Sexual function is one of the parameters affecting female life and life quality. Sexual dysfunction has been studied mostly on males. Lauman et al. recorded the incidence of sexual dysfunction in males as 31 % and females as 43% ( 1 ). Sexual functions may be deteriorated at one or more of the levels of sexual desire, excitement, lubricity, orgasm, satiety and pain and discomfort may arise during a sexual intercourse. Sexual functions are affected by many physical, psychological and social factors. Some metabolic syndromes, chronic diseases, obesity, presence of male sexual dysfunction, age, psychological stress, menopause, urinary incontinence, may increase the possibility of female sexual dysfunction( 2 ). One of the factors associated with sexual functions is the mode of delivery. Many parameters such as mode of delivery, number of episiotomies, the interval between deliveries are included in the research topics of former studies assessing sexual function. In this study, we aimed to examine if the mode of delivery is effective in sexual functions.

Between June 2017 and January 2018, 184 volunteer women aged 18-49 years were included in the study. Women who labored at least six months ago and who did not have any systemic diseases were included.

Women who were lactating or using medications for any systemic or psychiatric illness, menopausal, nulliparous, had genital system operation except cesarean were excluded from the study. The study was conducted after approval from the Ethics Committee of Ahi Evran University Faculty of Medicine was obtained (No: 2017-09/86). Women were divided into three groups as Group 1 who delivered vaginally, Group 2 who delivered by cesarean and Group 3 who delivered with both cesarean and vaginal birth. Demographic variables were recorded. Female sexual function index scoring questionnaire (FSFI) used by Rosen et al. was translated into Turkish and adapted for Turkish women and used in the study ( 3 , 4 ). This form was designed to evaluate sexual desire, excitement, lubricity, orgasm, satiety, and dyspareunia. Sexual functions at last four weeks were evaluated and rated between 4 and 43. The distribution of data was analyzed by Kolmogorov-Smirnov and Shapiro Wilk tests. Descriptive statistics of continuous variables were expressed as a mean ± standard deviation. Chi-square test was used for analysis of categorical variables. The effect of mode of delivery on age, sexual desire, excitement, lubricity, orgasm, dyspareunia and satiety on the total FSFI score was analyzed by ANOVA test. Statistically different means determined by ANOVA were analyzed by DUNCAN multiple comparison and lettered. α significance level was accepted as 0.05. Statistical Package for Social Sciences (SPSS) version 21 Software for Windows program was used for statistical analysis.

Demographic variables are shown in Table-1. The comparison of sexual functions according to the mode of delivery is presented in Table-2. There was no statistically significant difference between the groups in total FSFI scores. Lubrication, orgasm, satisfaction scores were significantly higher in group 3. The variation of FSFI according to age is presented in Table-3. In terms of total FSFI scores, there was no correlation between FSFI score and age. Sexual desire scores were significantly low at ages between 41 and 49 (6.14±3.19, p<0.0001). Variation of FSFI according to educational status is shown in Table-4. The total FSFI score of the literate group was significantly lower (p<0.0001). As the educational status advances FSFI increases, although it is not statistically significant. There was no significant difference between the groups only in terms of orgasm scores (p=0.278).

Variation of FSFI according to working status is presented in Table-5. There was no significant difference in total FSFI scores between working and nonworking women (p=0.193). Variation of FSFI according to marital status is shown in Table-6. As the duration of marriage increases FSFI scores decreases significantly (p=0.014). FSFI scores of women in the first decade of marriage were significantly higher. Variation of FSFI according to the living area is presented in Table-7. There was no effect of living area on FSFI scores (p=0.992).

Variation of FSFI according to a number of births is presented in Table-8. There was no effect of a number of birth on FSFI total scores (p=0.171). The sexual desire scores of women with 4 births were significantly lower (p=0.012). Variation of FSFI according to episiotomies is presented in Table-9 (at most one episiotomy was performed for each delivery). There was no statistically significant difference in total FSFI scores between the groups (p=0.144). There was a significant difference in the excitement, lubrication, orgasm scores between the groups. The excitement scores of women who have no episiotomy or 2 episiotomies were significantly higher (p<0.0001). The lubrication scores of women with 3 episiotomies were significantly lower (p<0.000). The orgasm scores of women with two episiotomies were significantly higher (p<0.002).

Sexual functions are affected by many factors such as hormones, socioeconomic status, and psychological factors _. In the study, we examined the effect of mode of delivery on sexual functions in long-term. It is assumed that the pelvic floor may be damaged due to delivery, especially after vaginal births some problems like dyspareunia may arise and this is less possible after cesarean delivery ( 5 ).

Signorello et al. concluded that operative vaginal births increase dyspareunia at 3 and six-month periods after birth ( 6 ). Suntara et al. reported that sexual function disorder prevalence during the first three months of the postpartum period was 52% for vaginal delivery, 34% for cesarean delivery ( 7 ). Güngör et al. examined the primiparous women who delivered at least one year ago and found that women who delivered with cesarean had higher FSFI and lower prevalence of sexual function disorders than women who delivered vaginally with episiotomy ( 8 ). We examined women who delivered at least six months ago and concluded that the mode of delivery did not affect the FSFI score in the long term. There are conflicting results of researches evaluating the postpartum six months or later period. Buhring et al. found no difference between vaginal birth and cesarean in terms of dyspareunia whereas Safarinejad et al. found higher FSGI scores in an elective cesarean group than the vaginal birth group ( 9 , 10 ). We composed a third group different from the literature that is our third group, women who delivered with both vaginally and cesarean. In this group, the lubrication, orgasm and satisfaction scores were significantly higher. The mean age of this group was 47.5±2.43, and this was significantly higher than the other groups. The difference may be due to experience and harmony between partners rather than a mode of delivery. The number of women in the third group was low, so it is necessary to make researches with ahigher number of participants. There was no significant difference in FSFI scores between groups according to age. Only sexual desire score was significantly low at ages between 41 and 49. Laumann et al. concluded that older ages had adverse effects on FSFI ( 1 ). Whereas Güvel et al. recorded that age did not affect FSFI scores ( 11 ). Our upper limit for age was 49, so there was no correlation between age and FSFI. The total FSFI score of the literate group was significantly lower (p<0.0001). As educational status advances FSFI increases, although it is not statistically significant. There was no significant difference between the groups regarding orgasm scores (p=0.278). Güvel et al. recorded that duration of marriage was a negative risk factor whereas Çayan et al. didn’t accept it like that ( 11 , 12 ). We found that as the duration of marriage increases FSFI scores decrease. Klein et al. concluded that the median episiotomy detoriated sexual function ( 13 ). We found that existence and number of episiotomy do not effect FSFI scores.

In conclusion, our study shows that the mode of delivery does not affect FSFI scores in the long term.