald,a D Gartland,a R Small,b SJ Browna,c
a
Healthy Mothers Healthy Families Research Group, Murdoch Childrens Research Institute, Melbourne, Vic., Australia b The Judith Lumley
Centre, La Trobe University, Melbourne, Vic., Australia c General Practice and Primary Health Care Academic Centre, The University of
Melbourne, Melbourne, Vic., Australia
Correspondence: EA McDonald, Healthy Mothers Healthy Families Research Group, Murdoch Childrens Research Institute, The Royal
Children’s Hospital, Flemington Road, Parkville, Vic. 3052, Australia. Email ellie.mcdonald@mcri.edu.au

Accepted 15 November 2014. Published Online 21 January 2015.

Objective To investigate the relationship between mode of
delivery, perineal trauma and dyspareunia.
Design Prospective cohort study.
Setting Six maternity hospitals in Melbourne, Australia.
Sample A total of 1507 nulliparous women recruited in the first
and second trimesters of pregnancy.
Method Data from baseline and postnatal questionnaires (3, 6, 12
and 18 months) were analysed using univariable and multivariable
logistic regression.
Main outcome measure Study-designed self-report measure of
dyspareunia at 18 months postpartum.
Results In all, 1244/1507 (83%) women completed the baseline
and all four postpartum questionnaires; 1211/1237 (98%) had
resumed vaginal intercourse by 18 months postpartum, with 289/
1211 (24%) women reporting dyspareunia. Compared with
women who had a spontaneous vaginal delivery with an intact
perineum or unsutured tear, women who had an emergency
caesarean section (adjusted odds ratio [aOR] 2.41, 95% confidence
interval [95% CI] 1.4–4.0; P = 0.001), vacuum extraction (aOR
2.28, 95% CI 1.3–4.1; P = 0.005) or elective caesarean section
(aOR 1.71, 95% CI 0.9–3.2; P = 0.087) had increased odds of
reporting dyspareunia at 18 months postpartum, adjusting for
maternal age and other potential confounders.
Conclusions Obstetric intervention is associated with persisting
dyspareunia. Greater recognition and increased understanding of
the roles of mode of delivery and perineal trauma in contributing
to postpartum maternal morbidities, and ways to prevent
postpartum dyspareunia where possible, are warranted.
Keywords Cohort studies, delivery obstetric, dyspareunia, pain,
perineum, postpartum period, prospective studies, sexual intercourse.
Linked article This article is commented on by C Sakala, p. 680 in
this issue. To view this mini commentary visit http://dx.doi.org/
10.1111/1471-0528.13264.

Please cite this paper as: McDonald EA, Gartland D, Small R, Brown SJ. Dyspareunia and childbirth: a prospective cohort study. BJOG 2015;122:672–679.

nulliparous pregnancy cohort study.8 The primary objective

Introduction
The relationship between obstetric risk factors including
mode of delivery and perineal trauma and dyspareunia is
not well characterised or understood.1–7 Previous studies
have suffered from several methodological limitations
including cross-sectional study design,1–3,5,6 limited power
to assess associations with obstetric risk factors1–7 and lack
of long-term follow up.1–7 Inferences drawn from the exist-
ing literature are limited by the failure of the studies to
consider prepregnancy dyspareunia2–7 and a range of post-
partum factors, such as breastfeeding and intimate partner
abuse, that may confound associations.2–6
This study draws on data collected in the Maternal
Health Study, an Australian multicentre, prospective
of this paper was to investigate the contribution of obstet-
ric risk factors, including mode of delivery and perineal
trauma, to postpartum dyspareunia. In addition, we aimed
to assess the influence of potential confounders, including
breastfeeding, maternal fatigue, maternal depression and
intimate partner abuse.
Methods
Sample and participants
Details regarding study eligibility and exclusion criteria and
recruitment methods are available in a published study pro-
tocol.8 Briefly, women were recruited to the study between
April 2003 and December 2005 from six metropolitan public

672 ª 2015 Royal College of Obstetricians and Gynaecologists


maternity hospitals in Melbourne, Australia. We recruited
nulliparous women, aged over 18 years, in the first and
second trimesters of pregnancy. Women with poor Eng-
lish language literacy were excluded.
Measures and definitions
At recruitment, participants were asked to complete a
baseline questionnaire recording demographic and social
characteristics, including age, country of birth and socio-
economic status, and baseline measures of common maternal
morbidities, including dyspareunia before and during preg-
nancy.1 Follow-up questionnaires were administered at 3, 6,
12 and 18 months postpartum. Data regarding the mode of
delivery and degree of perineal trauma were collected in the
3-month postpartum questionnaire and abstracted from
medical records for a subset of women. There was a high
degree of congruity between women’s own accounts of mode
of delivery and other obstetric events and data abstracted
from medical records.9,10
Follow-up questionnaires included study-designed ques-
tions regarding sexual health and dyspareunia drawing on
questions included in the Australian Longitudinal Women’s
Health Study11 and a study by Barrett et al.1 assessing
women’s health after childbirth. Study questionnaires also
included validated measures of maternal depressive symp-
toms (Edinburgh Postnatal Depression Scale)12 and inti-
mate partner abuse (Composite Abuse Scale),13,14 and
single item measures assessing maternal fatigue15 and infant
feeding.16 Pretesting of the questionnaires, paying particu-
lar attention to study-designed questions, was undertaken
with a pilot sample of women recruited through participat-
ing hospitals. The baseline Maternal Health Study ques-
tionnaire is available on the study website.17 Postnatal
questionnaires can be made available by contacting the
authors.
Statistical analysis
Data were analysed using STATA version 13 (StataCorp.,
College Station, TX, USA).18 Sample representativeness was
assessed by comparing data on social and obstetric charac-
teristics of participants with routinely collected perinatal
data for nulliparous women giving birth in the study per-
iod at the six participating hospitals, and at all public
maternity hospitals in Victoria.
Analyses presented in the paper are restricted to women
who completed the baseline questionnaire and all follow-up
questionnaires. The proportions of women resuming vagi-
nal sex by 3, 6 and 12 months postpartum were calculated
based on the proportion of women reporting resumption
of sex divided by the total number of women with valid
responses at each time point.
The period prevalence of dyspareunia at 6 and
18 months postpartum was calculated based on the
ª 2015 Royal College of Obstetricians and Gynaecologists
Dyspareunia and childbirth
proportions of women reporting symptoms divided by the
total number of women who had resumed vaginal sex and
had data available for the relevant period. Pain on first vag-
inal sex is reported separately.
Risk factors for postpartum dyspareunia were investi-
gated using univariable and multivariable logistic regres-
sion. Logistic regression modelling was used to examine the
association between mode of delivery and perineal trauma
(exposures of main interest) and dyspareunia at 18 months
postpartum (primary outcome), taking into account poten-
tial confounders. Maternal age was included in modelling
analyses for a priori reasons. Other variables were included
based on associations that were observed in univariable
analyses at 6 and/or 18 months postpartum. Data are pre-
sented as crude or adjusted odds ratios (ORs) with 95%
confidence intervals (95% CI).
Ethical approval for the study was provided by La Trobe
University (2002/38); Royal Children’s Hospital, Melbourne
(27056A); Royal Women’s Hospital, Melbourne (2002/23);
Southern Health, Melbourne (2002-099B); and Angliss
Hospital, Melbourne (2002).
Results
Participants
A total of 1507 women enrolled in the study. The mean
gestation of study participants at the time of enrolment
was 15.0 weeks (range 6–24 weeks). We were unable to
determine a precise response fraction, but conservatively
estimate that the response was between 1507/5400 (28%)
and 1507/4800 (31%). The follow-up response fractions
were 1431/1507 (95%), 1400/1507 (93%), 1387/1507
(92%), 1326/1507 (88%) at 3, 6, 12 and 18 months post-
partum, respectively. In all, 1211/1239 (98%) participants
were sexually active at 18 months postpartum.
Study participants were representative in relation to
obstetric characteristics including mode of delivery and
perineal trauma (see Table 1). Women born overseas in
countries where English is not the first language, and youn-
ger women were under-represented. Further information
regarding sociodemographic and reproductive characteris-
tics of the sample and representativeness of study partici-
pants is available in previous papers.10,19 The 1244/1507
(83%) women who completed all four follow-up question-
naires comprise the sample for the analyses in this paper
(Figure 1).
Birth outcomes
A total of 609/1244 (49.0%) women had a spontaneous
vaginal birth, two-thirds of whom (411/609, 67.5%) sus-
tained a sutured tear and/or episiotomy; 134/1244 (10.8%)
had an operative vaginal birth assisted by vacuum extrac-
tion and 133/1244 (10.7%) gave birth assisted by forceps.
673
 McDonald et al.

Table 1. Social characteristics of participants in the Maternal Health Study compared with Victorian Perinatal Data Collection Unit data

Maternal Health Nulliparous women Nulliparous women

Study participants ≥18 years giving ≥18 years giving
(n = 1507) birth in Victorian birth in the six
public hospitals participating
1/7/03 to 31/12/05 Victorian hospitals
(n = 40 905) 1/7/03 to 31/12/05
(n = 13 803)

n % n % n %

Maternal age at birth of first child

18–24 years 212 14.1 12 216 29.8 3813 27.6
25–29 years 437 29.0 13 802 33.7 4645 33.7
30–34 years 580 38.4 10 740 26.3 3769 27.3
35–39 years 236 15.7 3552 8.7 1319 9.6
≥40 years 42 2.8 595 1.5 257 1.9
Relationship status*
Married 914 60.7 22 790 56.0 8300 60.3
Unmarried 593 39.3 17 932 44.0 5469 39.7
Country of birth*
Australia 1115 74.4 29 791 73.3 8603 62.5
Overseas—English speaking 141 9.4 2109 5.2 905 6.6
Overseas—non-English speaking background 243 16.2 8738 21.5 4267 30.9
Mode of delivery*
Caesarean—no labour 140 9.8 3750 9.2 1237 9.0
Caesarean—laboured 292 20.4 7665 18.7 2587 18.7
Spontaneous vaginal birth 695 48.6 20 785 50.8 7000 50.7
Vaginal breech birth 5 0.3 182 0.4 95 0.7
Vaginal with forceps 150 10.5 3915 9.6 1426 10.3
Vaginal with vacuum extraction 149 10.4 4603 11.3 1457 10.6
Perineal trauma**
Intact perineum 595 41.7 19 805 48.4 6296 45.6
Unsutured laceration 72 5.0 n/a n/a n/a n/a
Sutured laceration 439 30.8 11 074 27.1 4221 30.6
Episiotomy 228 16.0 9068 22.2 3089 22.4
Episiotomy and tear 93 6.5 958 2.3 197 1.4

*Denominators vary due to missing values.

**Data collected by the Perinatal Data Collection Unit on perineal trauma does not include information regarding unsutured lacerations or
nonperineal lacerations, e.g. vaginal wall tears.

The majority of these women sustained a sutured tear and/
or episiotomy (124/134, 92.5% and 129/133, 97.0%, respec-
tively). In all, 120/1244 (9.7%) were delivered by elective
caesarean section and 248/1244 (19.9%) were delivered by
emergency caesarean section.
Dyspareunia following childbirth
By 3 months postpartum, 970/1239 (78.3%) had resumed
vaginal intercourse; 1165/1239 (94.0%) by 6 months post-
partum, 1202/1239 (97.0%) by 12 months postpartum and
1211/1239 (97.7%) by 18 months postpartum. Most of the
women who had resumed sex by 12 months postpartum
experienced pain during first vaginal sex after childbirth
(961/1122, 85.7%). Dyspareunia was reported by 431/964
(44.7%) women at 3 months postpartum, 496/1144
(43.4%) women at 6 months postpartum, 333/1184
(28.1%) women at 12 months postpartum and 289/1236
(23.4%) women at 18 months postpartum. Of the 496
women who reported dyspareunia at 6 months postpartum,
one-third (162/496, 32.7%) reported persisting dyspareunia
at 18 months postpartum. In all, 338/1234 (27.4%) women
reported dyspareunia in the year prior to the index preg-
nancy.
Associations with dyspareunia
The unadjusted odds of dyspareunia at 18 months postpar-
tum were higher in women who gave birth by vacuum
extraction (OR 2.01, 95% CI 1.2–3.5; P = 0.013),

674 ª 2015 Royal College of Obstetricians and Gynaecologists


Q1: 1507 eligible participants
Q2: 1494 participants
1431 completed (95.0% of 1507 participants)
Q3: 1486 participants
1400 completed (92.9% of 1507 participants)
Q4: 1464 participants
1357 completed (90.0% of 1507 participants)
Q5: 1452 participants
1327 completed (88.1% of 1507 participants)
Figure 1. Maternal Health Study participation flowchart to 18 months postpartum.
emergency caesarean section (OR 2.04, 95% CI 1.3–3.3;
P = 0.004) or elective caesarean section (OR 1.65, 95% CI
0.9–2.9; P = 0.090) compared with women who had a
spontaneous vaginal birth with an intact perineum. Youn-
ger women (OR 1.58, 95% CI 1.0–2.5; P = 0.057), women
who experienced dyspareunia before the index pregnancy
(OR 2.18, 95% CI 1.6–2.9; P = 0.000), women who
reported intimate partner abuse from birth to 12 months
postpartum (OR 1.84, 95% CI 1.3–2.6; P = 0.001), women
who reported fatigue at 18 months postpartum (OR 1.65,
95% CI 1.2–2.3; P = 0.002) and women who reported
depressive symptoms at 18 months postpartum (OR 1.97,
95% CI 1.3–3.0; P = 0.002) also had increased odds of
reporting dyspareunia at 18 months postpartum.
To obtain more precise estimates of the association
between mode of delivery and dyspareunia at 18 months
postpartum, we developed a multivariable logistic regres-
sion model (Table 2). A composite variable combining data
on mode of delivery and perineal trauma was the exposure
of main interest. Maternal age was included in the model
for a priori reasons based on previous research showing
that younger women are more likely to experience dyspa-
reunia.20,21 Dyspareunia before pregnancy, maternal depres-
sion, maternal fatigue and intimate partner abuse were
included because of the significant associations with dyspa-
reunia at 6 and/or 18 months postpartum noted in univari-
able analyses.
Women who gave birth by emergency caesarean section
or vacuum extraction and those who reported prepregnan-
cy dyspareunia had greater than a twofold increase in
adjusted odds of persisting dyspareunia at 18 months post-
partum compared with women who had a spontaneous
vaginal birth with an intact perineum after adjusting for
ª 2015 Royal College of Obstetricians and Gynaecologists
Dyspareunia and childbirth
13 Withdrew
5 Withdrew
3 lost to follow up
16 Withdrew
6 lost to follow up
6 Withdrew
6 lost to follow up
other variables in the model. Elective caesarean section was
also associated with increased odds of dyspareunia at
18 months postpartum, although the confidence interval
suggests borderline statistical significance.
Similar patterns of association were found between
dyspareunia at 6 months postpartum, mode of delivery,
perineal trauma and other maternal and postnatal factors
(Table 3). Women who had an operative vaginal delivery
(with forceps or vacuum extraction) had greater than a
three-fold increase in adjusted odds of dyspareunia at
6 months postpartum. Emergency caesarean section and
vaginal birth with a sutured tear and/or episiotomy were
associated with a two-fold increase in odds of dyspareunia
after taking into account other factors in the model.
Women who had an elective caesarean section did not
have raised odds of reporting dyspareunia at 6 months
postpartum. Prepregnancy dyspareunia was associated with
a two-fold increase in odds of dyspareunia at both 6 and
18 months postpartum. Observed associations with obstet-
ric intervention in multivariable models were stronger
than associations with postnatal factors, including mater-
nal depressive symptoms, fatigue and intimate partner
abuse.
Discussion
Main findings
Almost all women experience some pain during sexual
intercourse following childbirth. Our findings show that
the extent to which women report dyspareunia at 6 and
18 months postpartum is influenced by events during
labour and birth. The odds of dyspareunia at 18 months
were substantially higher in women who delivered by
675
 McDonald et al.

Table 2. Adjusted odds of dyspareunia at 18 months postpartum associated with mode of delivery, perineal trauma and other risk factors*

Dyspareunia at 18 months Adjusted OR (95% CI) P values

postpartum

No Yes
n (%) n (%)

Mode of delivery and perineal trauma

Spontaneous vaginal birth
Intact perineum/unsutured tear 153 (83.2) 31 (16.8) 1.0 ref
Sutured tear/episiotomy 307 (80.2) 76 (19.8) 1.37 (0.8–2.2) 0.201
Caesarean section (intact perineum)
Elective 84 (75.0) 28 (25.0) 1.71 (0.9–3.2) 0.087
Emergency 157 (70.7) 65 (29.3) 2.41 (1.4–4.0) 0.001
Forceps (sutured tear/episiotomy) 95 (79.8) 24 (20.2) 1.56 (0.8–2.9) 0.156
Vacuum extraction (sutured tear/episiotomy) 86 (71.1) 35 (28.9) 2.28 (1.3–4.1) 0.005
Prepregnancy dyspareunia
No 679 (81.5) 154 (18.5) 1.0 ref
Yes 210 (66.9) 104 (33.1) 2.09 (1.5–2.8) 0.000
Maternal age at index birth
30–34 years 254 (78.9) 68 (21.1) 1.0 ref
18–24 years 85 (70.3) 36 (29.7) 1.45 (0.9–2.4) 0.165
25–29 years 366 (76.1) 115 (23.9) 1.10 (0.8–1.6) 0.602
35+ years 189 (81.8) 42 (18.2) 0.77 (0.5–1.2) 0.263
Highest educational qualification
University degree 436 (77.0) 130 (23.0) 1.0 ref
Certificate/diploma 226 (76.4) 70 (23.6) 0.91 (0.6–1.3) 0.620
Year 12 165 (81.3) 38 (18.7) 0.69 (0.4–1.1) 0.091
<Year 12 62 (73.8) 22 (26.2) 1.02 (0.6–1.8) 0.938
Maternal fatigue at 18 months postpartum
No 297 (83.0) 61 (17.0) 1.0 ref
Yes 592 (74.8) 200 (25.2) 1.51 (1.1–2.1) 0.018
EPDS ≥13 at 18 months postpartum
No 824 (78.8) 222 (21.2) 1.0 ref
Yes 68 (65.4) 36 (34.6) 1.27 (0.8–2.0) 0.318
Intimate partner abuse in first 12 months postpartum
No 766 (79.3) 200 (20.7) 1.0 ref
Yes 125 (67.6) 60 (32.4) 1.65 (1.1–2.4) 0.009

EPDS, Edinburgh Postnatal Depression Scale.

*Excludes women who report giving birth to second baby by 18 months postpartum and denominators vary due to missing values.

emergency caesarean section or vacuum extraction, and
somewhat higher for women who had an elective caesarean
section, compared with women who had a spontaneous
vaginal birth with an intact perineum. At 6 months post-
partum, vaginal birth assisted with forceps was also associ-
ated with dyspareunia, but elective caesarean section was
not. These differences in the pattern of association with
mode of delivery may reflect limited study power for com-
parisons of these subgroups. Alternatively, it is possible that
women recover more quickly from forceps than from vac-
uum extraction, and that women having an elective caesar-
ean section that do experience postpartum dyspareunia are
slow to recover. It is noteworthy that the proportion of
women reporting dyspareunia at 18 months postpartum is
similar for women who had a spontaneous vaginal birth
with and without perineal damage.
Other factors associated with dyspareunia at 18 months
postpartum include prepregnancy dyspareunia, intimate
partner abuse and maternal fatigue. These results suggest
that clinicians should be alert to the possibility that inti-
mate partner abuse is a potential underlying factor in per-
sisting dyspareunia.
The finding that breastfeeding is associated with dyspa-
reunia in the early postnatal period confirms previous
study findings.1 Women still breastfeeding at 6 months
postpartum had a higher likelihood of experiencing

676 ª 2015 Royal College of Obstetricians and Gynaecologists

 Dyspareunia and childbirth

Table 3. Adjusted odds of dyspareunia at 6 months postpartum associated with mode of delivery, perineal trauma and other risk factors*

Dyspareunia at 6 months Adjusted OR (95% CI) P values

postpartum

No Yes

Mode of delivery and perineal trauma

Spontaneous vaginal birth
Intact perineum/unsutured tear 130 (68.8) 59 (31.2) 1.0 ref
Sutured tear/episiotomy 201 (53.6) 174 (46.4) 2.32 (1.5–3.5) 0.000
Caesarean section (intact perineum)
Elective 72 (68.6) 33 (31.4) 0.76 (0.4–1.4) 0.387
Emergency 133 (59.4) 91 (40.6) 1.83 (1.2–2.9) 0.010
Forceps (sutured tear/episiotomy) 59 (48.0) 64 (52.0) 3.11 (1.9–5.2) 0.000
Vacuum extraction (sutured tear/episiotomy) 45 (40.5) 66 (59.5) 3.36 (2.0–5.8) 0.000
Prepregnancy dyspareunia
No 503 (60.8) 325 (39.2) 1.0 ref
Yes 140 (45.8) 166 (54.2) 1.91 (1.4–2.6) 0.000
Maternal age at index birth
30–34 years 203 (60.1) 135 (39.9) 1.0 ref
18–24 years 77 (59.2) 53 (40.8) 1.39 (0.9–2.3) 0.181
25–29 years 249 (53.4) 217 (46.6) 1.30 (0.9–1.8) 0.118
35+ years 119 (56.7) 91 (43.3) 1.25 (0.8–1.9) 0.293
Highest educational qualification
University degree 293 (53.5) 255 (46.5) 1.0 ref
Certificate/diploma 168 (56.2) 131 (43.8) 1.03 (0.7–1.4) 0.882
Year 12 122 (61.0) 78 (39.0) 0.81 (0.6–1.2) 0.286
<Year 12 62 (68.9) 28 (31.1) 0.61 (0.3–1.1) 0.102
Breastfeeding at 6 months postpartum
No 183 (62.0) 112 (38.0) 1.0 ref
Yes 373 (52.5) 337 (47.5) 1.55 (1.1–2.1) 0.007
Maternal fatigue at 6 months postpartum
No 283 (60.1) 188 (39.9) 1.0 ref
Yes 363 (54.4) 304 (45.6) 1.28 (1.0–1.7) 0.081
EPDS ≥13 at 6 months postpartum
No 598 (57.3) 445 (42.7) 1.0 ref
Yes 47 (48.5) 50 (51.5) 1.62 (1.0–2.7) 0.060
Intimate partner abuse in first 12 months postpartum
No 552 (57.1) 414 (42.9) 1.0 ref
Yes 94 (53.4) 82 (46.6) 1.26 (0.9–1.8) 0.237

EPDS, Edinburgh Postnatal Depression Scale.

*Denominators vary due to missing values.

dyspareunia at 6 months postpartum, even after adjusting
for other maternal factors including mode of delivery and
perineal trauma.
Strengths and limitations
Major strengths of this study are recruitment of a nullipa-
rous pregnancy cohort in early pregnancy, frequent follow
up and high retention of participants to 18 months post-
partum. All of these key features of the design of the study
reduce the likelihood of recall bias, which is a major con-
cern in much of the previous literature. Additionally, the
study was designed to facilitate ascertainment and differen-
tiation of pain on first vaginal sex after childbirth and pain
on subsequent sex. Importantly for the analyses presented
in this paper, the sample was representative in relation to
mode of delivery.
The recruitment method did result in under-representa-
tion of younger women and women born overseas with a
non-English-speaking background. However, this is unlikely
to have biased the results, as these social characteristics
were unrelated to the primary outcomes reported in the
paper. The fact that recruitment was restricted to nullipa-
rous women, while very valuable in providing rich detail
about the experiences of women having their first baby,
means that we are unable to comment on outcomes follow-
ing second and subsequent births.

ª 2015 Royal College of Obstetricians and Gynaecologists 677

 McDonald et al.
Interpretation
The major contribution of this study is that it provides
much more robust evidence than previously available about
the extent and persistence of postpartum dyspareunia, and
associations with mode of delivery and perineal trauma.
No other study has undertaken such detailed, frequent and
long-term follow up with a sufficiently large nulliparous
cohort recruited in early pregnancy to assess associations
with obstetric risk factors.
The higher prevalence of persisting dyspareunia in
women who had an operative birth raises important ques-
tions about the longer-term impact of operative procedures
on women’s health. Although in a study of this nature we
cannot be confident in drawing causal inferences, the find-
ings raise important questions about the extent to which
obstetric procedures have long-term consequences for
women’s health and wellbeing, and whether any of this
morbidity could be prevented. It is striking that so few
prospective studies have collected data on the persistence
of dyspareunia beyond 6 months postpartum. The study
findings highlight the importance of continuing efforts to
improve understanding of postpartum maternal morbidi-
ties, including factors that influence severity and persistence
of symptoms. The fact that dyspareunia persists for a sub-
stantial proportion of women also points to the need for
focusing clinical attention on ways to help women experi-
encing ongoing morbidity, and increased efforts to prevent
postpartum morbidity whenever possible.
Conclusions
The findings of this multicentre prospective cohort of nul-
liparous women suggest that obstetric intervention—specif-
ically vacuum extraction and caesarean section—contribute
to persisting dyspareunia affecting a significant proportion
of women up to 18 months postpartum. Greater recogni-
tion and better overall understanding of the role of obstet-
ric intervention in contributing to maternal postpartum
morbidities, and ways to prevent postpartum dyspareunia
where possible, are warranted.
Disclosure of interests
None disclosed.
Contribution to authorship
EM planned and conducted the analyses and wrote the
paper. SB wrote the study protocol, took primary responsi-
bility for the design and conduct of the study, contributed
to analysis and interpretation of data and contributed to
writing the paper. DG and RS contributed to interpretation
of data and reviewed and commented on drafts of the
paper. All authors have approved the final draft of the
678
paper for publication. EM and DG were responsible for
data management.
Funding
This research was supported by project grants from the
Australian National Health and Medical Research Council
(ID191222 and ID433006 Melbourne, Australia); a Vic-
Health Public Health Research Fellowship (2002–2006), a
National Health and Medical Research Council Career
Development Fellowship (ID491205, 2008–2011) and an
ARC Future Fellowship (2012–2015) awarded to SB; a La
Trobe University Postgraduate Scholarship awarded to EM,
and the Victorian Government’s Operational Infrastructure
Support Programme.
Acknowledgements
We are grateful to members of the Maternal Health Study
research team who have contributed to data collection and
coding (Maggie Flood, Ann Krastev, Renee Paxton, Susan
Perlen, Martine Spaull, Hannah Woolhouse). &
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