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ORIGINAL ARTICLE
Year : 2022  |  Volume : 66  |  Issue : 3  |  Page : 295-299  

Does the mode of delivery affect the health-related quality of life? A comparative analysis


1 Resident, Department of Community Medicine, Lady Hardinge Medical College, New Delhi, India
2 Director Professor and Head, Department of Community Medicine, Lady Hardinge Medical College, New Delhi, India

Date of Submission12-Dec-2021
Date of Decision06-Apr-2022
Date of Acceptance31-Jul-2022
Date of Web Publication22-Sep-2022

Correspondence Address:
Pallika Singh
Department of Community Medicine, Lady Hardinge Medical College, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.ijph_2149_21

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   Abstract 


Background: Health-related quality of life (HRQoL) of postpartum mothers is a multidimensional concept and is relatively neglected in both researches and in practice as most postpartum researches have focused on the physical complications. In line with the global trends, India has witnessed a sharp rise in cesarean section (CS) deliveries and has become a global concern for the health of the mother as well as her quality of life. Objectives: This study was conducted to analyze and compare the HRQoL after normal vaginal delivery and CS in the postpartum women. Methods: It was a community-based cross-sectional study and a predesigned, pretested interview schedule was used in the form of a questionnaire including the Medical Outcomes Study Short Form 36 Health Survey for HRQoL. The study was conducted in a resettlement colony, Kalyanpuri located in Delhi, India with a total population of 25,754 with 4596 eligible couples in 4302 households from November 2018 to March 2020. The study participants comprised of a sample size of 330 post-partum women and the data were collected in the 6th week of post-partum period. Results: In our study, there were statistically significant (P < 0.05) differences with mode of delivery as one of the predictors of HRQoL of postpartum mothers. The study subjects with vaginal delivery had higher mean HRQoL score under all the domains. Conclusion: In CS, reduced physical activity, body pain not only affected the mental health domain score but also significantly impacted the emotional domain. Promoting the use of family planning services is also significant in improving maternal health and should be made a provision of quality of care and strengthening of quality improvement and sustainable quality assurance mechanisms are major problem-solving steps in improving access to healthcare.

Keywords: Caesarean section, health-related quality of life, postpartum women, quality of life


How to cite this article:
Singh P, Rasania S K. Does the mode of delivery affect the health-related quality of life? A comparative analysis. Indian J Public Health 2022;66:295-9

How to cite this URL:
Singh P, Rasania S K. Does the mode of delivery affect the health-related quality of life? A comparative analysis. Indian J Public Health [serial online] 2022 [cited 2022 Nov 26];66:295-9. Available from: https://www.ijph.in/text.asp?2022/66/3/295/356603




   Introduction Top


Cesarean section (CS) as a mode of delivery is increasing around the world and has become a global concern for the health of the mother as well as her quality of life. In line with the global trends, India has witnessed a sharp rise in CS deliveries, especially in the private sector. This global epidemic of CSs, increased from 12% in 2000 to about 21% in 2015.[1] High CS rates are of concern because they expose the mother and child to short-term and long-term health risks and impose a financial burden on families and health systems[2] thereby, increasing the incidence of surgical interventions and problems resulting from hospitalization and thus affecting the quality of life in women after delivery.[3] Adding to this, the fear of labor pain has also been responsible in causing a decline in normal vaginal delivery. The reason behind this unethical practice might be money making in the private sector or inadequate knowledge of gynecologists. CSs should be reserved to treat or prevent foetal and maternal complications, but in reality, this has not been the actual practice.[4] While many countries have a CS rate indicative of reduced access to this lifesaving procedure, the majority have a rate above the 10%–15% range that is considered to be medically justifiable.[5] The postpartum period may have a significant impact on physical, emotional, and social health, and hence, the quality of a woman's life especially of an underprivileged community and to assist women in informed decision making. Therefore, they need more attention during this period. Health-related quality of life (HRQoL) is an important indicator of the quality of healthcare.[6] The World Health Organization (WHO) defined Quality of Life as “An individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns. It is a broad concept, affected in a complex way by the person's physical health, psychological state, and level of independence, social relationships, personal beliefs, and their relationship with environmental characteristics.”[7]

Most postpartum researches have focused on physical complications. HRQoL of postpartum mothers is relatively neglected in both researches and in practice. This study aims to compare the quality of life in women after normal delivery and CS. Exploring predictors affecting the quality of life of postpartum women which will eventually improve the perceptions of their quality of life which is an essential measure of the quality and effectiveness of maternal and child health interventions. Paucity of literature and dearth of community-based research in the aspects of quality of life among post-partum women in the study area and largely in India are also one of the major concerns being addressed through this study.

Cesarean sections have been increasing worldwide and have become a global concern. Cesarean sections should be reserved to treat or prevent fetal and maternal complications, but in reality, this has not been the actual practice.[1] Fear of labor pain and an increased tendency toward cesarean section have been causing a decline in normal vaginal delivery. According to the WHO, cesarean sections have been increasing worldwide and have become a global concern. Cesarean sections should be reserved to treat or prevent fetal and maternal complications, but in reality, this has not been the actual practice.[1] Fear of labor pain and an increased tendency toward cesarean section have been causing a decline in normal vaginal delivery. According to the WHO, cesarean sections have been increasing worldwide and have become a global concern. Cesarean sections should be reserved to treat or prevent fetal and maternal complications, but in reality, this has not been the actual practice.[1] Fear of labor pain and an increased tendency toward cesarean section have been causing a decline in normal vaginal delivery. According to the WHO, cesarean sections have been increasing worldwide and have become a global concern. Cesarean sections should be reserved to treat or prevent fetal and maternal complications, but in reality, this has not been the actual practice.[1] Fear of labor pain and an increased tendency toward cesarean section have been causing a decline in normal vaginal delivery.


   Materials and Methods Top


It was a community-based cross-sectional study, conducted to find out the HRQoL among post-partum women residing in a resettlement colony at Kalyanpuri area of East Delhi, India.

The study population

The area is divided into 11 blocks with a total population of 25,754 with 4596 eligible couples in 4302 households. The study was carried out from November 2018 to March 2020 and comprised of the postpartum women in the age group of 15–49 years who delivered in the year 2019. The study subjects were asked questions and the data were collected in the 6th week of postpartum period.

The study subjects

The total number of 330 study subjects was included in the study as the sample size. Enrolment of study subjects was started with registration during the antenatal period during third trimester, from the registers of ASHA/Anganwadi workers.

Sample size

The sample size was calculated within 95% confidence limit using the following formula:



Where, N is the required sample size, σ is standard deviation (SD), d is the precision. Based on SD of HRQoL = 22,[8] Precision (d) =2.5 at 95% confidence interval and power of 80%, calculated sample size is 298. Assuming the nonresponse rate of 10%. The calculated minimum sample size will be 328.

The total number of 330 study subjects was included in the study.

Inclusion criteria for subjects

All postpartum women residing in the study area in Kalyanpuri resettlement colony of Delhi.

Exclusion criteria for subjects

There were no exclusion criteria set as all the females who delivered between January 1, 2019 and December 15, 2019 were included in the study.

Sampling and enrolment of study subjects

Enrolment of study subjects was started with registration during antenatal period during third trimester, from the registers of ASHA/Anganwadi workers. This study involved convenience sampling (nonprobability sampling method) for the collection of data. Enrolment continued till the end of October 2019. The study population comprised of all the post-partum women who delivered between January 1, 2019 and December 15, 2019 in the resettlement colony of Kalyanpuri, East Delhi. Data collection was done between January 1, 2019 and December 31, 2019.

Study tools

A predesigned, pretested, validated and a semistructured interview schedule was used in the form of a questionnaire in the study. The questionnaire consisted of three parts. Part I included general information of the subjects. Part II consisted of maternal and child health factors in antepartum, intra partum and post-partum period. Part III included a standardized questionnaire, namely Medical Outcomes Study Short Form 36 Health Survey was used in this study for information related to HRQoL followed by the general physical examination of the study subject. The scoring of SF-36 was done according to the SF-36 Health Survey Manual and Interpretation Guide.[9]

Data analysis and interpretation

A sample size of 330 study subjects was included in the study. Data collected in the pro forma were coded, entered, and analyzed using the IBM SPSS Statistics 25 SPSS Inc. Released 2017. SPSS for Windows, Version 25.0. (Chicago, SPSS Inc.). All observations were analyzed using the unpaired't' test and ANOVA and P < 0.05 was considered to be statistically significant.

Ethical considerations

The study protocol was approved by the Institutional Ethical Committee, Lady Hardinge Medical College, New Delhi. A written consent was taken from the study subjects in the language that they understand before the administration of the study. The privacy and confidentiality of the study subjects was maintained.

Standard working definitions

  • Quality of life: It is an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns. It is a broad ranging concept affected in a complex way by the person's physical health, psychological state, personal beliefs, social relationships, and their relationship to salient features of their environment[7]
  • Mistreatment and abuse: The term “mistreatment” includes physical abuse and neglect, psychologic abuse, financial exploitation, and violation of rights.[10]


It also includes physical abuse, nonconsented clinical care, nonconfidential care, nondignified care (including verbal abuse), discrimination based on specific patient attributes, abandonment or denial of care, and detention in facilities.[11]

  • Postpartum period: The term postnatal” should be used for all issues pertaining to the mother and the baby after birth. The postnatal period begins immediately after the birth of the baby and extends up to 6 weeks (42 days) after birth[12]
  • The terms “postpartum period” and “postnatal period” are often used interchangeably, “postpartum” refers to the issues pertaining to the mother and “postnatal” refers to the issues concerning the baby. The terms “antenatal,” “antepartum,” “intranatal,” and “intrapartum” refer to issues pertaining to events before or during childbirth.[12]



   Observations and Results Top


We studied a total of 330 women.

Majority of the subjects in our study were in the age of 21–35 years (87%). The mean age for study subjects was 25.33 ± 4.0 years. Most of the study subjects, i.e. 269 (81.5%) were literate and 186 (56.4%) of them were educated up to high school and above. Most 213 (64.5%) of the study subjects belonged to the joint family, whereas 117 (35.5%) subjects lived in the nuclear family. Majority of the study subjects, i.e. 211 (63.9%) lived in pucca houses and 68.8% families lived in overcrowded living conditions. More than half (55.8%, n = 184) of the study subjects belonged to upper lower socio-economic status according to the Modified Kuppuswamy Scale CPI, 2018 [Table 1].
Table 1: Distribution of the study subjects according to their age, literacy status, type of family, overcrowding, type of house and socioeconomic status

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Among the study subjects, 46.1% had birth order one followed by 113 (34.2%) with birth order two. Only 4.8% subjects had birth order of more than three. More than half 188 (57%) of the subjects were multigravida. One hundred and forty-two (43%) participants were primigravida among the study participants. Majority of the study subjects 247 (74.8%) delivered in Government hospitals and 10.9% subjects delivered in the private hospitals. Among the participants, 14.2% subjects delivered at home.

Among the study subjects, 78.2% had vaginal delivery and had higher mean HRQoL score of 69.0 ± 18.0 as compared to CS (47.8 ± 14.9). The participants with vaginal delivery had good median HRQoL score of 73.5 in comparison to the median score of 49.8 in CS in the present pregnancy. The difference was statistically significant. Unpaired t-test, (P < 0.05) [Table 2].
Table 2: Distribution of mean health related quality of life score of the study subjects according to the mode of delivery

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The mean score of eight (8) domains of HRQoL using SF-36 for normal vaginal delivery and CS was observed in postpartum women at six weeks. The study subjects with vaginal delivery had higher mean HRQoL score under all the domains as compared to CS. The mean scores of physical functioning (PF) (26.5 ± 22.0), role physical (3.1 ± 13.9), bodily pain (32.9 ± 14.0), vitality (55.1 ± 14.0), social functioning (57.6 ± 15.5) and mental health (68.7 ± 14.6) were significantly less in case of CS delivery. The mean scores of role physical (RP) were found to be the least among all. These above mentioned association were statistically significant. ANOVA, (P < 0.05) [Table 3].
Table 3: Distribution of average health-related quality of life scores of study subjects for various domains and mode of delivery

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   Discussion Top


In our study there were significant (P < 0.05) differences between HRQoL among women after normal vaginal delivery and CS and hence mode of delivery was one of the predictors of HRQoL of postpartum mothers. It showed that HRQoL at 6 weeks postpartum period was significantly better in women with vaginal delivery. These findings of superior physical health, vitality (59.7 ± 15.2) and social functioning (68.8 ± 16.5) of the new mother after a normal vaginal delivery showed better quality of life domain scores among the study subjects. A study by Torkan et al.[13] in 2008 in Iran which showed congruence with the results of our study, it concluded that the normal vaginal delivery group showed more improvements on physical HRQoL while the CS group showed more improvements on mental HRQoL. The overall mothers in normal delivery group reported a better HRQoL and slightly scored higher (better) on the SF-36 questionnaire. The study subjects with vaginal delivery resumed their daily activities early in time with better general health and good self-appraisal of health and improved quality of life. CS was not simply a mode of childbirth, but a surgical intervention particularly emergency surgery resulting in hospitalisation and requiring greater care in the postpartum period with regular follow-ups in the postpartum period. The mean score of RP (3.1 ± 13.9) domain of SF-36 questionnaire was the least among all implying to reduced PF and excessive bodily pain as major health outcomes after a CS which often lead to mental stress, depression and neglect by the family members with poor quality of care in the postpartum period which even lead to significant reduction in Mental Health domain score (68.7 ± 14.6) after CS. In CS, reduced physical activity, body pain not only affected the mental health domain score but also significantly impacted the emotional domain (66.7 ± 45.1) of the study subject. Surgical interventions in the form of CS often lead to financial hardships in the family due to excessively high costs of treatment in the private hospitals which eventually impacted the emotion and mental health domains of Quality of Life of the mothers in the postpartum period. There were many studies that assessed morbidity and mortality resulting from vaginal delivery and CS, but only a few studies had focused on women's postpartum HRQoL. The results of the present study are in line with a study conducted by Sadat et al.[14] in 2007–2008 and Malik et al.[3] in 2017 in Pakistan which concluded that physical HRQoL at 2 and 4 months after delivery is better in women with Vaginal Delivery and postpartum quality of life of most of the women undergoing normal vaginal delivery was better as compared to women undergoing CSs. There were significant differences in the PF and RP domains at 2 months and in the PF domain at 4 months. In another similar study by Kavosi et al.[15] in 2015 in Iran concluded that NVD group had the highest mean score in physical health domains; the women with water birth had the highest mean score in mental health domains and total QOL.


   Conclusion and Recommendations Top


This study of HRQoL in post-partum women focuses on the neglected women healthcare and the aspects affecting the quality of care and HRQoL in mothers during pregnancy and postpartum period in Indian scenarios. In the above study, it was noticed that mothers undergoing vaginal delivery recovered earlier and had superior physical health than the ones who had undergone CS. The subjects with vaginal delivery resumed their daily activities early in time with better general health, mental and emotional health with improved quality of life. The study subjects with vaginal delivery resumed their daily activities early in time and thus, the overall mothers in normal delivery group reported a better HRQoL and scored higher (better) on the SF-36 questionnaire.

Women form an important pillar of the society. They are the primary caretaker of children in every country of the world. Improving the well-being of women is an important public health goal for India. The perinatal period is considered to be the most vulnerable and critical and yet the most neglected phase in the lives of mothers and babies which on the other hand is the most suitable for impactful interventions in the form of creating awareness, imparting knowledge regarding the importance of quality of life. A regular review of indications of CSs at health facilities should be made mandatory. Promoting the use of family planning services is also significant in improving maternal health and should be made a provision of quality of care as higher levels of contraceptive uptake and decreasing the unmet needs is still a challenge in various high burden states in India. Strengthening of quality improvement and sustainable quality assurance mechanisms are the major problem solving steps in improving access to healthcare and achieving “Health for All” agenda and is absolutely critical for India to achieve its Sustainable Development Goals 2030 (SDG)target of reducing maternal mortality.

Limitations

This study has some limitations:

  1. Paucity of literature and dearth of community based research in the aspects of quality of life among post-partum women in the study area and largely in India was also one of the major limitation of this study.
  2. The study was carried out in a small number of the study participants residing in a single geographical area which has limited the chances of its extrapolation on the general population in the country and represent variation of all the country population. For detailed results, similar studies on larger sample size might provide greater insights on the aspects of quality of life of postpartum women in India.
  3. This was a cross-sectional study where one time data were collected and therefore does not take into account any improvement or worsening of quality of life among the postpartum women in the study area.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Boerma T, Ronsmans C, Melesse DY, Barros AJ, Barros FC, Juan L, et al. Global epidemiology of use of and disparities in caesarean sections. Lancet 2018;392:1341-8.  Back to cited text no. 1
    
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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. Available from: https://pubmed.ncbi.nlm.nih.gov/27022506/. [Last accessed on 2021 Nov 30].  Back to cited text no. 8
    
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Ware JE, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey Manual and Interpretation Guide. Boston, MA: New England Medical Center, The Health Institute; 1993.  Back to cited text no. 9
    
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Swagerty DL Jr., Takahashi PY, Evans JM. Elder mistreatment. Am Fam Physician 1999;59:2804-8.  Back to cited text no. 10
    
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WRA. Respectful Maternity Care: The Universal Rights of Childbearing Women. Washington, DC: White Ribbon Alliance; 2011. Available from: https://www.whiteribbonalliance.org/wp-content/uploads/2017/11/Final_RMC_Charter.pdf. [Last accessed on 2021 Nov 30].  Back to cited text no. 11
    
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WHO Technical Consultation on Postpartum and Postnatal Care. Geneva: World Health Organization; 2010. Available from: https://www.who.int/maternal_child_adolescent/documents/WHO_MPS. [Last accessed on 2021 Nov 30].  Back to cited text no. 12
    
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Torkan B, Parsay S, Lamieian M, Kazemnezhad A, Montazeri A. Comparative analysis of life quality in mothers after cesarean section and normal vaginal delivery. Iran J Nurs Midwifery Res 2008;12:1-5.  Back to cited text no. 13
    
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Sadat Z, Taebi M, Saberi F, Kalarhoudi MA. The relationship between mode of delivery and postpartum physical and mental health related quality of life. Iran J Nurs Midwifery Res 2013;18:499-504.  Back to cited text no. 14
    
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Kavosi Z, Keshtkaran A, Setoodehzadeh F, Kasraeian M, Khammarnia M, Eslahi M. A comparison of mothers' quality of life after normal vaginal, cesarean, and water birth deliveries. Int J Community Based Nurs Midwifery 2015;3:198-204.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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