REF-1777 · Lan et al., 2026 · Women's Health · Paper · PubMed

Guidelines on activity after birth agree on a weekly floor of at least 120-150 min of moderate activity, and most add pelvic-floor (67%) and strengthening (56%) exercise: a systematic review of 18 national and international guidelines (2016-2025), 7 of satisfactory quality by AGREE II (overall scores 50-92%); it reports what guidelines say, not new trial evidence, and few name a start time

Main caveat: Authors' own: limited databases and Google Scholar, so guidelines from resource-limited countries may be missing.
moderate evidenceMeasured on non-athletes and recreational peopleRead in full

Lan and colleagues (University of Sydney) searched six databases and grey literature for evidence-based guidelines giving physical-activity advice to women after birth, and appraised each with AGREE II, a 23-item tool scored in six domains.

Eighteen guidelines from 2016 to 2025 qualified: two from WHO, three from the USA, two from Australia and one each from Austria, Brazil, Brunei, Canada, Qatar, Kenya, Singapore, Sri Lanka, Sweden, Switzerland and the UK; five were specific to pregnancy and the postpartum period and thirteen were general-population guidelines.

Overall AGREE II scores ran from 50% to 92% (WHO 2022 highest, Canada 2025 at 89%), and seven guidelines met the authors' satisfactory threshold of at least 50% in every domain; rigour of development, applicability and editorial independence were the weak domains.

In content the guidelines largely agreed: at least 150 min a week of moderate aerobic activity (the 2025 Canadian guideline sets a minimum of 120 min, on meta-analytic evidence the review does not detail), spread over the week, any activity better than none, plus pelvic-floor, strengthening and stretching exercise, and advice to see a health professional when a woman has a special condition or is unsure.

Few guidelines said when to start, how to progress or whether caesarean birth changes anything; only the Canadian guideline listed contraindications in a structured way. The authors conclude that guidelines agree on 120-150 min of moderate activity weekly and that evidence on type, timing, delivery mode and implementation is thin.

Participants

No participants: 18 guidelines, 16 in English, one in Swedish and one in German.
5 guidelines (27% as printed) specific to pregnancy and postpartum; 13 (73%) general-population guidelines with postpartum women as a special population.
Table 1: 8 guidelines report GRADE as their rating method (three of them with the AGREE tool as well); 10 report no rating method; 9 report no conflict-of-interest statement.

Protocol

Search: six databases from inception to 15 August 2023, updated 24 June 2025; Google Scholar first 250 records; reference lists; no language limit, with official English versions or translation checked by fluent health professionals.
Inclusion: produced under a professional, public, private or government body; systematically developed recommendations on physical activity after birth; published or updated within 10 years. Excluded: consensus-only documents without an explicit literature search.
Selection by two reviewers in Covidence, a third for disagreements; extraction and appraisal in pairs after AGREE II online training.
AGREE II: 23 items in six domains (scope and purpose, stakeholder involvement, rigour of development, clarity of presentation, applicability, editorial independence) plus two overall items, each 1-7, scaled to a percentage. AGREE II sets no quality cut-off; the authors called a guideline satisfactory with at least 50% in all six domains.
Synthesis: narrative counts of recommendations; no meta-analysis.
Funding: none; the authors declare no conflicts of interest.

Key Results

AGREE II appraisal (18 guidelines):

DomainRangeAverage
Scope and purpose69-100%83%
Stakeholder involvement42-100%74%
Rigour of development23-94%59%
Clarity of presentation56-90%69%
Applicability21-85%50%
Editorial independence25-100%55%
Overall assessment50-92%not given
Satisfactory (at least 50% in all six domains): 7 of 18 (39%) — by Table 2, USA 2018 (both documents), UK 2019, Australia 2020, WHO 2020, WHO 2022 and Canada 2025.

What the guidelines recommend (share of guidelines, as printed):

RecommendationShare
At least 150 min/week of moderate aerobic activity for healthy women88%
Aerobic activity94%
Activity spread through the week (could be split into 2-3 sessions a week)82%
A variety of activity (pelvic-floor, strengthening or stretching)83% (15 guidelines)
Pelvic-floor muscle exercise67%
Strengthening exercise56%
Stretching41%
Yoga or Pilates24%
Any activity is better than none9 guidelines (printed as 53% and as 69%)
Women vigorously active before and during pregnancy may continuemore than 50%
Previously inactive women build up gradually35%
Return differs by delivery modeunder 35% (Results); under 30% (Discussion)
Minimum dose: most guidelines 150 min/week; the 2025 Canadian guideline 120 min/week.
When to start: pelvic-floor exercise immediately after birth in 4 guidelines; moderate activity resumed gradually from 4-8 weeks in 3; Austria 4-6 weeks after a vaginal birth; Qatar 4-8 weeks after a vaginal birth and 8-12 weeks after a caesarean; Canada 2025 daily pelvic-floor exercise through the first year, with no start time.
Safety: all guidelines endorse some activity for women without contraindications; most give no full contraindication list and send women to a health professional before resuming; only Canada 2025 gives a structured list of contraindications and precautions.
Benefits the guidelines name: less postpartum depression (61%), weight management (47%), physical fitness (39%), emotional well-being (24%), lower risk of urinary incontinence (17%).

Practical Application

Official guidelines set a floor, not a ceiling: after birth, once cleared, at least 120-150 min a week of moderate activity, spread over the week, with pelvic-floor and strengthening work, and any activity counts. The 120-150 min floor is what the guidelines agree on; pelvic-floor work appears in 67% of them, strengthening in 56% and 'any activity is better than none' in 9 of 18, and none of it is a dose tested in this review; for a woman who trains it is a public-health minimum, as SYNTH-95 already treats the pregnancy floor.
Women who were vigorously active through pregnancy may continue in more than half of the guidelines, which fits SYNTH-95's "keep training once cleared"; previously inactive women build up gradually.
Where this differs from [SYNTH-95]: the guide gives no return date and tells the assistant not to quote 6 weeks, 12 weeks or 3 months as a rule; three of the 18 guidelines, as this review reports them, give a window for resuming moderate activity (4-8 weeks), and Qatar's adds 8-12 weeks after a caesarean; the Austrian (4-6 weeks) and Qatari (4-8 weeks) windows are for vaginal births, and neither of those two guidelines met the review's satisfactory-quality threshold (Table 2).These are a minority of guidelines, reported second-hand (the guidelines themselves were not read), and rest on no trial reported here, so they do not overturn the guide's screen-not-date return; the assistant can say that some guidelines name such windows, never give one as her date.
The 2025 Canadian guideline ([REF-1394]), whose recommendations the base had not read, is reported here as setting a 120-min weekly minimum, listing contraindications and precautions, and advising daily pelvic-floor exercise through the first year — a second-hand report from this review, not checked against the guideline itself.
Not treatment advice: when and how to resume after birth, and any contraindication, is the obstetric provider's call; a pelvic-floor programme belongs to a pelvic-health physiotherapist.

Limitations

Authors' own: limited databases and Google Scholar, so guidelines from resource-limited countries may be missing; AGREE II has no quality cut-offs and rates method, not clinical appropriateness; mixing postpartum-specific and general-population guidelines dilutes specificity; unpublished guidelines may be missed.
The review counts recommendations; it does not test whether any dose or timing improves an outcome, and it does not report the evidence behind each guideline's numbers (the Canadian 120 min is attributed to "meta-analytic evidence" without detail).
The percentages use denominators that are not stated: 9 guidelines appear as 53% and as 69%, 88% of 18 is not a whole number of guidelines, and the delivery-mode share is under 35% in Results and under 30% in the Discussion; several shares fit a denominator of 17 rather than 18 (stretching 41% with 7 guidelines cited, weight management 47% with 8); the 'more than 50%' for women vigorously active before and during pregnancy cites a single guideline; and the Discussion calls the 18 'guidelines, consensus statements, and position papers' although consensus-only documents were an exclusion criterion.
10 of 18 guidelines report no evidence-rating method and 9 no conflict-of-interest statement (Table 1).
The supplemental tables with each guideline's wording were not read; the start windows and contraindication content are taken from the main text.
No guideline is described as addressing athletes, return to running or racing.
How this entry was checked and changed
Why this level

the AGREE II appraisal was read in full, but the review collects recommendations rather than trial results and grades no evidence itself (the authors state that a risk-of-bias assessment did not apply), so it carries the weight of a consensus document, not of a meta-analysis