Introduction
Childbirth and the postpartum period are the most important experiences in women’s lives [1]. During this stage, women experience unique and rapid changes in their body’s shape and size, which may affect their sense toward themselves and interrupt their overall function [26] so that a large number of women report negative attitudes towards their body and their function in the postpartum period [27]. At the same time, such changes may overshadow the sexual self-esteem and sexual function in these individuals [8, 9]. This raises questions about the different types of delivery and their effects among two groups of women with a history of natural delivery and cesarean delivery. Also, contradictions have been reported in the history of research regarding the effects of natural childbirth and cesarean on women. Accordingly, investigating these variables in the two groups of aforementioned women can clarify multiple aspects and consequences of different types of childbirth on women. The aim of the current research was to compare sexual function, body image concern, and sexual self-esteem in women after natural delivery with episiotomy and cesarean delivery.

Methods
This is a casual-comparative study. The statistical population consisted of married women with a history of childbirth referred to health centers affiliated with the Tehran University of Medical Sciences in 2022. A total of 200 participants were selected using the available sampling method. Inclusion criteria included married Iranian women aged between 18 and 45, spending at least three months and a maximum of six months after delivery, spending at least one month from starting sexual intercourse again after childbirth, under five delivery rates, not having a history of sexual dysfunction, and no medical diseases or drug and alcohol addiction. Exclusion criteria included incomplete or unfinished questionnaires. The research data were analyzed using descriptive statistics (mean and standard deviation) and inferential statistics (independent t-test and multivariate analysis of variance) using SPSS software, version 22. To collect the data, Female Sexual Function Index (FSFI), Sexual Self-Esteem Index (SSFI-W), and Body Image Concern Inventory (BICI) were used. Regarding the ethical considerations, participants were informed about the research purposes and they were also assured about the confidentiality of their information. Moreover, they could leave the study whenever they wished, and if desired, the research results would be available to them. 

Results
As shown in Table 1, there was a difference between the mean and standard deviation of the body image concern subscales in the two groups.


Also, the mean and standard deviation of sexual self-esteem in all subscales except experience and skill in the cesarean delivery group were higher than the natural delivery group. In addition, the mean and standard deviation of the cesarean delivery group were higher than the natural delivery group in all subscales of women’s sexual function, except for sexual pain.
According to Table 2, there was no significant difference between the mean scores of body image concern in the two groups.


However, a significant difference was found between the mean scores of the two groups in sexual self-esteem and sexual function (p=0.05) so that the mean scores of sexual self-esteem and sexual function in women with cesarean delivery were higher than in women with natural delivery. 
As shown in Table 3 about the subscales of body image concern, there was a significant difference between the mean scores of the dysmorphic appearance concern among the two groups (p=0.05) so that the scores of this subscale were higher in women with natural delivery than in women with cesarean delivery.


No significant difference was found between the mean scores of interference in social functioning among the two groups. Regarding sexual self-esteem, except for the attractiveness subscale, there was a significant difference between the mean scores of other subscales in the two groups (p=0.05). Women with natural delivery showed higher scores in experience and skill subscales than women with cesarean delivery. However, women with cesarean delivery had higher scores in other subscales of sexual self-esteem (control, moral judgment, and adaptiveness). Regarding sexual function, there was a significant difference between the mean scores among the two groups (p=0.05). Women with natural delivery reported more sexual pain than women with cesarean delivery. In addition, in desire, arousal, lubrication, orgasm, and sexual satisfaction, they had lower scores than women with cesarean delivery. 

Discussion
The aim of the current research was to compare sexual function, body image concern, and sexual self-esteem in women after natural delivery with episiotomy and cesarean delivery. The results showed a significant difference between sexual function and sexual self-esteem among two the groups so that women with a history of cesarean delivery reported higher self-esteem and sexual function. On the other hand, the results indicated that there was no significant difference in body image concern among these two groups of women.
The results regarding the difference in sexual function in women with natural delivery and cesarean delivery are in line with the results of the previous research, including Barbara et al. [17] and Saydam et al. [18], and inconsistent with the research by Chang et al. [19], Fan et al. [21], and Gutziet et al. [12]. In explaining this finding, it should be noted that perineal injury and fear of pain caused by episiotomy are the main factors affecting the sexual function of women with natural childbirth, which decrease desire, stimulation, lubrication, sexual dissatisfaction, and even anorgasmia in these women [51].
The findings of the present research regarding body image indicated that although two groups of women experienced dissatisfaction with their bodies, there was no significant difference between the two groups in terms of body image concern, which is in line with the research by Youseflu et al. [33] and Tavakoli [31], and Pasupuleti et al. [32]. It can be said that the most important defects occurring during pregnancy are weight gain and physical changes. These ongoing changes after childbirth are one of the main concerns in women so that they face many changes in their bodies and feel embarrassed because they believe that they cannot return to their previous form and weight [57, 58]. In addition, socio-cultural factors, such as the media, peers, family, and partners, and the social comparison process may put a great deal of pressure on women to return to the initial weight before pregnancy, which can be one of the important factors affecting body image in women. Therefore, regardless of delivery type, it can be concluded that most women experience physical changes and body image concerns due to pregnancy.
Finally, the present study showed a significant difference between sexual self-esteem among women with cesarean delivery and natural delivery, which is in line with the research by Zielinski et al. [7]. In their research, they showed that women with natural childbirth who underwent episiotomy reported a decrease in sexual/body self-esteem. In explaining these findings, it can be said that physical and vaginal changes caused by episiotomy, may result in sexual problems, such as dryness and pain during intercourse [23, 52], and consequently, lead to lower sexual self-esteem in women after natural childbirth with episiotomy [7].

Ethical Considerations
Compliance with ethical guidelines
In this study, all ethical principles such as confidentiality of data and obtaining informed consent from the participants were considered. The study was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences (Code: IR.SBMU.MSP.REC.1401.119).

Funding
This study was funded by the Shahid Beheshti University of Medical Sciences.

Authors contributions
The authors contributed equally to preparing this paper.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors would like to thank all participants for their cooperation in this study. 

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