Cesarean section (CS) is a surgical procedure involving incisions through the abdominal wall and uterus to deliver a baby (1). Historically, it was performed only in life-threatening situations; however, advancements in surgical techniques and anesthesia have made it a common obstetric practice (2–4). According to the guidelines of the Polish Society of Gynecologists and Obstetricians (5) and the American College of Obstetricians and Gynecologists (3), the main indications for CS include: obstructed labor, abnormal fetal presentation, multiple pregnancy (especially when the first fetus is not in cephalic presentation), placenta previa, placental abruption, a history of uterine surgery (e.g., previous CS or myomectomy), abnormal fetal heart rate patterns (suggesting fetal distress), maternal infections such as active genital herpes and serious maternal medical conditions, i.e., severe preeclampsia or eclampsia. An analysis of data from over nine million births across 28 European countries confirms that CS is a widely used method of childbirth. In 2015, national CS rates ranged from 16.0% to 55.9% and from 16.0% to 52.2% and in 2019 (6).

The indications for performing CS are evolving and now, in many countries, they also include psychosocial factors such as fear of childbirth or even CS on maternal request, but only in the absence of medical indications. Data on the prevalence of CS upon maternal request in developed countries are limited, as many healthcare systems do not record these cases separately (7). Nevertheless, the reasons behind increasingly liberal attitudes toward CS are complex and not always simple to define. The rising number of such procedures is mainly attributed to sociocultural and economic factors as well as the widespread belief that CS is a safe and convenient alternative to vaginal birth. Advances in surgical care have further reinforced this perception, despite the fact that operative delivery still carries significant risks for both mother and child. The growing demand for CS without medical indications continues to generate controversy among clinicians and researchers due to well-documented negative health consequences in both the short- and long-term (8). The main short-term maternal complications include, among others, excessive bleeding, injury to adjacent organs (such as the bladder, intestines or ureters), uterine scar dehiscence and longer postpartum recovery (9). Long-term complications may involve bowel obstruction (ileus), abdominal wall disorders and an increased risk of complications in subsequent pregnancies, such as uterine rupture, placenta accreta spectrum disorders, ectopic pregnancy, intrauterine fetal demise and pre-term birth. In the most severe cases, additional surgical interventions may be required, for instance hysterectomy or revision of the surgical wound (10). In conclusion, although CS remains an essential tool in modern obstetrics, alike any other medical intervention, it should be used only when medically justified.

Previous research on CS has been primarily focused on short-term clinical outcomes, such as perioperative complications, neonatal condition and postpartum recovery. Significantly less attention has been given to the potential long-term impact of CS on women's health behaviors, including PA levels and body mass management—factors that are essential determinants of maternal health. It was hypothesized that women with a history of CS are more likely to undergo repeat cesarean deliveries, have lower levels of PA and are at greater risk of excessive gestational body mass gain (GMBG) or postpartum body mass retention compared to women with a history of vaginal birth. We also assumed that the decline in PA following CS is not merely a temporary phenomenon, but may persist over time and negatively affect maternal health as well as the course of future pregnancies.

The aim of this study was to evaluate the long-term consequences of a previous CS on the course of subsequent pregnancies and selected lifestyle-related factors, particularly PA and GBMG. To the best of the authors' knowledge, this is one of the first studies focused on the long-term behavioral and health-related consequences of a primary cesarean delivery, going beyond the commonly studied short-term postpartum outcomes. The findings indicate that a prior CS is associated with an increased risk of excessive GBMG and a higher likelihood of undergoing a repeat cesarean delivery. However, no significant associations were found between previous cesarean section and insufficient gestational body mass gain (GBMG) or lower levels of physical activity before or during pregnancy, which is consistent with the findings of other studies in this area (12).

One possible explanation for the observed association between a history of CS and excessive GBMG in subsequent pregnancies is the potential long-term impact of surgical delivery on maternal health behaviors and metabolic adaptation. Cesarean delivery may contribute to more prolonged postpartum recovery, reduced physical functioning as well as persistent changes in abdominal and pelvic musculature which, in turn, could limit the return to regular PA and predispose to gradual body mass retention between pregnancies. The retained postpartum body mass may create a baseline for excessive body mass gain during subsequent pregnancies, especially if combined with common lifestyle factors such as reduced PA or inadequate dietary habits.

Furthermore, CS is often medically linked with maternal conditions such as obesity, gestational diabetes and hypertensive disorders, which are themselves associated with altered metabolic regulation and a higher risk of excessive GBMG (13–15). Thus, the pathway may be partly biological and partially behavioral, involving both the physical limitations resulting from a prior surgical delivery and the broader context of maternal health status. Excessive GBMG carries significant health implications for both the mother and the offspring, including an increased risk of hypertensive disorders, gestational diabetes, macrosomia, postpartum body mass retention and long-term obesity, all of which may further increase the likelihood of surgical delivery in future pregnancies (13, 16). This allows to underline the significance of preconception counseling and body mass management among women with a history of cesarean section in order to minimize the cycle of repeat surgical deliveries and metabolic complications.

Excessive GBMG following a previous CS can have substantial health consequences for the mother, both in the short- and long-term. From an obstetric perspective, excessive body mass gain is associated with an increased risk of pregnancy complications such as gestational diabetes, hypertensive disorders and labor dystocia—all of which are known to elevate the likelihood of another cesarean delivery (13, 17, 18). Moreover, higher GBMG may lead to excessive fetal growth (macrosomia), which not only complicates vaginal delivery but also increases the risk of birth injuries and necessitates operative delivery (9, 19).

Beyond delivery, excessive body mass gain during pregnancy is a strong predictor of postpartum body mass retention, which contributes to long-term maternal overweightness and obesity (20–23). This, in turn, escalates the risk of developing chronic conditions such as type 2 diabetes, cardiovascular disease and metabolic syndrome (13, 20, 21). Additionally, maternal obesity negatively influences fertility and increases the risk of complications in future pregnancies, thus, creating a self-perpetuating cycle of adverse health outcomes (15). These findings allow to highlight the importance of body mass monitoring and individualized nutritional counseling during pregnancy, particularly in women with a history of cesarean section, to reduce the likelihood of excessive body mass gain and its subsequent health burdens.

A prior CS is a well-established risk factor for repeat cesarean delivery in subsequent pregnancies, and this association is both clinical and structural. Current obstetric guidelines acknowledge that previous cesarean delivery is often a direct indication for planned repeat cesarean section, especially in the absence of conditions favorable for a trial of labor after cesarean (TOLAC) (24, 25). Although TOLAC is considered a safe and recommended option in specific circumstances, including a low-transverse uterine scar and no contraindicating obstetric factors, many women do not meet these criteria or are advised against TOLAC due to individual risk profiles.

The decision to perform a repeat cesarean is often influenced by concerns related to uterine rupture, which, while relatively rare, is associated with severe maternal and neonatal morbidity as well as mortality (26, 27). Beyond the delivery itself, undergoing multiple cesarean sections substantially increases the risk of significant complications, including excessive intraoperative bleeding, placenta previa, placenta accreta spectrum disorders and surgical injuries to the bladder or bowel. Moreover, repeated cesarean deliveries are associated with a higher likelihood of postoperative infections, thromboembolic events, longer hospitalization and chronic pelvic pain (16, 27, 28).

In the current study, a significant association was not demonstrated between a history of CS and reduced PA levels before or during a subsequent pregnancy. This finding may suggest that cesarean delivery itself does not substantially influence long-term behavioral patterns related to PA. However, it remains an open question as to what the baseline PA levels were before the previous pregnancy, as it is possible that these were already insufficient. In the present research, this aspect was not assessed and the behavioral dimension of PA was the sole focus in the context of subsequent pregnancies. Moreover, to date, the available literature primarily offers guidelines and expert recommendations on the timing, safety and benefits of returning to PA after CS, as well as suggested types of exercises (29, 30), rather than objective data on the actual activity levels in this population. This gap highlights the novelty of the trial, as there is still a lack of empirical studies in which authors would directly address the PA patterns of women following cesarean delivery.

The findings of this study have significant practical implications, particularly in the context of healthcare management for women who have undergone CS. The results suggest that a history of cesarean delivery is associated with an increased risk of excessive GBMG and a higher likelihood of repeat CS delivery in subsequent pregnancies. Therefore, it is crucial to systematically monitor the metabolic health of women post-cesarean, offering appropriate preventive strategies aimed at controlling body mass gain during pregnancy and promoting PA, which could potentially reduce these adverse outcomes. In terms of decision-making regarding the mode of delivery, the need for a more individualized approach to women who have previously undergone a CS is highlighted in this study, ensuring that each case is evaluated based on the specific risks and benefits for both the mother and child.

In the present study, it is highlighted that women who have had a CS in a previous pregnancy are at a higher risk of excessive GBMS and may be more likely to have another cesarean in subsequent pregnancies. The importance of carefully considering cesarean delivery due to its potential long-term impact on maternal health is also emphasized. Future studies should be focused on understanding how pre-pregnancy PA levels influence outcomes after cesarean delivery and explore the long-term effects of cesarean births on maternal health. Additionally, further research is needed to develop targeted interventions to promote safe PA and body mass management after CS, improving overall maternal well-being in subsequent pregnancies.