Mode of birth and postnatal health-related quality of life after one previous cesarean in three European countries.

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DOI: 10.1111/birt.12324

O R I G I N A L A R T I C L E

Mode of birth and postnatal health- related quality of life after one previous cesarean in three European countries

Maaike Fobelets MSc

¹

| Katrien Beeckman PhD

^2,3

| Ronald Buyl PhD

⁴

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Déirdre Daly PhD

⁵

| Marlene Sinclair PhD

⁶

| Patricia Healy PhD

⁷

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Susanne Grylka-Baeschlin MSc

⁸

| Jane Nicoletti MD

⁹

| Mechthild M. Gross PhD

⁸

|

Sandra Morano MD

¹⁰

| Koen Putman PhD

¹

1Department of Public Health, Interuniversity Centre for Health Economics Research (I-CHER), Vrije Universiteit Brussel, Brussels, Belgium

2Department of Public Health, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium

3Department of Nursing and Midwifery, Nursing and Midwifery research group, Universitair Ziekenhuis Brussel, Brussels, Belgium

4Department of Public Health, Biostatistics and Medical Informatics Research group, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium

5School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland

6University of Ulster, Institute of Nursing and Health Research, Jordanstown, Newtownabbey, Northern Ireland, UK

7School of Nursing and Midwifery, National University of Ireland, Galway, Ireland

8Midwifery Research and Education Unit, Hannover Medical School, Hannover, Germany

9Universita degli Studi di Genova, Genova, Italy

10IRCCS Azienda Ospedaliera Universitaria S. Martino IST, Largo R. Benzi, Genova, Italy

Correspondence

Maaike Fobelets, Department of Public Health, Interuniversity Centre for Health Economics Research (I-CHER), Vrije Universiteit Brussel, Brussels, Belgium.

E-mail: maaike.fobelets@vub.ac.be Funding information

European Union’s Seventh Framework Program

Abstract

Background: How a woman gives birth can affect her health- related quality of life (HRQoL). This study explored HRQoL at 3 months postpartum in women with a history of one previous cesarean in three European countries.

Methods: A prospective longitudinal survey, embedded within a cluster randomized trial in three countries, exploring women’s postnatal HRQoL up to 3 months postpartum. The Short- Form Six- Dimensions (SF- 6D) was used to measure HRQoL, and multivariate analyses were used to examine the relationship with mode of birth.

Results: Complete data were available from 880 women. Women with a spontane- ous vaginal birth had the highest HRQoL scores, whereas women with an emergency repeat cesarean (P = .01) had the lowest. Postnatal readmission of the mother (P = .03), having public health insurance (P = .04), and a low antenatal HRQoL score (P < .01) contributes to poorer HRQoL scores. More specifically, women with a spontaneous vaginal birth had significantly higher HRQoL scores on the vitality dimension compared with women with an emergency repeat cesarean (P = .04).

Conclusions: In women with low- risk factors, repeat cesareans result in a poorer HRQoL compared with vaginal birth. When there are no contraindications for vaginal birth, women with a history of one previous cesarean should be encouraged to give birth vaginally rather than have an elective repeat cesarean.

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1 | I N T RO D U C T I O N

Measuring health- related quality of life (HRQoL) has be- come an integral component of assessing health care outcomes.¹ HRQoL is a broad, multidimensional concept that encompasses physical, psychological, and social dimensions of health² and is measured by individuals’ subjective perception of their well- being and functioning.³ HRQoL means different things to different people, and their experiences of major life events may vary between countries.

Giving birth is a major life event that affects women’s physical and psychological health and their HRQoL postnatally.⁴ Socioeconomic status and postnatal depression are associated with women’s HRQoL postnatally,⁵ and factors related to the mode of birth, for example, perineal trauma following vaginal birth or bladder trauma following cesarean, affect HRQoL postnatally.⁶

Previous studies have shown the importance of mode of birth and childbirth experience on HRQoL.^7-10 In general, the postnatal HRQoL is higher among women who birth vaginally compared with women with a cesarean. More specifically, women with low- risk factors who birth vaginally have more favorable HRQoL scores across physical functioning, mental health, social functioning, and bodily pain dimensions.^7-10 However, results can differ between studies conducted with low- risk populations and studies conducted in specific clinical contexts, for example, preeclampsia or gestational hypertension. Hoedjes et al.’s¹¹ study comparing the HRQoL in women with mild and severe preeclampsia showed no significant differences in HRQoL by mode of birth. On the contrary, a study by Prick et al.^7,12 investigating the determinants of postnatal HRQoL after obstetric complications (gestational hypertension, intrauterine growth restriction, or postpartum hemorrhage) found that the mode of birth has a profound impact on the physical functioning dimension of the postnatal HRQoL.

In addition, women’s actual experiences of childbirth may not meet their expectations, and this can also affect their HRQoL. For example, women who have an unplanned or emergency cesarean may have a negative childbirth experience and therefore a lower HRQoL.¹³ The negative influence of giving birth by cesarean has an impact on the long- term HRQoL⁷ and therefore may influence the HRQoL in a subsequent pregnancy. Women with one prior cesarean may be suitable for a vaginal birth after cesarean as an alternative to a repeat cesarean. Little is known about the postnatal HRQoL of women with a vaginal birth after cesarean compared with women with a repeat cesarean, yet cesarean

rates are rising globally and are a concern for health policy- makers. Randomized controlled trials have been performed to assess the effectiveness of interventions to increase the likelihood of vaginal birth after cesarean as an alternative to a repeat cesarean.^14,15 An example of such a study is the OptiBIRTH trial,¹⁶ a multicenter cluster randomized controlled trial, conducted in Germany, Ireland, and Italy, that aimed to improve maternal health service delivery, and op- timize perinatal care, by increasing vaginal birth after cesarean through enhanced patient- centered maternity care.

Self- administered HRQoL questionnaires, incorporating the Short- Form Six- Dimensions (SF- 6D),¹⁷ were collected at time of recruitment antenatally and 3 months postnatally.

This paper reports on mode of birth and postnatal HRQoL in women with a history of one previous cesarean in three European countries.

2 | M E T H O D S

Between April 2014 and October 2015, women in 15 maternity units in three EU countries (Germany, Ireland, and Italy) were recruited to the OptiBIRTH trial. Women in the intervention group received a complex innovative program of evidence- based antenatal strategies, incentives, and ac- tivities, designed to increase their empowerment, engagement, and involvement. Ethical approval was obtained from the Faculty of Health Sciences, Trinity College Dublin, Ireland, and Research Ethics Committees of all participat- ing sites in each country. Women were eligible to partici- pate if they (1) were ≥18 years of age at their first booking visit, (2) had one previous cesarean using a lower segment transverse incision, not classical/high vertical incision, (3) spoke and understood the language in at least one of the trial countries (English, German, or Italian), and (4) provided informed consent. There were two levels of participation: full participation (completion of questionnaires and engagement with the OptiBIRTH intervention in the intervention sites) or routine data collection (access to the health care records and no engagement with the OptiBIRTH intervention). Women’s sociodemographic characteristics and HRQoL were collected at enrollment, clinical characteristics were collected from women’s health care records and by a postnatal questionnaire, and HRQoL data were collected in the context of a health economic evaluation of the study via self- administered questionnaires antenatally and again at 3 months postnatally. More details of the trial are described in a separate paper.¹⁸

K E Y W O R D S

Europe (MeSH), obstetric delivery (MeSH), perinatal care (MeSH), pregnancy (MeSH), quality of life (MeSH)

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2.1 | Data collection on

sociodemographic and clinical characteristics

Women’s demographic data included age, educational level, employment status, health insurance status, and relationship status.^19-22 Age was categorized into three groups:

≤30, 31- 35, and ≥36 years. Educational level was categorized as secondary education or lower, third- level nondegree (National Certificate or Diploma)/third- level primary degree (Bachelor), postgraduate certificate, or diploma/postgraduate degree (Masters)/PhD. Employment status was divided into three categories: full- time employment, part- time employment, and unemployed. The following variables were dichot- omized: health insurance status (private/semiprivate insured, public insured) and relationship status (married/cohabiting, single).

Clinical data included mode of birth, parity, pregnancy duration (gestational age <37 weeks (preterm birth), or 37 weeks and longer), type of infant feeding, prolonged postnatal hospital stay of the mother (longer than the national average length of stay for vaginal birth or cesarean), infant admission to a neonatal unit, readmission of mother after discharge from hospital postnatally and readmission of the infant after discharge from hospital, and gestational age at the time of inclusion in the study.7,11,12,19,20 Clinical characteristics were coded as follows: mode of birth (spontaneous vaginal birth, instrument- assisted vaginal birth, elective repeat cesarean, emergency repeat cesarean), parity (one previous birth, two or more births), preterm birth (yes, no), type of infant feeding (breastfeeding, formula feeding), prolonged postnatal stay of the mother (yes, no), infant admission to a neonatal unit after birth (yes, no), readmission of the mother after discharge (yes, no), readmission of the infant postnatally (yes, no). Gestational age at recruitment was included as a continuous variable.

2.2 | Data collection on health- related quality of life

HRQoL was measured using a generic HRQoL instrument.

Generic HRQoL instruments focus on the general aspects of health and are the most widely used instruments in maternity care even though they were not developed specifically for the maternity population and focus on the general aspects of health. Examples include the EuroQol Five- Dimensions (EQ- 5D)²³ and the SF- 6D.¹⁷ Condition- specific HRQoL instruments are designed for a specific diagnosis or patient group/group of women. However, condition- specific instruments do not allow comparisons with the general population and are therefore limited in their use. The generic SF- 6D was selected for this study because of its empirical validity, that is, the measure-generated utility scores that reflect the population preferences, in the maternity care context.²⁴

HRQoL was measured using the Short- Form- 36 Health Survey version 2 (SF- 36v2),²⁵ which was validated for use in English, German, and Italian.^26-29 Responses were converted to utility scores, a quantitative expression of an individual’s preference or desire for a particular health state,³⁰ using the SF- 6D algorithm from the UK general population.¹⁷ The SF- 6D measures six dimensions: physical functioning, role limitation (because of physical and emotional problems), social functioning, pain (bodily), mental health (psychological distress and psychological well- being), and vitality (energy/

fatigue). Each of these dimensions receives a score, ranging from 0 to 100, and higher scores indicate better HRQoL. A utility algorithm was applied to predict unique health states which were assessed for valuation by the UK general population using the standard gamble valuation method. The reason for this was the absence of country- specific value sets, that is, a set of preference weights for a population used because populations may have different preferences.^17,24 Summary scores ranging from 0 to 1 were calculated to assess overall utility scores between the various birth modes.

For the pur poses of this analysis, antenatal and postnatal HRQoL data were assessed for all women recruited in the OptiBIRTH trial, irrespective of women being in the control or intervention group.

2.3 | Statistical analysis

First, general sociodemographic and clinical characteristics of women who did versus did not respond to both HRQoL questionnaires in each country were compared using a chi- square test and t test. Second, a multivariate model analysis was performed to investigate the effects of the independent fixed factors (age, educational level, employment status, health insurance status, relationship status, mode of birth, parity, preterm birth, type of infant feeding, prolonged postnatal stay of mother, admission to neonatal unit, readmission of mother postnatally, readmission of infant postnatally, country) on the postnatal HRQoL while controlling for the covariates (gestational age at recruitment and antenatal HRQoL). An analysis of (co- )variance model (ANCOVA) was chosen instead of models such as Tobit, Beta, or two- part regression, which are currently often used for modeling HRQoL data when dealing with possible censored data. As the data showed only a small proportion being really close to 1 or exactly 1, possible underestimation of the parameters will be relatively small.³¹ In addition, all the model assump- tions were met, and the model showed a good residual analysis, providing the necessary evidence for the interpretation of the ANCOVA model in this context. All two- way interaction effects with country were included in the model, given country is probably an important factor for the differences in HRQoL scores when controlling for all independent factors.

Finally, the same multivariate model was used to evaluate the

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estimated marginal means of the SF- 6D postnatal dimension scores for mode of birth, controlling for fixed factors, covariates, and interactions described above. All analyses were performed in IBM SPSS statistics version 24.

3 | R E S U LT S 3.1 | Study population

A total of 2002 women recruited from 15 maternity units in the three countries participated in the study, 1831 of whom participated fully. The remaining 171 women consented to collection of their routine data only, and their data are not considered in these analyses. All sociodemographic and clinical characteristics and data on the antenatal and postnatal HRQoL were available for 880 women (48.1%). The final HRQoL data set comprised 328 women from Germany, 131 women from Ireland, and 421 women from Italy. The majority of women were older than 30 years, had a high educational level, were active in the labor market, publicly insured, and married. Clinical characteristics show the most frequent birth mode to be vaginal birth in Germany (34.8%) and elective repeat cesareans in Ireland (44.3%) and Italy (62.7%).

The majority of women had a history of just one previous birth, and weeks of gestation at enrollment (mean, ±SD) var- ied from 18.3 (±6.0) weeks in Ireland, to 26.9 (±10.4) weeks in Italy and 31.0 (±8.1) weeks in Germany.

The clinical and demographic characteristics of women who did and those who did not respond to the HRQoL questionnaires are presented in Table 1. Women who did not respond were significantly younger (Germany [P < .01] and Ireland [P = .01]), had a lower educational level (Germany [P < .01] and Italy [P = .02]), were more frequently single (Germany [P = 0.04]), and were unemployed (Germany [P < .01] and Italy [P = .01]). In addition, women who did not respond had a significantly higher parity (Ireland [P = .03]), had more preterm births (Germany [P < .01], Ireland [P = .02], and Italy [P < .01]), and were at a more advanced gestational age when recruited to the trial (Ireland [P = .02]).

3.2 | Postnatal HRQoL and women’s characteristics

There were significant differences in women’s HRQoL postnatal utility scores between countries (Table 2). Women in Germany had the lowest utility scores, and women in Ireland had the highest utility scores (0.77 vs 0.80, P < .01). Prolonged postnatal stay of the mother (P = .01) and readmission of the mother (P = .01) or infant (P = .03) postnatally contributed to lower utility scores. Being at more advanced gestation at the time of recruitment or having a low antenatal utility score (P < .01) resulted in significantly lower postnatal utility scores.

Significant differences in utility scores were found for health insurance status, after controlling for sociodemographic and clinical characteristics. Publicly insured women had significantly lower utility scores compared with privately insured women (0.78 vs 0.79, P = .04).

There were significant differences in utility scores by mode of birth in the multivariate model (P = .01).

Specifically, higher utility scores (mean, ±SD) were found in women who birthed spontaneously (0.81 ± 0.11) followed by instrument- assisted vaginal birth (0.81 ± 0.10) and by elective repeat cesarean (0.77 ± 0.12). Women who had an emergency repeat cesarean had the lowest utility scores (0.76 ± 0.12). Furthermore, the difference in utility scores between modes of birth was significant between women who had a spontaneous vaginal birth compared with women who had an emergency repeat cesarean, 0.81 vs 0.76 (P = .01), respectively. These results exceed the minimally clinical important difference in utility score of 0.03, which could have an influence on women’s health.^7,32

Readmission of the mother postnatally (P = .03) and low antenatal utility scores (P < .01) were significantly associated with lower postnatal utility scores. In the model, country did not have a significant main effect (P = .14) but did have interaction effects with gestational age at recruitment (P = .03) and antenatal utility scores (P = .03). This indicates that there is a country- specific difference in the association of gestational age at recruitment and the value of the antenatal utility on the HRQoL postnatally. More specifically, the effect of gestational age at recruitment and the value of the antenatal utility on the postnatal HRQoL are country dependent.

3.3 | Postnatal HRQoL dimension scores by mode of birth

The estimated marginal means of the postnatal dimension scores are presented in Figure 1. Women who birthed vaginally, either spontaneously or assisted with instruments, had higher dimension scores for five of the six dimensions compared with women who had a repeat cesarean, either electively or as an emergency. Multivariate analyses showed a significant difference (P = .04) in the dimension scores for vitality between women who birthed spontaneously and those who had an emergency repeat cesarean (results available on request).

4 | D I S C U S S I O N

This study demonstrated a significant difference in HRQoL by mode of birth. The highest utility scores were found in women who had a spontaneous vaginal birth, followed by instrument- assisted vaginal birth and then elective repeat cesarean, and then in women who had an emergency repeat cesarean.

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TABLE 1 Sociodemographic and clinical characteristics by responders and nonresponders per country; OptiBIRTH Prospective Population- Based Study; Germany, Ireland, and Italy; 2014- 2016 RespondersNonrespondersP- valuea,b Germany (n = 328)Ireland (n = 131)Italy (n = 421)Germany (n = 427)Ireland (n = 491)Italy (n = 204) n (%) or Mean ± SD n (%) or Mean ± SD n (%) or Mean ± SD n (%) or Mean ± SD n (%) or Mean ± SD

n (%) or Mean ± SDGermanyIrelandItaly Sociodemographic characteristics Agec <0.010.010.15 ≤30 years57 (17.4)23 (17.6)70 (16.6)127 (29.7)149 (30.3)47 (23.0) 31- 35 years146 (44.5)71 (54.2)157 (37.3)163 (38.2)215 (43.8)69 (33.8) ≥36 years125 (38.1)37 (28.2)194 (46.1)137 (32.1)127 (25.9)87 (42.6) Missing0 (0.0)0 (0.0)0 (0.0)0 (0.0)0 (0.0)1 (0.6) Educational levelc <0.010.060.02 Secondary education or lower62 (18.9)18 (13.8)84 (20.0)119 (27.9)80 (16.3)49 (24.0) Third- level nondegree/primary degree100 (30.5)87 (66.4)296 (70.3)78 (18.3)199 (40.5)94 (46.1) Postgraduate/PhD166 (50.6)26 (19.8)41 (19.7)124 (29.0)77 (15.7)16 (7.8) Missing0 (0.0)0 (0.0)0 (0.0)106 (24.8)135 (27.5)45 (22.1) Employment statusc 0.010.050.01 Full- time employment77 (23.5)79 (60.3)230 (54.6)48 (11.2)167 (34.0)69 (33.8) Part- time employment166 (50.6)25 (19.1)87 (20.7)106 (24.8)85 (17.3)27 (13.2) Unemployed85 (25.9)27 (20.6)104 (24.7)102 (23.9)97 (19.8)58 (28.4) Missing0 (0.0)0 (0.0)0 (0.0)171 (40.1)142 (28.9)50 (24.6) Health insurance statusc0.200.050.89 Private/semiprivate58 (17.7)16 (12.2)59 (14.0)50 (11.7)81 (16.5)27 (13.2) Public270 (82.3)115 (87.8)362 (86.0)304 (71.2)332 (67.6)160 (78.5) Missing0 (0.0)0 (0.0)0 (0.0)73 (17.1)78 (15.9)17 (8.3) Relationship statusc 0.040.100.49 Married/cohabiting317 (96.6)127 (96.9)412 (97.9)295 (69.1)331 (67.4)155 (76.0) Single11 (3.4)4 (3.1)9 (2.1)22 (5.1)25 (5.1)5 (2.4) Missing0 (0.0)0 (0.0)0 (0.0)110 (25.8)135 (27.5)44 (21.6) (Continued)

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RespondersNonrespondersP- valuea,b Germany (n = 328) Ireland (n = 131) Italy (n = 421) Germany (n = 427) Ireland (n = 491)

Italy (n = 204) n (%) or Mean ± SDn (%) or Mean ± SDn (%) or Mean ± SDn (%) or Mean ± SDn (%) or Mean ± SDn (%) or Mean ± SDGermanyIrelandItaly Clinical characteristics Mode of birthc0.120.220.94 Spontaneous vaginal birth114 (34.8)30 (22.9)81 (19.2)128 (30.0)92 (18.8)31 (15.1) Instrument- assisted vaginal birth25 (7.6)16 (12.2)9 (2.1)26 (6.1)52 (10.6)5 (2.5) Elective repeat cesarean107 (32.6)58 (44.3)264 (62.7)170 (39.8)192 (39.1)107 (52.5) Emergency repeat cesarean82 (25.0)27 (20.6)67 (16.0)89 (20.8)143 (29.1)28 (13.7) Missing0 (0.0)0 (0.0)0 (0.0)14 (3.3)12 (2.4)33 (16.2) Parityc 0.100.030.34 One291 (88.7)111 (84.7)338 (80.3)366 (85.7)373 (76.0)165 (80.9) Two or more37 (11.3)20 (15.3)83 (19.7)56 (13.1)118 (24.0)38 (18.6) Missing0 (0.0)0 (0.0)0 (0.0)5 (1.2)0 (0.0)1 (0.5) Preterm birthc,d 22 (6.7)2 (1.5)33 (7.8)13 (3.0)35 (7.2)17 (8.3)<0.010.02<0.01 Type of infant feedingc0.840.330.31 Breastfeeding only263 (80.2)46 (35.1)321 (76.2)73 (17.1)15 (4.8)78 (38.2) Formula feeding65 (19.8)85 (64.9)100 (23.8)17 (4.0)19 (3.9)31 (15.2) Missing0 (0.0)0 (0.0)0 (0.0)337 (78.9)457 (93.1)95 (46.6) Prolonged postnatal stay of motherc,d 25 (7.6)3 (2.3)73 (17.3)26 (6.1)26 (5.3)30 (14.7)0.550.130.74 Admission to neonatal unitc,d32 (9.8)10 (7.6)14 (3.3)32 (7.5)60 (12.2)9 (4.4)0.410.070.09 Readmission of mother postnatallyc,d 17 (5.2)9 (6.9)9 (2.1)4 (0.9)2 (0.4)3 (1.4)0.930.840.71 Readmission of infant postnatallyc,d24 (6.3)17 (13.0)23 (5.5)10 (2.4)2 (0.4)7 (3.4)0.170.270.72 Gestational age at recruitmente 30.95 ± 8.1318.32 ± 5.9826.85 ± 10.3730.17 ± 8.8619.01 ± 5.7327.73 ± 9.840.150.020.74 Antenatal HRQoL scoree 0.68 ± 0.110.73 ± 0.100.72 ± 0.120.67 ± 0.110.73 ± 0.090.70 ± 0.130.380.950.23 a Comparing the sociodemographic and clinical characteristics of responders vs nonresponders. bStatistically significant (P ≤ .05) shown in bold. cChi- square test. dThe n (%) represent the presence of the variable. e Independent t test.

TABLE 1 Continued

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T A B L E 2 Univariate and multivariate analysis of the SF- 6D health utility score postnatally by sociodemographic characteristics; OptiBIRTH Prospective Population- Based Study; Germany, Ireland, and Italy; 2014- 2016

Mean ± SD

Multivariate analysis (P- value^a)

Main effect Interaction country Sociodemographic characteristics

Age 0.14 0.24

≤30 years 0.78 ± 0.12

31- 35 years 0.79 ± 0.12

≥ 36 years 0.78 ± 0.12

Educational level 0.19 0.17

Secondary education or lower 0.76 ± 0.13

Third- level nondegree/primary degree 0.79 ± 0.12

Postgraduate/PhD 0.78 ± 0.11

Employment status 0.50 0.77

Full- time employment 0.79 ± 0.12

Part- time employment 0.77 ± 0.12

Unemployed 0.77 ± 0.12

Health insurance status 0.04 0.41

Private/semiprivate 0.79 ± 0.12

Public 0.78 ± 0.12

Relationship status 0.95 0.66

Married/cohabiting 0.78 ± 0.12

Single 0.77 ± 0.12

Country 0.14 NA

Germany 0.77 ± 0.11

Ireland 0.80 ± 0.12

Italy 0.78 ± 0.12

Clinical characteristics

Mode of birth 0.01^b 0.06

Spontaneous vaginal birth 0.81 ± 0.11

Instrument- assisted vaginal birth 0.81 ± 0.10

Elective repeat cesarean 0.77 ± 0.12

Emergency repeat cesarean 0.76 ± 0.12

Parity 0.48 0.35

One 0.78 ± 0.12

Two or more 0.78 ± 0.13

Preterm birth 0.58 0.59

Yes 0.75 ± 0.13

No 0.78 ± 0.12

Type of infant feeding 0.40 0.06

Breastfeeding 0.78 ± 0.12

Formula feeding 0.78 ± 0.12

Prolonged postnatal stay of mother 0.08 0.62

Yes 0.75 ± 0.14

No 0.79 ± 0.12

(Continued)

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Women who had public health insurance, had a low antenatal utility score, or were readmitted to the hospital postnatally had significantly poorer utility scores. Dimension scores were more likely to be higher for women who birthed vaginally compared with women who had a repeat cesarean, either electively or as an emergency. Significant higher vitality scores were found in women who birthed spontaneously compared with women who had an emergency repeat cesarean.

To the best of our knowledge, this is the first multicountry prospective study, based on a large sample, to report postnatal HRQoL and mode of birth in women with one prior cesarean. Similar to a study by Petrou et al.⁷ we found a 0.05 reduction in utility scores when comparing emergency repeat cesarean with spontaneous vaginal birth, and this exceeds the minimally clinical important difference in utility score of 0.03 suggested in the literature.^7,32 Our results are consistent with

Mean ± SD

Multivariate analysis (P- value^a)

Main effect Interaction country

Admission to neonatal unit 0.41 0.94

Yes 0.75 ± 0.13

No 0.78 ± 0.12

Readmission of mother postnatally 0.03 1.00

Yes 0.72 ± 0.12

No 0.78 ± 0.12

Readmission of infant postnatally 0.06 0.29

Yes 0.75 ± 0.13

No 0.79 ± 0.12

Gestational age at recruitment NA 0.65 0.03

Antenatal HRQoL score NA <0.01 0.03

aStatistically significant P- values (P ≤ .05) shown in bold.

bSignificant difference for spontaneous vaginal birth and emergency repeat cesarean (P = .014).

SF- 6D, Short- Form Six- Dimensions; SD, standard deviation; NA, not applicable.

T A B L E 2 Continued

F I G U R E 1 Estimated means ±SE for health- related quality of life postnatally subdomain scores by mode of birth; OptiBIRTH Prospective Population- Based Study; Germany, Ireland, and Italy; 2014- 2016. Adjusted for maternal age, educational level, employment status, health insurance status, relationship status, parity, preterm birth, type of infant feeding, prolonged postnatal stay of the mother, infant admission to neonatal unit, readmission of mother postnatally, readmission of infant postnatally, gestational age at recruitment, and antenatal health- related quality of life score.

SF- 6D, Short- Form Six- Dimensions

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those of published studies and show that giving birth vaginally is significantly associated with a more favorable HRQoL score postnatally, compared with having a cesarean.^7-10

We identified also other factors that had an influence on women’s HRQoL postnatally. Readmission of the mother postnatally was associated with lower utility scores. We were unable to find other studies reporting on this association, but a possible explanation is that the occurrence of morbidities during pregnancy or postnatally is associated with postnatal readmission to the hospital. Hoedjes et al.¹¹ found a poor postnatal HRQoL in women with morbidities such as severe preeclampsia. Prick et al.¹² investigated the determinants of postnatal HRQoL following obstetric complications and concluded that gestational hypertension had a small negative effect on the SF- 36’s physical component score, but no effect was found for other complications such as postpartum hemorrhage or endometritis. We found a significant association between low antenatal and postnatal HRQoL scores. Women’s psychosocial well- being is crucial to their overall HRQoL.

Setse et al.³³ found that women who were depressed in both the second and third trimester of pregnancy had a lower antenatal HRQoL and postnatal HRQoL compared with women without depressive symptoms.³⁴

Having a (semi- )private health insurance status was significantly associated with a higher postnatal utility score. The socioeconomic gradient of health insurance status can be re- garded as a proxy for socioeconomic status. The latter is a factor known to be associated with HRQoL.^35,36

In this paper, we focussed on the relationship between the mode of birth and HRQoL up to 3 months postnatally, con- sidering a range of important influencing factors. A minor point is that we did not examine the impact of these factors on long- term HRQoL. Unfortunately, data collection for a longer period was not feasible in this international context.

A study by Carlander et al.³⁷ showed a poorer HRQoL in women with an emergency cesarean or a cesarean for medical reasons compared with women with a (instrumental) vaginal birth or an elective cesarean 5 years after birth. This indicates that women undergoing an emergency cesarean or a cesarean for medical reasons have a longer psychological recovery time compared with others. Health care practitioners should be aware of the long- term impact of the mode of delivery on the psychological health of women and identify the potential need for extra (mental) support. These psychosocial and other potential clinical pathways, such as placental accreta which is associated with multiple cesareans or urinary incontinence following instrument- assisted birth, influence the long- term HRQoL.^7,13 Longitudinal, prospective studies are needed to examine associations between these pathways and the long- term HRQoL after different modes of birth.¹³

This study has some limitations. First, women were asked to complete antenatal questionnaires at recruitment to the study, regardless of the duration of their pregnancy,

and the observed differences between the countries, that is, 18.3 weeks in Ireland, 26.9 weeks in Italy, and 31.0 weeks in Germany, make direct comparisons between groups difficult. Because of this, we corrected our model for pregnancy duration at recruitment and examined possible interaction effects with country. Second, 3 months is rather short for assessing long- term outcomes in maternity care. Other longitudinal studies have reported differences in HRQoL according to the mode of birth 1 year and even 5 years after birth.^7,37 Although a study including a longer postnatal time horizon is desirable, this can be difficult in the context of large international trials. Third, cesarean was categorized as elective or emergency during data collection,³⁸ and we were unable to recategorize these data retrospectively. Four, only data from women with complete sociodemographic and clinical characteristics, and who completed antenatal and postnatal SF- 6D questionnaires, were included in the analyses. This resulted in a smaller study sample, but improved the quality of the data because the multivariate model included complete HRQoL data. Moreover, the statistical analysis showed, for those variables significantly associated with HRQoL (Table 2), there are no significant differences between responders versus nonresponders (Table 1), indicating that the effect of the nonresponders on the postnatal HRQoL results is smaller than expected. Therefore, we can assume that our results can be extrapolated to the total study population. Last, the data in this study were collected in the context of the OptiBIRTH trial in Germany, Ireland, and Italy with a vaginal birth after cesarean rate of 35% or less before the trial.¹⁸ These rates are low compared to some other European countries such as The Netherlands (45%) or Finland (55%). Reasons for these lower rates include medico- legal factors, organizational differences such as inaccessibility of tertiary centers, or differences in clinical practice.¹⁸ These differences might independently influence the long- term HRQoL in women postnatally.

In conclusion, this study showed that women who had a spontaneous vaginal birth after one previous cesarean had higher postnatal HRQoL, on both the main and dimension scores, compared with women having a repeat cesarean either electively or as an emergency. This indicates that besides the known clinical benefits of vaginal birth after cesarean, it also results in an improved HRQoL and should be encouraged in low- risk women when clinically appropriate. To the best of our knowledge, this is the first study reporting on HRQoL in women eligible for a vaginal birth after cesarean within a European context. Therefore, more research in this study population is warranted to increase the body of knowledge of postnatal HRQoL and permit comparison of results.

AC K NOW L E D G E M E N T S

We are grateful to the European Commission for funding this study under the European Union’s Seventh

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Framework Program (FP7- HEALTH- 2012- INNOVATION- 1 HEALTH.2012.3.2- 1), improving the organization of health service delivery [grant agreement no. 305208]. The opinions expressed here are those of the study team and are not neces- sarily those of the European Commission.

We would also like to thank the Wetenschappelijk Fonds Willy Gepts of the UZ Brussel for the additional funding en- abling M. Fobelets to conduct these analyses.

O RC I D

Maaike Fobelets http://orcid.org/0000-0002-8316-6422

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How to cite this article: Fobelets M, Beeckman K, Buyl R, et al. Mode of birth and postnatal health- related quality of life after one previous cesarean in three European countries. Birth. 2018;45:137‐147. https://doi.

org/10.1111/birt.12324