Early resumption of postpartum sexual intercourse and its associated risk factors among married postpartum women who visited public hospitals of Jimma zone, Southwest Ethiopia: A cross-sectional study.

INTRODUCTION: Postpartum sexual resumption without the use of contraception is a risk for unintended and closely spaced pregnancies. Although counseling related to the resumption of postpartum sexual intercourse is a key component of postpartum sexual health, it is not widely addressed during the postnatal period. Thus, this study aimed to assess the early resumption of postpartum sexual intercourse and its associated risk factors among married postpartum women who visited public hospitals of Jimma zone, Southwest Ethiopia, for child immunization services.
METHODS: The facility-based cross-sectional study design was undertaken, and a systematic random sampling technique was carried out to select 330 participants. Data were collected using a pretested interviewer-administered questionnaire from August to September 2019. Obtained data were analyzed using descriptive statistics. A bivariate analysis was used to determine the significance of the association. Variables that showed association in the bivariate analysis at p-value <0.2 were fitted into a multivariable logistic regression model to control for confounders, and the significance of association was determined at p-value <0.05 with a 95% confidence interval (CI).
RESULTS: Approximately 53.9% of the respondents practiced early resumption of postpartum sexual intercourse. Factors such as low income (AOR = 0.19 (95% CI = 0.10-.37)), monogamous marriage 3.78(1.32-10.79), practicing sexual intercourse during pregnancy (AOR = 4.55 (95% CI = 1.29-15.97)), a cesarean delivery (AOR = 0.06 95%CI = (0.03-0.15)) and use of contraceptives (AOR = 3.7(95%CI = 1.92-7.14)) were significantly associated with early resumption of postpartum sexual intercourse. CONCLUSION AND RECOMMENDATION: The findings of this study suggested that, most postpartum mothers resumed sexual intercourse during the early postpartum period and its associated risk factors include low income, monogamous marriage, practicing sexual intercourse during pregnancy, cesarean delivery, and use of contraceptives. Discussion with couples about postpartum sexual health during the antenatal and postnatal period is crucial to prevent unwanted pregnancies and adverse health outcomes.

Introduction

Postpartum sexual health attributes include the resumption of sexual intercourse, sexual arousal, desire, orgasm, and sexual satisfaction [1]. Resumption of postpartum sexual resumption is defined as having the first penetrative vaginal sexual intercourse after childbirth [2].

Recent evidence showed that the period of postpartum sexual abstinence is decreasing globally. For instance, the result of a recent study conducted in Australia revealed that sexual abstinence for most women ends at 7 weeks of postpartum, showing a shift from the taboo against sexual intercourse after childbirth [3].

A study conducted in Nigeria among postpartum women found that 67.9% resumed sexual intercourse by 8 weeks following childbirth [4], similar to study conducted in Ethiopia which found that 73.4% of women resumed sexual intercourse after childbirth by 6 weeks [5]. Reportedly, the early resumption of postpartum sexual intercourse exposes many women to sexual and reproductive health problems such as sexual discomfort, due to incomplete healing of episiotomy or any lacerations [6, 7].

Consequently, postpartum mothers who resume sexual intercourse too soon after childbirth are at substantially greater risk for infections due to vaginal lesions and abrasions following the labor and delivery process than those who do not practice early resumption of sexual intercourse [6]. In addition, other evidence showed that a majority of mothers who have resumed postpartum sexual intercourse during the first three months typical experienced sexual morbidity such as dyspareunia, lack of vaginal lubrication, difficulty in achieving orgasm, vaginal loosening, lack of sexual desire, abnormal vaginal discharge, and genital tear [4, 6–8].

Furthermore, early resumption of postpartum sexual intercourse might cause unintended pregnancies that may result in numerous poor maternal and child health outcomes if not supplemented with effective contraceptive methods [9, 10].

Unpredictably, a research study conducted in Southeast Nigeria revealed that early resumption of sexual intercourse after childbirth has endangered child health by increasing the incidence of a childhood disease such as fever, diarrhea, measles, and tetanus that culminates in under-five mortality [11].

Factors like spontaneous vaginal delivery [3, 4, 8], a low parity [3, 4], low alive child [3, 4, 12], using contraceptive methods [4, 12], resumption of menses [4, 8], a monogamous marriage [4], and the young age of mothers [3, 4] were some of the factors affecting the early resumption of sexual intercourse among women in the postpartum period.

Though the World Health Organization (WHO) recommends that all women be evaluated regarding the resumption of sexual intercourse as a part of general assessment 2-6weeks following delivery, little attention has been given by researchers, policymakers, and health care providers [13].

Besides, in most developing countries, many postpartum women do not get information or counseling about postpartum sexual health during the antenatal and postnatal period when to resume sexual intercourse safely after delivery [4, 5, 8, 9]. Similarly in Ethiopia, most studies conducted on women’s health during the postpartum period focused primarily on family planning utilization [5, 10].

In conclusion, postpartum sexual health is one of the globally emerging agendas since sexual health can be significantly altered during pregnancy, birth, and postpartum [1, 2]. Postpartum counseling for women concerning the early resumption of sexual intercourse, and its associated risk factors remains poorly documented. Hence, this study was aimed to assess the early resumption of postpartum sexual intercourse and its associated risk factors among married women who visited public hospitals of Jimma zone for child immunization services.

Methods

Study area, study period, and study design

The facility-based cross-sectional study design was conducted in public hospitals of Jimma Zone, Southwest Ethiopia from August to September 2019.

Population

The source population of this study was all postpartum women who resumed sexual intercourse and visited public hospitals of the Jimma zone for child immunization services at 14 weeks after childbirth. The study population was postpartum women who resumed sexual intercourse and visited the selected public hospitals of Jimma zone for immunization services at 14th weeks after childbirth.

Inclusion and exclusion criteria

Married mothers who have resumed sexual intercourse and visited these hospitals for child immunization services at 14 weeks after childbirth were included in the study. Mothers who were critically ill during the study period were excluded from the study.

Sample size determination

The sample size for this study was determined by using a single population proportion formula with the following assumptions: p = 0.734 from a study conducted in Addis Ababa [5] and confidence interval = 95%, critical value z = 1.96 and degree of precision = 0.05 and considering a 10% non-response rate, the final sample size was 330.

Sampling procedures

Four out of seven public hospitals, namely; Shenen Gibe, Limmu, Seka, and Omo Nada hospitals were selected randomly by the lottery method. The final sample size was proportionally allocated for the four hospitals based on the previous six-month performance report of postpartum mothers visited in each hospital.

Sampling technique

The sampling interval of women was determined by dividing the total number of postpartum mothers visited for the previous six months from each hospital by the final sample size that was 4. The first study participant was selected by the lottery method and the subsequent study participants were selected systematically at every fourth interval until the allocated sample size was obtained from each hospital.

Study variables

Outcome variable

Early resumption of postpartum sexual intercourse (resumption of sexual intercourse before six weeks after childbirth).

Independent variables

The independent variables of this study include socio-demographic, reproductive and obstetric, sexual health-related variables.

Operational definitions and definition of terms

The timing of sexual intercourse resumption

Was categorized into resumption before 6 weeks (early/unrecommended period) = coded by 1 and after 6 weeks (recommended time) = coded by 0.

Unrecommended period for sexual resumption

Vaginal sexual intercourse which occurred within 6 weeks postpartum [

Recommended period for sexual resumption

Vaginal sexual intercourse initiated after 6 weeks postpartum [

Data collection tools and procedures

The questionnaire was prepared in the English language, translated to the Afaan Oromo language (Local language), and then back into the English language to ensure consistency. The questionnaire had both open and close-ended questions and categorized into four major parts:-Socio-demographic factors, obstetric and reproductive factors, postnatal, and sexual health-related factors. The reliability of the tool was checked by cronbach’s alpha which was 0.781. This tool also checked for validity by three professional experts and the experts’ feedbacks was incorporated into the final questionnaire which was used for the data collection.

Data were collected by structured questionnaires using a face-to-face interview. A two days training was given for data collectors and supervisors of the study and finally, data were collected by four bachelor degrees of science (B.Sc.) holder female midwives and two supervisors working in other health facilities and who have proved experience in data collection.

Data quality management

During the supervision, the quality, and completeness of gathered information by the data collectors was checked daily by the supervisors, and timely corrections were made and it could help a lot in improving the quality, consistency, and completeness of data for subsequent interviews. A pretest was undertaken on 10% of the calculated sample size before the actual data collection on women visiting immunization services at 14th weeks postpartum in Bedele hospital. Following the result of a pretest inconsistency, skipping problem, and wording ambiguity was seen and modified accordingly.

Data processing and analysis

Data were entered into the computer using data manager version 4.6 and exported to SPSS version 23 for analysis. And sexual intercourse resumption was coded by 1 for mothers who practiced sexual intercourse resumption before six weeks and a code by 0 for those who practiced sexual intercourse resumption after six weeks (recommended time).

Bivariate logistic regression analysis was used to show the significance of the association. The variable that showed the significant association in a bivariate analysis at p-value ≤ 0.2 [5] was entered into multivariable logistic regressions to control for confounding and the significance of association was determined at 95% confidence interval and p-value <0.05. The Hosmer-Lemeshow statistic p-value had a chi-square value of 10.3 and a significance level of 0.174 thus, the model is fit. Multi-collinearity was checked interaction among independent variables by a variance inflation factor (VIF) which was less than ten.

Ethical approval

Ethical clearance was obtained from the Institutional Review Board (IRB) of Mekelle University, College of Health Sciences, and brought to the Jimma zone Health Bureau and from there to respective selected hospitals. The data collectors gave detailed explanations on the purpose of the study, clarified that participation was voluntary. The informed written consent was obtained from each participant before the interview. In addition; informed written consent was taken from the parents or the legal guardian for the participants who were less than 18 years of age. The privacy of the participants was secured by interviewing them in a private classroom. The information provided by each respondent was kept confidential and de-identified.

Results

Socio-demographic characteristics

Of the total 330 sampled postpartum women, 319 participants have completed the interview and making a response rate of 96.7%. The mean age of participants was 27.88 years (SD ± 6.157) and About 277(86.8%) of the participants were having a monogamous relationship and 42(13.2%) were polygamous relationships. About 199(62.4%) participants were from urban residence and 120(37.6% were from rural residence and 198 (62%) participants have family monthly income of below or equal to the mean 1532 ETB and 121(37.9%) participants have above the mean (Table 1).

Table 1

Distribution of socio-demographic, reproductive and obstetric related characteristics among married postpartum women at the selected four Jimma zone Public Hospitals, August 15 to September 15, 2019.

N = 319.

Variables	Category	Frequency	Percent
Age	15–19	21	6.6
	20–24	78	24.5
	25–29	105	32.9
	30–34	58	18.1
	35–49	57	17.9
Ethnicity	Oromo	270	84.6
	Dawuro	17	5.3
	Gurage	12	3.8
	Kefa	13	4.1
	Others*	7	2.2
Religion	Muslim	268	84
	Orthodox Christian	33	10.4
	Protestant Christian	11	3.4
	Catholic	7	2.2
Educational status	No formal education	83	26.0
	Primary(1–8)	49	15.4
	Secondary(9–12)	95	29.8
	Diploma/Degree	92	28.8
Occupation	Housewife	185	58.0
	Private /self employed	50	15.7
	Government employed	55	17.2
	Merchant	15	4.7
	Others**	14	4.4
Duration of living together with husband	<2	102	32.0
	2–4	60	18.8
	>/ = 5	157	49.2
Parity	Primipara	155	48.6
	Multipara	88	27.6
	Grand multipara	76	23.8
Number of alive children	1–2	207	64.9
	3–4	36	11.3
	>/ = 5	76	23.8
Interpregnancy interval	<24	104	55.3
	24–47	49	26.1
	≥48	35	18.6
Index pregnancy status	Planned	249	78.1
	Un planned	70	21.9
ANC follow up for the last pregnancy	Yes	285	89.3
	No	34	10.7
ANC number	1–3	82	28.8
	>/ = 4	203	71.2
Obstetric complication during last pregnancy	Yes	51	16
	No	268	84
Type of complication	APH	18	35.3
	Hypertensive disorders	16	31.4
	PROM	12	23.5
	Other	5	9.8
Place of birth	Health center	77	24.1
	Governmental hospital	214	67.1
	Private clinic/Hospital	15	4.7
	Home	13	4.1
Labor duration in hrs.	<6	90	28.2
	6–12	160	50.2
	>12	69	21.6
Mode of birth	Vaginally delivery	257	81%
	Cesarean delivery	62	19%

NB: * = Silte, Yem, Amhara and

** = Student, daily laborer and

*** = Multiple pregnancy and Anemia

Obstetric and reproductive related characteristics

According to this study, the mean parity of mothers was 2.76(SD±2.32), and the mean living children were 2.79(SD± 2.37) and more than half of participants had 104(55.3%) interpregnancy intervals in less than two years. About 53 (28.2%) of participants reported a history of abortion and of this nearly half, 46.8 (86.8%) reported history of one abortion (Table 1).

Postnatal related characteristics

The study found that 287 (90%) of participants had no PNC visit whereas 32(10%) had postnatal care visit and concerning infant feeding practice, more than four-fifth 274(85.9%) of participants were practicing exclusive breastfeeding and 45 (14.1%) were practiced formula feeding (Table 2).

Table 2

Distribution of postnatal, sexual health related characteristics among married postpartum women who were attending immunization centers at the selected four Jimma zone Public Hospitals, Jimma, Southwestern Ethiopia, August 15 to September 15, 2019.

N = 319.

Variable	Category	Frequency	Percent
Postpartum related complications	Yes	23	7.2
	No	296	92.8
Type of postpartum complication reported	PPH	12	52.2
	Hypertensive disorder	6	26.1
	Puerperal sepsis	5	21.7
Knowledge of at least one contraceptive method	Yes	289	90.6
	No	30	9.4
Which contraceptive methods you did you know?	Pills	153	20.4
	Injectable	279	37.2
	Implants	219	29.2
	IUCD	79	10.5
	Others*****	20	2.7
Are you using contraceptive method currently?	Yes	184	57.7
	No	135	42.3
Which method are you currently using?	Pills	10	5.4
	Injectable	132	71.7
	Implants	34	18.5
	IUCD	8	4.3
Practice of sexual intercourse during index pregnancy	Yes	285	89.3
	No	34	10.7
Weeks last sexual intercourse ends during index pregnancy	<28	74	26.0
	28–37	137	48.1
	>/ = 37	74	26.0
Early resumption of sexual intercourse	Yes	172	53.9
	No	147	46.1
Reason given for resumption of intercourse	Husband demand sex	244	76.5
	Jointly decision for sexual intercourse resumption	54	16.9
	Others ******	21	6.6

Other ***** = Female sterlization, condom,

****** = cultural demand, fear of marital disharmony, felt convenient

Sexual health-related characteristics

Sexual intercourse during the index pregnancy

Among the participants, 285 (89.3%) had practiced sexual intercourse during the last pregnancy and of this nearly half 137(48.1%) of them ends sexual intercourse between 28–37 weeks of gestation (Table 2).

Early resumption of postpartum sexual intercourse

This study revealed that the earliest period of sexual resumption was week two and the latest was 13 weeks. The mean time of sexual resumption was 6.7 weeks (SD≤ 2.25). Overall total participants 319,172(53.9%) were resumed sexual intercourse during the unrecommended time (participants were reported that the reason for resumption was requested by their husbands (Table 2).

Factors associated with early resumption of postpartum sexual intercourse

Variables having a p-value less than or equal to 0.2 on binary logistic regression was a candidate for multivariable logistic analysis, these variables were household income, wife number, nature of index pregnancy(planned/unplanned), the practice of sexual intercourse during the index pregnancy, mode of birth, infant feeding practice, menstrual resumption pattern and using contraceptive methods.

In multivariable logistic regression husband-wife number, household monthly income, the practice of sexual intercourse during the index pregnancy, mode of birth, and using contraceptive methods were found to be significantly associated with resumption of sexual intercourse during the unrecommended period at a p-value less than 0.05 with 95% confidence interval.

This study revealed that, those study participants whose average household monthly income ETB were reduced odds by 80.9% to resume sexual intercourse before six weeks than mothers whose monthly income greater than 1532ETB (AOR = 0.19, 95% CI (0.10-.37).

Mothers who practiced sexual intercourse during pregnancy were increased odds by 4.547 to resume sexual intercourse during an unrecommended period when compared to mothers who did not practice sexual intercourse during pregnancy (AOR = 4.55, 95% CI = 1.29–15.97).

Mothers who undergo cesarean delivery were reduced odds by 93.5% to resume sexual intercourse during an unrecommended period than mothers who delivered by vaginal delivery (AOR = 0.06, 95% CI = 0.03–0.15).

Similarly, women from a husband with one wife was around four times more likely to resume sexual intercourse during the unrecommended period than mothers from a husband who has more than or equal two wives (AOR = 3.78, 95% CI = 1.32–10.79) and using contraceptive the method has around four times 3.7 more likely to resume sexual intercourse during the unrecommended period than mothers who did not use contraception (AOR = 3.7, 95% CI = 1.92–7.14) (Table 3).

Table 3

Factors associated with early resumption of postpartum sexual intercourse from August 15 to September 15, 2019 n = 319.

Variables	Category	Early postpartum sexual resumption		COR	AOR
		Yes	No
Pregnancy index	Planned	141(56.6%)	108(43.4%)	1.64(.96–2.8)*	0.95(0.44–2.03)
	Unplanned	31(44.3%)	39(55.7%)	1	1
Form of marriage	1	166(59.9%)	111(40.1%)	8.97(3.66–22.04)*	3.78(1.32–10.79)**
	>/ = 2	6 (14.3%)	36 (85.7%)	1	1
Infant feeding practice	Exclusive breastfeeding	151(55.1%)	123(44.9%)	1.4(.746–2.64)*	0.81(0.33–1.99)
	Formula feeding	21(46.7%)	24(53.3%)	1	1
Family monthly income	</ = 1542 ETB	77(38.9%)	121 (61.1%)	0.17(0.1–0.29)*	0.19 (0.1–0.37)**
	>1542 ETB	95(78.5%)	26(21.5%)	1	1
The practice of sexual intercourse in pregnancy	Yes	167(58.6%)	118(41.4%)	8.21(3.09–21.83)*	4.55 (1.29–15.97)**
	No	5(14.7%)	29(85.3%)	1	1
Mode of birth	Vaginally	161(62.6%)	96(37.4%)	1	1
	Cesarean	11(17.7%)	51(82.3%)	0.13(0.06–0.26)*	0.06(0.03-.15)**
Using contraceptive	Yes	128(69.6%)	56(30.4%)	4.73(2.93–7.62)*	3.7 (1.92–7.14)**
	No	44(32.6%)	91(67.4%)	1	1
Resumption of menses	Yes	100(58.8%)	70(41.2%)	1.528(0.981–2.380)*	0.79 (0.43–1.46)
	No	72(48.3%)	77(51.7%)	1	1

NB: 1 = Reference

* = p-value ≤ 0.2 and

** = p-value < 0.05

Discussion

Evidence from this study revealed that half of participants 172(53.9%) had resumed sexual intercourse before six weeks (during the unrecommended time) which was almost similar to the study reported from Malaysia, 51.6% [9]. However, this result was higher than earlier reports of most countries like the USA (43%), India (28.3%), Nigeria (27.6%), and Uganda (21, 9%) [12, 14, 15, 16] and Ogbomoso, Nigeria, 40% [17].

And this result was again lower compared to figures reported from Poland (72.8%), Brazil (70%) [18, 19], and Addis Ababa 73.4% [5]. The discrepancy in the time of resumption of postpartum sexual intercourse might be due to diverse socio-economic that exists in low, middle, and high-income countries and also diverse sexual attitudes of women in different parts of the world.

It is interesting to note that, the slight decrease from the study done in Addis Ababa in the same locality compare to this study [5].

Maybe because, as the study from Addis Ababa [5] was done in the capital city of the country, where peoples from a lot of countries living and which may share cultural transformations, modernizations, and social changes among peoples which can affect an individual’s perceptions and behavior mostly on sexuality issue. Whereas, these study settings in which most of the women adhere to the preexisting culture.

Similarly, this study revealed that the earliest time for sexual intercourse resumption was on week two, this finding is supported by research reported from Kenya [20], the earliest sexual resumption was week two, the possible reason might be similarity in due sharing some preexisting socio-cultural context where the study was conducted. But earlier than studies reported from Malaysia (7 weeks), Nigeria (8 weeks), and Poland (10 weeks) [9, 17, 18] and these discrepancies might be since postpartum sexuality counseling received from health care providers better than in this study.

From the multivariable regression analysis, the monogamous form of marriage was one of the significant factors of sexual intercourse resumption during the unrecommended period. This study revealed that women with monogamous marriage were nearly four times more likely to resume sexual intercourse during the unrecommended postpartum period than mothers with polygamous marriage(AOR = 3.779, 95% CI = 1.323–10.794). This study is supported by a study done in Nigeria [8].

This might be justified that a husband who had a polygamous form of marriage can create an environment to have sexual intercourse with one of the wives when the other one was abstaining.

But recently due cultural transformation, modernization, and the introduction of modern contraceptives, polygamous marriage is decreasing globally which increases the resumption of sexual intercourse earlier, unlike in the past [3, 8].

This study also revealed that those study respondents’ average household monthly income ETB were reduced odds by 80.9% to resume sexual intercourse during the unrecommended time when compared to mothers whose monthly income >1532 ETB(AOR = .191, 95% CI (.10-.367). The finding of this study is in line with the study reported from Malaysia, Nigeria [9, 15]. This might be because relatively women who had better income may need more children and those with low income may not want to have more children beyond their family income.

This study also found that mothers who practiced sexual intercourse during pregnancy were 4.547 times raised odds of resuming sexual intercourse during unrecommended time than mothers who did not practice sexual intercourse during the last pregnancy (AOR = 4.547:95% (CI = 1.295–15.972). This finding is consistent with the study reported from China [21], this might be explained that most of the time the husband was the main initiator of sexual activity and so women were forced to resume soon childbirth to satisfy their husband’s demand.

Mothers who undergo cesarean delivery was reduced odds by 93.5% to resume sexual intercourse during an unrecommended period than mothers who delivered by vaginal delivery (AOR = .065, 95% CI = .028 - .153). This study finding was consistent with the study reported from Australia, Kano Nigeria, Southwest Nigeria [3, 4, 17] and the possible reason might be the recovery process associated with a cesarean section is longer than vaginal delivery, because women may have more pain and discomfort in her abdomen as the skin and nerves surrounding her surgical scar need a long time for healing.

Finally, this study found that those postpartum women who were using contraceptive methods at the time of the study were 3.704 times more likely to resume sexual intercourse during unrecommended time than mothers who did not use contraceptive methods (AOR = 3.487, 95% CI = 1.920–7.145). This study is consistent with the study figures reported from Malaysia, USA, Uganda, Nigeria, Malawi [9, 12, 16, 17, 22]. This might be because when women using contraceptives, they consider themselves to be no risk for pregnancy only, which motivates them to resume sexual intercourse before six weeks postpartum. But early sexual intercourse resumption may increase the chance of postpartum sexual morbidity [5] and incomplete healing of episiotomy/tear (if any) in which the open wound is susceptible to infection [6].

Limitation of the study

Mothers who had a most recent stillbirth were not included in this study since this study was done among mothers who came for vaccination of their child. The study mainly focused on the period of sexual intercourse resumption rather than considering the degree of postpartum sexual function. Being only a facility-based study, recall bias and not approaching women at other MCH services was also among the limitation of this study. Finally, a causal relationship could not be assessed due to the cross-sectional design of the study.

Conclusions

This study revealed that a high number of respondents were resumed postpartum sexual intercourse during the unrecommended time (the early postpartum period) and this finding, in addition to those of other studies, postpartum resumption of sexual intercourse during unrecommended time is significantly associated with factors such as low income, a monogamous form of marriage, practicing sexual intercourse during pregnancy, cesarean delivery, and contraceptive usage.

Recommendations

Postpartum sexuality counseling should be strengthening during the antenatal and postpartum periods. Postpartum women should receive adequate sexuality counseling before leaving the health facility and Additional studies using qualitative study designs may be useful to explore further findings concerning the internal feelings of women regarding postpartum sexual intercourse resumption and the reason why women in this setting had practiced postpartum sexual intercourse during the unrecommended period.

Acronyms / abbreviations

ACOG, the American College of Obstetrics and Gynecology; AIDS, Acquired Immune Deficiency syndrome; APH, Ante Partum Hemorrhage, Central Statistical Agency; EDHS, Ethiopian Demographic and Health Survey; IUCD, Intrauterine contraceptive device; JUMC, Jimma University Medical Center; SDG, Sustainable Development Goal; SPSS, Statistical Package for Social Science; WHO, World Health Organization.

Questionnaire in both English and local version.

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Consent form.

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18 Sep 2020

PONE-D-20-25368

Early resumption of post partum sexual intercourse and its associated factors among married post partum women at Jimma Zone public Hospitals,Jimma ,South West Ethiopia :The cross sectional study.

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Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors tried to address a gap on postpartum sexual health. That is interesting.

Here are my concerns

1. Generally, it has many editorial problems: grammatical, wording, sentence word agreement.

Title Page:

2. The title is too long catch its concept therefore make short up to 15 words.

3. Both of the following individuals were listed on acknowledgment and authors. Generally, you put them on acknowledgment list means; they do not meet authorship criteria. So, we need strong justification why they included as authors.

i. Dr. Mengistu Welday

ii. Mr.Mihretab Mehari

Abstract:

1. Method: Every four intervals how? It is obvious that the study participants came randomly and how do you know whether the mother is on fourth or not?

2. Result: Your sample: 319, Your respondents: 319,172: so from where you got this?

Body of the manuscript

Introduction

1. Totally it requires rearrangement of paragraphs and sentences. For example paragraph 2, 3 and 4 talks about its consequence, the rest paragraph talks about what early resumption of sexual intercourse mean.

Rearrange like this, definition, start with the global outlook, you can continue with consequence and at the end the reason why you conduct this study.

2. Remove, “Additionally, Early intercourse sexual resumption to past, men were generally married to several wives and could have sexual intercourse with the other wives, whereas the other wife was obliged to stay away from the husband to offer her opportunity to the breast for as long as 2-3 years without intercourse to prevent the pregnancy [9].”…Unrelated to your topic of interest. This about marriage not sexual resumption.

Method

1. Your study populations are mothers who came for vaccination. What about mothers who came for others services a mother of 10 wks and came for outpatient department services, other MCH services?

2. Avoid redundancy example: The married postpartum women who already resumed sexual intercourse and on their 14 weeks

3. “Knowledge of modern contraceptive methods: When a woman spontaneously mentions at least one of the modern contraceptives. She was considered as knowledgeable [14].” What is the importance of this? Are you going to address about knowledge of family planning. Remove this

4. In some places you used 14th weeks for time of the event, and in other places you mentioned six weeks. Make it consistent either use 14thweeks or 6weeks.

5. Sampling technique is totally not clear and invisible for me. You don’t know the mother who is on 1st, 2nd etc.. so how do you reached?

6. 6A. “The questionnaire was prepared in the English language then translated to the Afaan Oromo language (Local language)” and again.

6B. “Data were collected by structured questionnaires using a face-to-face interview which was adopted from related published articles and modified for the current study.”

� Confusing, make it clear. Have you prepared? For what purpose? if your data is collected with the adopted instrument correct.

Result

1. “Overall total participants 319,172(53.9%) were resumed …. 319 sample vs 319,172 respondent. Based on this it is difficult to look all result. I have doubt.

2. How do you use mean for parity and living children? Is it continues variable? More clarification

Discussion

1. Your discussion almost seems copy of result. So let you see and amend it. Because no neeed of copy pasting what was available in the result. Start with your result, interpret , compare with other and put what does it implies.

2. Avoid redundancy. Example 1st paragraph: According to this study, about 172(53.9%) Second pargraph : Evidence from this study revealed that half of participants 172(53.9%).

a. What is the implication of this result?

3. Socio-economic vs sexual resumption. How do you relate it?

4. “sexual intercourse resumption was 2 and 13”..how do you give justification based on study period?

a. No way even your comparison groups are not from similar background people. Therefore modify your justification

Limitation of the study

The design you used by itself is also an another limitation of this study

Recommendation: you forwarded as postpartum counseling on sexual health. But 90% of your study participants have no any PNC visit. Did your recommendation and finding go together?

ACKNOWLEDGMENTS

Requires modification. Because those who were acknowledged were put here under acknowledgment

Reviewer #2: Abstract

Regarding the variables that were related to the early onset of sexual intercourse after childbirth, it can be concluded that these variables are considered as a risk factor and to prevent adverse consequences, early onset in people who have a risk factor. Consider and give these people special knowledge and advice.

Introduction

- Paragraphs 2, 3 and 4 can be merged into one paragraph. Modify the whole article in terms of paragraphing. The manuscript was edited by a native speaker.

- These sentences to be cited "And most of the published articles were reported only on the timing of postpartum sexual intercourse resumption without considering its associated factors even though, knowing associated factors of postpartum sexual intercourse resumption is an important element to take an intervention".

- At the end of discussion, it is necessary to imply the studies with similar and different results.

- The difference between the research community conducted in this study and the connection of the Ethiopian country should be noted. So the writers can show the importance of the issue better.

Method

- In the abstract, the type of study is mentioned the Institution-based cross-sectional and in the method section of the manuscript, it is facility-based cross-sectional.

- Some information in population part and Eligibility criteria part are repetitive.

- "Operational definitions and definition of terms" It is usually not available in the journal format. This explanation can be fully explained in the inclusion and exclusion criteria. Assigning codes to variables can be explained in the analysis section.

- In the section on ethical considerations, it is necessary to mention the code of ethics.

Results

- Descriptive data (demographic, fertility and postpartum) can be summarized in one table and the other table devoted to analytical data. It is better to explain in the table and report the adjusted and unadjusted. The number of tables is a lot.

Discussion

- These sentences to be cited "It is interesting to note that, the slight decrease from the study done in Addis Ababa in the same locality compare to this study."

- There is not recommendation for future study. This sentence is not limitation of study " lacking qualitative part of study design was other the limitation of this study because mother’s potential experience on intercourse resumption by culture, norms, and myths related factors were not exhaustively included".

- One of the limitations of the study was .facility base and non-random sample selection, which needs to be mentioned.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #1: No

Reviewer #2: No

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2 Oct 2020

Article Title: Early resumption of sexual intercourse and associated factors among married postpartum women at Jimma zone Public Hospitals, South West Ethiopia: A cross-sectional study.

1) To the academic editor. Thank you, Prof., for your smart feedback. Here are our responses to your points.

• The PLOS ONE style templates: The final manuscript has modified by using PLOS ONE style linkage

• Ethics statement: Informed written consent was obtained from each participant before the interview. The parents or the legal guardian written consent was taken for the participant age less than 18 years old.

• Validated the questionnaire: the validity of the questionnaire was checked by senior professional experts of Maternal and Child health. The questionnaire was given to three professional experts, and they saw the whole tool and provided their input. Finally, the input provided was incorporated into the final version of the questionnaire that was used for data collection.

• ORCID iD: This my ORCID ID https://orcid.org/0000-0002-8132-8678

• Supporting files of this study was included in the submission of the manuscript and again revised.

1. Response to Reviewer One

First, we want to appreciate your smart comments and suggestions, and said these here are our concerns and with some clarification on comments given:

1. Generally comments on grammar ,spelling and subject verb agreement= revised

2. Title modification=Early resumption of sexual intercourse and associated factors among married postpartum women in Jimma Zone Public Hospitals, Southwest, Ethiopia.

3. Concerning Dr. Mengistu Welday & Mr.Mihretab Mehari both helped me throughout my thesis and manuscript work and mistakenly written under the acknowledgment part. And both of them fit preset criteria of PLOS ONE journal for authorship and are written as authors of this article.

Abstract sections

1. Methods .The study populations were

� Only mothers you have resumed sexual intercourse and came for vaccination of their child at 14th weeks of postpartum.

� First, four mothers waited, then from four mothers one mother was selected by lottery method, then after the first mother was selected, the subsequent every four mothers (since k=4) were included until the desired sample size was obtained from each Hospital.

2. Result: The total sample was 330. From 330 samples, 319 were participated in the study making a response rate of 96.7%: From 319 participants who resumed sexual intercourse, 172(53.9%) resumed sexual intercourse before six weeks or during the early postpartum time and 147(46.1%) resumed after six weeks (during the safe time for resumption).

Body of the manuscript sections

1. The study populations were married postpartum mothers came for vaccination of their child at 14 weeks postpartum (14 weeks postpartum was selected to access all the postpartum women )

2. Study participants also women who resumed sexual intercourse after their recent birth.

3. Mothers who came on 6th, 10th -week vaccination, outpatient, and MCH service were not reached by this study.14th postpartum was selected to access all postpartum women came for vaccination because it is 3rd Ethiopia pediatrics immunization schedule(the vaccination schedule is 1st at 6 weeks postpartum, 2nd at 10th weeks postpartum, and 3rd at 14th weeks postpartum).

4. Redundancy issue appropriate modification was done accordingly

5. Knowledge of modern contraceptive methods: Removed since unrelated to the subject matter.

6. This study was done on mothers visited for vaccination of their child at 14 weeks. The time of sexual resumption was categorized into 6 weeks and below represents early postpartum sexual resumption, and after 6 weeks represent as safe sexual resumption period (the recommended period).

7. The issue on sampling technique: In the beginning, four mothers who resumed sexual intercourse waited then one mother was selected by the lottery method, and then systematic random sampling at every four intervals was applied until the desired sample size was obtained at each hospital.

8. The questionnaires were prepared by the co-author by reviewing related published articles .Afaan Oromo (local language) version was used for the collection of the data.

Result

1. The total sample size was 330 and of this 319 was responded to the questioner. From 319 participants, 172 participants were resumed sexual intercourse during the early postpartum period (participants were resumed during a safe period (> 6weeks).

2. Parity and living children: We asked in terms of a number e,g.How many living children you have? ___in number: In this case, it is a continuous variable for this reason, we used mean and SD before dummy coded into categorical data on SPSS.

Discussion

1. Result and Discussion overlapping issue has amended.

2. The redundancy issue amended accordingly, and 53.9 = implies that half of the mothers resumed sexual intercourse during the early postpartum period.

3. Socioeconomic vs sexual resumption: From the findings of this study and also other study findings, socioeconomic variables have an association with early sexual intercourse resumption. For instance, mothers who have better income can have an early resumption of sexual intercourse than mothers who have low income.

4. 2 and 13 weeks justification. Both countries share some preexisting socio-cultural context among the continent.

Limitation

1. Yes, the cross-sectional study design was also among the limitation= modified.

Recommendations

1. My recommendation is not only for mothers during a postnatal visit rather starting sexual health counseling during ANC visit and strengthening during the early postpartum period (better if it is given before leaving health facilities after birth).

Acknowledgments

1. 1) Amended

Thank you very much.

With best regards!

1. For the second reviewer & many thanks for your suggestions, comments, and concerns

Here are a response to your comments and concerns

1. The knowledge and advice gap on postpartum sexual health has been seen and modified.

So, the women must get adequate knowledge and advice on postpartum sexual health during the antenatal and postnatal period.

1. Paragraph 2, 3, and 4 one paragraph=the introduction section are rearranged and this paragraph also merged into one paragraph.

Methods

1. And most of the published articles were reported only on the timing of postpartum sexual intercourse resumption without considering its associated factors even though, knowing associated factors of postpartum sexual intercourse resumption are an important element to take an intervention". Cited by Reference No [5] and revised in the new paragraph.

2. The type of this study is facility-based cross-sectional and the consistency issue is corrected.

3. Code of ethics: the study participants were informed about the purpose, risks, and benefits of this study. And voluntary participation and no relation with the service given whether she participated in the study or not. Data collections were conducted after getting written informed consent from each participant. And for the participants aged below 18 years (to fit preset WHO criteria of the age) informed written consent was obtained from the parents or legal guardians.

4. Operational definitions and definitions of terms are omitted and written under the eligibility criteria and analysis section.

Results

1. Table:1 & 2 merged into Table :1 ,Table:3 & 4=merged in to Table=2 and Table :5 to Table:3

2. “It is interesting to note that, the slight decrease from the study done in Addis Ababa in the same locality compare to this study." Cited by Reference No [5]

3. The limitation of the study. “Lacking qualitative part of study design was other the limitation of this study because mother’s potential experience on intercourse resumption by culture, norms, and myths related factors were not exhaustively included”. Omitted and revised into being only a facility-based study was also among the limitation of this study. Finally, a causal relationship could not be assessed due to the cross-sectional design.

Thank you very much.

With best regards!

Submitted filename: Response to reviewer two.docx

Click here for additional data file.

4 Jan 2021

PONE-D-20-25368R1

Early resumption of  sexual intercourse and associated factors among married post partum women at Jimma Zone public Hospitals,Jimma ,South West Ethiopia :The cross sectional study.

PLOS ONE

Dear Dr. Gadisa,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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We look forward to receiving your revised manuscript.

Kind regards,

Nülüfer Erbil, Ph.D, Prof.

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: No

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Generally, the Authors made a substantial improvement for the previous comment. What was left is editorial problem and I do have only few concern for clarification and what the authors have to enrich for the article.

1. Answer for 6 states that, “This study was done on mothers visited for vaccination of their child at 14 weeks. The time of sexual resumption was categorized into 6 weeks and below represents early postpartum sexual resumption, and after 6 weeks represent as safe sexual resumption period (the recommended period). Therefore if early sexual resumption is less than six (6) weeks, how do you say early sexual resumption for mothers who came at 14th week?

2. Your response also indicated that mothers who came at 6weeks, 10th weeks and mothers visiting other MCH services were not included. So you can state this under limitation.

Methods

3. There are many sub sections but contents under some of the subsection are not as much sound. It needs some modifications and merging

Result

4. This study revealed that the earliest period of sexual resumption was week two and the latest was 13 weeks. Look this with your definition of early which is of less than 6 weeks.

Reviewer #2: all coments have ben addressed.only concers about format of article. maybe it would be better changed to journal format.

Reviewer #3: Comment1: Best evidences about the best timing for “sexual intercourse start” after delivery are lacking. Some say after two weeks, others say 6 weeks and some others blindly counsel if the mother is ready for the intercourse, she can enjoy (unknown time). So, please, incorporate your best advice (with strong recommendations) in the methodology part!

Comment2: Your title is too sensitive. Asking and getting true information about the issue may be questionable. Had been self-administered, it would be good. So, please, explain when (entry or exit time) and how data collectors interviewed the study participants.

Comment3: Comment on your study population

Your study population is all postpartum women who resumed sexual intercourse and attended the 14th immunization schedule at the setting. Why you didn’t take the 6th immunization schedule for the interview? Because at this time you could get whether or not the study participants resumed their sexual intercourse. The longer the time (14th schedule), the higher the recall bias will be.

Comment4: Comment on your sample size

Your sample size is small. It was good if you were using degree of precision less than 5% because the proportion you used is 73.4%, rule of thumb directs to use either 3% or 4% of degree of precision for such proportion. So that you would increase your sample size and generalizability as well. So, if any reason to use your small sample size you can tell your readers. I know my question is the proposal stage question!

Comment5: On the data processing and analysis section

The author used the P-value ≤ 0.2 in the crudes odds ratio to declare a variable as significant. Please, indicate or cite where you got this cut of point!

Comment6: Comments on the result section, socio-demographic part: The author said ‘About 199(62.4%) participants were from urban residence and 120(37.6% were from rural residence’… The reddened one can be removed because everything is found in the table.

Comment7: 5.2 Obstetrics and Reproductive related characteristics: The author used a sentence ‘About 53 (28.2%) of participants reported a history of abortion and of this nearly half, 46.8 (86.8%) reported once’… The sentence is not clear, especially at the reddened one!

Comment8: Comment on your sentence structure

Please, revise your grammar, subject-verb agreement, active and passive voice of sentences (example: Were resumed, were practiced, number of study participants were reported etc…) had made your sentences vague. Please, try to revise your manuscript with language expertise!

Comment9: In the discussion section, paragraph 5; the author said ‘But earlier than studies reported from Malaysia (7 weeks), Nigeria (8 weeks), and Poland (10 weeks) [9, 17, 18] and these discrepancies might be since postpartum sexuality counseling received from health care providers better than in this study.’ This sentence seems to be paradoxical. The earliest practice is 2 weeks in you study and 7 and above in the comparison studies but your logical explanation is not clear. If am not mistaken, please, correct!

Comment10: On the decimal points

Please, try to use only two digits after the decimal point to make the numbers attractive to be read... Scan your full length manuscript for the problem!

Commen11: Confidence intervals

I have seen some of your confidence intervals are wide which could be due to your small sample size… What is the recommended difference (scientific logic) between the upper and lower boundaries of the CI?

Comment12: Limitation

Don’t you think that the recall bias is there? Because you got the study participants at the 14th week postpartum, they might have forgotten whether or not they practiced sexual intercourse at 2, 3 4…. 13 weeks

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Leila Amiri Farahani

Reviewer #3: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

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27 Jan 2021

Article Title: Early resumption of sexual intercourse and associated factors among married postpartum women at Jimma zone Public Hospitals, South West Ethiopia: A cross-sectional study

1. Response to Reviewer One

First, we want to appreciate your smart comments and suggestions, and said these here are our concerns and with some clarification on comments given:

Generally comments

1. Generally, comments on grammar, spelling, and subject-verb agreement= revised

2. Yes, this study was done on mothers visited for vaccination of their child at 14 weeks.

• In the beginning, I intended to see a number of mothers resumed sexual intercourse during recommended and unrecommended period. We used 14 weeks because it is 3rd EPI schedule in Ethiopia and to access postpartum women easily.

• This study included mothers who visited immunization centers and women visiting other MCH services who were not approached by this study and we added them as a limitation of this study.

Methods sections.

• Many improvements have been done and the population also merged into one.

Result sections

• Amended

Thank you very much.

With best regards!

2. For the second reviewer & many thanks for your suggestions, comments, and concerns:

• We have modified the language clarity issue accordingly.

• From the previous comments, we have made many changes to the document to have the PLOS-ONE journal format.

Thank you in advance.

With best regards!

3.For the second reviewer.Many thanks for your suggestions, comments, and concerns.

As per the comments given, here are a response to your comments and concerns

1. Comment 1: my evidence for the best time for sexual resumption is a published research article cited by [1,7,8,9,16,17 ].The best time to resume sexual resumption is after six weeks postpartum. It is a recommendation of many scholars, and also we included operational definitions in the methods part.

2. Yes, it is a sensitive topic but silent adverse health impact on the mother and child health also on the family at all. As you said, had it been a self-administered question, it was nice but this study is facility-based and almost 26% of participants are illiterate.

3. The reason why I took the 14 weeks rather than 6 weeks (2st EPI schedule in Ethiopia) is my intention at first was to see a percentage of women resumed during recommended vs unrecommended period. Balancing those resumed before and after six weeks. Also is selected because 14 weeks is the 3rd EPI schedule in Ethiopia to access all the postpartum women.

4. Sample size issue we used 73% proportion which was taken from the study done in Addis Ababa. This study is the most recent study done in Ethiopia.

5. P≤2 this cut of a point is taken from reference number [5]

6. Modified according to the comment give, and the place of residence is not mentioned under the table so we wrote it in the form text.

7. Modified accordingly

8. We revised the whole manuscript with language expertise.

9. The explanations issue was modified

10. Decimal point corrected throughout the document

11. Confidence interval issue, we will read it but still, we did not get the exact cut-off point for it.

12. This study is not free from recall bias. However, to minimize recall bias careful design was considered and data collectors asked them freely to remember it.

Thank you very much.

With best regards!

Submitted filename: Response to Reviewers =new.docx

Click here for additional data file.

15 Feb 2021

Early resumption of postpartum sexual intercourse and its associated risk factors among married postpartum women who visited public hospitals of Jimma zone, Southwest Ethiopia: A cross-sectional study

PONE-D-20-25368R2

Dear Dr. Gadisa,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Nülüfer Erbil, Ph.D, Prof.

Academic Editor

PLOS ONE

18 Mar 2021

PONE-D-20-25368R2

Early resumption of postpartum sexual intercourse and its associated risk factors among married postpartum women who visited public hospitals of Jimma zone, Southwest Ethiopia: A cross-sectional study.

Dear Dr. Gadisa:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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on behalf of

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Academic Editor

PLOS ONE