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Am Fam Physician. 2006;74(4):660-664

More than three fourths of first-time mothers in the United States who are employed during pregnancy return to work within one year after giving birth, many before the end of the traditional six-week postpartum period. Little evidence exists about what factors influence physical and mental well-being and symptoms during this period. McGovern and colleagues studied how delivery type and breastfeeding status relate to the health of working mothers five weeks after childbirth.

The prospective cohort study included 817 women 18 years or older who gave birth to healthy single infants at one of three Minneapolis–St. Paul community hospitals from April to November 2001. Eligible participants spoke English, were employed during pregnancy, and intended to return to work after childbirth. Trained study personnel conducted a 45-minute telephone interview with each participant at five weeks postpartum. Women who declined to complete the full interview were asked to complete a mini-interview lasting about 10 minutes. A total of 716 women completed a full interview, 30 women completed a mini-interview, and the remainder could not be reached.

The interview assessed overall physical and mental health using items from standardized norm-based questionnaires. Postpartum symptoms were assessed with a checklist derived from a previous study of postpartum women. A multivariate analysis identified factors associated with better physical, mental, and postpartum symptom scores. The strength of each association was rated as small to moderate, moderate to large, or very large, based on a numeric scale.

The factor most strongly associated with better overall physical health five weeks post-partum was vaginal rather than cesarean delivery. Mental health was not affected by delivery type or breastfeeding status. Common symptoms included fatigue, decreased libido, back and neck pain, constipation, hemorrhoids, and decreased appetite. Women who were breastfeeding reported more symptoms than those who were not.

The authors conclude that women who delivered by cesarean section were in significantly worse physical health five weeks after birth than women who delivered vaginally. Although most women experienced some postpartum symptoms at five weeks, breast-feeding mothers were more likely to have symptoms. The authors suggest that these findings could help guide physicians when counseling pregnant women about expectations for physical recovery after childbirth and about postpartum symptoms.

editor’s note: The cesarean delivery rate reached a record high of 29.1 percent of all U.S. births in 2004, as a result of an 8 percent increase in the primary cesarean delivery rate and a 13 percent decrease from 2003 in vaginal births after cesarean.1 Because of the increase in cesarean births, the study by McGovern and colleagues has important implications for physicians who provide maternity care. In many communities, trials of labor after having a previous cesarean delivery are actively discouraged, even though 76 percent of these women who attempt a vaginal birth are successful.2 Although an expert panel and a systematic literature review found no conclusive evidence that elective or planned cesarean delivery increases a mother’s short-term risk compared with a vaginal delivery,3 more studies are needed to examine the effect of delivery type on postpartum health.—k.w.l.

REFERENCESHamiltonBEMartinJAVenturaSTSuttonPDMenackerFBirths: preliminary data for 2004.Natl Vital Stat Rep2005;54:1–17.American Academy of Family Physicians. Trial of labor after cesarean (TOLAC), formerly trial of labor versus elective repeat cesarean section for the woman with a previous cesarean section. March 2005. Accessed May 25, 2006, at: Institutes of Health. NIH State-of-the-Science Conference Statement: Cesarean delivery on maternal request. Draft statement. March 29, 2006. Accessed May 25, 2006, at:

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