The Association Between Infant Feeding Methods and Female Sexual Dysfunctions

Abstract

Background:

Although postpartum sexual problems are common, the impact of the infant feeding method on sexual life is still unclear. The aim of this study was to investigate the effects of different infant feeding methods and other influencing factors on female sexual life 3 months postpartum.

Materials and Methods:

Three hundred women from three obstetrical institutes were enrolled in this cross-sectional study. An online questionnaire was administered 3 months postpartum. Women were categorized into three groups: exclusive breastfeeding (n = 180), mixed feeding (n = 75), and formula-feeding (n = 45) groups. The infant feeding method was assessed by self-constructed questions. Sexual dysfunctions were evaluated by the Hungarian version of the Female Sexual Function Index (FSFI).

Results:

Of the women, 50.55% reported sexual dysfunction in the exclusive breastfeeding group, 42.66% in the mixed feeding group, and 31.11% in the formula-feeding group. Lack of sexual desire was the most prevalent dysfunction regardless of the infant feeding method. Significantly lower median scores were found in the exclusive breastfeeding group compared with the formula-feeding group for the total FSFI score (p = 0.002), arousal (p = 0.034), lubrication (p = 0.020), orgasm (p = 0.015), and pain (p = 0.021) subgroups. Breastfeeding (p = 0.032) and the quality of prepregnancy sexual life (p < 0.001) were significant factors, whereas prepregnancy dyspareunia, parity, age, income, and educational level did not predict women's postpartum sexual function.

Conclusions:

Our findings indicate that exclusive breastfeeding women have an increased likelihood of sexual problems 3 months postpartum. Extensive and professional counseling is needed for couples about postpartum sexuality and influencing factors such as breastfeeding to maintain sexual health and promote long-term breastfeeding.

Introduction

Female sexual dysfunction is a prevalent problem in 12–46% of women and influenced by multiple factors and special life events.^1,2 The postpartum period is normally a stressful life event for couples. However, 80–93% of women turn back to sexual activity within 3 months after delivery^3,4 and 30–70% of them report difficulties in sexual life.^3–6 Despite this prevalence, only 15% of them expressed their need for help or advice.^3,7

According to the World Health Organization, exclusive breastfeeding (the infant takes only breast milk and no additional food, water, or other fluids) is recommended up to 6 months of age and up to 2 years of age or beyond with appropriate complementary food.⁸ However, only 17% of 6-month-old infants were exclusively breastfed in Hungary in 2018; 58% of infants were also breastfed, but not exclusively. More than 75% of breastfeeding mothers chose to breastfeed on demand.⁹ Since long-term breastfeeding is supported, and the rate of breastfeeding mothers is significant, its effect on sexual life has to be examined.

Despite several studies on this topic, the association between the mode of infant feeding and sexual dysfunctions after childbirth is controversial. On the one hand, Escasa-Dorne found that breastfeeding mothers report the highest level of sexual functions after birth¹⁰ and Albustan et al. revealed that breastfeeding mothers exceeded their prepregnancy level of sexual functions earlier than formula-feeding mothers.¹¹ On the other hand, several studies show that breastfeeding women are more likely to report difficulties in sexual life. Breastfeeding mothers have a higher likelihood of experiencing dyspareunia at 3 and 6 months after delivery compared with nonbreastfeeding mothers^4,6,12,13 and suffer from lower sexual interest and vaginal dryness.^3,14,15

The prevalence of postpartum sexual dysfunctions suggests a potentially high level of unmet needs.^3,16 Extensive literature review indicated that comparative studies categorized women usually into breastfeeding and nonbreastfeeding categories. Therefore, there are just a few studies distinguishing not only breastfeeding itself but also the effects of different infant feeding methods, such as exclusive breastfeeding, mixed feeding, and formula-feeding, on female sexual life. In Anbaran et al.'s research, a significant difference was found in the prevalence of sexual dysfunctions among women for four different infant feeding methods (exclusive breastfeeding, breastfeeding plus complementary feeding, formula-feeding, and breastfeeding plus formula), and sexual dysfunctions were with the lowest incidence in the exclusive breastfeeding group.¹⁷ In contrast, Matthies et al. revealed in their prospective study that mothers who experienced ablactation and never breastfed reported a significantly higher level of sexual life than exclusive or partial breastfeeding mothers.¹⁸

The aim of this study was to investigate effects of different infant feeding methods and other influencing factors on female sexual life at 3 months postpartum.

Materials and Methods

Study design and settings

This cross-sectional study was carried out in three obstetric institutions in Budapest, Hungary. Women were personally invited within 3 days after their delivery to participate in our study. The invitation period was between June 2018 and August 2019. Participants applied voluntarily, the objectives, procedures, risks, and benefits of the study and data protection regulations were explained, and they signed an informed consent.

Inclusion criteria included women with singleton pregnancies and who were aged 18–45 years, currently in a relationship with their partner since at least 6 months before their latest pregnancy, and already returned to sexual life. Women were excluded if they had multiple pregnancies, delivery with complications, and delivery before the 37th gestation week; furthermore, cases where the infant's birth weight was under 1500 g or needed to have intensive care after birth were excluded.

Data were collected using an online questionnaire 3 months after delivery. The SurveyMonkey program—which is a General Data Protection Regulation (GDPR)-compliant survey program specified for market and scientific research surveys—was used for designing the survey, collecting responses, creating the database, and preanalyzing the results. The link to the questionnaire was sent through e-mail to participants 3 months after their delivery. A reminder e-mail was sent 4 days after the invitation to participants with no or partial responses. Questionnaires were available for 7 days.

The study was approved by the Semmelweis University Regional and Institutional Committee of Scientific and Research Ethics in May 2018 (SE REB number: 24/2017).

Measures

Women were evaluated at 3 months postpartum using a self-constructed questionnaire to assess sociodemographic determinants such as age, educational level, income, parity, and sexual history. Prepregnancy sexual life was examined by the frequency of prepregnancy dyspareunia with the following possible answers: never/hardly ever, sometimes, or often. Self-assessed quality of prepregnancy sexual life was evaluated using a 5-item Likert scale, where 1 meant the lowest level and 5 meant the highest level. Participants were asked how they feed their baby currently. To distinguish the infant feeding method, they could choose from the following potential answers in the questionnaire: exclusive breastfeeding (feeding the baby only with breast milk, the baby does not get any other liquid, solid, or formula except minerals, vitamins, or medicines), mixed feeding (baby is fed both breast milk and formula), and formula-feeding (baby is fed only formula). During multivariate linear regression, we considered the exclusive breastfeeding group and mixed feeding group as the breastfeeding group and the formula-feeding group as the nonbreastfeeding group.

Women were asked questions regarding their most recent postpartum experiences. Female sexual dysfunctions were evaluated by the Female Sexual Function Index (FSFI).¹⁹ The 19-item tool was used to assess the following domains: desire, arousal, lubrication, orgasm, satisfaction, and pain. The score of each domain was multiplied by a correlation factor; therefore, the total score could vary between 2 and 36 points. The scale of the cutoff value was 26.55, therefore a total FSFI score below 26.55 was defined as having sexual dysfunction and >26.55 as having normal sexual function.²⁰

Analysis

Data were analyzed using the Statistica 13.4.0 program. The demographic, obstetric, and sexual health-related data of women are reported using descriptive statistics such as mean, percentage, minimum–maximum, and standard deviation. The differences between the median scores of FSFI and subgroups in the three categories of infant feeding methods were evaluated by the Kruskal–Wallis test. Pairwise comparisons were examined by the Mann–Whitney U test with Bonferroni correction. The influence of breastfeeding and other potential factors, such as prepregnancy dyspareunia, quality of prepregnancy sexual life, parity, income level, educational level, and age, on sexual functions was assessed by multivariate linear regression analysis. Continuous predictors were entered with restricted cubic spline expansion, and possible nonlinearities were checked with a global test. All predictors were entered without variable selection. A value of p < 0.05 was considered statistically significant with a 95% confidence interval.

Results

Three hundred women were enrolled in this study. Sixty percent of them were exclusive breastfeeding mothers, 25% fed their baby with a mixed feeding method, and 15% were formula-feeding mothers. The demographic characteristics of the sample categorized by the infant feeding method are shown in Table 1. The majority of women had bachelor's or master's degrees in the exclusive breastfeeding (74.44%) and mixed feeding (65.33%) groups, but in the formula-feeding group, the rate of higher education was lower (35.55%). The majority of women assessed their income level as high in all groups. More primiparous women participated in our study than multiparous women. The majority of the total sample never or hardly ever experienced painful intercourse before pregnancy and evaluated their prepregnancy sexual life as 4 or 5 on a 5-item Likert scale (Table 2).

Table 1.

Sociodemographic Characteristics of Participants According to Infant Feeding Method

Variable	Total sample (n = 300)	Exclusive breastfeeding (n = 180)	Mixed feeding (n = 75)	Formula-feeding (n = 45)
Age, years (mean ± SD)	31.53 (±4.74)	32.06 (±4.49)	30.66 (±4.94)	30.88 (±5.19)
Educational level
Elementary school	1 (0.33%)	1 (0.55%)	0 (0%)	0 (0%)
Vocational school	10 (3.33%)	6 (3.33%)	3 (4.0%)	1 (2.22%)
High school	61 (20.33%)	24 (13.33%)	16 (21.33%)	21 (46.66%)
Some college	29 (9.66%)	15 (8.33%)	7 (9.33%)	7 (15.55%)
Bachelor's or master's degree	199 (66.33%)	134 (74.44%)	49 (65.33%)	16 (35.55%)
Income level
Low	3 (0.01%)	2 (0.01%)	1 (0.01%)	0 (0%)
Middle	64 (21.33%)	37 (20.55%)	14 (14.66%)	13 (28.88%)
High	233 (77.66%)	141 (78.33%)	60 (80.0%)	32 (71.11%)

SD, standard deviation.

Table 2.

Obstetrical and Sexual History According to Infant Feeding Method

Variables	Total sample (n = 300)	Exclusive breastfeeding (n = 180)	Mixed feeding (n = 75)	Formula-feeding (n = 45)
Dyspareunia before pregnancy
Never/hardly ever	269 (89.66%)	158 (87.77%)	71 (94.66%)	40 (88.88%)
Sometimes	26 (8.66%)	18 (10.0%)	3 (4.0%)	5 (11.11%)
Often	5 (1.66%)	4 (2.22%)	1 (1.33%)	0 (0%)
Quality of prepregnancy sexual life
1	1 (0.33%)	0 (0%)	1 (1.33%)	0 (0%)
2	4 (1.33%)	3 (1.66%)	0 (0%)	1 (2.22%)
3	25 (8.33%)	12 (6.66%)	9 (12.0%)	4 (8.88%)
4	105 (35.0%)	68 (37.77%)	26 (34.66%)	11 (24.44%)
5	165 (55.0%)	97(53.88%)	39 (52.0%)	29 (64.44%)
Parity
Primiparous	181(60.33%)	99 (55.0%)	56 (74.66%)	26 (57.77%)
Multiparous	119 (39.66%)	81 (45.0%)	19 (25.33%)	19 (42.22%)

Of the participants, 45.66% had sexual dysfunction according to total FSFI scores (FSFI >26.55); 50.55% of participants reported sexual dysfunctions in the exclusive breastfeeding group, 42.66% in the mixed feeding group, and 31.11% in the formula-feeding group.

The total FSFI and the subgroup scores of each category of infant feeding methods and the comparison among the groups are given in Table 3. Significant differences were observed in total FSFI (H [2, N = 300] = 14.28051 p < 0.001), desire (H [2, N = 300] = 11.42183 p = 0.003), arousal (H [2, N = 300] = 9.959603 p = 0.006), lubrication (H [2, N = 300] = 9.592776 p = 0.008), orgasm (H [2, N = 300] = 9.276175 p = 0.009), satisfaction (H [2, N = 300] = 7.155117 p = 0.027), and pain (H [2, N = 300] = 8.817909 p = 0.012) subgroup scores among different infant feeding groups. The lowest total FSFI and subgroup scores were found in the exclusive breastfeeding group and the highest in the formula-feeding group. Lack of sexual desire was the most prevalent dysfunction, showing the lowest subgroup scores in each infant feeding group. Follow-up Mann–Whitney U tests with Bonferroni correction showed that exclusive breastfeeding mothers had significantly lower total FSFI (p = 0.002), arousal (p = 0.034), lubrication (p = 0.020), orgasm (p = 0.015), and pain (p = 0.021) scores compared with formula-feeding mothers. No significant difference was found between mixed feeding and exclusive breastfeeding and mixed feeding and formula-feeding mothers in any FSFI subgroups.

Table 3.

Comparison of Female Sexual Function Index Scores in Exclusive Breastfeeding, Mixed Feeding, and Formula-Feeding Groups

	Min–max score^a	Total sample (n = 300) Median (min–max)	Exclusive breastfeeding (n = 180) Median (min–max)	Mixed feeding (n = 75) Median (min–max)	Formula-feeding (n = 45) Median (min–max)	p Value^b
Desire	1.2–6.0	3.6 (1.2–6)	3.6 (1.2–6.0)	4.2 (1.2–6.0)	4.2 (1.2–6.0)	0.003
Arousal	0–6.0	4.5 (0–6.0)	4.5 (0–6.0)	4.8 (0–6.0)	4.8 (1.8–6.0)	0.006
Lubrication	0–6.0	5.1 (0–6.0)	4.8 (0–6.0)	5.4 (0–6.0)	5.7 (2.1–6.0)	0.008
Orgasm	0–6.0	4.8 (0–6.0)	4.8 (0–6.0)	5.2 (0–6.0)	5.2 (2.8–6.0)	0.009
Satisfaction	0.8–6.0	4.8 (0.8–6.0)	4.8 (1.2–6.0)	4.8 (0.8–6.0)	5.2 (1.2–6.0)	0.027
Pain	0–6.0	4.8 (0–6.0)	4.4 (0–6.0)	4.8 (0–6.0)	5.6 (2.0–6.0)	0.012
FSFI	2.0–36.0	27.4 (2.0–36.0)	26.0 (4.0–36.0)	27.9 (2.0–34.8)	29.8 (12.7–36.0)	<0.001

Minimum and maximum scores are calculated according to the Rosen et al.¹⁹ study.

Comparison of 3 months postpartum FSFI median scores among infant feeding groups using the Kruskal–Wallis test.

FSFI, Female Sexual Function Index.

Linear regression analysis was used to investigate effects of the infant feeding method and other contributing factors such as quality of prepregnancy sexual life, frequency of dyspareunia before pregnancy, and parity on total FSFI scores. As a consequence of multivariate linear regression, the Model 2 degree of predicting FSFI was increased (R² = 0.08) compared with Model 1 (R² = 0.03). Results indicated that breastfeeding (p < 0.001) and the quality of prepregnancy sexual life (p < 0.001) significantly influenced total FSFI scores, but dyspareunia and parity had no significant effect on total FSFI scores (Table 4).

Table 4.

Effects of Breastfeeding and Other Influencing Factors on the Total Female Sexual Function Index Score

	B	Standard error of B	β	t
Model 1
Constant	22.50	1.21		t(298) = 18.46 p < 0.001
Breastfeeding	3.11	1.01	0.17	t(298) = 3.08 p = 0.002
Model 2
Constant	15.23	2.80		t(295) = 5.43 p < 0.001
Breastfeeding	2.95	0.98	0.16	t(295) = 2.99 p < 0.001
Frequency of dyspareunia before pregnancy	−0.67	0.58	−0.06	t(295) = −1.08 p = 0.27
Quality of prepregnancy sexual life	1.93	0.48	0.22	t(295) = 3.95 p < 0.001
Parity	−0.24	0.72	−0.01	t(295) = −0.34 p = 0.73

Model 1: R² = 0.03090 R²adj = 0.0276 F(1, 298) = 9.50 p = 0.002.

Model 2: R² = 0.0887 R²adj = 0.0760 F(4, 295) = 7.18 p < 0.001.

Demographic factors were also analyzed for their contribution in explaining total FSFI scores with a multivariate linear regression model. There was no significant nonlinearity (p = 0.197). The effect of breastfeeding remained significant (+2.2-unit increase in FSFI [95% confidence interval: 0.2–4.2], p = 0.032) even after controlling for parity (p = 0.738), quality of prepregnancy sexual life (p < 0.001), prepregnancy dyspareunia (p = 0.676), income level (p = 0.254), education level (p = 0.300), and age (p = 0.143).

Discussion

This comparative study was conducted to investigate effects of different infant feeding methods on the sexual life of women.

The proportion of women who had sexual dysfunctions in our study (45.66%) corresponds to the proportion reported in previous studies (30–70%).^3–6,21 However, there are just a few studies assessing the higher level of sexual functions in breastfeeding mothers compared with formula-feeding women,^10,17 the majority of results reported an adverse effect of breastfeeding on the sexual life of women.^{3,4,6,12–15,18,22} In our study, the highest rate of sexual difficulties was assessed among exclusive breastfeeding mothers (50.55%), and we found the lowest level of sexual dysfunctions among formula-feeding mothers (31.11%).

Previous studies reported that the decrease in sexual interest among breastfeeding mothers is one of the most frequently experienced changes in postpartum sexual life.^22–24 This tendency is also reported in our current study. Lack of sexual interest was the most prevalent sexual dysfunction regardless of the infant feeding method. Exclusive breastfeeding women had a significantly lower level of arousal (p = 0.034) compared with formula-feeding mothers.

In previous studies, breastfeeding is frequently associated with dyspareunia within 6 months postpartum.^3,6,16,18 Yilmaz et al. found that breastfeeding mothers are more likely to suffer from dyspareunia than nonbreastfeeding mothers.²⁵ Signorello et al. reported that breastfeeding mothers were four times more likely to struggle with dyspareunia than those who did not breastfeed.⁴ In this current study, exclusive breastfeeding mothers had the lowest pain scores, therefore they are more likely to suffer from dyspareunia than formula-feeding mothers (p = 0.021), which is consistent with results of previous studies. O'Malley et al. revealed that a lower level of lubrication among breastfeeding mothers is one of the main causes of dyspareunia.²⁶ We also found significantly lower lubrication scores in the exclusive breastfeeding group compared with the formula-feeding group (p = 0.020).

Regarding potential explanations, lactating mothers generally show some hormonal changes in the postpartum period. Due to breastfeeding, mothers have a higher level of prolactin and decreased secretion of androgens and estrogen.¹⁵ A lower level of estrogen causes atrophy of the vaginal epithelium, which therefore leads to problems with lubrication, decreased sexual desire and arousal, and as a consequence, dyspareunia.^27,28 If a woman starts to be afraid of pain during intercourse, she can develop more anxiety, which can create a cycle of a lower level of sexual interest and dyspareunia.²³ Another hormone that plays an important role in lactation and sexual life is oxytocin. Oxytocin is responsible for milk ejection from the breasts and contractions of the uterus and vagina during orgasm.²⁹ Therefore, women can experience milk ejection during orgasm, which can cause embarrassment for them.³⁰

Matthies et al. and Wallwiener et al. found in their studies that mothers who exclusively breastfed reported the lowest FSFI scores 4 months postpartum, compared with mothers who never breastfed.^18,22 However, no further significant difference was found among the other group comparisons (partly breastfeeding mothers and ablactation mothers).²² On the one hand, this can be explained by hormonal changes caused by lactation, which has been previously reported. On the other hand, another explanation can be the potentially higher level of fatigue caused by breastfeeding and nighttime nursing. Breastfeeding mothers—especially those who breastfeed their baby on demand—could suffer from sleep deprivation due to regular nursing at night, which could be accompanied by lower sexual interest.^27,31 Although mixed feeding mothers continue to breastfeed, they may no longer do so during the night, therefore they do not suffer from that high level of fatigue. In agreement with this, according to our results, exclusive breastfeeding mothers had the lowest level of sexual functions. We found a significant difference between the exclusive breastfeeding and formula-feeding groups; however, the mixed feeding group was not significantly different from the other two groups.

According to some previous studies, breastfeeding might satisfy a very great part of the mother's need for intimacy, even if she is only partially breastfeeding, which consequently reduces the need for the closeness of the partner.^30,32 Yilmaz et al.²⁵ found that breastfeeding mothers had less sexual activity and sexual desire than nonbreastfeeding mothers, and the rate of the women who enjoyed sexual satisfaction was higher in the nonbreastfeeding group. Nonetheless, breastfeeding and nonbreastfeeding women reported similar quality of sexual life, and the difference between the two groups was not significant.²⁵ This result suggests that breastfeeding may have a special sexual aspect that helps mothers to be satisfied easily regardless of the lower frequency of sexual life and lower level of sexual desire.^25,33 Our results confirm the negative effect of breastfeeding, showing that exclusive breastfeeding mothers had the lowest level of sexual functions, including desire, orgasm, and satisfaction; however, the quality of sexual life was not examined in this current study.

According to our results, the self-assessed quality of prepregnancy sexual life seems to be an important predictor of sexual dysfunctions. The higher the women assessed their prepregnancy sexual life, the higher the FSFI score they had postpartum (p < 0.001); however, prepregnancy dyspareunia showed no effect on postpartum sexual life in the analysis. These results suggest that sexual life cannot be determined only by the presence or absence of sexual dysfunctions, the relevance of the self-assessed sexual life also has to be considered.

Parity is commonly examined as a risk factor for postpartum sexual dysfunctions; however, the connection between parity and postpartum sexual life is still controversial in the literature. The results of the studies by Martinez-Galiano et al. and Yee et al. show that primiparous women experience more lactation and sexual problems than multiparous women.^12,34 In contrast, Byrd et al. and Fehninger et al. found no association between parity and sexual dysfunctions,^32,35 in line with our results. Primiparity cannot be considered as a predictive factor of sexual dysfunctions; however, it can have an indirect effect on sexual life because of a higher level of insecurity and inexperience. Postpartum counseling is important for all mothers regardless of their sexual history before their delivery.

German studies documented that exclusive breastfeeding mothers have the lowest level of sexual life,^18,22 while an Iranian study revealed that exclusive breastfeeding women report the highest FSFI scores compared with formula-feeding mothers.¹⁷ In a Turkish study, breastfeeding did not have any association with sexual dysfunctions.³⁶ In this current Hungarian study, breastfeeding mothers reported the lowest level of sexual life. Consequently, cultural aspects also have to be considered in understanding the differences in breastfeeding rates and postpartum sexual life in different societies.^25,33

However, we found that breastfeeding negatively influences the sexual life of women. Exclusive breastfeeding plays an essential role in a child's health and has several positive effects on the mother's health as well. Therefore, breastfeeding is recommended until at least 6 months of age.⁸ To support breastfeeding and female sexual health, health care professionals should inform couples about potential postpartum changes in sexual life during pre- and postnatal care counseling.

Limitations

Some limitations have to be considered.

No data were collected on the partner's experience and other relationship factors. In addition, as sexual life depends on two persons, getting information from only the female partner is unilateral.

We did not collect data about chronic diseases that may affect sexual life, therefore patients with chronic illnesses were not excluded from the study. However, we did exclude participants falling into the following categories: those who had a preterm delivery and those who delivered with complications or before the 37th gestation week. Furthermore, exclusion criteria included cases where the infant's birth weight was <1500 g or if the infant needed to have intensive care after birth. These disturbances are more common among women with positive medical anamnesis.

Despite the relatively large sample size, the majority of cases were in the exclusive breastfeeding group than in the formula or mixed feeding group and therefore an analysis of a larger sample size would be needed for more accurate results.

Conclusions

The present results highlight important concerns regarding the connection between breastfeeding and sexual dysfunctions and reveal that postpartum sexual dysfunctions are common in the first 3 months after delivery. The most relevant difficulty was the lack of sexual desire. There was a difference in the sexual life of women according to different infant feeding methods. The level of overall sexual functions was lowest among exclusive breastfeeding mothers who are more likely to suffer from a lack of sexual interest and problems with lubrication, orgasm, and dyspareunia than formula-feeding mothers. Postpartum sexual life is hindered by several factors, where breastfeeding and prepregnancy sexual life seem to play an important role. Further investigation is needed to assess the effect of breastfeeding with other influencing factors on female sexual life.

Footnotes

Disclosure Statement

No competing financial interests exist.

Funding Information

The authors received no financial support for the research, authorship, and/or publication of this article.

References

Laumann

, Paik

, Rosen

. Sexual dysfunction in the United States: Prevalence and predictors. JAMA, 1999; 281:537–544.

Shifren

JLM

, Monz

BUM

, Russo

PAP

, et al. Sexual problems and distress in United States women: Prevalence and correlates. Obstet Gynecol, 2008; 112:970–978.

Barrett

, Pendry

, Peacock

, et al. Women's sexual health after childbirth. BJOG, 2000; 107:186–195.

Signorello

, Harlow

, Chekos

, et al. Postpartum sexual functioning and its relationship to perineal trauma: A retrospective cohort study of primiparous women. Am J Obstet Gynecol, 2001; 184:881–888.

Borders

. After the afterbirth: A critical review of postpartum health relative to method of delivery. J Midwifery Womens Health, 2006; 51:242–248.

Connolly

, Thorp

, Pahel

. Effects of pregnancy and childbirth on postpartum sexual function: A longitudinal prospective study. Int Urogynecol J Pelvic Floor Dysfunct, 2005; 16:263–267.

Hughes

. Management of postpartum loss of libido. J Fam Health Care, 2008; 18:123–125.

World Health Organization. Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services. 2017. Available at https://apps.who.int/iris/bitstream/handle/10665/259386/9789241550086-eng.pdf?sequence=1 (accessed August 6, 2020).

Kohorsz. Csecsemők táplálása. 2018. Available at https://kohorsz18.hu/eredmenyek/elozetes-eredmenyek/49-csecsemok-taplalasa.html (accessed August 6, 2020).

10.

Escasa-Dorne

. Sexual functioning and commitment to their current relationship among breastfeeding and regularly cycling women in Manila, Philippines. Hum Nat, 2015; 26:89–101.

11.

Albustan

, Eltomi

, Faiwalla

, et al. Maternal sexuality during pregnancy and after childbirth in muslim Kuwaiti women. Arch Sex Behav, 1995; 24:207–215.

12.

Yee

, Kaimal

, Nakagawa

, et al. Predictors of postpartum sexual activity and function in a diverse population of women. J Midwifery Womens Health, 2013; 58:654–661.

13.

Barrett

, Peacock

, Victor

, et al. Cesarean section and postnatal sexual health. Birth, 2005; 32:306–311.

14.

Trivino-Juarez

, Romero-Ayuso

, Nieto-Pereda

, et al. Resumption of intercourse, self-reported decline in sexual intercourse and dyspareunia in women by mode of birth: A prospective follow-up study. J Adv Nurs, 2018; 74:637–650.

15.

LaMarre

, Paterson

, Gorzalka

. Breastfeeding and postpartum maternal sexual functioning: A review. Can J Hum Sex, 2003; 12:151–168.

16.

Lagaert

, Weyers

, Van Kerrebroeck

, et al. Postpartum dyspareunia and sexual functioning: A prospective cohort study. Eur J Contracept Reprod Health Care, 2017; 22:200–206.

17.

Anbaran

, Baghdari

, Pourshirazi

, et al. Postpartum sexual function in women and infant feeding methods. J Pak Med Assoc, 2015; 65:248–252.

18.

Matthies

, Wallwiener

, Sohn

, et al. The influence of partnership quality and breastfeeding on postpartum female sexual function. Arch Gynecol Obstet, 2019; 299:69–77.

19.

Rosen

, Brown

, Heiman

, et al. The Female Sexual Function Index (FSFI): A multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther, 2000; 26:191–208.

20.

Wiegel

, Meston

, Rosen

. The Female Sexual Function Index (FSFI): Cross-validation and development of clinical cut off scores. J Sex Marital, 2005; 31:1–20.

21.

Chayachinda

, Titapant

, Ungkanungdecha

. Dyspareunia and sexual dysfunction after vaginal delivery in Thai primiparous women with episiotomy. J Sex Med, 2015; 12:1275–1282.

22.

Wallwiener

, Muller

, Doster

, et al. Sexual activity and sexual dysfunction of women in the perinatal period: A longitudinal study. Arch Gynecol Obstet, 2017; 295:873–883.

23.

DeJudicibus

, McCabe

. Psychological factors and the sexuality of pregnant and postpartum women. J Sex Res, 2002; 39:94–103.

24.

Fuentealba-Torres

, Cartagena-Ramos

, Lara

LAS

, et al. Determinants of female sexual function in breastfeeding women. J Sex Marital Ther, 2019; 45:538–549.

25.

Yilmaz

, Taplak

, Polat

. Breastfeeding and sexual activity and sexual quality in postpartum women. Breastfeed Med, 2019; 14:587–591.

26.

O'Malley

, Higgins

, Begley

, et al. Prevalence of and risk factors associated with sexual health issues in primiparous women at 6 and 12 months postpartum; a longitudinal prospective cohort study (the MAMMI study). BMC Pregnancy Childbirth, 2018; 18:196.

27.

Avery

, Duckett

, Frantzich

. The experience of sexuality during breastfeeding among primiparous women. J Midwifery Womens Health, 2000; 45:227–237.

28.

Khajehei

, Doherty

, Tilley

PJM

, et al. Prevalence and risk factors of sexual dysfunction in postpartum Australian women. J Sex Med, 2015; 12:1415–1426.

29.

Convery

, Spatz

. Sexuality and breastfeeding: What do you know?. MCN Am J Matern Child Nurs, 2009; 34:218–223.

30.

Polomeno

. Sex and breastfeeding: An educational perspective. J Perinat Educ, 1999; 8:30–40.

31.

Olsson

, Lundqvist

, Faxelid

, et al. Women's thoughts about sexual life after childbirth: Focus group discussions with women after childbirth. Scand J Caring Sci, 2005; 19:381–387.

32.

Byrd

, Hyde

, DeLamater

, et al. Sexuality during pregnancy and the year postpartum. J Fam Pract, 1998; 47:305–308.

33.

Eidelman

. Sexual activity, psychosocial dynamics, and cultural context impact on breastfeeding rates. Breastfeed Med, 2019; 14:519–520.

34.

Martinez-Galiano

, Hernandez-Martinez

, Rodriguez-Almagro

, et al. Relationship between parity and the problems that appear in the postpartum period. Sci Rep, 2019; 9:911763.

35.

Fehniger

, Brown

, Creasman

, et al. Childbirth and female sexual function later in life. Obstet Gynecol, 2013; 122:988–997.

36.

Yilmaz

, Avci

, Aba

, et al. Sexual dysfunction in postpartum Turkish women: It's relationship with depression and some risk factors. Afr J Reprod Health, 2018; 22:54–63.