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\begin{document}

\title{Predictors for sexual dysfunction in the first year postpartum: a
systematic review and meta-analysis}



\author[1]{Laura Cattani}%
\author[2]{Liza De Maeyer}%
\author[1]{Jan Verbakel}%
\author[1]{Jan Bosteels}%
\author[3]{Jan Deprest}%
\affil[1]{Katholieke Universiteit Leuven UZ Leuven}%
\affil[2]{KU Leuven Biomedical Sciences Group}%
\affil[3]{Universitaire Ziekenhuizen Leuven}%


\vspace{-1em}



  
  \date{June 17, 2024}


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\selectlanguage{english}
\begin{abstract}
Background Pregnancy and childbirth increase the risk for pelvic floor
dysfunction, including sexual dysfunction. So far, the mechanisms and
the extent to which certain risk factors play a role, remain unclear.
Objectives In this systematic review of literature, we aimed to
determine the risk factors for sexual dysfunction in the first year
after delivery. Search Strategy We searched MEDLINE, Embase and CENTRAL
using the search strategy: Sexual dysfunction AND Obstetric events.
Selection Criteria We included original English, comparative studies
that used validated questionnaires and the ICS/IUGA terminology for
sexual dysfunction, dyspareunia and vaginal dryness. Data Collection and
Analysis We assessed the quality and the risk of bias of the included
studies with the Newcastle Ottawa Scale. We extracted the reported data
and we performed random-effects meta-analysis to obtain the summary Odds
Ratios (OR) with 95\% Confidence Intervals. Heterogeneity across studies
was assessed using the I2 statistic. Main Results We found no
significant difference in the odds for both sexual dysfunction and
dyspareunia between cesarean section and spontaneous delivery
(OR:1.17{[}0.88-1.57{]} and OR:0.75{[}0.53-1.07{]}) and between
operative delivery and spontaneous delivery (OR:1.56{[}0.87-2.79{]} and
OR:1.35{[}0.75-2.42{]}). Anal sphincter injury was associated with
increased odds for both sexual dysfunction (OR:3.00{[}1.28-7.03{]}) and
dyspareunia (OR:1.71{[}1.09-2.67{]}). Episiotomy was associated with
dyspareunia (OR:1.65{[}1.20-2.29{]}) but not with sexual dysfunction
(OR:1.90{[}0.94-3.84{]}). We retrieved one study of low quality which
reported on vaginal dryness and found no significant association with
obstetric events.%
\end{abstract}%



\sloppy


TITLE PAGE

\textbf{Title: Predictors for sexual dysfunction in the first year
postpartum: a systematic review and meta-analysis}

\textbf{Authors:}

\textbf{Laura Cattani*}

\textsuperscript{1} Department Development and Regeneration, Cluster
Urogenital Surgery, Biomedical Sciences, KU Leuven, Leuven, Belgium

\textbf{Liza De Maeyer*}

\textsuperscript{1} Department Development and Regeneration, Cluster
Urogenital Surgery, Biomedical Sciences, KU Leuven, Leuven, Belgium

\textbf{Jan Y~Verbakel}

\textsuperscript{3~}Department of Public Health and Primary Care, KU
Leuven, Leuven, Belgium

\textsuperscript{4~}Nuffield Department of Primary Care Health Sciences,
University of Oxford, Oxford, United Kingdom

\textbf{Jan Bosteels}

\textsuperscript{1} Department Development and Regeneration, Cluster
Urogenital Surgery, Biomedical Sciences, KU Leuven, Leuven, Belgium

\textsuperscript{5}~Department Obstetrics and Gynaecology, Imelda
Hospital, Bonheiden, Belgium

\textbf{Jan Deprest}

\textsuperscript{1} Department Development and Regeneration, Cluster
Urogenital Surgery, Biomedical Sciences, KU Leuven, Leuven, Belgium

\textsuperscript{6} Research Department of Maternal Fetal Medicine,
Institute for Women's Health, University College London, London, UK

\textbf{Corresponding Author}

Jan Deprest, MD, PhD, FRCOG

Herestraat 49, B-3000 Leuven

tel. +32 16 34 51 23

fax +32 16 34 42 05

jan.deprest@uzleuven.be

\textbf{Short running title} : Postpartum sexual dysfunction: systematic
review

Authors' contribution to the Manuscript:

L Cattani: protocol development and registration, data collection, data
analysis, manuscript writing, other (quality/risk of bias assessment)

L De Maeyer: data collection, data analysis, manuscript writing, other
(quality/risk of bias assessment)

J Y Verbakel: manuscript editing, other (supervision of data analysis)

J Bosteels: protocol development, manuscript editing

J Deprest: protocol development, manuscript writing

*LC and LDM contributed equally to this review

FINANCIAL DISCLAIMER/CONFLICT OF INTEREST: J Deprest has received
educational grants from GE Medical, which were handled by the KU Leuven
Transfer office, which were not for conducting this review. The other
authors have no conflicts of interest associated with this publication
and there has been no financial support for this work.

This work has been presented on 12\textsuperscript{th} November 2020 as
`podium presentation' at the online EUGA meeting 2020.

TOT.WORDS: 2556

ABSTRACT

\textbf{Background} Pregnancy and childbirth increase the risk for
pelvic floor dysfunction, including sexual dysfunction. So far, the
mechanisms and the extent to which certain risk factors play a role,
remain unclear.

\textbf{Objectives} In this systematic review of literature, we aimed to
determine the risk factors for sexual dysfunction in the first year
after delivery.

\textbf{Search Strategy} We searched MEDLINE, Embase and CENTRAL using
the search strategy: Sexual dysfunction AND Obstetric events.

\textbf{Selection Criteria} We included original English, comparative
studies that used validated questionnaires and the ICS/IUGA terminology
for sexual dysfunction, dyspareunia and vaginal dryness.

\textbf{Data Collection and Analysis} We assessed the quality and the
risk of bias of the included studies with the Newcastle Ottawa Scale. We
extracted the reported data and we performed random-effects
meta-analysis to obtain the summary Odds Ratios (OR) with 95\%
Confidence Intervals. Heterogeneity across studies was assessed using
the I\textsuperscript{2} statistic.

\textbf{Main Results} We found no significant difference in the odds for
both sexual dysfunction and dyspareunia between cesarean section and
spontaneous delivery (OR:1.17{[}0.88-1.57{]} and OR:0.75{[}0.53-1.07{]})
and between operative delivery and spontaneous delivery
(OR:1.56{[}0.87-2.79{]} and OR:1.35{[}0.75-2.42{]}). Anal sphincter
injury was associated with increased odds for both sexual dysfunction
(OR:3.00{[}1.28-7.03{]}) and dyspareunia (OR:1.71{[}1.09-2.67{]}).
Episiotomy was associated with dyspareunia (OR:1.65{[}1.20-2.29{]}) but
not with sexual dysfunction (OR:1.90{[}0.94-3.84{]}). We retrieved one
study of low quality which reported on vaginal dryness and found no
significant association with obstetric events.

\textbf{Conclusions:} Perineal trauma, rather than the mode of delivery,
increases the odds for sexual dysfunction in the first year after
delivery.

\textbf{Keywords:} sexual dysfunction, dyspareunia, childbirth,
delivery, postpartum

\textbf{Tweetable abstract:} Perineal trauma, rather than mode of
delivery, correlates with sexual dysfunction postpartum \#dyspareunia
\#OASI \#episiotomy

MAIN TEXT

\textbf{Introduction}

Sexual dysfunction is a broad term encompassing several symptoms which
have been defined by the International Uro-Gynecology Association (IUGA)
and the International Continence Society (ICS)(1). Some sexual symptoms
are specific to pelvic floor dysfunction, such as dyspareunia and
vaginal dryness(1). Pregnancy and childbirth are likely to lead to
pelvic floor dysfunction, including sexual dysfunction(2). Previous
studies showed that sexual dysfunction was common in the first year
postpartum(3, 4). The reported prevalence of sexual dysfunction after
childbirth reaches 83\% at three months after delivery and it declines
to 64\% at six months(5). Sexual dysfunction also has a negative impact
on the quality of life (5-7). Defining the possible risk factors can
contribute to counsel and prepare women during the antenatal period on
the possibility of sexual dysfunction after childbirth and also,
theoretically its prevention. The relationship between obstetric events
and sexual function after delivery has been well investigated, and
operative delivery, perineal laceration and episiotomy are considered to
negatively affect sexual function (8-11). Sexual function is thought to
be related to a women's self-perceived body image, which may change
around the time of delivery (12). However, the relationship between
sexual function and self-perceived body image in the postpartum period
has been poorly investigated.

Herein we aim to address which obstetric events are risk factors
for\emph{sexual dysfunction, dyspareunia and vaginal dryness} in women
up to one year after delivery and what is their effect estimate. In
addition, we attempt to answer whether there is a relationship between
sexual dysfunction after delivery and \emph{body image dissatisfaction}
.

\textbf{Materials and methods}

\emph{Protocol and registration}

The study was conducted in line with the PRISMA guidelines for
systematic reviews(13). Its protocol was prospectively registered on
PROSPERO (CRD42020135555).

\emph{Search strategy and selection of studies}

We searched MEDLINE, Embase and CENTRAL from inception until 2019. We
used a search strategy that combined MeSH terms for MEDLINE/Emtree terms
for Embase and free text words. The search strings are available in
Appendix S1. We used EndNote web to eliminate duplicates. Two authors
(LC and LDM) independently assessed eligibility by screening study
records by titles and abstracts, and the full-text manuscripts for final
inclusion using Rayyan (Qatar Computing Research Institute, Doha,
Qatar). In case of discrepancy, conflicts were resolved by discussion,
and if not possible by arbitration with one of two senior authors (JB,
JDP). In case of overlapping study populations, the largest and most
complete dataset was included.

\emph{Eligibility criteria}

We included all randomized clinical trials, controlled clinical trials,
cohort, cross-sectional and case-control studies, comparing potential
obstetric risk factors for developing sexual dysfunction up to one year
after delivery. Duplicate records, reviews, case reports, incomplete
reports, book chapters, conference abstracts, letters to the editor and
comments were excluded. We used language restrictions due to the lack of
resources for translation(14); only studies written in English were
retrieved in the full text format. The PICO format was used to identify
studies and data to be extracted(15).

PATIENT/POPULATION: All childbearing women without age and ethnicity
restrictions.

INTERVENTION/EXPOSURE: Childbirth irrespective of the mode of delivery

COMPARATOR(S)/CONTROL(S) were the following categories:

\begin{itemize}
\tightlist
\item
  Delivery mode, either cesarean section, vacuum extraction, forceps
  extraction, instrumental delivery (if the previous is unknown), fundal
  pressure versus spontaneous vaginal delivery
\item
  Obstetric anal sphincter injury (III-IV grade) versus no tear or minor
  vaginal tear (I-II grade)(9)
\item
  Episiotomy: mediolateral or median versus no episiotomy
\item
  Maternal age at first delivery, as a continuous variable or
  categorized as either [?]35 or \textless{}35 years(16)
\item
  Maternal BMI, categorized as either [?]30
  kg/m\textsuperscript{2}(obesity) or \textless{}30
  kg/m\textsuperscript{2}(17)
\item
  Pre-pregnancy dyspareunia present vs. not present
\item
  Primiparous vs. multiparous
\item
  Breastfeeding vs. no breastfeeding
\item
  Contraception use vs. no contraception use
\item
  Prolonged second stage of labour, including the definition used(18)
\end{itemize}

OUTCOMES: Primary outcomes were \emph{sexual dysfunction}
and\emph{dyspareunia} consistent with the ICS/IUGA Terminology(1) and
assessed with validated and standardized tools. Secondary outcomes
were\emph{vaginal dryness(1)} and \emph{body image
dissatisfaction(19-21)} . When Female Sexual Function Index (FSFI)
scores were available, the total score was retrieved or calculated by
addition of the separate subscores. An FSFI total score of [?]26.55 was
used as a cut off for differentiating women with and without sexual
dysfunction(22).

\emph{Data collection}

LC and LDM extracted Odds Ratios (ORs) with 95\% Confidence Intervals
(CIs) and other usable data using a data extraction sheet on Excel,
Microsoft Office 365 (Redmond, WA, USA). If other usable data were
reported (e.g. count data), they were converted to ORs. When more than
one study reported data from the same cohort, we used the most complete
results. We extracted missing data from less complete results where
suitable.

\emph{Quality assessment of studies}

The quality of the studies was assessed with the Newcastle Ottawa scale
(University of Ottawa, Ottawa, Ontario, Canada) using the appropriate
forms for cohort studies (prospective/retrospective), cross-sectional
and case-control studies (23). For ranking the adequacy of follow-up, we
awarded one star to studies with the follow-up rate [?]70\% or description
of those lost suggesting no difference from those followed. We
considered high-quality studies those ones with a total score [?]7 stars
since standardized criteria for conversion have not been universally
established(24, 25).

\textbf{Strategy for data synthesis}

We reported data using count data and ORs with 95\% Confidence
Intervals. We tested for statistical heterogeneity using the
I\textsuperscript{2} test. We only pooled studies that were sufficiently
comparable in terms of study design, setting, population, intervention
and comparator. The summary statistic was reported as a pooled OR with
95\% confidence intervals (CIs) for sexual dysfunctions. We used the
random-effects model and inverse variance method for meta-analysis. We
performed a subgroup analysis for each outcome: \emph{sexual
dysfunction, dyspareunia, vaginal dryness} and \emph{body image
dissatisfaction} .

\textbf{Funding}

We received no funding to conduct this review.

\textbf{Patient and public involvement}

No patients or public were involved to conduct this systematic review.



\textbf{Results}

\emph{Literature search and study characteristics}

The electronic search resulted in 8,546 articles of which 3,031 in
MEDLINE, 2,029 in Embase and 3,086 in the Cochrane Library. We removed
3,620 duplicates, leaving 4,926 articles to be screened by title and
abstract. 4,803 studies were excluded for the reasons displayed in
Figure 1. This left 123 articles that were eligible for full-text
analysis. During that process, another 82 articles were excluded for the
reasons displayed in the supplement (table S1). As a result, there were
41 studies of which 25 had data that were not compatible with our
methodology for quantitative analysis (Supplement, table S2). Most of
these studies were comparing mean scores, making it impossible to
extract or extrapolate ORs and quantitatively synthesize the findings.
These studies were used at a later stage during the qualitative
interpretation. Quantitative synthesis was therefore made, based on the
remaining 16 articles (Supplement, table S3).

\emph{Risk of bias-assessment}

Among the eligible studies, 7 (44\%) were of high quality. Most studies
were at low risk for selection bias (12/16, 75\%) and all studies
controlled for at least one confounding factor (maternal age, body mass
index (BMI) and parity). Given we only considered studies using
validated questionnaires for patient self-reporting, by definition we
scored all studies at risk of bias for the assessment of outcome. Nine
of the included studies for quantitative synthesis (9/16, 56\%) were at
high risk of bias for outcome/exposure domain, though. Details on
quality assessment and risk of bias for individual studies are displayed
in Appendix 2B.

\emph{Summary of results}

\begin{enumerate}
\tightlist
\item
  \textbf{Cesarean section versus vaginal delivery}We found no
  significant difference in terms of sexual dysfunction
  (OR:1.17{[}0.88-1.57{]}) or dyspareunia following cesarean section
  (OR:0.79{[}0.58-1.07{]}) or vaginal delivery (Figure 2).
\item
  \textbf{Operative delivery versus spontaneous vaginal delivery}Not all
  studies discriminated between the type of operative delivery.
  Therefore, only results for the occurrence of sexual dysfunction are
  given (OR:1.56{[}0.87-2.79{]}). As for dyspareunia, a break down for
  type of delivery was possible, but again there was no significant
  difference for any specific type of assisted delivery (Figure 3).
\item
  \textbf{Perineal trauma}The occurrence of anal sphincter injury was
  associated with increased odds for both sexual dysfunction
  (OR:3.00{[}1.28-7.03{]}) and dyspareunia
  (OR:1.71{[}1.09-2.67{]})(Figure 4, analysis 2.1.1 and 2.1.2). Also
  episiotomy was associated with an increased odds for dyspareunia
  (OR:1.65{[}1.20-2.29{]}) (Figure 4, analysis 2.1.3 and 2.1.4).
\end{enumerate}

A summary of the total ORs for sexual dysfunction, dyspareunia and
vaginal dryness are displayed in Table 1. One can find the forest plots
on additional risk factors for sexual dysfunction and dyspareunia are in
the supplement (Figures S4-S8).



\textbf{Discussion}

\emph{Main findings}

We systematically reviewed the literature on obstetric risk factors for
sexual dysfunction up to one year after delivery, and assessed their
effect estimate. Eligible studies were exclusively observational and we
performed random-effect meta-analysis with subgroup analysis for sexual
dysfunction, for the occurrence of dyspareunia and vaginal dryness. We
did not find a significant effect of the mode of delivery. When
assessing the effect of perineal trauma, we found that anal sphincter
injury was associated with increased odds for both sexual dysfunction
and dyspareunia, and that episiotomy was associated with dyspareunia. We
found no association of vaginal dryness with any of the studied factors,
neither between body image dissatisfaction and sexual function up to one
year after delivery.

\emph{Strengths and limitations}

This is the first \emph{systematic} review with \emph{critical
appraisal} on sexual dysfunction including dyspareunia, vaginal dryness
and body image dissatisfaction as outcomes. We focused on studies which
used standardized validated tools and definitions consistent with the
IUGA/ICS terminology for the assessment of sexual health in women with
pelvic floor dysfunction, with the intention to pool comparable
results(1). Nonetheless, we acknowledge some limitations. First, we
could include only observational studies in the quantitative analysis.
Among those, only 44\% were of high quality. As a result, the level of
the evidence is low. Second, we could include in the quantitative
synthesis, only studies were the outcome measurements were presented as
dichotomous. Studies reporting on sexual function as mean score were
excluded from quantitative analysis, as the individual data could not
been retrieved. A solution may be to conduct a meta-analysis with
individual patient data (if available). Moreover, not all eligible
studies performed multivariate analysis with logistic regression.
Therefore, in our meta-analysis we reported summary ORs from count data
and crude ORs, and the possible effect of confounders cannot be
excluded. Third, we retrieved few studies that discriminated between
elective and emergency cesarean section and among the types of operative
delivery, and their association with sexual function after delivery
(26-30). Fourth, there is only one study of low quality reporting on
vaginal dryness after delivery (26). Furthermore, only two studies
addressed body image dissatisfaction(26, 31). Their definition and
methodology differ and their findings are inconclusive, which makes is
difficult to make a statement about a possible correlation between
sexual dysfunction and body image in the first after delivery.

\emph{Interpretation}

Under the assumption that the association of perineal trauma plays a
causative role in the later occurrence of sexual dysfunction and
dyspareunia, it would seem that perineal trauma needs to be avoided
whenever possible. Obviously, this factor is not always that easily
malleable, except for the trauma that is \emph{iatrogenic} in nature:
based on our observations, liberal use of episiotomy in non-instrumental
deliveries, as a strategy to reduce sexual dysfunction, should not be
recommended. Also, perineal trauma is more likely following instrumental
vaginal delivery, therefore -- if clinically feasible- women should be
offered the opportunity to discuss the risks and benefits of
instrumental delivery with their physician.

We found that cesarean section is not protective neither for sexual
dysfunction, nor for dyspareunia occurring within the first year after
delivery, when compared to spontaneous delivery. We did not anticipate
this, as cesarean section typically makes perineal trauma very unlikely,
hence should be protective. Apparently other factors than perineal
trauma, may play a more important role in the development of pelvic
floor sexual dysfunction. Also, the included studies may have measured
dysfunction rather late after delivery (Median months after delivery
{[}IQR{]}: 6.0 {[}5.1; 7.5{]}), by what time any difference according to
delivery mode, may have faded out(32-35). Also, women who are at high
risk for sexual dysfunction, may be more likely to receive a cesarean
section, because of that dysfunction -- though the data we have do not
allow us to make that conclusion.

It is difficult to make a firm statement on the different impact of
elective or emergency cesarean section, as only three studies were
included that report outcomes after elective and emergency section
separately. Prado et al. who reported on sexual dysfunction at 6-8
months after delivery, did not find any difference between elective
cesarean section and vaginal delivery (RR:1.23{[}0.87-1.74{]}; p=0.26),
whereas \emph{emergency} cesarean section was increasing the odds for
sexual dysfunction (RR:1.68{[}1.14-2.48{]})(28). O'Malley et al. and
Lipschuetz et al. reported on dyspareunia at 12 months after
delivery(26, 27); we pooled their count data in the supplement (Figure
S4). Apparently, elective cesarean section was protective for
dyspareunia (OR:0.50{[}0.29-0.85{]}), though no difference was found
between emergency cesarean section and vaginal delivery
(OR:0.91{[}0.61-1.35{]}). Moreover, the effect of mode of delivery on
sexual function, might be limited in time, and though this study looked
a pre-existing dyspareunia, it did not report separately on \emph{de
novo} sexual dysfunction(26). In conclusion, our observations do not
suggest the existence of obvious upfront risk factors for sexual
dysfunction in relation to delivery mode, whereas perineal trauma is.
This may however be a risk factor that is not easily modifiable. The
occurrence of perineal trauma should alert the clinician for the later
likelihood for sexual dysfunction, which should be brought up during
postpartum surveillance and may benefit from active management(36).

\textbf{Conclusion}

Perineal trauma, including anal sphincter injury and episiotomy, is
associated with sexual dysfunction after delivery, whereas delivery
route seems to be less relevant. Further research should contribute to a
better understanding of the former, and of vaginal dryness and body
image satisfaction after childbirth.



\textbf{References}

1. Rogers R, Pauls R, Thakar R, Morin M, Kuhn A, Petri E, et al. An
international Urogynecological association (IUGA)/international
continence society (ICS) joint report on the terminology for the
assessment of sexual health of women with pelvic floor dysfunction.
International Urogynecology Journal. 2018;29(5):647-66.

2. Callewaert G, Albersen M, Janssen K, Damaser M, Van Mieghem T, van
der Vaart C, et al. The impact of vaginal delivery on pelvic floor
function -- delivery as a time point for secondary prevention. BJOG: An
International Journal of Obstetrics \& Gynaecology. 2016;123(5):678-81.

3. M K, M D, PJ T, K S. Prevalence and risk factors of sexual
dysfunction in postpartum Australian women. J Sex Med.
2015;12(6):1415-26.

4. EO A, Z K. Sexual problems in women during the first postpartum year
and related conditions. J Clin Nurs. 2012;21(7-8):929-37.

5. Barrett G. Women's sexual health after childbirth. Bjog.
2000;107(2):186-95.

6. Signorello LB, Harlow BL, Chekos AK, Repke JT. Postpartum sexual
functioning and its relationship to perineal trauma: A retrospective
cohort study of primiparous women. American Journal of Obstetrics and
Gynecology. 2001;184(5):881-90.

7. Lagaert L, Weyers S, Van Kerrebroeck H, Elaut E. Postpartum
dyspareunia and sexual functioning: a prospective cohort study. Eur J
Contracept Reprod Health Care. 2017;22(3):200-6.

8. S B, AP L, A F, L D, C D, A C, et al. Impact of episiotomy on pelvic
floor disorders and their influence on women's. BMC Womens Health.
2011;11(12):1472-6874.

9. Glazener C. - Sexual function after childbirth: women's experiences,
persistent morbidity and. Br J Obstet Gynaecol. 1997;104(3):330-5.

10. Johanson R, Wilkinson P, Bastible A, Ryan S, Murphy H, O' Brien S. -
Health after childbirth: a comparison of normal and assisted vaginal
delivery. Midwifery. 1993;9(3):161-8.

11. Deane RP. Operative vaginal delivery and pelvic floor complications.
Best Pract Res Clin Obstet Gynaecol. 2019;56:81-92.

12. Jelovsek JE, Barber MD. Women seeking treatment for advanced pelvic
organ prolapse have decreased body image and quality of life. Am J
Obstet Gynecol. 2006;194(5):1455-61.

13. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting
items for systematic reviews and meta-analyses: the PRISMA statement.
Annals of internal medicine. 2009;151(4):264-9.

14. Morrison A, Polisena J, Husereau D, Moulton K, Clark M, Fiander M,
et al. THE EFFECT OF ENGLISH-LANGUAGE RESTRICTION ON SYSTEMATIC
REVIEW-BASED META-ANALYSES: A SYSTEMATIC REVIEW OF EMPIRICAL STUDIES.
International Journal of Technology Assessment in Health Care.
2012;28(2):138-44.

15. Methley AM, Campbell S, Chew-Graham C, McNally R, Cheraghi-Sohi S.
PICO, PICOS and SPIDER: a comparison study of specificity and
sensitivity in three search tools for qualitative systematic reviews.
BMC Health Services Research. 2014;14(1).

16. Lampinen R, Vehvil\selectlanguage{ngerman}äinen-Julkunen K, Kankkunen P. A review of
pregnancy in women over 35 years of age. Open Nurs J. 2009;3:33-8.

17. Organization WH. Obesity and overweight. Factsheet N°311. 2015.

18. Organisation WH. WHO recommendation on definition and duration of
the second stage of labour. 2018.

19. Stein A, Fairburn CG. Eating Habits and Attitudes in the Postpartum
Period. Psychosomatic Medicine. 1996;58(4):321-5.

20. Rallis S, Skouteris H, Wertheim EH, Paxton SJ. Predictors of Body
Image During the First Year Postpartum: A Prospective Study. Women \&
Health. 2007;45(1):87-104.

21. Clark A, Skouteris H, Wertheim EH, Paxton SJ, Milgrom J. My baby
body: A qualitative insight into women's body-related experiences and
mood during pregnancy and the postpartum. Journal of Reproductive and
Infant Psychology. 2009;27(4):330-45.

22. Wiegel M, Meston C, Rosen R. - The female sexual function index
(FSFI): cross-validation and development of. J Sex Marital Ther.
2005;31(1):1-20.

23. Wells GA SB, O'Connell D, Peterson J, Welch V, Losos M, et al. The
Newcastle-Ottawa Scale (NOS) for assessing the quality if nonrandomized
studies in meta-analyses. 2000 {[}Available from:
http://www.ohri.ca/programs/clinical\_epidemiology/oxford.htm.

24. Sharmin S, Kypri K, Khanam M, Wadolowski M, Bruno R, Mattick RP.
Parental Supply of Alcohol in Childhood and Risky Drinking in
Adolescence: Systematic Review and Meta-Analysis. Int J Environ Res
Public Health. 2017;14(3).

25. Islam MM, Iqbal U, Walther B, Atique S, Dubey NK, Nguyen PA, et al.
Benzodiazepine Use and Risk of Dementia in the Elderly Population: A
Systematic Review and Meta-Analysis. Neuroepidemiology.
2016;47(3-4):181-91.

26. O'Malley D, Higgins A, Begley C, Daly D, Smith V. 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 and Childbirth. 2018;18(1).

27. Lipschuetz M, Cohen SM, Liebergall-Wischnitzer M, Zbedat K,
Hochner-Celnikier D, Lavy Y, et al. Degree of bother from pelvic floor
dysfunction in women one year after first delivery. Eur J Obstet Gynecol
Reprod Biol. 2015;191:90-4.

28. Prado DS, Mendes RB, Gurgel RQ, Barreto IDC, Cipolotti R. The
influence of mode of delivery on neonatal and maternal short and
long-term outcomes. Revista de saude publica. 2018;52:95.

29. Chayachinda C, Titapant V, Ungkanungdecha A. Dyspareunia and Sexual
Dysfunction after Vaginal Delivery in Thai Primiparous Women with
Episiotomy. The Journal of Sexual Medicine. 2015;12(5):1275-82.

30. Ejegård H, Ryding EL, Sjögren B. Sexuality after Delivery with
Episiotomy: A Long-Term Follow-Up. Gynecologic and Obstetric
Investigation. 2008;66(1):1-7.

31. Acele EÖ, Karaçam Z. Sexual problems in women during the first
postpartum year and related conditions. Journal of Clinical Nursing.
2012;21(7-8):929-37.

32. Fan D, Li S, Wang W, Tian G, Liu L, Wu S, et al. Sexual dysfunction
and mode of delivery in Chinese primiparous women: a systematic review
and meta-analysis. BMC Pregnancy and Childbirth. 2017;17(1).

33. Hannah ME, Hannah WJ, Hodnett ED, Chalmers B, Kung R, Willan A, et
al. Outcomes at 3 months after planned cesarean vs planned vaginal
delivery for breech presentation at term: the international randomized
Term Breech Trial. JAMA. 2002;287(14):1822\selectlanguage{english}-31.

34. Hannah ME, Whyte H, Hannah WJ, Hewson S, Amankwah K, Cheng M, et al.
Maternal outcomes at 2 years after planned cesarean section versus
planned vaginal birth for breech presentation at term: the international
randomized Term Breech Trial. American journal of obstetrics and
gynecology. 2004;191(3):917\selectlanguage{english}-27.

35. Barrett G, Peacock J, Victor CR, Manyonda I. Cesarean section and
postnatal sexual health. Birth. 2005;32(4):306-11.

36. Hickman LC, Propst K, Swenson CW, Lewicky-Gaupp C. Subspecialty care
for peripartum pelvic floor disorders. American Journal of Obstetrics
and Gynecology. 2020;223(5):709-14.\selectlanguage{english}
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