Assessment of quality of life indicators in the postpartum period

Patient-reported outcome measures evaluating postpartum maternal health and well-being: a systematic review and evaluation of measurement properties

OBJECTIVE

This study aimed to systematically review and evaluate postpartum health and well-being using patient-reported outcome measures across all domains of postpartum health using the COnsensus-based Standards for the selection of health Measurement INstruments guidelines.

DATA SOURCES

Based on a preprepared published protocol, a systematic search of PubMed, Embase, and CINAHL was undertaken to identify patient-reported outcome tools. The protocol was registered with the International Prospective Register of Systematic Reviews (registration number CRD42021283472), and this work followed the COnsensus-based Standards for the selection of health Measurement INstruments guidelines for systematic reviews.

STUDY ELIGIBILITY CRITERIA

Studies eligible for inclusion included those that assessed a patient-reported outcome measure examining postpartum women's health and well-being with no limitation on the domain. The included studies aimed to evaluate one or more measurement properties of the patient-reported outcome measure.

METHODS

Data extraction and the methodological assessment of the quality of the patient-reported outcome measure were assessed by 2 reviewers independently based on content validity, structural validity, internal consistency, cross-cultural validity or measurement invariance, reliability, measurement error, hypotheses testing for construct validity, and responsiveness, as defined by the COnsensus-based Standards for the selection of health Measurement INstruments. The standard used for content validity were the domains of importance to women in postpartum health and well-being proposed by the International Consortium for Health Outcomes Measurement. The outcome domains for patient-reported health status include mental health, health-related quality of life, incontinence, pain with intercourse, breastfeeding, and motherhood role transition. The quality of the methods was rated an overall rating of results, awarded a level of evidence, and assessed using the Grading of Recommendations, Assessment, Development, and Evaluations assessment tool, and a level of recommendation was awarded for each tool.

RESULTS

There were 10,324 studies identified in the initial search, of which 29 tools were identified from 41 eligible studies included in the review. Moreover, 21 tools were awarded an "A" grading of recommendation for use as a patient-reported outcome measure in postpartum women following the COnsensus-based Standards for the selection of health Measurement Instruments standards. Of the "A"-rated tools, 17 (80%) examined the domain of mental health, 5 examined health-related quality of life, 4 examined breastfeeding, and 6 represented role transition. No "A"-recommended tool examined postpartum incontinence or pain with intercourse. Of note, 3 tools did not cover domains as recommended by the International Consortium for Health Outcomes Measurement, and 5 tools were awarded a "B" rating, requiring more research before their recommendation for use. Here, most tools were awarded very low-moderate Recommendations, Assessment, Development, and Evaluations level of evidence. Moreover, the highest quality tool identified that covered multiple domains of postpartum health and well-being was the women's Postpartum Quality-of-Life Questionnaire.

CONCLUSION

This systematic review identified the best performing patient-reported outcome measures to assess postpartum health and well-being. No individual tool covers all 6 domains of postpartum health and well-being. Here, the highest quality tool found that covered multiple domains of postpartum health and well-being was the Postpartum Quality-of-Life Questionnaire. The Postpartum Quality-of-Life Questionnaire captures 4 of 6 domains of importance to women, with domains of incontinence and sexual health unevaluated. The domain of urinary incontinence was represented by the International Consultation on Incontinence Questionnaire Short Form, which requires further psychometric analysis before its recommended use. Postpartum sexual health, not represented by any tool, necessitates the development of a patient-reported outcome measure. A postpartum patient-reported outcome measure would be best provided by a combination of tools; however, further research is required before its implementation.

Quality of Life instruments and their psychometric properties for use in parents during pregnancy and the postpartum period: a systematic scoping review

Purpose

To identify instruments used to measure parents’ Quality of Life (QoL) during pregnancy and the postpartum period, and to describe their characteristics and psychometric properties.

Methods

For this scoping review we conducted systematic literature searches in MEDLINE, EMBASE, PsychINFO, CINAHL and HaPI in mid-December 2020, to identify studies evaluating psychometric properties. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) were used to define and categorize psychometric properties. Two reviewers screened the studies independently, and customized screening questions were used to assess eligibility against inclusion criteria. Data were systematically extracted into a predesigned data charting matrix, and descriptively analyzed.

Results

The searches identified 5671 studies, of which 53 studies met the inclusion criteria. In total, there were 19 QoL instruments: 12 generic and seven period specific. The most reported instruments were SF-36, SF-12 and WHOQOL-BREF, and the most evaluated instruments were SF-12, WHOQOL-BREF, QOL-GRAV, and PQOL. We found that none of the identified instruments had been evaluated for all nine psychometric properties recommended by the COSMIN. The most reported psychometric properties were internal consistency and structural validity. The instruments were primarily assessed in parents residing in Asia (50%), and 83% of the studies were conducted from 2010 to 2020. Only three studies included psychometric measures assessed on fathers.

Conclusion

Our review shows there is extensive evidence on the internal consistency and structural validity of QoL instruments used on parents during pregnancy and the postpartum period, but that the evidence on other psychometric properties is sparse. Validation studies and primary studies are needed to provide evidence on the reliability, validity, responsiveness, and interpretability of QoL instruments for this target group, in particular for fathers and partners.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-022-02011-y.

Impact of maternal morbidities on the longitudinal health-related quality of life trajectories among women who gave childbirth in four hospitals of Northwest Ethiopia: a group-based trajectory modelling study

OBJECTIVES

To identify distinct trajectories of health-related quality of life and its predictors among postpartum women in Northwest Ethiopia.

DESIGN

Health facility-linked community-based prospective follow-up study.

SETTING

South Gondar zone, Northwest Ethiopia.

PARTICIPANTS

We recruited 775 mothers (252 exposed and 523 non-exposed) after childbirth and before discharge. Exposed and non-exposed mothers were identified based on the criteria published by the WHO Maternal Morbidity Working Group.

OUTCOME MEASURES

The primary outcome measure of this study was trajectories of health-related quality of life. The Stata Traj package was used to determine the trajectories using a group-based trajectory modelling. Multinomial logistic regression model was used to identify predictors of trajectory membership.

RESULTS

Four distinct trajectories for physical and psychological and five trajectories for the social relationships and environmental health-related quality of life were identified. Direct and indirect maternal morbidities, lower educational status, poor social support, being government employed and merchant/student in occupation, vaginal delivery, lower monthly expenditure, stress, fear of childbirth and anxiety were found to be predictors of lower health-related quality of life trajectory group membership.

CONCLUSIONS

Health professionals should target maternal morbidities and mental health problems when developing health intervention strategies to improve maternal health-related quality of life in the postpartum period. Developing encouraging strategies for social support and providing health education or counselling for women with less or no education are essential to avert the decrease in health-related quality of life trajectories of postpartum women.

The effect of mode of delivery on health-related quality-of-life in mothers: a systematic review and meta-analysis

BACKGROUND

Previous research is inconclusive on the effects of mode of delivery on maternal health-related quality-of-life (HRQoL). We conducted a systematic review and meta-analysis to assess the current evidence for associations between mode of delivery and postpartum health-related quality-of-life.

METHODS

Electronic databases MEDLINE ALL (OVID), Web of Science, The Cochrane Library, CINAHL and EMBASE (OVID) were searched for English written articles investigating the relationship between mode of delivery and quality-of-life published form inception to 15th October 2020. Two reviewers independently screened titles and abstracts, assessed full texts, and extracted data. Meta-analysis was conducted where possible.

RESULTS

Twenty-one studies, including 19,879 women, met the inclusion criteria. A meta-analysis of 18 studies found HRQoL scores were significantly higher for women after vaginal delivery in comparison to caesarean (emergency and elective combined) (Effect Size (ES) 0.17, 95% CI 0.01-0.25, n = 7665) with highest scores after assisted vaginal delivery (ES 0.21, 95% CI 0.13-0.30, n = 2547). Physical functioning (ES 11.18, 95% CI = 2.29-20.06, n = 1746), physical role (ES 13.10, 95% CI = 1.16-25.05, n = 1471), vitality (ES 6.31, 95% CI = 1.14-10.29, n = 1746) and social functioning (ES 5.69, 95% CI = 1.26-10.11, n = 1746) were significantly higher after vaginal delivery compared to caesarean.

CONCLUSIONS

Health-related quality-of-life scores were higher for women after vaginal delivery in comparison to caesarean section. Consequently, women should be encouraged to deliver vaginally where possible. The findings of this research should be available to the relevant population to help support informed choice.

Use of Patient-Reported Outcome Measures to Assess Outpatient Postpartum Recovery: A Systematic Review

IMPORTANCE

Outpatient postpartum recovery is an underexplored area of obstetrics. There is currently no consensus regarding which patient-reported outcome measure (PROM) clinicians and researchers should use to evaluate postpartum recovery.

OBJECTIVE

To evaluate PROMs of outpatient postpartum recovery using Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines.

EVIDENCE REVIEW

An initial literature search performed in July 2019 identified postpartum recovery PROMs and validation studies. A secondary search in July 2020 identified additional validation studies. Both searches were performed using 4 databases (Web of Science, Embase, PubMed, and CINAHL), with no date limiters. Studies with PROMs evaluating more than 3 proposed outpatient postpartum recovery domains were considered. Studies were included if they assessed any psychometric measurement property of the included PROMs in the outpatient postpartum setting. The PROMs were assessed for the following 8 psychometric measurement properties, as defined by COSMIN: content validity, structural validity, internal consistency, cross-cultural validity and measurement invariance, reliability, measurement error, hypothesis testing, and responsiveness. Psychometric measurement properties were evaluated in each included study using the COSMIN criteria by assessing (1) the quality of the methods (very good, adequate, doubtful, inadequate, or not assessed); (2) overall rating of results (sufficient, insufficient, inconsistent, or indeterminate); (3) level of evidence assessed using the Grading of Recommendations, Assessment, Development and Evaluations assessment tool; and (4) level of recommendation, which included class A (recommended for use; showed adequate content validity with at least low-quality evidence for sufficient internal consistency), class B (not class A or class C), or class C (not recommended).

FINDINGS

In total, 15 PROMs (7 obstetric specific and 8 non-obstetric specific) were identified, evaluating outpatient postpartum recovery in 46 studies involving 19 165 women. The majority of psychometric measurement properties of the included PROMs were graded as having very-low-level or low-level evidence. The best-performing PROMs that received class A recommendations were the Maternal Concerns Questionnaire, the Postpartum Quality of Life tool, and the World Health Organization Quality of Life-BREF. The remainder of the evaluated PROMs had insufficient evidence to make recommendations regarding their use (and received class B recommendations).

CONCLUSIONS AND RELEVANCE

This review found that the best-performing PROMs currently available to evaluate outpatient postpartum recovery were the Maternal Concerns Questionnaire, the Postpartum Quality of Life tool, and the World Health Organization Quality of Life-BREF; however, these tools all had significant limitations. This study highlights the need to focus future efforts on robustly developing and validating a new PROM that may comprehensively evaluate outpatient postpartum recovery.

Measuring perinatal and postpartum quality of life of women and associated factors in semi-urban Bangladesh

PURPOSE

The objective of this study was to measure the health-related quality of life (HRQoL) among pregnant women in the perinatal and postpartum periods and determine influencing factors that predict their HRQoL.

METHODS

The study was conducted among pregnant women who live in a semi-urban area of Chandpur, Bangladesh. A total of 465 women were recruited. The EuroQoL 5-Dimension 3-Level (EQ-5D-3L) and EuroQoL visual analog scale (EQ-VAS) instruments were used to measure the HRQoL of participants. Two-sample mean test (t test) was performed to examine the changes in HRQoL between the perinatal and postnatal periods of the same individuals. Multivariate linear regression was employed to identify the factors influencing HRQoL during the two periods.

RESULTS

Overall, the HRQoL scores improved significantly from the perinatal (0.49) to postpartum (0.86) period. Approximately 58% of women experienced moderate or extreme levels of health problems during the perinatal period regardless of their health status. However, most women had significantly improved health status in the postpartum period. Gestational weight gain and recommended postnatal care were significantly associated with improved HRQoL. Factors that negatively influenced changes in HRQoL included adolescent motherhood, caesarean delivery, inadequate antenatal care consultations and living in a poor household, during both the perinatal and postpartum periods.

CONCLUSIONS

Overall health status is found to be poor among women during the perinatal period compared with the postpartum period. The study indicates that interventions to address the influencing factors are needed to ensure better quality of life for women both pre- and post-birth. Community-based initiatives, such as awareness building, might address negative factors and subsequently improve health status and reduce adverse health outcomes related to pregnancy and postnatal care.

Quality of Life of Women after Giving Birth: Associated Factors Related with the Birth Process

The World Health Organization (WHO) considers quality of life a fundamental indicator. The effect of birth on women’s long-term quality of life (QoL) has barely been studied. The purpose of this study was to determine the factors related with the pregnancy, delivery and puerperium, and assess women’s QoL after giving birth. A cross-sectional study with Spanish puerperal women was carried out; it collected data on socio-demographic variables, obstetric variables, newborn data, and several quality of life parameters. An ad hoc online questionnaire, including SF-36 (validated instrument to measure QoL), was used. Crude mean differences (MD) and adjusted mean differences (aMD) were estimated by multiple linear regression. A total of 2990 women participated whose overall QoL lowered with time until three years postpartum (p = 0.045). Caesarean section (aMD = −3.61, 95% confidence interval (CI): −5.07, −2.15), mother admitted to ICU (aMD = −4.81, 95% CI: −9.56, −2.68), newborn hospitalized (aMD = −2.10, 95% CI: −4.31, −0.13) or third/fourth degree perineal tears (aMD = −6.87 95%CI: −9.93, −3.82) were detected as risk factors that affect negatively and significantly on postpartum QoL scores. Women’s postpartum QoL worsens with time. Some determining factors negatively influence postpartum QoL: Caesarean section, a mother´s admission to an intensive care unit (ICU) or a premature newborn.

Pain in the immediate puerperium: nursing care contribution

OBJECTIVE

to analyze the contribution of clinical nursing care to the mother who has recently given birth with immediate postpartum pain based on the Kolcaba's Theory of Comfort.

METHOD

qualitative study by the research-care method. Three nurses, who provided care for women in the immediate puerperium as caregiver-researchers and 30 postpartum women, were admitted to a public maternity hospital. A semi-structured interview was used for data collection, from which the thematic analysis of the content was carried out.

RESULTS

nursing care with influences from the biomedical model was observed, but it expresses concern when being cared for. It offers administration of medications, guidelines and non-pharmacological measures for pain relief.

FINAL CONSIDERATIONS

nursing care based on the Theory of Comfort contributed to pain relief in the immediate puerperium.

Mode of Delivery and Long-Term Health-Related Quality-of-Life Outcomes: A Prospective Population-Based Study

BACKGROUND

Relatively little is known about the effects of mode of delivery on long-term health-related quality-of-life outcomes. Furthermore, no previous study has expressed these outcomes in preference-based (utility) metrics.

METHODS

The study population comprised 2,161 mothers recruited from a prospective population-based study in the East Midlands of England encompassing live births and stillbirths between 32⁺⁰ and 36⁺⁶ weeks' gestation and a sample of term-born controls. Perinatal data were extracted from the mothers' maternity records. Health-related quality-of-life outcomes were assessed at 12 months postpartum, using the EuroQol Five Dimensions (EQ-5D) measure with responses to the EQ-5D descriptive system converted into health utility scores. Descriptive statistics and multivariable analyses were used to estimate the relationship between the mode of delivery and health-related quality-of-life outcomes.

RESULTS

The overall health-related quality-of-life profile of the women in the study cohort mirrored that of the English adult population as revealed by national health surveys. A significantly higher proportion of women delivering by cesarean delivery reported some, moderate, severe, or extreme pain or discomfort at 12 months postpartum than women undergoing spontaneous vaginal delivery. Multivariable analyses, using the Ordinary Least Squares estimator revealed that, after controlling for maternal sociodemographic characteristics, cesarean delivery without maternal or fetal compromise was associated with a significant EQ-5D utility decrement in comparison to spontaneous vaginal delivery among all women (-0.026; p = 0.038) and among mothers of term-born infants (-0.062; p < 0.001). Among mothers of term-born infants, this result was replicated in models that controlled for all maternal and infant characteristics (utility decrement of -0.061; p < 0.001). The results were confirmed by sensitivity analyses that varied the categorization of the main exposure variable (mode of delivery) and the econometric strategy.

CONCLUSIONS

Among mothers of term-born infants, cesarean delivery without maternal or fetal compromise is associated with poorer long-term health-related quality of life in comparison to spontaneous vaginal delivery. Further longitudinal studies are needed to understand the magnitude, trajectory, and underpinning mechanisms of health-related quality-of-life outcomes following different modes of delivery.

Postpartum related morbidities among women visiting government health facilities in Udupi Taluk, Karnataka, India

Background:

Maternal morbidities are considered a leading contributor to the burden of disease among women. Especially, if postpartum morbidities are left untreated, this can cause a negative impact on the quality of life. The study was conducted to determine the proportion and types of postpartum morbidities among women visiting government health facilities in Udupi Taluk, Karnataka and to find out the association between the morbidities and various factors.

Subjects and Methods:

A cross-sectional study was conducted in various government hospitals in Udupi Taluk, consisted of 229 postpartum women. These subjects were selected from mothers who accompanied their children for immunization from February 2013 to July 2013 using purposive sampling technique. Multiple logistic regression analysis was used to find out the association between the morbidities and various factors using SPSS version 15.

Results:

Among 112 (48.9%) women who experienced postpartum morbidities, back pain (23.6%), and perineal pain (15.7%) were most commonly reported physical morbidities. Similarly, anxiety (10%) and irritability (7.9%) were the most common psychological problems. Demographic factors such as religion 2.4 (95% confidence interval [CI] 1.1, 5.4) and occupation 2.5 (95% CI 1.1, 5.9) were associated with the morbidities. Likewise, obstetric factors such as place of delivery 1.5 (95% CI 0.8, 2.9) and type of delivery 1.9 (95% CI 1.0, 3.6) were also associated with various morbidities.

Conclusions:

The findings showed a high proportion of postpartum morbidities being reported in our study settings. These observation priorities a need of health program for early recognition, treatment and improving awareness of postpartum morbidities among near mothers.

Depressive symptoms, pain, and sexual dysfunction over the first year following vaginal or cesarean delivery: A prospective longitudinal study

BACKGROUND

Childbirth has a significant impact on maternal health, and the high rate of cesarean delivery is a global health concern. Few studies have used validated measures to explore depression, pain, and sexual dysfunction following vaginal or cesarean delivery over a prolonged time period.

OBJECTIVE

We examined the associations between vaginal and cesarean delivery and depressive symptoms, pain, and sexual function during the 1-year postpartum period.

DESIGN

A prospective, five-time-point longitudinal study.

SETTING

Maternity unit at a medical center.

PARTICIPANTS

A total of 351 of 736 women completed a questionnaire that described demographic characteristics, depressive symptoms, and pain levels at 3-5 days postpartum, and updated personal data, depressive symptoms, pain levels, and sexual function at 4-6 weeks and at 3, 6, and 12 months after delivery.

METHODS

Differences between the vaginal and cesarean groups in depressive symptoms, pain, and sexual function and trends of changes in these factors over the first postpartum year were examined.

RESULTS

Compared with the vaginal birth group, the cesarean birth group had a significantly higher prevalence of depressive symptoms at 3 months (p=0.03); higher scores for non-localized pain at 3-5 days (p<0.001), 4-6 weeks (p=0.03), and 3 months (p=0.046); higher scores for abdominal pain at 3-5 days (p<0.001), 4-6 weeks (p<0.001), and 6 months (p=0.01); lower perineal pain scores at 3-5 days (p <0.001); and higher sexual desire scores (p=0.04) but lower sexual satisfaction scores (p=0.02) at 4-6 weeks. Differences between the vaginal and cesarean groups were significant (p=0.01, p=0.049, respectively) in terms of the decrease in non-localized pain from 3-5 days to 4-6 weeks postpartum and the increase in sexual desire from 4-6 weeks to 3 months postpartum.

CONCLUSIONS

Cesarean delivery was associated with an increased prevalence of depressive symptoms at 3 months and higher pain levels that persisted at 6 months postpartum in Taiwan. We found no difference in sexual function between vaginal and cesarean delivery after 6 weeks postpartum, and no differences in the trends related to depressive symptoms or in sexual functioning (except for desire) within 1 year postpartum.

Health status and quality of life in postpartum women: a systematic review of associated factors

Since health care is becoming more and more patient centered, patient-reported outcomes such as quality of life (QOL) and health status (HS) are becoming increasingly important. The aim of this systematic review was to provide an overview of physical, psychological, and social domains of QOL and HS in postpartum women, and to assess which factors are associated with QOL and HS domains postpartum. A computerized literature search was performed using the PubMed, PsycINFO, and Cochrane databases. Studies were selected if the three domains of QOL or HS were measured in a (sub)group of postpartum women, by using validated standardized questionnaires. The methodological quality of the 66 included studies was examined by two independent reviewers. All three domains of QOL were impaired in postpartum women with urinary incontinence, with even worse QOL in women with mixed urinary incontinence. Mental QOL was impaired in women with urge urinary incontinence after cesarean section. Social QOL was decreased in HIV-positive women. HS was impaired in all three domains in postpartum depressed women. Physical HS was impaired after cesarean section for at least two months postpartum. Additional supportive interventions from health care social support were not associated with improved HS. Urinary incontinence and being HIV-positive seemed to be associated with impaired QOL. Postpartum depression and a cesarean section seemed to be associated with impaired HS. Prospective longitudinal research is needed in order to draw valid conclusions regarding postpartum HS and QOL, and the predictive value of the associated factors.

Cultural differences in postnatal quality of life among German-speaking women - a prospective survey in two countries

BACKGROUND

Assessment of quality of life after childbirth is an important health-outcome measurement for new mothers and is of special interest in midwifery. The Mother-Generated Index (MGI) is a validated instrument to assess postnatal quality of life. The tool has not been applied for making a cross-cultural comparison before. This study investigated (a) responses to the MGI in German-speaking women in Germany and Switzerland; and (b) associations between MGI scores on the one hand and maternity and midwifery care on the other.

METHODS

A two-stage survey was conducted in two rural hospitals 10 km apart, on opposite sides of the German-Swiss border. The questionnaires included the MGI and questions on socio-demographics, physical and mental health and maternity care, and were distributed during the first days after birth and six weeks postpartum. Parametric and non-parametric tests were computed with the statistical programme SPSS.

RESULTS

A total of 129 questionnaires were returned an average of three days after birth and 83 in the follow-up after seven weeks. There were no statistically significant differences in the MGI scores between the German and the Swiss women (p = 0.22). Significantly more favourable MGI scores were found associated with more adequate information during pregnancy (p = 0.02), a more satisfactory birth experience (p < .01), epidural anaesthesia (p < 0.01), more information (p = 0.01) and better support (p = 0.02) during the time in hospital and less disturbed sleep (p < 0.01). Significantly lower MGI scores were associated with the presence of a private doctor during birth (p = 0.01) and with exclusive breastfeeding during the first postnatal days (p = 0.04).

CONCLUSION

The MGI scores of these German-speaking women were higher than those in other studies reported previously. Thus the tool may be able to detect differences in postnatal quality of life among women with substantially divergent cultural backgrounds. Shortcomings in maternity and midwifery care were detected, as for example the inadequate provision of information during pregnancy, a lack of individualised postpartum care during the hospital stay and insufficient support for exclusively breastfeeding mothers. The MGI is an appropriate instrument for maternity care outcome measurement in cross-cultural comparison research.