The global rate of caesarean sections has risen 21% in 15 years (2000–2015) (35). More women are requesting caesarean sections for personal reasons such as fear of labor or negative vaginal delivery experiences accounting for up to 42% of all caesarean sections (36, 37). Literature shows the impact delivery has on postpartum health quality-of-life varies between delivery types (12, 13, 17, 18, 38). However, there is no unanimity in the direction of these associations. The aim of this systematic review was to examine the relationship between mode of delivery and postpartum HRQoL though a systematic review of published evidence. To our knowledge this is the largest and most recent review investigating this association. The findings are expected to increase health professional’s awareness to support women’s quality-of-life after childbirth.
The results showed women who delivered vaginally had a significantly higher postpartum HRQoL than those that delivered via caesarean section. These findings are consistent with primary studies that found QoL was better after vaginal delivery in early postpartum months and five years later (39, 40). They also support the findings of a related review where, up to 2015, caesarean section was negatively associated with HRQoL (17). The current review provides new evidence that the association continues into the present. Yet not all research agrees, some found caesarean section was not a contributing factor to reduced QoL and others found no statistically significant difference between delivery types (18, 41, 42). The discordance between literature may be explained by the diverse study methodologies observed by this review, including QoL measurement tools, HRQoL dimensions, and study location.
This review showed the strength of association varied between spontaneous vaginal delivery and assisted vaginal delivery. Both had significantly higher HRQoL scores than those who delivered by caesarean section, though there was no statistically significant relationship between the vaginal delivery types. The effect was strongest for AVD and findings harmonious. However, when interpretating these results it should be considered AVD sample size was half that of SVD.
This study revealed physical HRQoL was also better after vaginal delivery. Significant relationships were found between delivery modes and physical component, functioning, and role, with the latter two having the strongest associations of all dimensions. Furthermore, bodily pain, general health, and environmental scores were also higher after VD but non-significantly. This strengthens previous evidence that physical recovery is slower after caesarean (43). Mental HRQoL was also found higher after VD on all dimensions with a significant association for vitality and social functioning, but non-significant for mental component, emotional role, or mental health.
This review highlights that HRQoL has been found higher after vaginal delivery, than caesarean, for over a decade. This demonstrates a consistency in obstetric practices and shows the benefits of CS do not consider postpartum effects where recovery and quality-of-life remains increased after VD.
Policy Implications
The findings of this review have implications for obstetric practitioners and health professionals in health centers. Understanding how delivery modes effect postpartum QoL can lead to more informed choices and postpartum care, thus improving QoL. Traditional physical postpartum checks should be supplemented with QoL assessment to identify the full range of needs required for recovery after birth enabling women to reach and maintain optimum health for themselves, and their babies. Therefore findings of this study should also be used by health authorities to implement effective health programs, stratagies and policies.
This study is timely with the rise in CS rates and has implications for healthcare policy makers. The results are consistent with studies reporting that CS leads to slower recovery, prolonged hospital stays, and increased health service costs (43). For these economic reasons policies should be reviewed to encourage women to give birth vaginally in the absence of medical indications.
Strengths and Limitations
There are several caveats in this study which can be attributed to a lack of specification of the study population. For instance, most of the delivery mode subgroups (SVD, AVD, VD, EmCS, ElCS) were analysed according to their overarching groups (VD and CS). Analysing subgroups in this combined manner induces interpretation bias. The included studies observed deliveries in hospitals and health centres. Other settings such as home births were not reported resulting in subject bias. Predominantly the studies did not adequately adjust for confounders therefore the exploration of additional factors as intended in the protocol (CRD42020145090) was restricted. Finally, data were typically collected within six months postpartum limiting the reviews’ ability to make longitudinal conclusions.
Review methodology limitations (first) include the exclusion criteria. Papers not presented in the English language were excluded, thus the generalizability of results is limited. Secondly qualitative studies were excluded as they did not measure HRQoL however further qualitative work would help give greater detail about women’s perceptions of their postpartum mental and physical health. Moreover, the included HRQoL tools measure different constructs thus the subscales were too different to harmonize and study results were pooled individually by tool rather than together as originally intended. However, most included studies used the SF-36 tool providing a consistent basis to this study. The SF-36 is reportedly the most suitable tool for measuring HRQoL providing the findings of this review with credibility (30, 44). Finally, due to the different timepoints observed between studies the latest time-points were used for analysis in this study. Thus, observations of changes in QoL over time could not be made. Medium-high heterogeneity was present, and location and study design showed a small effect on dimension scores. Further research is required to substantiate these indications.
The strengths of this review include following Cochrane methods and a comprehensive search of the literature. All aspects of the reviewing process were conducted by two independent reviewers thus the likelihood of reviewing bias is low. This is an up-to-date review including the largest sample and worldwide, high-quality studies. The included QoL tools were validated and comprised of generic and disease-specifics measures. Study results were found constant since 2007 and 2014 for component and dimensions scores respectively. Meta regressions were conducted to account for heterogeneities and control for follow-up showing heterogeneity was not consequential of publication bias, study design, or year.