Sexual dysfunction among six months postpartum women in north-eastern Malaysia

Female sexual dysfunction (FSD) is a common problem among postpartum women. However, little is known about this topic in Malaysia. This study aimed to determine the prevalence of sexual dysfunction and its associated factors in postpartum women in Kelantan, Malaysia. In this cross-sectional study, we recruited 452 sexually active women at six months postpartum from four primary care clinics in Kota Bharu, Kelantan, Malaysia. The participants were asked to fill in questionnaires consisting of sociodemographic information and the Malay Version of the Female Sexual Function Index-6. The data were analyzed using bivariate and multivariate logistic regression analyses. With a 95% response rate, the prevalence of sexual dysfunction among sexually active, six months postpartum women was 52.4% (n = 225). FSD was significantly associated with the older husband’s age (p = 0.034) and lower frequency of sexual intercourse (p<0.001). Therefore, the prevalence of postpartum sexual dysfunction in women is relatively high in Kota Bharu, Kelantan, Malaysia. Efforts should be made to raise awareness among healthcare providers about screening for FSD in postpartum women and for their counseling and early treatment.


Introduction
The American Psychiatric Association defines female sexual dysfunction (FSD) as a disturbance in the process that characterizes the sexual response cycle or pain associated with sexual intercourse [1]; these prevent individuals from experiencing satisfaction with sexual activity [2]. Sexual dysfunction is a complex clinical entity that involves biopsychosocial components and cultural and religious factors that play a role in its development [3]. Among Malaysian women, sexual problems tend to be ignored, and openly discussing this issue is discouraged owing to culture and religion [3]. Furthermore, the conservative sociocultural standards in Malaysian society also make women feel embarrassed when discussing sexual issues, as these topics are considered taboo [3]. This can negatively affect the well-being of women and lead to interpersonal difficulties, marital dissatisfaction, divorce, and reduced quality of life [4].
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, simplified the classification of FSD into three groups (instead of five) in the last version, namely, female sexual interest/arousal disorder, female orgasmic disorder, and genital pelvic pain/penetration a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 from February to November 2019. Women who came for their 6-month-old child's immunization at the primary care center were identified. Women at six months postpartum were included in this study to reflect the long-term consequences of morbidity [18]. The other inclusion criteria were: women aged �18 years, singleton childbirth at term, and living with a husband. Women with psychosis, in same-sex relationships, who had not yet resumed sexual intercourse after delivery, pregnant women, and non-Malaysian women were excluded from this study.

Sample size
The sample size to determine the prevalence of sexual dysfunction among postpartum women was calculated using a single-proportion formula as follows: where n = number of samples; Z = standard normal deviate, which is 1.96 (95% confidence level); P = prevalence rate 43.5% (0.435) from a previous study by De Lima Holanda et al. [19]; = precision rate of 5% (0.05). The minimum sample size was 378; and after considering a 20% nonresponse rate, the calculated sample size was 452.

Instruments
The questionnaire used in this study consisted of two parts. The first part included the participant's information, which consisted of sociodemographic data, general clinical well-being, and marital and sexual profiles. The second part was the Malay version of the Female Sexual Function Index-6 (FSFI-6).
Sociodemographic data, clinical and general well-being, marital and sexual profile. This section consists of the patient's sociodemographic data (age, family income, education level, and occupation), clinical and general well-being (number of children, mode of delivery, parity, breastfeeding, presence of chronic medical illness, such as diabetes mellitus, hypertension, chronic kidney disease, heart disease, and cancer, confinement practices, such as consuming herbs, having a body massage or heat therapy "bertungku" during the first 40 days postpartum), and marital and sexual profile (husband's age, time of resumption of sexual intercourse after childbirth, duration of marriage, and frequency of sexual intercourse).
Malay Version Female Sexual Function Index-6 (FSFI-6). The FSFI-6 is a questionnaire used to assess women's sexual function during the previous four weeks. It is a simplified version of the FSFI-19 [20] and has been validated among 200 women attending outpatient clinics for sexual and reproductive health [21]. The FSF1-6 includes one question for each of the six domains: desire, arousal, lubrication, orgasm, satisfaction, and pain. Desire and satisfaction items were rated from 1-5, and the other domains' items were rated from 0-5. The total score ranges from 2-30, with lower scores indicating poorer sexual functioning. The receiver operating characteristic (ROC) curves of the FSFI-6 showed that women who scored �19 points were classified as screened positive for FSD. Using 19 as the cut-off, the sensitivity and specificity of the test were 0.93 and 0.94, respectively; Cronbach's alpha was 0.789 [21]. The Malay version of the FSFI-6 was tested and validated in 128 breast cancer patients enrolled in another study, with a Cronbach's alpha of 0.93 [22]. The FSFI-6 is a faster screening tool for FSD and is easy to use during studies or outpatient visits.

Procedure
Based on attendance at the Maternal Child Health Clinic in the four primary health clinics with family medicine specialists, a nonproportionate systematic random sampling with a 1:2 ratio was applied. Participants were identified based on the eligibility criteria for the study; then, they were briefed and invited to participate. Written consent was obtained once participants voluntarily agreed. Self-administered questionnaires were distributed, and it took approximately 10-15 minutes to complete the questionnaires in a private space. During this time, the researcher was available for any clarification of the questionnaire, which was collected once completed, and participants were reassured of their information confidentiality. Those who scored positive for FSD on the questionnaire were immediately notified of the results. Those who desired further FSD management were referred to a psychiatrist, while those who did not were given the psychiatric clinic's contact information in case, they wished to seek treatment in the future.

Data analysis
Data were analyzed using IBM SPSS Statistics for Windows, version 26.0 (IBM Corp., Armonk, NY, USA). Descriptive analyses were used to describe all categorical (frequency and percentage) and numerical (mean and standard deviation [SD]) variables. Bivariate and multivariate logistic regression analyses were performed to screen for potential factors associated with FSD. All variables with p-value �0.25 for bivariate logistic analysis were included in the multivariate logistic regression analysis to determine the factors associated with FSD [23], whereas other confounders in the model were controlled. The dependent variable was FSD (categorized as FSD with a score of FSFI-6 �19 and non-FSD with a score of FSFI-6 >19), whereas the independent variables were sociodemographic characteristics. The results were presented as an odds ratio (OR) with a 95% confidence interval (CI). A p-value <0.05 following multivariate logistic analysis was considered statistically significant.

Results
A total of 452 women who attended the clinic were invited to participate in this study. All participants had resumed sexual activities six months post-delivery. However, 23 women were excluded due to refusal to participate or incomplete questionnaires. The response rate was 95%, and 429 respondents were included in further analyses.
The sociodemographic, clinical, and marital data of the participants are summarized in Table 1. The mean age of participants was 30.9 years (SD = 5.55), and the mean household income was US$593 (SD = 428.5); half of them had attained secondary school education (53.4%) and were housewives (54.8%). Approximately two-thirds of the participants were multiparous (68.1%) and had delivered vaginally with sutures (71.3%). The rates of mixed feeding and exclusive breastfeeding were comparable at 45.2% and 43.4%, respectively. Most participants had no chronic medical illness (97%), and they underwent confinement practices, such as consuming herbs, having a body massage or heat therapy "bertungku", within 40 days after delivery (79%). The mean age of their husbands was 33.9 years (SD = 6.5), the mean duration of marriage was 6.7 years (SD = 5), and the mean number of weeks of resumption of first sexual intercourse after delivery was 12.9 weeks (SD = 3.4). Also, approximately 54.8% of the participants had sexual intercourse once a week or more.
Of the 429 respondents, 225 screened positive for FSD, a total prevalence of 52.4%. The mean FSD and its subdomains' scores are presented in Table 2.
The bivariate logistic regression analysis of the factors associated with FSD is shown in Table 3. Education level, mode of delivery, husbands' age, duration of the marriage, and frequency of sexual intercourse were statistically significant after bivariate analysis. Then, a multivariate logistic regression analysis was performed using the presence of FSD as the dependent variable and all parameters that were significantly associated with FSD in the bivariate analysis. The multivariate analysis models were the same regardless of the variable selection method applied (forward or backward logistic regression). Only the husband's age and frequency of sexual intercourse remained statistically significant (p<0.05) in the multivariate logistic regression analysis (

Discussion
Sexual dysfunction has a crucial effect on the quality of life and intermarital relationships between couples. During the postpartum period, women experience numerous physical and psychological changes that may affect their sexual function. According to Acele et al., the prevalence of sexual dysfunction was higher during the postpartum period than before pregnancy [12]. Postpartum sexual function is important for couples, especially for the first instance of postpartum sex, to establish intimate relationships [17]. Our study was conducted to evaluate the female sexual function at six months postpartum. The cultural practice of abstaining from sexual intercourse during the confinement period in Malaysia varies [3]; however, one study showed that most women resumed sexual intercourse within six months postpartum [24].

Prevalence of sexual dysfunction among women after childbirth
Our study showed that the prevalence of FSD in sexually active married women at six months postpartum was 52.4%. This result is comparable with another local study conducted among women at four to six months postpartum in urban primary care settings in Malaysia, where the prevalence was 57% [25]. However, some developed countries had reported an even higher prevalence of FSD. For example, a study in Australia reported that sexual dysfunction was observed in 64% of women during the first year after childbirth [26]. Furthermore, in a sample of Iranian women at eight weeks to eight months postpartum, it was even higher at 76.3% [27]. Compared with other ASEAN countries, sexual dysfunction among six months postpartum women was demonstrated in approximately 31% and 34.2% in Thailand [28] and China [29], respectively. Different sociodemographic backgrounds, cultural backgrounds, and beliefs may contribute to the different prevalence of sexual dysfunction among postpartum women [30]. This variation may also be due to differences in the time postpartum women were studied, such as four to six months or a year after childbirth. Sexual dysfunction is highly prevalent in postpartum women worldwide.
In the postpartum period, many changes can affect a woman's sexual response cycle, including pain during intercourse, lack of sexual desire, vaginal dryness, and failure to reach orgasm [31]. This study showed that the mean score for desire problem was 2.9, which was the lowest among the six domains, followed by a mean score of 3 for lubrication and arousal problems. One factor is the high prolactin hormone level in breastfeeding mothers, which can lead to decreased estrogen hormone levels and contribute to low sexual desire and decreased vaginal lubrication [32]. This is in line with the results of the present study, as the majority of participants (88.6%) breastfed their babies. Breastfeeding can also cause tiredness, changes in a mother's sexual desire, and changes in a couple's relationship, as nursing is a time-consuming activity that may interfere with intimate emotional exchanges between partners [26]. Parents who are fatigued and frequently suffer from sleep deprivation, such as denoting the time and effort to care for a newborn and loss of sexual desire, were factors that interfered with couples' sexual lives and relationships [33].

FSD-associated factors
In this study, half of the women (54.3%) were sexually active at least once per week. Regression analyses showed that women who had sexual intercourse less frequently than once a week had a higher risk of sexual dysfunction. According to this study model, for women who had sexual intercourse every two weeks, the OR for FSD was 2.09 times higher than that for women who had sexual intercourse once a week or more. These findings are consistent with those of a study in Australia indicating that a low frequency of sexual activity is associated with problems in sexual function [26]. The weekly frequency of sexual intercourse decreased in 75% of couples, which was caused by the time dedicated to the child and dyspareunia [34]. Furthermore, in Malaysia, it is common to have small children sleep with their parents in the same bedroom up to the child's schooling age [35]. In contrast, women with sexual dysfunction are more likely to have less frequent or no sexual activity than women without it [26]. Another explanation is that a higher frequency of sexual activity can improve intimate relationships between couples, leading to lower a risk of sexual dysfunction. This has also been found in another study that reported a correlation between the degree of sexual satisfaction and changes in the frequency of intercourse [36]. Additionally, this study found that the husband's age was significantly associated with FSD. This is probably due to multiple factors related to increasing age, such as a decline in health and increased use of medicines, which may affect sexual function [7]. Another local study reported a similar finding: women married to older husbands had an increased probability of developing FSD [3]. This finding suggests that sexual dysfunction in women can be affected by husbands' performance. Male partners' sexual dysfunction is a risk factor for FSD. Female partners reported significantly lower sex drive and reduced in sexual activity [37]. However, the present study did not investigate the details of husbands' risk factors for sexual dysfunction, such as medical conditions and smoking. Further studies could examine the factors of sexual dysfunction in husbands and their effects on women's sexual function.
The results of the present study showed that the mode of delivery was not significantly associated with FSD, although many studies have shown this association, especially between FSD and vaginal delivery with sutures or episiotomy [19,38,39]. The mean number of weeks between delivery and first sexual intercourse encounter was 12.9 weeks, which was comparable with some cultural beliefs of sexual abstinence for 100 days to allow proper healing after childbirth [15]. Some sexual problems that occur after vaginal delivery can be due to early initiation of sexual intercourse and incomplete healing of the episiotomy wound [40]. A meta-analysis conducted in 2017 showed that the mode of delivery-cesarean or vaginal delivery-did not affect sexual function [41]. Therefore, there are mixed findings in the literature on the relationship between the mode of delivery and sexual function. Owing to concerns regarding the rise in maternal requests for cesarean section in recent years, these observations should be further investigated in larger prospective longitudinal studies. Furthermore, future studies should be conducted to survey women's perceptions and concerns about the mode of delivery that affects sexual function after childbirth.
Additionally, our study found no significant association between FSD and age, education level, employment, parity, or breastfeeding, which is supported by another study from Japan [42]. According to some researchers, breastfeeding mothers experience increased sexual arousal and libido. However, some studies have reported lower sexual activity in women who breastfeed, which can be attributed to a decline in estrogen levels, leading to reduced vaginal lubrication and possible dyspareunia [43,44]. Further studies with larger sample sizes are required to investigate this association.
This study has some limitations. First, these results cannot be generalized to the Malaysian population because most participants in Kelantan are Malays; therefore, this does not reflect the true ethnic distribution of Malaysia. The results are also not generalizable to all postpartum women, as this study did not include women who did not bring their 6-month-old children for immunization, those who were non-married, and those with psychosis. Second, a causal relationship could not be established because a cross-sectional study was conducted. Finally, we did not include the confounding effects of other variables, such as intimate partner violence and the quality of the couple's relationship.
To our knowledge, this is the first study to use a simplified version of the FSFI-6 questionnaire to screen for FSD among postpartum women. It is important to remember that this measure is intended to assess sexual function and identify women with poorer function rather than to establish a clear diagnosis of FSD. Additionally, as the study was a self-administered questionnaire, the participants were expected to provide more reliable answers, as discussing sexuality openly is perceived as taboo. However, there is still a risk of information bias, even with the use of a self-reporting methods.
Future research studies should include a larger sample and prolonged postpartum followup to verify these findings and assess the effect of other demographic, cultural, psychological, and couple variables that may influence women's sexual functioning in the postpartum period.

Conclusions
Our study highlighted that a significant number of women at six months postpartum screened positive for sexual dysfunction, underscoring the importance of the current understanding of the effects of FSD on our population. Postpartum sexual health is a common concern but seldom discussed during prenatal or postpartum care [45]. Most women who have sexual issues do not seek professional help due to embarrassment and preoccupations with their newborn (s) [46]. Other potential barriers to conversations regarding sexual health issues in primary care include lack of knowledge, cultural taboos, and restriction of time allotted for each medical appointment [47]. Although sexual issues among women have begun to receive attention in Western nations, this is not the case in Malaysia. Traditionally, Malay women are not supposed to comment on their sexual desire or dissatisfaction because Islam forbids sexual disclosure unless for medical purposes [3]. Women have the right to receive treatment and reassurance, as this has been shown to affect the relationship between the couple and the mother's psychological status. Therefore, healthcare providers play a significant role in assisting postpartum women by screening for FSD with a simple questionnaire (e.g., FSFI-6) and initiating a conversation about their sexual health as a protocol-based postnatal follow-up. Prenatal visits are also an ideal time for healthcare providers to address these concerns with expectant mothers and offer helpful advice that may be referenced at the follow-up postpartum appointment. Efforts should be made to engage women and their partners, and appropriate referrals for multidisciplinary support should be made as needed.