Deconstructing Current Postpartum Recovery Research—The Need to Contextualize Patient-Reported Outcome Measures

Ruth Landau
2021 JAMA Network Open  
Undoubtedly, optimal postpartum recovery is essential to ensure women's physical and mental health, their ability to optimally care for their newborn(s), and their return to prepregnancy function and well-being, whether at work or at home. Much emphasis has been placed on developing enhanced recovery after cesarean protocols, 1 including ways to prevent persistent opioid use; however, standardized tools to assess global postpartum recovery are still lacking. In a systematic review, Sultan and
more » ... lleagues 2 evaluated 46 prospective studies, involving 19 165 patients giving birth between 1988 and 2020, that used a variety of patient-reported outcome measures (PROMs). Before delving further, understanding the methods and taxonomy are essential; the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) method for systematic reviews of PROMs created an exhaustive checklist with criteria to evaluate the quality of PROMs and review the psychometric results and overall quality of measurement properties. 3 The PROMs are to be regarded as "structured questionnaires allowing patients to report their health status" 4(p2) and are deemed the gold standard for assessing recovery after surgery. The domains of inpatient and outpatient postpartum recovery assessed in PROMs have so far included (1) general physical recovery, (2) medical or surgical factors (including complications such as genitourinary or gynecological and fecal incontinence), (3) anesthesia-related adverse events, (4) comfort and satisfaction, (5) pain, (6) psychosocial distress (including depression, anxiety, and other psychological morbidity), (7) psychosocial and patient support, (8) sleep, (9) fatigue, (10) motherhood experience (including adapting to the maternal role and motherhood experience), (11) sexual function, (12) feeding and breast health, (13) cognition, (14) appearance and cosmetic factors, and (15) infant health. A recent scoping review conducted by Sultan and colleagues 4 identified a total of 201 PROMs used to assess outpatient postpartum recovery and 73 PROMs used to assess inpatient postpartum recovery. Of the 13 domains identified, the 5 most studied domains of outpatient postpartum recovery were psychosocial distress (77 PROMs), surgical complications (26 PROMs), psychosocial support (27 PROMs), motherhood experience (16 PROMs), and (5) sexual function (13 PROMs), but the authors concluded that most PROMs evaluated only 1 domain of recovery and proposed that a multidimensional approach to assess global postpartum recovery is necessary. 4 In another systematic review using the COSMIN checklist, 5 Sultan and colleagues evaluated PROMs on the quality of immediate functional recovery after cesarean delivery. They identified 20 studies involving 9214 patients using 13 different PROMs, each covering between 2 and 7 recovery domains. As emphasized by the authors, there was no high-quality PROM for use after cesarean delivery beyond 25 hours post partum, and the Obstetric Quality of Recovery-11 (since modified to a 10-item version) performed best for assessing immediate inpatient postpartum recovery. 6 The novelty and significance in the present work by Sultan and colleagues 2 lie in attempting to identify, using the COSMIN checklist, the best available multidomain PROMs assessing postpartum recovery beyond the delivery hospitalization; the goal is to provide a standardized framework by which maternal physical and emotional health will be adequately evaluated, enabling screening and intervention when women are not recovering, coping, or meeting expected milestones after childbirth. For a PROM to be included in this systematic review, it had to assess at least 3 of 13 domains to better capture the multidimensionality of postpartum recovery, and it had to include +
doi:10.1001/jamanetworkopen.2021.11689 fatcat:sjaiuupyybhgllamh7gpcqty5e