Abstract
Background
Epidemiological studies do not provide accurate statistics on the percentage of breastfeeding women experiencing sexual dysfunctions and restraining from sexual activity. The data vary between 40% and 83% in the first group and 20–50% in the second one. Despite excessive studies on contributors to intimacy changes, breast feeding received little attention from researchers. The relationship between lactation and postpartum sexual dysfunctions remains unclear. This systematic review and meta-analysis will synthesise available data and establish the link between breast feeding and sexuality problems.
Methods and analysis
A comprehensive literature search will be performed in biomedical databases PubMed/Medline, Scopus, Web of Science, EMBASE and CINAHL. We will extract peer-reviewed original studies written in English, Arabic or Polish from 2000 to June 2023. We will also search for reports from international health organisations and local health authorities. The preliminary search was performed on 04 April 2023. The studies must provide data on dysfunction prevalence/incidence and the strength of the relationship between breast feeding and sexuality in generally healthy women. The Covidence software will be used to perform literature screening, data extraction and quality assessment of individual studies. We will use a random-effects model meta-analysis to calculate pooled weighted frequency measures and effect size. Between-study heterogeneity will be assessed with the I2 test.
Ethics and dissemination
This meta-analysis does not require ethical approval because it synthesises data from previously published original studies. The final work will be published in a peer-reviewed journal and presented at scientific conferences.
PROSPERO registration number
CRD42023411053.
Keywords: GENITOURINARY MEDICINE, Maternal medicine, SEXUAL MEDICINE, GYNAECOLOGY
STRENGTHS AND LIMITATIONS OF THIS STUDY.
The protocol is prepared following the Preferred Reporting Items for Systematic Review and Meta-Analyses Protocol checklist and registered in the PROSPERO database for systematic reviews.
The review will compare the effect of breastfeeding type on sexual dysfunctions.
The subgroup analysis will show the impact of breastfeeding type on a specific sexual dysfunction and prolonged sexual abstinence.
The review will analyse original studies and statistical reports from international health organisations and local health authorities.
A notable limitation of the review is that we will include a small number of articles in the analysis due to scarce research on sexuality in breastfeeding women.
Introduction
Female sexuality: concepts and physiology
Mental and physiological changes affect sexual life, especially in the postpartum period. New mothers may experience dyspareunia (pain during intercourse) and insufficient lubrication; they may also have a lack of desire, excitement, satisfaction and orgasm. The persistent conditions causing distress in sexual life are classified as female sexual disorders (FSDs).1 The FSD triggers after delivery are painful recovery, changes in self-image, sleep deprivation and breast feeding.2 The diagnostic criteria for sexual dysfunctions in females are not clear. In particular, it is challenging to identify problems with arousal, lubrication and orgasm3 due to variability in definition of the female sexual dysfunction in distinct classification systems, including the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases and Statistics (ICD).4 According to the DSM-5, FSD is ‘any sexual complaint or problem resulting from disorders of desire, arousal, orgasm, or sexual pain that causes marked distress or interpersonal difficulty’. The ICD-10 placed FSDs in two different chapters: ‘diseases of the genitourinary system’ and ‘mental and behavioural disorders’.5 Division of sexual dysfunctions into these groups challenges diagnostics and treatment of FSDs. Recent evidence proves the interaction between physical and psychological factors resulting in occurrence of sexual problems.6 Consequently, FSDs remain unreported, which can result in women’s emotional distress, worries and feeling of isolation.7
Postpartum sexual dysfunctions are associated with numerous risk factors, including relationship dissatisfaction, depression, mode of delivery, amenorrhoea, obesity and hormonal changes.8 During lactation, the level of oestrogen decreases and prolactin increases, which results in dyspareunia and insufficient vaginal lubrication.7 Low sexual drive is associated with the oxytocin release and lowering of androgens during breast feeding.9
Neurophysiological mechanisms of sexual function are not clearly specified.10 11 Sexual stimulation activates the medial preoptic region, the anterior hypothalamic region and the related limbic hippocampal structures.12 However, brain imaging studies could not identify the activity of these regions during sexual excitement and orgasm.13 Also, little is known about the pathological changes in women’s sexual functioning postpartum. It was found that functional MRI detected suppressed amygdala responses to sexual pictures in breastfeeding women.9 The role of other brain regions in postpartum sexual health has not been thoroughly studied because of ethical considerations in sexology research.
The current psychophysiology describes the concept of sexuality with two models. According to Masters and Johnson, the female sexual response follows a linear model and passes four sequential phases: excitement (arousal), plateau, orgasm and resolution.14 Currently recognised, Rosemary Basson’s circular model of sexual response proposes the conception that desire can be responsive or spontaneous and that orgasm is not necessary for satisfaction. Moreover, she says that relationship factors can affect one’s willingness and ability to participate in sex.15 The latter is a combination of mental and physical states induced by stimuli triggering pleasure and desire to reach orgasm. In certain conditions, one component of arousal can occur without another,11 and subjective sexual arousal has a low or non-significant correlation with genital arousal. For example, a genital response can be evoked during sexual assault and other sexual threat stimuli.16 In contrast, female mental excitement depends on contextual pleasant factors.17 Peripheral mechanisms of genital arousal response cover vasocongestion, engorgement and production of lubricating mucus, which result from an increased blood flow to the clitoris, vagina and labia.18 A decrease in vaginal lubrication may cause pain and reduce sexual satisfaction.19 In case of a major disturbance at any stage of sexual activity, women are advised to seek professional help.
To diagnose FSDs, clinicians use multidimensional psychometric instruments which measure the physical and emotional components of sexuality. The most common inventory is the Female Sexual Function Index (FSFI). It consists of 19 items assessing sexual desire, arousal, lubrication, orgasm, satisfaction and pain.20 Recently, several studies examined the relationship between breast feeding and scores in sexuality domains assessed with FSFI: desire, arousal, lubrication, orgasm and pain. A summary of the findings on each component is provided below. Still, the data are insufficient for drawing conclusions regarding postpartum sexuality.
Sexual desire decreases during pregnancy and the decline may continue post partum. Many women still experience a reduced sex drive 6 months after delivery. In several studies, breast feeders reported lower sexual desire compared with those who ceased nursing.21 22 FSFI scores in the desire domain were significantly lower in exclusive breast feeders compared with mothers with mixed or bottle feeding.23 Contrarily, some studies stated that breast feeding did not impact FSFI scores including sexual desire, while change in routine decreased the willingness to engage in sex.24 25
Sexual arousal disorder is the ‘persistent or recurrent inability to attain or maintain sufficient sexual excitement which causes personal distress’.26 In the peripartum, women have FSFI scores for arousal lower than those in the third trimester of pregnancy.27 The decreased arousal can be associated with the longer duration of breast feeding.28 The type of breast feeding does not affect arousal FSFI scores.29 30
Lubrication develops slowly, and it is lower in quantity at 6 months post partum compared with the pre-pregnancy period. The amount of lubrication can come back to a peripartum level at 12 months.31 Women resorting to mixed feeding have better lubrication compared with exclusively breastfeeding mothers.32
Orgasm differs in its intensity considerably among women, and confirmation of orgasm is subjective.33 During sexual intercourse, women may experience physiological responses like those occurring while giving milk. The spontaneous let-down of breast milk happens in some women because of the release of oxytocin and the uterine contractions after orgasm.34 Nursing women have weaker and shorter orgasms at 4–5 weeks post partum.28 Formula-feeding mothers have higher FSFI scores for orgasm compared with the ones feeding exclusively (5.2 vs 4.8).23
Satisfaction is less likely to happen in nursing mothers compared with those who weaned their babies during 6 months post partum (adjusted OR 0.62).29 One and 4 months following childbirth, sexual satisfaction is greater in mothers opting for infant formula instead of breast milk for feeding their babies.35 If breastfeeding women are compared at 1 and 12 months post partum, their FSFI scores are similar.25
Pain is diagnosed in 41% of women at 3 months post partum and 22% at 6 months.36 Dyspareunia incidence rates are higher in nursing women compared with those who ceased the process (21.2% vs 15.9%, respectively).37
Impact of FSDs on quality of sexual life
The necessity of the study on postpartum sexual dysfunctions is supported by their unfavourable impact on life quality.38 Postpartum dissatisfaction with sexual life may negatively affect marital life and lead to divorce. The percentage of women with postpartum FSDs varies between 40% and 83%.39 40 A recent publication stated that 30.3% of nursing women did not get easily aroused, 20.2% of participants complained about difficult penetration and 14.4% of respondents could not reach orgasm.41 Banaei et al estimated that the prevalence of dyspareunia was 35% at 2 months postpartum and 22% at 6–12 months.42 85.6% of participants had insufficient lubrication. Other common disorders included lack of desire (69.7%) and pain (62.9%). Satisfaction and orgasmic disorders occured in 7.3% and 9.7% of new mothers.43
Because of unpleasant feelings during the first intercourse postpartum, women delay resuming active sexual life. In general, new mothers are advised to refrain from vaginal intercourse within 6 weeks after delivery. However, the actual return to sexual activity depends on the physical and mental state of women and the readiness of both partners to resume intercourse.44 Apart from physiological reasons, culture and sociodemographics influence the decision of women to return to sexual activity.45 46 According to recent studies, 20–50% of women do not engage in intercourse before 3 months post partum.41 47 Breastfeeding mothers are less likely to resume sexual relations at early post partum. This observation was confirmed by a population study in 17 African and Asian countries.47 In a longitudinal study, 38.7% of breastfeeding and 58.2% of non-breastfeeding women resumed intercourse by 6 weeks post partum.21 Ninety per cent of women engage in intercourse with their partners within 24 months after the delivery.48 The role of the baby feeding methods in sexual avoidance is still not well covered in research.
Modern literature lacks conclusive evidence for an association between infant nursing and sexuality problems. Moreover, while some authors report a strong risk ratio for having FSDs in women breast feeding exclusively,45 48 others do not confirm any association between lactation and problems in the sexuality domains.49 With this systematic review, we aim to synthesise available data on sexual dysfunctions in breastfeeding women.
Objective
The primary objective is to find out the relationship between breast feeding and female sexual dysfunctions. The secondary objectives are as follows:
Calculate pooled prevalence or incidence of sexual dysfunctions in nursing women.
Identify the relationship between the type of breast feeding and problems in sexuality domains.
Study the impact of breast feeding on the time to resumption of sexual activity after childbirth.
Find risk factors for sexual dysfunctions in breastfeeding females (eg, frequency of breast feeding, impaired lubrication).
Identify the most common sexual dysfunction in breastfeeding females.
Methods and analysis
The protocol will be prepared per the Preferred Reporting Items for Systematic Review and Meta-Analyses Protocol checklist which is available as online supplemental file 1. Figure 1 illustrates the study pipeline.
Figure 1.
Study pipeline. FSDs, female sexual disorders.
bmjopen-2023-074630supp001.pdf (147KB, pdf)
Study design and data source
A comprehensive literature search will be performed in biomedical databases PubMed/Medline, Scopus, Web of Science, EMBASE and CINAHL. We will extract peer-reviewed original studies written in English, Arabic or Polish and published from January 2000 to June 2023. The start year corresponds to the first mention of the FSFI tool. The preliminary search was performed on 04 April 2023. The keywords will be as follows: breastfeeding, lactation, nursing, sex, sexuality, desire, arousal, aversion, orgasm, excitement, drive, interest, resolution, “sexual pain”, vulvodynia, dyspareunia, vaginismus, phobias, libido, lubrication, function. Online supplemental file 2 provides a detailed search strategy for the PubMed database.
bmjopen-2023-074630supp002.pdf (46.3KB, pdf)
We will also review official reports from international organisations and associations such as WHO, Africa Centers for Disease Control and Prevention, European Centre for Disease Prevention and Control, Pan American Health Organization, European Public Health Association, and the American College of Obstetricians and Gynecologists. Health data from local health authorities will be also reviewed if they are available in English, Polish and Arabic. No other grey literature sources will be considered.
Eligibility criteria
The systematic review will focus on generally healthy breastfeeding females aged from 15 to 50 years who reported at least one sexual dysfunction or a condition negatively affecting sexual life. We will consider studies of observational, retrospective and cross-sectional designs which described sexual dysfunctions and/or abstinence within 5 years after giving birth. We will exclude dissertations, protocol papers, reviews, case studies and papers reporting data on women facing any type of violence or sexual abuse.
Study participants should be free from mental and psychological disorders, cerebrovascular diseases, organic pathologies of the central nervous system, addictions and other conditions that may impact sexuality, for example, diabetes mellitus and systemic mastocytosis. Original papers should not include participants who had serious fetal abnormalities and sexual dysfunctions known before pregnancy. Official documents should state a number of participants, scales used to assess sexual health, age of the surveyed population, time since giving birth and prevalence/incidence rates of sexual dysfunctions.
Study records
Selection process
All papers matching the search strategy will be uploaded to the Covidence software for automatic deduplication. Once duplicates are removed, two independent reviewers will screen the titles and abstracts of the studies for eligibility. If the reviewers cannot reach an agreement on the exclusion of the article, a third reviewer will resolve the conflict. The final decision on the inclusion of the papers will be performed at the full-text screening stage. A clear reason for the exclusion of articles will be specified. Once the reviewers complete screening articles uploaded to the Covidence, they will perform a hand screening of reference lists of the retrieved studies. The eligible studies will be uploaded to the Covidence software to ensure their presentation in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart.
To assess the accuracy of reviewers and the compliance of the selected studies with inclusion criteria, we will calculate Cohen’s kappa index ranging from 0 to 1. A greater value signals a better inter-reviewer reliability and shows that the agreement between judges is not due to chance. We will calculate kappa index at both screening stages.50
Data extraction
Two reviewers will use an online workbook to enter study characteristics. Basic information will include author name, publications, country, study design, sample size, age of participants, time since delivery, breastfeeding type, an instrument used for the assessment of sexual dysfunctions and FSD. Outcome measures will consist of a return to sexual activity in months, prevalence/incidence rates of sexual dysfunctions or abstinence, FSFI score for each sexuality domain and OR of having a disorder.
Quality assessment of individual studies
The two reviewers will score the papers for potential risk of bias using Joanna Briggs Institute checklists for cross-sectional, cohort and prevalence studies. In case of disputes, the third reviewer will decide on the final score. To assess publication bias due to a sample size of individual studies, we will use Begg’s and Egger’s tests and construct funnel plots.
Data analysis and synthesis
Once the data are extracted, we will identify the outcome measures for statistical analysis. If 3 and more studies have a similar methodology and interpret the same estimates, two reviewers will assess these studies for homogeneity using I2 statistics. If the heterogeneity index does not exceed 75%, we will perform a meta-analysis. If the retrieved literature does not meet the criteria, we will do a narrative review of relevant papers and official reports. We expect that the literature will have methodological interstudy heterogeneity. The variability can occur in age range of the participants, type of baby feeding and time from delivery. To ensure uniform presentation of data, we will perform a subgroup analysis. The subgroups will be identified once the outcome measures are extracted from the retrieved studies. To address the first specific objective, we will perform random-effects model meta-analysis for calculating pooled weighted incidence and prevalence. The random-effects model estimates the mean of the distribution of true effects. Therefore, it is an optimal choice due to anticipated methodological variance and non-uniform effect sizes between the studies.51 Working on the second specific objective, we will compute pooled OR for having specific sexual dysfunctions in women choosing either exclusive or mixed breast feeding. The subgroup analysis will help us to identify a likelihood of each sexual dysfunction in females opting for a particular feeding type. In the third specific objective, we will explore the relationship between breast feeding and the time to resumption of sexual activity by computing pooled OR. All pooled estimates will be provided with 95% CIs. For the fourth and fifth specific objectives, we will rank identified risk factors and sexual dysfunctions. The meta-analysis will be performed using the R package ‘meta’.52 To verify the robustness of the study results, we will perform a sensitivity analysis using leave-one-out method. It investigates the influence of each included study on the overall results of the meta-analysis. The presence of outliers in the meta-analysis signals insufficient interstudy homogeneity and questions the results of the study.53 The calculation will be performed in the R package ‘metaphor’.54
Patient and public involvement
The study does not include patients and the general public.
Review status
The review is set to start in April 2023.
Potential amendments
To avoid potential amendments, we performed the initial literature search and identified inclusion and exclusion criteria. Any modifications during the review preparation will be documented and updated in the PROSPERO protocol.
Ethics and dissemination
The study does not require ethical approval because it synthesises data from previously published original studies. The final work will be published in a peer-reviewed journal.
Supplementary Material
Acknowledgments
The authors would like to thank Dr Fayez Alshamsi, Assistant Professor and Consultant in Internal and Critical Care Medicine, College of Medicine and Health Sciences, UAEU, for his guidance on literature search.
Footnotes
Twitter: @StatsenkoE
Contributors: KTZ, YS and KMD specified research questions and study design. DS performed the literature search and wrote the manuscript. SAA, HK, ML, KTZ and MA contributed to preparing the abstract, title and full-text screening.
Funding: This work was supported by UAEU SURE+ grant G00004394 (PI: Kornelia Zaręba).
Competing interests: None declared.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review: Not commissioned; externally peer reviewed.
Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.
Ethics statements
Patient consent for publication
Not required.
References
- 1.Abdool Z, Thakar R, Sultan AH. Postpartum female sexual function. Eur J Obstet Gynecol Reprod Biol 2009;145:133–7. 10.1016/j.ejogrb.2009.04.014 [DOI] [PubMed] [Google Scholar]
- 2.Chiaravalloti ND, DeLuca J, Salter A, et al. The relationship between processing speed and verbal and non-verbal new learning and memory in progressive multiple sclerosis. Mult Scler 2022;28:1783–92. 10.1177/13524585221088190 [DOI] [PubMed] [Google Scholar]
- 3.Chen C-H, Lin Y-C, Chiu L-H, et al. Female sexual dysfunction: definition, classification, and debates. Taiwan J Obstet Gynecol 2013;52:3–7. 10.1016/j.tjog.2013.01.002 [DOI] [PubMed] [Google Scholar]
- 4.Parish SJ, Cottler-Casanova S, Clayton AH, et al. The evolution of the female sexual disorder/dysfunction definitions, nomenclature, and classifications: a review of DSM, ICSM, ISSWSH, and ICD. Sex Med Rev 2021;9:36–56. 10.1016/j.sxmr.2020.05.001 [DOI] [PubMed] [Google Scholar]
- 5.Kershaw V, Jha S. Female sexual dysfunction. Obstet Gynaecol 2022;24:12–23. 10.1111/tog.12778 [DOI] [Google Scholar]
- 6.Parameshwaran S, Chandra PS. The new Avatar of female sexual dysfunction in ICD-11—will it herald a better future? J Psychosexual Health 2019;1:111–3. 10.1177/2631831819862408 [DOI] [Google Scholar]
- 7.McBride HL, Olson S, Kwee J, et al. Women’s postpartum sexual health program: a collaborative and integrated approach to restoring sexual health in the postpartum period. J Sex Marital Ther 2017;43:147–58. 10.1080/0092623X.2016.1141818 [DOI] [PubMed] [Google Scholar]
- 8.Szöllősi K, Komka K, Szabó L. Risk factors for sexual dysfunction during the first year postpartum: a prospective study. Int J Gynaecol Obstet 2022;157:303–12. 10.1002/ijgo.13892 [DOI] [PubMed] [Google Scholar]
- 9.Rupp HA, James TW, Ketterson ED, et al. Lower sexual interest in postpartum women: relationship to amygdala activation and intranasal oxytocin. Horm Behav 2013;63:114–21. 10.1016/j.yhbeh.2012.10.007 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.McKenna KE. The neurophysiology of female sexual function. World J Urol 2002;20:93–100. 10.1007/s00345-002-0270-7 [DOI] [PubMed] [Google Scholar]
- 11.Levin RJ, Both S, Georgiadis J, et al. The physiology of female sexual function and the pathophysiology of female sexual dysfunction (committee 13A). J Sex Med 2016;13:733–59. 10.1016/j.jsxm.2016.02.172 [DOI] [PubMed] [Google Scholar]
- 12.Azadzoi KM, Siroky MB. Neurologic factors in female sexual function and dysfunction. Korean J Urol 2010;51:443–9. 10.4111/kju.2010.51.7.443 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Levin R, Riley A. The physiology of human sexual function. Psychiatry 2007;6:90–4. 10.1016/j.mppsy.2007.01.004 [DOI] [Google Scholar]
- 14.Masters WH, Johnson VE. Human sexual response; 1966.
- 15.Basson R. Female sexual response: the role of drugs in the management of sexual dysfunction. Obstet Gynecol 2001;98:350–3. 10.1016/s0029-7844(01)01452-1 [DOI] [PubMed] [Google Scholar]
- 16.Levin RJ, van Berlo W. Sexual arousal and orgasm in subjects who experience forced or non-consensual sexual stimulation–a review. J Clin Forensic Med 2004;11:82–8. 10.1016/j.jcfm.2003.10.008 [DOI] [PubMed] [Google Scholar]
- 17.Laan E, Everaerd W, van der Velde J, et al. Determinants of subjective experience of sexual arousal in women: feedback from genital arousal and erotic stimulus content. Psychophysiology 1995;32:444–51. 10.1111/j.1469-8986.1995.tb02095.x [DOI] [PubMed] [Google Scholar]
- 18.Traish AM, Botchevar E, Kim NN. Biochemical factors Modulating female genital sexual arousal physiology. J Sex Med 2010;7:2925–46. 10.1111/j.1743-6109.2010.01903.x [DOI] [PubMed] [Google Scholar]
- 19.Shahhosseini Z, Gardeshi ZH, Pourasghar M, et al. A review of affecting factors on sexual satisfaction in women. Mater Sociomed 2014;26:378–81. 10.5455/msm.2014.26.378-381 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Neijenhuijs KI, Hooghiemstra N, Holtmaat K, et al. The female sexual function index (FSFI)-A systematic review of measurement properties. J Sex Med 2019;16:640–60. 10.1016/j.jsxm.2019.03.001 [DOI] [PubMed] [Google Scholar]
- 21.Rowland M, Foxcroft L, Hopman WM, et al. Breastfeeding and sexuality immediately post partum. Can Fam Physician 2005;51:1366–7. [PMC free article] [PubMed] [Google Scholar]
- 22.Rosen NO, Bailey K, Muise A. Degree and direction of sexual desire discrepancy are linked to sexual and relationship satisfaction in couples transitioning to parenthood. J Sex Res 2018;55:214–25. 10.1080/00224499.2017.1321732 [DOI] [PubMed] [Google Scholar]
- 23.Szöllősi K, Szabó L. The association between infant feeding methods and female sexual dysfunctions. Breastfeed Med 2021;16:93–9. 10.1089/bfm.2020.0256 [DOI] [PubMed] [Google Scholar]
- 24.Hipp LE, Kane Low L, van Anders SM. Exploring women’s postpartum sexuality: social, psychological, relational, and birth-related contextual factors. J Sex Med 2012;9:2330–41. 10.1111/j.1743-6109.2012.02804.x [DOI] [PubMed] [Google Scholar]
- 25.Saotome TT, Yonezawa K, Suganuma N. Sexual dysfunction and satisfaction in Japanese couples during pregnancy and postpartum. Sex Med 2018;6:348–55. 10.1016/j.esxm.2018.08.003 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Basson R, Leiblum S, Brotto L, et al. Revised definitions of women’s sexual dysfunction. J Sex Med 2004;1:40–8. 10.1111/j.1743-6109.2004.10107.x [DOI] [PubMed] [Google Scholar]
- 27.Wallwiener S, Müller M, Doster A, et al. Sexual activity and sexual dysfunction of women in the perinatal period: a longitudinal study. Arch Gynecol Obstet 2017;295:873–83. 10.1007/s00404-017-4305-0 [DOI] [PubMed] [Google Scholar]
- 28.Avery MD, Duckett L, Frantzich CR. The experience of sexuality during breastfeeding among primiparous women. J Midwifery Womens Health 2000;45:227–37. 10.1016/s1526-9523(00)00020-9 [DOI] [PubMed] [Google Scholar]
- 29.McDonald E, Woolhouse H, Brown SJ. Sexual pleasure and emotional satisfaction in the first 18 months after childbirth. Midwifery 2017;55:60–6. 10.1016/j.midw.2017.09.002 [DOI] [PubMed] [Google Scholar]
- 30.Fuchs A, Czech I, Dulska A, et al. The impact of motherhood on sexuality. Ginekol Pol 2021;92:1–6. 10.5603/GP.a2020.0162 [DOI] [PubMed] [Google Scholar]
- 31.O’Malley D, Higgins A, Begley C, et al. Prevalence of and risk factors associated with sexual health issues in primiparous women at 6 and 12 months postpartum; a longitudinal prospective cohort study (the MAMMI study). BMC Pregnancy Childbirth 2018;18:196. 10.1186/s12884-018-1838-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Holanda J de L, Richter S, Campos RB, et al. Relationship of the type of breastfeeding in the sexual function of women. Rev Lat Am Enfermagem 2021;29:e3438. 10.1590/1518.8345.3160.3438 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Levin RJ. The mechanisms of human female sexual arousal. Annu Rev Sex Res 1992;3:1–48. 10.1080/10532528.1992.10559874 [DOI] [Google Scholar]
- 34.Grussu P, Vicini B, Quatraro RM. Sexuality in the perinatal period: a systematic review of reviews and recommendations for practice. Sex Reprod Healthc 2021;30:100668. 10.1016/j.srhc.2021.100668 [DOI] [PubMed] [Google Scholar]
- 35.Byrd JE, Hyde JS, DeLamater JD, et al. Sexuality during pregnancy and the year postpartum. J Fam Pract 1998;47:305–8. [PubMed] [Google Scholar]
- 36.Seehusen DA, Baird DC, Bode DV. Dyspareunia in women. Am Fam Physician 2014;90:465–70. [PubMed] [Google Scholar]
- 37.Kettle C, Ismail KM, O’Mahony F. Dyspareunia following childbirth. Obstet Gynaecol 2005;7:245–9. 10.1576/toag.7.4.245.27119 [DOI] [Google Scholar]
- 38.Banaei M, Zahrani ST, Pormehr-Yabandeh A, et al. Investigating the impact of counseling based on PLISSIT model on sexual intimacy and satisfaction of breastfeeding women. Int J Pharm Res Allied Sci 2016;5. [Google Scholar]
- 39.Kouéta F, Dao L, Dao F, et al. Factors associated with overweight and obesity in children in ouagadougou (Burkina Faso). Cahiers Santé 2011;21:227–31. 10.1684/san.2011.0272 [DOI] [PubMed] [Google Scholar]
- 40.Khajehei M, Doherty M, Tilley PJM, et al. Prevalence and risk factors of sexual dysfunction in postpartum Australian women. J Sex Med 2015;12:1415–26. 10.1111/jsm.12901 [DOI] [PubMed] [Google Scholar]
- 41.Hidalgo-Lopezosa P, Pérez-Marín S, Jiménez-Ruz A, et al. Factors associated with postpartum sexual dysfunction in Spanish women: a cross-sectional study. J Pers Med 2022;12:926. 10.3390/jpm12060926 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.Banaei M, Kariman N, Ozgoli G, et al. Prevalence of postpartum dyspareunia: a systematic review and meta-analysis. Int J Gynaecol Obstet 2021;153:14–24. 10.1002/ijgo.13523 [DOI] [PubMed] [Google Scholar]
- 43.Khalid NN, Jamani NA, Abd Aziz KH, et al. The prevalence of sexual dysfunction among postpartum women on the East coast of Malaysia. J Taibah Univ Med Sci 2020;15:515–21. 10.1016/j.jtumed.2020.08.008 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44.Acele EÖ, Karaçam Z. Sexual problems in women during the first postpartum year and related conditions. J Clin Nurs 2012;21:929–37. 10.1111/j.1365-2702.2011.03882.x [DOI] [PubMed] [Google Scholar]
- 45.Rezaei N, Azadi A, Sayehmiri K, et al. Postpartum sexual functioning and its predicting factors among Iranian women. Malays J Med Sci 2017;24:94–103. 10.21315/mjms2017.24.1.10 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 46.Sule-Odu AO, Fakoya TA, Oluwole FA, et al. Postpartum sexual abstinence and breastfeeding pattern in Sagamu, Nigeria. Afr J Reprod Health 2008;12:96–100. [PubMed] [Google Scholar]
- 47.Borda MR, Winfrey W, McKaig C. Return to sexual activity and modern family planning use in the extended postpartum period: an analysis of findings from seventeen countries. Afr J Reprod Health 2010;14:72–9. [PubMed] [Google Scholar]
- 48.Connolly A, Thorp J, Pahel L. Effects of pregnancy and childbirth on postpartum sexual function: a longitudinal prospective study. Int Urogynecol J 2005;16:263–7. 10.1007/s00192-005-1293-6 [DOI] [PubMed] [Google Scholar]
- 49.Cattani L, De Maeyer L, Verbakel JY, et al. Predictors for sexual dysfunction in the first year postpartum: a systematic review and meta-analysis. BJOG 2022;129:1017–28. 10.1111/1471-0528.16934 [DOI] [PubMed] [Google Scholar]
- 50.Pérez J, Díaz J, Garcia-Martin J, et al. Systematic literature reviews in software engineering—enhancement of the study selection process using Cohen’s Kappa Statistic. J Syst Softw 2020;168:110657. 10.1016/j.jss.2020.110657 [DOI] [Google Scholar]
- 51.Harrer M, Cuijpers P, Furukawa TA, et al. Chapter 4 Pooling Effect Sizes | Doing Meta-Analysis in R. 2023. Available: https://bookdown.org/MathiasHarrer/Doing_Meta_Analysis_in_R/pooling-es.html#fem [Google Scholar]
- 52.Schwarzer G, Carpenter JR, Rücker G. Meta-Analysis with R, (Use R!). Cham: Springer International Publishing, 2015. Available: https://link.springer.com/10.1007/978-3-319-21416-0 [Google Scholar]
- 53.Viechtbauer W, Cheung MWL. Outlier and influence diagnostics for meta-analysis. Res Synth Methods 2010;1:112–25. 10.1002/jrsm.11 [DOI] [PubMed] [Google Scholar]
- 54.Viechtbauer W. Conducting meta-analyses in R with the metafor package. J Stat Softw 2010;36:1–48. 10.18637/jss.v036.i03 [DOI] [Google Scholar]
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