Study on the influencing factors of postpartum quality of life in women with heart disease

doi:10.21203/rs.3.rs-3134776/v1

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Study on the influencing factors of postpartum quality of life in women with heart disease

https://doi.org/10.21203/rs.3.rs-3134776/v1

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Background: Heart disease women's quality of life (QoL) has been neglected. To improve clinical communication and treatment, we integrated medical data and subjective characteristics to study postpartum QoL concerns.

Methods: The study assessed QoL six weeks after birth using the 12-Item Short-Form Health Survey (SF-12). The Edinburgh Postnatal Depression Scale (EPDS), Cardiac Anxiety Questionnaire (CAQ), European Heart Failure Self-Care Behavior Scale (EHFScBS), and a self-designed questionnaire based on earlier research were also used to assess patient characteristics. Patient system data were collected. Prediction models were created using multiple linear regression.

Results: This retrospective study examined 105 postpartum cardiac patients' QoL. Postpartum QoL scores were lower (90.69 ± 13.82) than those of general women, with physical component scores (41.09 ± 9.91) lower than mental component scores (49.60 ± 14.87). Postpartum depression (33.3%), moderate anxiety (37.14%), pregnancy concerns (57.14%), offspring heart problems (57.14%), and life expectancy worries (48.6%) were all prevalent. No previous cardiac surgery, multiparity, higher sadness and cardiac anxiety, and fear of unfavorable pregnancy outcomes were strongly related to lower QoL (R² value = 0.525).

Conclusions: Heart disease patients' postpartum QoL is linked to their physical and mental health. Our study emphasizes the need for healthcare workers to recognize and address the unique characteristics of these women while developing and implementing comprehensive management approaches during their maternity care journey.

heart disease

pregnancy

postpartum

quality of life

mental health

Heart disease during pregnancy includes preexisting or newly diagnosed congenital heart disease, pulmonary hypertension, aortic disease, valvular heart disease, coronary artery disease, cardiomyopathy, heart failure, and arrhythmias [1]. It complicates 1–4% of pregnancies and accounts for 15% of maternal deaths [2]. Due to the rise in the proportion of high-risk individuals in the modified World Health Organization pregnancy risk classification (mWHO classification), cardiovascular disease has become the leading cause of maternal mortality worldwide [2].

Women with heart disease experience pregnancies with a 1% mortality rate, which is 100 times higher than those without heart disease [3]. Dramatic hemodynamic changes during pregnancy—increased blood volume and cardiac output, contractions and pain during delivery, and postpartum inferior vena cava reflux [4] —increase the heart burden and worsen heart failure symptoms. Strict multidisciplinary team management (MDT) is needed, resulting in increased obstetric examinations and hospitalizations throughout pregnancy for one-fourth of affected women [3]. Compared to the general women, women with heart disease are more likely to experience pregnancy comorbidities, cesarean section rates, unfavorable pregnancy results, neonatal preterm delivery and complications, and shorter gestational periods [2, 3, 5].

In addition, these women suffer notable psychological stress. Following a diagnosis, they desire to parent [6–11] but lack autonomy and control over pregnancy decisions [7, 12]. When experiencing cardiac symptoms during and after pregnancy, they feel helpless, isolated, frightened, and vulnerable [7, 10, 11, 13–15], wondering about their safety and their children's health and care [6–8, 10–12, 16]. With complex diagnoses, people struggle to comprehend their illness fully and precisely [6, 8, 9, 16], rely heavily on medical institutions and personnel [6, 11, 16], and demand more social support [7, 11, 16, 17]. They suffer physical and psychological deterioration due to prognostic uncertainty and the complexity of pregnancy, delivery, and postpartum rehabilitation. Long-term effects include poorer quality of life (QoL), impaired postpartum recovery, heart disease self-management challenges, compromised mother-infant relationships, increased illness burden, and family and social issues [15, 16]. Guidelines emphasize the importance of MDT management and continuous close care during and after pregnancy for women with heart disease [1, 18]. This approach ensures safe pregnancies and seamless transitions, requiring strong cooperation with patients and their families [19]. These women need good medical care throughout pregnancy, delivery, and postpartum recovery [7, 16, 17].

Compared to their healthy peers, women with heart disease during and after pregnancy had a reduced QoL [20–22], as well as physical discomfort and mental health problems [14, 15, 20–23]. These issues result in decreased adherence and bad healthcare practices [10, 21, 23]. Existing research chiefly focuses on the clinical and physiological outcomes of these pregnancies[21, 24]. However, it lacks comprehensive subjective and objective data on patients' health lists, heart disease, and emotional-psychological effects on postpartum QoL [21, 24]. Moreover, there are inadequate assessments of the factors influencing postpartum QoL. Due to the unique characteristics of these women, web-based patient data are often collected well after delivery, which may not accurately reflect the crucial short-term postpartum transition period. In addition, the healthcare system continues to fall short of meeting the needs of women experiencing high-risk pregnancies [13].

This study examined the postpartum QoL of women with heart disease about their demographic, clinical, and pregnancy features and self-reported mental health status. Furthermore, the study aimed to explore the factors influencing healthcare professionals’ (HCPs’) knowledge of high-risk pregnancies' physical and mental health. This information seeks to improve two-way communication and provide a reference for patient-centered continuous MDT management during and after pregnancy.

2.1 Study protocol

Patients from the Maternal Cardiology Consultation Center of XXX were chosen for this cross-sectional retrospective study. Between March 2021 and March 2023, these patients received MDT consultations and successfully gave birth. Six weeks postpartum, participants completed an electronic version of the questionnaire, and study staff was quickly accessible for consultation in case of data loss.

2.2 Participants

Inclusion criteria: (a) pregnant women diagnosed with heart disease according to the 2018 European Society of Cardiology Guidelines [1]; (b) delivered one or more infants after 20 weeks of gestation with a minimum birth weight of 400 grams; (c) 18 years of age or older; and (d) adequate physical, cognitive, and linguistic abilities to complete the self-report questionnaire. Exclusion criteria: (a) prior history of mental illness or current use of psychotropic drugs; (b) multiple pregnancies; (c) primary diagnosis involving immunological, renal, or respiratory disorders other than heart disease.

2.3 Measurement

We obtained demographic, clinical, and pregnancy variables from the patient's hospital information system. In addition, participants completed the Chinese versions of the Edinburgh Postnatal Depression Scale (EPDS), Cardiac Anxiety Questionnaire (CAQ), European Heart Failure Self-Care Behavior Scale (EHFScBS), and 12-Item Short-Form Health Survey (SF-12) at six weeks postpartum. We also developed a questionnaire consisting of seven items on patient compliance, understanding of their condition, and worries linked to heart disease based on data from prior studies [20–22].

2.3.1 Postpartum Depression

Postpartum depression is a major depressive episode within six weeks of delivery [25]. The EPDS is a well-known and authoritative screening instrument for postpartum depression, renowned for its simplicity and validity in worldwide settings [26]. Higher scores imply more severe depressive symptoms [27]. The Chinese version of the EPDS recommends a score of 10 as indicative of depressive symptoms [28]. In our study, a more alert threshold of 13 implies potential postpartum depression (sensitivity range from 0.67 to 1.0 and specificity ≥ 0.87) [27, 29]. The measure showed high internal consistency with a Cronbach's alpha of 0.845.

2.3.2 Heart-focused Anxiety

Heart-focused anxiety (HFA) is distinguished from general anxiety by the fear of heart-related sensations, avoidance of symptom-caused activities, and obsession with heart-related symptoms [30]. The CAQ, the most widely used scale for assessing HFA in clinical settings, has shown solid psychometric features across multiple nations and groups, including those with and without heart disease [31]. The CAQ consists of 18 items corresponding to the definition of HFA and three subscales (Fear, Avoidance, and Heart-Focused Attention), each assessed on a 5-point Likert scale (ranging from 0 to 4). The total and subscale scores are averaged, with higher scores indicating a more severe HFA. Currently, there are no established clinical cut-off scores for this metric [30]. This study displayed strong internal consistency (Cronbach's α = 0.909).

2.3.3 Medical Behavior Adherence

Self-management comprises the decisions and strategies individuals use to maintain life, promote healthy functioning, and enhance well-being, and it has a significant role in enhancing the prognosis of heart failure patients [32]. The EHFScBS measures heart failure-related self-care behaviors recommended by American Heart Association guidelines for secondary prevention, including medication adherence, dietary management, exercise, symptom monitoring, and aid-seeking [32]. There are 12 items, and each scored on a 5-point Likert scale ranging from 1 to 5 [32]. Higher scores denote poorer self-care [32]. The instrument exhibits solid internal consistency, as evidenced by a Cronbach's α of 0.880.

2.3.4 Quality of Life

QoL assesses physical, mental, and social well-being and can help diagnose diseases and improve patient-clinician communication [33]. QoL is commonly measured using the SF-36 Health Survey [34]. The abridged SF-12, which has strong reliability and validity, was used in this investigation [35]. The SF-12 has two subscales, Physical Component Summary (PCS) and Mental Component Summary (MCS), with each total score ranging from 0 to 100, and 12 items with minimal information loss compared to the SF-36 [36]. These subscales include eight dimensions of general health, physical functioning, role-physical, bodily pain, vitality, social functioning, role-emotional and mental health. Higher total scores imply better functioning in this rating [36]. Chinese people had mean SF-12 PCS and MCS scores of 50.2 and 48.4, respectively [37]. Cronbach's α is 0.808, indicating excellent internal consistency.

2.4 Statistical methods

Our study needed 63 women, at least [38]. Appendix A provides sample size calculations. Categorical data were expressed as percentages, and continuous numerical variables were expressed as ranges, means ± SDs, and median ± interquartile ranges. Correlations between continuous numerical variables (e.g., gestational age, gestational weeks, newborn weight, EPDS, CAQ, EHFScBS) and SF-12 were determined using Pearson or Spearman coefficients.

Other potential physical and psychological factors were identified using univariate analysis utilizing the independent t test and ANOVA, followed by LSD post hoc testing. To include as many potential risk factors as possible in the linear regression model, we performed multivariate analysis of variance with a p value threshold of 0.10. Variables were manually screened based on their p values, and residual analyses were used to assess independence, normality, and homoscedasticity.

The Durbin-Watson (D-W) test was applied to further examine independence, while the variance inflation factor (VIF) and tolerance statistics were used to assess collinearity. All occurring p vales and tests were conducted on a two-sided basis. A p value below 0.05 indicated statistical significance. SPSS Statistics 27.0 (SPSS Inc, Chicago, Illinois) was utilized.

3.1 Participants

We sent out electronic questionnaires to 162 women who met the criteria and received 130 (participation rate of 80.25%), of whom 15 were excluded due to a lack of clarification regarding the diagnosis of heart disease during the postpartum review. Finally, 105 postnatal individuals with various heart diseases were included (see Appendix B).

3.2 Objective medical characteristics and postpartum quality of life

In this study, most women with heart disease were between 25 and 34 years old. These women typically had a high level of education and income (> 80k RMB), and they either did not work or worked less during pregnancy (Table 1). We examined the association between the demographic characteristics of women with heart disease and their QoL following childbirth. Interestingly, none of these factors were found to impact postpartum QoL in our patient population.

Table 1

Demographic characteristics and postpartum quality of life of the sample
Variables	N (%)	M ± SD	P Value
Gestational age, years	31.00 ± 5.00(19.00ཞ49.00)^a		0.064
Gestational age, years			0.266
< 25	8(7.62)	97.78 ± 9.00
25–34	80(76.19)	90.51 ± 13.81
≥ 35	17(16.19)	88.21 ± 15.29
Education			0.915
No more than junior middle school	8(7.62)	93.14 ± 10.87
Senior high school	13(12.38)	87.84 ± 15.43
Junior college	24(22.86)	91.86 ± 12.98
Bachelor degree	49(46.67)	90.57 ± 15.17
Master's degree or above	11(10.48)	90.27 ± 10.35
Annual household income, RMB			0.559
༜30k	14(13.33)	94.56 ± 13.24
30k-80k	23(21.90)	91.70 ± 12.21
80k-120k	25(23.81)	88.66 ± 16.69
120k-200k	22(20.95)	89.66 ± 14.55
200k-300k	15(14.29)	93.00 ± 9.55
≥ 300k	6(5.71)	92.58 ± 15.15
Work conditions during pregnancy			0.337
Did not work	43(40.95)	90.78 ± 13.53
Reduced workload	34(32.38)	88.27 ± 15.47
No change and increase in workload	28(26.67)	93.49 ± 11.96
^a median ± interquartile range (range).

The findings of clinical features are reported in Table 2. Most patients were of average weight and were newly diagnosed with structural heart disease. The postpartum QoL of patients who underwent heart surgery was superior (P = 0.007). We classified patients using the NYHA and mWHO classifications. Patients with worse heart function had lower postpartum QoL scores (P < 0.001). Those with mWHO severity grades II-III had significantly poorer postpartum QoL than those with severity grades I or III (P = 0.003, P = 0.016, respectively). Other clinical considerations have no bearing on postpartum QoL.

Table 2

Clinical characteristics and postpartum quality of life of the sample
Variables	N (%)	M ± SD	P Value
Prepregnant BMI (kg/m²)			0.408
< 18.5 (leaner)	12(11.43)	90.64 ± 13.90
18.5–24.9 (normal)	69(65.71)	91.84 ± 14.57
≥ 25 (overweight and obesity)	24(22.86)	87.43 ± 11.36
BMI increment (kg/m²)	4.92 ± 1.89 (-0.37ཞ9.86)^a		0.319
Pregnancy diagnosis			0.206
Yes	55 (52.38)	89.06 ± 12.55
No	50 (47.62)	92.49 ± 15.02
Prepregnant cardiac surgery			0.007^**
Yes	32(30.48)	96.14 ± 12.62
No	73(69.52)	88.30 ± 13.73
Type of heart disease			0.075
Structural	74(70.48)	92.25 ± 13.93
Functional	31(29.52)	86.98 ± 13.03
mWHO classification			0.026^*
Ⅰ	25(23.81)	96༎05 ± 13.48
Ⅱ	44(41.90)	89.71 ± 13.42
Ⅱ-Ⅲ	9(8.57)	80.42 ± 14.64
Ⅲ	10(9.52)	95.47 ± 12.85
Ⅳ	17(16.19)	87.97 ± 12.50
NYHA classification			༜0.001^**
Ⅰ	64(60.95)	94༎58 ± 13.22
Ⅱ	33(31.43)	87.01 ± 12.13
Ⅲ、Ⅳ	8(7.62)	74.78 ± 10.11
Abbreviations: BMI, body mass index; mWHO classification, modified World Health Organization pregnancy risk classification.
^a mean ± standard (range).
^P Value < 0.05; ^*P Value < 0.01

Table 3 displays the features of these women's pregnancies. The majority of patients were primipara without complications. We observed high rates of cesarean delivery (89.52%), short gestational weeks, and low newborn weight. Postpartum QoL was lower for multiparous women than primiparas (P = 0.026) and correlated positively with gestational weeks (P = 0.040). After birth, 35.24% of neonates required hospitalization, and their mothers' postpartum QoL was poorer (P = 0.037). Other pregnancy factors were unrelated to postpartum QoL.

Table 3

Pregnancy Characteristics and Postpartum Quality of Life of the Sample
Variables	N (%)	M ± SD	P Value
Gravidity			0.524
1	64(60.95)	90.26 ± 13.25
2	27(25.71)	89.69 ± 15.53
≥ 3	14(13.33)	94.58 ± 13.28
Parity			0.026^*
Primiparas	91(86.67)	91.86 ± 13.60
Multiparas	14(13.33)	83.09 ± 13.29
Pregnancy complications			0.052
Yes	34(32.38)	94.47 ± 12.90
No	71(67.62)	88.88 ± 13.97
Planned pregnancy			0.085
Yes	69(65.71)	92.37 ± 13.18
No	36(34.29)	84.48 ± 14.62
Delivery method			0.529
Vaginal delivery	11(10.48)	90.51 ± 14.77
Cesarean section	80(76.19)	92.18 ± 13.73
Emergency cesarean section	14(13.33)	87.40 ± 12.69
gestational weeks, d	264.00 ± 19.00(225.00ཞ285.00)^a		0.040^*
Neonatal gender			0.079
male	54(51.43)	93.82 ± 13.66
female	51(48.57)	88.78 ± 13.31
Neonatal weight	2977.91 ± 591.63(1640.00ཞ4650.00)^b		0.097
Neonatal hospitalization			0.037^*
Yes	37(35.24)	87.34 ± 14.57
No	68(64.76)	93.58 ± 12.72
Milk-feeding way			0༎965
Exclusive breastfeeding	40(38.00)	91.02 ± 13.45
Mixed feeding	43(41.00)	91.38 ± 13.11
Artificial feeding	22(21.00)	92.07 ± 15.69
^a median ± interquartile range (range). ^b mean ± standard deviation (range).
* P Value < 0.05

3.3 Emotional and psychological characteristics, compliance, and postpartum quality of life

Table 4 presents the key results for the EPDS, CAQ, EHFScBS, and SF-12, revealing that 33.33% (score ≥ 13) of the women screened positive for postpartum depression, which is considerably higher than the rate of positive perinatal screening (50.47% versus 40%, score ≥ 10) [39]. The sample EPDS mean score was 10.08 ± 5.08, above the usual degree of postpartum depression in Chinese women (7.09 ± 4.41) [40].

Table 4

Descriptive statistics for the EPDS, CAQ, EHFScBS, and SF-12 at six weeks postpartum
Variables	Value	M ± SD
EPDS	≤ 9	52(49.52)^a
	10–12	18(17.14)^a
	≥ 13	35(33.33)^a
	Total	10.08 ± 5.08
CAQ	≥ 2	39(37.14)^a
	Avoidance	1.59 ± 0.82
	Fear	1.52 ± 0.73
	Heart-Focused Attention	2.40 ± 1.34
	Total	1.79 ± 0.79
EHFScBS	Total	35.38 ± 10.51
SF-12	PCS	41.09 ± 9.91
	MCS	49.60 ± 14.87^b
	Total	90.69 ± 13.82
Abbreviation: EPDS, Edinburgh Postnatal Depression Scale; CAQ, Cardiac Anxiety Questionnaire; EHFScBS, European Heart Failure Self-Care Behavior Scale; SF-12, 12-Item Short-Form Health Survey; PCS, physical components summary; MCS, mental components summary.
^a n (%). ^b median ± interquartile range

A total of 37.14% of patients demonstrated at least moderate cardiac anxiety, with the highest heart-focused attention score (2.40 ± 1.34), followed by avoidance (1.59 ± 0.82) and fear (1.52 ± 0.73). The postnatal PCS score (41.09 ± 9.91) was significantly lower than the standard population level (50.2) [37], and the MCS score (49.60 ± 14.87) on the SF-12. The Pearson correlation coefficients among the EPDS, CAQ, EHFScBS, and SF-12 were statistically significant (-0.568, P < 0.001; -0.461, P < 0.001; and − 0.215, P < 0.028, respectively).

The majority (61.90%) of patients had their recovery and cardiac status assessed in the hospital following delivery, as shown in Table 5. Fascinatingly, over half (55.56%) of the patients who skipped medical appointments claimed family and childcare commitments. A portion (39.05%) of patients were advised against having children, and the majority (79.05%) acknowledged the complexity of heart disease diagnosis during pregnancy. A substantial proportion of patients with heart disease were concerned about unfavorable pregnancy outcomes (57.14%) and the risk of their children developing heart issues (57.14%), followed by concerns about how heart disease might affect their future life expectancy (48.57%). Those with poorer postpartum QoL (P < 0.05) voiced these concerns.

Table 5

Design-specific cardiac-related problems and quality of life of the sample at six weeks postpartum
Variables	N (%)	M ± SD	P Value
Compliance
Hospital review after ending the pregnancy			0.360
Yes	65(61.90)	91.67 ± 12.85
No	40(38.10)	89.11 ± 15.31
Understanding of the disease
Advised to avoid having children			0.125
Yes	41(39.05)	88.10 ± 16.11
No	64(60.95)	92.35 ± 11.98
Full consultation and understanding of the diagnosis			0.947
Yes	83(79.05)	90.64 ± 14.36
No	22(20.95)	90.87 ± 11.84
Medical concerns
Seek Psychological Counselling			0.907
Yes	3(2.86)	89.77 ± 15.92
No	102(97.14)	90.72 ± 13.85
Fear of a bad pregnancy			༜0.001^***
Yes	60(57.14)	86.38 ± 13.35
No	45(42.86)	96.44 ± 12.39
Worried about the child's heart			0.016^*
Yes	60(57.14)	87.89 ± 13.76
No	45(42.86)	94.42 ± 13.14
Worried about reduced longevity			0.007^**
Yes	51(48.57)	86.96 ± 14.16
No	54(51.43)	94.22 ± 12.63
* P Value < 0.05; P Value < 0.01;* P Value < 0.001

3.4 Determinants of Postpartum Quality of Life

We used a p value > 0.1 as the criterion for exclusion. Gestational age, prior cardiac surgery, heart disease type, mWHO classification, NYHA classification, primiparity status, gestational comorbidities, planned pregnancy, gestational weeks, neonatal weight and hospitalization, EPDS scores, CAQ scores, and EHFScBS scores were selected in the model. In addition, worries about the fetus's heart health, future life expectancy, and adverse pregnancy outcomes were also considered. After manual exclusion, the result of the linear regression model is given in Table 6. It highlights that prepregnancy cardiac surgery, CAQ, EPDS, fear of an unfavorable pregnancy, and primiparas can successfully explain the SF-12 scores (P < 0.001). The model fit the data well (adjusted R² = 0.525), and there was no evidence of linearity and normality violations in the residuals. The VIF ranged from 1.020 to 1.173, while tolerance statistics varied between 0.852 and 0.980. The D-W test showed adequate variance independence.

Table 6

Linear regression model results for the SF-12
Predictors	β	Standard Error	t	P-Value	95% Confidence Interval for β
Constant	127.304	6.431	19.795	༜0.001	114.543ཞ140.065
Without prepregnant cardiac surgery	-7.532	2.040	-3.692	༜0.001	-11.580ཞ-3.484
CAQ	-5.264	1.242	-4.237	༜0.001	-0.429ཞ-0.155
EPDS	-0.189	0.197	-6.041	༜0.001	-1.580ཞ-0.799
No fear of a bad pregnancy	4.193	2.035	2.060	0.042	0.155ཞ8.230
Multiparas	-7.457	2.781	-2.682	0.009	-12.974ཞ-1.939
Abbreviations: EPDS, Edinburgh Postnatal Depression Scale; CAQ, Cardiac Anxiety Questionnaire.
F(5,99) = 23.989, P Value < 0.001, R² = 0.548, adjusted R² = 0.525, D-W = 1.934。

Upon analysing the SF-12 outcomes alongside both subjective and objective predictors involved in the model, it was observed that prepregnancy heart surgery and reduced levels of pregnancy anxiety contributed to enhanced postpartum QoL. As EPDS scores climbed, so did the value of SF-12. Similar results were observed when analysing the CAQ variable. Additionally, postpartum QoL for primiparous women with heart disease was substantially enhanced.

Our research revealed that postpartum women with cardiac conditions typically exhibited compromised QoL and had significant physical and psychological stresses throughout their maternity journey. In addition, the deterioration of physical and mental health during and after pregnancy was substantially connected with the degree of QoL impairment these women with heart disease had.

QoL is essential to postpartum recovery and secondary prevention for heart disease patients. Unlike HCPs, who prioritize clinical and physical outcomes such as mortality and mode of birth, these women and their families prioritize overall wellness [24]. Health includes physical, emotional, and role functioning, QoL, and care provision [24]. Nonetheless, many of them are dissatisfied with these qualities [15]. Following earlier research [15, 20, 21, 41], our data suggested that postpartum QoL was generally diminished in women with heart disease. Some evidence indicates that the emotional burden of pregnancy and the postpartum period decreased over time, resulting in an increase in QoL [42] and beneficial physical and psychological results over the long run [22]. It has also been shown that persons with congenital heart disease who have children have higher health satisfaction, mental health, and social support scores [43]. However, some studies have reported that poor QoL and mental health outcomes after pregnancy may not necessarily improve beyond six weeks postpartum [21, 23]. As a result, these issues can be long-lasting and may not return to baseline mental and physical fitness levels [15]. Low QoL negatively affects the prognosis of heart failure patients, increases the incidence of adverse cardiac events [44], impedes postpartum recovery, and can damage mothers, newborns, families, and society [15]. Consequently, QoL assessment should be critical in the ongoing clinical therapy of women with heart disease following pregnancy [23]. Additional prospective longitudinal studies and a greater focus on long-term monitoring and management are also necessary for these women after birth.

Multiple linear regression was used to find statistically significant characteristics of postpartum QoL in women with heart disease. Our findings demonstrated that prepregnancy heart surgery, parity, EPDS score, CAQ score, and fear of an unfavorable pregnancy throughout pregnancy were predictors of perceived postpartum QoL.

In the general cardiac population, cardiac surgery reflects the severity of the disease and is associated with a decline in patients' QoL [43]. However, as predictors of postpartum QoL in cardiac patients, prepregnancy surgery was a positive factor for delivery, as recommended by guidelines [1, 18]. In this study, prepregnancy cardiac operations included atrial septal defect repair (25.00%), ventricular septal defect repair (21.87%), mechanical valve replacement (21.87%), correction of tetralogy of Fallot (9.38%), and radiofrequency ablation (9.38%). These surgical patients, representing 64.00% (32/50 cases) of preconception diagnoses, underwent procedures before conception, improving cardiac function, physical state [45], pregnancy tolerance, and reducing the mWHO classification [46–48]. As a result, most of them had planned pregnancies and paid greater attention to cardiac treatment through close follow-up and stringent pregnancy management, which eventually improved pregnancy outcomes [49]. Our findings indicated the benefits of timely diagnosis and early surgical intervention on postpartum QoL.

Consist with their counterparts without heart disease [50]. Primiparas hint enhanced QoL at six weeks postpartum in our results. Pregnancy generates numerous hemodynamic and physiological changes that increase cardiovascular stress, which is entirely reversed after delivery [51]. Extant research indicates that increasing parity harms women's health and elevates the risk of cardiovascular disease [52, 53]. In addition, repeated cardiovascular adaptation to volume overload can lead to adverse cardiac remodelling, an independent risk factor for left ventricular diastolic dysfunction in women with heart disease [54–56]. Although some studies have shown that women with heart disease have similar pregnancy outcomes in consecutive pregnancies [57], our results showed that repeated pregnancies reduced postpartum QoL. The condition underscores the importance of closely monitoring women's physical and mental health with multiple births after delivery.

Prior research has shown that the recovery of the cardiovascular system during the postpartum period does not correspond with emotional healing [15, 23]. The physical limits and cognitive impairments caused by the disease substantially influence these women's lives, resulting in enduring emotional responses [42]. In our study, the prevalence of postpartum depression was 33.33%, similar to previous research on women with heart disease [22, 23], twice that of the general Chinese population [58], and comparable to high-risk pregnancies [59]. Depressive disorders were identified as a potent predictor of postpartum QoL in our investigation, corroborating previous findings [41], and have also been demonstrated in the general postpartum population [60–62]. Depression is also associated with reduced health behaviors and exacerbating heart failure symptoms in mothers with heart disease [23]. We must focus on depression symptoms and intervene early to improve postpartum QoL and cardiovascular disease management.

In addition, HFA problems were common among our patients, resulting in a slightly lower total CAQ score. The score was lower than that of Australian research of 43 women with cardiac disease during pregnancy and the postpartum period [21] and those with peripartum cardiomyopathy [20]. Slightly lower scores may be because 65.71% of our patients were classified as mWHO class I and II. However, the score was considerably higher than that of the general population of women in the same age group [63], the postmyocardial infarction population [31], general cardiac patients [30], and individuals with noncardiac chest pain [64]. Prior research has also established a correlation between HFA and reduced QoL in heart disease patients, emphasizing the importance of routine diagnosis and intervention [64, 65]. Such a phenomenon is akin to how general anxiety influences the QoL for the average woman during the postpartum period [61].

We also designed a standardized questionnaire, and the proportion of patients concerned about their child's heart problems is consistent with earlier research (57.7%~73.8%) [20–22]. Interestingly, studies from developed countries showed that women with heart disease were more concerned about their physical health [20–22]. In contrast, our study found that more women with heart disease were concerned about their children acquiring cardiac conditions. They were considerably more likely than mothers in other countries to miss medical visits owing to child care (55.56% versus 10.7%~40.5%), highlighting cultural disparities. Prior research only offered descriptive statistics on these issues. However, our study incorporated these concerns into a multiple regression analysis, suggesting that women anxious about adverse pregnancy outcomes had lower postpartum QoL than their counterparts. Despite the importance of psychological factors on postpartum QoL, our results revealed that only 2.86% of the population sought psychological counselling, lower than that reported in developed countries [21] and comparable to general maternity trends in China [39]. The unpopularity of mental health care highlights the urgent need for HCPs to offer consultation and psychological support throughout pregnancy while ensuring continuity of care.

The following are potential limitations of our study. As an observational cross-sectional study, it cannot show causality but can serve as a basis for future research. Second, there is a selection bias because the sample consists of MDT consultation patients with more significant health literacy, and emotionally troubled patients might refuse to participate. Third, the small sample size, single-center design, and uneven participant distribution limit generalizability, despite diverse heart disease cases being included. Fourth, the EPDS is a screening instrument rather than a gold standard for postpartum depression diagnosis. Last, data on QoL and psychological status data were collected only six weeks postpartum, without continued monitoring. Despite these limitations, this study provides valuable insights into the postpartum recovery of high-risk women and its implications for HCP care.

Our research revealed that women with heart disease typically experienced challenges during maternity. To improve their well-being, HCPs should recognize their specific requirements, offer education, improve communication, and provide psychological support. Creating individualized treatment strategies from pregnancy to postpartum can optimize healthcare utilization, improve healing, and eventually assist these women in self-managing their heart issues.

QoL

Quality of Life

SF-12

12-Item Short-Form Health Survey

EPDS

Edinburgh Postnatal Depression Scale

CAQ

Cardiac Anxiety Questionnaire

EHFScBS

European Heart Failure Self-Care Behavior Scale

mWHO classification

modified World Health Organization pregnancy risk classification

MDT

multidisciplinary team

HCPs

healthcare professionals

HFA

Heart-focused anxiety

PCS

Physical Component Summary

MCS

Mental Component Summary

D-W

Durbin-Watson

VIF

variance inflation factor

7.1 Ethical approval and consent to participate: The proposal for this study was approved by the Ethics Committee of The General Hospital of Northern Theater (Y2023116). The study was conducted in accordance with the Declaration of Helsinki. There were no minors or individuals unable to read participated in this study. Participants were assured that all their information was confidential and that general publication of the project's results would not include their names or details. Informed consent was obtained from the participants.

7.2 Consent for publication: Not applicable.

7.3 Data Availability: All data generated and analyzed during this study are included in this article.

7.4 Competing interests: All authors have declared no competing interests.

7.5 Funding: This work was supported by the Liaoning Province Science and Technology Program (2021JH2/10300095).

7.6 Each author’s contributions: JL and DQ were involved in the design and conduct of the study as well as the interpretation of data. JL contributed to the statistical design of the study and the interpretation of data. QW was involved in the design of the study and interpretation of data. JL, QW, and DQ contributed as clinical experts for data interpretation. All authors participated in the development of the manuscript and approved the final version for submission.

7.7 Acknowledgments: The authors would like to thank all participants for their cooperation in the study.

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No competing interests reported.

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Study on the influencing factors of postpartum quality of life in women with heart disease

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Abstract

1. Introduction

2. Methods

2.1 Study protocol

2.2 Participants

2.3 Measurement

2.3.1 Postpartum Depression

2.3.2 Heart-focused Anxiety

2.3.3 Medical Behavior Adherence

2.3.4 Quality of Life

2.4 Statistical methods

3. Results

3.1 Participants

3.2 Objective medical characteristics and postpartum quality of life

3.3 Emotional and psychological characteristics, compliance, and postpartum quality of life

3.4 Determinants of Postpartum Quality of Life

4. Discussion

5. Conclusion

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

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