Systematic Review

What delivery-related factors affect postpartum

recovery? A systematic review
Zay€el Z. Frijmersum, MD; Eva Van der Meij, PhD; Petra C.A.M. Bakker, PhD; Ralph De Vries, MSc;
Johannes R. Anema, PhD; Judith A.F. Huirne, PhD

OBJECTIVE: This study aimed to identify the delivery-related factors that affect postpartum recovery.
DATA SOURCES: The PubMed, Embase, and Web of Science databases were searched until April 2024 using the following terms: “Child-
birth,” “Caesarean section,” “Complications,” “Recovery,” and “Time Factors.” Studies in English or Dutch were considered for inclusion.
STUDY ELIGIBILITY CRITERIA: All studies that included participants aged ≥18 years who delivered a live-born singleton and that eval-
uated the effect of delivery-related factors on recovery of health, ability, and activity in the postpartum period with a minimum follow-up period of
6 weeks were included.
METHODS: Data from the included studies were extracted, and quality assessment was performed using the Newcastle-Ottawa Scale.
RESULTS: A total of 38 articles were included. Of note, 5 different factors related to delivery that could affect recovery were identified as fol-
lows: mode of delivery, perineal lacerations, birth experience, parity, and neonatal factors. Articles could evaluate multiple affecting factors. Out-
come measures were related to (genitopelvic or surgical site) pain, incontinence, mental health, and functional ability. Of note, 8 articles reported
a negative effect on at least one of the outcome measures after cesarean delivery, 4 articles reported no significant difference between the deliv-
ery modes, and 2 articles found a negative effect on one of the outcome measures after vaginal delivery compared with cesarean delivery. Most
articles (14/17) on perineal trauma reported a negative effect on recovery regarding incontinence and perineal pain. A negative birth experience
was significantly associated with postpartum depression up to 6 weeks after childbirth. Parity of >2 was associated with more dyspareunia, and
a high neonatal birthweight was associated with more pelvic pain.
CONCLUSION: Our study findings indicate that mode of delivery, particularly cesarean delivery, is most frequently reported as having an
effect on postpartum recovery. Recovery took longer (and was more painful) after cesarean delivery than after vaginal delivery. Extensive (third-
and fourth-degree) perineal lacerations are frequently reported as an affecting factor. A small number of articles used functional ability as an out-
come measure and attention for social participation.

Key words: cesarean delivery, childbirth, functional ability, mode of delivery, perineal laceration, postpartum, recovery

Introduction every year go through recovery after is a process that affects not only physi-
The global number of childbirths in childbirth. However, this process cal and mental health but also the social
2022 was approximately 133 million.1 remains poorly defined and inade- well-being of a mother.2 It is affected by
This means that millions of women quately explored. Postpartum recovery many factors and processes, which can
either improve or hinder recovery.
Physical recovery during the postpar-
From the Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Vrije tum period consists of 3 phases. The
Universiteit Amsterdam, Amsterdam, The Netherlands (Frijmersum and Huirne); Amsterdam
initial or acute phase involves the first 6
Reproduction and Development Research Institute, Amsterdam, The Netherlands (Frijmersum and
Huirne); Department of Obstetrics and Gynecology, Amsterdam University Medical Center, to 12 hours after delivery. The second
Amsterdam Medical Center, Amsterdam, The Netherlands (Frijmersum, Bakker, and Huirne); phase is the subacute postpartum
Department of Obstetrics and Gynecology, Noordwest Ziekenhuisgroep, Alkmaar, The period, which lasts 6 weeks. The final
Netherlands (Meij); Medical Library, Vrije Universiteit, Amsterdam, The Netherlands (De Vries); phase is the delayed postpartum period,
Department of Public and Occupational Health, Amsterdam University Medical Center, Vrije
which can last up to 6 months.3 Recov-
Universiteit Amsterdam, Amsterdam, The Netherlands (Anema)
ery of social participation may take lon-
The authors report no conflict of interest.
ger in terms of resumption of
This study received no funding.
employment.4 Guidance during this
This article is registered in the International Prospective Register of Systematic Reviews recovery process is limited. The 6-week
(identification number: CRD42022361262).
postpartum checkup is most commonly
During the preparation of this work, the authors did not use generative artificial intelligence (AI) or
used in most countries to assess post-
AI-assisted technologies in the writing process.
partum recovery and is the only contact
€l Z. Frijmersum, MD. z.z.frijmersum@amsterdamumc.nl
Corresponding author: Zaye
with healthcare professionals after
2666-5778/$36.00
childbirth for most women, regardless
© 2025 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http://
creativecommons.org/licenses/by/4.0/)
of the course of their pregnancy,
http://dx.doi.org/10.1016/j.xagr.2025.100496

May 2025 AJOG Global Reports 1

Systematic Review

AJOG Global Reports at a Glance Materials and methods

Literature review
Why was this study conducted? The conduct and reporting of this
This study aimed to provide healthcare providers with a better insight into the review were in accordance with the Pre-
recovery process of women after childbirth, which will lead to more personalized ferred Reporting Items for Systematic
guidance in the recovery period to improve maternal health and social well- Reviews and Meta-Analyses (PRISMA)
being. guidelines20 and registered in the Inter-
Key findings national Prospective Register of System-
Mode of delivery was most frequently reported as having an effect on postpar- atic Reviews in advance.
tum recovery. Functional ability as an outcome measure and attention for social
participation was lacking. Eligibility criteria
The following inclusion criteria were
What does this add to what is known? used for selection.
Postpartum recovery is influenced by various delivery-related factors, such as
mode of delivery. Type of studies. We included cohort
studies, both prospective and retrospec-
tive, and randomized controlled trials
delivery, and recovery during their post- need to prioritize postpartum recovery (RCTs). Studies must contain informa-
partum period.5 to improve women’s functional ability, tion about factors influencing postpar-
Defining and measuring recovery are as defined by the ICF. tum recovery, with a minimum follow-
difficult, as recovery can be considered Different personal, pregnancy, and up duration of at least 6 weeks after
a biomedical or biopsychosocial pro- delivery-related factors affect postpar- childbirth. Only studies written in
cess.6 To get a better understanding of tum recovery.14,15 Here, we focused on Dutch or English were eligible for inclu-
recovery as a process, it is important to delivery-related factors, as it has been sion.
understand the definition of health. shown that these factors are important
Theoretical models of health outcomes predictors of prolonged sick leave.16 Type of participants. Women aged
or the consequences of disease have These factors relate to delivery from ≥18 years with a live-born child were
been models developed by the World the start of the delivery process (such included in the study.
Health Organization.7 The Interna- as mode of delivery) until after birth.
tional Classification of Functioning, Various studies have been conducted Type of affecting factors. Studies evalu-
Disability and Health (ICF) is based on to evaluate the relationship between ating the relationship between delivery-
a biopsychosocial model that integrates several delivery-related factors and related factors and recovery after child-
medical and social models. The ICF how they affect postpartum recov- birth were included. A comparison
identifies 3 main distinct components, ery.17−19 However, most of these stud- was made regarding recovery between
impairment, activity limitation, and ies focused only on a single domain of patient groups exposed to the affecting
participation restriction, and their recovery. No overview exists of all factor (affecting factor group) and
respective opposites, body function and delivery-related factors and their role patient groups not exposed to the affect-
structure, activity, and participation. in the different domains of recovery, ing factor (comparison group).
Therefore, the concept of health can be which is important as postpartum Studies on personal and social factors
defined as the ability to adapt and self- recovery is a complex process involv- were not included in this review. The
manage in the face of social, physical, ing biomedical and psychosocial findings will be presented in a second
and emotional challenges.8 Therefore, aspects. review in which we will focus more on
functional ability should be assessed in biopsychosocial factors related to post-
the domains of physical, mental, and partum recovery.
social health as it is an outcome mea-
sure that relates to long-term health Type of outcome measures. We
effects and societal participation.9,10 Lit- Objective included outcome measures for recov-
erature shows that up to 90% of women This systematic review aimed to identify ery in the postpartum period based on
deal with health-related problems dur- the delivery-related factors that affect the concepts of health defined by the
ing the first year after childbirth, such mental, physical, and functional recov- ICF, namely, components of body func-
as extreme tiredness, sexual disorders, ery after childbirth. Based on the results, tion and structure, activity, and partici-
depression, and back pelvic and abdom- we aim to facilitate more personal guid- pation.21 Therefore, outcome measures
inal pain.2,3,6,11 Consequently, 30% of ance to mothers at risk of delayed focusing on the physical, mental, and
these women have not resumed recovery to improve maternal health functional aspects of recovery were
employment after maternity leave.12,13 and social participation and to prevent included. Outcomes regarding anatomic
This indicates that there is an urgent negative long-term health effects. changes were not considered for

2 AJOG Global Reports May 2025

 Systematic Review

inclusion in women who did not experi- design, type of affecting factors mea- were retrospective cohort studies. The
ence morbidity from these anatomic sured, number of participants included, remaining 5 studies consisted of 2
changes. and time of inclusion of participants), cross-sectional studies, 1 longitudinal
(2) study participant characteristics study, 1 RCT, and 1 retrospective case-
Search strategy (inclusion and exclusion criteria, inter- control study.
To identify eligible publications, we vention, parity, and mean age), (3) type A total of 37 studies evaluated the
conducted systematic searches in col- of affecting factors/interventions, (4) relationship between specific delivery-
laboration with a medical information type of control group, and (5) outcome related factors (affecting factors) and
specialist from inception to April 2024 (type of outcome measure, methods of recovery. Of note, 1 study evaluated the
in the following databases: PubMed, assessing outcome measure, timing of effect of a specific intervention on
Embase, and Web of Science (core col- assessing outcome measure, and follow- recovery. Studies evaluating an affecting
lection). up duration). factor (A) made a comparison with a
The following terms were used group that was not exposed to the
(including synonyms and closely related Assessment of risk of bias affecting factor (B). For example, when
words) as index terms or free-text The assessment of quality for the non- the effect of induction of labor was eval-
words: “Postpartum period,” “Recovery randomized studies was performed uated on postpartum recovery, this was
of Function,” “Obstetric Labour Com- using the Newcastle-Ottawa Scale compared with a group of women in
plications,” and “Childbirth.” The refer- (NOS)24: form for cohort studies and whom labor was not induced. The fol-
ences of identified articles were cross-sectional studies. Of note, 1 low-up duration varied from a mini-
searched in relevant publications. We reviewer (Z.Z.F.) independently mum of 6 weeks to 36 months after
accepted articles written in Dutch and assessed the quality of the included delivery.
English. Duplicates were excluded using studies. The scoring system was used to
EndNote (version 20.0.1; Clarivate, assess the quality of the 3 broad per- Participants
Philadelphia, PA), following the spectives: the selection of study groups, All participants had a mean age of
Amsterdam Efficient Deduplication the comparability of the groups, and the 18 years (interquartile range, 18−50
method22 and the Bramer method.23 ascertainment of either the exposure or years). Most studies (n=22) included
The full search strategies for the used outcome of interest. The quality catego- both primiparous and multiparous par-
databases with the index terms can be ries defined using NOS are good, fair, ticipants. In 14 studies, only primipa-
found in Appendix. and poor. rous patients were included, and in 2
studies, parity was not mentioned.
Study selection Data synthesis
Of note, 2 reviewers (Z.Z.F. and E.V.D. Because of the large heterogeneity in Type of affecting factors/interventions
M.) independently screened all poten- terms of the type and number of affect- We identified 5 different categories of
tially relevant titles and abstracts for eli- ing factors, intervention, control delivery-related factors or interventions
gibility. If necessary, the full-text article groups, and type of outcome measures, affecting postpartum recovery (affecting
was checked for eligibility criteria. A it was not possible to conduct a meta- factors). These were factors or interven-
third reviewer (P.C.A.M.B.) was con- analysis. Therefore, we used narrative tions focused on mode of delivery, peri-
sulted in case of conflict between the synthesis to describe and integrate the neal lacerations, birth experience,
first 2 reviewers regarding the inclusion findings without formal statistical pool- parity, and neonatal factors.
or exclusion of articles. The remaining ing.
differences in judgment were resolved Type of outcome measures
through a consensus procedure among Results Different outcome measures were used.
the 3 reviewers. Search results The most frequently used outcome
A total of 7882 references were identi- measures were incontinence (n=13) and
Data extraction fied for further evaluation: 2453 in genitopelvic pain (n=13). The other cat-
A data extraction form was developed. PubMed, 3389 in Embase, and 2040 in egories were functional ability (n=5),
Data were extracted by 1 reviewer (Z.Z. Web of Science. After removing the mental health (n=5), and sexual func-
F.) and were checked by the second duplicates, 4553 references remained. A tion (n=4). Studies should report multi-
reviewer (E.V.D.M.). Conflicts were dis- flowchart of the search and selection ple outcome measures.
cussed, and if necessary, a third processes is presented in Figure 1.
reviewer (P.C.A.M.B) was consulted. Quality assessment of included studies
Designs of the included articles The quality of the included studies was
Data items Of the 38 included studies (references in assessed using the NOS. Of note, 34
From the included studies, we extracted the Table25−62), most (n=33) were studies were determined as having good
data on (1) study characteristics cohort studies. Of the 38 studies, 25 quality, 3 studies were determined as
(authors, year of publication, study were prospective cohort studies, and 8 having fair quality, and 1 study was

May 2025 AJOG Global Reports 3

Systematic Review

FIGURE 1
Flowchart of the search and selection procedure of studies

Frijmersum. Delivery related factors affecting postpartum recovery. Am J Obstet Gynecol Glob Rep 2025.

determined to have poor quality. The categories, namely, mode of deliv- studies (n=13), the effect of cesarean
Table25−62 presents the outcomes of the ery (n=23), type of perineal lacera- delivery (CD) vs vaginal delivery (VD)
included studies. tion (n=17), birth experience (n=2), was described. In 7 studies, the effect of
parity (n=1), and neonate (n=1) assisted VD vs spontaneous VD on
Affecting factors (Figure 2). recovery was evaluated. Of note, 4 stud-
A total of 38 studies reported ies reported on the influence of
delivery-related factors that could Mode of delivery unplanned CD vs planned CD on
affect postpartum recovery. Studies In 23 studies (60%), the influence of the recovery. Moreover, 1 study reported
could report on multiple affecting mode of delivery on postpartum recov- on the influence of induced delivery vs
factors affecting a certain outcome. ery was evaluated. Studies could report spontaneous delivery on postpartum
Factors could be divided into 5 on multiple modes of delivery. In most recovery, 1 study reported on the

4 AJOG Global Reports May 2025

 TABLE 1
Study characteristics
Study characteristics Patients Intervention group Outcome
Control group
Affecting factor Type of outcome Follow-up Quality
Author name and year Design Parity n Type of affecting factor category measure duration scorea Resultb
25
Tulman and Fawcett, 1988 Retrospective cohort Primipara, 70 CD Mode of delivery VD Resumption of house- 6 wk Good +; household tasks, societal
multipara hold, social and participation
occupational activi- X; employment resumption
ties, infant care
Goffeng et al,26 1998 Retrospective cohort Primipara, 42 OASI Perineal lacerations No OASI Incontinence, 12 mo Good +; flatus incontinence, dys-
multipara dyspareunia pareunia
X; fecal and urinary
incontinence
Kammerer et al,27 1999 Prospective cohort Primipara, 30 OASI Perineal lacerations No OASI Anal incontinence 4 mo Good +; more and worse anal
multipara incontinence
Goetsch et al,28 1999 Prospective cohort Primipara, 62 Parity ≥3 Parity Parity 1 or 2 Dyspareunia 12 mo Good ; less dyspareunia
multipara
Zetterstr€om et al,29 1999 Prospective cohort Primipara 278 1. Assisted VD 1. Mode of delivery 1. Spontaneous VD Anal incontinence 9 mo Good +; more anal incontinence
2. OASI 2. Perineal lacerations 2. No OASI
Abramowitz et al,30 2000 Prospective cohort Primipara, 233 1. Assisted VD 1. Mode of delivery 1. Spontaneous VD Anal incontinence 8 wk Good +; more anal incontinence
multipara 2. OASI 2. Perineal lacerations 2. No OASI
De Leeuw et al,31 2001 Retrospective cohort Primipara 250 OASI Perineal lacerations No OASI Anal incontinence 14 y Good +; more anal incontinence
X; urine incontinence
Fitzpatrick et al,32 2002 Prospective randomized Primipara 178 Immediate pushing Mode of delivery Delayed (1 h) 1. Assisted delivery 6 mo Good X; no difference in assisted
controlled trial 2. Incontinence delivery or incontinence
Peschers et al,33 2003 Retrospective cohort Primipara 100 Assisted VD Mode of delivery Spontaneous VD Incontinence — Poor X; no difference in anal and
urine incontinence
Nichols et al,34 2005 Prospective cohort Primipara 56 Fourth-degree perineal Perineal lacerations Third-degree perineal Anal incontinence 6 wk Good +; more incontinence
laceration lacerations
Jansen et al,35 2007 Prospective cohort Primipara, 141 1. CD Mode of delivery 1. VD Health related quality 6 wk Poor +; higher fatigue scores in
multipara 2. Unplanned CD 2. Elective CD of life CD than in VD and in
emergency CD than in
elective CD
Eisenach et al,36 2008 Prospective cohort Primipara, 939 CD Mode of delivery VD Postpartum depression 8 wk Good X; no difference
multipara
Zaers et al,37 2008 Prospective cohort Primipara, 47 Negative birth experience Birth experience Positive birth experience Postpartum depres- 6 mo Good +; more depressive
multipara sion, PTSD symptoms

Systematic Review
May 2025 AJOG Global Reports

Rogers et al,38 2009 Prospective cohort Primipara, 326 Major perineal trauma Perineal lacerations Minor perineal trauma Sexual function 3 mo Good X; no difference in activity at
multipara 3 months
Leeman et al,39 2009 Prospective cohort Primipara, 343 Major perineal trauma Perineal trauma Minor perineal trauma Dyspareunia 3 mo Good X; no difference in pain
multipara
Badiou et al,40 2010 Retrospective cohort Primipara 184 1. Assisted VD 1. Mode of delivery 1. Spontaneous VD Anal incontinence 15 mo Good +; more anal incontinence
2. OASI 2. Perineal lacerations 2. No OASI

Frijmersum. Delivery related factors affecting postpartum recovery. Am J Obstet Gynecol Glob Rep 2025. (continued)
5
6 AJOG Global Reports May 2025

Systematic Review
TABLE 1
Study characteristics (continued)
Study characteristics Patients Intervention group Outcome
Control group
Affecting factor Type of outcome Follow-up Quality
Author name and year Design Parity n Type of affecting factor category measure duration scorea Resultb
41
Kainu et al, 2010 Retrospective cohort Primipara, 438 CD Mode of delivery VD Persistent pain 12 mo Good +; persistent pain
multipara
Marsh et al,42 2011 Prospective cohort Primipara, 435 1. Assisted VD 1. Mode of delivery 1. Spontaneous VD Incontinence 3 mo Good +; more incontinence after
multipara 2. Internal anal sphincter 2. Perineal lacerations 2. External anal sphincter assisted VD
X; no difference in
incontinence
Woolhouse et al,43 2012 Prospective cohort Primipara 1431 1. CD Mode of delivery 1. VD Incontinence, tired- 18 mo Good 1 +; more extreme tired-
2. Assisted VD 2. Spontaneous VD ness, back pain ness, back/pelvic pain
after CD
1 ; urine incontinence
2 +; incontinence after
assisted VD
Hosseini et al,44 2012 Retrospective cross-sectional Primipara 213 CD Mode of delivery VD Sexual function 24 mo Fair X; sexual function
45
Persico et al, 2013 Prospective cohort Primipara, 451 Perineal laceration or Perineal lacerations No perineal laceration Dyspareunia 6 mo Good +; delayed resumption sex-
multipara episiotomy ual function
X; dyspareunia
Liu et al,46 2013 Prospective cohort Primipara, 426 Unplanned CD Mode of delivery Elective CD Persistent pain 12 mo Good X; no difference in persis-
multipara tent pain
Bjelland et al,47 2016 Longitudinal Primipara, 20.248 1. CD 1−3. Mode of delivery 1. VD Pelvic pain 24 mo Fair 1 ; pelvic pain
multipara 2. Unplanned CD 4. Neonatal 2. Elective CD 2 X; pelvic pain in
3. Assisted VD 3. Spontaneous VD unplanned and elective
4. High fetal birthweight 4. Lower fetal birthweight CD
3, 4 +; pelvic pain
Sayed Ahmed et al et al,48 2017 Prospective cohort Primipara, 156 Major lacerations Perineal lacerations Minor perineal lacerations Sexual function 12 mo Good +; decrease in FSF
multipara
Komatsu et al,49 2017 Prospective cohort Primipara 134 CD Mode of delivery VD Self-assessed func- 3 mo Good +; functional recovery and
tional ability pain resolution
Munro et al,50 2017 Prospective cohort Primipara 133 CD Mode of delivery VD Persistent pain 3 mo Good X; no difference in persis-
tent pain
Komatsu et al,51 2018 Prospective cohort Primipara 213 Induction of labor Mode of delivery Spontaneous onset of labor Self-assessed func- 4 mo Fair +
tional recovery
Angles-Acedo et al,52 2019 Prospective case-control Primipara, 318 OASI Perineal lacerations No OASI Sexual function 6 mo Good +; worse sexual function
multipara
Molin et al,53 2020 Prospective cohort Primipara, 1171 CD Mode of delivery VD Persistent pain 8 mo Good +
multipara
Rosseland et al,54 2020 Prospective cohort Primipara, 645 Negative birth experience Birth experience Normal birth experience Postpartum depression 8 wk Good +; more depression
multipara
Gommesen et al,55 2020 Prospective cohort Primipara 575 OASI Perineal lacerations No OASI Anal incontinence 12 mo Good +
Manresa et al,56 2020 Prospective cohort Primipara, 405 Major perineal trauma Perineal lacerations Minor perineal lacerations Perineal pain 6 mo Good +; more perineal pain and
multipara /dyspareunia dyspareunia

Frijmersum. Delivery related factors affecting postpartum recovery. Am J Obstet Gynecol Glob Rep 2025. (continued)
 Systematic Review

influence of immediate pushing vs

Newcastle-Ottawa Scale quality assessment score: good (5−9), fair (5−7), and poor (<5); b The “+” symbol indicates significant effect in favor of the group exposed to the affecting factor (intervention), the “ ” symbol indicates significant effect in favor of the nonex-
+; lower functional status at
X: higher risk of postpartum
X: trajectory of dyspareunia

+; important predictor for

delayed pushing, and 1 study reported

+; higher incidence and

depression at 3 mo

6 wk after delivery
on the influence of nonlabor analgesia

postpartum pain
vs labor analgesia.

+; at 1 mo
X; at 6 mo
severity
duration scorea Resultb

Cesarean vs vaginal delivery

Women who had a CD needed signifi-
Follow-up Quality

cantly more time to return to functional

Good

Good

Good

Good

Good

Good
Outcome

ability than those with a VD regarding

Unknown

Unknown
the resumption of household tasks, par-
Postpartum depression 12 mo

36 mo

24 mo

Postpartum depression 3 mo

ticipation in professional and/or reli-

gious organizations, and socializing
with friends (P<.001).25,49,61 In addi-
Functional recovery
Anal incontinence
Type of outcome

tion, significantly higher levels of fatigue

Dyspareunia

scores were found after CD (mean §

measure

standard error of the mean [SEM],

Pain

10.5§0.9) than after VD (mean§SEM,

9.9§0.9) at 6 weeks after delivery
Mode of delivery, minimal

labor + labor analgesia

(P<.001).35 Resumption of occupational

perineal lacerations
Unsuccessful trial of

activities was not found to be signifi-

Control group

cantly affected by the mode of delivery

Planned CD

in a particular study.25 Of note, 1 study

No OASI

looked at the effect of mode of delivery

VD

VD

on sexual function and found no signifi-

Mode of delivery, peri-
Perineal lacerations

cant differences in 6 domains concern-

neal lacerations

CD, cesarean delivery; FSF, Female Sexual Function; OASI, obstetrical anal sphincter injury; PTSD, posttraumatic stress disorder; VD, vaginal delivery.
Mode of delivery,
Mode of delivery

Mode of delivery

Mode of delivery
Affecting factor

ing sexual function after CD compared

analgesia

with after VD at 2 years after delivery

category
Intervention group

(P=.91).44
In addition, 2 studies reported that
posed group (control), and the “X” symbol indicates no significant difference between the groups in terms of the affecting factor.
Mode of delivery, extensive

persistent pain (defined as pain at the

Type of affecting factor

perineal lacerations

surgical site or genital tract) 1 year after

Unsuccessful trial of
labor + nonlabor

delivery was significantly more com-

Frijmersum. Delivery related factors affecting postpartum recovery. Am J Obstet Gynecol Glob Rep 2025.
Unplanned CD

analgesia

mon after CD than after VD (P=.004

and P=.021, respectively).41,53 However,
OASI

CD

CD

a different study did not support these

findings. The studies observed no signif-
2013

2400
213

582

451

220

icant differences in chronic pain

n

between the 2 modes of delivery at 3

Patients

months after delivery (P=.20).50 This

multipara

multipara
Primipara,

Primipara,

finding was supported by a second

Primipara

Primipara

Unknown
Parity

study group that also found no signifi-

—

cant relationship between mode of

delivery and chronic pain (P=.34). CD
was found to be an important predictor
Retrospective cohort

Retrospective cohort
Prospective cohort

Prospective cohort

Prospective cohort

of pain after delivery compared with

Cross-sectional
Study characteristics (continued)

VD (permutation importance level of

Study characteristics

>0.08).62
Design

Pelvic pain after delivery was more

often observed in women after VD at 6
Chandra and Smitha,61 2023

and 18 months after delivery than after

Xu and Sampson,62 2023
Author name and year

Attanasio et al,58 2024

CD (adjusted odds ratio [aOR], 0.48

Zhuang et al,60 2023
Rosen et al,59 2022
Sega et al, 2021

[95% confidence interval (CI), 0.31

−0.74]).47 In addition, no significant
57
TABLE 1

relationship was found between mode of

delivery and postpartum depression
a

(P=.56) 8 weeks after delivery.36 Of note,

May 2025 AJOG Global Reports 7

Systematic Review

FIGURE 2
The concept of recovery

The outcome measures for recovery are based on the concepts of health, ability, and activity according to the International Classification of Functioning,
Disability and Health.
Frijmersum. Delivery related factors affecting postpartum recovery. Am J Obstet Gynecol Glob Rep 2025.

1 study demonstrated more often back in return to functional ability in the pelvic pain after delivery was reported
pain and extreme tiredness at 6 and 12 induced labor group up to 4 months in association with assisted VD by 1
months after delivery in women after after delivery compared with the spon- study compared with spontaneous VD
CD than in women after VD (aORs: 1.37 taneous onset of the labor group (odds ratio [OR], 1.30 [95% CI, 1.06
and 1.40, respectively).43 In addition, (P=.004).51 −1.59]).47 It was reported that, after
this study reported that the CD group assisted VD, women resumed coitus sig-
was less likely to suffer from urine incon- Assisted vs spontaneous vaginal nificantly later and had worse sexual
tinence at 3, 6, and 12 months after delivery function than women who had a spon-
delivery than the VD group (aORs: 0.26, In addition, 4 studies reported that taneous VD (P<.001).52
0.36, and 0.48, respectively). assisted VD was significantly associated
with more anal incontinence complaints Immediate vs delayed pushing in
Induced vs spontaneous labor up to 15 months after delivery than vaginal delivery
In addition, 1 study reported on the spontaneous VD (P<.05).29,30,40,42 In Of note, 1 particular study evaluated the
effect of spontaneous and induced labor contrast, 1 study found no difference in effect of immediate vs delayed (1 hour)
on recovery, defined as self-assessed urinary or anal incontinence between pushing and found no significant differ-
functional recovery to predelivery level. assisted VD and spontaneous VD at 6 ence in anal incontinence up to 3
The study reported a significant delay months after delivery.33 In addition, months after delivery (P=.27).32

8 AJOG Global Reports May 2025

 Systematic Review

Unplanned vs planned caesarean difference in fecal symptoms between 34% (aOR, 1.34 [95% CI, 1.17−1.53])
delivery patients who suffered internal anal for every increase in neonatal birth-
The time to full recovery was more than sphincter injuries and patients who suf- weight by 1 kg. However, the relation-
6 weeks after unplanned CD than after fered external anal sphincter injuries.42 ship between the mode of delivery and
planned CD (P<.001). However, it is The other outcomes affected by peri- high fetal birthweight concerning pelvic
not reported how long exactly.35 neal lacerations were dyspareunia and pain was not described.
Unplanned CD was significantly associ- sexual function. Of note, 2 studies
ated with more frequent and severe reported significant lower female sexual Discussion
postpartum depressive symptoms than function scores at 6 and 12 months after Principal findings
planned CD (P=.038).57 No significant delivery in women who sustained major In this systematic review, we evaluated
association was found in persistent pel- perineal trauma (third- and fourth- which delivery-related factors affect
vic pain or surgical site pain between degree lacerations) than minor perineal postpartum recovery, which is defined
the 2 groups. trauma (first- and second-degree lacera- as maternal recovery after childbirth.
tion) (P<.0548 and P<.001,52 respec- Recovery was defined by concepts of
Nonlabor analgesia vs labor analgesia tively). In contrast, 3 other studies health, ability, and activity related to the
Of note, 1 study looked at the effect of reported no overall differences in sexual ICF. A total of 38 studies were included
nonlabor analgesia vs labor analgesia activity and function at 3 months after in this study. The evaluated studies
during an unsuccessful trial of labor delivery (P=.41,38 P=.34,45 and were heterogeneous regarding number
59
(resulting in CD) on postpartum P=.92 ). of patients, type of affecting factors,
depression at 3 months. They found Higher perineal pain scores and more interventions, outcome measures, and
that unsuccessful trial of labor while not analgesic use were observed with major follow-up duration.
receiving epidural analgesia did not perineal trauma up to 3 months after The most frequently reported out-
have a higher risk of postpartum delivery (P=.00345; OR, 5.5 [95% CI, come measures were the concept of
depression (OR, 0.331 [95% CI, 0.121 2.8−10.9]56). Afterward, no difference physical health conditions, such as
−0.902]; P=.026). in pain scores was observed between incontinence (n=13 [34%]) and genito-
major trauma and minor perineal pelvic or surgical site pain (n=12
Perineal lacerations trauma (P=.77).39 [31%]). Mental health was used as an
A total of 17 studies reported that peri- outcome measure in 5 studies (13%).
neal lacerations affected postpartum Negative birth experience The concept of functional ability after
recovery. The outcome mostly affected Of note, 2 studies reported on the effect delivery was evaluated in only 5 studies
by perineal lacerations was anal of birth experience on postpartum (13%), including 2 studies that defined
incontinence.26,27,29,30,31,34,40,55,58 Anal recovery. Both studies reported that a functional ability as self-assessed func-
incontinence was significantly more fre- negative birth experience was signifi- tional recovery to predelivery level.
quent and persisted longer in cases of cantly associated with postpartum Mode of delivery was the affecting
obstetrical anal sphincter injury (OASI) depression up to 6 weeks after child- factor that was most evaluated (n=23
than no OASI (P=.0827; OR, 3.029; birth ((P=0.03837 and P=.0154). No rela- [60%]). Of note, 12 studies evaluated
P=.00430; P=.004,31 OR, 18.734; P=.0240; tionship was found between birth the effect of CD vs VD on postpartum
adjusted relative risk, 2.4655). In addi- experience and persistent genitopelvic recovery. Moreover, 9 studies (75%)
tion, 1 study reported more accidental pain up to 8 weeks after delivery reported a negative effect of CD on
stool loss in patients with OASI at 1 (P=.73).54 recovery compared with VD, 4 studies
month after delivery than in those with- (33%) reported no significant difference
out OASI. However, at 6 months after Parity between the delivery modes, and 2 stud-
delivery, there was no statistically signif- Only 1 study evaluated the effect of par- ies (16%) found a negative effect
icant difference in outcomes by OASI.58 ity on postpartum recovery. This study on recovery after VD compared with
A different study found no significant found that women who delivered their after CD.
difference in urine incontinence and first or second child experienced dys- In addition, 7 studies evaluated the
fecal incontinence at 6 weeks after deliv- pareunia more often than multiparous effect of assisted VD vs spontaneous
ery between patients with OASI and women.28 VD. Moreover, 6 studies (86%) found a
those without OASI.26 However, they negative effect on recovery after assisted
did report significantly more involun- Neonatal factors VD. However, 1 study (14%) found no
tary flatus and dyspareunia in the OASI In addition, 1 study reported on the difference between both groups. Fur-
group (P<.01). A second study supports influence of neonatal birthweight on thermore, 4 studies compared the dif-
the finding of no difference in urinary recovery after delivery. A high neonatal ference between unplanned CD and
incontinence between patients with birthweight was found to be associated planned CD on recovery. In 2 studies
OASI and those without OASI (OR, with new-onset pelvic pain.47 The odds (50%), a negative effect on recovery was
1.46).31 In addition, 1 study found no of reporting pelvic pain increased by reported after unplanned CD. However,

May 2025 AJOG Global Reports 9

Systematic Review

in the other 2 studies, no effect was small (n=36). Concerning the conduct postpartum recovery is underexposed
found between both groups. Induction of daily activities in the first 2 months in current literature.
of labor was reported to delay self- after delivery, the authors found that Other studies reported negative
assessed functional recovery compared women who underwent CD were more effects of CD on recovery compared
with spontaneous onset of delivery. An likely to report interference of pain with with VD, including physical symptoms,
unsuccessful trial of labor without epi- daily activities than women who under- such as fatigue35,43 and persistent pain
dural analgesia was not found to have a went VD. (defined as surgical site or genitopelvic
higher risk of postpartum depression. In systematic reviews by Pretlove et pain).41,53,62 Kainu et al41 and Molin et
Of note, 17 studies evaluated the al17 and Cattani et al,64 significantly al53 reported CD as an affecting factor
effect of perineal lacerations on recovery more women suffered from anal incon- for persistent pain compared with VD,
using multiple outcome measures. tinence after assisted VD than sponta- whereas Eisenach et al36 and Munro et
In addition, 14 studies (82%) neous VD. The result was similar to our al50 did not report this finding. The rea-
reported that major perineal trauma findings.29,30,40,42,47,52 Finally, reviews son for this contradictory finding could
(third- or fourth-degree laceration) or by Cattani et al64 and Bols et al65 be the larger population size and longer
OASI had a negative effect on recovery observed a significant influence of OASI follow-up duration in the studies by
compared with minor perineal trauma on anal incontinence. Kainu et al41 and Molin et al.53 Both
(no or first-/second-degree laceration) Eisenach et al36 and Kainu et al41
or no OASI. Moreover, 5 studies (31%) adjusted persistent pain for acute pain
reported no significant difference in Interpretation of the results after delivery with contrasting results,
recovery between the groups. Finally, Of note, 5 studies used functional ability but only Kainu et al41 adjusted for
negative birth experience, first or sec- as an outcome measure, reporting on patient history of chronic disease and
ond parity, and high neonatal birth- resumption of social activities and self- previous pain. Considering the world-
weight were reported as factors that assessed functional recovery to predeliv- wide increasing CD rates, effects on
negatively influenced recovery. ery level.25,35,49,51,61 Tulman and Faw- maternal health should be considered,
cett25 reported that CD had a negative as they are very likely to influence
Comparison with existing literature effect on resumption of household tasks maternal functional ability, including
Only a few systematic reviews have been and societal participation compared societal participation.66
conducted that assessed the influence of with VD, but not on employment Assisted VD has been identified as a
1 single delivery-related factor on a spe- resumption. A possible explanation significant factor influencing postpar-
cific domain of postpartum recovery. could be that the length of maternity tum recovery, particularly concerning
Our findings are in accordance with leave was equal for both groups. Unfor- anal incontinence, pelvic pain, and
these results. Manresa et al18 reported a tunately, this was not disclosed in the diminished sexual function, compared
higher prevalence of dyspareunia at 6 study. Komatsu et al49,51 reported that with spontaneous delivery, likely due to
and 12 months after delivery in women CD and induction of labor delayed self- the association with more extensive per-
with major perineal trauma after spon- assessed functional recovery compared ineal lacerations.29,30,40,42,47,52 There-
taneous VD. However, their review with spontaneous VD. Jansen et al35 fore, the indication for assisted VD
includes studies on different repair and Chandra and Smitha61 reported should be carefully evaluated.
methods that we did not examine. lower health-related quality of life Similarly, induction of labor has been
Komatsu et al19 reviewed factors associ- scores in patients who underwent CD reported to affect recovery, specifically
ated with persistent pain after child- than in those who underwent VD, regarding self-assessed functional recov-
birth. Similar to our findings, the defining health-related quality of life in ery to predelivery levels, although the
authors found that perineal and vaginal the domains of physical, emotional, and small study sample sizes necessitate
pain was associated with tissue trauma social activities. The outcome measures cautious interpretation of these find-
related to assisted VD. Compared with used by these 5 studies illustrate that ings.51 In addition, labor analgesia for
spontaneous VD, assisted VD was con- postpartum recovery is rarely assessed unsuccessful vaginal childbirth did not
sistently reported as a risk factor for by functional ability. This is remarkable reduce the risk of postpartum depres-
persistent perineal pain. A survey study as several studies have revealed that the sion compared with those who did not
by Declercq et al63 reported no differ- effect of childbirth on participation in receive epidural analgesia. This may be
ence in persistent (perineal or surgical society is significant. A study by Beuker- due to the higher degree of cervical dila-
site) pain between women after elective ing et al14 showed that 30% of women tion and prolonged pain exposure
CD and women after emergency CD. In are still absent from work after mater- before emergency CD in the labor anal-
addition, their findings support the nity leave. As pregnant women belong gesia group, indicating that the poten-
findings of a higher prevalence of per- to a patient demographic with an tial benefits of early labor pain analgesia
sistent perineal pain after assisted VD important role in society, the effect of warrant further investigation.60
compared with spontaneous VD. How- these effects is considerable. This illus- Unplanned CD was found to have a
ever, their sample size was relatively trates that participation concerning negative effect on recovery compared

10 AJOG Global Reports May 2025

 Systematic Review

with planned CD in terms of time to full explanation could be the frequency of related factors. A broader scope of biop-
recovery and postpartum depressive perineal trauma that is more often expe- sychosocial factors, including personal
symptoms.35,57 Jansen et al35 reported rienced by primiparous women. High and external factors, will be evaluated in
that women who underwent an neonatal birthweight was associated a second review. By only including
unplanned CD needed more than 6 with a higher risk of pelvic pain than delivery-related factors in this review,
weeks to reach full recovery (defined as low neonatal birthweight.47 A higher there could have been bias toward cer-
mean scores of physical health-related birthweight might mean more mechani- tain specific factors, such as the mode of
quality of life scales, physical functioning cal pressure on the pelvis during preg- delivery. This could result in the under-
and role physical) compared with nancy and delivery, resulting in pelvic estimation of existing literature, which
women who underwent planned CD (6 pain. mentions other different factors. By
weeks) and VD (3 weeks). This could be Women with a negative birth experi- using broad search terms, we have tried
explained by the invasiveness of the dif- ence seem to be more likely to suffer to limit this bias. A second possible lim-
ferent delivery methods. Patients who from postpartum depression. Therefore, itation could be that outcomes regard-
underwent an unplanned CD experi- attention to mental health should be rec- ing anatomic changes were not
enced both labor and an operative proce- ommended for this group of patients to considered for inclusion in women who
dure, which may explain the worse prevent further health problems affecting did not experience morbidity from these
health-related quality of life scores. In social activities and participation.37,54 anatomic changes. This could result in
addition, the emotional aspects of an an under- or overreporting of affecting
unplanned CD, such as symptoms of Strengths and limitations factors. Finally, it was not possible to
anxiety and depression, have been To the best of our knowledge, this sys- conduct a meta-analysis because of het-
reported more often after an unplanned tematic review provides an overview of erogeneity regarding the type of affect-
CD, resulting in affected participation in all delivery-related factors affecting ing factors, outcome measures, and
social activities and functioning.57 From postpartum recovery. Postpartum follow-up duration. This diversity
this perspective, healthcare providers recovery is a complex process that has reflects the context of childbirth. Narra-
should take this into account when guid- an effect on outcome measures regard- tive synthesis supports this complexity,
ing patients through the recovery process ing all aspects of recovery. We have pro- providing a strong foundation for clini-
after an unplanned CD. Interestingly, 2 vided an overview of delivery-related cal guidance and future research into
other studies found no difference in factors affecting the different domains uniform recovery definitions.
chronic pain (surgical site or pelvic pain) of recovery, including physical, mental,
between unplanned and planned CDs, and functional recovery. Functional
suggesting that unplanned CD mainly ability is defined as the ability to adapt Implications for research and practice
affects psychosocial aspects of recovery and self-manage physical, emotional, Given the increasing number of CD and
and not so much biomedical aspects.46,47 and social activities.10 Considering most assisted VD worldwide, physicians
Women who suffered extensive articles reported on the physical domain should be more aware of the effect that
perineal trauma suffered significantly of recovery, this review is unique in the mode of delivery and the extent that
more from anal approach and assessment of postpartum perineal trauma have on physical recov-
incontinence.27,29,30,31,34,40,55,58 Of note, recovery in light of all domains of ery after childbirth, as this affects mater-
5 studies observed more dyspareunia recovery (physical, mental, and func- nal functioning.67 Our focus on ICF
and delayed resumption of sexual func- tional). Another quality of this review is domains of recovery reveals the under-
tion after major perineal trauma up to the methodologic approach following exposure of participation (13% of stud-
12 months after delivery.26,45,52,48,56 the PRISMA guidelines for systematic ies), despite its significant societal effect.
However, 3 studies did not support reviews.20 A very broad literature search For example, 30% of individuals do not
these findings at 3 months after with wide inclusion criteria was per- return to work after childbirth.12,13
delivery.38,45,59 No difference in follow- formed in collaboration with a medical Future studies should use functional
up duration or population size was information specialist. Therefore, we ability to measure recovery as it encom-
found between these studies to possibly were able to include an extensive num- passes physical, mental, and social com-
explain this discrepancy. Nevertheless, ber of studies to provide a broad over- ponents of health, and current literature
the effect of extensive perineal trauma view of delivery-related affecting factors shows that it is underexposed, yet the
on female sexual function should not influencing postpartum recovery. societal consequences are significant. In
be underestimated or overlooked and A possible limitation could be the the second review, we will focus on per-
should be an incentive for immediate decision to only include delivery-related sonal and pregnancy-related factors
referral to specialized physical health affecting factors and not personal and affecting different biopsychosocial com-
therapists for treatment. Dyspareunia pregnancy-related factors. Because a ponents regarding postpartum recovery.
was significantly observed more often large number of studies yielded after the By gaining a better understanding of
after a first or second VD, but not after first literature search, the decision was which factors affect postpartum recov-
more than 3 deliveries.29 A possible made to limit inclusions to delivery- ery, clinicians are able to provide

May 2025 AJOG Global Reports 11

Systematic Review

patients with more information and 5. Committee opinion no. 666: optimizing comparative systematic review. BJOG 2008;
personalized healthcare. postpartum care. Obstet Gynecol 2016;127: 115:421–34.
e187–92. 18. Manresa M, Pereda A, Bataller E, Terre-
6. O’Malley D, Higgins A, Begley C, Daly D, Rull C, Ismail KM, Webb SS. Incidence of peri-
Conclusion Smith V. Prevalence of and risk factors associ- neal pain and dyspareunia following spontane-
ated with sexual health issues in primiparous ous vaginal birth: a systematic review and
Our review highlights that postpartum
women at 6 and 12 months postpartum; a lon- meta-analysis. Int Urogynecol J 2019;30:853–
recovery is generally viewed as recovery gitudinal prospective cohort study (the MAMMI 68.
of health concept, such as biomedical study). BMC Pregnancy Childbirth 2018; 19. Komatsu R, Ando K, Flood PD. Factors
symptoms and complications, as 18:196. associated with persistent pain after childbirth:
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youth version: ICF-CY. Geneva: World Health 20. Page MJ, McKenzie JE, Bossuyt PM, et al.
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