Introduction: The postpartum period can have a significant physical, emotional, and social impact on the quality of a woman’s life. Most postpartum research has focused on physical complications and only a few studies have specifically investigated quality of life. The purpose of this study was to explore predictors affecting the quality of life of postpartum Brazilian mothers. Study Design and Methods: A cross-sectional Quality of Life survey was performed in 210 Brazilian mothers during the early postpartum period. Data were collected using an interview technique and two instruments: 1) a maternal questionnaire and the 2) Maternal Postpartum Quality of Life tool/Brazilian version. The association between maternal characteristics and quality of life in the post-partum period was investigated with bivariate and multivariable analyses. Results: Mothers who had the best Quality of Life were white, registered students, 30 - 40 years of age, who were married or living with a partner, and without physical complaints; in addition, they had at least an 8th grade education, more than 4 children, and had attended more than 8 prenatal visits with a nurse. The stepwise model indicated that white race (p < 0.05) and married or living with a partner (p < 0.05) were the best predictors of Quality of Life in postpartum women. Conclusions and Clinical Implications: Marital status and race conditions may predict quality of life in postpartum Brazilian mothers. In addition, improved knowledge concerning the postpartum, maternal experience may help develop health interventions to enhance the quality of life of this population.
The postpartum period can have a significant physical, emotional, and social impact on the quality of life for new mothers due to complications such as postpartum depression [
The term quality of life (QoL) is the result of a historical process whose conceptual beginnings emerged in 384. B.C., when Aristotle referred to the association between happiness and well-being. The concept of QoL was outlined by philosophers, theologians and others, leading to improved conceptualizing of the topic over time [
Currently, there is a growing interest in transforming QoL into a quantitative measure using an individual’s perception to calculate QoL scores [
Therefore, the purpose of this study is to explore predictors affecting quality of life in postpartum Brazilian women using the MAPP-QoL. The specific aims are to describe the following: 1) maternal variables and quality of life in Brazilian mothers during the postpartum period, 2) the relationship between maternal variables and quality of life during the postpartum period, and 3) predictors of quality of life among Brazilian postpartum mothers.
This study was a cross-sectional survey of QoL in postpartum mothers in the city of Fortaleza in northeast Brazil. Data collection was performed between April and July of 2012. The study was approved by the ethics committee at Federal University of Ceara, Fortaleza, Brazil and all participants provided written informed consent prior to study commencement.
Eligibility criteria included: age ≥ 18 years (this procedure was used for each woman interviewed could sign his own term of responsibility to participate in the study.), between 7 and 10 days postpartum (recommendation from author of the scale) and without obstetric complications related to the current birth (enable the study of quality of life in women without clinical complications) or any physical or mental constraints (preventing them from understanding the study related interviews and questionnaires). Exclusion criteria included: multiple gestation, obstetric, or neonatal complications during or after childbirth as well as delivering an infant with congenital abnormalities. All eligible patients were contacted by the research team and asked to complete a questionnaire during their follow-up consultation in an Obstetrics & Gynecology clinic of a public hospital in Fortaleza city, Brazil. Among a population of 4356 women (total demand in 2011) who attended the clinic, a sample of 210 was selected according to the inclusion criteria. The selection of the sample (n = 210) was proceeded in a systematic way and non-probabilistic.
Data collection was conducted through interview technique, and guided by two data collection instruments: 1) the maternal socio-demographic and obstetric questionnaire and the 2) Brazilian version of the MPPQ-QoL. Maternal socio-demographic characteristics including age, marital status, occupation, educational level, monthly income (US $) of the patient and race were collected from the maternal interviews. Obstetric demographics included parity, number of children, type of delivery method, number of prenatal consultations, type of professional that performed prenatal care, and the type of QoL health education provided in prenatal visits as well as in the hospital prior to discharge.
The MAPP-QoL is an index for measure Quality of Life in postpartum period and was developed by Pamela Hill, Aldag, Hekel, Riner, & Bloomfield (2006) [
Data analysis was conducted using the Statistical Package for Social Sciences (SPSS), version 21.0 [
The t-test and One Way ANOVA test were used to perform bivariate analysis to check the association between the independent variables (maternal socio-demographic and obstetric characteristics) and the dependent variables (quality of life during the postpartum period―MAPP-QoL scores). Such associations were considered statistically significant when the p value was ≤0.05 [
The frequency distributions for socio-demographics and obstetric characteristics are shown in
Distribution of obstetric characteristics indicates the majority of women were multiparous (57.1%), with 2 or 3 children (45.7%). Type of delivery had a similar frequency (52.4% caesarian section and 47.6% vaginal). Only 72.4% of women reported they did not experience physical complaints during the postpartum period. Over half of all mothers (59.0%) attended between 6 and 8 prenatal visits (average was 3 visits) and 54% of these visits were performed by a physician. More than half of women did not receive health education regarding QoL during the postpartum period; however, 67.6% received health education regarding QoL in the hospital immediately
Characteristics | N (%) | Mean (±SD*) | Value | |
---|---|---|---|---|
Min | Max | |||
Demographics | ||||
Age (years) | ||||
≤20 y | 48 (22.9) | 26.87 (±7.28) | 18 | 45 |
21 - 30 y | 89 (42.4) | |||
31 - 40 y | 61 (29.0) | |||
>40 y | 12 (5.7) | |||
Marital status | ||||
Married/with partner | 167 (79.5) | - | ||
Single | 43 (20.5) | - | ||
Occupation | ||||
Unemployed | 19 (9.0) | - | ||
Housewife | 49 (23.3) | - | ||
Student | 10 (4.8) | - | ||
Formal employment | 66 (31.4) | - | ||
Informal employment | 66 (31.4) | - | ||
Education | ||||
8th grade or less | 74 (35.3) | - | ||
Grades 9 - 11 | 31 (14.8) | - | ||
High school | 90 (42.9) | - | ||
Some college | 7 (3.3) | - | ||
Bachelor’s degree | 8 (3.8) | - | ||
Monthly income (U$) of the patient | ||||
<678.00 | 98 (46.7) | 524.90 (±419.26) | 0 | 3.333 |
678.00 - 1017.00 | 89 (42.4) | |||
˃1017.00 | 23 (11.0) | |||
Race | ||||
White | 186 (88.6) | - | ||
Black | 20 (9.5) | - | ||
Asian | 4 (1.9) | - | ||
Obstetrics | ||||
Parity | ||||
Primiparous | 90 (42.8) | 1.97 (±1.46) | 0 | 11 |
Multiparous | 120 (57.1) | |||
Number of children | ||||
1 | 93 (44.3) | 1.99 (±1.30) | 1 | 11 |
2 - 3 | 96 (45.7) | |||
≥4 | 21 (10.0) | |||
Type of delivery (last) | ||||
Abdominal | 110 (52.4) | - | ||
Vaginal | 100 (47.6) | - |
Physical complaints | ||||
---|---|---|---|---|
No | 152 (72.4) | - | ||
Yes | 58 (27.6) | - | ||
Number prenatal visits | ||||
None | 3 (1.4) | 2.85 (±0.65) | 1 | 14 |
<6 | 54 (25.7) | |||
6 - 8 | 124 (59.0) | |||
˃8 | 29 (13.8) | |||
Professional performing prenatal care | ||||
Nurse | 30 (14.3) | - | ||
Physician | 114 (54.3) | - | ||
Nurse + physician | 63 (30.0) | - | ||
None | 3 (1.4) | |||
Health education regarding QoL** during prenatal visits | ||||
No | 142 (67.6) | - | ||
Yes | 68 (32.4) | - | ||
Health education regarding QoL in hospital prior to discharge | ||||
Yes | 142 (67.6) | - | ||
No | 68 (32.4) | - |
*SD = Standard deviation; **QoL = Quality of life.
prior to discharge.
QoL scores reported among Brazilian mothers during the postpartum period and their correlation with socio- demographics and obstetric characteristics are listed in
Mean scores for the MAPP-QoL was 15.24 (±0.08), with a small variance of 14.85 to 15.38. The range possible for this scale is 0 to 30. Better QoL score is related to the best conditions of quality of life [
The highest QoL scores were in white women 30 - 40 years of age, who were married, or living with a partner, working as a student, and achieved a high school or 8th grade education. QoL was similar for all monthly income groups, parity, type of delivery method, and whether or not they received QoL health education prior to hospital discharge. The mean QoL score was significantly higher for mothers with more than 4 children, without physical complaints, who attended more than 8 prenatal visits performed by a nurse and who did not receive health education about QoL during prenatal care.
Marital status (p = 0.01), educational level (p = 0.01) and race (p = 0.04) were significantly correlated with QoL and were therefore included in the multiple regression analyses to evaluate for prediction.
Stepwise multiple regression analysis was utilized to assess the strength of the association between the predictor variables and the independent MAPP-QoL scores.
The first predictor variable included in the stepwise regression was marital status, which had the highest bivariate correlation with a dependent variable (DV): QoL. The predictor variable selected in the second step was race followed by educational level. Due to the combination of variables, assumptions for multicollinearity were examined. In the regression equation, the tolerance was 1.00 and the VIF in the final model was 1.00, so the assumptions for multicollinearity were not violated. The stepwise model included as the best predictor in race was
Characteristics | MAPP-QoL scores | ||
---|---|---|---|
Demographics | Mean (±SD) | T-scorea or F-ratiob | p value |
Age | 2.16b | ||
≤20 y | 15.23 (±0.09) | 0.48 | |
21 - 30 y | 15.23 (±0.09) | ||
31 - 40 y | 15.26 (±0.07) | ||
>40 y | 15.23 (±0.10) | ||
Marital status | 2.50a | ||
Married/with partner | 15.25 (±0.08) | 0.01* | |
Single | 15.21 (±0.09) | ||
Occupation | 0.48b | ||
Unemployment | 15.24 (±0.08) | 0.74 | |
Housewife | 15.22 (±0.10) | ||
Student | 15.26 (±0.07) | ||
Formal employment | 15.24 (±0.08) | ||
Informal employment | 15.24 (±0.08) | ||
Education | 4.62b | ||
8th grade or less | 15.25 (±0.07) | 0.01* | |
Grades 9 - 11 | 15.21 (±0.09) | ||
High school | 15.25 (±0.08) | ||
Some college | 15.14 (±0.15) | ||
Bachelor’s degree | 15.18 (±0.08) | ||
Monthly income of the patient | 0.06b | ||
15.24 (±0.09) | 0.83 | ||
US $ 678.00 - 1017.00 | 15.24 (±0.08) | ||
˃US $ 1017.00 | 15.24 (±0.10) | ||
Race | 2.80b | ||
White | 15.26 (±0.07) | 0.04* | |
Black | 15.22 (±0.09) | ||
Asian | 15.24 (±0.05) | ||
Obstetrics | |||
Parity | 0.04b | ||
Primiparous | 15.24 (±0.01) | 0.09 | |
Multiparous | 15.24 (±0.02) | ||
Number of children | 0.16b | ||
1 | 15.24 (±0.07) | 0.12 | |
2 - 3 | 15.23 (±0.09) | ||
≥4 | 15.25 (±0.09) |
Type of delivery (last) | 0.21a | ||
---|---|---|---|
Caesarian section | 15.24 (±0.08) | 0.90 | |
Vaginal | 15.24 (±0.09) | ||
Physical Complains | −0.47a | ||
No | 15.24 (±0.09) | 0.63 | |
Yes | 15.23 (±0.07) | ||
Number prenatal visits | 1.14b | ||
None | 15.16 (±0.04) | 0.33 | |
<6 | 15.24 (±0.01) | ||
6 - 8 | 15.23 (±0.01) | ||
˃8 | 15.25 (±0.00) | ||
Professionally performed prenatal care | 1.17b | ||
Nurse | 15.25 (±0.06) | 0.32 | |
Physician | 15.24 (±0.08) | ||
Nurse + physician | 15.23 (±0.10) | ||
None | 15.16 (±0.07) | ||
Health education regarding QoL in prenatal visits | 1.22b | ||
No | 15.24 (±0.08) | 0.22 | |
Yes | 15.23 (±0.09) | ||
Health education regarding QoL in hospital (immediately prior to discharged) | 0.62b | ||
Yes | 15.24 (±0.09) | 0.53 | |
No | 15.24 (±0.08) |
aby T-test, b: by ANOVA; Overall MAPP-QoL total score (n = 210), Mean = 15.24 (±0.08), Range actual (14.85 - 15.38), Range possible (0 - 30); *p < 0.05, correlation significant; Note: There are illiterates in our sample, But the illiterates were allocated in the following category of education: “8th grade or less”.
Predictor variable | B | SE | β | R-Square | Adjusted R-Square | 95% CI for B | p | |
---|---|---|---|---|---|---|---|---|
Lower | Upper | |||||||
Race (White) | 0.037 | 0.013 | 0.199 | 0.39 | 0.35 | 0.012 | 0.062 | 0.003* |
Marital status (Married/live with partner) | 0.038 | 0.015 | 0.171 | 0.69 | 0.60 | 0.009 | 0.067 | 0.011* |
Overall R2 = 0.69, Adjusted R2 = 0.60, F (2,14) = 7.63, p = 0.001; *p < 0.05, correlation significant, B―partial regression coefficient; SE―standard error; β―standardized regression coefficient; CI―confidence interval; R―variance.
white (p < 0.05) and in marital status was married/live with partner (p < 0.05). Black race (p = 0.78) and all educational levels (p > 0.05) were excluded from the stepwise model.
We obtained an R2 of 0.39 (adjusted R2 = 0.35) for white race; thus, 35% of the variance in QoL in postpartum was explained by white race alone. When marital status (married/living with partner) was added to the equation of stepwise regression, R2 increased to 0.69 (adjusted R2 = 0.60); therefore, 60% of the variance in QoL in postpartum women was explained by white race and marital status (married/living with partner).
Regarding individual predictors, the regression coefficient B for all predictors different from zero contributes significantly to the prediction of QoL during the postpartum period [
This study examined the overall perceived QoL during the early postpartum period in Brazilian mothers of term infants. Results indicate that marital status and race may predict the quality of life during the postpartum period; in particular, women who were white and either married or living with a partner had higher QoL scores.
Researchers have long known that social conditions, economic status, and health concerns influence the health and well-being of individuals [
Maternal characteristics such as nonwhite race and lower socioeconomic status are risk factors for decreased maternal QoL during the postpartum period [
Although the correlation between the obstetric characteristics (e.g. parity, child number, route of last delivery and physical complaints) and QoL scores in postpartum women were not significant, the difference between groups for each variable was distinct and may be representative of the health and well-being of new mothers. For example, having more than one child was associated with a higher QoL in postpartum mothers, a finding supported by previous research [
In our study, an association between type of delivery and QoL among Brazilian women was not found. Hill and Aldag (2007) [
Timely educational interventions including breastfeeding as well as anticipatory guidance for infant and maternal health may contribute to improved levels of health, and consequently to greater QoL following birth. The relationship between QoL scores and obstetrical factors that may affect women in the post-partum period include frequency of prenatal visits and education about how to improve their QoL following childbirth. Women with the most prenatal visits had the highest QoL, which is supported by Akýn, Ege, Koçoðlu, Demirören, & Yýlmaz (2009) [
The roles of some obstetrics characteristics like prior method of delivery and health education during prenatal visits had less impact on postpartum QoL than the experience of having several children. This indicates that multiple children provides mothers with the experience they need to adjust to the demands of motherhood. In addition, women with adequate social support have an increased chance of experiencing a healthy postpartum period. In contrast, conditions such as primiparity and poor social support are risks for poor QoL during the postpartum period, and women vulnerable to these factors deserve special attention from health professionals.
Several limitations existed in this study. First, the sample size was small and utilized only one site for data collection. Generalization to sociodemographically dissimilar samples may be problematic and therefore a larger and more diverse sample of mothers is required. Second, a re-test was not performed, limiting the analysis regarding stability of the measuring instrument. Future longitudinal studies are needed to clarify the stability of quality of life at different times of the postpartum period.
Postpartum mothers should be informed that their personal health satisfaction and overall QoL will likely improve with time [
Health care providers should be sensitive to predictors of women’s quality of life in the postpartum period, including race and marital status, as well as conditions associated with maternal vulnerability such as extreme age, lack of social support, nonwhite race, unemployment, low level of education, low socioeconomic status, birth of only one child, presence of physical complaints, few prenatal visits, and lack of education regarding QoL in the postpartum period. In addition, improved knowledge concerning the postpartum and maternal experience may assist in the development of health interventions to enhance the quality of life in this population.
No conflict declared.
This research was supported by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) of Brazil, process number 245286/2012-8 during one Doctoral Exchange in the College of Nursing/University of Florida in 2014.