‘Feeling Ready’: A Feminist Poststructural Analysis of Postpartum Sexual Health

Abstract

There exists a lack of literature surrounding how postpartum individuals define feeling ‘ready’ to resume sexual activities after childbirth. Many factors may influence feelings of desire or readiness for sexual activities, such as breastfeeding. Therefore, it is important to understand why and how postpartum individuals understand and make meaning of their experiences surrounding postpartum sexual activities, as well as how those experiences are influenced or negotiated through relations of power. This study was guided by feminist poststructuralism and discourse analysis. Eleven participants who were between 1 and 6 months postpartum and living in Nova Scotia, Canada, were interviewed using semi-structured interviews. Participants challenged certain discourses surrounding sexual activities postpartum, including the social discourse that positions sexual activities as a requirement within romantic relationships and the discourse that positions health care providers as the authority on postpartum sexual health. ‘Feeling ready’ centered on four main issues: (1) navigating physical recovery; (2) personal knowing and emotional readiness; (3) the 6-week check; and (4) redefining intimacy. This article describes one branch of the findings within the overall study. Choosing to resume sexual activities postpartum, or feeling ready to do so, is individual, fluid, and complex. This research has important implications for practice and policy, specifically as it pertains to postpartum care.

Sexual health is important to overall health and wellbeing throughout the lifespan, which includes the postpartum period (World Health Organization, 2023). However, sexual health remains a largely taboo topic, even more so within the postpartum context (Pardell-Dominguez et al., 2021). Much of the current and previous research on sexual health after birth has focused on sexual activities, specifically the resumption, initiation, or frequency of sexual activities (Sok et al., 2016; Vannier, Rosen, & Adare, 2018; Wallwiener et al., 2017) and associated physical issues such as genital pain during sexual activities, also known as dyspareunia (Andreucci et al., 2015; O’Malley et al., 2018). Collected statistics indicate the following percentage of participants who had resumed sexual activities at different time points after birth: 21.9% before 6 weeks (Alum et al., 2015), 43% at 6 weeks (Sok et al., 2016), 56% at 8 weeks, 78% by 12 weeks (McDonald et al., 2019), 92% by 12 weeks (Sok et al., 2016), 94% by 6 months, and 97% by 12 months (McDonald et al., 2019). Even between studies, these percentages change and do not necessarily indicate a universal norm but rather focus on documenting the resumption of sexual activities, which are variable.

Important literature has clearly articulated that sexual activities are a central focus of sexual health postpartum (Bucher & Spatz, 2019; von Sydow, 1999). However, there is a lack of literature exploring if, how, and why postpartum individuals create meaning within ‘feeling ready’ to engage in sexual activities. The researchers who conducted this study aimed to explore how postpartum individuals experience their sexual health after birth and how those experiences were influenced or negotiated through relations of power. The primary research question was: How do postpartum individuals (who have birthed a baby) experience postpartum sexual health? Sub-questions included: (1) How do postpartum individuals negotiate relations of power related to their sexual health? and (2) How is postpartum sexual health socially and institutionally constructed through different discourses? This study had multiple findings, some of which are outside the scope of this article. This article will focus on one salient theme, which centered on how participants defined ‘feeling ready’ for sexual activities.

It is well known that the postpartum period often involves many physical, mental, and emotional changes. These changes may include perineal tearing (Gutzeit et al., 2020), bleeding (lochia) (Chi et al., 2010), postpartum depression or postpartum blues (Berglund, 2020), anxiety (Ashford et al., 2017), sleep deprivation and fatigue (Badr & Zauszniewski, 2017), stress (Clout & Brown, 2015), role adjustment as a parent and/or a partner (Perun, 2013; Walker et al., 1986), changes to romantic relationship(s) (Rosen et al., 2017), attachment to the newborn baby (Petri et al., 2018), and feelings of isolation (Eastwood et al., 2013; Ollivier et al., 2021).

While it is common for people who have recently given birth to wait at least 6 weeks before resuming sexual activities (O’Malley et al., 2019), as often recommended by their health care providers, there exists limited research that justifies the 6-week mark (DeMaria et al., 2019). Some say that 6 weeks tends to coincide with the first postpartum health visit and presents a convenient time to “bring [the topic] up” (McDonald & Brown, 2013), while others state that it takes 4–6 weeks for the cervix, vagina, and perineal area to properly heal (Owonikoko et al., 2017). However, there is a gap in the published literature exploring how postpartum individuals navigate the resumption of sexual activities after birth, both in terms of emotional and physical considerations. Researchers have shown that the time points and reasons for resuming (or not resuming) sexual activities are highly variable and dependent on many factors. Factors influencing one’s decision to resume sexual activities after birth may also be culturally or religiously influenced (Alnuaimi et al., 2020; Shabangu & Madiba, 2019). Other motivations for resuming sexual activities may include a desire for emotional intimacy, curiosity as to whether or not certain sexual activities are still possible or pleasurable, or a desire to return to the status quo of the relationship (O’Malley et al., 2019). As such, there is a need for more qualitative research exploring the experiences of postpartum individuals in choosing if, when, how, and why they resume sexual activities after birth.

Participants, Ethics, and Methods

Eleven postpartum individuals who were between 1 and 6 months postpartum, currently living in Nova Scotia, Canada, fluent in English, and 18 years of age or older at the time of data collection were recruited using a purposive sampling strategy. Participants lived in both rural and urban locations, which affected their access to health care or specialized support, such as pelvic floor physiotherapy. Given the time during which this research took place, many new parents were accessing information or support on virtual platforms, such as Facebook. Based on what was shared during the interviews, the youngest participant was 21 and the oldest was 38, though not all participants chose to share their age. Although sexual health remained a taboo topic in this Canadian context, some participants detailed how they felt comfortable discussing it with close friends or other new parents. The timeframe for eligibility, being the first 6 months of the postpartum period, was chosen to ensure richness of the data and to allow participants to share their experiences, thoughts, and feelings as they were happening.

Data collection occurred in September and October 2020. Postpartum individuals were defined as those who had carried a pregnancy and given birth, understanding that not all people who give birth necessarily identify as women. The term ‘sexual activities’ is used throughout this paper. While no universally accepted theoretical definition for this term exists, the authors employed an operational definition where sexual activities could include (but were not limited to) intimate massage, intimate touching, deep kissing, oral sex, anal sex, vaginal sex, masturbation, mutual masturbation, role play, sexual fantasy, or use of sex toys (O’Malley et al., 2023). In this study, no demographic data was collected. Instead, the research team allowed for participants to authentically share their subjective positioning(s) in alignment with feminist methodology.

Data was collected using semi-structured interviews, which were between 45 and 70 minutes in length and audio-recorded using a digital recording device. Due to the public health restrictions that were in place as a result of the COVID-19 pandemic at the time of data collection, all interviews occurred over the telephone. Telephone interviews are being increasingly utilized in nursing research and represent a valid and reliable way to conduct data analysis, especially when considering the safety of participant(s) (Musselwhite et al., 2007; Rahman, 2015). Telephone interviews may have in fact helped the participants to feel more physically and emotionally comfortable while providing some level of anonymity, given that the interviewer and the participants never met face to face (t’Hart, 2023). On the other hand, the researcher’s relationship with the participants may have also been negatively impacted due to a disrupted ability to listen deeply, interpret non-verbal communication cues, or assess the other person’s general affect (t’Hart, 2023). The semi-structured interview guide included questions such as: ‘What emotions do you experience when you think of your sexuality or sexual relationships after having a baby?’ or ‘Tell me about a time when you thought about your sexual health and sexuality after giving birth. What came up for you?’. The interviews were transcribed by a professional transcriptionist and were also de-identified to protect participant confidentiality. Research ethics approval was received from the IWK Health Centre’s Research Ethics Board (#1025879) in August 2020 and was renewed as necessary throughout the study period. All participants were required to sign a consent form prior to participation and were given the opportunity to withdraw from the study without reason up to 10 days following the interview, though no participants chose to do so.

Theory and Methodology

This study employed feminist poststructuralism (FPS) as a guiding philosophy and theory (Butler, 1992; Foucault, 1983; Weedon, 1987). From an epistemological and ontological perspective, feminist poststructuralism recognizes the existence of multiple ways of knowing as well as multiple truths (Weedon, 1987). Feminist poststructuralism is a critical social theory that aims to uncover how individuals’ experiences are socially and institutionally constructed through relations of power, which also includes concepts such as agency, subjectivity, meaning, and language (Foucault, 1983; Weedon, 1987). Agency is one’s response to personal beliefs, values, or discourses by way of transformation, challenge, resistance, acceptance, or adaptation (Weedon, 1987). According to Weedon, subjectivity is “the conscious and unconscious thoughts and emotions of the individual, her sense of herself and her ways of understanding her relation to the world” (1987, p. 32). Feminist poststructuralism pays specific attention to gender and subjectivity, making it an appropriate and meaningful approach to address the aims of this study.

The use of feminist poststructuralism allowed the authors to uncover certain social or institutional discourses surrounding sexual health after birth and understand how postpartum individuals respond to these discourses through relations of power (Foucault, 1983). The research team largely employed philosophical understandings from Michel Foucault, Chris Weedon, and Julianne Cheek. For the purpose of this research, discourse was defined as “a set of common assumptions which, although they may be so taken for granted as to be invisible, provide the basis for conscious knowledge” (Cheek, 2000, p. 23). Discourse is shaped by relations of power, knowledge, and language amidst differing political, social, institutional, or personal influences (Baxter, 2016). Dominant discourses represent approved ways of being, though the existence of “competing or resistant discourses” (Baxter, 2016, p. 38) makes the navigation of such discourses much more complex. Discourse is often invisible and taken for granted as a part of ‘the way things are’ (Weedon, 1987). ‘Invisible’ refers to meaning becoming status quo or part of normal, everyday practices that people don’t necessarily think about (Cheek, 2000). It is therefore important to identify discourses and how they are constructed as a way of challenging the status quo (Aston, 2016; Weedon, 1987). In the findings presented, both social and institutional discourses are discussed. Social discourse refers to that which is socially, societally, or culturally embedded, whereas institutional discourse is often reproduced or perceived in certain settings or contexts, such as academic or medical institutions. While social and institutional discourses are nuanced and may influence one another, this understanding is important to our discussion.

In this paper, we specifically discuss the dominant discourse that positions sexual activities as something that postpartum individuals should feel ready for (and may be expected to perform) by the 6-week mark (O’Malley et al., 2023). Constructed socio-sexual scripts, defined as ideas or behaviors surrounding sexuality that are created and promoted by society, culture, and history, continue to dominate how female or feminine sexualities are depicted, treated, explored, or interacted with in a variety of contexts (Ifeka et al., 1983). In a heteronormative society, these widely accepted, traditional scripts generally depict women as “unassertive, compliant, passive receivers of sex” (O’Malley et al., 2019, p. 57) who uphold ‘good morals’ by refusing to discuss or engage in topics or activities of a sexual nature, especially in public (Faulkner & Mansfield, 2002). Women are expected to be sexually mysterious yet available and demure, but also assertive in knowing what they want from sexual or romantic partners (Haug, 1987; Miller & Fowlkes, 1980). These opposing narratives surrounding women’s sexuality require them to constantly navigate competing expectations of how they should express or share their sexuality (Daniluk, 1993), including at the postpartum 6-week mark. In the Results and Discussion sections, we also discuss another dominant social discourse that positions sexual activities as the ‘best’ or most ‘valid’ way to express intimacy within romantic relationships.

Feminist poststructuralist discourse analysis was used to analyze the interview transcripts (Butler, 2005; Cheek, 2000; Scott, 1992). Feminist poststructuralist discourse analysis is not a linear process; rather, it is fluid and cyclical, often requiring collaboration and idea sharing between team members to identify key issues (Aston, 2016). Feminist poststructuralism trusts that the words of the participants are truthful and do not need to be checked by any other means, such as triangulation (Aston, 2016). It is essential to conduct postpartum health research in ways that are anti-oppressive so as to uncover hidden meanings and possibilities for change. In conducting this research, it was imperative to also address the existence of a normative White, able-bodied, hetero-femininity that governs ideas about sex and sexuality postpartum. For example, norms regarding postpartum sexual health are often constructed through discourses that individuals may or may not agree with, or choose to resist. Although different people may hold different positionalities in relation to certain dominant or non-dominant discourses, they must nonetheless contend with dominant discourses, such as those which support the resumption of sexual activities at 6 weeks postpartum.

Throughout the analysis, the authors paid close attention to the ways in which participants shared their experiences of postpartum sexual health, including the language they used and the meaning behind the words they used. It is important to note that trustworthiness was upheld throughout data collection and analysis through the use of personal memos and investigator field notes to account for personal thoughts, biases, observations, and feelings.

Researcher Positionality

In qualitative research, it is imperative that researchers reflect on their positionality and lens in approaching the research topic and the methods (Brown & Strega, 2015). All researchers involved in this study identify as cisgender, Caucasian, heterosexual women. The Principal Investigator/first author has never had a postpartum experience, though the other four researchers have. While England (1994) emphasizes that the research relationship is “inherently hierarchical; this is simply part and parcel of the (conflicted) role of the researcher” (p. 86), reflexivity may enhance our awareness of asymmetrical relationships by exposing our own perspectives and positioning. While a more in-depth reflection does not fit the scope or purpose of this paper, it is possible that the identities, lived experiences, and positionalities of the research team influenced who chose to (or chose not to) engage in this research. For example, the authors believe that sexual health is an important component of postpartum wellbeing and that it is important to discuss such topics more openly, though not all people may agree with this view. Throughout analysis, the authors were attentive to their own experiences and knowledge of both the subject and the Canadian context, using this as a strength to collaboratively identify nuances within the data that may have been overlooked had analysis been performed by only one researcher.

Results

Although sexual health is multi-faceted in the sense that it encompasses physical, mental, emotional, and social components (World Health Organization, 2023), sexual activities were foregrounded in how participants defined their sexual health after birth. Negotiating if, how, and when to engage in or resume sexual activities after birth was deeply individual, fluid, and complex. In addition, feeling ‘ready’ encompassed both physical and emotional factors that were often interwoven. The process of feeling ready was not necessarily linear but rather fluctuated throughout the postpartum period. Several factors influenced how participants felt about resuming sexual activities, some of which included physical recovery, personal knowing, the 6-week postpartum appointment with their primary health care provider, and redefining intimacy. In what follows, each of these factors will be discussed in further detail.

Navigating Physical Recovery

Physical recovery, specifically pelvic floor recovery, was important for postpartum individuals in choosing when to resume sexual activities after birth. Given that some participants sustained pelvic floor injuries, pelvic pain and fear of pain was very real and included both genito-pelvic pain and dyspareunia. Participants chose to shift relations of power by creating their own meaning of pelvic floor health and how it could impede or promote their sexual health. More specifically, they focused on how pelvic floor recovery influenced their ability to comfortably, safely, and pleasurably engage in partnered or unpartnered sexual activities. For example, one participant shared how she used masturbation to explore her physical recovery and feelings of sexual pleasure:

I was less scared because when I was [masturbating], I didn’t feel any pain or discomfort but [my partner] was more scared of hurting me. It didn’t really feel bad but you certainly don’t feel sexy right after you have a baby with all your bleeding and all that stuff and you don’t feel good, and then when you stop bleeding you want to sleep with your boyfriend or significant other again but then you don’t feel sexy because you’re terrified of your own vagina area.

In discussing how feeling “terrified of your own vagina area” due to fear of “pain and discomfort” can be something that postpartum individuals experience, this participant uncovered a discourse that positioned postpartum sexual activities as “pain[ful]” and “terrif[ying].” Another participant shared:

It’s been kind of a cascade where my pelvic floor was wrecked from the pregnancy and it just kind of slowed everything down quite a bit. […] In terms of actual sexual activity, I have a lot of pain. Like for any sort of penetration, the muscles are just way too tight so it’s one where my homework for my pelvic floor physio is to try to have sex so and we have yet to be successful with any of the trying just because the muscles are so frigging tight that like nothing can make it in. […] I feel hopeful but it’s definitely a slower return to functioning than I had anticipated.

This is perhaps due to the social construction of childbirth as something that is inherently traumatic or damaging to the body, which thereby normalizes pelvic floor issues after birth.

Of course, there are also other possible discourses surrounding this issue. For example, an equally dominant discourse might suggest that genital pain is unimportant or something postpartum individuals ‘have to deal with’; therefore, they should be able to resume sexual activities regardless of pain. This normalization of postpartum pelvic floor issues was exemplified in the following participant quote:

I know with my mom’s sexual health she jokes that she can’t go to a comedian because she pees when she laughs and that’s a component of sexual health, like if she had seen a pelvic floor physio after she had my brother and I, like potentially that component of her health would be better but there was so much shame around it.

There may also be alternative discourses that exist within different social or professional groups, such as those which position the vagina as permanently compromised or ‘loose’ after birth. The notion of ‘readiness’ for sexual activity can be understood to be expressive of a social discourse whereby postpartum individuals may be understood in their fitness or physical ability to meet the sexual needs of their partners. Issues such as pelvic pain and/or dyspareunia can be hugely important in influencing the choice surrounding if and when to resume sexual activities after birth. While this is not a new experience for most postpartum individuals, what is important to note is how social discourse continues to be perpetuated in a way that silences dialogue about women’s postpartum sexuality and pelvic pain.

Participants chose to define pelvic floor health as an important component of their postpartum sexual health, something that is relatively new in Western society. Discussion of this topic (if it happens) continues to occur only in very specific settings, such as a medical office, in trusted mom groups, or with the public health nurse during a home visit. From a broader social perspective, postpartum individuals are not provided with the opportunity to share their experiences and, as such, myths or misconceptions may be produced or reproduced (Ollivier et al., 2019). The participants in this study showed how postpartum individuals are beginning to discuss their pelvic floor health and recovery and are using their power to challenge the taboo that has historically surrounded this topic (Ollivier et al., 2019). For example, one participant shared how, given that this was her second postpartum experience, she was proactive in asking her physician for an estrogen cream because she knew what to expect and what she needed to assist her physical comfort and healing. Another participant shared how she was able to connect with a physiotherapist to learn more about her body and postpartum physical recovery:

I wish there had been more conversation about like how to get yourself ready physically. I’m seeing a pelvic floor physiotherapist and she’s a wealth of knowledge and I’m like oh wow I wish someone had told me some of these things before I actually gave birth because then I think I would have been more prepared for birth but also more prepared of how I might feel physically afterwards and what some of those things might be that would impact sexual health and sexuality.

The need for “more conversation” points to a social discourse that silences issues surrounding pain and dyspareunia after birth by positioning them as normal and therefore unacknowledged (Snyder et al., 2022). As such, several of the participants felt compelled to specifically seek out resources at their own will and ask for what they needed. Many participants found that pelvic floor physiotherapy had a positive impact on their postpartum sexual health, though also commented on how it was quite expensive and therefore inaccessible. Seeking physiotherapy was an example of agency in caring for their sexual health.

Personal Knowing and Emotional Readiness: ‘Trust Your Gut’

Although physical components were important in influencing the resumption of sexual activities, emotional factors were also at the forefront of participants’ experiences when choosing to engage in sexual activities. Participants spoke of the need to listen to their instinct and ‘trust their gut’ in knowing what was best for them. The data revealed a social discourse that expects and requires sexual activities within romantic relationships. Participants were required to negotiate relations of power in response to this discourse and used their power to shift the meaning of ‘feeling ready’. Participants believed that it was important that they felt both “emotionally and physically ready” to resume sexual activities, as one stated:

Just trust your own body in terms of what feels right for you both physically and emotionally because, as I said, when we tried to [have sex] at four weeks I was not emotionally or physically ready at all and I should have trusted that instinct. But because I had all those worries about what does my sexual health look like now, I felt like I kind of needed to experiment with that and toy with it when really I should have just trusted my instinct and be like I’m not there yet, I need to wait until I’m more emotionally and physically ready.

This participant shared a discourse that positions sexual health as something that changes significantly after birth, as evidenced by her statement outlining how she had “worries about what does my sexual health look like now.” It is possible that the discourse that frames birth as something that changes sexual health and the discourse that positions birth as something that damages the body, specifically the genito-pelvic area, are connected. In stating that she “should have […] trusted that instinct,” we can see how she did not initially trust her “instinct” but then later valued it.

Part of feeling emotionally ready and trusting their instinct also came from knowing that everyone experiences sexual health differently, as another participant explained:

I would say that probably everybody is different and you just have to kind of do what feels right to you and if having a lot of sex at this point is something that you feel comfortable with or you feel like you want, perfect, go for it and if it’s not, if you feel like you don’t have the energy for it, if you feel like you don’t want to, that’s fine too. I think it’s important for us to honour what we feel like we can handle and what we feel like we want to do.

No matter the individual, the need to “honour” one’s own personal needs, desires, “instinct”, or experiences was acknowledged by several individuals in this study, including this participant. However, it is also important to note the difficulties participants had when navigating conflicting discourses. We need to dig a little deeper and ask the following questions: Why did some participants not trust their gut or their instincts? What were they looking for? What other discourses influenced their decision? Perhaps wanting confirmation from a health care provider operating from a health or medical discourse influenced their decisions. How strongly did they feel about their ‘instincts’? Whatever choice they made, we can see that it is important to recognize the influence that various discourses had on their practices surrounding postpartum sexual health. Participants also negotiated relations of power when thinking about different types of knowledge and information. For example, participants often used their agency when they relied on their personal knowing to ‘do what felt right’ and used that knowing as a way of challenging certain norms or expectations regarding the resumption of sexual activities postpartum.

The 6-Week Check

All eleven participants discussed the 6-week postpartum check-up with their primary health care provider (usually a physician) when they were asked about a moment when they thought about their sexual health postpartum. The 6-week check was interpreted differently by participants; how they defined or made meaning of the purpose of the 6-week check profoundly affected how they felt about resuming sexual activities. Some felt pressured to resume sexual activities earlier than they wanted to because of how they ascribed meaning to receiving the ‘green light’ from their health care provider. To be clear, this was not necessarily about what their health care provider did or said but rather about how the appointment was viewed and interpreted by the individual participant. Feelings of pressure, anxiety, fear, and ‘dread’ were experienced by several participants, as exemplified in this quote:

I just remember this feeling like not quite dread but within that category of emotions when I was going in and I was hoping that [the doctor] wouldn’t clear me because I was like I don’t want to have to go home and have the discussion about when are we going to have sex, I don’t feel like it, things don’t feel right down there. I’m still swollen, I’m still bleeding, and I just remember this feeling of just being like “please don’t say yes, please can I have another month,” so it was definitely like that component where it was like it just felt too soon. And it felt like such an arbitrary date at six weeks.

Believing that the 6-week mark represented a time when they should be feeling ready to resume sexual activities was common for participants, though others also interpreted it as a finish line of sorts—something that represented a return to their ‘normal’. The institutional medical discourse that positions health care providers as the authority on sexual health after birth was present in many experiences; participants discussed the importance of being “cleared for sex” or given the “green light”. Despite valuing their health care provider’s opinion about physical recovery and the ability to safely engage in sexual activities (i.e., without risking infection or damage to the perineum), some participants felt brushed off by their health care providers, with one participant detailing how she was told by her physician to use Crisco to assist with vaginal lubrication and return 6 months later if she was still experiencing issues.

The discourse of the 6-week mark assumes that one’s sexual practices (and identity in relation to them) are a linear experience in which childbirth and the postpartum period are merely an interruption. This is part of a medical institutional discourse that views female sexuality as being primarily for the purpose of reproduction, which the postpartum individual must be ‘available’ for as soon as possible. It is imperative to consider that while health care providers may be able to assess physical healing and ‘readiness’, subjective experiences such as pelvic pain and emotional readiness are equally, if not more, important. Participants’ experiences clearly demonstrate how both social and institutional discourses affected their decisions, as well as how they negotiated and challenged the meaning of the 6-week check-up.

Redefining Intimacy

Due to the general decrease in sexual desire that the majority of participants experienced, many chose to redefine intimacy as a way of enacting agency and negotiating relations of power. Intimacy after birth was often defined in non-sexual or non-physical ways, and participants created a new meaning of intimacy that could include kissing, cuddling, cooking together, flirting, or talking alone with their partner without interruption, as described in the following quote:

You really do have to kind of re-learn everything so that’s been a fun aspect of intimacy after having a baby. Again, even though it’s not as much as I would like the actual act of sex, it’s great to have that that connection and that intimacy on an emotional level, like having words of affirmation for one another and even if it’s not the full sexual act, just deep kisses and hugging and what not can even just be really nice.

Participants valued time with their partner(s) and believed it was important to maintain closeness within their relationship and show signs of affection, trust, respect, and appreciation. In detailing how they shifted the meaning of intimacy, participants revealed a social discourse that prioritizes and positions sexual activities as a requirement within romantic relationships (Keogh, 2005). There also existed another similar social discourse that positioned sexual activities as the ‘best’ or most valid way to show affection to one’s romantic partner(s), as described by one participant: “I think too and it shouldn’t matter, but society’s views of if I said oh we haven’t had sex since I had a baby, I would be embarrassed to say that because of what society expects from relationships.” Another participant resisted this social discourse by describing how intimacy did not necessarily need to include sexual activities:

Even just spending time together and really just talking and being in each other’s company is almost just as good for me right now as having sex probably because it involves a little bit less energy and we still get to spend time together and you know kind of connect in a different way than connecting sexually without putting the energy into having sex. It’s a more relaxed way to be together right now.

Many participants echoed similar thoughts about how intimacy after birth was often valued for maintaining and promoting emotional connection with their partner(s) rather than having solely a sexual meaning.

Discussion

It is important to acknowledge that ‘feeling ready’ to resume sexual activities after birth involves both emotional and physical factors, some of which are interwoven (O’Malley et al., 2023). In the current literature, postpartum pelvic floor recovery has primarily been assessed with a focus on pain or initiation of sexual intercourse, with several researchers outlining how perineal lacerations or physical trauma might negatively impact sexual functioning (Leeman & Rogers, 2012; Sobhgol et al., 2019) without considering the emotional aspects of pelvic floor injury. Although it is known that many people experience pelvic floor injuries during childbirth (Fairchild et al., 2020; Gong et al., 2020), our research uniquely shows how definitions of postpartum sexual health are personal and intuitive. More specifically, this research provides an enhanced understanding of how postpartum individuals create meaning of their pelvic floor health through a combination of discourses. Participants did so by shaping it as something that was important to their wellbeing and sexual health, even beyond the postpartum period. For participants, their pelvic floor health and recovery was important to them because it affected future childbearing, influenced their ability to engage in and enjoy sexual activities, and prevented urinary incontinence.

The authors believe it is also critical to consider how knowledge regarding pelvic floor recovery and sexual health is shared or valued through different social and institutional discourses. From a feminist poststructural perspective, it is important to explore the idea that knowledge regarding pelvic floor recovery does not always need to be medicalized. This is important because it allows for the patient’s personal experience to instead be valued and prioritized, rather than medical assumptions or formal knowledge. There are other recent examples of postpartum health research that employ feminist poststructuralism (Joy et al., 2020; Ollivier et al., 2021); however, this is the first study to explore sexual health after birth using this methodology. While postpartum individuals may find it helpful to seek health care services, they may also have ownership in knowing their own bodies and how to promote their own recovery. Other researchers have begun to explore aspects of strategizing or problem-solving with regard to postpartum sexual health (O’Malley et al., 2019), which this work helps to build upon. This study is an example of how recognition of one’s agency and ability to question and negotiate different discourses can be empowering.

The participants in this study also showed how the 6-week mark, which usually includes an appointment with their health care provider, was interpreted as a time when participants felt they should be feeling ready to resume sexual activities, though many did not feel ready and believed that the 6-week mark felt ‘arbitrary’. The 6-week check-up has been previously described by other researchers as a time when postpartum women often feel that they are not ready to resume sexual intercourse, though value input and assessment by their health care providers (Barrett et al., 2000). Researchers have also described how the 6-week mark is not in line with realistic patient needs or desires, specifically as it relates to contraception and timing of the associated return to sexual activities (Glazer et al., 2011). It is not to say that the participants in this study were feeling forced or told by their health care providers to resume sexual activities. Rather, they responded to the 6-week appointment by feeling pressured based on how they created meaning of their health care provider’s approval and the postpartum check-up more generally. This is an example of the way institutional discourses can perpetuate feelings of pressure when individuals respond in different ways to socially constructed meanings. The significance of the 6-week check-up has also been discussed in other research, where participants have spoken of being “cleared” (p. 1166) for sexual activities after birth or receiving “doctor’s orders” (p. 1166) to resume sexual activities (DeMaria et al., 2019). This research indicates how the significance of the 6-week mark may be similarly viewed as a time when postpartum individuals traditionally receive health care providers’ ‘approval’ to resume sexual activities.

In considering the meaning that is placed on health care providers’ interactions and/or assessment, it is important that postpartum sexual health is addressed by health care providers throughout the prenatal and postnatal period. Moreover, it must be addressed in a way that centers the postpartum individual’s definition and meaning of sexual health, whether that is focused on certain aspects of sexual health such as pelvic pain/dyspareunia, sexual desire, anxiety, discomfort, or uncertainty. Due to the taboo and invisibility surrounding the topic of sexual health after birth, postpartum individuals require reliable, trusted sources of information (such as nurses/nurse practitioners, midwives, pelvic floor physiotherapists, or physicians) to provide support and demonstrate a willingness to explore different meanings of postpartum sexual health (LaMarre et al., 2003; Ollivier et al., 2019).

Different meanings were also described when it came to intimacy. Other researchers have described how postpartum women may prefer non-sexual ways of connecting with their partners to maintain a sense of closeness and intimacy (Bender et al., 2018; O’Malley et al., 2019; Vannier, Rosen, & Adare, 2018), though this paper is the first to describe how postpartum individuals negotiate relations of power to create new meanings of intimacy as a way of responding to their emotional and sexual needs. Intimacy within romantic relationships is socially defined to include sexual activity or intercourse, though the postpartum individuals in this study were able to shift what intimacy looked or felt like based on factors such as new parenting responsibilities, decreased sexual desire, fatigue, or stress. This tells us that some postpartum individuals may therefore choose to define intimacy in non-physical or non-sexual ways, either temporarily or as a way of adapting to life after childbirth.

Limitations

This study was limited to one province within Canada to ensure feasibility, therefore limiting other possible geographical or cultural influences (as only some examples). This study also focused on the first 6 months postpartum to ensure richness of the data, though it would be highly beneficial to explore sexual health further along in the postpartum period as well given that some participants still had concerns about their sexual health at 6 months postpartum. In conducting this research, the authors aimed to center the unique perspective(s) of postpartum individuals. However, it would be valuable to explore couples’ sexual health and relationships after birth to allow for a better understanding of sexual health and how it is experienced during the postpartum period. More specifically, there exists a severe lack of literature exploring how two-spirit, lesbian, gay, bisexual, transgender, and queer (2SLGBTQ+) folks experience sexual health during the postpartum period. This study occurred during the COVID-19 pandemic, which may have affected results given that many new parents in Nova Scotia experienced increased isolation, stress, anxiety, and other mental health issues during this time (Joy et al., 2020; Ollivier et al., 2021).

Conclusion

Sexual activities were foregrounded in how participants defined sexual health. This research uniquely showed how participants navigated the resumption of sexual activities, which included knowing what was best for them and choosing how, if, and when to engage in sexual activities either with themselves or with their partners. The choice to resume sexual activities was complex and was not necessarily linear or definite. Participants used subjectivity and agency to position themselves as knowledgeable agents in their own sexual health, especially when their own beliefs or thoughts were challenged by others, such as health care providers. The choice surrounding when to resume sexual activities after birth was influenced by many competing discourses, including those which surrounded the 6-week check-up. Each of these discourses must be considered in order to improve postpartum health and wellbeing in Canada. The postpartum individuals in this study actively negotiated relations of power in response to both social and institutional discourses as a way of ensuring that their choice(s) represented what was best for them.