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. 2024 Jan 17;19(1):e0288536. doi: 10.1371/journal.pone.0288536

Prevalence and factors associated with early resumption of sexual intercourse among postpartum women: Systematic review and meta-analysis

Kelemu Abebe Gelaw 1,*, Yibeletal Assefa Atalay 2, Adisu Yeshambel 1, Getachew Asmare Adella 3, Belete Gelaw Walle 4, Liknaw Bewket Zeleke 5,6, Natnael Atnafu Gebeyehu 1
Editor: Frank T Spradley7
PMCID: PMC10793940  PMID: 38232099

Abstract

Introduction

Postpartum sexual health is indicated by a resumption of sexual activity as well as arousal, desire, orgasm, and sexual satisfaction. The issue of resuming sexual intercourse after childbirth has received limited attention because healthcare professionals rarely provide adequate care to postnatal women. The present study aimed to ascertain the overall prevalence of early resumption of sexual intercourse among most women.

Methods

Searches were conducted in PubMed, Web of Science, Science Direct, Google Scholar, African Journals Online, and the Cochrane Library. Data were extracted using Microsoft Excel, and STATA version 14 was used for analysis. Publication bias was checked by funnel plot, Egger, and Begg regression tests. A p-value of 0.05 was regarded to indicate potential publication bias. Using I2 statistics, the heterogeneity of the studies was evaluated. By country, a subgroup analysis was conducted. A sensitivity analysis was carried out to determine the effect of each study’s findings on the overall estimate. The random effects model was used to assess the overall effect of the study and then measured using prevalence rates and odds ratio with 95% CI.

Results

Twenty-one studies with 4,482 postpartum women participants were included in the study. The pooled prevalence of early resumption sexual intercourse among post-partum women was 57.26% (95% CI 50.14, 64.39) with significant heterogeneity between studies (I2  =  99.2%; P-value ≤ 0.000) observed. Current contraceptive use (AOR = 1.48, 95%CI = 1.03, 6.21), primipara (AOR = 2.88, 95%CI = 1.41, 5.89), and no history of severe genital injury on the last delivery (AOR = 2.27, 95%CI = 1.05, 4.93) were significantly associated with early resumption of sexual intercourse.

Conclusion

This study found that more than half of women resumed sexual intercourse early after giving birth. This suggests that a significant number of women may be at higher risk of unwanted pregnancies, short birth intervals, and postpartum sepsis. Thus, stakeholders should improve the integration of postpartum sexual education with maternal health services to reduce the resumption of postpartum sexual intercourse.

Introduction

Sexuality evolves throughout a person’s life and is essential to being human [1]. It is a key idea in human sexual health [2]. Sexual health is a key component of the overall health and quality of life of both men and women [3]. It has at least three connected purposes: communication, pleasure, and reproduction. Pregnancy, childbirth, and the postpartum period are crucial times for women’s sexual health [4]. Women’s bodies experience physiological as well as anatomical changes after giving birth which have an impact on their lives, including sexual activity, which is essential to human existence [5]. Postpartum sexual health is indicated by resuming sexual activity as well as by arousal, desire, orgasm, and sexual satisfaction [6]. World Health Organization (WHO) advises that postpartum sexual health is one of the most crucial issues that need to be addressed during the postpartum period [7].

The desire to engage in sexual activity declines during pregnancy but returns to normal, usually six weeks after delivery [8]. Resuming postpartum sexual activity should be done at least six weeks after giving birth [9]. However, the decision to resume sexual activity after delivery differs from woman to woman and is influenced by several factors such as the quantity of bleeding, mode of delivery, culture, maternal mental health, infant health, the relationship with one’s partner, and the mother’s general health [10].

Early resumption of sexual intercourse among postpartum women may cause maternal health problems: unfavorable birth outcomes, wound infection, painful intercourse, vaginal dryness, and inability to achieve orgasm [11]. In addition, early resuming sexual intercourse without utilizing contraception after giving birth can lead to an unplanned pregnancy and short birth interval. Due to this, there may be a high risk of death for infants under the age of one year [12]. Sociocultural norms and beliefs, education, the place of the birth, the mother’s breastfeeding status, and mode of delivery, low parity, use of contraceptives, and residence are some of the factors that have been found to affect the early resumption of sexual activity after delivery [13].

The previous study has provided evidence that the use of hands-free perineal control techniques during the second stage of labor may represent a promising delivery approach to maintain perineal integrity. In addition, these techniques can have a positive effect on the resumption of sexual activity in the postpartum period, as they include several factors that can facilitate this process [14]. Numerous cohort studies have shown that women who undergo spontaneous vaginal delivery with intact perineum have a higher likelihood of having vaginal intercourse again within six to eight weeks after birth compared to women who undergo an episiotomy assisted vaginal birth etc. undergo a Cesarean Section [15–17]. Even though the WHO advises that all women should be evaluated 2–6 weeks after childbirth, the problem of early resumption of sexual activity during postpartum has received little attention from researchers, policymakers, and healthcare providers [18]. Therefore, it is important to examine the various aspects of early resumption of sexual relationships in the postpartum period to understand the direct and indirect effects of this problem and highlight the importance of studying these issues at a global level [19]. Furthermore, the prevalence of early resumption of sexual intercourse varied in the previous studies, with rates ranging from 20.2% in Ethiopia [42] to 90.2% in the USA [24]. Given these differences, there is no systematic review or meta-analysis conducted on the prevalence and contributing variables associated with early postpartum sexual resumption worldwide.

Additionally, the results of this study might help in developing new approaches to postpartum sexuality education. Hence, this study aimed to assess the prevalence and factors associated with early resuming postpartum sexual intercourse at the global level.

Methods

Search strategy and information sources

An extensive data search was performed on International online databases (PubMed, Web of Science, Science Direct, Google Scholar, Cochrane Library, and African Journals Online (AJOL) databases used to get the research articles. We also retrieved gray literature from Addis Ababa and Bitesema University’s online research institutional repository. Searching strategies were established by using Boolean operators ("OR" or "AND") and the following key terms: early sexual intercourse, associated factors, and post-partum. The search strategies for Google Scholar were: "early sexual intercourse" and ("associated factors”) and “post-partum". We also retrieved gray literature from Addis Ababa and Busitema University’s online research institutional repository. During the search process, the following phrases and keywords were used: "prevalence," "incidence," "magnitude," "early resumption," "sexual intercourse," "determinant," "factor," "predictor," and "postpartum period" The last date of search that all databases were checked from February 15/2023 to February 27/2023.

Reporting

We used PICO questions that had been modified to follow the PEO (Population, Exposure, and Outcome) style for the explicit presentation of our review question and the explicit clarification of the inclusion and exclusion criteria. We reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria for conducting the systematic review [20] (S1 Table). The authors of this systematic review and meta-analysis work were registered with Prospero at CRD42023427034.

PEO guide

P: Population (Patients)

✓ Postpartum women who had early resumption of sexual intercourse.

E: Exposure

✓ Factors that affect for early resumption of sexual intercourse among postpartum women.

O: Outcome

✓ Prevalence of early resumption of sexual intercourse among postpartum women.

✓ Factors associated with early resumption of sexual intercourse among postpartum women.

Study population

✓ Postpartum women.

Eligibility criteria

Studies that included full-text articles, English-language articles, both published and unpublished articles, cross-sectional studies, case-control studies, and cohort studies were included in this study. Duplicate sources, interventional studies, case reports, systematic reviews, qualitative articles, case series, conference abstracts, letters to the editor, and any articles that were not fully accessible after exchanging at least two emails with the lead author were all excluded. A COCOPOP (Condition, Context, and Population) paradigm was utilized to determine the suitability of the included studies for this investigation. Postpartum women who had early resumption of sexual intercourse made up the study’s population (POP), while the prevalence of early resumption of sexual intercourse served as the condition and global served as the setting.

Outcome measurements

This review and meta-analysis had two main outcomes. The primary outcome was the global prevalence of early resumption of sexual intercourse among postpartum women. The second outcome was factors associated with the early resumption of sexual intercourse among postpartum women. We used the following variables for factors: contraceptive use, multiparous, maternal educational status, sexual intercourse during pregnancy, history of genital injury on the last delivery, mode of delivery, breastfeeding status, the onset of menstruation, husband educational status, and timing resumption of intercourse if they were listed as a factor in at least two studies. Data were taken in the form of two two-by-two tables from the primary studies for each factor to calculate the odds ratio.

Study selection and data extraction

Retrieved articles were exported to the reference manager software; endnote software was used to remove duplicate studies. Three independent reviewers screened the title and abstract (KA, YA, and NA). The disagreement was handled based on one established article selection criteria. Data were extracted using a standardized data extraction format prepared in Microsoft Excel by five independent authors (KA, AY, BG, GA, and LB). Any difference during extraction was solved through discussion. The name of the first author, study area and country, the study design, year of publication, study design, study setting, sample size, and prevalence of early resumption of sexual intercourse among postpartum women were collected.

Risk of bias (Quality assessment)

The scientific validity and quality of each study were assessed using the Joanna Briggs Institute (JBI) quality assessment approach, which is designed for cross-sectional, case-control, and cohort studies. Each author assessed each study separately using the above assessment method. Analyzes for cross-sectional studies were performed using assessment results that met (4 of 8) a 50% low-risk quality assessment requirement. For case-control and cohort studies, assessments (5 of 10) and (5 of 11) each met a low-risk quality assessment requirement of 50% (S2 Table). Two independent authors (KA and YA) assessed the quality of the study. Any disagreements raised during the bias assessment were resolved through a discussion led by the third author (NAG).

Publication bias, heterogeneity, and statistical analysis

Data were extracted using Microsoft Excel and analyzed using STATA version 14 statistical software. The presence of significant between-study heterogeneity was assessed using Cochrane Q and I2 statistics. The presence of heterogeneity was illustrated by a forest plot. We utilized a random-effect model for analysis to estimate the pooled effect because we found a high level of heterogeneity. Analysis of the subgroups was done by study setting, study design, and country. A sensitivity analysis was carried out to determine the effect of one study’s findings on the overall estimate. To detect the presence of considerable heterogeneity, meta-regression was computed based on publication year and country. Publication bias was checked by funnel plot and Egger’s regression tests. At a p-value of less than 0.05, publication bias was considered to be statistically significant. We used adjusted odds ratio estimates with confidence intervals (CI) as a measure of association. The random effect model was used to assess the overall effect of early resumption of sexual intercourse, which was then measured by the prevalence rates and odds ratio with 95% CI. The result was presented in the form of text, tables, and figures.

Result

Selection of included studies

A PubMed, Web of Science, Science Direct, Google Scholar, Cochrane Library, and African Journals Online AJOL resulted in a total of 8,460 research articles. Among these studies, 6,850 duplicate studies were removed, and 1,510 studies were excluded after reviewing their titles and abstracts. At the eligibility evaluation phase, out of the remaining 100 studies, 79 articles were removed after examining their full text, and similar by considering the inclusion and exclusion criteria. Lastly, 21 studies [21–41] and 4,482 participants were included in the analysis(Fig 1).

Fig 1. PRISMA flow chart displays studies used for systematic review and meta-analysis of prevalence and factors associated with early resumption of sexual intercourse among postpartum women.

Fig 1

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Description of included studies

Table 1 displays the characteristics of all included studies. The author’s name, publication year, study setting, study design, sample size, country, and the percentage of early resumption of sexual intercourse In terms of country-wise distribution, the included 21 studies were comprised of 2 from the United States of America (23 and 24), 5 from Ethiopia (39,40,41,42, and 43), 4 from Uganda(35,36,37 and 38), 3 in Nigeria (32,33, and 34), 2 from China (25 and 26), 2 from India (30 and 31), and the rest 3 were from Spain (27), Norway (28), and Iran (29). None of the studies were excluded based on the quality assessment criteria (Table 1).

Table 1. Descriptions of the studies used in the systematic review and meta-analysis for prevalence and factors associated with early resumption of sexual intercourse among postpartum women.

First Author/year Study Setting Country Study design Prevalence((95%CI) Sample Size Study Quality
Yee et al./2013 [21] health facility USA Cohort 60.7 160 Low risk
Brubaker L et al./2008 [22] health facility USA Cohort 90.2 509 Low risk
Xiaorong Fan /2021 [23] health facility China cross-sectional 55.9 15, 834 Low risk
Caixia Zhuang et.al/2019 [24] Community China cross-sectional 36 550 Low risk
Sònia Anglès et.al/2019 [25] health facility Spain case-control 73 318 Low risk
Kathrine Fodstad et.al/2016 [26] health facility Norway case-control 51.4 2848 2846 Low risk
Prakash P 2021 [27] health facility India cross-sectional 41 3,112 Low risk
Gyan P et.al/2021 [28] Community India cross-sectional 65 1564 Low risk
Fatemeh D/2014 [29] health facility Iran cross-sectional 68 150 Low risk
Olugbenga Bello et.al/2017 [30] health facility Nigeria cross-sectional 45.2 460 Low risk
Anzaku AS eta.al/2014 [31] health facility Nigeria cross-sectional 67.6 340 Low risk
Kola M/2014 [32] health facility Nigeria cross-sectional 40 257 Low risk
Alice C et. al/2015 [33] health facility Uganda cross-sectional 21.6 374 Low risk
Rose N et.al/2021 [34] health facility Uganda Cohort 88.2 507 Low risk
MADENJE M et.al/2019 [35] Community Uganda cross-sectional 25 622 Low risk
Emmanuel O et.al/2003 [36] health facility Uganda cross-sectional 66.4 216 Low risk
Tariku B et.al/2021 [37] health facility Ethiopia cross-sectional 53.9 330 Low risk
Dejene E/2022 [38] health facility Ethiopia cross-sectional 31.6 424 Low risk
Melaku H/2022 [39] Community Ethiopia cross-sectional 60.4 6447 Low risk
Ebisa Turi et.al/2022 [40] health facility Ethiopia cross-sectional 20.2 528 Low risk
Frewoini T/2014 [41] health facility Ethiopia cross-sectional 78.3 424 Low risk
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Meta-analysis

Prevalence of early resumption of sexual intercourse among postpartum women

From these reviewed studies, the prevalence of early resumption of sexual intercourse among post-partum women ranged from 20.2 to 90.2% [19, 37]. The global pooled prevalence of early resumption of sexual intercourse among post-partum women was 57.26% (95% CI 50.14, 64.39). The random-effect model was used to analyze the pooled prevalence; however a high and significant heterogeneity among the included studies (I2  =  99.2%; P-value ≤ 0.000) was observed (Fig 2).

Fig 2. Forest plot of the prevalence with corresponding 95% CIs of the twenty-one studies on prevalence and factors associated with early resumption of sexual intercourse among postpartum women.

Fig 2

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Subgroup analysis

After confirming the presence of heterogeneity among the studies, subgroup analysis was done based on the study setting, country, and study design to identify the source of heterogeneity. Nevertheless, there was still proof of study heterogeneity. In the sub-group analysis, the United States of America had the highest prevalence of early resumption of sexual intercourse among postpartum women(75.670%; 95% CI: 46.77; 104.58) while China had the lowest prevalence the pooled prevalence of early resumption of sexual intercourse among post-partum (45.98;26.48, 65.48) (Table 2).

Table 2. The pooled prevalence of early resumption of sexual intercourse among postpartum women, 95% CI, and heterogeneity estimate with a p-value for subgroup analysis.

Country Random effects(95%CI) Test of heterogeneity I2
USA 75.67(46.77, 104.58) 98.1
China 45.98(26.48, 65.48) 98.2
Spain 73.00 (68.120, 77.88) ----
Norway 51.40 (49.57, 53.24) ----
India 52.98 (29.47, 76.51) 99.6
Iran 68.00 (60.54,75.47) ------
Nigeria 50.97 (34.50, 67.45) 99.8
Uganda 59.89 (30.65, 89.14) 99.6
Ethiopia 53.86 (41.70, 66.04) 99.9
Overall 57.26 (50.14,64.39) 99.2
Study setting
Health Facility 59.78 (50.87,68.75) 99.2
Community 46.67 (30.67,62.68) 99.4
Overall 57.26 (50.14,64.39) 99.2
Study design
Cohort 80.60 (70.04,91.16) 96.2
Cross-sectional 52.40(45.72,59.06) 98.7
Case-control 62.08(40.91, 83.24) 98.5
Overall 57.26 (50.14, 64.39) 99.2
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Sensitivity analysis

The influence of each study on the overall prevalence of early resumption of sexual intercourse among postpartum women was examined using a leave-one-out sensitivity analysis, which involved removing one study at a time. The outcome showed that the omitted study had no significant effect on postpartum women’s early resumption of sexual activity (Table 3).

Table 3. Sensitivity analysis for prevalence and factors associated with early resumption of sexual intercourse among postpartum women.

Study omitted Estimate (95%CI)
Lynn M et. Al/2013 57.1 49.77, 64.42
Linda Brubaker et.al/2008 55.59 49.11, 62.06
Xiaorong Fan /2021| 57.33 49.87, 64.78
Caixia Zhuang et.al/2019 58.32 51.08-,65.57
Sonia Angles et.al/2019 56.48 49.16,63.7
Kathrine Fodstad et.al/2016 57.56 57.56,65.31
Prakash P /2021 58.08 50.8,65.32
Gyan P et.al/2021 56.87 49.32,64.42
Fatemeh D/2014 56.74 49.42–64.06
Olugbenga Bello et.al/2017 57.86 50.51,65.21
Anzaku AS eta.al/2014 56.74 49.40,64.09
Kola M/2014 58.11 50.81,65.41
Alice C et al./2015 57.12 50.81,65.41
Rose N et al./2021 55.69 48.95,62.43
MADENJE M/2019 55.69 48.95,62.43
Emmanuel O et al./2001 56.81 49.48,64.14
Tariku B et al./2021 57.43 50.07,64.79
Dejene E et al./2022 58.54 51.35,65.73
Melaku H/2022 57.1 57.1,65.41
Ebisa Turi et al./2022 57.26 50.13,64.39
Frewoini T/2014 56.20 48.96, 63.45
Overall 57.26 50.13,64.39
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Meta-regression

Meta-regression was done using publication year and country to test for underlying the source of heterogeneity. There was no evidence to support publication year, and country were the causes of the heterogeneity (p-value = 0.723) and (p = 0.16), respectively (Table 4).

Table 4. Meta-regression analysis based on year of publication and country.

Source of heterogeneity Coefficient Standard error P value
Publication year .975 .0682 .72
Country 1.019 0.120 0.16
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Publication bias

The results of the funnel plot demonstrate that there was no publication bias present in any of the studies, which was an asymmetric distribution. In addition, both the funnel plot and Eggers regression test were used to determine publication bias in included studies. However, no evidence of publication bias was found by the Eggers and Begg regression test with p-values of 0.422 and 0.386, respectively (Fig 3).

Fig 3. Funnel plots for prevalence and factors associated with early resumption of sexual intercourse among postpartum women.

Fig 3

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Factors associated with early resumption of sexual intercourse among post-partum women

The association between the prevalence of early resumption of sexual intercourse among post-partum women and the use of contraception was evaluated by using four studies [33, 34, 37, 39]. The result revealed that the pooled effect of the use of contraception was significantly associated with the early resumption of sexual intercourse among post-partum women. Women who used contraceptives were 1.48 times more likely to have an early resumption of sexual intercourse during the postpartum period than those who didn’t use (AOR = 1.48, 95%CI = 1.03, 6.2.12). Heterogeneity was not detected across the studies (I-squared = 0.0%, p = 0.42 (Fig 4).

Fig 4. Forest plot showing the association between the early resumption of sexual intercourse and current contraceptive usage.

Fig 4

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The association between the prevalence of early sexual intercourse among post-partum women and parity was evaluated by using four studies [21, 32, 33, 37]. The result revealed that the primipara was significantly associated with the early resumption of sexual intercourse among post-partum women. Women with primipara were 2.88 times more likely to engage in early sexual intercourse during the postpartum period than those multipara women (AOR = 2.88, 95%CI = 1.41, 5.89). No evidence of heterogeneity was found in any of the studies. (I-squared = 100.0%, p = 0.00.Hence, a random effect model was used (Fig 5).

Fig 5. Forest plot showing the association between the early resumption of sexual intercourse and parity.

Fig 5

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The association between the prevalence of early resumption of sexual intercourse among post-partum women and having a history of severe genital injury on the last delivery was evaluated by using three studies [26, 32, 33]. The result revealed that the pooled effect of having no history of severe genital injury on the last delivery was significantly associated with the early resumption of sexual intercourse among post-partum women. Women who had no history of severe genital injury on the last delivery were 2.27 times more likely to have an early resumption of sexual intercourse than women who had a history of severe genital injury on the last delivery(AOR = 2.27, 95%CI = 1.05, 4.93). No evidence of heterogeneity was found in any of the studies (I-squared = 0.00%, p = 0.00) (Fig 6).

Fig 6. Forest plot showing the association between the early resumption of sexual intercourse and a history of severe genital injury.

Fig 6

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Discussion

The World Health Organization has advised that research be done on sexual health because of its significance, separate from reproductive health, and because lack of knowledge about sexual health is the root cause of many dysfunctions and diseases throughout the world [42]. The compressive research findings must be included by healthcare professionals to implement evidence-based practice. Addressing the early resumption of postpartum intercourse and its factors is essential when focusing on postpartum issues of maternal health outcomes [43].

According to a database search, no systematic review has been conducted on the prevalence and factors associated with early resumption of sexual intercourse in postpartum women at a global level. Systematic reviews and meta-analyses are considered to provide the most robust evidence for clinical decision-making related to postpartum health compared to individual studies. This is due to the comprehensive and rigorous nature of these methods, allowing the synthesis and analysis of data from multiple studies. As a result, decision-makers are better equipped to achieve optimal postpartum sexual health outcomes.

In this systematic review and meta-analysis, the overall resumption of early sexual intercourse among post-partum was 57.26% (95% CI 50.14, 64.39). This review is lower than the compared study in Sub-Saharan Africa [44]. These discrepancies may be explained by changes in sociocultural, social beliefs and norms, religious conduct, and the sexual attitudes of women in various geographic locations. Subjective norms, societal values, and ideas regarding postpartum sexual abstinence all have an impact on early sexual resumption [45].

For women from various cultural backgrounds, the postpartum period is known as a vulnerable and stressful time. During this time, women experienced enormous social and personal changes in addition to several new concerns and problems [46]. Given the significance of the first sexual encounter in establishing a committed relationship, postpartum sexual function is a significant concern for couples. Several factors, including lower parity, breastfeeding, cesarean section, severe genital injury, living child, maternal and paternal educational status, occupation, and current contraceptive use, could influence the early resumption of sexual intercourse in the postpartum period [47]. We found that the use of contraceptives; having less parity and having severe genital tears on the last delivery were statically associated with early resumption of sexual intercourse during the post-partum period. In the previous study, one of the factors linked to the early postpartum resumption of sexual activity was the use of contraceptives during the postpartum period [48]. Women who used contraceptives were 1.48 times more likely to have an early resumption of sexual intercourse during the postpartum period than those who didn’t use (AOR = 1.48, 95%CI = 1.03, 6.2.12). This may be due to women who use contraceptives believing that they are not a risk for pregnancy, which encourages them to resume sexual activity six weeks after giving birth. However, early resumption of sexual activity may increase the risk of postpartum sexual dysfunction and unintended pregnancy [49]. Similarly, parity has affected women’s early resumption of sexual intercourse; primiparous women are more likely to have an early resumption of sexual intercourse among postpartum women than multiparous women [50]. We found that women with primipara were 2.88 times more likely to engage in early sexual intercourse during the postpartum period than those multipara women (AOR = 2.88, 95%CI = 1.41, 5.89). This may be explained by their lack of experience, primiparae typically feel less confident in their postpartum sexual intercourse.

After giving birth, women who have trauma to the perineum may experience discomfort and other issues. First, second, third, and fourth-degree tears are used to characterize the degree of injury, with first-degree tears causing the least harm and fourth-degree tears causing the most. The anal sphincter or mucosa is affected by third- and fourth-degree tears, which are the most problematic [51]. Additionally, several perineal methods are employed to delay the head birth of the infant. Midwives and other delivery attendants frequently utilize massage, warm compresses, and various perineal management techniques. If these reduce trauma and discomfort for women, it is important to know. Even though episiotomy is one of the most frequently done procedures, there is an ongoing dispute in the professional literature about whether it has a preventive effect from third- and fourth-degree tears [52]. According to this review, no history of severe genital injury (severe perineal injury) on the last delivery had effects on the early resumption of sexual intercourse. Women who had no history of severe genital injury on the last delivery were 2.27 times more likely to have an early resumption of sexual intercourse than women who had a history of severe genital injury on the last delivery(AOR = 2.27, 95%CI = 1.05, 4.93). This might be the result of women who haven’t experienced postpartum dyspareunia (painful sexual intercourse).

Strengths and limitations of the study

To reduce selection bias, we conducted a systematic literature review and included research based on clearly defined criteria. However, we only examined English-language publications. In addition, we included preprint articles that have not yet been peer-reviewed. The results of these studies may change in the future and there may be methodological biases.

Conclusion

This systematic review and meta-analyses found that more than half of women resumed sexual intercourse early after giving birth. This suggests that a significant number of women may be at higher risk of unwanted pregnancies, short birth intervals, postpartum sepsis, and other factors. Contraceptive use, parity, and history of serious genital injury were significantly associated with early resumption of sexual intercourse in postpartum women. Therefore, stakeholders should improve the integration of postpartum sex education into maternal health services, and obstetricians should focus on these criteria while educating prenatal women about resuming sexual intercourse after childbirth.

Supporting information

S1 Table. This is the PRISMA 2020 checklist.

(DOCX)

Click here for additional data file. (35.3KB, docx)
S2 Table. This quality assessment for the 21 included studies.

(DOCX)

Click here for additional data file. (21.5KB, docx)

Data Availability

All relevant data are within the paper and its supporting Information files.

Funding Statement

The authors received no specific funding for this work.

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Decision Letter 0

Antonio Simone Laganà

2 Jun 2023

PONE-D-23-11384Factors associated with early resumption of sexual intercourse among postpartum women: Systematic review and meta-analysisPLOS ONE

Dear Dr. Abebe,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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PLOS ONE

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www.ajol.info

https://www.nature.com/articles/s41598-020-74477-z

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Additional Editor Comments:

The topic of the manuscript is interesting. Nevertheless, the reviewers raised several concerns: considering this point, I invite authors to perform the required major revisions.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

Reviewer #3: Partly

Reviewer #4: No

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: No

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: No

Reviewer #4: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: No

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I read with great interest the Manuscript titled " Factors associated with early resumption of sexual intercourse among postpartum women: Systematic review and meta-analysis”, topic interesting enough to attract readers' attention.

Authors should clarify some point and improve the quality of manuscript citing relevant and novel key articles about the topic:

- I suggest a round of language revision, in order to correct few typos and improve readability.

- Authors should add further details to discuss the role of the perineum protection techniques during the management of the second phase of labour and the effect on the postpartum period (authors may refer to: PMID: 25909491; PMID: 24942141).

Because of these reasons, the article should be revised and completed. Tables and images are clear and interesting. Considering all these points, I think it could be of interest to the readers and, in my opinion, it deserves the priority to be published after minor revisions.

Reviewer #2: I suggest to add further details abot use and choice of contraception and to highlight the effect on different way of delivery (cesarean section vs vaginal delivery) on female post partum sexual functioning (author may refer to: PMID: 27318024, PMID: 24942141

Reviewer #3: Thank you for inviting me to review an interested topic of women’s health entitled “Factors associated with early resumption of sexual intercourse among postpartum women: Systematic review and meta-analysis”. The authors of this review tried to determine the global prevalence of early sexual resumption following birthing and estimate pooled effect size for common identified factors influencing it. Accordingly, I reviewed the manuscript and raised the following major concerns. Though there are many minor errors in the document that should be revised, I give emphasis and write here the major issues.

1. The authors didn’t provide justification or rationale why they conducted this review. Moreover, the objective of the study is not clearly stated as it was better to stated clear objective at the introduction part.

2. The inclusion and exclusion criteria are not clear. For instance, what the authors would like mean by “Studies were exclude (I read as included, but you better to change it) if they reported an observational study on the variables influencing the early resumption of sexual activity among postpartum women, described the techniques used to evaluate such activity,…..”. and “Studies were excluded if unrelated research works;…..”

3. The search strategy for each database with the number of articles identified should be provided as supplementary file.

4. What do you mean by ‘the search period was from February 15/2023 to February 29/2023”? It would be better to state here the last date of search that all databases were checked.

5. A total of 80,510 results identified as per the given searching term from the manuscript for PubMed: (((((("early resumption"[Text Word] OR "return"[Text Word]) AND "sexual intercourse"[Text Word]) OR "Coitus"[MeSH Terms]) AND ("Factor"[Text Word] OR "determinants"[Text Word])) OR "Risk factors"[MeSH Terms]) AND ("Postpartum"[Text Word] OR "post-delivery"[Text Word])) OR "Postpartum period"[MeSH Terms]. I checked it by considering the last date of search was February 28/2023 because February never be 29 (though your search period indicates up to February 29/2023). However, you stated that 7,228 records identified through PubMed database searching (Figure 1). How this much variation is there?

6. As per described in supplementary file 3, the quality all studies was assessed with similar components which is not acceptable because the JBI tool had different components for each study design. Also, what is the need of reporting supplementary file 2 and 3 which both are quality assessment results (supplementary file 2 sounds good than 3)

7. In Figure 1, the number of articles in each database and other additional sources should be recorded per each source. However, you didn’t to record the search terms used for and number of articles identified in each database. This reduces the trustworthiness of your searching strategy and number of articles identified.

8. The authors stated that “an extensive data search was performed on PubMed, Web of Science, Scopus, Google Scholar, Cochrane Library, and African Journals Online (AJOL) databases used to get the research articles”. However, where are the results of Web of Science and Cochrane Library? And how was Scopus, Web of Science and Cochrane Library? Furthermore, Scopus is a database that shouldn’t be included with other sources (Figure 1).

9. For study screening and selection process (Figure 1), you should use the ‘PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers and other sources’, which is available at: http://www.prisma-statement.org/PRISMAStatement/FlowDiagram.

10. All 79 articles which were excluded after the examination of their full text should be either cited in the manuscript or should be included as supplementary file with reason. The current systematic review and the PRISMA checklist that you have used strongly recommended it. In the PRISMA checklist that you have used, you stated that “not applicable”; why for? it is belied that you screened all the 79 articles and excluded with reason. In addition, The appropriate PRISMA checklist without no need of edition is available in both PDF and Word doc at: http://www.prisma-statement.org/PRISMAStatement/Checklist.aspx.

11. The other major issue I observed is pooled proportion and cases together for meta-analysis. How is possible to pooled cases in case control study with proportions of cohort and cross-sectional studies. Where did you get the proportion/prevalence for case control studies because cases are not proportion. This totally produces a misleading and unacceptable result.

12. The reported prevalence among studies ranged from 20.2 to 90.2 %, which is very wide variation, and which is difficult to pooled together. However, you did a meta-analysis using random effects model even without acknowledging it.

13. I strongly recommended you revising your literature searching and include the many studies which were missing to be included in your review; then execute the analysis. Besides, better to review the document again and again before submitting to the journal.

14. Extensive grammar errors are observed throughout the manuscript with many statements are difficult to understand. Thus, thoroughly rereading and rewriting or language consultation might be necessary.

15. Though the author stated that they used the reference manager endnote software, the reference lists don’t seem Endnote output. Better you check it.

16. The final critical issue is that the manuscript has very high (46%) textual similarity with existing studies. This ithenticate report couldn’t include references.

Reviewer #4: Review comments by Mohammed S. Obsa

Factors associated with early resumption of sexual intercourse among postpartum.

women: Systematic review and meta-analysis

Write a step-by-step response to these comments:

•

• The area of the study is very important; however, the manuscript needs major revision to be accepted for publications in the PLoS one.

• It is essential that a manuscript should undergo gross language editing before it is accepted for publication in PLoS one.

• Include the total sample size of this study in the abstract as well.

• Explain briefly why you used statistical methods in your abstracts for major findings.

• This conclusion does not seem to make sense, so it should be refined.

• Would you recommend resuming early sexual relations?

• The introduction should begin with a brief description of the study's background. The introduction in this case was not focused.

• In the introduction, the author should describe the magnitude of the problem and what factors affect it.

• This gap was not clearly identified by the author, and it would be helpful if they could specify where it lies?

• There should be a thorough mention of the key term used for the search. The manuscript presents search terms inconsistently.

• In both cases, you mention exclusion criteria, but they are contradictory. It is therefore necessary to revise it thoroughly. It is recommended that the exclusion criteria be the default inclusion criteria.

• The author should use a citation software programme like Endnote. It is evident from what is written in the characteristics of the included studies that poor citation styles have been applied.

• The order in which the results were presented was inappropriate. After exploring sources of heterogeneity, publication bias should be investigated.

· The author should check the assumptions for subgroup analysis before running the data.

· The discussion should be substantially revised. There is a lack of coherence and implications of the major findings in the paper.

• It is recommended that the order of discussion follow the order of importance of the variables.

• There should be a clear explanation of the strengths and limitations of this review.

**********

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If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #1: Yes: Ilaria Cuccu

Reviewer #2: No

Reviewer #3: Yes: Birye Dessalegn Mekonnen

Reviewer #4: Yes: Mohammed Suleiman Obsa

**********

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Attachment

Submitted filename: Review comments by Mohammed S.docx

Click here for additional data file. (14.5KB, docx)
PLoS One. 2024 Jan 17;19(1):e0288536. doi: 10.1371/journal.pone.0288536.r002

Author response to Decision Letter 0

15 Jun 2023

Reviewer 1

Reviewer #1: I read with great interest the Manuscript titled " Factors associated with early resumption of sexual intercourse among postpartum women: Systematic review and meta-analysis”, topic interesting enough to attract readers' attention.

Authors should clarify some point and improve the quality of manuscript citing relevant and novel key articles about the topic:

- I suggest a round of language revision, in order to correct few typos and improve readability.

- Authors should add further details to discuss the role of the perineum protection techniques during the management of the second phase of labour and the effect on the postpartum period (authors may refer to: PMID: 25909491; PMID: 24942141).

Author response: After giving birth, women who have trauma to the perineum may experience discomfort and other issues. First, second, third, and fourth degree tears are used to characterize the degree of injury, with first degree tears causing the least harm and fourth degree tears causing the most. The anal sphincter or mucosa is affected by third- and fourth-degree tears, which are the most problematic(49). Additionally, several perineal methods are employed to delay the head birth of the infant. Midwives and other delivery attendants frequently utilize massage, warm compresses, and various perineal management techniques. If these reduce trauma and discomfort for women, it is important to know. Even though episiotomy is one of the most frequently done procedures, there is an ongoing dispute in the professional literature about whether it has a preventive effect from third- and fourth-degree tears(50).

Because of these reasons, the article should be revised and completed. Tables and images are clear and interesting. Considering all these points, I think it could be of interest to the readers and, in my opinion, it deserves the priority to be published after minor revisions.

Author response: We accepted your comments and suggestions.

Reviewer 2

Reviewer #2: I suggest to add further details abot use and choice of contraception and to highlight the effect on different way of delivery (cesarean section vs vaginal delivery) on female post partum sexual functioning (author may refer to: PMID: 27318024, PMID: 24942141

Author response:we didn’t acces it.But we were discuss with other similar literature.

Reviewer 3

Reviewer #3: Thank you for inviting me to review an interested topic of women’s health entitled “Factors associated with early resumption of sexual intercourse among postpartum women: Systematic review and meta-analysis”. The authors of this review tried to determine the global prevalence of early sexual resumption following birthing and estimate pooled effect size for common identified factors influencing it. Accordingly, I reviewed the manuscript and raised the following major concerns. Though there are many minor errors in the document that should be revised, I give emphasis and write here the major issues.

1. The authors didn’t provide justification or rationale why they conducted this review. Moreover, the objective of the study is not clearly stated as it was better to stated clear objective at the introduction part.

Author response: we have corrected as follows

Hence, this study aimed to assess the prevalence and factors associated with early resuming postpartum sexual intercourse at the global level.

2. The inclusion and exclusion criteria are not clear. For instance, what the authors would like mean by “Studies were exclude (I read as included, but you better to change it) if they reported an observational study on the variables influencing the early resumption of sexual activity among postpartum women, described the techniques used to evaluate such activity,…..”. and “Studies were excluded if unrelated research works;…..”

Author response: we have corrected as follows

Only studies that had full-text articles, English language articles, published and unpublished articles, cross-sectional, case-control and cohort research were included in this study. However, duplicate sources, interventional studies, case reports, systematic reviews, qualitative articles, case series, conference abstracts, letters to editors, and any articles that were not fully accessible after at least two emails had been exchanged with the primary author were all excluded. The COCOPOP(Condition, Context, and Population) paradigm was utilized to determine the suitability of the included studies for this investigation. Postpartum women who had early resumption of sexual intercourse made up the study's population (POP), while the prevalence of early resumption of sexual intercourse served as the condition and global served as the setting.

3. The search strategy for each database with the number of articles identified should be provided as supplementary file.

Author response:accepted

4. What do you mean by ‘the search period was from February 15/2023 to February 29/2023”? It would be better to state here the last date of search that all databases were checked.

Author response: we have corrected as follows

The last date of search that all databases were checked from February 15/2023 to February 29/2023.

5. A total of 80,510 results identified as per the given searching term from the manuscript for PubMed: (((((("early resumption"[Text Word] OR "return"[Text Word]) AND "sexual intercourse"[Text Word]) OR "Coitus"[MeSH Terms]) AND ("Factor"[Text Word] OR "determinants"[Text Word])) OR "Risk factors"[MeSH Terms]) AND ("Postpartum"[Text Word] OR "post-delivery"[Text Word])) OR "Postpartum period"[MeSH Terms]. I checked it by considering the last date of search was February 28/2023 because February never be 29 (though your search period indicates up to February 29/2023). However, you stated that 7,228 records identified through PubMed database searching (Figure 1). How this much variation is there?

Author response:accepted and checked

6. As per described in supplementary file 3, the quality all studies was assessed with similar components which is not acceptable because the JBI tool had different components for each study design. Also, what is the need of reporting supplementary file 2 and 3 which both are quality assessment results (supplementary file 2 sounds good than 3)

Author response:accepted and changed

7. In Figure 1, the number of articles in each database and other additional sources should be recorded per each source. However, you didn’t to record the search terms used for and number of articles identified in each database. This reduces the trustworthiness of your searching strategy and number of articles identified.

Author response: We have mentioned in The PRISMA diagram

8. The authors stated that “an extensive data search was performed on PubMed, Web of Science, Scopus, Google Scholar, Cochrane Library, and African Journals Online (AJOL) databases used to get the research articles”. However, where are the results of Web of Science and Cochrane Library? And how was Scopus, Web of Science and Cochrane Library? Furthermore, Scopus is a database that shouldn’t be included with other sources (Figure 1).

Author response:We have mentioned in The PRISMA diagram

9. For study screening and selection process (Figure 1), you should use the ‘PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers and other sources’, which is available at: http://www.prisma-statement.org/PRISMAStatement/FlowDiagram.

Author response: corrected as follow

Fig 1: PRISMA flow chart displays studies used for Systematic Review and Meta-analysis of Prevalence and factors associated with early resumption of sexual intercourse among postpartum women

10. All 79 articles which were excluded after the examination of their full text should be either cited in the manuscript or should be included as supplementary file with reason. The current systematic review and the PRISMA checklist that you have used strongly recommended it. In the PRISMA checklist that you have used, you stated that “not applicable”; why for? it is belied that you screened all the 79 articles and excluded with reason. In addition, The appropriate PRISMA checklist without no need of edition is available in both PDF and Word doc at: http://www.prisma-statement.org/PRISMAStatement/Checklist.aspx.

Author response: We updated with current PRISMA checklist

11. The other major issue I observed is pooled proportion and cases together for meta-analysis. How is possible to pooled cases in case control study with proportions of cohort and cross-sectional studies. Where did you get the proportion/prevalence for case control studies because cases are not proportion. This totally produces a misleading and unacceptable result.

Author response: Accepted

12. The reported prevalence among studies ranged from 20.2 to 90.2 %, which is very wide variation, and which is difficult to pooled together. However, you did a meta-analysis using random effects model even without acknowledging it.

Author response: Accepted

13. I strongly recommended you revising your literature searching and include the many studies which were missing to be included in your review; then execute the analysis. Besides, better to review the document again and again before submitting to the journal.

Author response: we revised again the whole document

14. Extensive grammar errors are observed throughout the manuscript with many statements are difficult to understand. Thus, thoroughly rereading and rewriting or language consultation might be necessary.

Author response: we have revised and corrected any grammar errors, spelling, active/passive voice, and others. Additionally, we edited through Grammarly

15. Though the author stated that they used the reference manager endnote software, the reference lists don’t seem Endnote output. Better you check it.

Author response: admmited

16. The final critical issue is that the manuscript has very high (46%) textual similarity with existing studies. This ithenticate report couldn’t include references.

Author response: We have paraphrased it again.

Reviewer 4

Reviewer #4: Review comments by Mohammed S. Obsa

Factors associated with early resumption of sexual intercourse among postpartum.

women: Systematic review and meta-analysis

Write a step-by-step response to these comments:

• The area of the study is very important; however, the manuscript needs major revision to be accepted for publications in the PLoS one.

• It is essential that a manuscript should undergo gross language editing before it is accepted for publication in PLoS one.

1. Include the total sample size of this study in the abstract as well.

Author response: twenty-one studies with 4,482 postpartum women participants were included in the Systematic Review and Meta-analysis

2. Explain briefly why you used statistical methods in your abstracts for major findings.

Author response: We have revised as follows

Methods: Searches were conducted in PubMed, Web of Science, Science Direct, Google Scholar, African Journals Online, and the Cochrane Library. Data were extracted using Microsoft Excel, and STATA version 14 was used for analysis. Publication bias was checked by funnel plot, Egger, and Begg regression tests. A p-value of 0.05 was regarded to indicate potential publication bias. Using I2 statistics, the heterogeneity of the studies was evaluated. By country, a subgroup analysis was conducted. A sensitivity analysis was carried out to determine the effect of each study's findings on the overall estimate. The random effect model was used to assess the overall effect of the study, then measured by the prevalence rates and odds ratio with 95% CI. The result was presented in the form of text, tables, and figures.

3. This conclusion does not seem to make sense, so it should be refined.

Author response: We have corrected as follows

This study revealed that more than half of postpartum women had early resumption of sexual intercourse. This suggests that a significant number of women may be at higher risk for high rates of unwanted pregnancy, short birth interval, and postpartum sepsis. Thus, stakeholders should improve the integration of postpartum sexual education with maternal health services to reduce the resumption of postpartum sexual intercourse.

4. Would you recommend resuming early sexual relations?

Author response: No, Early resumption of sexual intercourse among postpartum women may cause maternal health problems: unfavorable birth outcomes, wound infection, painful intercourse, vaginal dryness, and inability to achieve orgasm (11). In addition, early resuming sexual intercourse without utilizing contraception after giving birth can lead to an unplanned pregnancy and short birth interval. Due to this, there may be a high risk of death for infants under the age of one year (12).

5. The introduction should begin with a brief description of the study's background. The introduction in this case was not focused.

Author response: We have revised as follows

Sexuality evolves throughout a person's life and is essential to being human (1). It is a key idea in human sexual health (2). It has at least three connected purposes: communication, pleasure, and reproduction. Pregnancy, birth, and postpartum are all critical times for sexual health (4). Women's bodies experience changes after giving birth that have an impact on both their health and other parts of their lives, including sexual activity, which is essential to human existence(5). Postpartum sexual health is indicated by resuming sexual activity as well as by arousal, desire, orgasm, and sexual satisfaction (6). World Health Organization (WHO) recognizes postpartum sexual health to be one of the most crucial issues that need to be addressed during the postpartum period(7).

The desire to engage in sexual activity declines during pregnancy but returns to normal, usually six weeks after delivery (8). Resuming postpartum sexual activity should be done at least six weeks after giving birth(9). However, the decision to resume sexual activity after delivery differs from woman to woman and is influenced by several factors such as the quantity of bleeding, mode of delivery, culture, maternal mental health, infant health, the relationship with one's partner, and the mother's general health (10).

Early resumption of sexual intercourse among postpartum women may cause maternal health problems: unfavorable birth outcomes, wound infection, painful intercourse, vaginal dryness, and inability to achieve orgasm (11). In addition, early resuming sexual intercourse without utilizing contraception after giving birth can lead to an unplanned pregnancy and short birth interval. Due to this, there may be a high risk of death for infants under the age of one year (12). Sociocultural norms and beliefs, education, the place of the birth, the mother's breastfeeding status, mode of delivery, low parity, using contraceptives, and residence are some of the factors that have been found as having an effect on the early resumption of sexual activity after delivery (13).

Even though the WHO advises that all women should be evaluated 2–6 weeks after childbirth, the problem of early resumption of sexual activity during postpartum has received little attention from researchers, policymakers, and healthcare providers (14). Previous studies reported that exclusively address the utilization of postpartum family planning in the early postpartum period rather than identifying the risk factors for an early resumption of sexual intercourse among post-partum women (15, 16). As a result, it's vital to study the various aspects of the early resumption of sexual relationships during the postpartum period to understand the direct and indirect effects of this problem and emphasize the significance of looking into these issues(17). Furthermore, the prevalence of early resumption of sexual intercourse is varying in the previous studies, with rates ranging from 20.2% in Ethiopia (39) to 90.2% in the USA (21). Given these variances, there is no general estimation of early resumption of sexual intercourse among postpartum women at the global level. The present study aimed to ascertain the overall prevalence of early resumption of sexual intercourse among most women in the world.

Prevalence and factors contributing to the early resumption of postpartum sexual intercourse at the global level also require further study. Additionally, there was no systematic review or meta-analysis conducted on the prevalence and contributing variables associated with early postpartum sexual resumption worldwide. Identifying factors that impact on early resumption of sexual activity to lessen or eliminate issues and considerably improve the well-being of postpartum women. Additionally, the results of this study might help in developing new approaches to postpartum sexuality education. Hence, this study aimed to assess the prevalence and factors associated with early resuming postpartum sexual intercourse at the global level.

6. In the introduction, the author should describe the magnitude of the problem and what factors affect it.

Author response: the prevalence of early resumption of sexual intercourse is varying in the previous studies, with rates ranging from 20.2% in Ethiopia (39) to 90.2% in the USA (21). Sociocultural norms and beliefs, education, the place of the birth, the mother's breastfeeding status, mode of delivery, low parity, using contraceptives, and residence are some of the factors that have been found as having an effect on the early resumption of sexual activity after delivery (13).

7. This gap was not clearly identified by the author, and it would be helpful if they could specify where it lies?

Author response: Previous studies reported that exclusively address the utilization of postpartum family planning in the early postpartum period rather than identifying the risk factors for an early resumption of sexual intercourse among post-partum women (15, 16). As a result, it's vital to study the various aspects of the early resumption of sexual relationships during the postpartum period to understand the direct and indirect effects of this problem and emphasize the significance of looking into these issues(17). Furthermore, the prevalence of early resumption of sexual intercourse is varying in the previous studies, with rates ranging from 20.2% in Ethiopia (39) to 90.2% in the USA (21). Given these variances, there is no general estimation of early resumption of sexual intercourse among postpartum women at the global level. The present study aimed to ascertain the overall prevalence of early resumption of sexual intercourse among most women in the world.

Prevalence and factors contributing to the early resumption of postpartum sexual intercourse at the global level also require further study. Additionally, there was no systematic review or meta-analysis conducted on the prevalence and contributing variables associated with early postpartum sexual resumption worldwide. Identifying factors that impact on early resumption of sexual activity to lessen or eliminate issues and considerably improve the well-being of postpartum women. Additionally, the results of this study might help in developing new approaches to postpartum sexuality education. Hence, this study aimed to assess the prevalence and factors associated with early resuming postpartum sexual intercourse at the global level.

• There should be a thorough mention of the key term used for the search. The manuscript presents search terms inconsistently.

8. In both cases, you mention exclusion criteria, but they are contradictory. It is therefore necessary to revise it thoroughly. It is recommended that the exclusion criteria be the default inclusion criteria.

Author response: we have corrected as follows

Eligibility criteria

Studies that had full-text articles, English language articles, both published and unpublished articles, cross-sectional studies, case-control studies, and cohort studies were included in this study. Duplicate sources, interventional studies, case reports, systematic reviews, qualitative articles, case series, conference abstracts, letters to editors, and any articles that were not fully accessible after at least two emails had been exchanged with the primary author were all excluded. A COCOPOP(Condition, Context, and Population) paradigm was utilized to determine the suitability of the included studies for this investigation. Postpartum women who had early resumption of sexual intercourse made up the study's population (POP), while the prevalence of early resumption of sexual intercourse served as the condition and global served as the setting.

9.The author should use a citation software programme like Endnote. It is evident from what is written in the characteristics of the included studies that poor citation styles have been applied.

Author response: accepted.

10. The order in which the results were presented was inappropriate. After exploring sources of heterogeneity, publication bias should be investigated.

Author response: accepted.

• The author should check the assumptions for subgroup analysis before running the data.

• The discussion should be substantially revised. There is a lack of coherence and implications of the major findings in the paper.

11. Author response: We have revised as follows

Discussion

The World Health Organization has advised that research be done on sexual health because of its significance, separate from reproductive health, and because lack of knowledge about sexual health is the root cause of many dysfunctions and diseases throughout the world(41). The compressive research findings must be included by healthcare professionals to implement evidence-based practice. Addressing the early resumption of postpartum intercourse and its factors is essential when focusing on postpartum issues of maternal health outcomes (42).

According to a database search, no Systematic Review has been conducted on the prevalence and factors associated with early resumption of sexual intercourse among postpartum women at a global level. Systematic reviews and meta-analyses have the best evidence for clinical judgment than individual studies. In this systematic review and meta-analysis, the overall resumption of early sexual intercourse among post-partum was 57.26% (95% CI 50.14, 64.39). The current study is lower than the one conducted in Sub-Saharan Africa(43). These discrepancies may be explained by changes in sociocultural, social beliefs and norms, religious conduct, and the sexual attitudes of women in various geographic locations. Subjective norms, societal values, and ideas regarding postpartum sexual abstinence all have an impact on early sexual resumption(44).

For women from various cultural backgrounds, the postpartum period is known as a vulnerable and stressful time. During this time, women experience enormous social and personal changes in addition to several new concerns and problems(45). Given the significance of the first sexual encounter in establishing a committed relationship, postpartum sexual function is a significant concern for couples. Several factors, including less parity, breastfeeding, cesarean section, severe genital injury, alive child, maternal and paternal educational status, occupation, and current uses of contraceptives might affect the early resumption of sexual intercourse during the postpartum period(46).

We found that the use of contraceptives; having less parity and having severe genital tears on the last delivery were statically associated with early resumption of sexual intercourse during the post-partum period. According to a previous study, one of the factors linked to the early postpartum resumption of sexual activity is the use of contraceptives during the postpartum period(47). Women who used contraceptives were 1.48 times more likely to have an early resumption of sexual intercourse during the postpartum period than those who didn't use (AOR = 1.48, 95%CI = 1.03, 6.2.12). This may be the result of the fact that women who use contraceptives believe that they are not a risk for pregnancy, which encourages them to resume sexual activity six weeks after giving birth. However, early resumption of sexual activity may increase the risk of postpartum sexual dysfunction and unintended pregnancy (48).

Similarly, parity has affected how women's early resumption of sexual intercourse; primiparous women are more likely to have an early resumption of sexual intercourse among postpartum women than multiparous women(49). We found that women with primipara were 2.88 times more likely to engage in early sexual intercourse during the postpartum period than those multipara women (AOR = 2.88, 95%CI = 1.41, 5.89). This may be explained by their lack of experience, primiparae typically feel less confident in their postpartum sexual intercourse.

Even though episiotomy is one of the most frequently done procedures, there is an ongoing dispute in the professional literature about whether it has a preventive effect from third- and fourth-degree tears(50). According to this review, no history of severe genital injury(severe perineal injury) on the last delivery had effects on the early resumption of sexual intercourse. Women who had no history of severe genital injury on the last delivery were 2.27 times more likely to have an early resumption of sexual intercourse than women who had a history of severe genital injury on the last delivery(AOR = 2.27, 95%CI = 1.05, 4.93). This might be the result of women who haven't experienced postpartum dyspareunia (painful sexual intercourse).

12. It is recommended that the order of discussion follow the order of importance of the variables.

Author response: admitted

13. There should be a clear explanation of the strengths and limitations of this review.

Author response: accepted and changed

Attachment

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Decision Letter 1

Frank T Spradley

15 Sep 2023

PONE-D-23-11384R1Prevalence and factors associated with early resumption of sexual intercourse among postpartum women: Systematic Review and Meta-AnalysisPLOS ONE

Dear Dr. Abebe,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Oct 30 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Thank you for the resubmission of your study, which the reviewers still read with great interest. We thank the reviewers for their time and contributions to strengthen this body of work. Indeed, there is 1 issue that must be addressed pertaining to the current references cited. Please include updates references that better highlight the gap in knowledge that necessitated conducting this study and the importance of perineum protection techniques during the timing of management during labor.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

********** 

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Reviewer #1: Yes

Reviewer #2: Yes

********** 

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Reviewer #2: I Don't Know

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Reviewer #1: 

I think that Authors should clarify some points and improve the quality of manuscript citing relevant and novel key articles about the topic:

-the role of the perineum protection techniques during the management of the second phase of labour and the effect on the postpartum period (authors may refer to: PMID: 25909491; PMID: 24942141).

I think that this modification make the work more complete. . Considered all these points, I think it could be of interest for the readers and, in my opinion, it deserves the priority to be published after minor revisions.

Reviewer #2: I carefully evaluated the revised version of this manuscript.

Authors have performed the required changes, improving significantly the quality of the paper.

********** 

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Reviewer #1: No

Reviewer #2: Yes: Ornella Sgro

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PLoS One. 2024 Jan 17;19(1):e0288536. doi: 10.1371/journal.pone.0288536.r004

Author response to Decision Letter 1

17 Sep 2023

Point by point response for reviewer and edittor

Reviewer #1:

I think that Authors should clarify some points and improve the quality of manuscript citing relevant and novel key articles about the topic:

-the role of the perineum protection techniques during the management of the second phase of labour and the effect on the postpartum period (authors may refer to: PMID: 25909491; PMID: 24942141).

I think that this modification make the work more complete. . Considered all these points, I think it could be of interest to the readers and, in my opinion, it deserves the priority to be published after minor revisions.

Author response: we have updated as following

The previous study has provided evidence that the use of hands-free perineal control techniques during the second stage of labor may represent a promising delivery approach to maintain perineal integrity. In addition, these techniques can have a positive effect on the resumption of sexual activity in the postpartum period, as they include several factors that can facilitate this process [14]. Numerous cohort studies have shown that women who undergo spontaneous vaginal delivery with intact perineum have a higher likelihood of having vaginal intercourse again within six to eight weeks after birth compared to women who undergo an episiotomy assisted vaginal birth etc. undergo a Cesarean Section[15,16,17].

References

14.Laganà AS, Burgio MA, Retto G, Pizzo A, Granese R, Sturlese E, Ciancimino L, Chiofalo B, Retto A, Triolo O. Management of the second phase of labour: perineum protection techniques. Minerva Ginecol. 2015 Jun 1;67(3):289-96.

15. Laganà AS, Burgio MA, Ciancimino L, Sicilia A, Pizzo A, Magno C, Butticè S, Triolo O. Evaluation of recovery and quality of sexual activity in women during postpartum in relation to the different mode of delivery: a retrospective analysis. Minerva Ginecol. 2015 Aug 1;67(4):315-20.

16. McDonald, E.; Brown, S. Does the method of birth make a difference to when women resume sex after childbirth? BJOG Int. J. Obstet. Gynaecol. 2013, 120, 823–830. [Google Scholar] [CrossRef]

Additional Editor Comments:

Thank you for the resubmission of your study, which the reviewers still read with great interest. We thank the reviewers for their time and contributions to strengthen this body of work. Indeed, there is 1 issue that must be addressed pertaining to the current references cited. Please include updates references that better highlight the gap in knowledge that necessitated conducting this study and the importance of perineum protection techniques during the timing of management during labor.

Author response: We have updated

The previous study has provided evidence that the use of hands-free perineal control techniques during the second stage of labor may represent a promising delivery approach to maintain perineal integrity. In addition, these techniques can have a positive effect on the resumption of sexual activity in the postpartum period, as they include several factors that can facilitate this process [14]. Numerous cohort studies have shown that women who undergo spontaneous vaginal delivery with intact perineum have a higher likelihood of having vaginal intercourse again within six to eight weeks after birth compared to women who undergo an episiotomy assisted vaginal birth etc. undergo a Cesarean Section[15,16,17].

Therefore, it is important to examine the various aspects of the early resumption of sexual relationships in the postpartum period to understand the direct and indirect effects of this problem and highlight the importance of studying these issues at a global level [19].

Attachment

Submitted filename: Response for reviewer.docx

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Decision Letter 2

Frank T Spradley

25 Oct 2023

Prevalence and factors associated with early resumption of sexual intercourse among postpartum women: Systematic Review and Meta-Analysis

PONE-D-23-11384R2

Dear Dr. Abebe,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Frank T. Spradley

Academic Editor

PLOS ONE

Acceptance letter

Frank T Spradley

8 Nov 2023

PONE-D-23-11384R2

Prevalence and factors associated with early resumption of sexual intercourse among postpartum women: Systematic Review and Meta-Analysis

Dear Dr. Abebe Gelaw:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Frank T. Spradley

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Table. This is the PRISMA 2020 checklist.

    (DOCX)

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    S2 Table. This quality assessment for the 21 included studies.

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