ARTICLE IN PRESS Sexual & Reproductive Healthcare ■■ (2015) ■■–■■

Contents lists available at ScienceDirect

Sexual & Reproductive Healthcare j o u r n a l h o m e p a g e : w w w. s r h c j o u r n a l . o r g

Health-related quality of life five years after birth of the first child Anna-Karin Klint Carlander a,*, Ellika Andolf a, Gunnar Edman b,c, Ingela Wiklund a a

Department of Clinical Sciences, Division of Obstetrics and Gynaecology, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden Department of Psychiatry, Tiohundra AB, Norrtälje, Sweden c Department of Neurobiology, Care Sciences and Society, Centre of Family Medicine, Karolinska Institutet, Stockholm, Sweden b

A R T I C L E

I N F O

Article history: Received 19 July 2014 Revised 14 January 2015 Accepted 16 January 2015 Keywords: Quality of life Health-related quality of life Mode of delivery Follow-up

A B S T R A C T

Objectives: The aim of this study was to describe the overall health-related quality of life (HRQoL) in women five years after the birth of their first child as well as the HRQoL in relation to mode of delivery. Methods: 545 first-time pregnant women, drawn from a hospital situated in Sweden, consented to be included in a cohort. Five years after the birth of the first child, 372 (68%) women agreed to participate in a follow-up study. HRQoL was measured using the Swedish Health-Related Quality of Life Survey (SWEDQUAL) questionnaire. Socio-demographic background and variables related to pregnancy and childbirth were collected using a self-report questionnaire. Results: Overall, the HRQoL was perceived to be good. Suboptimal scores were obtained for the three variables: Sleeping problems, Emotional well-being – negative affect and Family functioning – sexual functioning. Women having a vaginal birth, an instrumental vaginal birth or women who underwent caesarean section on maternal request were more likely to report better perceived HRQoL than women who had undergone an emergency caesarean section or caesarean section due to medical indication. Conclusion: This study demonstrates that the overall HRQoL of the women in the cohort was reported as good. Mode of delivery was associated with differences in HRQoL five years after birth of the first child. Our result suggests that some differences in perceived HRQoL persist in the long term. © 2015 Published by Elsevier B.V.

Introduction Health Related Quality of Life (HRQoL) is a multidimensional concept that refers to aspects such as general health, physical functioning, physical symptoms, emotional functioning, role functioning, social support and well being, sexual functioning and also existential issues [1,2]. The concept of HRQoL has evolved to include those aspects of overall quality of life that may affect health, either physical or mental [3]. To give birth to the first child is a major event in life and involves many changes, both from a physical as well as a psychological perspective, which may affect women’s quality of life. Postpartum mothers’ experience of certain physical and psychological health issues may affect their life and future health. The health of a new mother might not only be important for her own well-being, but might also affect the newborn child and the family. The standard 6-week postnatal visit is the last routine assessment following childbirth, marking the end of the puerperium based on the assumption that the women then are physically recovered. Nevertheless,

* Corresponding author. Department of Clinical Sciences, Danderyd Hospital, Division of Obstetrics and Gynaecology, SE-182 88 Stockholm, Sweden. Tel.: +46 8 655 78 88. E-mail address: [email protected] (A.-K.K. Carlander).

there are studies showing that some time after childbirth many physical and emotional health problems like extreme tiredness, headache, perineal pain, urinary incontinence and depressive symptoms, are rather common [4–8] and that some symptoms even appear to increase during the first year of parenthood [5–7]. It has also been suggested that there is a relationship between the woman’s mode of delivery and perceived health. Women who had a caesarean section or an assisted vaginal birth have been found to report lower postpartum general health status during the first year after birth as compared to women with unassisted vaginal birth [4,6,8,9]. Moreover, postnatal physical health or social health issues have been found to be risk factors for poorer mental health and postnatal anxiety [10,11]. Although there are some studies of the effects of recent motherhood on general health status [12–15] it remains unclear how women perceive their health and HRQoL in a longer perspective. The aim of this study was to describe the overall HRQoL as well as the HRQoL in relation to mode of delivery, in women five years after the birth of their first child. Methods This study is a five-year follow-up of a prospective matched cohort study.

http://dx.doi.org/10.1016/j.srhc.2015.01.005 1877-5756/© 2015 Published by Elsevier B.V.

Please cite this article in press as: Anna-Karin Klint Carlander, Ellika Andolf, Gunnar Edman, Ingela Wiklund, Health-related quality of life five years after birth of the first child, Sexual & Reproductive Healthcare (2015), doi: 10.1016/j.srhc.2015.01.005

ARTICLE IN PRESS A.-K.K. Carlander et al./Sexual & Reproductive Healthcare ■■ (2015) ■■–■■

2

Ethical approval

Swedish Health-Related Quality of Life questionnaire

Ethical approval was obtained by the Research Ethics Committee of Karolinska Institute, Stockholm, Sweden, Dnr 2007/1614-31. Written consent was obtained from all participants. The participants were informed that they could withdraw from the study at any time.

The HRQoL in this study was measured with the Swedish HealthRelated Quality of Life questionnaire (SWED-QUAL), an inventory developed by Brorsson and colleagues [17], based on the Medical Outcomes Study (MOS) [18,19]. The inventory consists of 61 items summarized into seven scales, which measures the following aspects of HRQoL: Physical function, Pain, Role functioning, Emotional well-being, Sleep, General health perceptions, and Family functioning (Table 1). All items were administrated using a “during the last week” or “now” time frame. The items are designed as both questions and statements with both positive and negative response alternatives. Items within a health domain are summed and linearly transformed into scores 0–100% of the maximum score, where a high score indicates better HRQoL/more favourable HRQoL state. The questionnaire is translated and tested for use in Swedish populations. In a general population sample the reliability, which was calculated by using Cronbach’s α, coefficients, ranged from 0.79 to 0.89. Preliminary support for the construct validity has also been reported [17]. A cut off was set at 70% and women who scored below 70% of the maximum score were considered to have suboptimal quality of life. The main reason why we chose a cut off level at 70% was based on clinical judgement and the fact that we studied a healthy sample. A variety of different instruments for measurement of health have been developed, for example SF36 [20] and EQ-5D [21,22] Based on our knowledge, there is no specific instrument measuring the health and quality of life among childbearing women. In our case the SWED-QUAL was preferred, as it is rather brief with wider approaches to the concept of health considered to be appropriate for women of childbearing age. Unlike the more well-known HRQoL instrument SF-36 it includes issues of quality of life such as sleep, family, partner functioning and sexual functioning, which were considered to be aspects of interest for this study.

Setting The hospital, where this study was conducted, is situated in the northern part of Stockholm, Sweden, and has two labour wards with approximately 10,000 deliveries per year. The caesarean section rate in the two labour wards including both primiparous and multiparous was 23% and 16% respectively in 2012. Elective caesarean section accounted for approximately 10% of all deliveries. The percentage of instrumental vaginal deliveries in the two labour wards was 6% and 8% respectively. The area, where the study was conducted, is a well-situated area of the Stockholm County.

Participants The women in this study gave birth to their first child between January 2003 and June 2005. The criteria for inclusion at baseline were being a healthy, Swedish-speaking, first-time mothers with a normal pregnancy in gestational week between 37 and 39 weeks. In order to find participants for the case-group, with a planned caesarean section, one of the researchers identified patients scheduled for elective caesarean section at the hospital. One of the researchers telephoned the women scheduled for elective caesarean section, provided them with information about the study and asked if they were willing to participate. For every woman scheduled for a caesarean section one to two controls living in the same geographical area as the case-group and planning a vaginal birth were consecutively telephoned and asked to participate. In total, 545 healthy first-time mothers with normal pregnancies were recruited. Data from this cohort have previously been reported in several articles and details of the recruitment process and study procedures have been described elsewhere [16]. Five years after the birth of the first child, all women from the cohort were invited to participate in a follow up study; 372 (68% of the initial cohort) accepted to continue to participate in the followup. Two hundred and forty-nine or 67% of those who had agreed to the follow-up completed two questionnaires. The participants had five different modes of delivery: vaginal birth (n = 86), instrumental vaginal birth (n = 25), emergency caesarean section (n = 25), caesarean section on maternal request (n = 38) and caesarean section due to medical indication (n = 75). Women who underwent an elective caesarean section due to breech presentation were referred to as caesarean section on medical indication. Caesarean section on maternal request is referred to an elective birth on maternal request in the absence of any medical or obstetric indications.

Table 1 Quality of life items in SWED-QUAL. Scale

Description

Physical functioning (7)

Perform activities (work, sports, stairs, dressing) Need for assistance Satisfaction with ability to do what one wanted Pain frequency, intensity and interference with daily activities, sleep and mood

Mobility (1) Satisfaction with physical ability (1) Pain (6) Role limitations due to Physical health (3) Emotional health (3) Emotional well-being Positive affect (6) Negative affect (6)

Questionnaires Five years after the participants gave birth to their first child a letter with information about the follow-up study and an enquiry to participate was distributed to the cohort. If they agreed to continue to participate in the study they were asked to return a written consent. Two separate forms designed for self-administration concerning estimated health and HRQoL were then sent out. The participants were asked to complete the forms, marked with an identification number, and to return them in a closed envelope. If questionnaires were not returned within three weeks, a reminder was sent out.

Sleep problems (6) General health perception Current health (2) Prior health (2) Resistance to illness (3) Health concern (1) Family functioning Satisfaction with family (4) Marital functioning (6) Sexual functioning (4)

Extent to which physical problems interfere with activities of daily living Extent to which physical health problems interfere with activities of daily living A happy person, harmonic, feel liked, optimistic Felt nervous, tense, down, sad, impatient, annoyed Sleep initiation, maintenance, somnolence Overall rating of health Been sick for a long time Ones body resists illness quite well Concerns about own health Satisfaction with cohesiveness, talking things over, understanding Expressing wishes, sharing feelings, being supportive Lack of interest, inability to enjoy sex

Number in parenthesis indicates the number of items for that scale.

Please cite this article in press as: Anna-Karin Klint Carlander, Ellika Andolf, Gunnar Edman, Ingela Wiklund, Health-related quality of life five years after birth of the first child, Sexual & Reproductive Healthcare (2015), doi: 10.1016/j.srhc.2015.01.005

ARTICLE IN PRESS A.-K.K. Carlander et al./Sexual & Reproductive Healthcare ■■ (2015) ■■–■■

General questionnaire This questionnaire was designed by the research team and consists of 32 questions about socio-demographic background, the overall health and issues related to pregnancy and childbirth. The items were designed as both questions and statements. A four-point Likert scale (1 = “Does not apply at all” to 4 = Applies completely) was used and the participants rated their agreement. In order to collect data on issues related to pregnancy and childbirth the questionnaire included questions concerning miscarriage or abortion after the first pregnancy, parity and complications during the next pregnancies. Questions regarding the overall health included topics such as estimation of the state of health the past three months, tobacco-use as well as questions regarding leakage of urine or faeces and coital pain. Statistical analysis The Statistical Package for Social Sciences (SPSS) version 22 was used for statistical analysis. All variables were summarized with standard descriptive statistics such as frequency, mean and range. Differences between types of birth in the HRQoL variables were tested with one-way analysis of variance and Kruskal–Wallis H test for severely skewed variables. Post-hoc tests were conducted with Tukey’s HSD test. Chi-square tests were used for analyses of categorical data (e.g. dropout vs. mode of delivery). Relationships between the HRQoL variables were expressed as non-parametric Kendall’s rank order correlation coefficients. The level of significance was set to 5% (two-tailed) in all analyses.

3

Table 2 Characteristics of the participating women five years after birth of the first child (n = 249). Age Civil status Living with a partner Not living with a partner Country of birth Sweden Other countries University degree Tobacco user Smokes Snuff Body Mass Index ≤ 18.5 18.6–24.9 25–29.9 ≥ 30 Miscarriage Abortions Delivery of first child Vaginal birth Instrumental vaginal birth CS on maternal request CS on medical indication Emergency CS Paritya One child Two children or more

Mean: 36.9 Range: 23–47 n (%) 220 (94) 13 (6) 219 (90) 25 (10) 172 (70) 14 (6) 8 (4) 9 (4) 168 (76) 34 (15) 11 (5) 54 (23) 33 (14) 86 (35) 25 (10) 38 (15) 75 (30) 25 (10) 62 (25) 183 (75)

a Categories may not sum up to the total number of 249 due to sporadic missing data. CS = Caesarean section.

Dropouts Out of the 372 women who agreed to participate in the followup study five years after the first birth, 33% (n = 123) of the women did not return the questionnaire. A dropout analysis was performed. The analysis was based on a number of background variables considered to be of particular interest for this study such as educational level, age, experience of childbirth (measured by the Visual Analogue Scale – VAS), mode of delivery as well as variables measuring postpartum depression (Edinburgh Postnatal Depression Scale – EPDS) and personality traits (Karolinska Scales of Personality – KSP). Results Background of the respondents Characteristics of the participants are shown in Table 2. The age of the participants ranged from 23 to 47 years and the average maternal age was 37 years. The majority of women was living with a partner (94%), was of Swedish origin (90%), had a university degree (70%) and was not a tobacco user (90%). The result of the dropout analysis showed that the dropout rate was higher among women who had a university degree (61% within the group of women who had a university degree compared to 39% among those without a university education). There was also a higher dropout rate among women who underwent caesarean section on maternal request compared with the other groups (68% for women who underwent a caesarean section on maternal request, 60% for women who had a vaginal birth, 48% for women who underwent a caesarean section due to medical reasons, 51% for women who underwent an emergency caesarean section and 55% for the group of women who had an instrumental vaginal birth). Also, there were significant differences in some of the personality variables. Women with somatic anxiety (p = 0.024), muscular tension (p = 0.031) and psychic anxiety (p = 0.010) replied to the questionnaire to a lesser extent. The analysis showed no significant differences between the

respondents and the non-respondents regarding age, postpartum depression and childbirth experience at two days postpartum. Self-perceived health-related quality of life of the participants Fig. 1 provides an overview of the perceived HRQoL among all women included in the study. More than half of the participants reported maximum score on the following variables; Physical functioning (M = 95,74 and Md = 100), Mobility (M = 71.58 and Md = 100), Satisfaction with physical ability (M = 89.26 and Md = 100), Pain (M = 88.46 and Md = 100), Role limitations due to physical health (M = 93.20 and Md = 100), Role limitations due to emotional health (M = 94.10 and Md =100), General health perceptions – prior health (M = 93.65 and Md = 100), General health perception – resistance to illness (M = 83.94 and Md = 100), General health perception – health concern (M = 86.01 and Md = 100). Three of the variables had a mean score below 70%, namely, the variables Sleeping problems, Emotional well-being – negative affect and Family functioning – sexual functioning. Thirty-four per cent of the women reported sleeping problems (M = 66.28 and Md = 70.83), 33% reported Emotional well-being – negative affect (M = 67.11 and Md = 75) and 30% of the women reported lower scores on Family functioning – sexual functioning (M = 69.71 and Md = 81.25). A separate analysis was performed in order to investigate if there were any factors that were related to the variables with a mean score below 70% using some of the variables from the general questionnaire as explanatory variables (bandage for leakage of urine the last seven days, leakage of urine the last seven days, leakage of faeces the last seven days, coital pain and parity). The result shows that leakage of urine for the last seven days (p = 0.028) or having a second child or more (p = 0.041) was related to a poorer Family functioning – sexual functioning. The analysis also showed a negative association between more than one child and the variable Role limitations due to physical health (p = 0.039). A significant negative association was observed between coital pain and the variables

Please cite this article in press as: Anna-Karin Klint Carlander, Ellika Andolf, Gunnar Edman, Ingela Wiklund, Health-related quality of life five years after birth of the first child, Sexual & Reproductive Healthcare (2015), doi: 10.1016/j.srhc.2015.01.005

ARTICLE IN PRESS A.-K.K. Carlander et al./Sexual & Reproductive Healthcare ■■ (2015) ■■–■■

4

Fig. 1. The overall perceived HRQoL among all women (n = 249) included in the study according to the Swedish Health-Related Quality of Life survey. All values represent scale mean scores for HRQoL [range 0 (worst) – 100 (best possible)].

Emotional well-being – negative affect (p = 0.036), Family functioning – sexual functioning (p < .001) and Mobility (p = 0.040). HRQoL in relation to mode of delivery Means, standard deviations, chi square (χ2) and p-values for the items in SWED-QUAL, five years after the birth of the first child, are presented in Table 3. As shown in the table, differences in HRQoL were found. Women with a vaginal birth and women in the group who requested a caesarean section at birth of the first child were significantly more likely to agree with the statement regarding a resistance to illness (My body resists illness quite well; p < .001) in comparison with women having undergone a instrumental vaginal birth or women who had undergone an emergency caesarean section or caesarean section due to medical indication. Women with a vaginal birth, an instrumental vaginal birth or caesarean section on maternal request were less likely to report health concerns (My health worries me; p = 0.029) compared with women who had undergone an emergency caesarean section or a caesarean section

due to medical indication. Women who had undergone a vaginal birth, an instrumental vaginal birth or a caesarean section on medical indication were also significantly more likely to report higher scores on the variable General health perceptions – prior health (rating of prior and current health; p = 0.043) compared with the other groups. Discussion To our knowledge, there are no previous studies examining the health and HRQoL of women after childbirth in the longer term. The key findings in this five-year follow-up of a prospective cohort study are that the overall HRQoL of the women in the cohort was reported as good, although some aspects such as Sleeping problems and Family functioning – sexual functioning indicated problems for the women. Mode of delivery was associated with differences in HRQoL five years after birth of the first child. This study showed that the women in the cohort generally experienced their HRQoL as rather good. Since the population in the area of the study is healthy and well educated compared to other

Please cite this article in press as: Anna-Karin Klint Carlander, Ellika Andolf, Gunnar Edman, Ingela Wiklund, Health-related quality of life five years after birth of the first child, Sexual & Reproductive Healthcare (2015), doi: 10.1016/j.srhc.2015.01.005

ARTICLE IN PRESS A.-K.K. Carlander et al./Sexual & Reproductive Healthcare ■■ (2015) ■■–■■

5

Table 3 Quality of life five years after the birth of the first child according to the Swedish Health-Related Quality of Life survey (SWED-QUAL) in relation to mode of delivery; vaginal birth (n = 86); instrumental vaginal birth (n = 25); caesarean section on medical indication (n = 75); caesarean section on maternal request (n = 38); and emergency caesarean section (n = 25). Variable

Mode of delivery

M

SD

Physical functioning

Vaginal birth Instrumental vaginal birth CS on medical indication CS on maternal request Emergency CS Vaginal birth Instrumental vaginal birth CS on medical indication CS on maternal request Emergency CS Vaginal birth Instrumental vaginal birth CS on medical indication CS on maternal request Emergency CS Vaginal birth Instrumental vaginal birth CS on medical indication CS on maternal request Emergency CS Vaginal birth Instrumental vaginal birth CS on medical indication CS on maternal request Emergency caesarean Vaginal birth Instrumental vaginal birth CS on medical indication CS on maternal request Emergency CS Vaginal birth Instrumental vaginal birth CS on medical indication CS on maternal request Emergency CS Vaginal birth Instrumental vaginal birth CS on medical indication CS on maternal request Emergency CS Vaginal birth Instrumental vaginal birth CS on medical indication CS on maternal request Emergency CS Vaginal birth Instrumental vaginal birth CS on medical indication CS on maternal request Emergency CS Vaginal birth Instrumental vaginal birth CS on medical indication CS on maternal request Emergency CS Vaginal birth Instrumental vaginal birth CS on medical indication CS on maternal request Emergency CS Vaginal birth Instrumental vaginal birth CS on medical indication CS on maternal request Emergency CS

95.6 95.8 96.6 94.4 95.4 67.8 75.0 76.1 77.1 60.9 91.5 89.6 86.8 88.9 89.4 90.1 89.5 86.9 88.5 86.5 94.4 93.8 90.5 92.9 97.6 93.8 98.6 92.2 96.9 94.2 74.4 77.3 74.2 82.6 74.0 65.7 70.1 64.9 77.5 61.6 67.3 74.5 63.0 67.1 66.1 86.4 84.9 80.4 87.7 83.3 96.8 95.3 89.5 94.4 91.8 88.4 80.5 77.0 92.7 76.6 90.6 90.6 79.0 92.4 77.2

12.23 7.14 7.90 13.10 11.79 46.74 44.72 42.27 42.60 49.90 21.53 20.07 28.09 25.91 18.93 14.89 14.45 17.39 16.57 11.61 15.42 13.44 20.37 15.97 8.18 14.70 5.56 16.13 8.23 14.16 21.79 16.45 21.12 16.62 18.37 26.68 29.78 28.08 25.06 26.47 22.11 16.02 22.83 26.39 21.07 18.34 23.02 23.67 14.70 14.43 10.41 12.81 20.69 18.53 17.11 20.12 35.05 28.14 18.27 27.26 22.09 25.62 31.85 15.61 33.64

Vaginal birth Instrumental vaginal birth CS on medical indication CS on maternal request Emergency CS Vaginal birth Instrumental vaginal birth CS on medical indication CS on maternal request Emergency CS Vaginal birth Instrumental vaginal birth CS on medical indication CS on maternal request Emergency CS

84.4 86.7 80.5 79.6 85.8 81.5 82.0 79.2 71.1 83.5 69.3 78.1 67.4 64.1 82.1

18.66 15.33 25.20 27.67 19.10 20.09 18.24 23.08 29.39 16.79 30.05 27.58 28.70 31.56 20.07

Mobility

Satisfaction with physical ability

Pain

Role limitations due to physical health

Role limitations due to emotional health

Emotional well-being, positive affect

Emotional well-being, negative affect

Sleeping problems

General health perceptions, current health

General health perceptions, prior health

General health perceptions, resistance to illness

General health perceptions, health concern

Family functioning, satisfaction with family

Family functioning, marital functioning

Family functioning, sexual functioning

χ2

p

0.64

0.959

3.07

0.546

1.61

0.807

3.72

0.445

5.13

0.274

4.26

0.372

5.31

0.257

9.16

0.057

4.21

0.379

3.70

0.448

9.87

0.043

20.26

0.000

10.77

0.029

0.54

0.969

2.55

0.636

6.85

0.144

CS = Cesarean section.

Please cite this article in press as: Anna-Karin Klint Carlander, Ellika Andolf, Gunnar Edman, Ingela Wiklund, Health-related quality of life five years after birth of the first child, Sexual & Reproductive Healthcare (2015), doi: 10.1016/j.srhc.2015.01.005

ARTICLE IN PRESS 6

A.-K.K. Carlander et al./Sexual & Reproductive Healthcare ■■ (2015) ■■–■■

municipalities [23], the findings that the overall HRQoL within the women in the cohort was reported as relatively good is not surprising and may reflect a generally high health status and quality of life in the area. Moreover, it was found that Sleeping problems, Emotional well-being – negative affect and Family functioning – sexual functioning indicated problems for the women. These findings are consistent with previous reports showing that both physical and emotional health problems like tiredness, urinary incontinence and depressive symptoms, are common following childbirth [4–8] and that some symptoms even appear to increase during the first year of parenthood [5–7]. It seems that the findings do not only apply to the first year after birth but, as demonstrated in this study, also appear to persist in the long term. Differences in perceived HRQoL were evident when parity (more than one child), urinary incontinence and coital pain were taken into account. The result showed that leakage of urine or parity (more than one child) had a negative association with Family functioning – sexual functioning. Parity was also negatively related to Role limitations due to physical health. Coital pain had a negative association with Emotional well-being – negative affect, Family functioning – sexual functioning and Mobility. Although it is difficult to prove that these variables are causally related to childbirth, they give an indication that some factors related to childbearing may have an impact on women’s health in the long term. In a prospective cohort study including 1507 women it was found that physical health problems commonly persist or recur throughout the first 18 months postpartum, with potential long-term consequences for women’s satisfaction with their life. The authors concluded that a postnatal check-up at six weeks is likely to provide only a limited protection for certain health problems that may persist in the long term after childbirth [24]. A qualitative study conducted in Sweden showed that the women had hoped to be able to discuss physical changes after childbirth and its consequences at the postpartum check-up but were disappointed when their problems were not addressed [25]. The authors suggest that a second check up after a few months might be valuable. Given these results, and as physical and emotional problems seem to persist for some time after childbirth [4–8,24], an alternative approach to post partum check up might be of importance for the women and their health. Mode of delivery was associated with HRQoL outcomes five years after birth. It was found that women who had undergone an emergency caesarean section or caesarean section due to medical indication were less likely to report a resistance to illness in comparison with women having undergone a vaginal or instrumental vaginal birth and women who underwent caesarean section on maternal request at birth of their first child. Moreover, women with a vaginal birth, an instrumental vaginal birth or a caesarean section on maternal request were less likely to report health concerns and reported higher ratings of prior and current health compared with women in the other groups. These results indicate that women having a vaginal or instrumental vaginal birth or women who underwent caesarean section on maternal request at birth of their first child in some respects were more likely to report better perceived HRQoL than women who had undergone an emergency caesarean section or caesarean section due to medical indication. These findings are to some extent consistent with previous research, which has shown that women who had caesarean section or assisted vaginal birth report poorer HRQoL than women with a vaginal birth, within the first year after giving birth [4,6,8,9]. In addition, our results distinguish themselves in terms of perceived quality of life by showing that there are differences depending on the indication for caesarean section since women who underwent a caesarean section on maternal request reported more favourable HRQoL status than those who had an emergency caesarean or a caesarean section due to medical indication. Previous research has suggested that the risk of experiencing psychological reactions after childbirth is higher after

emergency caesarean section births and instrumental vaginal birth [26–28]. As for our findings, it is interesting to note that emergency caesarean section is associated with both short-term and long-term consequences on the self-perceived HRQoL. Besides women undergoing emergency caesarean section, it was also found in our study that women undergoing a caesarean section due to medical indications reported a less favourable HRQoL. Since a caesarean section has been associated with poorer HRQoL and with negative psychological effects, women who have had such a birth might not recover from their psychological state as rapidly as women following an uncomplicated birth. Our findings also revealed that the group of women, who underwent a caesarean section on maternal request, was more likely to report better perceived health and quality of life. On the contrary, it has been reported that women requesting caesarean section experienced their health as less good in late pregnancy and postpartum, compared to those planning a vaginal birth [16]. In a qualitative study it was found that women requesting a caesarean section have had difficulties with preparing themselves for their parenthood prior to the decision to have a caesarean section [29], which in turn may be an explanation that they experienced poorer health during pregnancy. Besides the documented physical effects following childbirth [4,6–8], the family structure changes as well. Having a child is a major adjustment and involves many changes of life. At baseline, only firsttime mothers were included, meaning that they at the same time were going through the great transformation that it means to become a parent for the first time. From this aspect, the results in this study offers a picture of perceived quality of life in a long term perspective for women in the cohort with the same starting point in terms of childbearing. Strengths and limitations Several potential limitations should be considered. First, this study has a limitation in not having measured a number of variables of importance for the self-perceived HRQoL. In addition to the variables investigated in this study, there are probably many other factors, both physical and psychological, that have an impact on the women’s self-perceived quality of life, for example if the woman suffered from any illness, was pregnant or had recently given birth at the time of measurement or was affected by psychological aspects such as being in grief for some reason. Neither was socio-economic factors or the family situation investigated, such as unemployment or if the women were divorced, which probably also is relevant to the perceived quality of life. The objective of the study was partly to study HRQoL in relation to mode of delivery at first birth. To describe mode of delivery in relation to HRQoL for those participants who have given birth to more than one child would probably provide additional interesting information to the study. Furthermore, there is no data on how the participants rated their HRQoL before the birth of their first child since HRQoL was measured at only one timepoint. This can be seen as a limitation since a comparison could have provided significant information to the study. A further limitation of the study is that the participants consist of a selected group of women from an area where the population is healthy, better off, and well educated compared to other municipalities. Thus, the results in this study are possible to generalize only to populations in similar contexts. Since differences in general health and quality of life status may be attributable to factors other than the birth method, and as this study was implemented five years after the first birth, no conclusive explanations regarding the causal relationship between self-perceived quality of life and mode of delivery can be made. The majority of the women in the cohort had given birth to second child (75%) within five years after the birth of the first child.

Please cite this article in press as: Anna-Karin Klint Carlander, Ellika Andolf, Gunnar Edman, Ingela Wiklund, Health-related quality of life five years after birth of the first child, Sexual & Reproductive Healthcare (2015), doi: 10.1016/j.srhc.2015.01.005

ARTICLE IN PRESS A.-K.K. Carlander et al./Sexual & Reproductive Healthcare ■■ (2015) ■■–■■

Accordingly, it is possible that some women were pregnant or recently had given birth at the time when the study was conducted, which in turn might have influenced their perceived HRQoL at this moment. However, our results provide evidence on how women perceive their HRQoL five years after giving birth to the first child and therefore give a picture of their quality of life in a long-term perspective. The strengths of the study include the recruitment of first-time mothers in late pregnancy, frequent follow-up of participants up to five years after their first birth as well as the use of an instrument that has been standardized for a broad spectrum of the Swedish population. Moreover, the fact that there was a rather homogenous cohort can be seen as strength, as participants at baseline consisted only of healthy first-time mothers with no experience of childbearing and the effect on their perceived HRQoL. In this five-year follow-up study, a high proportion (33%) of the women did not return the questionnaire. A non-response analysis has been performed in order to compare respondents and non-respondents for differences that could be correlated with non-response bias and to investigate if this loss can be considered to have an affect on the representativeness of the survey results. Since there was a higher dropout rate among women who underwent caesarean section on maternal request compared with the other groups, this could possibly have influenced the results. Even if dropout was significantly more common in certain groups in this cohort the result of this study is interesting because it probably reflects life after childbirth as it can be for many women. In addition, it would have been interesting to investigate how women without children perceive their HRQoL. Conclusion The findings of this study showed that the overall perceived HRQoL of the women in the cohort was reported as rather high five years after the birth of their first child. However, some aspects such as sleeping and sexual functioning indicated problems for the cohort. Women having a vaginal birth, an instrumental vaginal birth and women who underwent caesarean section on maternal request at birth of their first child were more likely than others to report a better perceived HRQoL. Further studies, both large-scale as well as studies with qualitative design, are needed to increase the body of knowledge and to get a deeper understanding for women’s health and quality of life after childbirth. Funding The study has been supported by BB Stockholm and grants from Praktikertjänst AB. References [1] Fayers PM, Machin D. Quality of life: the assessment, analysis and interpretation of patient-reported outcomes. West Sussex: John Wiley & Sons Ltd; 2007. [2] Fallowfield L. What is quality of life? 2nd ed. Hayward Medical Communications; 2009.

7

[3] Centers for Disease Control and Prevention. Measuring healthy days: population assessment of Health-Related Quality of Life. Atlanta. ; 2000 [accessed 27.09.13]. [4] Brown S, Lumley J. Maternal health after childbirth: results of an Australian population based survey. Br J Obstet Gynaecol 1998;105(2):156–61. [5] Saurel-Cubizolles MJ, Romito P, Lelong N, Ancel PY. Women’s health after childbirth: a longitudinal study in France and Italy. BJOG 2000;107(10):1202–9. [6] Schytt E, Hildingsson I. Physical and emotional self-rated health among Swedish women and men during pregnancy and the first year of parenthood. Sex Reprod Healthc 2011;2(2):57–64. [7] Schytt E, Lindmark G, Waldenström U. Physical symptoms after childbirth: prevalence and associations with self-rated health. BJOG 2005;112(2):210–17. [8] Thompson JF, Roberts CL, Currie M, Ellwood DA. Prevalence and persistence of health problems after childbirth: associations with parity and method of birth. Birth 2002;29(2):83–94. [9] Lydon-Rochelle MT, Holt VL, Martin DP. Delivery method and self-reported postpartum general health status among primiparous women. Paediatr Perinat Epidemiol 2001;15(3):232–40. [10] Woolhouse H, Gartland D, Perlen S, Donath S, Brown SJ. Physical health after childbirth and maternal depression in the first 12 months post partum: results of an Australian nulliparus pregnancy cohort. Midwifery 2014;30(3):378–84. [11] Yelland J, Sutherland G, Brown SJ. Postpartum anxiety, depression and social health: findings from a population-based survey of Australian women. BMC Public Health 2010;10:771. [12] Coyle SB. Health-related quality of life of mothers: a review of the research. Health Care Women Int 2009;30(6):484–506. [13] Hill PD, Aldag JC. Maternal perceived quality of life following childbirth. J Obstet Gynecol Neonatal Nurs 2007;36(4):328–34. [14] Symon A. A review of mothers’ prenatal and postnatal quality of life. Health Qual Life Outcomes 2003;1:38. [15] Webster J, Nicholas C, Velacott C, Cridland N, Fawcett L. Quality of life and depression following childbirth: impact of social support. Midwifery 2011;27(5):745–9. [16] Wiklund I, Edman G, Andolf E. Caesarean section on maternal request: reasons for the request, self-estimated health, expectations, experience of birth and signs of depression among first time-mothers. Acta Obstet Gynecol Scand 2007;86(4):451–6. [17] Brorsson B, Ifver J, Hays RD. The Swedish Health-Related Quality of Life survey (SWED-QUAL). Qual Life Res 1993;2(1):33–45. [18] Stewart A, Sherbourne CD, Hays RD, Wells KB, Nelson EC, Kamberg C, et al. Summary and discussion of MOS measures. In: Stewart AL, Ware JE, editors. Measuring functioning and well-being: the medical outcomes study approach. Duram, NC: Duke UniversityPress; 1992. p. 345–71. [19] Stewart AL, Hays RD, Ware JE Jr. The MOS short-form general health survey: reliability and validity in a patient population. Med Care 1988;26(7):724–35. [20] Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992;30(6):473–83. [21] Dolan P. Modeling valuations for EuroQol health states. Med Care 1997;35(11):1095–108. [22] Rabin R, de Charro F. EQ-5D: a measure of health status from the EuroQol Group. Ann Med 2001;33(5):337–43. [23] Burström B, Hemmingsson T, Burström K, Corman D, Farah A, Gustavsson A, et al. Livsvillkor, levnadsvanor och hälsa i Stockholms län – öppna jämförelser 2010. Stockholm: Karolinska Institutets folkhälsoakademi; ; 2010 [accessed 10.10.2013]. [24] Woolhouse H, Perlen S, Gartland D, Brown SJ. Physical health and recovery in the first 18 months postpartum: does cesarean section reduce long-term morbidity? Birth 2012;39(3):221–9. [25] Olsson A, Lundqvist M, Faxelid E, Nissen E. Women’s thoughts about sexual life after childbirth: focus group discussions with women after childbirth. Scand J Caring Sci 2005;19(4):381–7. [26] Ryding EL, Wijma K, Wijma B. Psychological impact of emergency cearseran section in comparison with elective ceaseran section, instrumental and normal vaginal delivery. J Psychosom Obstet Gynaecol 1998;19:135–44. [27] Ryding EL, Wijma K, Wijma B. Posttraumatic stress reactions after emergency caesarean section. Acta Obstet Gynecol Scand 1997;76(9):856–61. [28] Rowlands IJ, Redshaw M. Mode of birth and women’s psychological and physical wellbeing in the postnatal period. BMC Pregnancy Childbirth 2012;12:138. [29] Sahlin M, Carlander-Klint AK, Hildingsson I, Wiklund I. First-time mothers’ wish for a planned caesarean section: deeply rooted emotions. Midwifery 2013;29(5):447–52.

Please cite this article in press as: Anna-Karin Klint Carlander, Ellika Andolf, Gunnar Edman, Ingela Wiklund, Health-related quality of life five years after birth of the first child, Sexual & Reproductive Healthcare (2015), doi: 10.1016/j.srhc.2015.01.005

Health-related quality of life five years after birth of the first child.

The aim of this study was to describe the overall health-related quality of life (HRQoL) in women five years after the birth of their first child as w...
585KB Sizes 3 Downloads 8 Views