Evaluation of patient‐reported outcome measures of functional recovery following caesarean section: a systematic review using the consensus‐based standards for the selection of health measurement instruments (COSMIN) checklist

Quality of Recovery After Unplanned and Planned Cesarean Deliveries: A Prospective Observational Study Using the Obstetric Quality of Recovery-10 Tool

BACKGROUND

There is a paucity of literature examining the differences between patient-reported outcome measures after planned and unplanned cesarean delivery using a validated quality of recovery tool. The Obstetric Quality of Recovery-10 (ObsQoR-10) scoring tool has been validated to quantify functional recovery after cesarean delivery. We aimed to use the ObsQoR-10 to compare the postoperative recovery characteristics of patients undergoing planned and unplanned cesarean deliveries.

METHODS

We conducted a prospective single-center observational study. Patients undergoing planned and unplanned cesarean deliveries under neuraxial anesthesia were asked to complete the ObsQoR-10 questionnaire 24 hours, 48 hours, and 1 week postpartum. We collected information on total in-hospital postoperative opioid consumption and patients´ perception of readiness for discharge at 24 and 48 hours postpartum. Additionally, patient characteristics were collected to assess their correlation with our findings.

RESULTS

We included 112 patients (56 in each group). No statistical differences in ObsQoR-10 scores at 24 hours, 48 hours, and 1 week postpartum were observed between the planned and unplanned cesarean deliveries. Additionally, there was no difference between the groups in patients' perception of readiness for hospital discharge at 24 and 48 hours and opioid consumption in the first 2 days after surgery. Most patients in both groups did not think they would be ready for discharge at 24 hours postpartum. Analysis of the individual components of ObsQoR-10 at 24 hours showed a difference in the responses assessing the severity of shivering (higher in unplanned cesarean deliveries) and the ability to look after personal hygiene (lower in unplanned cesarean deliveries).

CONCLUSIONS

As assessed by the ObsQoR-10, no significant difference in the quality of recovery was observed between patients undergoing planned and unplanned cesarean delivery.

Association of inpatient postpartum recovery with patient-reported outcome measures following hospital discharge: a prospective cohort study

BACKGROUND

The relationship between the quality of inpatient versus outpatient obstetric postpartum recovery is under-explored. We examined the association between inpatient reported quality of recovery with outpatient global recovery, pain severity, pain interference, anxiety, and depression screening scores postpartum.

METHODS

We conducted a multicenter observational cohort study of women in labor who underwent vaginal, operative vaginal, or intrapartum cesarean birth. Subjects completed baseline assessments of pain, social support, anxiety, and depression in early labor. We assessed the Obstetric Quality of Recovery-10 (ObsQoR-10) on the day of discharge and the ObsQoR-10, Global Health Scale (GHVAS; 0-100), Brief Pain Inventory (BPI), and the Edinburgh Postnatal Depression Scale (EPDS) on postpartum day seven. We hypothesized that the ObsQoR-10 scores at discharge would be useful in predicting postpartum day seven measures of recovery and postpartum depression screening scores.

RESULTS

We consented 558 subjects, 551/558(98%) completed baseline assessments, 400/551(72%) completed the ObsQoR-10 tool, and 344/551(62%) completed an EPDS assessment. Median (1st, 3rd quartile) ObsQoR-10 scores were 78 (63, 90) at discharge and 85 (68,93) on postpartum day seven, (difference of 7 [99% CI 2 to 13], P < 0.001). GHVAS on postpartum day seven identified 204/344 (59%) of subjects with good recovery. An ObsQoR-10 score of > 86 at discharge had a RR of 1.5 [95% CI 1.2 to 1.8], P < 0.001 for good recovery at postpartum day seven, the EPDS identified 20/344 (5.8%) respondents with a score ≥ 13 on postpartum day seven. The area under the curve between the ObsQoR-10 at discharge with an EPDS ≥ 13 was 0.74 (99% CI 0.61 to 0.86, P < 0.001). The RR for an EPDS ≥ 13 on postpartum day seven with an ObsQoR-10 < 77 on the day of discharge was 7.8 (95% CI 1.8 to 33.8; P = 0.001).

CONCLUSIONS

ObsQoR-10 scores at discharge and postpartum day seven demonstrated increased obstetric recovery in the post-discharge period. The observed association between the ObsQoR-10 and the EPDS, suggests that the ObsQoR-10 might facilitate identification of women at increased risk of postpartum anxiety or depression. Identification of high-risk women at discharge may allow early interventions to reduce morbidity secondary to postpartum depression.

The correlation between quality of recovery and parturient outcomes after Cesarean delivery: a cohort study

PURPOSE

Recent studies have reported the use of the obstetric-specific quality of recovery tool (ObsQoR-10) to assess the quality of recovery in parturients after childbirth; however, the correlation between ObsQoR-10 scores and important postpartum outcomes are unclear. The primary aim of the present study was to investigate the correlations between ObsQoR-10 scores at 24 hr after Cesarean delivery and breastfeeding, depressive symptomatology, overall health, and pain at seven days postpartum.

METHODS

We recruited parturients who underwent elective Cesarean delivery at KK Hospital in Singapore. Parturients provided responses to post-Cesarean questionnaires at 1) 24 hr (ObsQoR-10, EuroQol EQ-Visual Analogue Scale, Edinburgh Postnatal Depression Scale), 2) 48 hr (ObsQoR-10, EQ-Visual Analogue Scale), and 3) seven days after Cesarean delivery (ObsQoR-10, Breastfeeding Self-Efficacy Scale-Short form, EQ-Visual Analogue Scale, Edinburgh Postnatal Depression Scale, pain survey).

RESULTS

We enrolled 222 participants, 200 (90%) of whom completed the seven-day follow-up between September 2022 and April 2023. There was limited correlation between ObsQoR-10 at 24 hr with the Edinburgh Postnatal Depression Scale (r = 0.135), EQ-Visual Analogue Scale (r = 0.158), Breastfeeding Self-Efficacy Scale-Short form (r = 0.225), and averaged pain scores (r = -0.107) at seven days postpartum. ObsQoR-10 breastfeeding sub-score at 24 hr was weakly correlated with Breastfeeding Self-Efficacy Scale-Short form at seven days postpartum (r = 0.307).

CONCLUSION

ObsQoR-10 at 24 hr postpartum had limited correlation with breastfeeding, depressive symptomatology, overall health, and pain at seven days.

STUDY REGISTRATION

ClinicalTrials.gov ( NCT04989894 ); first submitted 4 July 2021.

Patient reported outcome measures in childbirth and postpartum maternal quality of life: a protocol for systematic review of measurement properties

Background

Patient centred healthcare is the corner stone to many healthcare strategies. Patient specific health needs should be at the fore of healthcare improvements and quality measurements. Patient reported outcome measures (PROM) that support real world clinical effectiveness assessments are increasingly being used to highlight domains where there is the greatest scope for change.

Objectives

This systematic review aims to identify and evaluate existing patient reported assessment measures/tool(s) that can be used in developing a PROM for postpartum women. We will assess and evaluate their measurement properties in a transparent and structured way in accordance with the COSMIN guidelines.

Methods

Methodological guidelines for systematic reviews of PROMs have been developed by the COSMIN initiative and will be followed for this systematic review. A systematic literature review will be performed using PubMed, CINAHL and EMBASE from inception to the present day. Two reviewers independently will judge eligibility, conduct data extraction and assess the methodological quality of each study as per COSMIN guidelines. Inclusion criteria: studies should concern PROM with an aim to evaluate measurement properties in the development or the evaluation of a PROM of interest. Included PROM will focus upon postpartum women assessing morbidity and quality of care. All peer reviewed studies with an assessment tool designed for patient completion will be considered. Exclusion criteria; abstract, letters and non-peer reviewed publications. Studies will be graded on measurement properties and quality of evidence as laid out by COSMIN. All studies and characteristics eligible for inclusion will be summarised and a recommendation to the most suitable measurement tool(s) will be given.

Discussion

We will provide a comprehensive description of all available patient reported assessment tools available for childbirth and postpartum quality of life and recommend based on COSMIN guidelines the most suitable instrument(s) available for use.

Development and validation of a Spanish version of the Obstetric Quality of Recovery-10 item score (ObsQoR-10-Spanish)

Background

Spanish is the second most spoken language globally with around 475 million native speakers. We aimed to validate a Spanish version of the Obstetric Quality of Recovery-10 item (ObsQoR-10) patient-reported outcome measure.

Methods

ObsQoR-10-Spanish was developed using EuroQoL methodology. ObsQoR-10-Spanish was assessed in 100 Spanish-speaking patients undergoing elective Caesarean or vaginal delivery. Patients <38 weeks, undergoing an intrapartum Caesarean delivery, intrauterine death, or maternal admission to the intensive care unit (ICU) were excluded. Validity was assessed by evaluating (i) convergent validity-correlation with 24-h EuroQoL and global health visual analogue scale (GHVAS) scores (0-100); (ii) discriminant validity-difference in ObsQoR-10-Spanish score for patients with GHVAS scores >70 vs <70; (iii) hypothesis testing-correlation of ObsQoR score with maternal and neonatal factors; and (iv) cross-cultural validity assessed using differential item functioning analysis. Reliability was assessed by evaluating: (i) internal consistency; (ii) split-half reliability and (iii) test-retest reliability; and (iv) floor and ceiling effects.

Results

One hundred patients were approached, recruited, and completed surveys. Validity: (i) convergent validity: the ObsQoR 24-h score correlated moderately with the 24-h EuroQoL (r=-0.632) and GHVAS scores (r=0.590); (ii) discriminant validity: the ObsQoR-10-Spanish 24-h scores were higher in women who delivered vaginally compared to via Caesarean delivery, (mean [standard deviation] scores were 89 [9] vs 81 [12]; P<0.001). The 24-h ObsQoR-Spanish scores were lower in patients experiencing a poor vs a good recovery (mean [standard deviation] scores were 76 [12.3] vs 87.1 [10.6]; P=0.001); (iii) hypothesis testing: the ObsQoR-10 score correlated negatively with age (r=-0.207) and positively with 5-min (r=0.204) and 10-min (r=0.243) Apgar scores. Remaining correlations were not significant; and (iv) differential item functioning analysis suggested no potential bias among the 10 items. Reliability: (i) internal consistency was good (Cronbach alpha=0.763); (ii) split-half reliability was good (Spearman-Brown prophesy reliability estimate of 0.866); (iii) test-retest reliability was excellent with an intra-class correlation coefficient of 0.90; and (iv) floor and ceiling effects: six patients scored a maximum total ObsQoR-10 score.

Conclusions

The ObsQoR-10-Spanish patient-reported outcome measure is valid, reliable, and clinically feasible, and should be considered for use in Spanish-speaking women to assess quality of inpatient postpartum recovery.

A narrative review of the literature relevant to obstetric anesthesiologists: the 2023 Gerard W. Ostheimer lecture

This narrative review of the 2023 Gerard W. Ostheimer lecture presented at the Society for Obstetric Anesthesia and Perinatology 2023 annual meeting summarizes 2022 literature relevant to obstetric anesthesiologists.

ANTENATAL STUDIES

Neonatal morbidity is reduced with antenatal maternal buprenorphine compared with methadone for treatment of opioid use disorder. Antenatal pregnancy allergy testing is safe and feasible.

ANALGESIA AND ANESTHESIA STUDIES

Intrathecal (IT) 3% chloroprocaine for cervical cerclage results in faster sensory block resolution and discharge readiness compared with bupivacaine. The ED90 of 3% chloroprocaine (with IT fentanyl 10 µg) is 49.5 mg. Dural puncture epidural technique does not improve the quality of labor analgesia in obese parturients compared with epidural analgesia. Low- (>0.08 to ≤0.1%) and ultra-low (<0.08%) concentrations of bupivacaine for epidural analgesia maintenance result in similar maternal and neonatal outcomes. Lower doses of first line uterotonic agents are non-inferior to higher doses (oxytocin 0.5 IU vs. 5 IU and carbetocin 20 vs. 100 µg) in patients at low risk for postpartum hemorrhage. Supplemental analgesia or conversion to general anesthesia is necessary in approximately 15% of elective cesarean deliveries. Intravenous dexamethasone improves analgesia outcomes, however optimal dosing and timing remain unclear; it may induce neonatal hypoglycemia in the setting of gestational diabetes.

POSTPARTUM STUDIES

A core outcome set may help evaluate enhanced recovery protocol implementation. History of migraine and accidental dural puncture (ADP) above the L3 level are associated with epidural blood patch (EBP) failure and ADP at or below L3 and >48 h interval between ADP and EBP are associated with success.

Clinical and exercise professional opinion on designing a postpartum return-to-running training programme: an international Delphi study and consensus statement

Returning to running postpartum presents challenges such as musculoskeletal pain and pelvic floor dysfunction for some females, but there is little guidance on developing and progressing postpartum training programmes. This study aims to establish expert consensus recommendations on designing and modifying a postpartum return-to-running training programme, highlight costs and access to qualified professionals as potential barriers and discuss clinical, research and sports policy implications.A three-round Delphi survey of clinical and exercise professionals working with postpartum runners was conducted. Round I consisted of open-ended questions related to designing the training plan, modifications based on biopsychosocial factors, key muscle groups to train and referral and payment sources. Rounds II and III involved Likert-scale voting to identify consensus (≥75% agreement).118 participants completed Round I, 107 completed Round II (response rate 90.6%) and 95 completed Round III (response rate 80.5%). Consensus was reached in 42/47 (89%) statements, including recommendations for a period of relative rest, gradual increases in duration and intensity, starting with a walk-run protocol and incorporating strength training. Training should be modified based on musculoskeletal or pelvic symptoms, sleep, mental health, lactation or energy availability concerns. Cost and access to experienced postpartum running professionals were identified as potential barriers for runners to receive care.Consensus recommendations for a postpartum return-to-running programme include an individualised exercise prescription, gradual increases in physical activity, walk-run protocols and targeted muscle strengthening. Further research and improved access to clinical and exercise professionals are needed to inform and facilitate best practices.

Outcomes and outcome measures utilised in randomised controlled trials of postoperative caesarean delivery pain: a scoping review

BACKGROUND

Inadequately treated postoperative pain following caesarean delivery can delay recovery and the ability to care for a newborn. Effectiveness studies of interventions to treat postoperative caesarean delivery pain measure different outcomes, limiting data pooling for meta-analysis. We performed a comprehensive review of existing outcomes with the aim of recommending core outcomes for future research.

METHODS

A scoping review to identify all outcomes reported in randomised controlled trials (RCTs) and clinical trial registries of interventions to treat or prevent postoperative caesarean delivery pain, with postoperative pain as a primary outcome measure. We searched PubMed, Web of Science, CINAHL, LILACS, Embase, CDSR and CRCT for studies from May 2016 to 2021. Outcomes were extracted and frequencies tabulated.

RESULTS

Ninety RCTs and 11 trial registries were included. In total, 392 outcomes (375 inpatient and 17 outpatient) were identified and categorised. The most reported outcome domain was analgesia (n = 242/375, 64.5%), reported in 96% of inpatient studies, with analgesic consumption accounting for 108/375, 28.8% of analgesia outcomes. The second most common domain was pain intensity (n = 120/375, 32%), reported in 97% of inpatient studies, using the visual analogue scale (68/120, 59%) and the numerical reporting scale (37/120, 25%). Maternal and neonatal adverse effects accounted for 65/375 (17.3%) and 19/375 (5.1%) of inpatient outcomes, respectively.

CONCLUSIONS

Outcomes reported in RCTs for postoperative caesarean delivery pain vary widely. The results of this review suggest that standardisation is needed to promote research efficiency and aid future meta-analyses to identify optimal postoperative caesarean delivery pain management.

Association of inpatient postpartum quality of recovery with postpartum depression: A prospective observational study

STUDY OBJECTIVE

To explore the relationship between Obstetric Quality of Recovery survey (ObsQoR-10-Heb) and Edinburgh postnatal depression scale (EPDS) measured 6 weeks after delivery, adjusted for potential confounding factors.

DESIGN

Prospective, longitudinal cohort study.

SETTING

Large postpartum department, 13,000 annual deliveries, quaternary medical center in Israel.

PATIENTS

Women ≥18 years old, gestational age ≥ 37 weeks after term delivery (spontaneous vaginal, operative vaginal, planned, and unplanned cesarean delivery), with non-anomalous neonates not requiring special support after delivery or at the time of recruitment. Written informed consent was provided. Women unable to read or understand Hebrew were excluded.

INTERVENTIONS

No interventions were done.

MEASUREMENTS

We investigated the relationship between inpatient postpartum recovery and positive postpartum depression (PPD) screening at 6 weeks postpartum. Enrolled women completed the validated Hebrew version of ObsQoR-10 survey (ObsQoR-10-Heb; scored between 0 and 100 with 0 and 100 representing worst and best possible recovery) from 24 to 48 h after delivery, and the Edinburgh Postnatal Depression Scale (EPDS) at 6- and 12 weeks postpartum. We assessed the univariate association between ObsQoR-10-Heb; patient factors; obstetric factors; and positive PPD screening at 6 weeks postpartum. Potential confounders were adjusted in a multiple logistic regression model.

MAIN RESULTS

Inpatient ObsQoR-10-Heb has been completed by 325 postpartum women; 270 (83.1%) and 253 (77.9%) completed the 6- and 12 weeks EPDS respectively. Lower ObsQoR-10-Heb (aOR 0.95 (95% CI 0.92, 0.98); p = 0.001); depression or anxiety before delivery (aOR 4.53 (95% CI 1.88, 10.90); p = 0.001); and hospital readmission (aOR 9.08 (95% CI 1.23, 67.14); p = 0.031) were associated with positive screening for postpartum depression at 6 weeks.

CONCLUSIONS

Our study demonstrates that worse inpatient postpartum recovery is an independent risk factor for positive PPD screening at 6 weeks postpartum. Other risk factors found in our study were maternal hospital readmission and a previous history of anxiety or depression.

Development, women-centricity and psychometric properties of maternity patient-reported outcome measures (PROMs): A systematic review

BACKGROUND

Measuring maternity care outcomes based on what women value is critical to promoting woman-centred maternity care. Patient-reported outcome measures (PROMs) are instruments that enable service users to assess healthcare service and system performance.

AIM

To identify and critically appraise the risk of bias, woman-centricity (content validity) and psychometric properties of maternity PROMs published in the scientific literature.

METHODS

MEDLINE, CINAHL Plus, PsycINFO and Embase were systematically searched for relevant records between 01/01/2010 and 07/10/2021. Included articles underwent risk of bias, content validity and psychometric properties assessments in line with COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidance. PROM results were summarised according to language subgroups and an overall recommendation for use was determined.

FINDINGS

Forty-four studies reported on the development and psychometric evaluation of 9 maternity PROMs, grouped into 32 language subgroups. Risk of bias assessments for the PROM development and content validity showed inadequate or doubtful methodological quality. Internal consistency reliability, hypothesis testing (for construct validity), structural validity and test-retest reliability varied markedly in sufficiency and evidence quality. No PROMs received a level 'A' recommendation, required for real-world use.

CONCLUSION

Maternity PROMs identified in this systematic review had poor quality evidence for their measurement properties and lacked sufficient content validity, indicating a lack of woman-centricity in instrument development. Future research should prioritise women's voices in deciding what is relevant, comprehensive and comprehensible to measure, as this will impact overall validity and reliability and facilitate real-world use.

A systematic review of patient-reported outcome measures used in maternal postpartum anxiety

OBJECTIVE

This study aimed to conduct a systematic review and to evaluate the psychometric measurement properties of instruments for postpartum anxiety using the Consensus-Based Standards for the Selection of Health Measurement Instruments guidelines to identify the best available patient-reported outcome measure.

DATA SOURCES

We searched 4 databases (CINAHL, Embase, PubMed, and Web of Science in July 2022) and included studies that evaluated at least 1 psychometric measurement property of a patient-reported outcome measurement instrument. The protocol was registered with the International Prospective Register for Systematic Reviews under identifier CRD42021260004 and followed the Consensus-Based Standards for the Selection of Health Measurement Instruments guidelines for systematic reviews.

STUDY ELIGIBILITY

Studies eligible for inclusion were those that assessed the performance of a patient-reported outcome measure for screening for postpartum anxiety. We included studies in which the instruments were subjected to some form of psychometric property assessment in the postpartum maternal population, consisted of at least 2 questions, and were not subscales.

METHODS

This systematic review used the Consensus-Based Standards for the Selection of Health Measurement Instruments and the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to identify the best patient-reported outcome measurement instrument for examining postpartum anxiety. A risk of bias assessment was performed, and a modified GRADE approach was used to assess the level of evidence with recommendations being made for the overall quality of each instrument.

RESULTS

A total of 28 studies evaluating 13 instruments in 10,570 patients were included. Content validity was sufficient in 9 with 5 instruments receiving a class A recommendation (recommended for use). The Postpartum Specific Anxiety Scale, Postpartum Specific Anxiety Scale Research Short Form, Postpartum Specific Anxiety Scale Research Short Form Covid, Postpartum Specific Anxiety Scale-Persian, and the State-Trait Anxiety Inventory demonstrated adequate content validity and sufficient internal consistency. Nine instruments received a recommendation of class B (further research required). No instrument received a class C recommendation (not recommended for use).

CONCLUSION

Five instruments received a class A recommendation, all with limitations, such as not being specific to the postpartum population, not assessing all domains, lacking generalizability, or evaluation of cross-cultural validity. There is currently no freely available instrument that assess all domains of postpartum anxiety. Future studies are needed to determine the optimum current instrument or to develop and validate a more specific measure for maternal postpartum anxiety.

Postpartum recovery of nulliparous women following scheduled cesarean delivery and spontaneous vaginal delivery: a prospective observational study

BACKGROUND

Inpatient postpartum recovery trajectories following cesarean delivery and spontaneous vaginal delivery are underexplored.

OBJECTIVE

This study primarily aimed to compare recovery following cesarean delivery and spontaneous vaginal delivery in the first postpartum week, and secondarily to evaluate psychometrically the Japanese version of the Obstetric Quality of Recovery-10 scoring tool.

STUDY DESIGN

Following institutional review board approval, the EQ-5D-3L (EuroQoL 5-Dimension 3-Level) questionnaire and a Japanese version of the Obstetric Quality of Recovery-10 measure were used to evaluate inpatient postpartum recovery in uncomplicated nulliparous parturients delivering via scheduled cesarean delivery or spontaneous vaginal delivery.

RESULTS

A total of 48 and 50 women who delivered via cesarean delivery and spontaneous vaginal delivery, respectively, were recruited. Women delivering via scheduled cesarean delivery experienced significantly worse quality of recovery on days 1 and 2 compared with those who had spontaneous vaginal delivery. Quality of recovery significantly improved daily, plateauing at days 4 and 3 for cesarean delivery and spontaneous vaginal delivery groups, respectively. Compared with cesarean delivery, spontaneous vaginal delivery was associated with prolonged time to analgesia requirement, decreased opioid consumption, reduced antiemetic requirement, and reduced times to liquid/solid intake, ambulation, and discharge. Obstetric Quality of Recovery-10-Japanese is a valid (correlates with the EQ-5D-3L including a global health visual analog scale, gestational age, blood loss, opioid consumption, time until first analgesic request, liquid/solid intake, ambulation, catheter removal, and discharge), reliable (Cronbach alpha=0.88; Spearman-Brown reliability estimate=0.94; and intraclass correlation coefficient=0.89), and clinically feasible (98% 24-hour response rate) measure.

CONCLUSION

Inpatient postpartum recovery is significantly better in the first 2 postpartum days following spontaneous vaginal delivery compared with scheduled cesarean delivery. Inpatient recovery is largely achieved within 4 and 3 days following scheduled cesarean delivery and spontaneous vaginal delivery, respectively. Obstetric Quality of Recovery-10-Japanese is a valid, reliable, and feasible measure of inpatient postpartum recovery.

Validation of Chinese version of a global anesthetic recovery questionnaire: A multicenter observational trial on ObsQoR-11

BACKGROUND

The obstetric quality of recovery (ObsQoR-11) is considered one of the best patient-reported outcome measures of post-cesarean recovery. However, it has been neither validated in Chinese nor evaluated at >24 h after delivery.

METHODS

Parturients from three hospitals (n = 279) completed the Chinese ObsQoR-11 at 24 h (T1) and 96 h (T2) after elective cesarean delivery. Convergent validity was assessed by correlation of Chinese ObsQoR-11 with a 100-mm numerical rating scale (NRS) of general health status; discriminant validity of good recovery (NRS ≥ 70-mm); and construct validity by correlation with influential factors to post-cesarean recovery. The reliability and responsiveness were also assessed.

RESULTS

The Chinese ObsQoR-11 correlated moderately with the NRS [T1: r = 0.38 (95% confidence interval: 0.28-0.48), p < 0.0001; T2: r = 0.43 (95% confidence interval: 0.32-0.52), p < 0.0001] and discriminated between good and poor recovery [T1: mean (SD) score: 64 (20) vs 49 (17), p < 0.0001; T2: median (IQR) score: 81 (66-94) vs. 61 (53-72); p = 0.0002]; weakly correlated with gestational age, successful breastfeeding, and operation time. It was reliable (internal consistency: 0.75 (T1) and 0.82 (T2); split-half: 0.77 (T1) and 0.85 (T2); test-retest intraclass correlation coefficient r > 0.6 for each item) and responsive (Cohen effect size: 0.88; standardized response mean: 0.81).

CONCLUSION

The Chinese ObsQoR-11may be used for assessing recovery at 24 h and 96 h after cesarean delivery. However, its' cutoff value for good recovery may be lower than that of other versions.

Validation of the Thai version of the obstetric quality of recovery score (obsqor-10-Thai) after elective cesarean delivery

BACKGROUND

The Obstetric Quality of Recovery score (ObsQoR-10) is a questionnaire used to assess recovery after cesarean delivery. However, the original ObsQoR-10 is in English and was mainly validated in the Western population. We therefore evaluated the reliability, validity, and responsiveness of the ObsQoR-10-Thai in patients undergoing elective cesarean delivery.

METHODS

The original ObsQoR-10 was translated into Thai, and psychometric validation was performed to evaluate the quality of post-cesarean recovery. The ObsQoR-10-Thai, activities of daily living checklist, and 100-mm visual analog scale of global health (VAS-GH) questionnaires were administered to the study participants before and 24 and 48-h postpartum. Validity, reliability, responsiveness, and feasibility of the ObsQoR-10-Thai were assessed.

RESULTS

We included 110 patients undergoing elective cesarean delivery. The mean ObsQoR-10-Thai score at baseline and 24 and 48-h postpartum was 83.35 ± 11.15, 56.75 ± 11.6, and 70.96 ± 13.65, respectively. The ObsQoR-10-Thai score differed significantly between the two groups divided based on the VAS-GH (≥ 70 vs. < 70): 75.58 ± 13.81 and 52.56 ± 10.61, respectively (P < 0.001). The convergent validity between the ObsQoR-10-Thai and VAS-GH was good (r = 0.60, P < 0.001). The ObsQoR-10-Thai displayed good internal consistency (Cronbach's alpha = 0.87), split-half reliability (0.92), and test-retest reliability (0.99, 95% CI: 0.98-0.99). The median time to complete the questionnaire was 2 (IQR, 1-6) min.

CONCLUSIONS

Our findings indicate that the ObsQoR-10-Thai is valid and has good reliability, with a high degree of responsiveness in terms of assessment of recovery after elective cesarean delivery.

TRIAL REGISTRATION

This study was registered on the Thai Clinical Trials Registry, identifier TCTR20210204001, registered on 04/02/2021 (Prospectively registration).

Safety of performing classical versus low transverse caesarean sections in extremely preterm and very preterm births: Maternal and neonatal complications

AIMS

Improved survivability of extremely preterm infants has led to increased rates of caesarean sections. Short-term maternal and neonatal risks of classical caesarean sections (CCS) in the context of extreme prematurity remain unclear. The aim was to examine maternal and neonatal complications associated with CCSs versus low transverse caesarean sections (LTCS) at extremely preterm (23 0/7-27 6/7 weeks) and very preterm gestational ages (28 0/7-31 6/7 weeks).

METHODS

A retrospective cohort study was conducted at Royal Brisbane and Womens Hospital, Queensland, Australia between 2016 and 2020. Maternal and neonatal outcomes were examined using univariate and multivariate statistical analysis.

RESULTS

CCSs (extremely preterm: n = 93; very preterm: n = 83) were associated with higher estimated blood loss than LTCS (extremely preterm: n = 70; very preterm: n = 287) in very preterm births (CCS: 638 ± 410 mL; LTCS: 556 ± 397 mL; P = 0.01). There was no significant difference in composite maternal outcomes between CCS and LTCS for extremely preterm (adjusted odds ratio (aOR): 1.11; 95% confidence interval (CI): 0.58-2.12; P = 0.75) or very preterm births (aOR: 1.08; 95% CI: 0.63-1.94; P = 0.79) after accounting for multiple pregnancy, placenta accreta and non-cephalic fetal presentations. Although CCSs were associated with lower Apgar scores at 1 min post-birth than LTCSs at very preterm gestational ages (CCS: 5.58 ± 2.10; LTCS: 6.25 ± 2.14; P = 0.02), there was no statistical difference in the rates of intraoperative neonatal injuries or composite outcomes when corrected for low birth weight.

CONCLUSION

Short-term maternal and neonatal outcomes do not significantly differ between CCS and LTCS for extremely preterm or very preterm births.

Measuring enhanced recovery in obstetrics: a narrative review

Enhanced recovery after cesarean delivery is a protocolized approach to perioperative care, with the aim to optimize maternal recovery after surgery. It is associated with improved maternal and neonatal outcomes, including decreased length of hospital stay, opioid consumption, pain scores, complications, increased maternal satisfaction, and increased breastfeeding success. However, the pace and enthusiasm of adoption of enhanced recovery after cesarean delivery internationally has not yet been matched with high-quality evidence demonstrating its benefit, and current studies provide low- to very low-quality evidence in support of enhanced recovery after cesarean delivery. This article provides a summary of current measures of enhanced recovery after cesarean delivery success, and optimal measures of inpatient and outpatient postpartum recovery. We summarize outcomes from 22 published enhanced recovery after cesarean delivery implementation studies and 2 meta-analyses. A variety of disparate metrics have been used to measure enhanced recovery after cesarean delivery success, including process measures (length of hospital stay, bundle compliance, preoperative fasting time, time to first mobilization, time to urinary catheter removal), maternal outcomes (patient-reported outcome measures, complications, opioid consumption, satisfaction), neonatal outcomes (breastfeeding success, Apgar scores, maternal-neonatal bonding), cost savings, and complication rates (maternal readmission rate, urinary recatheterization rate, neonatal readmission rate). A core outcome set for use in enhanced recovery after cesarean delivery studies has been developed through Delphi consensus, involving stakeholders including obstetricians, anesthesiologists, patients, and a midwife. Fifteen measures covering key aspects of enhanced recovery after cesarean delivery adoption are recommended for use in future enhanced recovery after cesarean delivery implementation studies. The use of these outcome measures could improve the quality of evidence surrounding enhanced recovery after cesarean delivery. Using evidence-based evaluation guidelines developed by the COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) group, the Obstetric Quality of Recovery score (ObsQoR) was identified as the best patient-reported outcome measure for inpatient postpartum recovery. Advances in our understanding of postpartum recovery as a multidimensional and dynamic construct have opened new avenues for the identification of optimum patient-reported outcome measures in this context. The use of standardized measures such as these will facilitate pooling of data in future studies and improve overall levels of evidence surrounding enhanced recovery after cesarean delivery. Larger studies with optimal study designs, using recommended outcomes including patient-reported outcome measures, will reduce variation and improve data quality to help guide future recommendations.

The impact of implementing patient-reported measures in routine maternity care: a systematic review

INTRODUCTION

While there is growing interest in applying patient-reported measures (PRMs) in clinical routine, limited collective evidence of the impact of PRMs hinder their widespread use in specific contexts, such as maternity care. Our objective was to synthesize existing emperical evidence on the impact of implementing PRMs in routine maternity care.

MATERIAL AND METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines (version 2020). We electronically searched six databases for the literature on the implementation of PRMs in maternity care. A multi-level (woman, clinical, organizational, national and societal) analytic framework for analyzing and synthesizing emperically proven impacts of PRMs was developed. Quality was assessed using the Mixed Method Appraisal Tool. The GRADE-CERQual approach was used to assess the confidence in the review findings and arguments. The protocol was registered in PROSPERO (CRD42021234501).

RESULTS

Overall, 4971 articles were screened. The emperical evidence, collected from 11 relevant studies, showed that the use of PRMs in routine maternity care could produce positive effects on clinical process (assessment and detection of health problems, clinical visit preparation, resource use, woman-professional communication, decision-making, woman-professional relationship, and care quality), and health behavior and outcomes (women's health and wellbeing, quality of life, health behavior, experiences and satisfaction with healthcare services), awareness, engagement and self-management of own health, and disclosure of health issues. The confidence in the review findings was low to moderate due to a limited number of studies, inadequate data and methodological limitations of included studies.

CONCLUSIONS

The limited emperical evidence available suggested that the use of PRMs may have positive effects at the individual health level and clinical process level. However, the evidence was not strong enough to provide policy recommendations on the use of PRMs in routine maternity care. This review revealed limitations of currently available research, such as lack of generalizability and narrow scopes in investigating impact. Efforts are needed to improve the quality of research on the use of PRMs in routine maternity care by widening the study population, including different types of PRMs, and considering the effects of PRMs at different levels and domains of healthcare.

Development and validation of a Portuguese version of Obstetric Quality of Recovery-10 (ObsQoR-10-Portuguese)

BACKGROUND

We aimed to develop and validate a Portuguese version of the Obstetric Quality of Recovery-10 (ObsQoR-10-Portuguese) patient-reported outcome measure and evaluate its psychometric properties.

METHODS

After ethical approval, we recruited term pregnant women undergoing uncomplicated elective cesarean delivery in a single Brazilian institution. Women were invited to complete the translated ObsQoR-10-Portuguese and EuroQoL (EQ-5D) questionnaires (including a global health visual analog scale [GHVAS]) at 24 h (±6 h) following delivery, and a subset of women an hour later. We assessed validity and reliability of ObsQoR-10-Portuguese.

RESULTS

One hundred thirteen enrolled women completed the surveys at 24 h and 29 women at 25 h (100% response rate).

VALIDITY

(i) convergent validity: ObsQoR-10-Portuguese correlated moderately with EuroQoL score (r = -0.587) and GHVAS score (r = 0.568) at 24 h. (ii) Discriminant validity: ObsQoR-10 discriminated well between good versus poor recovery (GHVAS score ≥ 70 versus < 70; difference in mean scores 14.2; p < 0.001). (iii) Hypothesis testing: 24-h ObsQoR-10-Portuguese scores correlated with gestational age (r = 0.191; p = 0.043). (iv) Cross-cultural validity: differential item functioning analysis suggested bias in 2 items. Reliability: (i) internal consistency was good (Cronbach's alpha = 0.82 and inter-item correlation = 0.31). (ii) Split-half reliability was very good (Spearman-Brown Prophesy Reliability Estimate = 0.80). (iii) Test re-test reliability was excellent (intra-class correlation coefficient = 0.87). (iv) Floor and ceiling effects: < 5% women scored either 0 or 100 (lowest and highest scores, respectively).

CONCLUSION

ObsQoR-10-Portuguese is valid and reliable, and should be considered for use in Portuguese-speaking women to assess their quality of inpatient recovery following cesarean delivery.

Expert Consensus Regarding Core Outcomes for Enhanced Recovery after Cesarean Delivery Studies: A Delphi study

BACKGROUND

Heterogeneity among reported outcomes from enhanced recovery after cesarean delivery impact studies is high. This study aimed to develop a standardized enhanced recovery core outcome set for use in future enhanced recovery after cesarean delivery studies.

METHODS

An international consensus study involving physicians, patients and a director of Midwifery and Nursing Services, was conducted using a three-round modified Delphi approach (2 rounds of electronic questionnaires and a 3rd round e-discussion), to produce the core outcome set. An initial list of outcomes was based on a previously published systematic review. Consensus was obtained for the final core outcome set, including definitions for key terms, and preferred units of measurement. Strong consensus was defined as ≥70% agreement and weak consensus as 50-69% agreement. Of the 64 stakeholders who were approached, 32 agreed to participate. All 32, 31 and 26 stakeholders completed Rounds 1, 2 and 3, respectively.

RESULTS

The number of outcomes in the final core outcome set was reduced from 98 to 15. Strong consensus (≥70% stakeholder agreement) was achieved for 15 outcomes. The core outcome set included: length of hospital stay; compliance with enhanced recovery protocol; maternal morbidity (hospital re-admissions or unplanned consultations); provision of optimal analgesia (maternal satisfaction, compliance with analgesia, opioid consumption / requirement and incidence of nausea or vomiting); fasting times; breastfeeding success; and times to mobilization and urinary catheter removal. The Obstetric Quality of Recovery-10 item composite measure was also included in the final core outcome set. Areas identified as requiring further research included readiness for discharge and analysis of cost savings.

CONCLUSIONS

Results from an international consensus to develop a core outcome set for enhanced recovery after cesarean delivery are presented. These are outcomes that could be considered when designing future enhanced recovery studies.

Evaluating the development, woman-centricity and psychometric properties of maternity patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs): A systematic review protocol

INTRODUCTION

Woman-centred care is the right of every woman receiving maternity care, irrespective of where care is being received and who is providing care. This protocol describes a planned systematic review that will identify, describe and critically appraise the psychometric properties of maternity patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs). The woman-centricity of PROM and PREM development and content validation (ie, the extent to which women were involved in these processes) will also be assessed. This information will be used to develop a maternity PROMs and PREMs database to support service and system performance measurement, and value-based maternity care initiatives.

METHODS AND ANALYSIS

This study will be guided by the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guideline for systematic reviews of outcome measurement instruments. Studies identified via MEDLINE, CINAHL Plus, PsycINFO and EMBASE describing the development, content validation and/or psychometric evaluation of PROMs and PREMs specifically designed for maternity populations throughout pregnancy, childbirth and postnatal periods will be considered if published from 2010 onward, in English, and available in full text. The COSMIN risk of bias checklist will be used to evaluate the quality of studies reporting on the development, content validation and/or psychometric evaluation of PROMs and PREMs. COSMIN criteria for good content validity will be used to assess the woman-centricity of PROM and PREM development and content validation studies. COSMIN standards of good psychometric properties will be used to evaluate the validity and reliability of the identified instruments.

ETHICS AND DISSEMINATION

Ethical permission for this research is not required. The findings of this research will be submitted for publication in an international, peer-reviewed journal. Abstracts for national and international conference presentations will also be submitted. The proposed maternity PROMs and PREMs database will be freely accessible online, and developed with consumer input to ensure its usefulness to a range of maternity care stakeholders.

PROSPERO REGISTRATION NUMBER

CRD42021288854.

Evaluation of Patient-Reported Outcome Measures of Positive Psychosocial Constructs in Children and Adolescent/Young Adults with Cancer: A Systematic Review of Measurement Properties

Introduction: Children, adolescents, and young adults with cancer are a vulnerable population in whom improvements in psycho-oncology care would be valuable. We previously published a scoping review exploring what is known about positive psychological constructs in this population. A key finding was that evidence-based patient-reported outcome measures (PROMs) were needed to standardize psycho-oncology research. Methods: We undertook a systematic review of measurement properties focused on PROMs in the pediatric and adolescent/young adults (AYAs) with cancer populations. We searched for PROMs that measured at least 1 of 15 previously identified, key positive constructs. This systematic review followed COSMIN guidelines, considered the gold standard manual for systematic reviews of measurement properties. Results: We identified 20 (22 if proxy reports are counted separately) unique PROMs that met inclusion criteria. Of those, only five were recommended for use given the current evidence. The remainder may be used if no alternative exists. Only eight PROMs had any evidence of content validity, considered the most important psychometric property by COSMIN. Many studies were at risk of bias owing to incomplete or suboptimal methods. Discussion: Five PROMs are considered reliable for the pediatric and AYA with cancer populations. A number of PROMs require additional research to ensure their items and instructions are comprehensive, relevant, and comprehensible to children and AYAs. Given the overall lack of research, this review may be considered a starting point for the future refinement of a core set of PROMs to measure positive psychological constructs.

Reliability of hip joint position sense tests using a clinically applicable measurement tool in elderly participants with unilateral hip osteoarthritis

Hip joint proprioception is vital in maintaining posture and stability in elderly individuals. Examining hip joint position sense (JPS) using reliable tools is important in contemporary clinical practice. The objective of this study is to evaluate the intra-rater and inter-rater reliability of hip JPS tests using a clinically applicable measurement tool in elderly individuals with unilateral hip osteoarthritis (OA). Sixty-two individuals (mean age = 67.5 years) diagnosed with unilateral hip OA participated in this study. The JPS tests were evaluated using a digital inclinometer in hip flexion and abduction directions. The absolute difference between target and reproduced angle (repositioning error) in degrees was taken to measure JPS accuracy. The intraclass correlation coefficient (ICC (2.k), was used to assess the reliability. The Intra rater-reliability for hip JPS tests showed very good agreement in the lying position (hip flexion-ICC = 0.88–0.92; standard error of measurement (SEM) = 0.06–0.07, hip abduction-ICC = 0.89–0.91; SEM = 0.06–0.07) and good agreement in the standing position (hip flexion-ICC = 0.69–0.72; SEM = 0.07, hip abduction-ICC = 0.66–0.69; SEM = 0.06–0.08). Likewise, inter-rater reliability for hip JPS tests demonstrated very good agreement in the lying position (hip flexion-ICC = 0.87–0.89; SEM = 0.06–0.07, hip abduction-ICC = 0.87–0.91; SEM = 0.07) and good agreement in the standing position (hip flexion-ICC = 0.64–0.66; SEM = 0.08, hip abduction-ICC = 0.60–0.72; SEM = 0.06–0.09). The results support the use of hip JPS tests in clinical practice and should be incorporated in assessing and managing elderly participants with hip OA.

Validation of translated Obstetric Quality of Recovery (ObsQoR-10A) score after nonelective cesarean delivery (CD) in an Arabic-speaking population

Background:

The ObsQoR-11 is a validated scale that assesses recovery after cesarean delivery (CD). This observational study aimed to evaluate the psychometric properties of its Arabic version.

Methods:

The original ObsQoR-11 was translated into an Arabic version (ObsQoR-10A). All participants completed the ObsQoR-10A at 24 h and 48 h postoperatively after CD. Validity, reliability, responsiveness, and feasibility were assessed.

Results:

The ObsQoR-10A correlated with Global Health Numerical Rating Scale (NRS) at 24 h (R = 0.68, 95% CI: 0.56–0.80, P < 0.001) and at 48 h (R = 0.66, 95% CI: 0.54–0.78, P < 0.001) and differentiated between good and poor recovery (median scores at 24 h 88 vs. 71, P < 0.001; at 48 h 95.5 vs. 70, P < 0.001). ObsQoR-10A correlated with hospital length of stay at 24 h (R = −0.21, 95% CI: −0.40 to −0.02, P = 0.03) and at 48 h (R = −0.21, 95% CI: −0.40 to −0.03, P = 0.02); gestational age at 24 h (R = 0.22, 95% CI: 0.03–0.40, P = 0.02); change in hemoglobin at 24 h (R = −0.30, 95% CI: 0.51 to −0.10, P < 0.01); and total opioids at 48 h (R = −0.45, 95% CI: −0.62 to −0.27, P < 0.001). There was a significant difference between 24 h and 48 h postoperative ObsQoR-10A scores (median difference: −18; P < 0.001 which shows responsiveness). Other key measures included a Cronbach's alpha of 0.87, split-half 0.75, and intra-class correlation >0.62 with no floor or ceiling effects. Median (IQR) completion time was 3 (3-5) and 3 (2.5-3.5) minutes at 24 h and 48 h.

Conclusions:

ObsQoR-10A is a valid, reliable, responsive, and a clinically feasible tool in an Arabic-speaking obstetric population.

Patient reported outcome measures in childbirth and postpartum maternal quality of life: a protocol for systematic review of measurement properties

Background: Patient centred healthcare is the corner stone to many healthcare strategies. Patient specific health needs should be at the fore of healthcare improvements and quality measurements.  Patient reported outcome measures (PROM) that support real world clinical effectiveness assessments are increasingly being used to highlight domains where there is the greatest scope for change. Objectives: This systematic review aims to identify and evaluate existing patient reported assessment measures/tool(s) that can be used in developing a PROM for postpartum women. We will assess and evaluate their measurement properties in a transparent and structured way in accordance with the COSMIN guidelines. Methods: Methodological guidelines for systematic reviews of PROMs have been developed by the COSMIN initiative and will be followed for this systematic review. A systematic literature review will be performed using PubMed and EMBASE from inception to the present day. Two reviewers independently will judge eligibility, conduct data extraction and assess the methodological quality of each study as per COSMIN guidelines. Inclusion criteria: studies should concern PROM with an aim to evaluate measurement properties in the development or the evaluation of a PROM of interest. Included PROMS will focus upon postpartum women assessing morbidity and quality of care. All peer reviewed studies with an assessment tool designed for patient completion will be considered. Exclusion criteria; abstract, letters and non-peer reviewed publications. Studies will be graded on measurement properties and quality of evidence as laid out by COSMIN. All studies and characteristics eligible for inclusion will be summarised and a recommendation to the most suitable measurement tool(s) will be given. Discussion: We will provide a comprehensive description of all available patient reported assessment tools available for childbirth and postpartum quality of life and recommend based on COSMIN guidelines the most suitable instrument(s) available for use.

Impact of enhanced recovery after cesarean delivery on maternal outcomes: A systematic review and meta-analysis

BACKGROUND

This meta-analysis explores the impact of enhanced recovery after cesarean delivery (ERAC) on maternal outcomes.

METHODS

We searched 4 databases (Web of Science, Embase, PubMed and CINAHL) in October 2020 without date limiters, for studies quantitatively comparing ERAC implementation to a control group. The primary outcome was length of hospital stay and secondary outcomes included time to mobilization and time to urinary catheter removal, opioid consumption, readmission rates and cost savings. Mean differences and odds ratios (MD and OR with 95% confidence intervals) were calculated. Levels of evidence were assessed using GRADE.

RESULTS

Twelve studies involving 17,607 patients (9693 without ERAC and 7914 with ERAC) were included. ERAC was associated with reduced: length of hospital stay (MD -0.51 days [-0.94, -0.09]; p = 0.018; I2 = 99%), time to first mobilization (MD -11.05 h [-18.64, -3.46]; p = 0.004; I2 = 98%), time to urinary catheter removal (MD -13.19 h [-17.59, -8.79]; p < 0.001; I2 = 97%) and opioid consumption (MD -21.85 mg morphine equivalents [-33.19, -10.50]; p = < 0.001; I2 = 91%), with no difference in maternal readmission rate (OR 1.23 [0.96, 1.57]; p = 0.10; I2 = 0%). Three studies reported cost savings associated with ERAC. The GRADE levels of evidence were rated as low or very low quality for all study outcomes.

CONCLUSION

ERAC is associated with reduction in length of stay, times to first mobilization and urinary catheter removal and opioid consumption. ERAC does not significantly affect maternal hospital readmission rates following discharge. Further studies are required to determine which ERAC interventions to implement and which outcomes best determine ERAC efficacy.

Proposed domains for assessing postpartum recovery: a concept elicitation study

OBJECTIVE

To propose postpartum recovery domains.

DESIGN

Concept elicitation study.

SETTING

Semi-structured interviews.

POPULATION

Ten writing committee members and 50 stakeholder interviews (23 postpartum women, nine general obstetricians, five maternal and fetal medicine specialists, eight nurses and five obstetric anaesthetists).

METHODS

Alternating interviews and focus group meetings until concept saturation was achieved (no new themes discussed in three consecutive interviews). Interviews were digitally recorded and transcribed, and an iterative coding process was used to identify domains.

MAIN OUTCOME MEASURES

The primary outcome was to identify recovery domains. We also report key symptoms and concerns. Discussion frequency and importance scores (0-100; 0 = not important; 100 = vitally important to recovery) were used to rank domains. Discussion frequency was used to rank factors helping and hindering recovery, and to determine the greatest challenges experienced postpartum.

RESULTS

Thirty-four interviews and two focus group meetings were performed. The 13 postpartum recovery domains identified, (ranked highest to lowest) were: psychosocial distress, surgical/medical factors, infant feeding and breast health, psychosocial support, pain, physical function, sleep, motherhood experience, infant health, fatigue, appearance, sexual function and cognition. The most frequently discussed factors facilitating postpartum recovery were: family support, lactation/breastfeeding support and partner support. The most frequently discussed factor hindering recovery was inadequate social support. The most frequent challenges reported were: breastfeeding (week 1), breastfeeding (week 3) and sleep (week 6).

CONCLUSIONS

We propose 13 domains that comprehensively describe recovery in women delivering in a single centre within the USA. This provides a novel framework to study the postpartum recovery process.

TWEETABLE ABSTRACT

We propose 13 postpartum recovery domains that provide a framework to study the recovery process following childbirth.

A systematic review of patient-reported outcome measures used to assess sleep in postpartum women using Consensus Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines

STUDY OBJECTIVES

We performed a systematic review to identify the best patient-reported outcome measure (PROM) of postpartum sleep in women.

METHODS

We searched 4 databases for validated PROMs used to assess postpartum sleep. Studies were considered if they evaluated at least 1 psychometric measurement property of a PROM. An overall rating was assigned for each psychometric measurement property of each PROM based upon COSMIN criteria. A modified GRADE approach was used to assess the level of evidence and recommendations were then made for each PROM.

RESULTS

We identified 15 validation studies of 8 PROMs, in 9,070 postpartum women. An adequate number of sleep domains was assessed by 5 PROMs: Bergen Insomnia Scale (BIS), Pittsburgh Sleep Quality Index (PSQI), General Sleep Disturbance Scale (GSDS), Athens Insomnia Scale (AIS) and the Sleep Symptom Checklist (SSC). BIS and GSDS were the only PROMs to demonstrate adequate content validity and at least a low level of evidence of sufficient internal consistency, resulting in Class A recommendations. The BIS was the only PROM, which is easily accessible and free to use for non-commercial research, that achieved a Class A recommendation.

CONCLUSION

The BIS is the best currently available PROM of postpartum sleep. However, this PROM fails to assess several important domains such as sleep duration (and efficiency), chronotype, sleep-disordered breathing and medication usage. Future studies should focus on evaluating the psychometric measurement properties of BIS in the North American setting and in different cultural groups, or to develop a more specific PROM of postpartum sleep.

A systematic review of patient-reported outcome measures to assess postpartum pain using Consensus Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines

BACKGROUND

We performed a systematic review using Consensus Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines to identify the best available patient-reported outcome measure (PROM) of postpartum pain.

METHODS

This review follows COSMIN guidelines. We searched four databases with no date limiters, for previously identified validated PROMs used to assess postpartum pain. PROMs evaluating more than one author-defined domain of postpartum pain were assessed. We sought studies evaluating psychometric properties. An overall rating was then assigned based upon COSMIN analysis, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess the level of evidence for psychometric properties of included PROMs. These assessments were used to make recommendations and identify the best PROM to assess postpartum pain.

RESULTS

We identified 19 studies using seven PROMs (involving 3511 women), which evaluated postpartum pain. All included studies evaluated ≥1 psychometric property of the included PROMs. An adequate number of pain domains was assessed by the Brief Pain Inventory (BPI), Short Form-BPI (SF-BPI), and McGill Pain Questionnaire (MPQ). The SF-BPI was the only PROM to demonstrate adequate content validity and at least a low-level of evidence for sufficient internal consistency, resulting in a Class A recommendation (the best performing instrument, recommended for use).

CONCLUSION

SF-BPI is the best currently available PROM to assess postpartum pain. However, it fails to assess several important domains and only just met the criteria for a Class A recommendation. Future studies are warranted to develop, evaluate, and implement a new PROM designed to specifically assess postpartum pain.

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.

Postpartum recovery: what does it take to get back to a baseline?

PURPOSE OF REVIEW

Limited guidance exists regarding how to assess postpartum recovery. In this article, we discuss various aspects of inpatient and outpatient postpartum recovery.

RECENT FINDINGS

The postpartum period for many women includes sleep deprivation, maternal-neonatal bonding, breastfeeding, and integrating a new life into the family unit. Factors which impact inpatient quality of recovery include pain, nausea or vomiting, dizziness, shivering, comfort, mobilization, ability to hold and feed the baby, personal hygiene maintenance, and feeling in control. Outpatient recovery domains include psychosocial distress, surgical/medical factors, feeding and breast health, psychosocial support, pain, physical function, sleep, motherhood experience, infant health, fatigue, appearance / cosmetic factors, sexual function, and cognition. Postpartum recovery is likely to take longer than six weeks; however, no consensus regarding recovery duration exists among professional societies. Obstetric quality of recovery (ObsQoR) is a recommended measure of inpatient postpartum recovery; however, studies are needed to determine the optimum outpatient recovery assessment tool.

SUMMARY

Postpartum recovery is an important area that requires clinical and research attention. Future studies should focus on identifying and developing valid, reliable, and responsive measures of recovery as well as tracking and optimizing recovery domains following all delivery modes.

SUPPLEMENTARY VIDEO ABSTRACT ALSO AVAILABLE

http://links.lww.com/COOG/A65.

Self-reported questionnaires for lymphoedema: a systematic review of measurement properties using COSMIN framework

INTRODUCTION

Lymphoedema may develop as a result of numerous genetic and traumatic causes; however, treatment for cancer is the most common cause of its development in more economically developed nations. This systematic review critically appraised, compared and summarised the measurement properties of lymphoedema-specific self-reported questionnaires (SRQs) measuring various patient-reported outcomes including quality of life (QOL), function, morbidity, and symptoms.

METHODS

Seven databases were searched to identify studies of the measurement properties of SRQs. Two review teams independently evaluated the quality of the individual studies using the risk of bias tool from the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN). Measurement properties of the SRQs presented in the studies were then rated. Study level ratings were summarised for an SRQ if they were reported in multiple studies, and their overall quality of the evidence were then graded.

RESULTS

Forty articles, reporting on 19 SRQs were identified from 8615 records. The focus of the 19 SRQs included eight on QOL, four on symptoms, two on function, and two on impairment. The other three SRQs were on illness perception, self-efficacy, and patient-relevant treatment benefit, respectively. Eight and three SRQs were upper limb and lower limb-specific, respectively, whereas seven questionnaires were for both upper and lower limb lymphoedema. One SRQ was developed for head and neck lymphoedema. According to the COSMIN framework, none of the SRQs reviewed had sufficient evidence to support all nine measurement properties. In lower limb questionnaires, the LYMQOL-leg has sufficient content, structural, and construct validity as well as internal consistency and reliability. For upper limb lymphoedema questionnaires, the Lymph-ICF-UL had sufficient content and construct validity as well as reliability.

CONCLUSION

LYMQOL-leg SRQ is recommended with confidence for evaluation of QOL of people with lower limb lymphoedema while the Lymph-ICF-UL is recommended for evaluation of the QOL of the breast cancer-related lymphoedema with some confidence. In view of the high level of the indeterminate ratings of the measurement properties of the existing SRQs, further research is desirable.

Evaluation of Domains of Patient-Reported Outcome Measures for Recovery After Childbirth: A Scoping and Systematic Review

IMPORTANCE

Despite the global delivery rate being approximately 259 deliveries per minute in 2018, postpartum recovery remains poorly defined.

OBJECTIVES

To identify validated patient-reported outcome measures (PROMs) used to assess outpatient and inpatient postpartum recovery, evaluate frequency of PROM use, report the proportion of identified PROMs used within each recovery domain, report the number of published studies within each recovery domain, summarize descriptive data (country of origin, year of study, and journal specialty) for published studies using PROMs to evaluate postpartum recovery, and report PROMs used to evaluate global postpartum recovery.

EVIDENCE REVIEW

This study followed PRISMA-ScR guidelines. A literature search of 4 databases (MEDLINE through PubMed, Embase, Web of Science, and CINAHL) was performed on July 1, 2019, to identify PROMs used to evaluate 12 author-defined domains of postpartum recovery. All psychometrically evaluated PROMs used to evaluate inpatient or outpatient postpartum recovery after all delivery modes were included.

FINDINGS

From 8008 screened titles and abstracts, 573 studies (515 outpatient and 58 inpatient) were identified in this review. A total of 201 PROMs were used to assess recovery for outpatient studies and 73 PROMs were used to assess recovery for inpatient studies. The top 5 domains (with highest to lowest numbers of PROMs) used to assess outpatient recovery were psychosocial distress (77 PROMs), surgical complications (26 PROMs), psychosocial support (27 PROMs), motherhood experience (16 PROMs), and sexual function (13 PROMs). Among inpatient studies, the top 5 domains were psychosocial distress (32 PROMs), motherhood experience (7 PROMs), psychosocial support (5 PROMs), fatigue (5 PROMs), and cognition (3 PROMs). The 3 most frequently used PROMs were the Edinburgh Postnatal Depression Scale (267 studies), Short-Form 36 Health Questionnaire (global recovery assessment; 40 studies), and Female Sexual Function Index (35 studies). A total of 24 global recovery PROMs were identified among all included studies. Most studies were undertaken in the United States within the last decade and were published in psychiatry and obstetrics and gynecology journals.

CONCLUSIONS AND RELEVANCE

Most PROMs identified in this review evaluated a single domain of recovery. Future research should focus on determining the psychometric properties of individual and global recovery PROMs identified in this review to provide recommendations regarding optimum measures of postpartum recovery.