General gynaecology

DOI: 10.1111/1471-0528.13263
www.bjog.org

Dyspareunia and childbirth: a prospective cohort

study
EA McDonald,a D Gartland,a R Small,b SJ Browna,c
a
Healthy Mothers Healthy Families Research Group, Murdoch Childrens Research Institute, Melbourne, Vic., Australia b The Judith Lumley
Centre, La Trobe University, Melbourne, Vic., Australia c General Practice and Primary Health Care Academic Centre, The University of
Melbourne, Melbourne, Vic., Australia
Correspondence: EA McDonald, Healthy Mothers Healthy Families Research Group, Murdoch Childrens Research Institute, The Royal
Childrens Hospital, Flemington Road, Parkville, Vic. 3052, Australia. Email [email protected]

Accepted 15 November 2014. Published Online 21 January 2015.

Objective To investigate the relationship between mode of

delivery, perineal trauma and dyspareunia.

Design Prospective cohort study.
Setting Six maternity hospitals in Melbourne, Australia.
Sample A total of 1507 nulliparous women recruited in the first

and second trimesters of pregnancy.

Method Data from baseline and postnatal questionnaires (3, 6, 12

and 18 months) were analysed using univariable and multivariable

logistic regression.
Main outcome measure Study-designed self-report measure of

dyspareunia at 18 months postpartum.

Results In all, 1244/1507 (83%) women completed the baseline

and all four postpartum questionnaires; 1211/1237 (98%) had

resumed vaginal intercourse by 18 months postpartum, with 289/
1211 (24%) women reporting dyspareunia. Compared with
women who had a spontaneous vaginal delivery with an intact

perineum or unsutured tear, women who had an emergency

caesarean section (adjusted odds ratio [aOR] 2.41, 95% confidence
interval [95% CI] 1.44.0; P = 0.001), vacuum extraction (aOR
2.28, 95% CI 1.34.1; P = 0.005) or elective caesarean section
(aOR 1.71, 95% CI 0.93.2; P = 0.087) had increased odds of
reporting dyspareunia at 18 months postpartum, adjusting for
maternal age and other potential confounders.
Conclusions Obstetric intervention is associated with persisting

dyspareunia. Greater recognition and increased understanding of

the roles of mode of delivery and perineal trauma in contributing
to postpartum maternal morbidities, and ways to prevent
postpartum dyspareunia where possible, are warranted.
Keywords Cohort studies, delivery obstetric, dyspareunia, pain,
perineum, postpartum period, prospective studies, sexual intercourse.
Linked article This article is commented on by C Sakala, p. 680 in
this issue. To view this mini commentary visit http://dx.doi.org/
10.1111/1471-0528.13264.

Please cite this paper as: McDonald EA, Gartland D, Small R, Brown SJ. Dyspareunia and childbirth: a prospective cohort study. BJOG 2015;122:672679.

Introduction
The relationship between obstetric risk factors including
mode of delivery and perineal trauma and dyspareunia is
not well characterised or understood.17 Previous studies
have suffered from several methodological limitations
including cross-sectional study design,13,5,6 limited power
to assess associations with obstetric risk factors17 and lack
of long-term follow up.17 Inferences drawn from the existing literature are limited by the failure of the studies to
consider prepregnancy dyspareunia27 and a range of postpartum factors, such as breastfeeding and intimate partner
abuse, that may confound associations.26
This study draws on data collected in the Maternal
Health Study, an Australian multicentre, prospective

672

nulliparous pregnancy cohort study.8 The primary objective

of this paper was to investigate the contribution of obstetric risk factors, including mode of delivery and perineal
trauma, to postpartum dyspareunia. In addition, we aimed
to assess the influence of potential confounders, including
breastfeeding, maternal fatigue, maternal depression and
intimate partner abuse.

Methods
Sample and participants
Details regarding study eligibility and exclusion criteria and
recruitment methods are available in a published study protocol.8 Briefly, women were recruited to the study between
April 2003 and December 2005 from six metropolitan public

2015 Royal College of Obstetricians and Gynaecologists

Dyspareunia and childbirth

maternity hospitals in Melbourne, Australia. We recruited

nulliparous women, aged over 18 years, in the first and
second trimesters of pregnancy. Women with poor English language literacy were excluded.

Measures and definitions

At recruitment, participants were asked to complete a
baseline questionnaire recording demographic and social
characteristics, including age, country of birth and socioeconomic status, and baseline measures of common maternal
morbidities, including dyspareunia before and during pregnancy.1 Follow-up questionnaires were administered at 3, 6,
12 and 18 months postpartum. Data regarding the mode of
delivery and degree of perineal trauma were collected in the
3-month postpartum questionnaire and abstracted from
medical records for a subset of women. There was a high
degree of congruity between womens own accounts of mode
of delivery and other obstetric events and data abstracted
from medical records.9,10
Follow-up questionnaires included study-designed questions regarding sexual health and dyspareunia drawing on
questions included in the Australian Longitudinal Womens
Health Study11 and a study by Barrett et al.1 assessing
womens health after childbirth. Study questionnaires also
included validated measures of maternal depressive symptoms (Edinburgh Postnatal Depression Scale)12 and intimate partner abuse (Composite Abuse Scale),13,14 and
single item measures assessing maternal fatigue15 and infant
feeding.16 Pretesting of the questionnaires, paying particular attention to study-designed questions, was undertaken
with a pilot sample of women recruited through participating hospitals. The baseline Maternal Health Study questionnaire is available on the study website.17 Postnatal
questionnaires can be made available by contacting the
authors.

Statistical analysis
Data were analysed using STATA version 13 (StataCorp.,
College Station, TX, USA).18 Sample representativeness was
assessed by comparing data on social and obstetric characteristics of participants with routinely collected perinatal
data for nulliparous women giving birth in the study period at the six participating hospitals, and at all public
maternity hospitals in Victoria.
Analyses presented in the paper are restricted to women
who completed the baseline questionnaire and all follow-up
questionnaires. The proportions of women resuming vaginal sex by 3, 6 and 12 months postpartum were calculated
based on the proportion of women reporting resumption
of sex divided by the total number of women with valid
responses at each time point.
The period prevalence of dyspareunia at 6 and
18 months postpartum was calculated based on the

2015 Royal College of Obstetricians and Gynaecologists

proportions of women reporting symptoms divided by the

total number of women who had resumed vaginal sex and
had data available for the relevant period. Pain on first vaginal sex is reported separately.
Risk factors for postpartum dyspareunia were investigated using univariable and multivariable logistic regression. Logistic regression modelling was used to examine the
association between mode of delivery and perineal trauma
(exposures of main interest) and dyspareunia at 18 months
postpartum (primary outcome), taking into account potential confounders. Maternal age was included in modelling
analyses for a priori reasons. Other variables were included
based on associations that were observed in univariable
analyses at 6 and/or 18 months postpartum. Data are presented as crude or adjusted odds ratios (ORs) with 95%
confidence intervals (95% CI).
Ethical approval for the study was provided by La Trobe
University (2002/38); Royal Childrens Hospital, Melbourne
(27056A); Royal Womens Hospital, Melbourne (2002/23);
Southern Health, Melbourne (2002-099B); and Angliss
Hospital, Melbourne (2002).

Results
Participants
A total of 1507 women enrolled in the study. The mean
gestation of study participants at the time of enrolment
was 15.0 weeks (range 624 weeks). We were unable to
determine a precise response fraction, but conservatively
estimate that the response was between 1507/5400 (28%)
and 1507/4800 (31%). The follow-up response fractions
were 1431/1507 (95%), 1400/1507 (93%), 1387/1507
(92%), 1326/1507 (88%) at 3, 6, 12 and 18 months postpartum, respectively. In all, 1211/1239 (98%) participants
were sexually active at 18 months postpartum.
Study participants were representative in relation to
obstetric characteristics including mode of delivery and
perineal trauma (see Table 1). Women born overseas in
countries where English is not the first language, and younger women were under-represented. Further information
regarding sociodemographic and reproductive characteristics of the sample and representativeness of study participants is available in previous papers.10,19 The 1244/1507
(83%) women who completed all four follow-up questionnaires comprise the sample for the analyses in this paper
(Figure 1).

Birth outcomes
A total of 609/1244 (49.0%) women had a spontaneous
vaginal birth, two-thirds of whom (411/609, 67.5%) sustained a sutured tear and/or episiotomy; 134/1244 (10.8%)
had an operative vaginal birth assisted by vacuum extraction and 133/1244 (10.7%) gave birth assisted by forceps.

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McDonald et al.

Table 1. Social characteristics of participants in the Maternal Health Study compared with Victorian Perinatal Data Collection Unit data
Maternal Health
Study participants
(n = 1507)

Maternal age at birth of first child

1824 years
2529 years
3034 years
3539 years
40 years
Relationship status*
Married
Unmarried
Country of birth*
Australia
OverseasEnglish speaking
Overseasnon-English speaking background
Mode of delivery*
Caesareanno labour
Caesareanlaboured
Spontaneous vaginal birth
Vaginal breech birth
Vaginal with forceps
Vaginal with vacuum extraction
Perineal trauma**
Intact perineum
Unsutured laceration
Sutured laceration
Episiotomy
Episiotomy and tear

Nulliparous women
18 years giving
birth in Victorian
public hospitals
1/7/03 to 31/12/05
(n = 40 905)

Nulliparous women
18 years giving
birth in the six
participating
Victorian hospitals
1/7/03 to 31/12/05
(n = 13 803)

212
437
580
236
42

14.1
29.0
38.4
15.7
2.8

12 216
13 802
10 740
3552
595

29.8
33.7
26.3
8.7
1.5

3813
4645
3769
1319
257

27.6
33.7
27.3
9.6
1.9

914
593

60.7
39.3

22 790
17 932

56.0
44.0

8300
5469

60.3
39.7

1115
141
243

74.4
9.4
16.2

29 791
2109
8738

73.3
5.2
21.5

8603
905
4267

62.5
6.6
30.9

140
292
695
5
150
149

9.8
20.4
48.6
0.3
10.5
10.4

3750
7665
20 785
182
3915
4603

9.2
18.7
50.8
0.4
9.6
11.3

1237
2587
7000
95
1426
1457

9.0
18.7
50.7
0.7
10.3
10.6

595
72
439
228
93

41.7
5.0
30.8
16.0
6.5

19 805
n/a
11 074
9068
958

48.4
n/a
27.1
22.2
2.3

6296
n/a
4221
3089
197

45.6
n/a
30.6
22.4
1.4

*Denominators vary due to missing values.

**Data collected by the Perinatal Data Collection Unit on perineal trauma does not include information regarding unsutured lacerations or
nonperineal lacerations, e.g. vaginal wall tears.

The majority of these women sustained a sutured tear and/

or episiotomy (124/134, 92.5% and 129/133, 97.0%, respectively). In all, 120/1244 (9.7%) were delivered by elective
caesarean section and 248/1244 (19.9%) were delivered by
emergency caesarean section.

Dyspareunia following childbirth

By 3 months postpartum, 970/1239 (78.3%) had resumed
vaginal intercourse; 1165/1239 (94.0%) by 6 months postpartum, 1202/1239 (97.0%) by 12 months postpartum and
1211/1239 (97.7%) by 18 months postpartum. Most of the
women who had resumed sex by 12 months postpartum
experienced pain during first vaginal sex after childbirth
(961/1122, 85.7%). Dyspareunia was reported by 431/964

674

(44.7%) women at 3 months postpartum, 496/1144

(43.4%) women at 6 months postpartum, 333/1184
(28.1%) women at 12 months postpartum and 289/1236
(23.4%) women at 18 months postpartum. Of the 496
women who reported dyspareunia at 6 months postpartum,
one-third (162/496, 32.7%) reported persisting dyspareunia
at 18 months postpartum. In all, 338/1234 (27.4%) women
reported dyspareunia in the year prior to the index pregnancy.

Associations with dyspareunia

The unadjusted odds of dyspareunia at 18 months postpartum were higher in women who gave birth by vacuum
extraction (OR 2.01, 95% CI 1.23.5; P = 0.013),

2015 Royal College of Obstetricians and Gynaecologists

Dyspareunia and childbirth

Q1: 1507 eligible participants

13 Withdrew

Q2: 1494 participants

1431 completed (95.0% of 1507 participants)
5 Withdrew
3 lost to follow up
Q3: 1486 participants
1400 completed (92.9% of 1507 participants)
16 Withdrew
6 lost to follow up
Q4: 1464 participants
1357 completed (90.0% of 1507 participants)
6 Withdrew
6 lost to follow up
Q5: 1452 participants
1327 completed (88.1% of 1507 participants)

Figure 1. Maternal Health Study participation flowchart to 18 months postpartum.

emergency caesarean section (OR 2.04, 95% CI 1.33.3;

P = 0.004) or elective caesarean section (OR 1.65, 95% CI
0.92.9; P = 0.090) compared with women who had a
spontaneous vaginal birth with an intact perineum. Younger women (OR 1.58, 95% CI 1.02.5; P = 0.057), women
who experienced dyspareunia before the index pregnancy
(OR 2.18, 95% CI 1.62.9; P = 0.000), women who
reported intimate partner abuse from birth to 12 months
postpartum (OR 1.84, 95% CI 1.32.6; P = 0.001), women
who reported fatigue at 18 months postpartum (OR 1.65,
95% CI 1.22.3; P = 0.002) and women who reported
depressive symptoms at 18 months postpartum (OR 1.97,
95% CI 1.33.0; P = 0.002) also had increased odds of
reporting dyspareunia at 18 months postpartum.
To obtain more precise estimates of the association
between mode of delivery and dyspareunia at 18 months
postpartum, we developed a multivariable logistic regression model (Table 2). A composite variable combining data
on mode of delivery and perineal trauma was the exposure
of main interest. Maternal age was included in the model
for a priori reasons based on previous research showing
that younger women are more likely to experience dyspareunia.20,21 Dyspareunia before pregnancy, maternal depression, maternal fatigue and intimate partner abuse were
included because of the significant associations with dyspareunia at 6 and/or 18 months postpartum noted in univariable analyses.
Women who gave birth by emergency caesarean section
or vacuum extraction and those who reported prepregnancy dyspareunia had greater than a twofold increase in
adjusted odds of persisting dyspareunia at 18 months postpartum compared with women who had a spontaneous
vaginal birth with an intact perineum after adjusting for

2015 Royal College of Obstetricians and Gynaecologists

other variables in the model. Elective caesarean section was

also associated with increased odds of dyspareunia at
18 months postpartum, although the confidence interval
suggests borderline statistical significance.
Similar patterns of association were found between
dyspareunia at 6 months postpartum, mode of delivery,
perineal trauma and other maternal and postnatal factors
(Table 3). Women who had an operative vaginal delivery
(with forceps or vacuum extraction) had greater than a
three-fold increase in adjusted odds of dyspareunia at
6 months postpartum. Emergency caesarean section and
vaginal birth with a sutured tear and/or episiotomy were
associated with a two-fold increase in odds of dyspareunia
after taking into account other factors in the model.
Women who had an elective caesarean section did not
have raised odds of reporting dyspareunia at 6 months
postpartum. Prepregnancy dyspareunia was associated with
a two-fold increase in odds of dyspareunia at both 6 and
18 months postpartum. Observed associations with obstetric intervention in multivariable models were stronger
than associations with postnatal factors, including maternal depressive symptoms, fatigue and intimate partner
abuse.

Discussion
Main findings
Almost all women experience some pain during sexual
intercourse following childbirth. Our findings show that
the extent to which women report dyspareunia at 6 and
18 months postpartum is influenced by events during
labour and birth. The odds of dyspareunia at 18 months
were substantially higher in women who delivered by

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McDonald et al.

Table 2. Adjusted odds of dyspareunia at 18 months postpartum associated with mode of delivery, perineal trauma and other risk factors*
Dyspareunia at 18 months
postpartum
No
n (%)
Mode of delivery and perineal trauma
Spontaneous vaginal birth
Intact perineum/unsutured tear
Sutured tear/episiotomy
Caesarean section (intact perineum)
Elective
Emergency
Forceps (sutured tear/episiotomy)
Vacuum extraction (sutured tear/episiotomy)
Prepregnancy dyspareunia
No
Yes
Maternal age at index birth
3034 years
1824 years
2529 years
35+ years
Highest educational qualification
University degree
Certificate/diploma
Year 12
<Year 12
Maternal fatigue at 18 months postpartum
No
Yes
EPDS 13 at 18 months postpartum
No
Yes
Intimate partner abuse in first 12 months postpartum
No
Yes

Adjusted OR (95% CI)

P values

Yes
n (%)

153 (83.2)
307 (80.2)

31 (16.8)
76 (19.8)

1.0 ref
1.37 (0.82.2)

0.201

84
157
95
86

28
65
24
35

1.71
2.41
1.56
2.28

(0.93.2)
(1.44.0)
(0.82.9)
(1.34.1)

0.087
0.001
0.156
0.005

(75.0)
(70.7)
(79.8)
(71.1)

(25.0)
(29.3)
(20.2)
(28.9)

679 (81.5)
210 (66.9)

154 (18.5)
104 (33.1)

1.0 ref
2.09 (1.52.8)

0.000

254
85
366
189

(78.9)
(70.3)
(76.1)
(81.8)

68
36
115
42

(21.1)
(29.7)
(23.9)
(18.2)

1.0 ref
1.45 (0.92.4)
1.10 (0.81.6)
0.77 (0.51.2)

0.165
0.602
0.263

436
226
165
62

(77.0)
(76.4)
(81.3)
(73.8)

130
70
38
22

(23.0)
(23.6)
(18.7)
(26.2)

1.0 ref
0.91 (0.61.3)
0.69 (0.41.1)
1.02 (0.61.8)

0.620
0.091
0.938

297 (83.0)
592 (74.8)

61 (17.0)
200 (25.2)

1.0 ref
1.51 (1.12.1)

0.018

824 (78.8)
68 (65.4)

222 (21.2)
36 (34.6)

1.0 ref
1.27 (0.82.0)

0.318

766 (79.3)
125 (67.6)

200 (20.7)
60 (32.4)

1.0 ref
1.65 (1.12.4)

0.009

EPDS, Edinburgh Postnatal Depression Scale.

*Excludes women who report giving birth to second baby by 18 months postpartum and denominators vary due to missing values.

emergency caesarean section or vacuum extraction, and

somewhat higher for women who had an elective caesarean
section, compared with women who had a spontaneous
vaginal birth with an intact perineum. At 6 months postpartum, vaginal birth assisted with forceps was also associated with dyspareunia, but elective caesarean section was
not. These differences in the pattern of association with
mode of delivery may reflect limited study power for comparisons of these subgroups. Alternatively, it is possible that
women recover more quickly from forceps than from vacuum extraction, and that women having an elective caesarean section that do experience postpartum dyspareunia are
slow to recover. It is noteworthy that the proportion of

676

women reporting dyspareunia at 18 months postpartum is

similar for women who had a spontaneous vaginal birth
with and without perineal damage.
Other factors associated with dyspareunia at 18 months
postpartum include prepregnancy dyspareunia, intimate
partner abuse and maternal fatigue. These results suggest
that clinicians should be alert to the possibility that intimate partner abuse is a potential underlying factor in persisting dyspareunia.
The finding that breastfeeding is associated with dyspareunia in the early postnatal period confirms previous
study findings.1 Women still breastfeeding at 6 months
postpartum had a higher likelihood of experiencing

2015 Royal College of Obstetricians and Gynaecologists

Dyspareunia and childbirth

Table 3. Adjusted odds of dyspareunia at 6 months postpartum associated with mode of delivery, perineal trauma and other risk factors*
Dyspareunia at 6 months
postpartum

Mode of delivery and perineal trauma

Spontaneous vaginal birth
Intact perineum/unsutured tear
Sutured tear/episiotomy
Caesarean section (intact perineum)
Elective
Emergency
Forceps (sutured tear/episiotomy)
Vacuum extraction (sutured tear/episiotomy)
Prepregnancy dyspareunia
No
Yes
Maternal age at index birth
3034 years
1824 years
2529 years
35+ years
Highest educational qualification
University degree
Certificate/diploma
Year 12
<Year 12
Breastfeeding at 6 months postpartum
No
Yes
Maternal fatigue at 6 months postpartum
No
Yes
EPDS 13 at 6 months postpartum
No
Yes
Intimate partner abuse in first 12 months postpartum
No
Yes

No

Yes

130 (68.8)
201 (53.6)

59 (31.2)
174 (46.4)

72
133
59
45

(68.6)
(59.4)
(48.0)
(40.5)

33
91
64
66

(31.4)
(40.6)
(52.0)
(59.5)

Adjusted OR (95% CI)

P values

1.0 ref
2.32 (1.53.5)

0.000

0.76
1.83
3.11
3.36

(0.41.4)
(1.22.9)
(1.95.2)
(2.05.8)

0.387
0.010
0.000
0.000

503 (60.8)
140 (45.8)

325 (39.2)
166 (54.2)

1.0 ref
1.91 (1.42.6)

0.000

203
77
249
119

(60.1)
(59.2)
(53.4)
(56.7)

135
53
217
91

(39.9)
(40.8)
(46.6)
(43.3)

1.0 ref
1.39 (0.92.3)
1.30 (0.91.8)
1.25 (0.81.9)

0.181
0.118
0.293

293
168
122
62

(53.5)
(56.2)
(61.0)
(68.9)

255
131
78
28

(46.5)
(43.8)
(39.0)
(31.1)

1.0 ref
1.03 (0.71.4)
0.81 (0.61.2)
0.61 (0.31.1)

0.882
0.286
0.102

183 (62.0)
373 (52.5)

112 (38.0)
337 (47.5)

1.0 ref
1.55 (1.12.1)

0.007

283 (60.1)
363 (54.4)

188 (39.9)
304 (45.6)

1.0 ref
1.28 (1.01.7)

0.081

598 (57.3)
47 (48.5)

445 (42.7)
50 (51.5)

1.0 ref
1.62 (1.02.7)

0.060

552 (57.1)
94 (53.4)

414 (42.9)
82 (46.6)

1.0 ref
1.26 (0.91.8)

0.237

EPDS, Edinburgh Postnatal Depression Scale.

*Denominators vary due to missing values.

dyspareunia at 6 months postpartum, even after adjusting

for other maternal factors including mode of delivery and
perineal trauma.

Strengths and limitations

Major strengths of this study are recruitment of a nulliparous pregnancy cohort in early pregnancy, frequent follow
up and high retention of participants to 18 months postpartum. All of these key features of the design of the study
reduce the likelihood of recall bias, which is a major concern in much of the previous literature. Additionally, the
study was designed to facilitate ascertainment and differentiation of pain on first vaginal sex after childbirth and pain

2015 Royal College of Obstetricians and Gynaecologists

on subsequent sex. Importantly for the analyses presented

in this paper, the sample was representative in relation to
mode of delivery.
The recruitment method did result in under-representation of younger women and women born overseas with a
non-English-speaking background. However, this is unlikely
to have biased the results, as these social characteristics
were unrelated to the primary outcomes reported in the
paper. The fact that recruitment was restricted to nulliparous women, while very valuable in providing rich detail
about the experiences of women having their first baby,
means that we are unable to comment on outcomes following second and subsequent births.

677

McDonald et al.

Interpretation
The major contribution of this study is that it provides
much more robust evidence than previously available about
the extent and persistence of postpartum dyspareunia, and
associations with mode of delivery and perineal trauma.
No other study has undertaken such detailed, frequent and
long-term follow up with a sufficiently large nulliparous
cohort recruited in early pregnancy to assess associations
with obstetric risk factors.
The higher prevalence of persisting dyspareunia in
women who had an operative birth raises important questions about the longer-term impact of operative procedures
on womens health. Although in a study of this nature we
cannot be confident in drawing causal inferences, the findings raise important questions about the extent to which
obstetric procedures have long-term consequences for
womens health and wellbeing, and whether any of this
morbidity could be prevented. It is striking that so few
prospective studies have collected data on the persistence
of dyspareunia beyond 6 months postpartum. The study
findings highlight the importance of continuing efforts to
improve understanding of postpartum maternal morbidities, including factors that influence severity and persistence
of symptoms. The fact that dyspareunia persists for a substantial proportion of women also points to the need for
focusing clinical attention on ways to help women experiencing ongoing morbidity, and increased efforts to prevent
postpartum morbidity whenever possible.

Conclusions
The findings of this multicentre prospective cohort of nulliparous women suggest that obstetric interventionspecifically vacuum extraction and caesarean sectioncontribute
to persisting dyspareunia affecting a significant proportion
of women up to 18 months postpartum. Greater recognition and better overall understanding of the role of obstetric intervention in contributing to maternal postpartum
morbidities, and ways to prevent postpartum dyspareunia
where possible, are warranted.

Disclosure of interests
None disclosed.

Contribution to authorship
EM planned and conducted the analyses and wrote the
paper. SB wrote the study protocol, took primary responsibility for the design and conduct of the study, contributed
to analysis and interpretation of data and contributed to
writing the paper. DG and RS contributed to interpretation
of data and reviewed and commented on drafts of the
paper. All authors have approved the final draft of the

678

paper for publication. EM and DG were responsible for

data management.

Funding
This research was supported by project grants from the
Australian National Health and Medical Research Council
(ID191222 and ID433006 Melbourne, Australia); a VicHealth Public Health Research Fellowship (20022006), a
National Health and Medical Research Council Career
Development Fellowship (ID491205, 20082011) and an
ARC Future Fellowship (20122015) awarded to SB; a La
Trobe University Postgraduate Scholarship awarded to EM,
and the Victorian Governments Operational Infrastructure
Support Programme.

Acknowledgements
We are grateful to members of the Maternal Health Study
research team who have contributed to data collection and
coding (Maggie Flood, Ann Krastev, Renee Paxton, Susan
Perlen, Martine Spaull, Hannah Woolhouse). &

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