The Impact of Mode of Birth, and Episiotomy, on Postpartum Sexual Function in the Medium- and Longer-Term: An Integrative Systematic Review

(1) Background: Sexual function can be affected up to and beyond 18 months postpartum, with some studies suggesting that spontaneous vaginal birth results in less sexual dysfunction. This review examined the impact of mode of birth on sexual function in the medium- (≥6 months and <12 months postpartum) and longer-term (≥12 months postpartum). (2) Methods: Literature published after January 2000 were identified in PubMed, Embase and CINAHL. Studies that compared at least two modes of birth and used valid sexual function measures were included. Systematic reviews, unpublished articles, protocols and articles not written in English were excluded. Quality was assessed using the Newcastle Ottawa Scale. (3) Results: In the medium-term, assisted vaginal birth and vaginal birth with episiotomy were associated with worse sexual function, compared to caesarean section. In the longer-term, assisted vaginal birth was associated with worse sexual function, compared with spontaneous vaginal birth and caesarean section; and planned caesarean section was associated with worse sexual function in several domains, compared to spontaneous vaginal birth. (4) Conclusions: Sexual function, in the medium- and longer-term, can be affected by mode of birth. Women should be encouraged to seek support should their sexual function be affected after birth.


Introduction
Birth can have profound effects on women's lives, including on their sexual function in the longer-term. Decreased sexual functioning is an important indicator of maternal morbidity [1], and determinant of quality of life in women of reproductive age; sexual dysfunction rates were found to be up to 64% at six months postpartum, and that approximately 6.4% of women experienced no physical pleasure in their sexual relationships at 18 months postpartum [2][3][4].
The American Psychiatric Association defines sexual function as "a person's ability to respond sexually or to experience sexual pleasure" [5]. Up until the publication of DSM-V, women's and men's sexual responses were thought to follow the same linear pattern (desire, arousal, pattern) [6]. It is now recognised that different genders differ in their sexual function [7]. Additionally, it is recognised that what is considered 'normal' sexual function Both quantitative and mixed method studies were eligible for inclusion in this review, including cohort studies, cross-sectional studies, case-control studies and randomised controlled trials. Systematic reviews, unpublished results or studies, protocols, studies not written in English or written prior to 2000 were excluded. In order to be included, studies must have compared at least two different modes of birth. To facilitate clinical usability of this review, as well as provide a useful framework for this review and other studies in the future, specific modes of birth were the main focus of the review. Therefore, studies that compared data on spontaneous vaginal birth, vaginal birth with episiotomy, assisted vaginal birth, planned (elective) caesarean section and emergency caesarean section were included. The secondary focus of this review were comparisons that incorporated multiple modes of birth in each category, as some studies combine multiple modes of birth into one group. Therefore, studies that compared non-specific mode of birth groups such as vaginal birth (without differentiation between spontaneous vaginal birth, vaginal birth with episiotomy or assisted vaginal birth), vaginal birth with breech presentation, and caesarean section (without differentiation between planned and emergency caesarean section) were included. Only episiotomy was considered, rather than other perineal trauma, as it is an intervention performed (or not) by a health care professional during birth, whereas other perineal trauma happens as a result of birth. In order to ensure comparability of the studies, only studies that used a validated sexual function measure were included.

Valid Measures of Sexual Function
All of the measures of sexual function used in the studies included in this review are self-reported measures. The measures contain questions/statements, to which women report on their sexual function, by rating their sexual function using a numeric/Likert scale. A measure was considered to be a valid measure for sexual function if it has undergone psychometric evaluation and its psychometric properties were found to be acceptable.
The Female Sexual Function Index (FSFI) consists of 19 items embedded in six domains (desire, arousal, lubrication, orgasm, satisfaction and pain). The theoretical range is 2.0 to 36.0, with higher total FSFI-scores indicating better sexual functioning [37]. A cut off of ≤26.55 is commonly used to report a dichotomous FSFI-score indicating sexual dysfunction [38]. The FSFI has been evaluated in terms of psychometric quality, which was found to be good in women with varying parity [37,39].
The Golombok Rust Inventory of Sexual Satisfaction (GRISS) for women consists of 28 items embedded in seven subscale domains (non-communication, infrequency, dissatis-faction, avoidance, non-sensuality, vaginismus, anorgasmia). The raw score is converted into a transformed score ranging between one and nine, which can be used to produce a diagnostic profile. A transformed score greater than or equal to 5 indicates sexual dysfunction [40][41][42]. The GRISS has been evaluated in terms of psychometric quality, which was found to be good [40].
The Sexual Health Outcomes in Women Questionnaire (SHOW-Q) has 12 items embedded in four subscales (satisfaction, orgasm, desire, pelvic problem interference). It was designed to be used on a diverse range of women, including women in same sex relationships, women who are sexually active without a partner, and sexually inactive women. All items are scored on a scale from zero to 100. For three of the subscales (satisfaction, orgasm, desire), higher scores represent better sexual function. For the final subscale (pelvic problem interference), higher scores indicate worse sexual function. After reversal of the pelvic problem interference scores, all items are totalled for an overall score with a theoretical range of zero to 400 [43]. Lower total scores indicate worse sexual functioning [43,44]. The SHOW-Q has been evaluated in terms of psychometric quality, which was found to acceptable in women with varying parity [44].
The Sexual Activity Questionnaire (SAQ) has 21 items embedded in three scales (pleasure, discomfort and habit). Each question has weighted loadings to create factor scores, with high scores in the pleasure domain representing high pleasure, and low scores in the discomfort domain representing low levels of discomfort. The habit domain is a single question and the value given as the answer is the score for this domain, with more habitual regular sexual activity resulting in higher scores. Each question is rated using a four-point Likert scale from 0 to 3, with the total score ranging from 0 to 30 [45,46]. The SAQ has been evaluated in terms of psychometric quality, which was found to be good [47,48].
The Sexual Function Questionnaire (SFQ28) has 28 items embedded in eight domains (desire, arousal (sensation), arousal (lubrication), arousal (cognitive), orgasm, pain, enjoyment, partner (questions regarding women's opinion of their sexual life with their partner)). Lower scores indicate increased probability of sexual dysfunction. Overall total score has a theoretical range of 14 to 170. Each domain is scored separately, with different ranges of scores indicating sexual dysfunction. For all domains, lower scores indicate worse sexual functioning [49,50]. The SFQ28 has been evaluated in terms of psychometric quality, which was found to be good [51].
The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) is a 12-item questionnaire that measures three domains: behavioural-emotive, physical and partner/related (questions regarding women's opinion of their sexual life with their partner). Each item is graded on a five-point Likert scale from always (zero) to never (zero). The behavioural-emotive items are reversely scored. Higher scores indicate better sexual functioning, with a maximum total score of 48 [52,53]. The PISQ-12 has been evaluated in terms of psychometric quality, which was found to be good in women with varying parity [52,54].

Classification of the Medium-and Longer-Term Studies
Results from the sexual function measures were categorised into medium-and longerterm: studies that collected data at beyond or equal to six months postpartum and at less than 12 months postpartum were classified as medium-term, whereas those that collected data at beyond or equal to 12 months postpartum were classified as longer-term.

Selection of the Studies
Studies that were identified as potentially eligible for inclusion were exported to Rayyan, a systematic review reference management tool. Duplicates were removed. When deciding which studies to include, two researchers (AMF, NG) independently screened the titles and abstracts. From there, full texts were evaluated for their eligibility by the two researchers, based on inclusion and exclusion criteria. Any inconsistency between researchers on whether studies should be included or not were discussed further in order to come to an agreement. If agreement could not be reached, a third author (LP) was involved in the discussion. Information on study design, location of study, descriptive characteristics of participants, types of modes of birth, the measure of sexual function, and the results of those studies related to mode of birth and sexual function was then extracted.

Quality Assessment
Quality of the included studies was assessed by two researchers (AMF, NG) independently using the Newcastle Ottawa Scale (NOS) [55]. The NOS tool was "developed to assess the quality of non-randomised studies" for use in systematic reviews and metaanalyses. The NOS has three domains: selection, comparability and exposure. The selection domain covers representativeness of the studied population in the community, selection of the non-exposed cohort, ascertainment of exposure, and demonstration that the outcome of interest was not present at start of the study [55]. The comparability domain assesses control for confounding variables. The outcome domain covers assessment of the outcome, length of the follow up and adequacy of follow up. Each domain contains several questions with multiple choice answer options. A maximum of one star can be awarded for each question [55]. We adapted the NOS, as self-reported measures of sexual function were considered the gold standard for assessing sexual measures by the authors, since sexual function can only be reported by the person experiencing it. The NOS was adapted by awarding a star for the assessment of outcome question, in the outcome domain.
A scoring system developed by  was used to group the included studies by quality score: a study was rated good quality if it scored three or four stars in selection, one or two stars in comparability, and two or three stars in outcomes. A study was rated fair quality if it scored two stars in selection, one or two stars in comparability and two or three stars in outcome. A study was rated poor quality if it scored zero or one star in selection, or zero stars in comparability, or zero or one star in outcomes [56,57]. Tabular explanations of the domains and the scoring system are presented in Tables S1 and S2 of the Supplementary Materials, respectively.

Data Extraction and Analysis
Data from the included studies was extracted and reported using the Population, Exposure, Comparator and Outcomes (PECO) framework [58]. Extracted information included the author(s), year of publication, country, population (number of participants, ethnicity, age, parity), exposure/comparator (mode of birth), outcomes (measure used to assess the level of sexual function, interval from birth to sexual function measurement) and the main findings. The main findings show the impact between modes of birth and sexual function with 1) associations (crude or adjusted): this includes odds ratios with 95% confidence intervals, or relative risk with 95% confidence intervals 2) differences between modes of birth and accompanying mean (standard deviation) or median (interquartile range) sexual function scores.

Search
In total, 6509 studies were identified in database searches. After removing the duplicates, screening of the titles and abstracts against the inclusion and exclusion criteria was carried out, as well as checking references and similar articles, 112 studies remained. These studies were further evaluated based on the full texts, of which 31 were included in the review. A detailed overview of the search, screening and selection process is presented in a PRISMA flowchart (Figure 1). A list of the studies that were excluded after reading the full text, and the reasons for their exclusion, is presented in Table S3 of the Supplementary  Materials. carried out, as well as checking references and similar articles, 112 studies remained. These studies were further evaluated based on the full texts, of which 31 were included in the review. A detailed overview of the search, screening and selection process is presented in a PRISMA flowchart (Figure 1). A list of the studies that were excluded after reading the full text, and the reasons for their exclusion, is presented in
Mean score for FSFI domain pain was significantly worse at 1 year postpartum in AVB group (mean = 2.9, SD ± 0.3) compared to other mode of birth groups (SVB mean = 4.3, SVB SD ± 0.7; VBE mean = 3.4, VBE SD ± 0.6; pCS mean = 3.6, pCS SD ± 0.6; eCS mean = 3.6, eCS SD ± 0.8), p ≤ 0.001 No significant difference for an total mean FSFI score between modes of birth groups. No significant differences for total FSFI score (median) found between mode of birth groups at 10-12 months postpartum.
There were 17 different modes of birth comparisons; the most common comparison was between vaginal birth (without differentiation between spontaneous vaginal birth, vaginal birth with episiotomy and assisted vaginal birth) and caesarean section (without differentiation between planned and emergency caesarean section) ( Table 1). None of the included studies compared modes of birth in cases of breech presentation.

Quality Assessment
Of the included studies, 21 were of a good quality, nine studies were rated as having a fair quality and one study was rated as being of a poor quality (Table 2).       Three studies showed three statistically significant associations between mode of birth and sexual function in the medium-term (Table 3) [64,77,80].
One study showed a statistically significant adjusted association between mode of birth and sexual function in the medium-term. Planned caesarean section was associated with better total sexual functioning scores and better scores for arousal, lubrication and orgasm when compared to assisted vaginal birth [80].
Two studies showed two statistically significant crude associations between mode of birth and sexual function in the medium-term. Spontaneous vaginal birth was associated with better total sexual functioning scores when compared to assisted vaginal birth [77]. Planned caesarean section was associated with better total sexual functioning scores and better scores for arousal, lubrication, orgasm, satisfaction and pain when compared to vaginal birth with episiotomy [64] (Table 3).
Six studies that showed no statistically significant associations between mode of birth and sexual function in the medium-term [62,69,78,83,87,88] (Table 3). Zgliczynska et al. 2021 [77] SVB protective 1 Adjusted association between mode of birth and sexual function Crude association between mode of birth and sexual function No association between mode of birth and sexual function No association calculated between mode of birth and sexual function SVB = spontaneous vaginal birth, VBE = vaginal birth with episiotomy, AVB = assisted vaginal birth, pCS = planned caesarean section, eCS = emergency caesarean section; Domains: 1 Total sexual function score, 2 Arousal, 4 Lubrication, 5 Orgasm, 6 Satisfaction, 7 Pain.
Two studies showed two statistically significant adjusted associations between mode of birth and sexual function in the longer-term. Assisted vaginal birth was associated with increased odds of pain at 12 months postpartum, in comparison with spontaneous vaginal birth [86]. Planned caesarean section was associated with an increased risk of pain and loss of desire at six years postpartum when compared to spontaneous vaginal birth [82].
Four studies showed 23 statistically significant crude associations between mode of birth and sexual function in the longer-term. Spontaneous vaginal birth was associated with better scores pain when compared to assisted vaginal birth [88]. Vaginal birth with episiotomy was associated with worse overall sexual function and worse scores for arousal and orgasm when compared to planned caesarean section [60]. Assisted vaginal birth was associated with worse scores for orgasm and satisfaction when compared to planned caesarean section [65]. One study showed mixed results for associations between modes of birth and sexual function [76] (Table 4). Four studies showed no statistically significant associations between mode of birth and sexual function in the longer-term [62,75,78,83] (Table 4). Seven studies showed 12 statistically significant associations between mode of birth and sexual function in the medium-term (Table 5) [67,71,77,[79][80][81]89]. Four studies showed five statistically significant adjusted associations between mode of birth and sexual function in the medium-term. Vaginal birth with episiotomy was associated with worse total sexual functioning scores and worse sexual functioning scores for desire, compared to caesarean section (without differentiation between planned and emergency caesarean section) [71]. Assisted vaginal birth was associated with worse sexual functioning scores for orgasm when compared to vaginal birth (without differentiation between spontaneous vaginal birth and vaginal birth with episiotomy) [80]. Caesarean section (without differentiation between planned and emergency caesarean section) was associated with better sexual functioning scores for arousal, desire and lubrication when compared to assisted vaginal birth [79]. Vaginal birth (without differentiation between spontaneous vaginal birth, vaginal birth with episiotomy and assisted vaginal birth) was associated with better total sexual functioning scores when compared to caesarean section (without differentiation between planned and emergency caesarean section) [67], but was associated with worse sexual functioning scores for arousal, desire and lubrication when compared to caesarean section (without differentiation between planned and emergency caesarean section) [79].

Secondary Focus
Four studies showed seven statistically significant crude associations between mode of birth and sexual function in the medium-term. Spontaneous vaginal birth was associated with better sexual functioning scores for arousal, compared to vaginal birth (without differentiation between vaginal episiotomy and assisted vaginal birth) and caesarean section (without differentiation between planned and emergency caesarean section) [77]. Caesarean section (without differentiation between planned and emergency caesarean section) was associated with better total sexual functioning scores and better scores for lubrication and orgasm yet was associated with worse scores for pain when compared to vaginal birth with episiotomy [89]. Assisted vaginal birth was associated with better scores for sexual satisfaction with partner, compared to vaginal birth (without differentiation between spontaneous vaginal birth and vaginal birth with episiotomy [79]. Caesarean section (without differentiation between planned and emergency caesarean section) was associated with better total sexual functioning scores and better scores for pain and arousal, compared to vaginal birth (without differentiation between spontaneous vaginal birth, vaginal birth with episiotomy and assisted vaginal birth) [77,81] (Table 5).

Longer-Term Outcomes (≥12 Months Postpartum)
Four studies showed 6 statistically significant associations between mode of birth and sexual function in the longer-term (Table 6) [66,70,71,73].  [73] CS protective 8 CS protective 8 Fehniger et al. 2013 [66] VB protective 3 CS protective 3 Ghorat et al. 2017 [70] CS protective 2 Gungor et al. 2007 [61] Moghadam et al. 2019 [71] CS protective 3 Spaich et al. 2020 [78] Adjusted association between mode of birth and sexual function Crude association between mode of birth and sexual Two studies showed four statistically significant adjusted associations between mode of birth and sexual function in the longer-term. Caesarean section (without differentiation between planned and emergency caesarean section) was associated with increased satisfaction with vaginal tone when compared to spontaneous vaginal birth and assisted vaginal birth [73]. Assisted vaginal birth was associated with an increased risk of loss of desire at ≥10 years postpartum, when compared to vaginal birth (without differentiation between spontaneous vaginal birth and vaginal birth with episiotomy), and caesarean section (without differentiation between planned and emergency caesarean section) [66].
Two studies showed two statistically significant crude associations between mode of birth and sexual function in the longer-term. Caesarean section (without differentiation between pCS and eCS) was associated with better scores for desire when compared to vaginal birth with episiotomy [71], and better scores for arousal when compared to vaginal birth (without differentiation between spontaneous vaginal birth, vaginal birth with episiotomy and assisted vaginal birth) [70].

Overall
Various factors were considered important when comparing the studies included in this review: study design, sample size, parity, adjustment for confounders, longitudinal follow up and study quality. Comparative analyses were performed to evaluate whether associations varied between the studies that differed in these factors.
Based on the existing literature on sexual function, the confounders considered of great importance include: sexual (dys)function prior to pregnancy, (risk of) depression, breastfeeding status, parity and perineal tears [3,20, [28][29][30][31][32][33]. Of the 15 studies that adjusted for any confounders in the analysis, nine adjusted for at least one of the most important confounders [68,73,74,77,80,82,83,85,86]. The other six studies adjusted for demographic and general health characteristics only [66,67,71,72,75,79]. No difference was seen in the results of the studies that adjusted for most important confounders and those that did not.
Of the longitudinal studies that were included, some showed no differences in associations between mode of birth and sexual functioning across various time points [62,74,78,83,85]. Some studies showed improved sexual function scores over time [71,77,89]. One longitudinal study showed worse sexual function scores for assisted vaginal births compared to spontaneous vaginal births for the domain pain at 12 months postpartum. This association was, however, not present at six months postpartum [88].
When comparing the results based on the quality of studies, no differences were seen in associations between studies that were of poor, fair and good quality.

Discussion
The main focus of our review was to examine the impact of specific mode of birth on medium-and longer-term sexual functioning. Our review shows that there are significant associations between mode of birth and women's sexual function in both the medium-and longer-term. Adjusted associations showed that: assisted vaginal birth was associated with worse sexual function (overall sexual function, and arousal and lubrication domains) when compared to planned caesarean section, in the medium-term (≥six months and <12 months postpartum); in the longer-term (≥12 months postpartum), spontaneous vaginal birth was associated with better sexual function when compared to assisted vaginal birth (pain domain) and planned caesarean section (desire and pain domains). In both the mediumand longer-term, assisted vaginal birth was consistently associated with worse sexual function, compared to other modes of birth.
In regard to the secondary focus of this review (multiple modes of birth combined into one groups), no consistent pattern was shown by adjusted associations to reflect that one mode of birth group was associated with better/worse sexual function compared to another, in the medium-or longer-term.
The results from both the main and secondary focus of this review suggest that sexual dysfunction does not necessarily resolve in the first year postpartum, and that assisted vaginal birth can have lasting effects on sexual function past 12 months postpartum.
Many studies included in this review show that mode of birth is not associated with postpartum sexual functioning in the medium-and longer-term. This supports the findings of Nikolaidou in their systematic review, on the effect of mode of birth on sexual function in the short-and medium-term (up until 12 months postpartum) [36].
The associations shown in this review between assisted vaginal birth, as well as vaginal birth with episiotomy, and worse sexual function can be linked to mechanisms of injury surrounding these operative interventions: assisted vaginal birth is associated with a higher incidence of episiotomy and severe perineal trauma, as well as pelvic floor trauma and nerve damage which can affect sexual function [91][92][93][94][95]. Worse sexual function after planned caesarean section compared to spontaneous vaginal birth could be contributed to by the increased probability of wound problems/scar pain due to the abdominal incision that is involved in caesarean sections as wound problems (both relating to caesarean abdominal wounds and perineal trauma in spontaneous vaginal births) are associated with impaired general sexual health [96]. The protective effect on sexual function that was seen with planned caesarean section could be because women who undergo caesarean section have less pelvic floor trauma compared to those who have had a vaginal birth [95,[97][98][99]. However, it must be noted that caesarean section is a major operation that can have serious implications for maternal health and should not be considered solely to preserve sexual function [100].
The included studies varied by study design, sample size, adjustment for confounders, and study quality, however the associations seem not to be affected by these differences.
The longitudinal improvement in sexual function could be due to the natural course of recovery after birth [101]. On the other hand, the worsening of sexual function over time could indicate that, if left untreated, postpartum sexual pain could get worse for those who had an assisted vaginal birth. However, worsening of postpartum sexual function over time could also be related to other postpartum risk factors such as breastfeeding, fatigue or stress [102].

Strengths and Limitations
The main strength of this integrative review is that only studies using validated measures to assess sexual functioning were included, allowing direct comparison between the studies, as well as increasing the ability to draw clinical implications from the results. Multiple mode of birth and intervention combinations were investigated. Additionally, we focused on the effects beyond six months postpartum, and did not limit the period of interest to a certain time after birth, meaning studies were included that examined associations up to and greater than 10 years postpartum. The majority of studies included in this review were of good quality.
Despite the strengths of this review, some limitations should be noted. When calculating associations between mode of birth and sexual function, some of the included studies did not adjust for important confounding factors in the analysis. Sexual function can be influenced by many factors, including postpartum stress and fatigue, managing relationships with partner (if applicable), life stressors (such as relationship with family, friends and work), breastfeeding, experiences during previous births, history of sexual abuse and degree of sexual dysfunction before pregnancy and birth [3,20, [28][29][30][31][32][33]. Without accounting for these factors, any associations, or lack of, may be misrepresented.
Despite the evidence showing the difference between male and female sexual function, some measures of sexual function are based on dated evidence which suggests that women's sexual function is equivalent to men's sexual function [103], even though this evidence has been found to ignore "major components of women's sexual satisfaction" [104], and is a more appropriate reflection of male sexuality [8]. In addition, the measures used by the studies included in this review have not yet been validated in postpartum women.
An additional limitation that should be noted is the lack of consensus on reporting standards in the papers: reporting for mode of births, as well as adjustment for confounding, was not consistent across the papers included in this review.
Two studies examined sexual function at and beyond six years postpartum and found significant adjusted associations with mode of birth [66,73]. Although it is important to examine longer-term postpartum sexual functioning, it should be noted that such a long time gap between birth and measurement of postpartum sexual function means that other factors, besides mode of birth and those adjusted for, may affect sexual function (e.g., menopause, mental health, physical health relationship satisfaction, relationship with child) [3, 20,[24][25][26][27][28][29][30][31][32][33].
Many of the included studies did not adjust for important confounders, with only nine of 31 studies adjusting for at least one of the most important confounders. Therefore, this needs to be considered as a limitation and taken into account when interpreting any associations reported in this review.

Recommendations
Future studies should take into account pre-existing sexual dysfunction, quality of the relationship between the parents before and after birth, experienced birth trauma and the model of care experienced, in order to elucidate whether these factors can explain the associations found between mode of birth and sexual function.
Another avenue of research that should be explored is how the health care a woman receives, if any, during the postpartum period affects sexual function. Given how important sexual functioning can be for a woman [1][2][3][4], future research should aim to identify types of care that can help avoid a decline in postpartum sexual function.
Additionally, studying women who have more complex births and are underrepresented in the current literature should be made a priority: for example, many studies excluded women who did not have a singleton birth despite the fact that the proportion of twin births out of total births (per 1000 births) is 14.4 in Europe [105]. In a similar vein, some studies excluded births of babies that were not in cephalic presentation, despite the fact that approximately three to five per cent of women give birth to a child in a breech presentation [106,107].
There is some evidence that incidence of perineal trauma after birth varies between different ethnic groups; a systematic review showed that the majority of studies conducted in Western countries describe women of Asian ethnicity as having increased risk of severe perineal trauma during birth, whereas Asian women living in Asia were not at increased risk. The reasons for this were unknown but could be attributed to differing care that women from different ethnic groups receive, differing birthing techniques, ethnic anatomical differences or cultural differences, and changes in diet when moving to Western countries [108,109]. Therefore, the diversity of the study population, within the geographical area that the study is conducted in, should be disclosed and associations between different ethnicities should be explored in order to attempt to explain why some ethnicities can be at higher risk during labour and birth, as well as during the postpartum period.
It would be valuable to contextualise sexual functioning scores by asking women more in depth, follow-up questions about their postpartum sexual function. This would help to understand why associations exist in the quantitative data, and identify how postpartum care, focused on sexual function, could help women. It is of vital importance that measures are validated in postpartum women. Additionally, it is important that sexual function measures and have undergone cross-cultural validation, for both linguistics and culture, when they are used to measure sexual function in women whose cultural backgrounds differ from those that the measures were originally validated in.

Conclusions
This integrative review summarises the existing evidence on the impact of different modes of birth on sexual functioning, in the medium-(≥six months and <12 months postpartum) and longer-term (≥12 months postpartum), published between 2005 and 2023. Assisted vaginal birth has been found to be associated with worse sexual function when compared to spontaneous vaginal birth and caesarean section in both the medium-and longer-term. However, it should also be noted that some studies showed that spontaneous vaginal birth and caesarean section were associated with worse sexual function in comparison to other modes of birth. No mode of birth can be recommended to preserve sexual function in the medium-or longer-term. Therefore, it is important that postpartum sexual functioning is discussed with mothers for all modes of births, in order to encourage women to seek help and support from healthcare professionals should their sexual function be impaired after birth.
Supplementary Materials: The following supporting information can be downloaded at: https: //www.mdpi.com/article/10.3390/ijerph20075252/s1, Table S1: domains and options for quality assessment using NOS; Table S2: scoring system for quality assessment using NOS; Table S3: studies that were excluded after reading full text and reasons for exclusion.