Physical and psychological problems after childbirth are common, and may have a significant negative and possibly long-term impact on women’s wellbeing and daily functioning 1 . One factor that has been more consistently identified as influencing the duration and severity of women’s physical and psychological symptoms following childbirth is the mode of birth. However, population-wide evidence to demonstrate this association is largely lacking; the quality of the research varies considerably and few studies have examined both women’s psychological and physical outcomes and explored the possibility that these symptoms may influence one another. Although findings from earlier studies related to postnatal outcomes and mode of birth were based on relatively large samples 2 3 , subsequent studies have relied on small samples, and there are few studies that have been able to separate the psychological and physical outcomes for women who have forceps-assisted births from ventouse-assisted births. A recent large, population-based study from Norway, focusing on antenatal and postnatal emotional health, did not differentiate between forceps and ventouse-assisted vaginal births and found no association with mode of birth 4 .

Perineal problems, backache, pain during intercourse, and extreme tiredness are common problems for women during the first three months after birth 5 6 . Although caesarean section births have been identified as contributing to reductions in women’s postnatal physical wellbeing, more recently there has been interest in exploring the impact of assisted vaginal births. In the first few months after birth, assisted vaginal births have been associated with a greater likelihood of perineal pain 7 8 urinary incontinence, haemorrhoids, and sexual problems 7 9 10 11 than unassisted vaginal births, even when taking into account aspects related to the birth such as the length of labour and degree of perineal trauma 7 11 . Women who have assisted vaginal births, particularly forceps-assisted vaginal births may also be at risk for ongoing and continuing physical problems 12 . A recent longitudinal study from Birmingham found that faecal incontinence at 12 years postpartum was increased among women who had a birth history that included a forceps-assisted vaginal birth, but not with a birth history that included a ventouse-assisted vaginal birth 13 .

Obstetric intervention, particularly emergency caesarean section, has also been associated with depressive symptoms after birth, however, results are inconsistent 14 and recent evidence from large cohort studies has found no association 4 15 16 . More consistently, caesarean section births have been associated with feelings of dissatisfaction related to the birth and with poor body image and lower self-esteem 14 , possibly increasing the risk of depression in the longer term. Recently, there has been an emergence of studies focusing on anxiety disorders, particularly posttraumatic stress disorder (PTSD) after childbirth, which occurs in a small proportion of women (1-6%) 17 . Studies show that the risk of postnatal PTSD symptoms is higher for women who have had unplanned caesarean section births followed by women who have had assisted vaginal births 18 19 20 . However, other researchers have found that women who have had an assisted vaginal birth are more likely to perceive the birth as “extremely distressing” six weeks after birth than women who have had a caesarean section or unassisted vaginal birth 21 . This study, however, did not differentiate between forceps and ventouse-assisted births and this may be important for understanding the influence of mode of birth on postnatal PTSD-type symptoms.

The experience of childbirth can be complex due to a wide range of individual, medical and social factors that can interact to influence women’s experiences and outcomes. This study examines the physical and psychological outcomes of women in the first three months after birth, and whether these varied by mode of birth. We specifically examined whether women who had assisted vaginal births and operative births experienced poorer psychological and physical health than women who had unassisted vaginal births. Because women’s physical symptoms after birth may affect the severity and duration of their self-reported psychological outcomes and vice versa 22 , we adjusted for concurrent psychological and physical symptoms in our analyses when examining women’s postnatal outcomes. The results of this study will provide important information for health professionals about those women who may be in greater need of support during and after childbirth.

Mode of birth may have a strong association with women’s psychological and physical outcomes in the first few months after birth. As expected, women’s symptoms were highest at 10 days after birth, and the health of most women improved emotionally and physically over the following 3 months. However, some outcomes appeared to be related to the type of delivery experienced, particularly when adjusting for sociodemographic variables and the other psychological and physical symptoms present at each time point. Specifically, women who had forceps-assisted vaginal births and unplanned caesareans appeared to have poor health and psychological wellbeing after birth. The health of women who had ventouse-assisted births appeared to be somewhat compromised, while the health of women who had unassisted vaginal births and planned caesareans did not appear to be influenced by the birth process.

Women who had a forceps-assisted vaginal birth were most likely to have ongoing psychological problems after childbirth. These women were more likely to report two or more PTSD-type symptoms at 3 months, and this may be explained by the fact that their labours were more likely to have been longer, and there may have been concern about their labour or their baby as indicated by the higher levels of constant electronic monitoring reported. A lack of control, worry and an intense period of anxiety or uncertainty during labour and birth may explain the psychological symptoms reported by these women. This, in combination with other individual factors related to the mode of birth, such as a woman’s labour and birth expectations may also predispose women to stress-related symptoms after birth, as well as factors occurring after the birth, including a lack of postnatal follow-up with a health professional when this might have been helpful 27 . In our study, more than half (58%) of women who had a forceps-assisted vaginal birth reported that they spoke about their labour with a health professional. However, of those women who didn’t speak to a health professional, 43% would have liked to speak to someone. While health professionals may be more aware of the physical morbidity for women after childbirth, the ongoing psychological issues may be less clear or alternatively, perceived as more difficult to treat or beyond their area of expertise. Referral pathways need to be in place to address this point 29 .

Although caesareans section births are often described as resulting in poorer postnatal psychological outcomes for women, it seems that the outcomes for women depend on whether the caesarean section is planned or not. Women having unplanned caesarean section births were marginally more likely to report PTSD-type symptoms, however, there was no association between PTSD-type symptoms and planned caesarean section births in our study. These findings are consistent with others 18 19 20 and are important for understanding the individual and social factors that may influence women’s postnatal psychological wellbeing. For a proportion of women it appears that there may be benefits of a planned caesarean birth, especially for those with health problems, previous complications or adverse experiences 14 30 . However, a large study of 55,000 Norwegian women did not find an association between mode of birth and a measure of emotional distress at 6 months postpartum 4 , which suggests that symptoms of anxiety in new mothers may attenuate significantly with time. On the other hand, in our study depression was not associated with mode of birth, and this may suggest the need to distinguish between symptoms of anxiety and depression rather than using general measures of distress. It is possible that because our study differentiated between assisted vaginal births (forceps vs. ventouse) when assessing women’s psychological outcomes, this may have contributed to the difference in findings.

Birth related symptoms, such as painful stitches and wound infections after birth, were problematic for women during the first 3 months after birth. Those who had forceps-assisted vaginal births were more likely to report problems, and this may be explained by the high rates of episiotomy and third and fourth degree tears requiring perineal repair in this group. Consistent with previous research 7 9 10 11 , the risk of bodily changes such as stress incontinence and backache were higher amongst women who had assisted vaginal births whereas these symptoms were less likely to affect women who had operative births.

This is one of the few studies to use population-based data to examine women’s physical and psychological outcomes after childbirth whilst taking into account co-occurring conditions and other key sociodemographic variables. As has been reported previously, women’s physical and psychological outcomes are important to take into account when examining their overall postnatal health and wellbeing 22 . In our study, we also found that women’s risk of postnatal physical symptoms was reduced when adjusting for co-occurring psychological symptoms. Our results suggest that both the psychological and physical domains need to be assessed in terms of understanding the factors influencing the duration and severity of problems affecting women’s postnatal health and wellbeing.

Although our findings are based on data from a large, national sample of women, a limitation of the study was the participation rate of 55%, a rate which is similar to that increasingly found in epidemiological studies 31 . Because women who did not participate in this study were more likely to be younger, living in a more disadvantaged area and from a BME background, and because these groups tend to have higher rates of poor health and wellbeing generally, our study may underestimate the magnitude of physical and psychological outcomes. However, the similarities between our results and those of previous studies strengthen our conclusions. Another limitation of this study was the reliance on women’s retrospective self-reports of their health and wellbeing after birth. However, the timing of survey completion and return was close enough to the birth for accuracy as far as mode of delivery and other aspects of care were concerned, and for symptom reporting at three months post-partum. Nevertheless, pre-existing experiences and those occurring after birth may be significant in increasing women’s vulnerability to distress and maintaining the distress 32 and we cannot be certain that women’s responses were not influenced by prior events or those occurring at the time of survey completion. It is also not clear how well the symptoms recorded in our study could relate to an actual diagnosis of PTSD, and thus we cannot comment on rates of clinical levels of PTSD in our sample. However, given that our findings do reflect those of previous research carried out using smaller samples and different study designs, it seems that the items used in our survey to assess PTSD-type symptoms appear to detect disturbances in new mothers.

This study provides additional evidence about the importance of mode of birth in understanding women’s postnatal health and wellbeing. Our results appear to suggest that there are unique issues for women according to the mode of birth, and thus future analyses should be aware of the potential differences in wellbeing among women who have planned and unplanned caesarean births as well as ventouse and forceps-assisted vaginal births relative to unassisted vaginal births. It is concerning that women who have a forceps-assisted vaginal birth are more likely to report ongoing psychological difficulties, but are not being offered the appropriate level of healthcare support. Because these women were mostly likely to report poorer psychological and physical health following childbirth, at the same time as adjusting to life with a new baby, it may be important for health professionals to initiate conversations with women about their birth to give women the opportunity to discuss distressing symptoms. Consistent with NICE guidelines, women who describe PTSD-type symptoms at 1 month after birth should be formally tested for PTSD using a standard instrument (e.g. Traumatic Event Scale-B (TES-B); PTSD Symptom Scale-Self Report (PSS-SR) 33 . Women at risk should be monitored carefully by health professionals and appropriate referral pathways should be used in an effort to prevent chronic symptoms. Ongoing support, however, may be necessary, particularly in relation to further pregnancies. The development of preventative and supportive strategies during pregnancy, birth and afterwards would be an initial step towards improving the long-term reproductive health and wellbeing of these women.

The authors declare that they have no competing interests.

The authors listed have contributed to this paper: IJR performed the statistical analysis and drafted the manuscript. MR was responsible for the concept and conduct of the UK 2010 National Maternity Survey and provided assistance in the interpretation of results and drafting the manuscript. IJR and MR have read and approved the final manuscript.