Health related quality of life and associated factors after cesarean delivery among postpartum mothers in Gondar, Ethiopia: a cross-sectional study

Abstract

Background

Health-related quality of life following cesarean delivery can be compromised due to the physical, mental, and emotional impacts of surgery and anesthesia. Despite the critical nature of the postpartum period after cesarean delivery, it remains under-explored, with most studies focusing on vaginal deliveries and neglecting the unique challenges of cesarean recovery. Therefore, this study aimed to assess health related quality of life and associated factors after caesarean delivery among postpartum mothers in Gondar, Ethiopia.

Methods

A cross-sectional study was conducted in public health facilities of Gondar town using the Medical Outcomes Study Short Form-36. Data were collected from 424 postpartum women following cesarean delivery between April and June 2024 through face-to-face interviews, semi-structured questionnaires, and medical chart reviews. Simple random sampling was used, with participants proportionally allocated to each health facility. Data were entered into Epi-data version 4.6 and analyzed using SPSS version 25. Logistic regression models were applied to predict the health-related quality of life.

Results

Among 418 post caesarean deliveries, 278 (66.5%) had lower level of health-related quality of life. The mean scores of physical component summary, mental component summary and overall health related quality of life were found 48.22 ± 5.63, 47.62 ± 6.02 and 47.92 ± 4.28 respectively. Factors associated with lower overall health related quality of life were postnatal care less than two (AOR = 2.58, 95% CI = 1.59–4.19), pregnancy complications [AOR 5.32, 95% CI (2.69–10.54)], general anesthesia (AOR = 2.36, 95% CI = 1.08–5.14), perceived pain after discharge (AOR = 2.64, 95% CI = 1.61–4.35) and postpartum depression (AOR = 2.41, 95% CI = 1.22–4.77).

Conclusion

Two-thirds of postpartum mothers had low health related quality of life after cesarean delivery. Key factors included inadequate postnatal care, postpartum depression, anesthesia type, pregnancy complications, and perceived pain. We suggest that health care providers need to give particular attention to mothers during the perioperative period and increased postnatal care services to improve maternal well-being.

Introduction

The postpartum period is the time after childbirth when a mother’s body recovers and adjusts physically and emotionally. Traditionally defined as six weeks [1, 2]. American College of Obstetricians and Gynecologists extends it to 12 weeks, calling it the “fourth trimester” [3]. It is further categorized into acute (24 h), early (7 days), and late (6 weeks to 6 months) phases, highlighting its critical impact on maternal health [4].This study focuses on the first six weeks of the postpartum period, as most pregnancy-related changes return to normal within this time frame [5].

According to the World Health Organization (WHO), quality of life is an individual’s perception of their position in life, considering cultural context, goals, expectations, and concerns [6]. Evidence shows that health related quality of life (HRQoL) is a strong indicator of maternal care, influenced by physical, psychological, relational, and social health [7]. HRQoL for pregnant and postpartum mothers has been frequently measured by generic validated multidimensional measurement tools such as, the SF-36 and SF-12 of the Medical Outcomes Study (MOS), followed by the WHO Quality of Life Scale-Bref (WHOQoL-Bref) and Mother Generated Index (MGI), respectively [8]. The SF-34 PREG, an adapted version of the SF-36 for pregnancy, offers high reliability and relevance for assessing HRQoL in pregnant women, though it omits the social functioning dimension [9]. Another tool, the QOL-GRAV scale, was developed to measure quality of life during pregnancy, showing strong reliability and validity with the WHOQoL-Bref [10]. However, this study used the validated MOS SF-36 tool, which is also validated in Amharic version and widely applicable for measuring HRQoL in various groups in Ethiopia [11, 12].

Cesarean delivery (CD), a surgical method of childbirth involving an incision in the uterus, has seen a rise in maternal requests beyond the WHO recommended rate of 10–15% [13, 14]. In Ethiopia, a systematic review and meta-analysis reported an overall CD prevalence of 29.55%, exceeding the ideal rate [15]. Women who request CD due to fear of labor or negative vaginal delivery (VD) experiences account for 42% of all CDs [16]. However, severe maternal morbidity is reported to be higher in CD compared to VD [17].

CD has several side effects such as discomfort, blood loss, weakness, restricted movement, difficulty in daily activities, and a visible scar that persists long after the surgery [7]. Moreover, a study showed that exposure for repeated cesarean sections had an impact on physical and mental domains of HRQoL [18]. Women’s pain, physical functioning, and overall well-being depend on complications associated with each mode of birth, emphasizing the need for comprehensive counseling to help them make informed decisions regarding delivery mode [19, 20].

The women’s postpartum period is a vulnerable and critical time characterized by several physiological, psychological, and social changes [14, 21]. Studies have shown 50% of postnatal mother deaths happen within the first 24 h of delivery, whereas the majority of maternal and baby deaths happen within the first four weeks following delivery [22, 23]. Common postpartum complications include urinary and fecal incontinence, infections, anemia, wound healing issues, headaches, backaches, exhaustion, and depression [24,25,26].

Surgery and anesthesia complications, such as delayed recovery, physical limitations, and pain, can negatively impact the mental and emotional aspects of HRQoL, leading to poor overall HRQoL in postpartum mothers [27, 28]. To reduce these risks, pregnant women should be fully informed and encouraged to opt for vaginal delivery unless medically indicated, supported by appropriate policies and guidelines [29]. Studies revealed that the physical and mental components of HRQoL were compromised in postpartum mothers who had CD than via VD [23, 29,30,31]. Postpartum women also experience more depressive and pain symptoms after CD [32]. This might have negative effect on their HRQoL during their next pregnancy and the postpartum period, as well as their attitude of parenthood and well-being of the family.

Despite the high risk of maternal and newborn deaths and the rising CD rates, WHO highlights the postpartum period as one of the most neglected phases in maternal health [33]. Studies in Ethiopia reported a mean HRQoL score below 50 [34, 35], and 63.2% of them experiencing low HRQoL either delivered vaginally or via cesarean Sect. [31]. Most studies assess postpartum HRQoL without distinguishing delivery modes, limiting insights into CD specific effects and often overlooks key recovery factors, particularly in the early postpartum period [27, 31, 36]. Therefore, this study aimed to assess the HRQoL of postpartum mothers following CD and identify the factors associated with it during the first six weeks of postpartum by using MOS SF-36 tool.

Methods

Study design and setting

This study used an institutional based cross-sectional study design conducted from April to June 2024 at public health facilities in Gondar town, Northwest Ethiopia. Gondar, the capital city of the Central Gondar administrative zone, is served by eight health centers and two hospitals providing immunization services. One hospital, University of Gondar Comprehensive Specialized Hospital and four health centers (Poly Health Center, Gabriel Health Center, Maraki Health Center, and Azezo Health Center) were randomly selected using a lottery method, taking into account the feasibility of the study.

Study population

The source population included all postpartum mothers who delivered via cesarean section in Gondar town. The study population consisted of mothers attending child immunization at public health facilities six weeks post-delivery.

Inclusion and exclusion criteria

The study included postpartum mothers aged 18 years and older who gave birth in Gondar town. Exclusion criteria encompassed women with physical disabilities (such as spinal cord injuries, amputations, paralysis, or limb deformities), those with preexisting chronic illnesses (including chronic hypertension, cardiovascular and pulmonary disorders, and neuropsychiatric conditions), and individuals who were unable to communicate or comprehend the study requirements.

Variables of the study

Independent variables were categorized into socio- demographic factors (age, BMI, marital status, education levels of both the mother and partner, occupation of both, family support, and number of living children) and obstetric-related and clinical factors (parity, antenatal care visits, birth order history, preterm labor, pregnancy desirability, postnatal care visits, pregnancy complications, postpartum anemia, HIV status, urinary incontinence, and postpartum depression). Additionally, anesthesia and surgery related variables includes urgency of the surgery, number of cesarean deliveries, type of anesthesia, type of postoperative analgesia, delivery complications, perceived pain after discharge, postoperative nausea and vomiting, and shivering.

Operational definition

The MOS-SF-36 contains eight domains comprising two main categories namely, physical and mental HRQoL. Each raw scale score on each domain was transformed from 0 to 100 (0–100 scale) by using the formula of transformed.

$$\,Scale = \frac{{actual\,raw\,score - lower\,possible\,score}}{{possible\,raw\,score\,range}} \times 100$$

(11)

Physical component Summary (PCS) mean score of HRQoL is the arithmetic average of the transformed scores of physical functioning, role physical, bodily pain, and general health domains [11].

Mental component Summary (MCS) mean score of HRQoL is the arithmetic average of the transformed scores of social functioning, mental health; role emotional, and vitality domains [11]. Overall HRQoL mean score is the arithmetic average of the transformed score of the eight domains [37].

Higher HRQoL is when participants scored greater than or equal to the standardized mean value of 50 [38]. Lower HRQoL is when participants scored less than the standardized mean value of 50 [38].

Postpartum depression: was assessed by using an Edinburgh Postnatal Depression Scale (EPDS). According to the EDPS, study participants who scored ≥ 13 are considered as having postpartum depression and it is validated in Addis Ababa, Ethiopia [39].

Multidimensional scale of perceived social support of family support domain was utilized to assess the extent of perceived social support from their families. According to the scale, mean scale score ranging from 1 to 2.9 could be considered poor support, 3.0 to 5.0 could be considered moderate support and 5.1 to 7 could be considered strong support [40]. Postpartum anemia: is defined as hemoglobin < 10 g/dl or hematocrit < 30% during postpartum period [41].

Sample size and sampling procedure

The sample size for this study was calculated using the single population proportion formula, assuming a prevalence of 50% due to the absence of prior studies in Ethiopia assessing HRQoL among postpartum mothers following CD. The formula used was $\:n=\frac{{\left(Z\raisebox{1ex}{$\alpha\:$}\!\left/\:\!\raisebox{-1ex}{$2$}\right.\right)}^{2}\rho\:\left(1-\rho\:\right)}{{\epsilon}^{2}}$, where n = initial estimated sample size, Z = Confidence level (α); α = 95%; $\:Z\raisebox{1ex}{$\alpha\:$}\!\left/\:\!\raisebox{-1ex}{$2$}\right.$=1.96,$\:\:\rho\:$ = proportion;$\:\:\rho\:=0.5$, $\:\epsilon\:$= marginal error;$\:\epsilon\:$ =5%, resulting in an initial sample size of approximately 384. After adding a 10% non-response rate, the final sample size was set at 424. Sampling was conducted through simple random sampling, with samples allocated proportionally to each health facility. Participants meeting the inclusion criteria were consecutively recruited until the target sample size was achieved (Fig. 1).

Fig. 1

Flow diagram of study participant recruitment for assessment of HRQoL of postpartum mothers after CD in Gondar town, 2024

Data collection procedure

Data were collected using structured and semi-structured questionnaires developed by the principal investigator, initially in English and subsequently translated into Amharic for simplicity. This translation was back-translated to ensure consistency by two bilingual experts. The questionnaire addressed socio-demographic variables, multidimensional social support, obstetric and clinical characteristics, postpartum depression, and HRQoL. Data were gathered through face-to-face interviews conducted in private settings. Additionally, information regarding pregnancy complications, postoperative hematocrit levels, types of postoperative analgesia, and delivery complications was extracted from medical records the day after the interview.

The MOS SF-36 was utilized to assess HRQoL across eight domains: physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional and mental health. Each domain was scored on a scale from 0 (worst) to 100 (best), with a Cronbach’s alpha above 0.70 for all domains, except for social functioning, which was 0.68 [11, 12, 42].

The EPDS, consisting of 10 items, was used to evaluate postpartum depression, demonstrating sensitivity and specificity of 78.9% and 75.3%, respectively, in a validation study in Ethiopia [39]. Additionally, perceived family support was measured using a 7-option Likert scale with a Cronbach’s alpha of at least 0.7 [43] (Annex I).

Data quality control

To ensure data quality, a pre-test was conducted with 5% of the calculated sample size prior to the main study. This pre-test facilitated necessary revision to the questionnaire, enhancing its clarity, logical flow, and skip patterns. Five data collectors participated in a comprehensive one-day training session, which covered research objectives, eligibility criteria, data collection tools, and procedures. The training also included protocols for addressing any acute pain or postpartum depression that participants may experience during the study. Additionally, the importance of maintaining confidentiality and implementing effective data quality management practices was emphasized. Throughout the data collection period, the principal investigator and supervisors conducted daily reviews of completed questionnaires to ensure data completeness and consistency.

Data processing and analysis procedures

Upon completion of data collection, variables were entered, coded, and cleaned for errors using Epi-data software, version 4.6. The cleaned data was then transferred to SPSS, version 25 for analysis. Descriptive statistics were computed in accordance with the MOS SF-36 tool developer’s guidelines [11]. Pre-coded numeric values were recorded, with 10 negatively worded items reverse-coded to ensure that higher scores reflected more favorable health states. Each item was scored on a scale of 0 to 100, using a transformation formula where 0 represented the worst possible health state and 100 the best. Items on the same scale was averaged together to create the 8-scale scores. Next, the PCS mean was computed from 4 scale scores namely physical functioning, role physical, bodily pain, and general health domain transformed scores, whereas the MCS mean was computed from the remaining 4 scale scores namely social functioning, mental health, vitality, and the role emotional domain transformed scores. The overall HRQoL mean was determined from the transformed scores of all eight domains, and participants were categorized into higher and lower HRQoL based on a standardized mean score of 50.

Socio-demographic characteristics, clinical factors, and obstetric-related variables were analyzed and presented in text and tables. Chi-square tests were employed to assess associations between independent variables and the outcome variable. Crude odds ratios (COR) and adjusted odds ratios (AOR) with 95% confidence intervals were calculated to evaluate the strength of associations with postpartum HRQoL. Bivariate and multivariate logistic regression analyses were conducted to explore the relationships between dependent and independent variables. Variables with a p-value < 0.25 in bivariate analyses were included in multivariate logistic regression, with a significance level set at p < 0.05 for identifying statistically significant factors associated with HRQoL. Model fitness was assessed using the Hosmer and Lemeshow goodness-of-fit test (p = 0.207), and multicollinearity was examined using the variance inflation factor, which revealed no significant issues. Normality data was checked using Kolmogorov-smirnov test with scatter plot. Normally distributed data was expressed with mean and standard deviation and median and interquartile range were employed for non-normally distributed data.

Results

Sociodemographic characteristics

From 424 eligible participants, 418 responded to the questionnaires with response rate of 98.58%. The mean age of the study participants was 30.28 with standard deviation of 6.43. The 46.4% of respondents had age between 25 and 34 years. Majority of participants (82.8%) were married, and more than half (56.2%) had secondary education or higher. Housewife comprised 58.6% of the sample, and majority (78.2) reported strong family support (Table 1).

Table 1 Socio demographic characteristics of postpartum mothers following caesarean delivery in Gondar town, 2024 (N = 418)

Obstetrics and clinical-related variables

Majority (71.1%) were multiparous, and about (56.5%) had received at least 4 antenatal care (ANC) visits. Participants who had received less than 2 post-natal care (PNC) visits comprised 56.7%. Moreover, 24.2% of the sample experienced obstetric complications during pregnancy. About 96 (23%) of postpartum women had anemia and 86 (20.6%) of women had postpartum depression (Table 2).

Table 2 Obstetrics and clinical-related characteristics of postpartum mothers following caesarean section in Gondar town, 2024 (N = 418)

Anesthesia and surgery related variables

Two-third (66.5%) of study participants were gave birth through emergency CD, and majority (78.9%) of respondents had one or more previous CD. Most (85.4%) of participants underwent CD under regional anesthesia. Moreover, more than half (63.6%) of respondents reported as they had feeling of pain continued even after discharge from which the majority accounts headache 156(58.6%) followed by surgical site pain 155 (58.3%) (Table 3).

Table 3 Anesthesia and surgery related characteristics of postpartum mothers following caesarean delivery in Gondar town, 2024 (N = 418)

HRQoL of the study participants

The MOS SF-36 scale found that 66.5% (95% CI: 61.8, 71.0) of postpartum women following CD had a low HRQoL (Fig. 2).

Fig. 2

Overall HRQoL of postpartum mothers following CD in Gondar town, 2024 (N = 418).

The mean of HRQoL of sample was 47.92 ± 4.28 (95% CI: 47.51, 48.33), and we found the mean score of PCS with 48.21 ± 5.63) and the mean score of MCS with (47.62 ± 6.02 (Table 4).

Table 4 Health related quality of life of postpartum mothers following caesarean delivery in Gondar town, 2024 (N = 418)

From the eight domains of HRQoL, the lowest mean score was observed in the social functioning domain with a Mean ± SD of 45.84 ± 13.99, whereas the highest mean score in the body pain domain was 50.08 ± 12.78 (Fig. 3).

Fig. 3

Mean score of each domain of HRQoL of postpartum mothers following CD in Gondar town, 2024 (N = 418)

Factors associated with HRQoL

In the binary logistic regression model, variables with p-value less than 0.25 were selected as candidate variables for multivariate logistic regression analysis. Thus, age of the mother, partner’s education, mother’s education, receiving at least four ANC visits, receiving at least two PNC, perceived family support, postpartum depression, complications during pregnancy, urgency of surgery, type of anesthesia and perceived pain after discharge were identified as a candidate variable for multivariate logistic regression analysis. The multivariate logistic regression analysis showed receiving at least two PNC, postpartum depression, type of anesthesia, complications during pregnancy and perceived pain after discharge were significantly associated with a low HRQoL.

Our study showed that postpartum women who had less than two PNC visits were 2.58 times more likely to have a low HRQoL than those postpartum women who had at least two PNC visits [AOR = 2.58, 95% CI: (1.59–4.19)]. The odds of having a low HRQoL among postpartum women who had complications during pregnancy were 5.32 times [AOR = 5.32, 95% CI (2.69–10.54)] higher than those postpartum women who had no complication during pregnancy. This study also identified that postpartum women had perceived pain after discharge were 2.64 times more likely to have a low HRQoL than postpartum women who had no perceived pain after discharge [AOR = 2.64, 95% CI (1.61–4.35)]. Postpartum women who underwent CD under general anesthesia were 2.36 times more likely to have a low HRQoL compared to those who underwent CD under regional anesthesia [AOR = 2.36, 95% CI: (1.08–5.14)]. Moreover, Postpartum women who had postpartum depression were 2.41 times more likely to have a low HRQoL than postpartum women who had no postpartum depression [AOR = 2.41, 95% CI: ( 1.22–4.77)] (Table 5).

Table 5 Bivariate and multivariate logistic regression analysis for factors associated with overall HRQoL among postpartum mothers following caesarean delivery in Gondar town, 2024 (N = 418)

Discussion

Assessment of HRQoL of women following CD is essential for global healthcare since the joint effect of pregnancy related changes and surgery and anesthesia related side effects increase maternal morbidity and mortality during the postpartum period. This study aimed to assess the HRQoL of postpartum mothers following CD and identify the factors associated with it during the first six weeks postpartum using MOS SF-36 validated tool.

Our study revealed that almost two-thirds [66.5%, 95% CI: (61.8, 71.0)] of postpartum mothers who gave birth via CD had a low level of HRQoL with mean and standard deviation of 47.92 ± 4.28. Key factors significantly associated with lower HRQoL included less than two postnatal care visits, postpartum depression, type of anesthesia, complications during pregnancy, and perceived pain after discharge.

This finding is higher than study done among postpartum women delivered via either of modes of deliveries in Arbaminch, Ethiopia (n = 409) which had 62.3% of low level of HRQoL with a mean score of 45.15 ± 8.13 [31]. The reason for the variation might be due to the effect of surgical procedure and anesthesia on postpartum physical recovery compared to vaginal birth [17]. However, in this study, the prevalence of low HRQoL is lower than the result of a study done among postpartum mothers (n = 429) who gave birth either vaginal via CD in Oromia region, Ethiopia which was [73.7% (95% CI: 69.4–77.7)] [44]. The explanation for this difference might be our study done included postpartum mothers who gave a live birth through CD in urban area. While, the study done in Oromia, Ethiopia included postpartum mothers who gave a live or still birth through either vaginal via CD in urban and rural area.

According to our result the mean score of overall HRQoL is [47.92 ± 4.28, 95% CI: 47.51, 48.33], lower than a finding in Iran with a mean score of 76.56 ± 14.04 [29]. The possible explanation for variation might be due to difference in study design and tool. Our study is conducted using cross sectional study design and MOS SF-36 validated tool, while the study in Iran was done with longitudinal study at 3rd trimester and at 8th week’s postpartum using WHOQoL- Bref questionnaire. More over our result is lower than a result in Spain with mean score of 71.94 ± 17.48 [45]. The possible explanation for these discrepancies may be due to differences in the study population, with the current study conducted on mothers at six weeks of postpartum, while the Spanish study included women who gave birth a year prior to the survey since women who gave birth a year before the study may have recovered from the impact of pregnancy and delivery. Our result also lower than the finding in Iran with mean score of 68.38 ± 13.6 [46], and Brazil with mean score of 86.86 ± 10.6 [32]. The reason for the variation might be due to differences in the tool used to assess quality of life. In this study, we used SF-36 questionnaires, but studies conducted in Brazil used the WHOQoL-Bref tool. The common explanation for the all differences might also be due to the surgical procedure, and the effect of anesthesia further affect their postpartum recovery compared to vaginal birth [17].

The results of our study reported the mean and SD scores of PCS and MCS with [48.22 ± 5.63, 95% CI: 47.68, 48.76] and [47.62 ± 4.28, 95% CI: 47.51, 48.33] respectively. The results are lower than a study conducted in Kuwait, with the mean PCS and MCS scores 54.5 and 52.9 respectively [47]. The possible reason for the difference might be the study participants and assessment tool. In this study we assessed quality of life at six weeks using SF 36 tool, while a study in Kuwait was done at six months and SF 12 tool was utilized. In addition, in our study mean scores of PCS and MCS are lower than mean scores of PCS (59.05 ± 19.48) and MCS (55.08 ± 25.17) of study conducted in North-East Romania [48]. The variation could be brought on by the differences in the study population. In this study only postpartum mothers who underwent CD were included, whereas the study conducted in North-East Romania included either of modes of deliveries. Another reason might be due to the effect of anesthesia, cesarean scar and other CD related factors that reduce components of physical health like physical functioning, role physical, bodily pain, and general health domains.

The mean PCS [48.22 ± 5.63, 95% CI: 47.68, 48.76] and MCS [47.62 ± 4.28, 95% CI: 47.51, 48.33] scores in our study are lower and higher than mean PCS (49.5 ± 9.3) and MCS scores (40.79 ± 10.90) of a study conducted in Ethiopia on 409 randomly selected post-partum women following either cesarean or vaginal deliveries [31]. Whereas, the mean MCS score in our study is higher. The possible justification for this difference can be the effect of anesthesia and surgery on physical recovery lead to low PCS score. However, special attention and support from family members may be good following CD which might bring better MCS score [49].

In this study postpartum women who had less than two postnatal care visits [AOR, 2.58, 95% CI: 91.59–4.19] were more likely to have a low HRQoL. Likewise, a study in rural china showed postnatal visit associated with HRQoL [30]. In addition, our finding is supported by a study in Ethiopia showed PNC positively associated with high HRQoL among postpartum women following either cesarean or vaginal deliveries [44]. WHO recommend postnatal visits to improve short and long term health wellbeing of the mother and newborn which might improve physical and psychological recovery [50]. Thus, postnatal visit might improve physical and mental component of HRQoL.

The result of this study revealed that postpartum women who had complications during pregnancy were negatively associated with HRQoL following CD [AOR, 5.32, 95% CI: 2.69–10.54]. This finding is congruent with a study done in Netherland [51], Austria [52] which found hypertensive disorders, antepartum hemorrhage, gestational diabetes were negatively associated with HRQoL. In addition, supported by a study done among postpartum mothers after either modes of deliveries in southern Ethiopia showed that preeclampsia were negatively associated with HRQoL [35]. This is due to the fact that gestational complications can have long-term physical, mental, and social consequences that result false women’s perception of health and overall well-being after childbirth [53]. Therefore, early screening and management of pregnancy related complications are essential to mitigate their impact on postpartum recovery.

Our study found pain during postpartum period was negatively associated with HRQoL [AOR, 2.64, 95% CI: 1.61–4.35]. One of the reasons for this might be pain results most common symptoms interfere with both quality of life and general functioning as a result of potential detrimental impacts on maternal movement, mobility, sleep and mental health which may influence a woman’s transition to pre pregnancy state [54]. Therefore, management of pain is particularly important for early recovery and satisfactory pain relief improves mobility and enhances breastfeeding and infant care in the postpartum period. Implementing standardized pain management protocols could significantly enhance maternal health outcome.

Postpartum women who underwent CD under general anesthesia were more likely to have low HRQoL [AOR, 2.36, 95% CI: 1.08–5.14]. This finding is supported by a study done in India [55]. This might be due to regional anesthesia enables patients to return to normal daily activities earlier than general anesthesia and it provides more effective pain control, less bleeding, early ambulation and better satisfaction for mothers there by increasing their quality of life [54]. Therefore, encouraging the use of regional anesthesia whenever clinically appropriate could enhance maternal outcomes following CD.

Finally, in this study postpartum women who had postpartum depression were more likely to have a low HRQoL than postpartum women who had no postpartum depression [AOR, 2.41, 95%CI:1.22–4.77]. This finding is supported by studies done in Nigeria, Kuwait, and Netherland [32, 47, 56]. The reason might be depression is negatively associated with mental and physical health, and depression by itself affects women’s ability to function, relation with her child, interpersonal relationship, sleeping pattern, and social engagement, thus lowering HRQoL. So, addressing postpartum depression through early screening and intervention programs is essential to improve HRQoL and overall maternal well-being.

This study has several limitations. First, recall bias may affect the accuracy of self-reported data. Second, the findings should be generalized with caution, as the study focused on women from a specific geographic area. Additionally, as a cross-sectional study assessing HRQoL only within the first six weeks postpartum, it does not capture changes in HRQoL throughout the early and late postpartum period. Despite these limitations, the study provides valuable insights into the factors influencing postpartum HRQoL and serves as a foundation for future interventions aimed at improving maternal well-being after cesarean delivery.

Conclusions

This study founds two-thirds of postpartum women underwent CD, had a low level of HRQoL. Factors significantly associated with lower HRQoL included less than two postnatal care visits, postpartum depression, type of anesthesia, pregnancy complications, and postpartum pain. These findings highlight the need for increased attention to the HRQoL of postpartum women following CD, especially in terms of minimizing morbidity related to surgery and anesthesia. To improve maternal outcomes, it is essential to enhance postnatal care by ensuring mothers receive the recommended number of visits and monitoring recovery closely. Addressing pregnancy complications, such as hypertensive disorders, gestational diabetes, and antepartum hemorrhage, is crucial in promoting better postpartum health. Additionally, encouraging the use of regional anesthesia and integrating effective postoperative pain management can improve recovery. Incorporating routine screening and support for postpartum depression is also vital for overall well-being. Finally, future research should focus on longitudinal studies to track changes in HRQoL across various stages of pregnancy and postpartum to develop more accurate interventions.