Health-related quality of life measured by SF-36 among postdelivery mothers attending maternal and child health clinic in Eastern Nepal: a cross-sectional study

Objectives: Assessing health-related quality of life (HRQoL) and its associated factors is essential for providing adequate healthcare and developing necessary interventions in women postdelivery. This study intended to find out the HRQoL score and related factors among women postdelivery in Nepal. Methodology: This was a cross-sectional study using nonprobability sampling conducted at a Maternal and Child Health (MCH) Clinic in Nepal. The study participants were 129 women postdelivery to 12 months who visited the MCH Clinic from 2 September 2018 to 28 September 2018. Outcome measures were sociodemographic, clinical indicators, obstetric indicators, and their relation with the overall HRQoL score of postdelivery mothers using the Short Form Health Survey (SF-36) Version 1. Results: Of 129 respondents, 68.22% were in the 21–30 age group, 36.43% were upper caste, 88.37% were Hindu, 87.60% were literate, 81.39% were homemakers, 53.49% with income less than 12 months, 88.37% had family support, and 50.39% with vaginal deliveries. HRQoL was significantly more in employed women (P=0.037), those with family support (P=0.003), and those who had a cesarean section (P=0.02) and wanted pregnancy (P=0.040). Conclusion: HRQoL in women postdelivery can be influenced by employment status, family support, type of delivery, and desirability of pregnancy.

Introduction WHO defined quality of life (QoL) 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' [1] . QoL is a broad concept, and nowadays, the term health-related quality of life (HRQoL) is employed, which can be defined as a subjective understanding regarding one's own physical and mental health over time [2] . HRQoL can assess people's self-reported health issues and devise interventions to address those issues at the individual, population, and policy-making levels [3] .
After childbirth, the body undergoes many physical, physiological, and psychological changes [4][5][6] . In this phase, women are vulnerable to various health-related issues and disorders. Psychiatric disorders such as postpartum depression, anxiety, and rarely psychosis can occur [7,8] . Other conditions, such as postpartum hemorrhage and cardiomyopathy, can also occur [9,10] . These conditions can negatively affect the health of the mother and child. Hence, it is crucial to assess the HRQoL to provide the best care and necessary interventions.
Various sociodemographic and obstetric factors can contribute to the HRQoL in women postdelivery. Nepal's National Demographic and Health Survey (NDHS) in 2016 showed that ∼41% of deliveries were done at home without assistance from trained healthcare workers [11] . Also, the survey revealed a big socioeconomic divide; only 34% of women in the lower quintile and only 38% without formal education underwent institutional delivery [11] . The scenario was similar regarding postnatal care, with only 37% of women in the low quintile availing of postnatal care compared to 81% of women in the high quintile [11] . Moreover, cesarean section deliveries were more likely in private facilities, urban areas, and among women with formal education [11] . In addition, women in low-quantile, rural areas and without formal education were more likely to have problems accessing health care [11] . These barriers may lead to poor QoL in women.

HIGHLIGHTS
• Health-related quality of life in women postdelivery can be influenced by employment status, family support, delivery type, and pregnancy desirability. • This study provides baseline data for future studies on the quality of life in women postdelivery in Nepal.
Jeong et al. [12] found marital intimacy as the most crucial element influencing the QoL in women postdelivery. Another study showed an association between relationship satisfaction and higher HRQoL scores [13] . From these studies, we can understand the importance of a woman's relationship with their spouse and its association with HRQoL. Also, occupational status can significantly influence the HRQoL of a mother [12] . Studies have shown that employed women had higher psychological and environmental HRQoL postpartum [14,15] . However, Malaju et al. [16] reported that postpartum women who worked outside their homes had poorer HRQoL. Other studies did not find any significant association of HRQoL with different modes of delivery [17,18] , level of education [15,19] , and income level [15,19] . Sadat et al. [20] reported that vaginal deliveries were associated with better HRQoL than cesarean section deliveries. In contrast, Malaju et al. [16] reported that women with vaginal deliveries were likelier to have a poorer HRQoL. Also, lower income was associated with poorer HRQoL after childbirth [21,22] . Level of education also affects the HRQoL [16,23] , with lower education levels in women significantly associated with a lower HRQoL [16] . In contrast, some studies have reported that higher education was significantly associated with a lower HRQoL [14,24] .
Earlier studies have found various associated factors of HRQoL among women postdelivery. However, there were discrepancies in the findings of various studies, which varied in different settings. Also, the NDHS 2016 showed that women with low socioeconomic status faced difficulty accessing maternal healthcare services. In addition, no investigation was conducted in Nepal using the SF-36 questionnaire. All the factors revealed a need to study the HRQoL in women postdelivery. Hence, we aim to assess the HRQoL and its associated factors among women postdelivery in Nepal.

Study design
This cross-sectional study involved women postdelivery to 12 months who visited the Maternal and Child Health (MCH) Clinic in Nepal.

Setting
Nepal has 125 government hospitals under the Ministry of Health and Population, with 18 government hospitals in Province 1 [17,25] . The study site is one of the oldest government hospitals in Province 1, providing preventive, curative, and promotive services to the public of eastern Nepal. The MCH Clinic of our selected study site caters to immunization, family planning, and abortion services in the eastern region of Nepal.

Study population
The study population included the mothers who attended the MCH clinic from postdelivery to 12 months postdelivery. Mothers with psychiatric disorders were excluded from the study population.

Sample size and sampling technique
We used a nonprobability purposive sampling technique to select mothers meeting the inclusion criteria. The sample size was calculated at a 95% CI with a 5% allowable error based on an SD of 27.71 by using the formula σ = / n z d 2 2 2[17] , where n is the required sample size; z is the value of standard normal variate at the desired level of confidence; σ is the variance; and d is the allowable error.
Hence, . We considered a nonresponse rate of 10%. Hence, the total sample size was 129.

Questionnaire design
We used Short Form Health Survey (SF-36) Version 1.0 to assess study participants' HRQoL after obtaining permission for Research and Development (RAND) [26] . RAND SF-36 was already validated for use in Nepal by Bhandari et al. [27] . However, we again pretested the translated Nepali SF-36 among 13 mothers in another MCH Clinic in Nepal. Cronbach's α was used to test the reliability, and the reported value was 0.752. Patient participants were involved in the study's pretesting. However, there was no public involvement in our research. The final questionnaire included three sections.

Section 1: Sociodemographic information
This part included questions about the mother's age, marital status, educational level, ethnicity, religion, occupation, family income, type of family, and support. Ethnicity was classified based on the NDHS 2016 survey of Nepal [11] . To better understand socioeconomic status, upper caste, and relatively advantaged Janajati were combined as a privileged group. Similarly, Dalit, disadvantaged non-Dalit terai, religious minorities, and disadvantaged Janajati were categorized as underprivileged. Categorizing income level was done based on the study by Mishra et al. [28] .

Section 2: Questions related to obstetric variables
This part included obstetric variables, including parity, number of living children, place of delivery, mode of delivery, postpartum duration, the desirability of pregnancy, and maternal complications. This part consisted of the RAND SF-36 version 1.0 questionnaire tool with 36 questions translated into various languages [26] . It measures eight health-related concepts: physical functioning, role limitation due to physical problems (role-physical), bodily pain, general health perceptions, vitality (energy and fatigue), social functioning, role limitation due to emotional problems (role-emotional), and perceived mental health/emotional wellbeing [26] . QoL is the composite summary of two domains Physical Health-Related Quality of Life (PQoL)/Physical Component Summary (PCS) and Mental Health-Related Quality of Life (MQoL)/Mental Component Summary (MCS) [26] . PQoL includes physical functioning, role-physical, bodily pain, and general health [29] . MQoL includes vitality, social functioning, role-emotional and mental health [29] .
The scores on each subscale range from 0 to 100 [30] . A zero score indicates the lowest level of health measurement on the scale, and higher scores indicate better HRQoL. The questions were combined and weighted on two scales, that is PCS and MCS [29] . The mean for each SF-36 subscale was classified into poor HRQoL level (with a score of 0-49) and a good level of HRQoL (with a score of 50-100) [30] .

Variables studied
Independent variables: age of mother, education status, ethnicity, religion, occupation, family income, type of family, family support, parity, number of living children, the desirability of pregnancy, mode of delivery, postpartum duration, place of delivery, and complications in recent delivery.

Dependent variable
Overall health-related QoL score of postdelivery mothers.

Data collection
Data was collected through face-to-face interviews using the RAND SF-36 Nepali version questionnaire from 2 September 2018 to 28 September 2018. We collected a total of 129 responses (Fig. 1).

Statistical analysis
The collected data were entered into an excel spreadsheet, followed by data cleaning. Then the data were exported into Statistical Package for Social Sciences (SPSS) software version 16 for analysis. Data analysis was done by using descriptive and inferential statistics. Descriptive statistics, that is number, percentage, mean, and standard deviation, were used to describe the demographic and obstetric variables. Mann-Whitney U test was applied to compare postnatal mothers' QoL in different delivery modes. Similarly, Kruskal-Wallis H and Mann-Whitney U tests were used to examine the difference between the QoL of postnatal mothers with selected sociodemographic and obstetric variables. Statistical significance was considered with a P value 0.05 or less. This work has been reported in line with STROCSS (strengthening the reporting of cohort, cross-sectional and case-control studies in surgery) 2021 criteria [31] .

Obstetric characteristics
More than half (70, 54.26%) of the respondents were primiparous, and approximately three-fifths (60.46%) had only  HRQoL Table 3 shows the mean score of the QoL in different domains. In the physical QoL domain, the highest (74.65) mean score was observed in physical functioning, whereas the lowest (48.26) mean score was observed in role limitation due to physical health. For the mental QoL, the highest mean score (86.43) was observed in social functioning, whereas the lowest (48.58) mean score was observed in role limitation due to emotional health. The QoL in the mental component score was 64.48 14.18. Likewise, the physical component's mean score was 64.09 15.49. The postnatal mothers' overall QoL score was 64.28 12.87.

Sociodemographic and obstetric predictors of HRQoL
Employed women (P = 0.037) and those with family support (P = 0.003) had significantly higher QoL (Table 4). Women with cesarean section (P = 0.020) and desirable pregnancies (P = 0.040) deliveries had a significantly higher QoL in the mental health subscale than women with vaginal delivery (Table 5). Also, women with desirable pregnancies (P = 0.040) had higher QoL than those with unwanted pregnancies (Table 6). We did not observe any statistically significant difference between the physical, mental, and overall QoL of respondents with different modes of delivery. Also, no statistically significant relation of QoL with parity, living children, duration of the postpartum period, place of delivery, and complications in recent delivery was found.

Discussion
We found that the overall QoL was good in women postdelivery and was significantly associated with cesarean delivery (in the mental health subscale), occupation, family support, and pregnancy desirability. The women in whom pregnancy was desirable, employed, underwent cesarean section deliveries, and had support from spouse and family members reported a higher HRQoL score.

Sociodemographic indicators
We found a significant association between QoL with family support, with better QoL among respondents with supportive families. The role of the spouse in general and regarding marital intimacy can also significantly impact the QoL in women postdelivery [12] . Studies by Akýn et al. [21] , Nohara et al. [32] , and Nishida et al. [33] found a significant relationship between QoL and support from spouses and family members. This might be because adequate family support in activities like rest and sleep and emotional and physical care might help improve QoL. Overall, our study findings highlighted the importance of support from family and spouse for maintaining a good QoL.

Obstetric indicators
A longitudinal study done in Spain did not find any significant difference in the QoL with different delivery modes [34] . Studies by Sadat et al. [20] and Moawad et al. [35] found better mental health after vaginal delivery. Davis et al. [36] reported a higher QoL in women with vaginal delivery. Also, a meta-analysis by Evans et al. [37] found a significantly higher QoL in women with vaginal delivery. However, similar to Torkan et al. [38] , we found a better mental QoL in women with cesarean delivery. This can be attributed to more care from family members following a surgical procedure, which is perceived as a complex event requiring more care. Though it is apparent that adequate care is being provided to mothers following cesarean section deliveries, there is also a  need to bridge the care gap for those who had vaginal deliveries. We also found a significant relationship between the QoL of mothers postdelivery and occupation, with employed mothers having a better QoL. This is in contrast to other studies, which reported better QoL in homemakers [35,39] , and a decreased QoL in women who resumed their work after delivery [16,40] . A better QoL among employed might be due to improved access to healthcare services before, during, and after delivery [11] . Another significant association was observed between the QoL of postnatal mothers and the desirability of pregnancy, with a better QoL in desirable pregnancies. In contrast to our findings, Gariepy et al. [41] found no significant association between QoL and desirability of pregnancy. However, Akýn et al. [21] and Hammoudeh et al. [42] found a significant association between QoL and desirability of pregnancy. This might be because women with desirable pregnancies are mentally prepared for motherhood and its challenges, perceiving their health as good.

Strengths and limitations
To the best of our knowledge, this is the first study conducted in Nepal using the SF-36 questionnaire in this study population. However, this study is not without limitations. Our study provides baseline data for future studies on the QoL in women postdelivery. We used nonprobability sampling because of which the results may not be generalized, and there is a possibility of information bias.

Policy and practice implications
This study highlighted the importance of the relationship between husband and wife and emphasized the need for support from other family members. In Nepal, 77% of men and 66% of women are married [11] . Hence, awareness programs highlighting the importance of a supportive relationship can significantly impact the QoL of child-bearing women and ultimately lead to better care of the newborn. Also, there is a need to identify the reasons for a significantly lower mean HRQoL score in the mental health subscale for women having vaginal deliveries. NDHS survey of Nepal reported that 57% of women were unemployed [11] . This is Table 5 Health-related quality of life (HRQoL) of the respondents in different modes of delivery (n = 129).   alarming as our study found better HRQoL in employed women.
Hence, mass employment drives should be launched to empower women, particularly in low-resource countries. This study also highlighted the importance of the desirability of pregnancy. The stakeholders should counsel the spouses regarding the significant impact of pregnancy desirability on the life of child-bearing women. Though employing women will require the stakeholders to launch various training programs after meticulous planning, other issues can be solved with minimal interventions. Preconceptional counseling of couples with emphasis on mutual support between spouses and educating couples about the importance of the desirability of pregnancy can be addressed by healthcare providers without additional costs.

Future research
The regional variations concerning the QoL with the mode of delivery and employment reflect a need to conduct studies to identify the exact relation in different settings. Hence, more studies with larger sample sizes and randomization are warranted to identify predictors of QoL in women postdelivery.

Conclusion
We can conclude that overall QoL was good among mothers postdelivery. The QoL of postnatal mothers following different delivery modes tends to be similar. Still, it tends to be better among postnatal mothers with cesarean section than vaginal deliveries in the mental health subscale. The QoL tends to be better among homemakers. And providing family support and making pregnancy desirable through proper counseling might help raise the QoL of postnatal mothers.

Patient consent for publication
The study subjects were enrolled only after obtaining informed written consent for both participation and dissemination of results.

Sources of funding
None.

Author contributions
P.C.: conceptualization, data acquisition, data analysis, data interpretation, making the first draft, and critically revising the manuscript; P.P. and A.A.: data analysis, data interpretation, making the first draft, and critically revising the manuscript; A.G. and D.S.: data interpretation, making the first draft, and critically revising the manuscript. All authors approved the final version of the manuscript and are accountable for all aspects of the work.

Conflicts of interest disclosure
There are no conflicts of interest.
Research registration unique identifying number (UIN) 1. Name of the registry: ClinicalTrials.gov. 2. Unique identifying number or registration ID: NCT05777382.

Data availability statement
Anonymized data will be made available on reasonable request.

Provenance and peer review
Not commissioned, externally peer-reviewed.