Reproductive Sciences

https://doi.org/10.1007/s43032-020-00254-y

REVIEW

Risk Factors for Postpartum Stress Urinary Incontinence: a Systematic

Review and Meta-analysis
Kai Wang 2 & Xianlin Xu 2 & Genmei Jia 1 & Hua Jiang 1

Received: 14 April 2020 / Revised: 5 June 2020 / Accepted: 30 June 2020

# Society for Reproductive Investigation 2020

Abstract
Stress urinary incontinence (SUI) is a distressing symptom affecting females globally and is one of the most common compli-
cations of delivery. The etiology of female SUI is multifactorial, and the trauma caused by delivery is one of the most important
risk factors for SUI. We performed a meta-analysis to determine the relationship between these various factors and postpartum
SUI. We searched PubMed, Embase, Web of Science, and the Cochrane Library until January 2019 using appropriate keywords
and extracted 46 eligible studies that included 73,010 participants. The study protocol was registered with PROSPERO (No.
CRD42020150094). The pooled results indicated that 12 risk factors, including vaginal delivery (OR 2.08, 95% CI 1.72–2.52),
advanced age at gestation (OR 1.06, 95% CI 1.04–1.08), advanced maternal BMI (OR 1.04, 95% CI 1.03–1.06), excess weight
gain during pregnancy (OR 1.13, 95% CI 1.00–1.26), advanced current BMI (OR 1.32, 95% CI 1.02–1.70), diabetes (OR 1.91,
95% CI 1.53–2.38), episiotomy (OR 1.76, 95% CI 1.06–2.94), forceps delivery (OR 2.69, 95% CI 1.25–5.76), gestational UI
(OR 5.04, 95% CI 2.07–12.28), gestational SUI (OR 4.28, 95% CI 2.61–7.01), prenatal UI (OR 8.54, 95% CI 3.52–20.70), and
early postpartum UI (OR 3.52, 95% CI 1.61–7.69), were associated with postpartum SUI. The findings of this analysis could
serve to generate risk prediction models and provide a basis for developing treatment strategies for patients with postpartum SUI.

Keywords Meta-analysis . Postpartum stress urinary incontinence . Pregnancy . Review . Risk factor

Abbreviations Introduction
SUI Stress urinary incontinence
UI Urinary incontinence Urinary incontinence (UI) is a health issue associated with
UUI Urge urinary incontinence negative quality of life in females globally and is one of the
OR Odds ratio most common complications of delivery. Stress urinary incon-
RR Relative risk tinence (SUI) accounts for most types of UI cases [1]. The
HR Hazard ratio etiology of female SUI is multifactorial, and the trauma
CI Confidence interval caused by delivery is one of the most important risk factors
BMI Body mass index for SUI. Many women with SUI cannot recover during the
OASIS Obstetrical anal sphincter injuries postpartum period and eventually develop persistent UI [2–4].
SUI can be accompanied by other forms of involuntary urine
leakage, including urge urinary incontinence (UUI) in 36% of
those studied [5]. Although symptoms could be severe, only a
small proportion of patients choose to seek medical help [6].
Numerous studies have reported that vaginal delivery and
* Hua Jiang
jianghua@njmu.edu.cn
labor with vacuum extraction or forceps are considered to greatly
increase the incidence of postpartum SUI [7, 8]. In contrast,
1
Department of Gynecology and Obstetrics, Women’s Hospital of cesarean delivery, especially elective cesarean, is known to pro-
Nanjing Medical University Nanjing Maternity and Child Health tect against postpartum SUI [9]. However, the factors associated
Care Hospital Tianfei Alley, Mochou Road, with the development of postpartum SUI across various popula-
Nanjing 210004, Jiangsu Province, China
tions remain to be evaluated. The factors that influence postpar-
2
Department of Urology, Sir Run Run Hospital Nanjing Medical tum SUI in the short term and long term vary.
University, Nanjing 211100, Jiangsu Province, China

We conducted a meta-analysis to determine the association
between various risk factors and the incidence of postpartum
SUI. The effects of these risk factors on postpartum SUI were
also discussed from short-term and long-term perspectives.
Sources
This meta-analysis was performed in accordance with the
Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) and Meta-Analyses and systematic
reviews Of Observational Studies (MOOSE) guidelines [10].
The study protocol was registered with PROSPERO (No.
CRD42020150094). We searched PubMed, Embase, Web of
Science, Medline, ClinicalTrials.gov, and Cochrane databases
for studies that analyzed the relationship between various risk
factors and postpartum SUI. The keywords used in this study
were “stress incontinence” OR “stress urinary incontinence”
OR “SUI” OR “urinary stress incontinence” (all fields) AND
“after birth” OR “after delivery” OR “post natal” OR
“postnatal” OR “lying in” OR “puerperal” OR “childbirth”
OR “postpartum” OR “postpartum period” (all fields) AND
“risk factor” OR “association” OR “relative risk” OR “OR”
OR “populations at risk” (all fields). The search was
performed by two researchers independently (KW and
XLX) on January 6, 2019. In addition, we screened the
references of the identified papers to further identify any
potential studies.
Study Selection
The criteria for eligible studies were as follows: (1) any pro-
spective, cross sectional, or retrospective study that recorded
the risk factors and SUI outcome after delivery; (2) studies that
reported sufficient data to estimate the odds ratio (OR), rela-
tive risk (RR), or hazard ratio (HR) and their 95% confidence
intervals (CIs) according to the risk factors; and (3) among
several studies that reported the same risk factors in the same
cohort, only complete or the latest studies were included.
Letters, comments, expert consensus, reviews, case reports,
non-human trials, and studies published in non-English lan-
guage were excluded. Studies lacking key data for further
analysis or whose sample sizes were smaller than 40 were also
excluded. Two authors screened the titles and abstracts of the
identified literature independently and excluded irrelevant
ones. Full texts of the identified studies were screened for
further evaluation. Any disagreement was resolved by
consensus.
The required information was extracted from all eligible
studies by two authors, including the surname of the first
author, publication year, country, population characteristics,
sample size, SUI incidence, types of survey and questionnaire,
Reprod. Sci.
follow-up time, detection method, and risk factors associated
with postpartum SUI.
The quality of each study was systematically assessed by
two authors independently in accordance with the Newcastle-
Ottawa Quality Assessment Scale (NOS) [11]. A total score of
9 represented the highest quality, while 0 represented the low-
est quality. A score of 6 or more represented that the research
had a high quality.
A risk factor with the data available in at least two studies
was considered for this study. Any RR and HR with similar
values were merged into OR. Pooled ORs and their 95% CIs
were used to describe the relationship between various risk
factors and postpartum SUI. Cochran’s Q test and Higgins’
I2 statistics were used to assess heterogeneity. A random ef-
fects model was applied when I2 > 50% and/or P < 0.1, which
implied a statistically significant heterogeneity. Otherwise, a
fixed effects model was used. Sensitivity analysis was per-
formed by excluding each of the studies to evaluate its contri-
bution to heterogeneity. The asymmetrical funnel plot implied
the presence of publication bias, and this was cross-checked
by Begg’s and Egger’s tests. If publication bias existed, the
trim-and-fill method was used. STATA software version 12.0
(Stata Corporation, College Station, TX, USA) was used in
this meta-analysis. P < 0.05 was considered as statistically
significant.
Disease definitions were based on recommendations re-
ported by International Urogynecological Association and
International Continence Society [12]. UI was defined as a
complaint of involuntary loss of urine; SUI was defined as a
complaint of involuntary loss of urine on effort or physical
exertion or on sneezing or coughing; and UUI was defined as
a complaint of involuntary loss of urine associated with ur-
gency. The major risk factors identified in this analysis asso-
ciated with postpartum SUI are defined below. Age at gesta-
tion was defined as the age when pregnancy was confirmed;
parity was defined as the number of children previously borne;
maternal body mass index (BMI) was defined as the BMI
measured during pregnancy; weight gain during pregnancy
was defined as the amount of weight gained by the pregnant
woman during pregnancy; current BMI was defined as the
BMI when patient was surveyed; waist circumference was
defined as the waist circumference when the patient was sur-
veyed; diabetes was defined based on diabetes history; vaginal
delivery was defined as birth of the offspring through the
vagina; elective cesarean section was defined as selective de-
livery of the fetus by surgical incision; emergency cesarean
section was defined as emergency delivery of the fetus by
surgical incision; episiotomy was defined as surgical enlarge-
ment of the vaginal orifice during the last part of the second
stage of labor or delivery; instrumental delivery was defined
as the use of instruments during delivery; forceps delivery was
defined as the use of forceps during delivery; vacuum extrac-
tion was defined as the use of vacuum extraction during
Reprod. Sci.
delivery; length of the second stage was defined as the length
of the second stage of delivery; labor was defined as the total
delivery time; oxytocin stimulation was defined as the use of
oxytocin during delivery; duration of epidural was defined as
the length of time when using epidural anesthesia; obstetrical
anal sphincter injuries (OASIS) were defined as anal sphincter
injury during delivery; laceration of perineum was defined as
perineum tear during delivery; 1st or 2nd degree laceration of
perineum was defined as 1st or 2nd degree perineum tear
during delivery; 3rd or 4th degree laceration of perineum
was defined as 3rd or 4th degree perineum tear during deliv-
ery; gestational UI was defined as the UI that occurred during
pregnancy; gestational SUI was defined as the SUI that oc-
curred during pregnancy; gestational UUI was defined as the
UUI that occurred during pregnancy; prenatal UI was defined
as the UI that occurred before pregnancy; early postpartum UI
was defined as UI existing in 3 months after delivery; fetal
weight was defined as the infant birth weight; and fetal head
circumference was defined as the head circumference of the
infant at birth.
Results
Study Selection and Characteristics
Initially, 1549 studies were retrieved. After deduplication and
further screening of the titles and abstracts, 300 articles were
further evaluated by screening the full text. Additionally, one
article was identified by screening the references. From the
remaining ones, 45 articles with 46 studies containing 73,010
participants were included in this analysis (Fig. 1) [13–57].
Fig. 1 Flow diagram of the study
selection process
The extracted data related to the main features of the in-
cluded studies are presented in Table 1. The participants with
approximately 13.3% incidence of postpartum SUI included
in this analysis were from Sweden (26.6%), China (21.2%),
Norway (16.4%), USA (15.8%), India (4.1%), France (3.9%),
Canada (3.2%), Thailand (1.5%), Egypt (1.5%), Spain (1.3%),
Ireland (1.2%), Italy (0.9%), Denmark (0.8%), UK (0.7%),
Netherlands (0.5%), and Iran (0.4%). Three studies [32, 33,
35] and two other studies [36, 38] probably used the same
cohort; however, the risk factors they reported were not the
same. Therefore, we still included them in this analysis. There
were 31 prospective studies, 12 cross-sectional studies, and 3
retrospective studies included in the meta-analysis, and the
year of publication ranged from 2001 to 2018. Caucasian,
Asian, and African-American populations were reported in
24, 13, and 1 studies, respectively, while the participants in
the remaining 8 studies were of mixed race.
Quality Assessment
Forty-six eligible studies included in this analysis were eval-
uated in accordance with the NOS. The quality of these studies
ranged from 6 to 9, with a mean score of 7.7. All the studies
included showed improved methodology. Consequently, each
study mentioned above was enrolled for further analysis.
Demographic Risk Factors
Data pooling was possible for seven variables, including age
at gestation, parity, maternal BMI, weight gain during preg-
nancy, current BMI, waist circumference, and diabetes
(Table 2).
 Reprod. Sci.

Table 1 Main characteristics of all studies included in this analysis

Study Nation Research Types of survey Sampling Postpartum Race Age Sample SUI Ratio
type frame follow-up size incidence
time

Van Kessel 2001 USA Retrospective Computerized SC NA Caucasian Mean 173 85 OR

[13] database 39.6
Goldberg 2003 USA Cross Given SC 2 years Mixed Median 733 333 OR
[15] sectional questionnaire 37
Dolan 2003 [14] UK Prospective Mailed SC 15 years Caucasian NA 55 28 RR
questionnaire
Rortveit 2003 Norway Cross Self-administered SC NA Caucasian 20–64 11,968 1711 OR
[16] sectional questionnaire
Schytt 2004 [18] Sweden Prospective Mailed MC 1 year Caucasian Mean 1847 21.70% OR
questionnaire 29.5
Fritel 2004 [17] France Cross Mailed SC 4 years Caucasian Mean 304 89 OR
sectional questionnaire 33
Casey 2005 [19] USA Prospective Questionnaire SC 7 months Mixed Mean 3887 144 OR
administered 22
by trained
assistants
Goldberg 2005 USA Cross Given SC NA Mixed Mean 341 221 OR
[22] sectional questionnaire 47.1
Fritel 2005 [21] France Prospective Mailed SC NA Caucasian Mean 2317 364 OR
questionnaire 55
Choua 2005 [20] China Prospective Telephone SC 1 year Asian Mean 180 13 OR
questionnaire 28.1
Choub 2005 [20] China Prospective Telephone SC 1 year Asian Mean 198 11 OR
questionnaire 28.1
Lukacz 2006 USA Cross Mailed SC NA Mixed Mean 3272 548 OR
[23] sectional questionnaire 57
Manonai 2006 Thailand Cross Questionnaire SC NA Asian Mean 1126 33.70% OR
[24] sectional administered 39.1
by a trained
staff
Van Brummen Netherlands Prospective Self-reported SC 1 year Caucasian Mean 344 36 OR
2006 [25] questionnaire 30.4
Altman 2007 Sweden Prospective Self-administered SC 10 years Caucasian Mean 395 135 OR
[26] questionnaire 40.7
El-Azab 2007 Egypt Cross Mailed SC NA Caucasian NA 1096 245 OR
[27] sectional questionnaire
Lewicky-Gaupp USA Prospective Given SC 6 weeks African-American Mean 58 3 OR
2008 [30] questionnaire 17.4
Agur 2008 [28] UK Prospective Telephone SC 8 years Caucasian Mean 164 61 RR
questionnaire 28.0
Scheer 2008 [31] UK Prospective Given SC 3 months Caucasian Mean 204 NA OR
questionnaire 28.4
Ekstroem 2008 Sweden Prospective Self-reported SC 9 months Caucasian Mean 376 39 RR,OR
[29] questionnaire 31.5
Arrue 2010 [32] Spain Prospective Given SC 6 months Caucasian Mean 330 50 OR
questionnaire 30.9
Diez-Itza 2010 Spain Prospective Given SC 1 year Caucasian Mean 352 40 OR
[33] questionnaire 31.2
Yang 2010 [34] China Prospective Telephone SC 6 weeks Asian Mean 1889 151 OR
questionnaire 30.6
Handa 2011 [36] USA Prospective Given MC 5–10 years Mixed Median 1011 112 OR
questionnaire 39.5
Arrue 2011 [35] Spain Prospective Telephone SC 2 years Caucasian Mean 272 26 OR
questionnaire 31.3
Handa 2012 [38] USA Prospective Given MC 5–10 years Mixed Median 499 71 OR
questionnaire 40
Chuang 2012 China Prospective Questionnaire SC 2 years Asian Mean 6653 292 OR
[37] administered 31
by a nurse
UK Prospective MC 1 year Caucasian NA 108 49 RR
Reprod. Sci.

Table 1 (continued)

Study Nation Research Types of survey Sampling Postpartum Race Age Sample SUI Ratio
type frame follow-up size incidence
time

Macleod 2013 Mailed

[42] questionnaire
Gyhagen 2013 Sweden Cross Mailed SC 20 years Caucasian NA 5118 768 OR
[40] sectional questionnaire
Singh 2013 [43] India Cross Questionnaire SC NA Asian Median 3000 484 OR
sectional administered 40
by a doctor
Liang 2013 [41] China Prospective Mailed SC 5 years Asian Mean 312 136 OR
questionnaire 29.4
Chan 2013 [39] China Prospective Questionnaire SC 1 year Asian Mean 330 85 OR
administered 30.6
by trained
assistants
Tettamanti 2014 Sweden Retrospective Web-based SC NA Caucasian NA 11,175 670 OR
[46] survey
Svare 2014 [45] Danish Prospective Mailed SC 1 year Asian Mean 575 89 OR
questionnaire 28.3
Chang 2014 [44] China Prospective Given SC 1 year Asian Mean 330 50 OR
questionnaire 32.9
Serati 2016 [48] Italy Prospective Telephone SC 3 months Caucasian Mean 656 163 OR
questionnaire 31.5
Mathe 2016 [47] France Retrospective Mailed SC 1 month Caucasian Mean 211 92 OR
questionnaire 30.0
Li 2016 [53] China Cross Telephone SC 7 weeks Asian Mean 4690 458 OR
sectional questionnaire 30.7
Blyholder 2017 USA Cross Web-based SC 2 years Mixed NA 199 38 OR
[49] sectional survey
Durnea 2017 Ireland Prospective Given SC 1 year Caucasian Mean 872 NA OR
[51] questionnaire 30.5
Kokabi 2017 Iran Prospective Given SC 1 month Caucasian Mean 286 32 OR
[52] questionnaire 29.1
Ng 2017 [54] China Prospective Mailed SC 3–5 years Asian Mean 506 185 RR
questionnaire 30.6
Chan 2017 [50] China Prospective Given SC 3–5 years Asian Mean 399 153 OR
questionnaire 34.68
Blomquist 2018 USA Prospective Telephone SC 5–10 years Mixed Mean 1360 138 HR
[56] questionnaire 30.6
Bergman 2018 Sweden Cross Mailed SC 2–31 years Caucasian Median 534 99 OR
[55] sectional questionnaire 43
Hutton 2018 Canada Prospective Self-administered MC 2 years Caucasian NA 2305 233 OR
[57] questionnaire

SUI, stress urinary incontinence; SC, single center; MC, multi-center; NA, not available; OR, odds risk; RR, relative risk; HR, hazard risk
a
Study by Chou et al. [20] that evaluated risk factors in a cohort of 180 vaginal delivery participants
b
Study by Chou et al. [20] that evaluated risk factors in a cohort of 198 cesarean delivery participants

Age at Gestation
The evidence from seven studies [18, 20, 25, 34, 37, 39] with
11,441 participants showed that age at gestation might be a risk
factor for postpartum SUI (I2 = 42.8%, P = 0.105; OR = 1.06,
95% CI = 1.04–1.08, P < 0.001; fixed effects model) and pregnant
women with older age at gestation would have a higher risk
(Fig. 2a). The P values of Begg’s and Egger’s tests were 0.133
and 0.018, respectively. After adjustment with the trim-and-fill
method, the pooled association between age at gestation and post-
partum SUI was still significant (fixed effects model: OR = 1.06,
95% CI = 1.04–1.08, P < 0.001; random effects model: OR = 1.07,
95% CI = 1.02–1.11, P = 0.003), and the results showed that age at
gestation was still a risk factor for postpartum SUI. Therefore, the
results for age at gestation were reliable.
Parity
The evidence from seven studies [14, 18, 26, 28, 41, 49, 55]
with 3506 participants showed that parity might not be a risk
factor for postpartum SUI (I2 = 45.3%, P = 0.089; OR = 1.15,
 Reprod. Sci.

Table 2 The pooled relationship

between various risk factors and Risk factors No. of No. of OR (95% CI) P value Model Heterogeneity
postpartum SUI studies patients
I2 P
(%)

Demographic risk factors

Age at gestation 7 11,441 1.06 (1.04–1.08) < 0.001 Fixed 42.80 0.105
Parity 7 3506 1.15 (0.92–1.43) 0.213 Random 45.30 0.089
Maternal BMI 8 11,875 1.04 (1.03–1.06) < 0.001 Fixed 42.70 0.094
Weight gain 3 708 1.13 (1.00–1.26) 0.041 Fixed 38.90 0.195
during
pregnancy
Current BMI 5 7360 1.32 (1.02–1.70) 0.034 Random 86.60 0.001
Waist 2 5562 14.73 (0.18–1186.99) 0.230 Random 91.40 0.001
circumference
Diabetes history 2 8970 1.91 (1.53–2.38) < 0.001 Fixed 0.00 0.519
Delivery-related risk factors
Vaginal delivery 25 46,152 2.08 (1.72–2.52) < 0.001 Random 86.20 < 0.001
Elective Cesarean 2 1052 0.33 (0.19–0.56) < 0.001 Fixed 0.00 0.426
Section
Emergency 2 1052 0.74 (0.24–2.29) 0.606 Random 52.90 0.145
Cesarean
Section
Episiotomy 8 7390 1.76 (1.06–2.94) 0.030 Random 86.30 < 0.001
Instrumental 9 5650 1.39 (0.91–2.12) 0.123 Random 65.80 0.003
delivery
Forceps delivery 4 6448 2.69 (1.25–5.76) 0.011 Random 65.20 0.035
Vacuum 3 1544 0.66 (0.48–0.90) 0.008 Fixed 0.00 0.541
extraction
Length of second 4 4444 1.10 (0.90–1.33) 0.348 Random 64.40 0.038
stage
Labor 3 946 2.47 (1.00–6.11) 0.050 Random 74.00 0.021
Oxytocin 2 4462 0.80 (0.34–1.88) 0.605 Random 86.30 0.007
stimulation
Duration of 2 4091 1.01 (0.76–1.36) 0.925 Fixed 0.00 0.355
epidural
OASIS 3 1174 1.85 (0.91–3.77) 0.088 Random 58.80 0.089
Laceration of 3 1254 1.03 (0.68–1.58) 0.875 Fixed 25.60 0.261
perineum
1st or 2nd degree 3 2567 1.97 (0.62–6.20) 0.249 Random 87.00 < 0.001
laceration of
perineum
3rd or 4th degree 4 6950 1.19 (0.75–1.88) 0.451 Random 69.00 0.021
laceration of
perineum
Urinary incontinence history
Gestational UI 3 1223 5.04 (2.07–12.28) < 0.001 Random 73.40 0.023
Gestational SUI 6 2572 4.28 (2.61–7.01) < 0.001 Random 61.80 0.023
Gestational UUI 2 642 1.67 (0.98–2.84) 0.159 Fixed 42.60 0.187
Prenatal UI 2 680 8.54 (3.52–20.70) < 0.001 Fixed 18.70 0.267
Early postpartum 3 2387 3.52 (1.61–7.69) 0.002 Random 90.40 < 0.001
UI
Fetal related
Fetal weight 7 16,730 0.999 (0.997–1.002) 0.444 Fixed 32.10 0.183
Fetal head 3 2273 1.21 (0.84–1.72) 0.306 Random 57.80 0.093
circumference

SUI, stress urinary incontinence; UUI, urge urinary incontinence; UI, urinary incontinence; BMI, body mass
index; OASIS, obstetrical anal sphincter injuries; OR, odds risk; CI, confidence interval
Reprod. Sci.
Fig. 2 Forest plots of studies evaluating association between demographic risk factors and postpartum stress urinary incontinence
95% CI = 0.92–1.43, P = 0.213; random effects model)
(Fig. 2b). There was no significant publication bias.
Maternal BMI
The evidence from 8 studies [18, 20, 34, 35, 37, 39,
54] with 11,875 participants showed that maternal BMI
might be a risk factor for postpartum SUI (I2 = 42.7%,
P = 0.094; OR = 1.04, 95% CI = 1.03–1.06, P < 0.001;
fixed effects model) and pregnant women with higher
maternal BMI would have a higher risk (Fig. 2c).
There was no significant publication bias.
Weight Gain during Pregnancy
The evidence from two articles that included three studies [20, 32] with
708 participants showed that weight gain during pregnancy might be a
risk factor for postpartum SUI (I2 = 38.9%, P = 0.195; OR = 1.13, 95%
CI = 1.00–1.26, P = 0.041; fixed effects model) and pregnant women
with excessive weight gain during pregnancy would have a higher risk
(Fig. 2d). There was no significant publication bias.
Current BMI
The evidence from five studies [39, 40, 51, 54, 55] with 7360
participants showed that current BMI might not be a risk

factor for postpartum SUI (I2 = 86.6%, P < 0.001; OR = 1.32,
95% CI = 1.02–1.70, P = 0.034; random effects model) and
women with higher current BMI after pregnancy are probably
at a higher risk (Fig. 2e). There was no significant publication
bias existed.
Waist Circumference
The evidence from two studies [51, 53] with 5562 participants
showed that waist circumference might not be a risk factor for
postpartum SUI (I2 = 91.4%, P = 0.001; OR = 14.73, 95%
CI = 0.18–1186.99, P = 0.23; random effects model)
(Fig. 2f). There was no significant publication bias.
Diabetes History
The evidence from two studies [21, 37] with 8970 participants
showed that diabetes history might be a risk factor for post-
partum SUI (I2 = 0.0%, P = 0.519; OR = 1.91, 95% CI = 1.53–
2.38, P < 0.001; fixed effects model) (Fig. 2g). There was no
significant publication bias.
Delivery-Related Risk Factors
Data pooling was possible for 15 variables, including vaginal
delivery, elective cesarean section, emergency cesarean sec-
tion, episiotomy, instrumental delivery, forceps delivery, vac-
uum extraction, length of the second stage, labor, oxytocin
stimulation, duration of epidural, OASIS, laceration of the
perineum, 1st or 2nd degree laceration of the perineum, and
3rd or 4th degree laceration of the perineum (Table 2).
Vaginal Delivery
The evidence from 25 studies [15–19, 21–29, 34, 36, 37, 39,
41, 43, 44, 52, 54, 56, 57] with 46,152 participants showed
that vaginal delivery might be a risk factor for postpartum SUI
(I2 = 86.2%, P < 0.001; OR = 2.08, 95% CI = 1.72–2.52,
P < 0.001; random effects model) (Fig. 3a). The P values of
Begg’s and Egger’s tests were 1.000 and 0.000, respectively.
After adjustment with the trim-and-fill method, the pooled
association between age at gestation and postpartum SUI
was still significant (fixed effects model: OR = 1.26, 95%
CI = 1.20–1.32, P < 0.001; random effects model: OR =
1.39, 95% CI = 1.15–1.67, P = 0.001), and the results showed
that vaginal delivery was still a risk factor for postpartum SUI.
Therefore, the results for vaginal delivery were reliable.
Elective Cesarean Section
The evidence from two studies [20, 51] with 1052 participants
showed that elective cesarean section might be a protective
factor for postpartum SUI (I2 = 0.0%, P = 0.426; OR = 0.33,
Reprod. Sci.
95% CI = 0.19–0.56, P < 0.001; fixed effects model) (Fig. 3b).
There was no significant publication bias.
Emergency Cesarean Section
The evidence from two studies [20, 51] with 1052 participants
showed that emergency cesarean section might not be a risk
factor for postpartum SUI (I2 = 52.9%, P = 0.145; OR = 0.74,
95% CI = 0.24–2.29, P = 0.606; random effects model)
(Fig. 3c). There was no significant publication bias.
Episiotomy
The evidence from eight studies [13, 19, 25, 31, 34, 38, 42,
52] with 7390 participants showed that episiotomy might be a
risk factor for postpartum SUI (I2 = 86.3%, P < 0.001; OR =
1.76, 95% CI = 1.06–2.94, P = 0.03; random effects model)
(Fig. 3d). There was no significant publication bias.
Instrumental Delivery
The evidence from nine studies [18, 25, 28–31, 36, 52, 56]
with 5650 participants showed that instrumental delivery
might not be a risk factor for postpartum SUI (I2 = 65.8%,
P = 0.003; OR = 1.39, 95% CI = 0.91–2.12, P = 0.123; ran-
dom effects model) (Fig. 3e). There was no significant publi-
cation bias.
Forceps Delivery
The evidence from four studies [13, 19, 34, 38] with 6448
participants showed that forceps delivery might be a risk fac-
tor for postpartum SUI (I2 = 65.2%, P = 0.035; OR = 2.69,
95% CI = 1.25–5.76, P = 0.011; random effects model)
(Fig. 3f). There was no significant publication bias.
Vacuum Extraction
The evidence from three studies [13, 38, 51] with 1544 par-
ticipants showed that vacuum extraction might be a protective
factor for postpartum SUI (I2 = 0.0%, P = 0.541; OR = 0.66,
95% CI = 0.48–0.90, P = 0.008; fixed effects model) (Fig. 3g).
There was no significant publication bias.
Length of the Second Stage
The evidence from four studies [13, 19, 20, 31] with 4444
participants showed that length of the second stage might
not be a risk factor for postpartum SUI (I2 = 64.4%, P =
0.038; OR = 1.10, 95% CI = 0.90–1.33, P = 0.348; random
effects model) (Fig. 4a). There was no significant publication
bias.
Reprod. Sci.
Fig. 3 Forest plots of studies evaluating association between seven delivery-related risk factors and postpartum stress urinary incontinence
Labor
The evidence from three studies [17, 32, 41] with 946 partic-
ipants showed that labor might not be a risk factor for post-
partum SUI (I2 = 74.0%, P = 0.021; OR = 2.47, 95% CI =
1.00–6.11, P = 0.05; random effects model) (Fig. 4b). There
was no significant publication bias.
Oxytocin Stimulation
The evidence from two studies [19, 45] with 4462 participants
showed that oxytocin stimulation might not be a risk factor for
postpartum SUI (I2 = 86.3%, P = 0.007; OR = 0.80, 95% CI =
0.34–1.88, P = 0.605; random effects model) (Fig. 4c). There
was no significant publication bias.
Duration of Epidural
The evidence from two studies [19, 31] with 4091 participants
showed that duration of epidural might not be a risk factor for
postpartum SUI (I2 = 0.0%, P = 0.355; OR = 1.01, 95% CI =
0.76–1.36, P = 0.925; fixed effects model) (Fig. 4d). There
was no significant publication bias.

Fig. 4 Forest plots of studies evaluating association between additional eight delivery-related risk factors and postpartum stress urinary incontinence
Oasis
The evidence from three studies [26, 31, 45] with 1174 par-
ticipants showed that OASIS might not be a risk factor for
postpartum SUI (I2 = 58.8%, P = 0.089; OR = 1.85, 95%
CI = 0.91–3.77, P = 0.088; random effects model) (Fig. 4e).
There was no significant publication bias.
Laceration of Perineum
The evidence from three studies [20, 38, 45] with 1254 par-
ticipants reported that laceration of perineum might not be a
Reprod. Sci.
risk factor for postpartum SUI (I2 = 25.6%, P = 0.261; OR =
1.03, 95% CI = 0.68–1.58, P = 0.875; fixed effects model)
(Fig. 4f). There was no significant publication bias.
1st or 2nd Degree Laceration of Perineum
The evidence from three studies [18, 25, 29] with 2567 par-
ticipants showed that 1st or 2nd degree laceration of perineum
might not be a risk factor for postpartum SUI (I2 = 87.0%,
P < 0.001; OR = 1.97, 95% CI = 0.62–6.20, P = 0.249; ran-
dom effects model) (Fig. 4g). There was no significant publi-
cation bias.
Reprod. Sci.
Fig. 5 Forest plots of studies reported urinary incontinence history and fetal-related risk factors for postpartum stress urinary incontinence
3rd or 4th Degree Laceration of Perineum
The evidence from four studies [18, 19, 25, 51] with 6950
participants showed that 3rd or 4th degree laceration of peri-
neum might not be a risk factor for postpartum SUI (I2 =
69.0%, P = 0.021; OR = 1.19, 95% CI = 0.75–1.88, P =
0.451; random effects model) (Fig. 4h). There was no signif-
icant publication bias.
Urinary Incontinence History
Data pooling was possible for five variables, including gesta-
tional UI (I2 = 73.4%, P = 0.023; OR = 5.04, 95% CI = 2.07–
12.28, P < 0.001; random effects model) [17, 25, 45], gesta-
tional SUI (I2 = 61.8%, P = 0.023; OR = 4.28, 95% CI = 2.61–
7.01, P < 0.001; random effects model) [29, 32, 33, 39, 41,
51], gestational UUI (I2 = 42.6%, P = 0.187; OR = 1.67, 95%
CI = 0.98–2.84, P = 0.159; fixed effects model) [39, 41], pre-
natal UI (I2 = 18.7%, P = 0.267; OR = 8.54, 95% CI = 3.52–
20.70, P < 0.001; fixed effects model) [17, 29], and early post-
partum UI (I2 = 90.4%, P < 0.001; OR = 3.52, 95% CI = 1.61–
7.69, P = 0.002; random effects model) [18, 28, 29] (Table 2).
All these factors might be risk factors for postpartum SUI
except gestational UUI (Fig. 5). There were no significant
publication biases.
Fetal-Related Risk Factors
Seven studies reported data on fetal weight (I2 = 32.1%, P =
0.183; OR = 0.999, 95% CI = 0.997–1.002, P = 0.444; fixed
effects model) [19, 20, 29, 31, 37, 40, 41] and three studies on
the fetal head circumference (I2 = 57.8%, P = 0.093; OR =

Fig. 6 Forest plots of risk factors reported only in one study for postpartum stress urinary incontinence
1.21, 95% CI = 0.84–1.72, P = 0.306; random effects model)
[20, 31, 34] (Table 2). Both of these factors might not be risk
factors for postpartum SUI (Fig. 5). There were no significant
publication biases.
Other Risk Factors
Twenty-six other risk factors were reported only in one study.
We have listed them in Fig. 6 as a reference for future studies.
Risk Factors of SUI Within 1 Year After Birth
We further analyzed 20 studies whose postpartum follow-up
time was within 1 year to detect risk factors for postpartum
SUI in the short term. Our results showed that vaginal deliv-
ery, advanced age at gestation, advanced maternal BMI, ex-
cess weight gain during pregnancy, episiotomy, gestational
UI, gestational SUI, and early postpartum UI were still the
risk factors for postpartum SUI (Table 3). Furthermore, we
Reprod. Sci.
identified that instrumental delivery and OASIS were also
the risk factors for postpartum SUI in the short term (Table 3).
Risk Factors of SUI at More than 1 Year After Birth
We also analyzed 17 other studies whose postpartum follow-
up time was more than 1 year to detect risk factors for post-
partum SUI in the long term. Our results showed that vaginal
delivery was still the risk factor for postpartum SUI (Table 4).
In addition, we found that fetal weight was the risk factor for
postpartum SUI in the long term (Table 4).
Sensitivity Analysis
Sensitivity analysis was performed by excluding each study
sequentially to evaluate the effect of each study on the obtain-
ed results. Sensitivity analysis showed that after excluding
Van Brummen et al. [25] and Chang et al. [44], the result of
heterogeneity from vaginal delivery became nonsignificant.
Reprod. Sci.

Table 3 The pooled relationship

between various risk factors and Risk factors No. of No. of OR (95% CI) P value Model Heterogeneity
postpartum SUI within 1 year studies patients
I2 P
(%)

Demographic risk factors

Age at gestation 6 4788 1.09 (1.06–1.13) < 0.001 Fixed 16.90 0.305
Maternal BMI 5 4620 1.04 (1.02–1.06) < 0.001 Fixed 19.5 0.290
Weight gain 3 708 1.13 (1.00–1.26) 0.041 Fixed 38.90 0.195
during
pregnancy
Current BMI 2 1202 1.59 (0.74–3.41) 0.233 Random 92.0 < 0.001
Waist 2 5562 14.73 (0.18–1186.99) 0.230 Random 91.40 0.001
circumference
Delivery-related risk factors
Vaginal delivery 8 9289 2.10 (1.50–2.93) < 0.001 Random 84.90 < 0.001
Elective cesarean 2 1052 0.33 (0.19–0.56) < 0.001 Fixed 0.00 0.426
section
Emergency 2 1052 0.74 (0.24–2.29) 0.606 Random 52.90 0.145
cesarean section
Episiotomy 6 6718 2.14 (1.17–3.92) 0.013 Random 88.60 < 0.001
Instrumental 6 3115 1.34 (1.01–1.77) 0.042 Fixed 14.40 0.322
delivery
Forceps delivery 2 5776 3.03 (0.67–13.63) 0.149 Random 83.70 0.013
Length of second 3 4271 1.28 (0.77–2.13) 0.335 Random 71.30 0.031
stage
Oxytocin 2 4462 0.80 (0.34–1.88) 0.605 Random 86.30 0.007
stimulation
Duration of 2 4091 1.01 (0.76–1.36) 0.925 Fixed 0.00 0.355
epidural
OASIS 2 779 2.63 (1.55–4.47) < 0.001 Fixed 0.00 0.495
Laceration of 2 755 0.80 (0.13–4.73) 0.804 Fixed 50.10 0.157
perineum
1st or 2nd degree 3 2567 1.97 (0.62–6.20) 0.249 Random 87.00 < 0.001
laceration of
perineum
3rd or 4th degree 4 6950 1.19 (0.75–1.88) 0.451 Random 69.00 0.021
laceration of
perineum
Urinary incontinence history
Gestational UI 2 919 9.82 (1.64–58.69) 0.012 Random 75.20 0.044
Gestational SUI 5 2260 5.02 (2.94–8.58) < 0.001 Random 54.10 0.069
Early postpartum 2 2223 5.46 (4.18–7.15) < 0.001 Fixed 0.00 0.348
UI
Fetal related
Fetal weight 4 4647 0.999 (0.997–1.002) 0.434 Fixed 0.00 0.587
Fetal head 3 2273 1.21 (0.84–1.72) 0.306 Random 57.80 0.093
circumference

SUI, stress urinary incontinence; UUI, urge urinary incontinence; UI, urinary incontinence; BMI, body mass
index; OASIS, obstetrical anal sphincter injuries; OR, odds risk; CI, confidence interval
After excluding Agur et al. [28] and Handa et al. [36], the Discussion
heterogeneity of pooled studies also changed in parity and
instrumental delivery. Furthermore, after excluding Yang The present meta-analysis aimed to comprehensively and sys-
et al. [34] and Kokabi et al. [52], the heterogeneity in maternal tematically analyze the relationship between various risk fac-
BMI and episiotomy reduced. When Scheer et al. [31] and tors and postpartum SUI. We aimed to provide composite
Durnea et al. [51] were deleted from subgroups of the length evidence on predictive variables responsible for the develop-
of the second stage and gestational SUI, respectively, hetero- ment of postpartum SUI. Compared with the previous meta-
geneity reduced significantly. analyses reported by Tähtinen et al. [7] and Hijaz et al. [58],
 Reprod. Sci.

Table 4 The pooled relationship

between various risk factors and Risk factors No. of No. of OR (95% CI) P value Model Heterogeneity
postpartum SUI more than 1 year studies patients
I2 P
(%)

Demographic risk factors

Parity 6 1659 1.04 (0.86–1.26) 0.692 Fixed 33.00 0.188
Maternal BMI 4 7761 1.07 (1.00–1.14) 0.066 Random 58.50 0.065
Current BMI 3 6158 1.21 (0.85–1.72) 0.281 Random 81.90 0.004
Delivery-related risk factors
Vaginal 10 13,743 2.27 (2.02–2.55) < 0.001 Fixed 30.10 0.169
delivery
Labor 2 616 1.87 (0.68–5.15) 0.228 Random 80.20 0.025
Fetal related
Fetal weight 3 12,083 1.67 (1.12–2.49) 0.011 Fixed 0.00 0.792

SUI, stress urinary incontinence; BMI, body mass index; OR, odds risk; CI, confidence interval

10 and 4 additional studies were included in the vaginal de-
livery and age at gestation subgroups, respectively. The results
showed that both vaginal delivery and advanced age at gesta-
tion were still risk factors for postpartum SUI. Moreover, vag-
inal delivery was identified to be a risk factor for postpartum
SUI in both the short term and long term. Six additional pre-
dictive variables, including advanced maternal BMI, excess
weight gain during pregnancy, advanced current BMI, diabe-
tes, episiotomy, and forceps delivery, were also identified. It
seemed that various types of UI appeared during pregnancy
and early postpartum might be a strong risk factor for postpar-
tum SUI in addition to gestational UUI. Elective cesarean
section and vacuum extraction were also identified as protec-
tive factors for postpartum SUI, although some studies have
reported that the use of vacuum extraction could increase the
risk of SUI [59]. The results of short-term and long-term anal-
yses also identified other additional risk factors.
Pregnancy is the most important one among the various
causes of SUI. It is widely believed that SUI might be caused
by the significant effects of pregnancy on the urinary tract.
Increased weight of the uterus during pregnancy not only in-
creases pressure on the bladder but also stimulates it and de-
creases its volume [60]. This leads to an increased frequency
of urination as the pregnancy progresses [60]. The weakness
of pelvic floor muscle could also contribute to urethral sphinc-
ter incompetence. When a pregnant woman performs certain
tasks that could increase the intra-abdominal pressure, the
pressure on the bladder increases. When the pressure on the
bladder is greater than the pressure range bearable by the weak
pelvic floor muscle, SUI occurs [61]. Therefore, any factors
that could damage the pelvic floor muscle might also lead to
the development of SUI. Furthermore, several studies have
reported that advanced maternal BMI might enhance the pres-
sure on the bladder and impair blood supply to the bladder
[62, 63]. This is consistent with the results of the present
study. Nevertheless, the clear causes of postpartum SUI are
still unclear [64].
Our study had some limitations that need to be addressed.
First, the data used in this meta-analysis were reported directly
instead of the patients’ clinical raw data. However, the hetero-
geneities of most factors identified were acceptable. Second,
only the studies with OR, RR, or HR were included. Third,
postpartum follow-up time was different in each study, and we
were not able to distinguish whether SUI was temporary or
persistent. This could become part of the source of heteroge-
neity. Fourth, partial factors existed for publication bias,
which could have an impact on actual results. Fifth, many
factors could not be pooled because only one paper supported
them. Current research on this topic is still limited, and more
well-designed studies are needed to further investigate the risk
factors of postpartum SUI.
In conclusion, 12 risk factors, including vaginal delivery,
advanced age at gestation, advanced maternal BMI, excess
weight gain during pregnancy, current BMI, diabetes, episiot-
omy, forceps delivery, gestational UI, gestational SUI, prena-
tal UI, and early postpartum UI, were identified to be associ-
ated with postpartum SUI. Moreover, elective cesarean sec-
tion and vacuum extraction were also identified as protective
factors. These data could serve to generate risk prediction
models and provide a basis for developing treatment strategies
for patients with postpartum SUI. Because of the limited data,
more studies on this topic are warranted.
Author’s Contributions H.J. designed this analysis. K.W. and G.M.J.
completed the search and determined eligible papers for inclusion.
K.W. and X.L.X. completed the quality evaluation of eligible papers
and extracted the data. K.W. wrote this manuscript.
Funding Information This work was supported by the National Natural
Science Foundation of China (Grant No. 81771597).
Reprod. Sci.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflicts of
interest.
References
1. Sangsawang B, Sangsawang N. Stress urinary incontinence in preg-
nant women: a review of prevalence, pathophysiology, and treat-
ment. Int Urogynecol J. 2013;24(6):901–12. https://doi.org/10.
1007/s00192-013-2061-7.
2. Dolan LM, Hilton P. Obstetric risk factors and pelvic floor dysfunc-
tion 20 years after first delivery. Int Urogynecol J. 2010;21(5):535–
44. https://doi.org/10.1007/s00192-009-1074-8.
3. Wang H, Ghoniem G. Postpartum stress urinary incontinence, is it
related to vaginal delivery? J Matern Fetal Neonatal Med.
2017;30(13):1552–5. https://doi.org/10.1080/14767058.2016.
1209648.
4. Zhu L, Li L, Lang J-h, Xu T. Prevalence and risk factors for peri-
and postpartum urinary incontinence in primiparous women in
China: a prospective longitudinal study. Int Urogynecol J.
2012;23(5):563–72. https://doi.org/10.1007/s00192-011-1640-8.
5. Hannestad YS, Rortveit G, Sandvik H, Hunskaar S. A community-
based epidemiological survey of female urinary incontinence: the
Norwegian EPINCONT study. Epidemiology of Incontinence in
the County of Nord-Trondelag. J Clin Epidemiol. 2000;53(11):
1150–7.
6. Mason L, Glenn S, Walton I, Hughes C. Women’s reluctance to
seek help for stress incontinence during pregnancy and following
childbirth. Midwifery. 2001;17(3):212–21. https://doi.org/10.1054/
midw.2001.0259.
7. Tahtinen RM, Cartwright R, Tsui JF, Aaltonen RL, Aoki Y,
Cardenas JL, et al. Long-term impact of mode of delivery on stress
urinary incontinence and urgency urinary incontinence: a system-
atic review and meta-analysis. Eur Urol. 2016;70(1):148–58.
https://doi.org/10.1016/j.eururo.2016.01.037.
8. Arya LA, Jackson ND, Myers DL, Verma A. Risk of new-onset
urinary incontinence after forceps and vacuum delivery in primip-
arous women. Am J Obstet Gynecol. 2001;185(6):1318–23; discus-
sion 23-4. https://doi.org/10.1067/mob.2001.120365.
9. Ege E, Akin B, Altuntug K, Benli S, Arioez A. Prevalence of
urinary incontinence in the 12-month postpartum period and related
risk factors in Turkey. Urol Int. 2008;80(4):355–61. https://doi.org/
10.1159/000132691.
10. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting
items for systematic reviews and meta-analyses: the PRISMA state-
ment. Open medicine : a peer-reviewed, independent, Open Med.
2009;3(3):e123–30.
11. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the
assessment of the quality of nonrandomized studies in meta-analy-
ses. Eur J Epidemiol. 2010;25(9):603–5. https://doi.org/10.1007/
s10654-010-9491-z.
12. Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B,
Lee J et al. An International Urogynecological Association (IUGA)/
International Continence Society (ICS) joint report on the terminol-
ogy for female pelvic floor dysfunction. Neurourol Urodyn.
2010;29(1). doi:https://doi.org/10.1002/nau.20798.
13. Van Kessel K, Reed S, Newton K, Meier A, Lentz G. The second
stage of labor and stress urinary incontinence. Am J Obstet
Gynecol. 2001;184(7):1571–5. https://doi.org/10.1067/mob.2001.
114856.
14. Dolan LM, Hosker GL, Mallett VT, Allen RE, Smith ARB. Stress
incontinence and pelvic floor neurophysiology 15 years after the
first delivery. BJOG. 2003;110(12):1107–14. https://doi.org/10.
1016/s1470-0328(03)02415-7.
15. Goldberg RP, Kwon C, Gandhi S, Atkuru LV, Sorensen M, Sand
PK, et al. Urinary incontinence among mothers of multiples: the
protective effect of cesarean delivery. Am J Obstet Gynecol.
2003;188(6):1447–53. https://doi.org/10.1067/mob.2003.451.
16. Rortveit G, Daltveit AK, Hannestad YS, Hunskaar S, Norwegian
ES. Urinary incontinence after vaginal delivery or cesarean section.
N Engl J Med. 2003;348(10):900–7. https://doi.org/10.1056/
NEJMoa021788.
17. Fritel X, Fauconnier A, Levet C, Benifla JL. Stress urinary incon-
tinence 4 years after the first delivery: a retrospective cohort survey.
Acta Obstet Gynecol Scand. 2004;83(10):941–5. https://doi.org/10.
1111/j.0001-6349.2004.00457.x.
18. Schytt E, Lindmark G, Waldenström U. Symptoms of stress incon-
tinence 1 year after childbirth: prevalence and predictors in a na-
tional Swedish sample. Acta Obstet Gynecol Scand. 2004;83(10):
928–36. https://doi.org/10.1111/j.0001-6349.2004.00431.x.
19. Casey BM, Schaffer JI, Bloom SL, Heartwell SF, McIntire DD,
Leveno KJ. Obstetric antecedents for postpartum pelvic floor dys-
function. Am J Obstet Gynecol. 2005;192(5):1655–62. https://doi.
org/10.1016/j.ajog.2004.11.031.
20. Chou PL, Chen FP, Teng LF. Factors associated with urinary stress
incontinence in primiparas. Taiwan J Obstet Gynecol. 2005;44(1):
42–7.
21. Fritel X, Ringa V, Varnoux N, Fauconnier A, Piault S, Bréart G.
Mode of delivery and severe stress incontinence. A cross-sectional
study among 2625 perimenopausal women. BJOG. 2005;112(12):
1646–51. https://doi.org/10.1111/j.1471-0528.2005.00763.x.
22. Goldberg RP, Abramov Y, Botros S, Miller JJ, Gandhi S, Nickolov
A, et al. Delivery mode is a major environmental determinant of
stress urinary incontinence: results of the Evanston-Northwestern
Twin Sisters Study. Am J Obstet Gynecol. 2005;193(6):2149–53.
https://doi.org/10.1016/j.ajog.2005.08.055.
23. Lukacz ES, Lawrence JM, Contreras R, Nager CW, Luber KM.
Parity, mode of delivery, and pelvic floor disorders. Obstet
Gynecol. 2006;107(6):1253–60. https://doi.org/10.1097/01.aog.
0000218096.54169.34.
24. Manonai J, Poowapirom A, Kittipiboon S, Patrachai S,
Udomsubpayakul U, Chittacharoen A. Female urinary inconti-
nence: a cross-sectional study from a Thai rural area. Int
Urogynecol J. 2006;17(4):321–5. https://doi.org/10.1007/s00192-
005-0002-9.
25. Van Brummen HJ, Bruinse HW, Van De Pol G, Heintz APM, Van
Der Vaart CH. Bothersome lower urinary tract symptoms 1 year
after first delivery: prevalence and the effect of childbirth. BJU Int.
2006;98(1):89–95. https://doi.org/10.1111/j.1464-410X.2006.
06211.x.
26. Altman D, Ekstrom A, Forsgren C, Nordenstam J, Zetterstrom J.
Symptoms of anal and urinary incontinence following cesarean
section or spontaneous vaginal delivery. Am J Obstet Gynecol.
2007;197(5). doi:https://doi.org/10.1016/j.ajog.2007.03.083.
27. El-Azab AS, Mohamed EM, Sabra HI. The prevalence and risk
factors of urinary incontinence and its influence on the quality of
life among Egyptian women. Neurourol Urodyn. 2007;26(6):783–
8.
28. Agur WI, Steggles P, Waterfield M, Freemana RM. The long-term
effectiveness of antenatal pelvic floor muscle training: eight-year
follow up of a randomised controlled trial. BJOG. 2008;115(8):
985–90. https://doi.org/10.1111/j.1471-0528.2008.01742.x.
29. Ekstroem A, Altman D, Wiklund I, Larsson C, Andolf E. Planned
cesarean section versus planned vaginal delivery: comparison of
lower urinary tract symptoms. Int Urogynecol J. 2008;19(4):459–
65. https://doi.org/10.1007/s00192-007-0461-2.
30. Lewicky-Gaupp C, Cao D-C, Culbertson S. Urinary and anal in-
continence in African American teenaged gravidas during

pregnancy and the puerperium. J Pediatr Adolesc Gynecol.
2008;21(1):21–6. https://doi.org/10.1016/j.jpag.2007.05.003.
31. Scheer I, Andrews V, Thakar R, Sultan AH. Urinary incontinence
after obstetric anal sphincter injuries (OASIS)-is there a relation-
ship? Int Urogynecol J. 2008;19(2):179–83. https://doi.org/10.
1007/s00192-007-0431-8.
32. Arrue M, Ibañez L, Paredes J, Murgiondo A, Belar M, Sarasqueta
C, et al. Stress urinary incontinence six months after first vaginal
delivery. Eur J Obstet Gynecol Reprod Biol. 2010;150(2):210–4.
https://doi.org/10.1016/j.ejogrb.2010.02.039.
33. Diez-Itza I, Arrue M, Ibañez L, Murgiondo A, Paredes J, Sarasqueta
C. Factors involved in stress urinary incontinence 1 year after first
delivery. Int Urogynecol J. 2010;21(4):439–45. https://doi.org/10.
1007/s00192-009-1055-y.
34. Yang X, Zhang HX, Yu HY, Gao XL, Yang HX, Dong Y. The
prevalence of fecal incontinence and urinary incontinence in pri-
miparous postpartum Chinese women. Eur J Obstet Gynecol
Reprod Biol. 2010;152(2):214–7. https://doi.org/10.1016/j.ejogrb.
2010.05.031.
35. Arrue M, Diez-Itza I, Ibanez L, Paredes J, Murgiondo A, Sarasqueta
C. Factors involved in the persistence of stress urinary incontinence
from pregnancy to 2 years post partum. Int J Gynecol Obstet.
2011;115(3):256–9. https://doi.org/10.1016/j.ijgo.2011.07.024.
36. Handa VL, Blomquist JL, Knoepp LR, Hoskey KA, McDermott
KC, Muñoz A. Pelvic floor disorders 5-10 years after vaginal or
cesarean childbirth. Obstet Gynecol. 2011;118(4):777–84. https://
doi.org/10.1097/AOG.0b013e3182267f2f.
37. Chuang CM, Lin IF, Horng HC, Hsiao YH, Shyu IL, Chou P. The
impact of gestational diabetes mellitus on postpartum urinary in-
continence: a longitudinal cohort study on singleton pregnancies.
BJOG. 2012;119(11):1334–43. https://doi.org/10.1111/j.1471-
0528.2012.03468.x.
38. Handa VL, Blomquist JL, McDermott KC, Friedman S, Muñoz A.
Pelvic floor disorders after vaginal birth: Effect of episiotomy, per-
ineal laceration, and operative birth. Obstet Gynecol. 2012;119(2
PART 1):233–9. https://doi.org/10.1097/AOG.0b013e318240df4f.
39. Chan SS, Cheung RY, Yiu KW, Lee LL, Chung TK. Prevalence of
urinary and fecal incontinence in Chinese women during and after
their first pregnancy. Int Urogynecol J. 2013;24(9):1473–9. https://
doi.org/10.1007/s00192-012-2004-8.
40. Gyhagen M, Bullarbo M, Nielsen TF, Milsom I. A comparison of
the long-term consequences of vaginal delivery versus caesarean
section on the prevalence, severity and bothersomeness of urinary
incontinence subtypes: a national cohort study in primiparous wom-
en. BJOG. 2013;120(12):1548–55. https://doi.org/10.1111/1471-
0528.12367.
41. Liang C-C, Wu M-P, Lin S-J, Lin Y Jr, Chang S-D, Wang H-H.
Clinical impact of and contributing factors to urinary incontinence
in women 5 years after first delivery. Int Urogynecol J. 2013;24(1):
99–104. https://doi.org/10.1007/s00192-012-1855-3.
42. Macleod M, Goyder K, Howarth L, Bahl R, Strachan B, Murphy
DJ. Morbidity experienced by women before and after operative
vaginal delivery: prospective cohort study nested within a two-
Centre randomised controlled trial of restrictive versus routine use
of episiotomy. BJOG. 2013;120(8):1020–7. https://doi.org/10.
1111/1471-0528.12184.
43. Singh U, Agarwal P, Verma ML, Dalela D, Singh N, Shankhwar P.
Prevalence and risk factors of urinary incontinence in Indian wom-
en: a hospital-based survey. Indian J Urol. 2013;29(1):31–6. https://
doi.org/10.4103/0970-1591.109981.
44. Chang SR, Chen KH, Lin HH, Lin MI, Chang TC, Lin WA.
Association of mode of delivery with urinary incontinence and
changes in urinary incontinence over the first year postpartum.
Obstet Gynecol. 2014;123(3):568–77. https://doi.org/10.1097/
aog.0000000000000141.
Reprod. Sci.
45. Svare JA, Hansen BB, Lose G. Risk factors for urinary inconti-
nence 1 year after the first vaginal delivery in a cohort of primipa-
rous Danish women. Int Urogynecol J. 2014;25(1):47–51. https://
doi.org/10.1007/s00192-013-2233-5.
46. Tettamanti G, Altman D, Cnattingius S, Bellocco R, Iliadou AN.
Does urinary incontinence have fetal origins? Results from a na-
tionwide twin study. Int Urogynecol J. 2014;25(11):1471–7.
https://doi.org/10.1007/s00192-014-2399-5.
47. Mathe M, Valancogne G, Atallah A, Sciard C, Doret M,
Gaucherand P, et al. Early pelvic floor muscle training after obstet-
rical anal sphincter injuries for the reduction of anal incontinence.
Eur J Obstet Gynecol Reprod Biol. 2016;199:201–6. https://doi.
org/10.1016/j.ejogrb.2016.01.025.
48. Serati M, Di Dedda MC, Bogani G, Sorice P, Cromi A, Uccella S,
et al. Position in the second stage of labour and de novo onset of
post-partum urinary incontinence. Int Urogynecol J. 2016;27(2):
281–6. https://doi.org/10.1007/s00192-015-2829-z.
49. Blyholder L, Chumanov E, Carr K, Heiderscheit B. Exercise be-
haviors and health conditions of runners after childbirth. Sports
Health. 2017;9(1):45–51. https://doi.org/10.1177/
1941738116673605.
50. Chan SSC, Cheung RYK, Lee LL, Choy RKW, Chung TKH.
Longitudinal follow-up of levator ani muscle avulsion: does a sec-
ond delivery affect it? Ultrasound Obstet Gynecol. 2017;50(1):
110–5. https://doi.org/10.1002/uog.16009.
51. Durnea CM, Khashan AS, Kenny LC, Durnea UA, Dornan JC,
O’Sullivan SM, et al. What is to blame for postnatal pelvic floor
dysfunction in primiparous women-pre-pregnancy or intrapartum
risk factors? Eur J Obstet Gynecol Reprod Biol. 2017;214:36–43.
https://doi.org/10.1016/j.ejogrb.2017.04.036.
52. Kokabi R, Yazdanpanah D. Effects of delivery mode and
sociodemographic factors on postpartum stress urinary incontinen-
cy in primipara women: a prospective cohort study. J Chin Med
Assoc. 2017;80(8):498–502. https://doi.org/10.1016/j.jcma.2016.
06.008.
53. Li Y, Zhang Z. Association between waist-to-height ratio and post-
partum urinary incontinence. Int Urogynecol J. 2017;28(6):835–43.
https://doi.org/10.1007/s00192-016-3220-4.
54. Ng K, Cheung RYK, Lee LL, Chung TKH, Chan SSC. An obser-
vational follow-up study on pelvic floor disorders to 3-5 years after
delivery. Int Urogynecol J. 2017;28(9):1393–9. https://doi.org/10.
1007/s00192-017-3281-z.
55. Bergman I, Westergren Soderberg M, Lundqvist A, Ek M.
Associations between childbirth and urinary incontinence after
midurethral sling surgery. Obstet Gynecol. 2018;131(2):297–303.
https://doi.org/10.1097/aog.0000000000002445.
56. Blomquist JL, Munoz A, Carroll M, Handa VL. Association of
delivery mode with pelvic floor disorders after childbirth. JAMA.
2018;320(23):2438–47. https://doi.org/10.1001/jama.2018.18315.
57. Hutton EK, Hannah ME, Willan AR, Ross S, Allen AC, Armson
BA, et al. Urinary stress incontinence and other maternal outcomes
2 years after caesarean or vaginal birth for twin pregnancy: a
multicentre randomised trial. BJOG. 2018;125(13):1682–90.
https://doi.org/10.1111/1471-0528.15407.
58. Hijaz A, Sadeghi Z, Byrne L, Hou JC, Daneshgari F. Advanced
maternal age as a risk factor for stress urinary incontinence: a re-
view of the literature. Int Urogynecol J. 2012;23(4):395–401.
https://doi.org/10.1007/s00192-011-1562-5.
59. Viktrup L, Lose G. The risk of stress incontinence 5 years after first
delivery. Am J Obstet Gynecol. 2001;185(1):82–7. https://doi.org/
10.1067/mob.2001.114501.
60. Francis WJ. Disturbances of bladder function in relation to preg-
nancy. J Obstet Gynaecol Br Emp. 1960;67:353–66.
61. Morkved S, Bo K, Schei B, Salvesen KA. Pelvic floor muscle
training during pregnancy to prevent urinary incontinence: a
single-blind randomized controlled trial. Obstet Gynecol.
Reprod. Sci.

2003;101(2):313–9. https://doi.org/10.1016/s0029-7844(02) weight loss. Am J Obstet Gynecol. 1992;167(2):392–7; discussion

02711-4. 7-9. https://doi.org/10.1016/s0002-9378(11)91418-5.
62. Pregazzi R, Sartore A, Troiano L, Grimaldi E, Bortoli P, Siracusano 64. Viktrup L. The risk of lower urinary tract symptoms five years after
S, et al. Postpartum urinary symptoms: prevalence and risk factors. the first delivery. Neurourol Urodyn. 2002;21(1):2–29.
Eur J Obstet Gynecol Reprod Biol. 2002;103(2):179–82. https://
doi.org/10.1016/s0301-2115(02)00045-3.
Publisher’s Note Springer Nature remains neutral with regard to jurisdic-
63. Bump RC, Sugerman HJ, Fantl JA, McClish DK. Obesity and
tional claims in published maps and institutional affiliations.
lower urinary tract function in women: effect of surgically induced