WITHDRAWN: Determinants of Postpartum quality of life in Iranian women: A cross-sectional study 

Abstract

Background: The postpartum period is also called the fourth stage of labor. In this period quality of life (QOL) is used as an important indicator of health.  Assessing the factors related to postpartum QOL can give a holistic approach from the individual level to the macro system for health program. This study will identify the determinants of PQOL in Iranian women.

Methods: 240 postpartum women participated in this cross-sectional study. demographic, obstetric and PQOL questionnaire was used. Descriptive statistics, Pearson correlation and multivariate linear regression was used to analyze the data.

Results: Education level, adequacy of household income for living expenses and planned pregnancy are three factors affecting the PQOL (p = 0.00).

Conclusion: Mothers' health ensures the health of the family and society So women should be classified based on determinants of PQOL and tailored to appropriate health programs to have a high quality postpartum period.

Introduction

The postpartum period is also called the fourth stage of labor and when a new member is added to the family and creates new conditions (1, 2). The mothers who need care themselves, complications of childbirth and the many problems of caring for the baby can negatively affect their Quality of life (QOL) (3, 4, 5). QOL is used as an important indicator of health that is related to mental and physical health at the twenty-four months' after birth (6, 7, 8).

Studies that conducted to examine the post-partum QOL (PQOL) of mothers, identified that the PQOL of the mothers is on the intermediate level (9, 10, 11). The reasons for this level of PQOL are not clear and are probably influenced by a range of different determinants including obstetric profile, sociodemographic and economic factors (12, 13). So far it has been determined that age, educational status, marital status, income level, parity, method of delivery, and psychosocial factors strongly associated with PQOL (14, 15). Nevertheless, PQOL is a concept affected by culture and social systems; so further studies are needed to confirm this association and other determinants of women’s PQOL in different communities (16, 17, 18). Assessing the factors related to postpartum QOL can give a holistic approach from the individual level to the macro system for health program; and it is better to design and implement mothers' mental health programs according to these cultural, social and medical factors. (19, 20, 21, 22).

This study was focused on determinants of postpartum quality of life in Iranian women because postpartum mothers' mental and physical health is important and most of these factors has not been studied before among this population. In addition, study in this topic is necessary because of the role of community culture in this issue and the need to identify influencing factor to design programs tailored to women's problems.

Method

The present study was the cross-sectional design and Method of sampling was convenient and Continuous. Sampling was done from 16 October to 9 February 2021 in 3 urban health centers of Shiraz. 

First 198 people were estimated at a confidence interval of 99% ( = 2.58) with an acceptable error ( d) of 1.45 (2.5% Mean: 58.11) and a standard deviation (σ) of 7.90 for PQOL in Iran (23,24). The researchers included 240 people in the study because of the 25% probability of participants not completing the questionnaires.

Eligible criteria included no mental retardation, no physical disability, Literacy for reading and writing, had a live birth at least 1 month and up to 18 months ago.  The objectives of the study, how to complete the questionnaire was stated and written informed consent was obtained from women.  It took 30 minutes to complete the questionnaires.

Data collection tools included 3 questionnaires: the demographic characteristics, the obstetric profile and the Persian version of the PQOL questionnaire (24). 

The demographic characteristics questionnaire included 5 questions about age, level of education, occupation, housing status and adequacy of household income for living expenses. 

The obstetric profile questionnaire consisted of 10 questions about the number of pregnancy, the number of parity, delivery method, history of abortion, the abortion method, history of infertility, sex of the baby, having a planned pregnancy, source of delivery, choice of source of delivery.

The Persian version of PQOL has validity of 0.88 through Cronbach's alpha calculation and validity of 0.77 through KMO and Bartlett's test at the level of p<0.00. This questionnaire has 4 dimensions and 40 questions, the dimensions of which are: 1- Child care 2- Physical function 3- Psychological function 4- Social support. The answering to the questions of the questionnaire was on the 5-point Likert scale which were scored between 0-100 (14) that lowest score indicates the unfavorable situation and the highest score indicates the favorable situation. 

Answering all the questions of the 3 questionnaires is self-reporting. After extracting the data, descriptive statistics such as frequency, mean and standard deviation were used to describe variables. Analytical statistical tests including the Pearson correlation test and multivariate linear regression were used to determine the relationship between variables. All calculations were performed with SPSS software version 25 (25).

Result

The mean score of women's PQOL was 61.63 ± 9.59 (range: 40- 87.5). The mean age of the participant was 31.34 ± 5.52 years (range: 16–47 years) and most of them in 25–35 years (150; 62.5%). 131 of women had a university education (54.6%) and 122 (50.8%) lived in a rental house. Most of the women (199; 82.9%) were housekeepers, and 141 (58.8%) were relatively desirable in terms of adequacy of family income for living expenses (Table 1).

Table 2 is a description of the participants' obstetric profile. The mean number of participant's pregnancy and parity was 2.12 ± 1.08 (range: 1–6) and 1.72 ± .74 (range: 1–4) respectively.

According to the results presented in Table 3 Pearson’s correlation test showed a significant linear relationship between level of education (r: .18), adequacy of household income for living expenses (r: .30), Planned pregnancy (r: .22) and PQOL (p = 0.00). Then, by performing multivariate linear regression, the effect of education level, adequacy of household income for living expenses, Planned pregnancy on PQOL was confirmed (p = 0.00) (Table 4).

Discussion

our results showed level of education (β = .16) and adequacy of household income for living expenses (β = .29) were two factors affecting PQOL. Similar to our study, studies showed relationship between education and health -related quality of life (HRQoL) (13, 14, 26) But the relationship between economic status and quality of life was not seen (13, 26). The reason for this disparity can be due to the different definition of adequacy of income for living expenses, which in her study is expressed as an index of wealth, but in our study is as a desirable level. Contrary to our results, other studies did not report any relationship between education level and economic status with postpartum QOL (9, 11) but relationship between occupation and QOL was seen (9, 26). The reason for this conflict can be different societies and cultures, which are two factors that affect the quality of life. Another factor influencing the PQOL in our study was planned pregnancy (β = .20). Unfortunately, we did not find a study that determine this relationship in the postpartum period, during pregnancy showed a link between a planned pregnancy and QOL (27, 28). It may be concluded from their study that improving the quality of life during pregnancy can lead to a better quality of life after childbirth. In our study, there was no correlation between delivery method and PQOL, but other studies described this relationship (2, 13, 14). Contradiction of these results can be due to the different quality of life questionnaire and as a result different dimensions and questions.

Due to the lack of studies on the quality of life after childbirth and related factors, there is no opportunity for further discussion here and further studies are suggested in this regard. It should be noted that study of the mother's mental health and PQOL and related factors is one of the most important measures of health services (29, 30, 31).

Limitations of our research include: 1. self-report of data that can be verified by other studies. 2. The number of articles in this field was small, which required similar studies. 3. The willingness of women to participate was low due to the Covid-19 epidemic and necessary measures should be taken in this regard.

Conclusion

The effect of education level, income adequacy for living expenses and planned pregnancy with PQOL indicates attention to these factors and identification of women at risk. Based on these factors, women should be classified during pregnancy and tailored to appropriate health programs to have a high quality postpartum period. Mothers' health ensures the health of the family and society.

Declarations

Authors' contributions

MHK as a supervisor, he supervised all the processes from the registration of the project proposal to the end of the final editing of the article.

KK collected and analyzed the data and wrote the article.

LGH participated in writing the proposal and expressing how to write the article.

MK advised statistical analysis and how to report it.

MN as an advisor, she participated in correcting the title of the project, choosing the instrument and how to conduct the study.

All authors read and approved the final manuscript.

Competing interests: None declared.

Ethics approval

Permission was obtained from the Research Ethics Committee (REC) of Shiraz University of Medical Sciences (SUMS) under approval ID: IR.SUMS.REC.1400.223, in 2021.   

Consent to participate 

written informed consent was obtained from women for completing questionnaires of study.  

Data Availability statement: Its available on request.

Funding: Not applicable.

Acknowledgments 

This study was supported by Shiraz University of Medical Sciences (SUMS) and we are grateful for this support. We would like to thank all the women who participated in this study and the staff of health centers for their cooperation with us.

References

1. -Özdemir F, Öztürk A, Karabulutlu Ö, Tezel A. Determination of the life quality and self-care ability of the mothers in post-partum period. J Pak Med Assoc. 2018;68(2):210–215. Available from https://pubmed.ncbi.nlm.nih.gov/29479095/.
2. -Kohler S, Sidney Annerstedt K, Diwan V, Lindholm L, Randive B, Vora K, et al. Postpartum quality of life in Indian women after vaginal birth and cesarean section: a pilot study using the EQ-5D-5L descriptive system. BMC Pregnancy Childbirth. 2018;18(1):427. doi: 10.1186/s12884-018-2038-0.
3. -Olza I, Leahy-Warren P, Benyamini Y, Kazmierczak M, Karlsdottir SI, Spyridou A, et al. Women's psychological experiences of physiological childbirth: a meta-synthesis. BMJ Open. 2018;8(10):e020347. doi: 10.1136/bmjopen-2017-020347.
4. -Mousavi F, Shojaei P. Postpartum Depression and Quality of Life: A Path Analysis. Yale J Biol Med. 2021;94(1):85–94. Available from https://pubmed.ncbi.nlm.nih.gov/33795985/
5. -Gökşin İ, Ayaz-Alkaya S. The effect of progressive muscle relaxation on the postpartum depression risk and general comfort levels in primiparas. Stress Health. 2020;36(3):322–329. doi: 10.1002/smi.2921.
6. -Alemu S, Herklots T, Almansa J, Mbarouk S, Sulkers E, Stekelenburg J, et al. Mental Health and Quality of Life of Women One Year after Maternal Near-Miss in Low and Middle-Income Countries: The Case of Zanzibar, Tanzania. Int J Environ Res Public Health. 2020;17(23):9034. doi: 10.3390/ijerph17239034.
7. -Faleschini S, Millar L, Rifas-Shiman SL, Skouteris H, Hivert MF, Oken E. Women's perceived social support: associations with postpartum weight retention, health behaviors and depressive symptoms. BMC Womens Health. 2019;19(1):143. doi: 10.1186/s12905-019-0839-6.
8. -Milgrom J, Hirshler Y, Reece J, Holt C, Gemmill AW. Social Support-A Protective Factor for Depressed Perinatal Women? Int J Environ Res Public Health. 2019;16(8):1426. doi: 10.3390/ijerph16081426.
9. -Jeong YJ, Nho JH, Kim HY, Kim JY. Factors Influencing Quality of Life in Early Postpartum Women. Int J Environ Res Public Health. 2021;18(6):2988. doi: 10.3390/ijerph18062988.
10. -Mokhtaryan-Gilani T, Ozgoli G, Kariman N, Sharif Nia H, Ahmadi Doulabi M, Nasiri M. Psychometric properties of the Persian translation of maternal postpartum quality of life questionnaire (MAPP-QOL). Health Qual Life Outcomes. 2021; 19(1):141. doi: 10.1186/s12955-021-01781-1.
11. -Hitimana R, Lindholm L, Krantz G, Nzayirambaho M, Condo J, Sengoma JPS, et al. Health-related quality of life determinants among Rwandan women after delivery: does antenatal care utilization matter? A cross-sectional study. J Health Popul Nutr. 2018;37(1):12. doi: 10.1186/s41043-018-0142-4.
12. -Lokubal P, Calvert C, Cousens S, Daniele M, Ganaba R, Filippi V. Investigating the effect of relationship satisfaction on postpartum women's health-related quality of life in Burkina Faso: a cross-sectional analysis. BMJ Open. 2021;11(9):e048230. doi: 10.1136/bmjopen-2020-048230.
13. -Martínez-Galiano JM, Hernández-Martínez A, Rodríguez-Almagro J, Delgado-Rodríguez M. Quality of Life of Women after Giving Birth: Associated Factors Related with the Birth Process. J Clin Med. 2019;8(3):324. doi: 10.3390/jcm8030324.
14. -Tola Y, Ayele G, Boti N, Yihune M, Gethahun F, Gebru Z. Health-Related Quality-of-Life and Associated Factors Among Post-Partum Women in Arba Minch Town. Int J Womens Health. 2021;13:601–611. doi: 10.2147/IJWH.S295325.
15. -Yamada A, Isumi A, Fujiwara T. Association between Lack of Social Support from Partner or Others and Postpartum Depression among Japanese Mothers: A Population-Based Cross-Sectional Study. Int J Environ Res Public Health. 2020;17(12):4270. doi: 10.3390/ijerph17124270.
16. -Papamarkou M, Sarafis P, Kaite CP, Malliarou M, Tsounis A, Niakas D. Investigation of the association between quality of life and depressive symptoms during postpartum period: a correlational study. BMC Womens Health. 2017;17(1):115. doi: 10.1186/s12905-017-0473-0.
17. -Badr HA, Zauszniewski JA, Quinn Griffin M, Burant CJ, Przeworski A, Almutairi WM, et al. Effects of Postpartum Fatigue and Depressive Cognitions on Life Satisfaction and Quality of Life in Arab Postpartum Women: The Intervening Role of Resourcefulness. Nurs Rep. 2021;11(1):84–94. doi: 10.3390/nursrep11010009.
18. -Khan S, Lovell K, Lunat F, Masood Y, Shah S, Tomenson B, Husain N. Culturally-adapted cognitive behavioural therapy based intervention for maternal depression: a mixed-methods feasibility study. BMC Womens Health. 2019;19(1):21. doi: 10.1186/s12905-019-0712-7.
19. -Almutairi AF, Salam M, Alanazi S, Alweldawi M, Alsomali N, Alotaibi N. Impact of help-seeking behavior and partner support on postpartum depression among Saudi women. Neuropsychiatr Dis Treat. 2017;13:1929–1936. doi: 10.2147/NDT.S135680.
20. -Tambag H, Turan Z, Tolun S, Can R. Perceived social support and depression levels of women in the postpartum period in Hatay, Turkey. Niger J Clin Pract. 2018;21(11):1525–1530. doi: 10.4103/njcp.njcp_285_17.
21. -Cardona Cordero NR, Ramos JP, Tavarez ZQ, McIntosh S, Avendaño E, DiMare C, et al. Relationship between perceived social support and postpartum care attendance in three Latin American countries: a cross-sectional analytic study. Glob Health Res Policy. 2021;6(1):16. doi: 10.1186/s41256-021-00196-1.
22. -Huma ZE, Gillani A, Shafique F, Rashid A, Mahjabeen B, Javed H, et al. Evaluating the impact of a common elements-based intervention to improve maternal psychological well-being and mother-infant interaction in rural Pakistan: study protocol for a randomised controlled trial. BMJ Open. 2021;11(7):e047609. doi: 10.1136/bmjopen-2020-047609.
23. -Sharma SK, Mudgal SK, Thakur K, Gaur R. How to calculate sample size for observational and experimental nursing research studies? National J of Physiology, Pharmacy and Pharmacology. 2020; 10(1). doi:10.5455/njppp.2020.10.0930717102019.
24. -Nikan F, Asghari Jafarabadi M, Mohammad-Alizadeh-Charandabi S, Mirghafourvand M, Montazeri A, Asadi S. Psychometric Properties of the Iranian Version of a Postpartum Women's Quality of Life Questionnaire (PQOL): A Methodological Study. Iran Red Crescent Med J. 2016 14;18(7):e35460. doi: 10.5812/ircmj.35460.
25. -IBM SPSS Statistics for Windows. 25 ed. Armonk, NY: IBM Corp; 2017.
26. -Rezaei N, Azadi A, Zargousi R, Sadoughi Z, Tavalaee Z, Rezayati M. Maternal Health-Related Quality of Life and Its Predicting Factors in the Postpartum Period in Iran. Scientifica (Cairo). 2016;2016:8542147. doi: 10.1155/2016/8542147.
27. -Sarı O, Dağcıoğlu BF, Akpak YK, Yerebatmaz N, İleri A. Planned and unplanned pregnancy and its association with coping styles and life quality. Health Care Women Int. 2021:1–11. doi: 10.1080/07399332.2021.1932895.
28. -Kazemi A, Dadkhah A, Torabi F. Changes of health related quality of life during pregnancy based on pregnancy context: a prospective study. Arch Public Health. 2022;80(1):37. doi: 10.1186/s13690-022-00802-9.
29. -Mercan Y, Tari Selcuk K. Association between postpartum depression level, social support level and breastfeeding attitude and breastfeeding self-efficacy in early postpartum women. PLoS One. 2021;16(4):e0249538. doi: 10.1371/journal.pone.0249538.
30. -Esmkhani M, Ahmadi L, Maleki A. The Effect of Client Needs Counseling on the Postpartum Quality of Life of Women. J Perinat Educ. 2020;29(2):95–102. doi: 10.1891/J-PE-D-18-00044.
31. -Zhou J, Havens KL, Starnes CP, Pickering TA, Brito NH, Hendrix CL, et al. Changes in social support of pregnant and postnatal mothers during the COVID-19 pandemic. Midwifery. 2021;103:103162. doi: 10.1016/j.midw.2021.103162.