Narratives from patient interviews revealed a multidimensional burden of chronic postsurgical pain, with persistent pain, sleep disruption, fatigue, psychological distress, and cognitive load interacting to impair infant care, functioning, and maternal identity. Ten themes captured physical, emotional, social, and healthcare-related impacts, with symptoms described as interrelated rather than isolated.

Women emphasised that pain was more than a physical sensation: it shaped maternal identity, interfered with caregiving, strained relationships, and influenced confidence and future plans. Sleep disturbance, fatigue, emotional distress, and cognitive load rarely occurred in isolation but interacted to worsen difficulties. Those who coped more effectively often reframed their experiences or developed strategies to break cycles of fear, pain, and exhaustion.

Sleep disturbance emerged as particularly important. One study of women with pregnancy-related back pain found that those with significant sleep disturbance at 4 months postpartum had nearly three time greater odds of experiencing persistent lumbopelvic pain compared to those sleeping well⁹. Pain and poor sleep likely reinforce each other in a cyclical manner, fragmenting rest and slowing healing.¹⁰ Postpartum fatigue, a prolonged state of exhaustion affecting many new mothers, further compounds this issue. Fatigue often correlates with emotional distress (including depressive symptoms) and both can increase pain sensitivity¹¹. For many women, the combined effect of sleep loss and fatigue in caring for an infant can reduce normal pain tolerance.¹²

Reluctance to use analgesia was another recurring theme. Consistent with prior work¹³, many women tolerated moderate pain rather than risk perceived harms to the infant, whether from maternal drowsiness or medication transfer in breast milk. This underscores the need for clear, evidence-based guidance on safe postpartum analgesia and for interventions that address fears and misconceptions. Others talked about the toll of pain on relationships and intimacy. Some avoided sexual intercourse for fear of pain or felt disconnected from their bodies. A recent qualitative study of early recovery after elective CD found that women experienced significant pain in the first few days, followed by faster-than-expected improvement¹⁴. Consistent with our study, women expressed a clear need for better information, especially around what to expect physically and how to manage recovery at home.

Our interviews showed how symptoms, pain, fatigue, poor sleep, low mood, anxious thinking, rarely occurred in isolation. Our participants described a cycle that was hard to break. Those who coped better often had ways of reframing the experience or finding distraction, and did not describe fear, pain and exhaustion. Emerging evidence portrays the transition from acute to chronic postpartum pain as a biopsychosocial process.¹⁵ Beyond the physical surgical injury, a host of non-physical factors - social support, psychological health, and cognitive pain appraisals - critically shape recovery.¹⁶ Women lacking strong support networks (e.g. unpartnered mothers) report higher postpartum pain levels¹⁷, suggesting that social stressors can amplify pain perception. Psychological factors are particularly important. Pre-existing anxiety or depression has been associated with more intense and prolonged postpartum pain¹⁸. In a Chinese cohort, women with symptoms of depression before delivery were significantly more likely to develop CPSP up to 6 months after CD¹⁸. Similarly, a prior history of chronic pain (such as back pain) or higher acute pain on the first day postpartum increases the risk of long-term pain¹¹. Pain catastrophizing, the tendency to have ruminating, negative thoughts about pain - is another key risk factor.¹⁹ This suggests that emotional state and pain-related cognitions can modulate pain experience and recovery course after childbirth.²⁰

The study findings suggest we need to reconsider how pain recovery is approached after CD. Pain scores alone are increasingly considered insufficient to evaluate the risk of CPSP, and multidomain assessment is called for²¹. Domains such as sleep quality, mood, cognitive load and fatigue are highly relevant, and could be integrated into routine postpartum assessment.²² The Stanford Obstetric Recovery Checklist (STORK) has already demonstrated the value of broader, patient-centred recovery assessments in routine maternity care.²³

Research indicates that poor sleep, intense acute pain, emotional distress and fatigue often cluster before chronic pain develops^24–27. Pain severity correlates with poor sleep quality and emotional distress, mediated by anxiety about sleep and poor sleep hygiene²⁸. Clusters of depressive symptoms, stress, fatigue, and lack of sleep in the perinatal period have been identified, which are potential contributors to adverse maternal health outcomes²⁹. Another study also found the bidirectional association between sleep disturbance and pain, noting that sleep disturbance can lower pain thresholds and exacerbate psychological distress³⁰. The importance of addressing sleep disturbance in chronic pain management has been highlighted, as poor sleep quality and insomnia-type symptoms are linked to higher levels of disability and depression^31,32. Collectively, these studies suggest that addressing sleep disturbance and emotional distress early in the postpartum period could be crucial in preventing the development of chronic pain.

The SPACE-Postpartum framework (Sleep, Pain, Affect, Cognition, Energy; “SPACE”), was recently conceptualised through triangulation of qualitative interviews, cohort observations and published literature,^24,33–35 with aim of comprehensively describing multidimensional postpartum pain and recovery. Key symptoms, impacts, and coping strategies identified in the current thematic analysis were consistent with the five pre-specified SPACE domains, thereby providing experiential support for this framework (Figure 1). Sleep disruption and fatigue were among the most frequently discussed concerns, described by almost all participants as worsening pain and distress, whereas cognitive impacts (concentration, intrusive thoughts) were less frequently discussed but strongly connected to mood disturbance. Although symptoms from all domains were described, pain interference, sleep disruption, and affective distress carried particular weight in narratives of daily functioning and maternal identity. Participants rarely described symptoms in isolation; rather, poor sleep worsened fatigue and mood, which in turn worsened pain, suggesting that relationships between domains were as important as the individual domains. In the present study, SPACE was applied only after inductive theme generation, serving as a means to integrate qualitative and quantitative findings, and to provide experiential validation of the framework. The convergence between participant-derived themes and the SPACE domains supports the model’s relevance, warranting evaluation in diverse populations and study designs.

We acknowledge that this study has limitations. This was a single-centre US study involving only 24 women, so findings may not reflect wider populations. While we included both English and Spanish speaking patients, other cultural and linguistic groups were not represented. As with all qualitative work, these are self-reported experiences that reflect individual perspectives. However data analysis was performed using robust methodology including independent coding and reflective analysis. SPACE was applied after inductive coding and theme development, in an interpretive manner. This carries some risk of deductive bias; however, all initial coding was inductive, and the framework was considered only once major thematic domains had been established. Its use was intended to support, rather than constrain, interpretation, consistent with a reflexive thematic approach.

In conclusion, this study demonstrates that CPSP after CD is rarely an isolated physical problem. Symptoms in sleep, mood, cognitive load, energy, and pain interact and impact each other, influencing both day-to-day function and 3-6 month pain experience. The themes identified aligned align with the multidomain SPACE-Postpartum framework, and support its further evaluation as a model for understanding and predicting postpartum pain outcomes.