Pelvic floor dysfunction after childbirth: A systematic review of prevalence and associated risk factors Breadcrumb

 Corresponding author: Komal Hagawane Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution License 4.0. Komal Hagawane * Ishani Sinha and Zeeshan Department of physiotherapy, Mewar University, Chittorgarh, Rajasthan, India. World Journal of Advanced Research and Reviews, 2025, 26(01), 3987-3995 Publication history: Received on 18 March 2025; revised on 23 April 2025; accepted on 26 April 2025 Article DOI: https://doi.org/10.30574/wjarr.2025.26.1.1371 Abstract Background: Pelvic floor dysfunction (PFD) is a prevalent issue that significantly impacts women's health and overall quality of life, often resulting from factors such as childbirth, anatomical changes, and lifestyle choices. Despite its widespread occurrence, both awareness and effective treatment options remain insufficient. Objective: This study aims to systematically review existing literature regarding the prevalence, risk factors, outcomes, and conservative treatment options for PFD in women. Methods: A total of thirty-one peer-reviewed articles published between 2007 and 2025 were examined. The study designs encompassed randomized controlled trials, cohort studies, cross-sectional studies, and longitudinal studies, with participant numbers ranging from 40 to 3,000. Results: The findings indicated that vaginal delivery is consistently linked to a higher incidence of PFD compared to cesarean delivery. The risk of developing PFD was found to increase with perineal injury, elevated body mass index (BMI), advancing age, and imbalances in vaginal microflora. Weakness in pelvic floor muscles (PFM) was strongly associated with incontinence and dyspareunia. Conservative treatment methods, particularly pelvic floor muscle training (PFMT), biofeedback, and the use of pessaries, demonstrated effectiveness in alleviating symptoms, although caution was advised for early implementation. The psychological effects, including issues related to body image and diminished quality of life, were significant yet often overlooked. Awareness of PFD was notably low among various populations, underscoring the necessity for improved education and early screening initiatives. Imaging and biometric assessment tools were found to be effective for clinical evaluation. Additionally, cultural and regional variations highlighted the importance of personalized care approaches. Conclusion: PFD is a complex condition with enduring effects on women's health. Key contributing factors include the mode of delivery, trauma, and muscle function. Individualized conservative management strategies can enhance patient outcomes. Increased awareness, timely intervention, and culturally appropriate care are crucial for addressing this condition effectively. Keywords: Pelvic floor dysfunction; Vaginal delivery; Pelvic floor muscle training; Risk factors; Women’s health 1. Introduction Pelvic floor dysfunction (PFD) encompasses a range of clinical conditions including urinary incontinence, fecal incontinence, pelvic organ prolapse, and sexual dysfunction. These disorders result from impairment of the pelvic floor muscles, connective tissues, and nerves, which play a crucial role in maintaining continence and supporting pelvic Pelvic floor dysfunction after childbirth: A systematic review of prevalence and associated risk factors World Journal of Advanced Research and Reviews, 2025, 26(01), 3987-3995 3988 organs. Childbirth, particularly vaginal delivery, is recognized as a major risk factor for the development of PFD, due to the mechanical and neurological trauma imposed on the pelvic floor structures during labor and delivery¹⁻². The process of childbirth leads to stretching, tearing, or avulsion of pelvic floor muscles, especially the levator ani muscle complex, contributing to both immediate and long-term pelvic floor disorders³. Vaginal deliveries, especially those involving forceps, prolonged second stages of labor, and obstetric anal sphincter injuries (OASIS), are associated with a higher risk of persistent dysfunction compared to cesarean deliveries⁴⁻⁵. Nonetheless, cesarean deliveries do not provide complete protection against PFD, as they may still result in pelvic floor changes due to pregnancy-related anatomical stress⁶⁻⁷. Prevalence reveals that a significant proportion of postpartum women experience one or more forms of PFD. Studies have shown that urinary incontinence affects approximately 20–50% of women in the first year following delivery⁸, with symptoms persisting for more than a year or two in some cases⁹. Also, up to 30% of women report symptoms of pelvic organ prolapse, and about 40% experience sexual dysfunction during the postpartum period¹⁰⁻¹². These disorders can have a profound impact on physical, mental and emotional well-being, including body image disturbances, reduced sexual satisfaction, and limitations in occupational and social functioning¹³⁻¹⁵. The clinical presentation and severity of PFD are influenced by several risk factors beyond delivery mode, including maternal age, body mass index (BMI), fetal birth weight, perineal trauma, and inadequate postpartum pelvic floor rehabilitation¹⁶⁻¹⁹. The severity of perineal tears and associated pain can further compromise pelvic floor muscle strength and delay recovery²⁰⁻²¹. Despite the high prevalence of PFD, awareness among postpartum women remain low, with many not seeking timely medical attention²². The stigma associated with urinary and fecal incontinence, and the perception that these are normal consequences of childbirth, contribute to underreporting and inadequate management²³. Moreover, healthcare systems often lack standardized protocols for routine screening and intervention in the postpartum period²⁴. Figure 1 Anatomy of pelvic floor muscle32 This systematic review aims to produce current evidence on the prevalence, risk factors, functional outcomes, and treatment approaches of PFD after childbirth, utilizing findings from recent and comprehensive studies. The goal is to provide an evidence-based framework to guide clinical practice, improve maternal outcomes, and inform future research on prevention and rehabilitation strategies for pelvic floor disorders. World Journal of Advanced Research and Reviews, 2025, 26(01), 3987-3995 3989 Figure 2 (A) Good pelvic support with firm base, organs in normal position. (B) Inadequate support, pelvic organs descend32 1.1. Need of the Study Pelvic floor dysfunction remains an underdiagnosed consequence of childbirth that profoundly affects women’s quality of life. The majority of postpartum women do not receive adequate education or screening related to pelvic floor health. There is a clear need to collect verified evidence on risk factors, prevalence, and management strategies in order to develop standardized care guidelines. Addressing this knowledge gap will aid clinicians in early identification and management of PFD, ultimately enhancing postpartum recovery and well-being. 1.2. Scope of the Study • This study reviews current literature to evaluate the prevalence, risk factors, and impact of pelvic floor dysfunction following childbirth. • It aims to highlight gaps in clinical practice and awareness while exploring evidence-based interventions such as pelvic floor muscle training. • The findings are intended to guide healthcare professionals in implementing effective screening and treatment strategies and encourage further research into holistic postpartum care. 2. Methodology A comprehensive literature search was conducted using PubMed, Scopus, and Google Scholar databases to identify peerreviewed studies related to pelvic floor dysfunction following childbirth. The search focused on studies published between 2007 and 2025, with a particular emphasis on the period from 2016 to 2024 to reflect the most recent evidence. Inclusion criteria were as follows: • Studies examining the prevalence, risk factors, and types of pelvic floor dysfunction post-childbirth • Research on treatment approaches and quality-of-life outcomes related to PFD • Articles involving human subjects and published in English • Observational studies, crosse-sectional studies, longitudinal cohort studies, and randomized controlled trials A total of 31 studies were selected based on their methodological quality and relevance to the research objectives. Key variables extracted included study design, sample size, type of delivery, identified risk factors, treatment interventions, and reported outcomes. World Journal of Advanced Research and Reviews, 2025, 26(01), 3987-3995 3990 3. Review of Literature Table 1 Tabulated format of review of literature No. Author(s) Year Title Methodology Sample Size Key Findings Conclusion 1 Blomquist et al.1 2020 Pelvic floor muscle strength and incidence of PFD Prospective cohort 1,528 49% vaginal births had PFD vs 11% cesarean Vaginal delivery increases longterm PFD risk 2 Burkhart et al.2 2021 Occupational impact and awareness of PFD Crosssectional survey 200 62% unaware of PFD; 35% reported work impact Need for better PFD education and support 3 Huber et al.3 2021 PFD & perineal tear severity Crosssectional 410 42% with 3rd/4th-degree tears had PFD Perineal injury is a risk factor 4 Hagen et al.4 2020 OPAL RCT - Biofeedback vs Basic PFMT RCT 600 20% improvement in PFM with biofeedback BiofeedbackPFMT more effective 5 Cheng et al.5 2022 Vaginal microflora and PFD Observational 150 35% with imbalance developed PFD Vaginal health predicts PFD 6 Huser et al.6 2017 Vaginal vs cesarean delivery and PFD Comparative cohort 450 60% vaginal vs 25% cesarean had symptoms Cesarean may reduce early PFD 7 Siafarikas et al.7 2022 Long-term PFD post-delivery Longitudinal 300 34% had persistent symptoms after 8 years Long-term follow-up needed 8 Dufour et al.8 2018 Association between lumbopelvic pain and pelvic floor dysfunction in women Crosssectional 150 40% with lumbopelvic pain had PFD Lumbopelvic pain correlates with PFD 9 Cattani et al.9 2024 Body image & PFD Prospective cohort 225 45% with poor body image had PFD Psychological health matters 10 Sigurdardottir et al.10 2011 PF muscle function pre/post childbirth Longitudinal 60 30% PF strength reduction postpartum Delivery weakens PFMs 11 Handa et al.11 2011 PFD 5–10 years post-delivery Longitudinal 1,011 37% vaginal vs 14% cesarean reported PFD Delivery method affects PFD 12 Aiyegbusi et al.12 2023 Prevalence of pelvic floor dysfunction and associated risk factors among Crosssectional 300 25% had PFD; age and BMI were key risks Younger age and BMI linked to PFD World Journal of Advanced Research and Reviews, 2025, 26(01), 3987-3995 3991 Nulligravida college students 13 Neels et al.13 2017 PF exercises & pain Experimental 120 28% experienced pain with early PFMT Tailor exercises post-delivery 14 Baytur et al.14 2007 Anatomical PF changes Crosssectional 150 64% had anatomical alteration postpartum Delivery alters PF anatomy 15 Zizzi et al.15 2017 Incontinence and PFM strength Crosssectional 150 52% with weak PFM had incontinence Strength relates to symptoms 16 Pereira et al.16 2018 Clinical & US evaluation of PFD Crosssectional 103 82% correlation between US and clinical eval. Ultrasound useful 17 Chan et al.17 2014 Biometry in primiparas Prospective 120 40% had altered PF parameters Biometric tools valuable 18 Oblasser et al.18 2016 Vaginal balls postchildbirth RCT 40 26% improvement in PF strength Feasible intervention 19 Simanauskaitė et al.19 2024 PFM strengthening in OASIS Intervention 80 32% PFM function improvement Rehab after trauma crucial 20 Sigurdardottir et al.20 2021 Early PFD postpartum Crosssectional 400 48% reported early symptoms Early screening needed 21 Dericioğlu et al.21 2018 Adolescent idiopathic scoliosis causes pelvic floor dysfunction Crosssectional 100 35% with scoliosis had PFD Scoliosis associated with PFD 22 Dasikan et al.22 2020 Risk factors for PFD Crosssectional 350 38% had PFD; age and parity were key risks Multifactorial risk 23 Tennfjord et al.23 2014 Dyspareunia & PF strength Longitudinal 60 42% with weak PFM had dyspareunia Sexual function affected 24 Barbosa et al.24 2013 PFD post-cesarean Crosssectional 116 32% had incontinence Cesarean doesn’t eliminate risk 25 Kiefner et al.25 2023 Pessary postpartum Prospective 200 68% reported symptom relief Conservative methods effective 26 Abdool et al.26 2018 PF morphology in African women Longitudinal 110 56% had measurable morphological changes Culture-specific data needed 27 Cristóvão et al.27 2025 PF strength and incontinence Cohort 260 44% with low strength had bothersome symptoms Strengthening improves QoL World Journal of Advanced Research and Reviews, 2025, 26(01), 3987-3995 3992 28 Urbankova et al.28 2019 Anatomy & dysfunction post vaginal birth Observational 130 57% anatomical changes seen Primiparity is a risk 29 Hagen et al.29 2024 PFD after 20–26 years Longitudinal 3,000 41% reported PFD decades later Long-term care needed 30 GonzálezTimoneda et al.30 2025 QoL and PFD Crosssectional 470 61% had QoL impairment PFD affects life significantly 31 Rao et al.31 2015 Prevalence of pelvic floor dysfunction among married women of Karnataka, India Crosssectional 250 21% had PFD; urinary incontinence was common PFD prevalent in rural India 4. Results and discussion 1.3. Prevalence and Risk Factors A majority of studies, including those conducted by Blomquist et al., Handa et al., and Siafarikas et al., have demonstrated a significantly higher prevalence of pelvic floor disorders (PFD) among women who underwent vaginal deliveries in comparison to those who had cesarean sections. The reported prevalence of PFD ranges from 21% (Rao et al.) to 60% (Huser et al.). Moreover, factors such as age, body mass index (BMI), and parity have been recognized as important contributors to this condition (Aiyegbusi et al., Dasikan et al.). Additionally, the incidence of thirdand fourth-degree perineal tears has been shown to considerably increase the risk of developing PFD (Huber et al.). 1.4. Pelvic Floor Muscle Function Reduced pelvic floor muscle (PFM) strength has been linked to urinary incontinence, pelvic organ prolapse, and dyspareunia, as noted by Zizzi et al. and Tennfjord et al. Research employing biometric assessments and ultrasound imaging, conducted by Pereira et al. and Chan et al., has validated the presence of anatomical and functional impairments in women following childbirth. Sigurdardottir et al. (2011, 2021) reported that muscle strength could decrease by as much as 30% after delivery, with nearly half of the participants experiencing this reduction several months postpartum. 1.5. Interventions and Management Multiple studies have assessed conservative treatment alternatives. Hagen et al. (2020) found that biofeedback-assisted pelvic floor muscle training (PFMT) resulted in more significant functional enhancements compared to standard PFMT. Kiefner et al. reported that 68% of postpartum women experienced symptom relief when using a pessary. However, Neels et al. warned that 28% of women felt discomfort when initiating PFMT too early, indicating the necessity for personalized timing in treatment. Additionally, Simanauskaitė et al. noted that focused rehabilitation for obstetric anal sphincter injury (OASIS) cases led to a 32% improvement in muscle function. 1.6. Psychological and Social Impact PFD has been linked to decreased satisfaction with body image (Cattani et al.), diminished sexual function, and difficulties in the workplace (Burkhart et al.). According to González-Timoneda et al., 61% of women experiencing this condition reported a notable decline in their quality of life. Additionally, Burkhart et al. noted that 62% of the participants were not aware of PFD, and more than one-third believed it impacted their job performance. 1.7. Diagnostic Tools and Epidemiological Trends: Pereira et al. identified an 82% correlation between clinical assessments and ultrasound results, thereby endorsing the latter as a valuable diagnostic tool. Region-specific research conducted by Abdool et al. and Rao et al. highlighted the influence of cultural differences on prevalence and symptomatology. For example, Rao et al. reported a 21% prevalence of urinary incontinence among women in rural India, identifying it as the most common symptom. World Journal of Advanced Research and Reviews, 2025, 26(01), 3987-3995 3993 5. Discussion This review highlights the intricate and multifaceted nature of pelvic floor dysfunction (PFD) in women. There is consistent evidence indicating that vaginal childbirth is the primary factor contributing to this condition, with mechanical injuries, perineal tears, and age-related tissue degeneration further increasing the risk. The persistence of PFD symptoms for years following delivery (Hagen et al. 2024; Siafarikas et al.) indicates a necessity for continuous monitoring that extends beyond the immediate postpartum phase. Pelvic floor muscle strength has been identified as a crucial factor influencing the severity of symptoms, with weakened muscles closely associated with urinary and sexual dysfunction. Advances in technology, such as ultrasound and biometric evaluations, improve clinical accuracy and facilitate non-invasive monitoring, yet these tools are still not widely adopted in standard care practices. Although conservative treatments like pelvic floor muscle training (PFMT) and the use of pessaries have demonstrated significant effectiveness and safety, the findings also emphasize the need for personalized treatment strategies. While early intervention may be beneficial for some, it can be uncomfortable or discouraging for others (Neels et al.), highlighting the necessity of patient-centered care approaches. The psychosocial aspects of PFD—such as dissatisfaction with body image, work-related limitations, and diminished quality of life—are significant but often overlooked in favor of physical symptoms. Despite the high prevalence of PFD, general awareness remains low across various demographics, including young nulligravida women (Aiyegbusi et al.) and individuals in rural areas (Rao et al.). These insights collectively indicate that while the physical aspects of PFD are becoming better understood, a comprehensive approach to managing this condition—one that incorporates social, psychological, and cultural factors—needs to be prioritized in both research and clinical settings. 6. Conclusion Pelvic floor dysfunction (PFD) is a common yet often overlooked condition that has lasting effects on women's health and overall well-being. Key factors contributing to PFD include vaginal delivery, perineal injury, age, number of childbirths, and diminished pelvic muscle strength. While conservative treatments, especially pelvic floor muscle training (PFMT) and the use of pessaries, have proven effective, they must be tailored to the individual, particularly during the postpartum phase. The psychological effects and implications for quality of life are significant but are not adequately addressed in current healthcare practices. There is an urgent need for early detection, heightened awareness among both the public and healthcare professionals, and comprehensive care strategies that take into account physical, emotional, and sociocultural dimensions. Innovations in diagnostics and culturally sensitive interventions will be essential for improving the management and prevention of pelvic floor dysfunction on a global scale. Future studies should focus on the following objectives: • Establish standardized protocols for postpartum screening to facilitate the early detection of pelvic floor dysfunction (PFD). • Investigate the long-term effects of new interventions, including pessaries, vaginal vibratory devices, and digital biofeedback tools. • Examine the influence of prenatal education and antenatal pelvic floor training on the prevention of postpartum dysfunction. • Implement longitudinal research to evaluate how sociocultural beliefs and health literacy affect individuals' willingness to seek treatment. • Advocate for the integration of pelvic floor assessments and care as a fundamental component of postnatal healthcare services within all tiers of healthcare systems. Compliance with ethical standards Acknowledgments We thank the authors of the included studies and peer reviewers for their valuable contributions. Also acknowledging the co-authors for their invaluable support. 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