The final inclusion and exclusion criteria yielded 46 articles (Tables 1, 2, 3). Of these 46 articles, five studies focused on positive sexual health, 13 studies on negative sexual health, and the remaining 28 on both positive and negative sexual health or without specified directionality. The most common outcome examined was resumption of sex after childbirth. The majority of studies occurred within sub-Saharan Africa (n = 27), with additional geographic spread throughout the Middle East (n = 10), Asia (n = 5), and North Africa (n = 3); one study analyzed data from 17 Demographic and Health Surveys (DHS) . Most studies were quantitative, including prospective cohort, cross-sectional, and clinical trial designs; however, eight studies solely or supplementally collected qualitative data.
Positive sexual health
Five studies examined positive sexual health during the postpartum period with outcomes including libido, satisfaction, stimulation, orgasm, pelvic floor muscle strength, sexual self-efficacy, female sexual function (measured via the Female Sexual Function Index (FSFI)), and intimacy [25,26,27,28,29] (Table 1). Notably, all five studies were conducted within the Islamic Republic of Iran and largely within the context of interventions or utilizing comparison groups. Specifically, Golmakani et al. examined the impact of a pelvic floor muscle exercise program on pelvic floor strength and sexual self-efficacy and found significant increases in both outcomes within the intervention compared to the control group . Zamani et al. examined the effectiveness of sexual health counseling and found increased sexual satisfaction among intervention participants . Two additional studies examined sexual function in relation to infant feeding practices, with mixed results [25, 27]. Additionally, Nezhad and Goodarzi examined intimacy and sexuality within the context of partnerships and found that having a high level of intimacy could potentially buffer against negative effects of low sexual satisfaction on overall marital satisfaction .
Negative sexual health
Thirteen studies explored negative sexual health outcomes, including vaginismus, dyspareunia, episiotomy, perineal tears, prolapse, infection, obstetric fistula, female genital cutting, postnatal pain, uterine prolapse, coercion to resume sex, sexual violence, and loss of sexual desire/arousal [30,31,32,33,34,35,36,37,38,39,40,41,42] (Table 2).
Dyspareunia, or painful intercourse, was one of the most examined negative sexual health outcomes for postpartum women. In Nigeria, Adanikin found that over one in three women reported dyspareunia within six months after delivery . Similarly, in Ethiopia, approximately one in five women reported sexual morbidities upon resuming intercourse in the postpartum period, and dyspareunia was the most common morbidity reported . In Pakistan, dyspareunia was examined in relation to episiotomy, where dyspareunia was more prevalent among episiotomy patients than those without (69% vs. 12%) . Further, in Nigeria, Oboro and Tabowei found that painful intercourse decreased throughout the postpartum period, with approximately 55% of women reporting painful intercourse at 6-weeks postpartum and dropping to less than 20% at 6-months postpartum; dyspareunia at 3-months postpartum was significantly more likely among women who had perineal trauma or reported pre-pregnancy dyspareunia .
Resumption of sex, if explored in relation to coercive or forced sex, was also included within negative sexual health outcomes. Postpartum sexual abstinence was largely practiced across settings (though length of time depended on cultural factors); however, not all women who resumed sex did so on their own accord. Specifically, in Ethiopia, among the 20% of women who had resumed sex within 6-weeks postpartum (and prior to the end of the 40 day sexual abstinence period largely observed within Ethiopia), half reported being pressured by their husband to resume intercourse .
While our search only uncovered three qualitative studies specific to negative sexual health, these studies were helpful for elucidating cultural beliefs and concerns surrounding sexual health in the postpartum period. In Cambodia, White explored Khmer women’s beliefs surrounding sex, specifically that resuming sex too soon after delivery, either by choice or by force, could cause physical health symptoms . In Mozambique, women with fistula reported no sexual activity since onset, with one woman reporting that her husband had used her “handicap” to justify taking an additional wife .
Across studies/settings, many women reported sexual health morbidities following pregnancy and childbirth, however, help-seeking or participation within interventions was minimal. In Tunisia, Achour et al. reported that while women experienced vaginismus symptoms following delivery, 60% did not feel that sex was important compared to motherhood, and no women completed the pelvic floor training program nor sought counseling from the sexologist . Moreover, some studies reported that women did not feel comfortable discussing sexual health issues or felt providers were poorly equipped to handle matters surrounding sexual health. In Nigeria, while 98% of women in the study reported receiving counseling on contraception, only 29% reported discussions surrounding sexual health . Similarly, in Iran, women felt their sexual health needs during the postpartum period were often neglected by healthcare providers .
Additional findings included associations between RTIs and uterine prolapse and postpartum depression , a cross-sectional examination of abnormal vaginal discharges in Zambian women , perineal tearing and postpartum complications related to FGC in Ethiopia , and perineal tearing and genital prolapse in Bangladesh .
Positive and negative (or neutral) sexual health
Studies that examined both positive and negative sexual health outcomes or examined women’s health within the postpartum period from a neutral perspective are outlined within Table 3 [24, 43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68] (n = 28). Of note, the majority of studies within this group explore prevalence or corelates of resumption of sex, with little discussion of the positive or negative impact of the timing of sexual activity within the postpartum period [24, 43, 46, 48,49,50, 53, 54, 58, 61, 66, 67]. In a multi-country DHS study, resumption of sex was related to the return of a woman’s menses , and this practice was corroborated via qualitative data from Cote d’Ivoire  and Malawi . In Cote d’Ivoire, Tanzania, Eswatini, and Malawi, postpartum sexual abstinence was further described in relation to breastfeeding or child developmental benchmarks, specifically the child being of age to walk [47, 56, 63, 68].
Multiple studies linked resumption of sexual activity to their husband’s sexual needs or demands [44, 52, 55, 57, 63]. A qualitative study in Cote d’Ivoire depicted this pressure on women to resume sex—while some women felt that polygynous marriages were useful in allowing for long abstinence periods, others expressed fear of infidelity and related STI risks . In one study from Kenya, increased odds of resumption of sex was associated with past-month forced sex .
Few studies explored specific cultural practices, withstanding timing of resumption of sex, in relation to women’s sexual health. In northern Nigeria, women reported a number of postpartum practices, including postpartum abstinence periods inclusive of confinement for 40 days after birth or longer, hot ritual baths, nursing in heated rooms, laying on heated beds, and consuming specific foods . In Malawi, substantial regional variation persisted in cultural practices, however, need for postpartum abstinence was described in relation to healing the mother, partner, and child, with early resumption linked to numerous health complications .
Notably, within qualitative data, women described feeling less sexually attractive during the postpartum period and felt that decreased self-confidence impacted their sexual health and desire; however, they also indicated that partner acceptance of their body changes helped improve their anxiety surrounding sex . Some women simply stated that they were too tired to engage in sex .
Within the studies on both negative and positive sexual health, women similarly reported difficulty seeking help or discussing sex with healthcare providers . In one Nigerian study, fewer than two thirds of postpartum women sought help for the sexual morbidities they were experiencing, and prominent reasons for not seeking health included feeling shy, the problem resolving on its own, cultural or religious factors, and not having a female doctor to ask . In Tanzania, women described that too much health education was provided at once during antenatal care, and felt that some of this information should be spread throughout postpartum care visits . In Uganda, women noted that the advice provided by health workers at discharge was inconsistent, leaving them unsure of when to resume sexual activity and how to navigate associated health and safety risks .
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.