Prevalence and risk factors of diastasis recti abdominis and a proposed hierarchical framework for clinical decision making

Abstract Background Diastasis recti abdominis (DRA) is characterized by widening of the linea alba and increased inter-recti distance (IRD). Reported prevalence and risk factors vary substantially across studies, leading to fragmented clinical understanding. Objective To synthesize the available evidence on the prevalence and risk factors of DRA, identify sources of heterogeneity, and propose a conceptual framework for organizing reported risk factors and informing clinical decision-making. Methods This narrative review searched PubMed, Embase, Web of Science, CNKI, and WanFang from January 2000 to April 2026. Two reviewers independently screened studies, with disagreements resolved by a third reviewer. A total of 50 studies were included. No formal risk-of-bias assessment was performed; quality was qualitatively considered during synthesis. Reported effect estimates (OR, RR, RRR with 95% CIs) were extracted from representative studies for risk factor synthesis. Results Reported DRA prevalence varies substantially across studies (39–89% in postpartum populations; 28–57% in general adults; 25–67% in men), reflecting heterogeneity in diagnostic methods, measurement sites, IRD thresholds, and assessment time points. An IRD threshold of > 3 cm has been proposed by some authors as potentially more specific than the widely used > 2 cm threshold, although this remains exploratory and has not been prospectively validated. Reported risk factors are organized into a heuristic three-tier framework based on consistency of evidence and clinical modifiability: a Core Stable Tier (pregnancy/parity, BMI, age), a Modifiable Tier (diabetes, smoking in men), and a Context-Dependent Tier (mode of delivery, obstetric maneuvers, exercise, others). Tier assignment reflects author interpretation rather than a formal evidence-grading system. Conclusion This review proposes a conceptual, author-derived hierarchical framework for organizing DRA risk factors and outlines proposed considerations for clinical assessment that require prospective validation before they can inform standardized practice. Future research should prioritize standardization of diagnostic methods and prospective validation of the proposed framework.