Health related quality of life and associated factors after cesarean delivery among postpartum mothers in Gondar, Ethiopia: a cross-sectional study | BMC Pregnancy and Childbirth

Study design and setting

This study used an institutional based cross-sectional study design conducted from April to June 2024 at public health facilities in Gondar town, Northwest Ethiopia. Gondar, the capital city of the Central Gondar administrative zone, is served by eight health centers and two hospitals providing immunization services. One hospital, University of Gondar Comprehensive Specialized Hospital and four health centers (Poly Health Center, Gabriel Health Center, Maraki Health Center, and Azezo Health Center) were randomly selected using a lottery method, taking into account the feasibility of the study.

Study population

The source population included all postpartum mothers who delivered via cesarean section in Gondar town. The study population consisted of mothers attending child immunization at public health facilities six weeks post-delivery.

Inclusion and exclusion criteria

The study included postpartum mothers aged 18 years and older who gave birth in Gondar town. Exclusion criteria encompassed women with physical disabilities (such as spinal cord injuries, amputations, paralysis, or limb deformities), those with preexisting chronic illnesses (including chronic hypertension, cardiovascular and pulmonary disorders, and neuropsychiatric conditions), and individuals who were unable to communicate or comprehend the study requirements.

Variables of the study

Independent variables were categorized into socio- demographic factors (age, BMI, marital status, education levels of both the mother and partner, occupation of both, family support, and number of living children) and obstetric-related and clinical factors (parity, antenatal care visits, birth order history, preterm labor, pregnancy desirability, postnatal care visits, pregnancy complications, postpartum anemia, HIV status, urinary incontinence, and postpartum depression). Additionally, anesthesia and surgery related variables includes urgency of the surgery, number of cesarean deliveries, type of anesthesia, type of postoperative analgesia, delivery complications, perceived pain after discharge, postoperative nausea and vomiting, and shivering.

Operational definition

The MOS-SF-36 contains eight domains comprising two main categories namely, physical and mental HRQoL. Each raw scale score on each domain was transformed from 0 to 100 (0–100 scale) by using the formula of transformed.

Physical component Summary (PCS) mean score of HRQoL is the arithmetic average of the transformed scores of physical functioning, role physical, bodily pain, and general health domains [11].

Mental component Summary (MCS) mean score of HRQoL is the arithmetic average of the transformed scores of social functioning, mental health; role emotional, and vitality domains [11]. Overall HRQoL mean score is the arithmetic average of the transformed score of the eight domains [37].

Higher HRQoL is when participants scored greater than or equal to the standardized mean value of 50 [38]. Lower HRQoL is when participants scored less than the standardized mean value of 50 [38].

Postpartum depression: was assessed by using an Edinburgh Postnatal Depression Scale (EPDS). According to the EDPS, study participants who scored ≥ 13 are considered as having postpartum depression and it is validated in Addis Ababa, Ethiopia [39].

Multidimensional scale of perceived social support of family support domain was utilized to assess the extent of perceived social support from their families. According to the scale, mean scale score ranging from 1 to 2.9 could be considered poor support, 3.0 to 5.0 could be considered moderate support and 5.1 to 7 could be considered strong support [40]. Postpartum anemia: is defined as hemoglobin < 10 g/dl or hematocrit < 30% during postpartum period [41].

Sample size and sampling procedure

The sample size for this study was calculated using the single population proportion formula, assuming a prevalence of 50% due to the absence of prior studies in Ethiopia assessing HRQoL among postpartum mothers following CD. The formula used was \(\:n=\frac{{\left(Z\raisebox{1ex}{$\alpha\:$}\!\left/\:\!\raisebox{-1ex}{$2$}\right.\right)}^{2}\rho\:\left(1-\rho\:\right)}{{\epsilon}^{2}}\), where n = initial estimated sample size, Z = Confidence level (α); α = 95%; \(\:Z\raisebox{1ex}{$\alpha\:$}\!\left/\:\!\raisebox{-1ex}{$2$}\right.\)=1.96,\(\:\:\rho\:\) = proportion;\(\:\:\rho\:=0.5\), \(\:\epsilon\:\)= marginal error;\(\:\epsilon\:\) =5%, resulting in an initial sample size of approximately 384. After adding a 10% non-response rate, the final sample size was set at 424. Sampling was conducted through simple random sampling, with samples allocated proportionally to each health facility. Participants meeting the inclusion criteria were consecutively recruited until the target sample size was achieved (Fig. 1).

Flow diagram of study participant recruitment for assessment of HRQoL of postpartum mothers after CD in Gondar town, 2024

Data collection procedure

Data were collected using structured and semi-structured questionnaires developed by the principal investigator, initially in English and subsequently translated into Amharic for simplicity. This translation was back-translated to ensure consistency by two bilingual experts. The questionnaire addressed socio-demographic variables, multidimensional social support, obstetric and clinical characteristics, postpartum depression, and HRQoL. Data were gathered through face-to-face interviews conducted in private settings. Additionally, information regarding pregnancy complications, postoperative hematocrit levels, types of postoperative analgesia, and delivery complications was extracted from medical records the day after the interview.

The MOS SF-36 was utilized to assess HRQoL across eight domains: physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional and mental health. Each domain was scored on a scale from 0 (worst) to 100 (best), with a Cronbach’s alpha above 0.70 for all domains, except for social functioning, which was 0.68 [11, 12, 42].

The EPDS, consisting of 10 items, was used to evaluate postpartum depression, demonstrating sensitivity and specificity of 78.9% and 75.3%, respectively, in a validation study in Ethiopia [39]. Additionally, perceived family support was measured using a 7-option Likert scale with a Cronbach’s alpha of at least 0.7 [43] (Annex I).

Data quality control

To ensure data quality, a pre-test was conducted with 5% of the calculated sample size prior to the main study. This pre-test facilitated necessary revision to the questionnaire, enhancing its clarity, logical flow, and skip patterns. Five data collectors participated in a comprehensive one-day training session, which covered research objectives, eligibility criteria, data collection tools, and procedures. The training also included protocols for addressing any acute pain or postpartum depression that participants may experience during the study. Additionally, the importance of maintaining confidentiality and implementing effective data quality management practices was emphasized. Throughout the data collection period, the principal investigator and supervisors conducted daily reviews of completed questionnaires to ensure data completeness and consistency.

Data processing and analysis procedures

Upon completion of data collection, variables were entered, coded, and cleaned for errors using Epi-data software, version 4.6. The cleaned data was then transferred to SPSS, version 25 for analysis. Descriptive statistics were computed in accordance with the MOS SF-36 tool developer’s guidelines [11]. Pre-coded numeric values were recorded, with 10 negatively worded items reverse-coded to ensure that higher scores reflected more favorable health states. Each item was scored on a scale of 0 to 100, using a transformation formula where 0 represented the worst possible health state and 100 the best. Items on the same scale was averaged together to create the 8-scale scores. Next, the PCS mean was computed from 4 scale scores namely physical functioning, role physical, bodily pain, and general health domain transformed scores, whereas the MCS mean was computed from the remaining 4 scale scores namely social functioning, mental health, vitality, and the role emotional domain transformed scores. The overall HRQoL mean was determined from the transformed scores of all eight domains, and participants were categorized into higher and lower HRQoL based on a standardized mean score of 50.

Socio-demographic characteristics, clinical factors, and obstetric-related variables were analyzed and presented in text and tables. Chi-square tests were employed to assess associations between independent variables and the outcome variable. Crude odds ratios (COR) and adjusted odds ratios (AOR) with 95% confidence intervals were calculated to evaluate the strength of associations with postpartum HRQoL. Bivariate and multivariate logistic regression analyses were conducted to explore the relationships between dependent and independent variables. Variables with a p-value < 0.25 in bivariate analyses were included in multivariate logistic regression, with a significance level set at p < 0.05 for identifying statistically significant factors associated with HRQoL. Model fitness was assessed using the Hosmer and Lemeshow goodness-of-fit test (p = 0.207), and multicollinearity was examined using the variance inflation factor, which revealed no significant issues. Normality data was checked using Kolmogorov-smirnov test with scatter plot. Normally distributed data was expressed with mean and standard deviation and median and interquartile range were employed for non-normally distributed data.