Postpartum quality of life and associated factors: a cross-sectional study

Purpose To determine factors associated with postpartum quality of life (QOL). Methods An analytic cross-sectional design was used in this study, and data was collected from December 2019 to March 2020. Participants were 252 postpartum women visiting eight governmental primary healthcare centers in Madinah city, Saudi Arabia. Data were collected using a sociodemographic questionnaire, the World Health Organization Quality of Life Assessment-BREF, Multidimensional Scale of Perceived Social Support (MSPSS), and Edinburgh Postnatal Depression Scale. Sleep problems were assessed using an item from the Prime-MD Patient Health Questionnaire. Results Maternal age between 26 and 35 years had a significant independent association with the physical health domain of QOL (p < .01). Postpartum depression was significantly associated with lower QOL in all dimensions (p < .01). In addition, sleep problems were associated with three out of the four QOL domains (p < .05). The significant other subscale of the MSPSS was significantly associated with higher QOL scores in all dimensions (p < .01); additionally, family and friends subscales of the MSPSS were significantly associated with the social domain of QOL (p < .01). Conclusions Maternal QOL, during the postpartum period, showed negative associations with age, postpartum depression, and sleep disturbances. Ultimately, social support appeared to be an essential factor in mothers’ ability to cope with the physical and psychological problems experienced during this period.


Introduction
Quality of life (QOL) has been recognized as a substantialoutcome measure for health service evaluation [1]. QOL is defined as individuals' perception of their position in life in the context of their culture and value systems, which concerns their targets and expectations [2]. In the area of maternal care, decreasing morbidity and mortality rates have prepared the ground for other goals such as enhancing QOL [3]. With regard to QOL during periods of childbirth and childcare, although health professionals are involved in prenatal care, postpartum maternal healthcare is relatively neglected [4].
The postpartum period is a time of transition in a mother's life marked by physical, psychological, and social changes [5] that begins after childbirth and lasts up to 6 months. It is often divided into three distinct phases: initial or acute phase, which lasts 6-12 h postpartum; second or subacute postpartum period, which lasts 2-6 weeks; third or delayed postpartum period, which can last up to 6 months [6]. Recent studies have quantified problems occurring during the postpartum period, such as mental distress, genital infections, physical complaints, and sleep problems [7,8]. Sociodemographic variables such as maternal age, educational level, and reproductive history have been shown to be significant influencing factors across the postnatal period [9,10]. Among the other factors associated with QOL, postnatal depression and social support have been reported to be significant [11,12]. Furthermore, maternal sleep disturbances are of concern because of their association with fatigue and depression, which are strongly associated with QOL [13,14].
In Saudi Arabia, the prevalence of postpartum depression (PPD) ranges from 14 to 17.8% [15,16]. While several studies suggest a significant association between QOL and symptoms of PPD [17,18], postpartum QOL is not well researched in Saudi Arabia. Existing studies have generally focused on physical postpartum complications such as hemorrhage and urinary incontinence [19,20] PPD [21] and the association of postpartum QOL with a particular type of delivery [5]. Other important factors considering Saudi Arabia's context and social diversity are not well investigated. Hence, this study aims to assess maternal QOL during the postpartum period and explore its correlates in a sample of Saudi Arabian women.

Study design and setting
This cross-sectional analytical study was conducted from December 2019 to March 2020 at eight governmental primary healthcare centers in Madinah city, Saudi Arabia. The participants were recruited through multi-stage sampling. In the first stage, we did a cluster sample to choose 8 PHCs out of the 54 centers in Madinah city; Two primary healthcare centers were randomly selected from each region (i.e., east, west, north, and south). In the second stage, women who attended well-baby clinics at the selected primary healthcare centers and who had a live birth in the last 6 months were invited to participate in the study.

Data collection tools
Participants completed a self-report questionnaire covering sociodemographic data and maternal and infant history. Sociodemographic data included age, occupation, educational level, income, and prenatal and postnatal history, such as type of delivery and time since previous delivery. Questions regarding the infant included sex, feeding method, daycare (i.e., home with mother, babysitter, or nursery), and health status. Furthermore, the following existing measures were used: the World Health Organization Quality of Life Assessment-BREF (WHOQOL-BREF), Multidimensional Scale of Perceived Social Support (MSPSS), maternal sleep measurements, and Edinburgh Postnatal Depression Scale (EPDS).

World Health Organization Quality of Life Assessment-BREF
The WHOQOL-BREF is a short version of the WHO-QOL-100 instrument used for measuring QOL in diverse cultural settings [2]. This tool includes 26 items across four domains-physical health, psychological health, social relationships, and environment-rated using a 5-point Likert scale [2]. Raw subscale scores are converted to a 0-100 scale; higher scores indicate better QOL. The WHOQOL-BREF has been validated in a range of languages, including Arabic (Cronbach's alpha ≥ 0.7) [22]. Additionally, the questionnaire has been validated among women in the postpartum period [23].

Multidimensional Scale of perceived social support
The MSPSS is a 12-item self-report tool used for measuring perceived social support from three sources: family, friends, and significant other. Items are scored on a 7-point Likert scale ranging from 1 (very strongly disagree) to 7 (very strongly agree). The mean total score ranges from 1 to 7; higher scores indicate higher levels of perceived social support [24]. The scale is well-validated, showing strong internal consistency, with an overall Cronbach's α ranging from 0.84 to 0.92 [25]. The Arabic version has been validated, with an overall Cronbach's α of 0.87 [26].

Maternal sleep measurements
Sleep problems were assessed using an item from the Arabic version of the Prime-MD Patient Health Questionnaire: "Trouble falling or staying asleep, or sleeping too much." Respondents were asked if they were bothered by the problem over the past 2 weeks. The response options were "not at all," "several days," "more than half the days," and "nearly every day," with scores ranging from 0 to 3 [27].

Edinburgh Postnatal Depression Scale
The EPDS is a self-report tool widely used to screen for PPD [28]. It consists of 10 items and addresses the intensity of depressive symptoms over the previous 7 days. Items are scored on a 4-point Likert scale ranging from 0 (no symptoms) to 3 (marked presence or change), resulting in a total score of 0-30. The Arabic version of the EPDS has been validated in a sample of Emirati women, with a Cronbach's α of 0.84. [29] Ethical considerations Approval for the study protocol and data collection procedure was obtained from the Research Ethical Committee in Madinah's Ministry of Health (IRB 356). The study's objectives were explained to the participants, and written informed consent was obtained.

Statistical analysis
Data were analyzed using SPSS version 25 (IBM Corp., Armonk, NY, USA). p-values < .05 were considered statistically significant. Descriptive statistics were presented as mean and standard deviation for continuous variables, and as frequency and percentage for categorical variables. Student's t-test and ANOVA were used to compare mean scores across QOL domains. Pearson's correlation was used to test the correlation between mean scores of the MSPSS, EPDS, and QOL domains. Multiple linear regression was used to identify the variables with independent associations with QOL during the postpartum period.

Sample characteristics
The data of all 252 women who were approached to participate in the study were analyzed. The participants had a mean age of 31.3 (± 6.2) years, and most were between 26 and 35 years (56%). Additionally, 58.7% were housewives and 35.7% were working. Regarding health status, 12.7% of the sample reported a chronic condition and 2.4% had mental health problems. In terms of obstetric history, 65.1% had experienced vaginal delivery. Regarding parity, 25.8% of women in the study were primigravida.Other characteristics are presented in Table 1. The mean total scores for the WHOQOL-BREF and the MSPSS were 95.2 (±16) and 5.3 (±1.2), respectively. The individual domain scores are shown in Table 2. Considering PPD, the mean EPDS score was 9.9 (±5.3). Regarding sleep problems over the past 2 weeks, participants' responses indicated 46.0, 22.2, 21.4, and 10.3% for "several days," "nearly every day," "more than half the days," and "no problems," respectively.

Factors associated with postpartum QOL
The highest mean QOL scores were among mothers aged under 26 years. The physical health domain score was statistically significantly different by maternal age group (p = .03). Mothers of infants aged between 1 and 3 months had a worse score on physical health domain 62.8 (± 16.3; p = .02). Pearson's correlation was used to assess the relationship between scores of the EPDS, sleep, MSPSS, and QOL domains (Table 3). There was a statistically significant correlation between the mean scores of various domains of QOL and EPDS score (p < .001). In addition, sleep problems were statistically significantly correlated with the mean total score of QOL and the mean scores of the domains of physical health, psychological health, and environment (<.01). Moreover, there was a statistically significant positive correlation between MSPSS mean total score and QOL domains (p < .001). The significant other and family subscale scores were also significantly correlated with QOL domains (p < .001). The friends subscale showed a significant correlation with the psychological health and environment domains of QOL (p < .01), as well as with the social relationships domain (p < .001).

Correlates of QOL during the postpartum period
The multiple regression models are presented in Table 4

Discussion
Numerous studies in Saudi Arabia have evaluated the physical and mental challenges that arise during the postpartum period. However, to the best of our knowledge, this is the first to assess QOL and its correlates, including PPD and social support, in this phase. Our findings showed maternal age between 26 and 35 years was significantly negatively associated with the physical health domain of QOL compared to younger mothers. There were also significant correlations between QOL domains and symptoms of PPD, sleep problems, and the significant other subscale of social support. Further, the family and friend subscales were ass ociated with the social domain of QOL.    [30]. This is probably explained by the fact that younger mothers are mostly primiparas and receive more attention and support from their partners and families than their older counterparts. Similarly, a Turkish study found that spousal support and QOL decrease with maternal age [12].
The present study revealed that depression is an independent risk factor associated with poor scores in all the domains of QOL. Several studies have reported the negative impact of depression on QOL during the postpartum period [31]. A study conducted in Kuwait showed that health-related QOL and the physical and mental health domains of QOL were associated with PPD [32]. Zubaran et al. investigated QOL and depressive symptoms among Brazilian women and reported a mean EPDS score of 8.35 (±5.6), which was significantly correlated with all domains of the WHOQOL-BREF [33]. Moreover, PPD negatively affects the mother, infant, and family relationships [34]. Evidence shows that the risk of PPD increases during the first 3 weeks after delivery and continues for almost 2 years [35]. However, in an Iranian study, the mean depression score decreased significantly from 6 to 8 to 14 weeks after delivery [36]. Furthermore, many studies have shown the protective role of social support in PPD [37]. Additionally, 12.7% of our sample had chronic medical conditions that could affect their experience of postpartum depression. Studies have found that pregnant women with chronic medical conditions were more likely to develop mental illnesses around childbirth, including postpartum depression [38]. Social support is a crucial component of the physical and emotional well-being of mothers following childbirth [39]. The current study showed that mothers received high levels of social support; the mean total MSPSS score was 5.3 (±1.2). A high level of social support for new mothers is a Saudi cultural norm; women receive a lot of help in the transitional time after delivery and the mother often spends the puerperium period, particularly the first forty days, at her mother's house to receive the necessary support until she recovers, which is necessary if she is new mother. Increased social support was found to be correlated with fewer physical role limitations and higher levels of general and mental health among postpartum women [40]. A recent Japanese study that explored factors associated with QOL among women rearing a 4-or 18-month-old child showed that emotional support from families was closely correlated with QOL [41]. Another study examining the impact of social support on QOL (measured by the WHOQOL-BREF) following delivery reported that women with low partner or family support had lower scores across all QOL domains compared to well-supported women [42]. Correspondingly, our findings reveal that social support, in general, is associated with better QOL scores in all domains. In addition, help from a significant other was independently associated with QOL. Several studies have identified the positive influence of spousal support on QOL in women after childbirth [12,41]. A study among postpartum Saudi women observed that 84% of participants had a good perception of partner support and were able to consider their extended family members, parents, and relatives as their primary help providers. [43] This study identified sleep problems as risk factors ofthree of the QOL domains (i.e., physical health, psychological health, environment) was identified in this study, similar to previous studies. For example, a study found that for mothers of 4-month-old infants, getting enough sleep enhanced QOL across all domains except social relationships [41]. Moreover, women in the postpartum period are more likely to experience interrupted and lower-quality sleep. Based on the Pittsburgh Sleep Quality Index total score, a study among postnatal women found that 59% reported poor sleep quality, and 16% reported medium or high sleep disturbance [44]. In our study, 22% of mothers experienced sleeping difficulties nearly every day. Postpartum sleep quality is affected by fatigue, frequency of nighttime awakening, mood disturbance, and childcare demands [45,46]. Moreover, poor sleep quality was linked to greater depressive and anxiety symptoms in women who had 6-month-old infants [47].

Limitations
There are some limitations to our study. First, it is crosssectional in nature; thus, we were unable to make causal inferences regarding the relationships among study variables. Second, a relatively small sample was used. Additional research using a longitudinal design is required to investigate QOL changes during postpartum period.

Conclusion
Postpartum QOL negatively correlated with maternal age, PPD, and sleep disturbances. Ultimately, positive social support is essential for the mother to cope with the physical and psychological problems experienced during the postpartum period.

Recommendation
Our findings suggest the importance of comprehensive care for mothers in the postpartum period. Healthcare providers need to be aware of the importance of QOL and how numerous variables influence it. PPD screening and assessment of sleep quality should be considered during postnatal visits. In addition, social support plays a positive role in maternal QOL. Healthcare providers need to be conscious of mothers' social circumstances during antenatal follow-up and encourage them to seek help if required.

Funding
The authors have not disclosed any funding.

Conflict of interest The authors declare that they have no conflict of interest
Ethics Approval Approval was obtained from the Research Ethical Committee in Madinah's Ministry of Health (IRB 356).

Consent to Participate Informed consent was obtained from all individual participants included in the study.
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