Abstract
Background:
Assessment of quality of life (QoL) during pregnancy can be a starting point for streamlining and promoting the humanization of evidence-based healthcare. We aimed to determine the life quality in pregnant women and its predictors.
Methods:
A cross-sectional study was conducted on pregnant women from Slovakia from March 2020 to January 2021. A method of purposive sampling was used. The research sample consisted of 393 women (age 29.11±4.65) with physiological pregnancy. Questionnaire method was used. The first part of the questionnaire consisted of a set of questions focused on identification items, which also represented the investigated predictors. The second part was the standardized questionnaire “Quality Of Life-Gravidity Questionnaire“(QOLGRAV), with Cronbach’s alpha value of 0.74. The received data were analysed using descriptive and inferential statistics.
Results:
The average life quality score was 18.79±5.04, which oscillates at the level of very good life quality. The lower life quality was recorded in connection with physical changes, satisfaction with social life, concerns about childbirth management failure and a need for physical activity reduction. Education (P=0.008), course of pregnancy (P=0.001), support from healthcare professionals (P=0.003) and concerns about COVID-19 (P=0.001) were the predictors of life quality.
Conclusion:
The proven significant predictors of life quality of pregnant women have shown that healthcare professionals should pay increased attention to the pregnant women with higher education and with problematic pregnancy, positively support and motivate pregnant women and be even more attentivedue to the current COVID-19 pandemic.
Keywords: Quality of life, Predictors, Pregnancy, Public health, Healthcare
Introduction
Although pregnancy is a physiological phenomenon, it is a period of life that requires serious biological and psychosocial adjustment of women to new circumstances. It is a period that can positively or negatively affect the QoL of women (1).
QoL is perceived as a consequence of the interaction of a number of different factors (social, health, economic or environmental) that interact with each other and thus affect the human development of the individual as well as society as a whole. It reflects the evaluation of the impact of all areas of life on the general well-being and satisfaction of the individual and not only those related to health (2). Pregnancy reduces the QoL of women (3, 4). Assessment of QoL in pregnancy is important due to physiological changes in the female body (physical, hormonal, emotional, psychological) (5, 6), which might endanger the life quality and health of even those women who have pregnancy without complications (3).
The effects of reduced QoL in pregnant women have been found to contribute to higher gestational weight gain (7), body dissatisfaction (8), fatigue, back and pelvic pain (9), stress, anxiety, depression (3, 6), as well as to low QoL in the postnatal period (10). Decreased QoL during pregnancy not only affects the mother herself, but can also have adverse consequences for the child (3), as it is associated withlow birth weight of the newborns (11), affects the quality of a secure attachment, which in turn may affect the child’s short-term and long-term psychological well-being and development (12, 3) as well as his social, emotional and cognitive adaptation (13). Low QoL can have a potential impact on both short-term and long-term public health outcomes (14).
We aimed to find out the QoL of women during pregnancy and its predictors.
Methods
A quantitative cross-sectional study was chosen for this study. The research was conducted from March 2020 to January 2021 in three Gynaecological Outpatient clinics of the Slovakia in the region of Žilina Town.
The sample group consisted of 393 respondents (mean age 29.11±4.65) who had fulfilled the following inclusion criteria: a woman with physiological pregnancy, age over 18 years. A method of purposive sampling was used.
The combined method of questionnaire administration was chosen. The questionnaire could be completed in either print or electronic form. Those pregnant women who had agreed to participate in the research study signed an informed consent. The respondents filled in the questionnaires in printed form in writing during their prenatal counselling at the outpatient clinics and placed them into a marked collection box reserved for this purpose. The respondents who decided to complete the questionnaire in electronic form provided an e-mail address to which a survey link to the online questionnaire was subsequently sent. A total of 450 questionnaires were distributed, with a response rate of 89.33%. Out of a total of 402 completed questionnaires, 9 questionnaires were excluded due to their non-compliance with the inclusion criteria.
An empirical method of data collection was used. The Quality Of Life-Gravidity (QOL-GRAV) standardized questionnaire was supplemented by the questions of our own design. These supplemented questions, focused mainly on the characteristics of the research group, also represented the investigated predictors in relation to QoL.
The QOL-GRAV used is a specific, screening and valid tool aimed at assessing the QoL in pregnant women (15). QOL-GRAV has been constructed and validated in the Czech Republic and the original Czech version of the questionnaire was translated into the Slovak language under the cooperation of several Slovak language experts. To maintain equivalence of the questionnaire in the Slovak language, the method of back-translation was applied which is considered the gold standard for quality assurance in the process of cross-cultural adaptation of research. The proximity of the Slovak and Czech culture, language similarity, genetic relationship and structural similarity resulting from the long period of the common state, served as a natural prerequisite for the possibility of questionnaire use in the Slovak Republic.
QOL-GRAV, using 9 questions rated on a 5-point Likert scale, provides an opportunity to capture more sensitively and accurately the extent of specific experience during physiological pregnancy (in the domain of physical, psychological and social relationships) that fundamentally affect the QoL of pregnant women. The lower the score, the higher the quality of life. Based on the total score, the QoL was evaluated as excellent (9–18 points), very good (19–27 points), good (28–36 points), not very good (37–45 points). The Cronbach α QOL-GRAV questionnaire was 0.74.
The data were analysed and processed using SPSS ver. 22 Software (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to describe the basic characteristics and inferential statistics procedures were used to identify QoL predictors. Prior to further analysis, the Kolmogorov-Smirnov normality test was used to test the normal distribution of our data. As the normal distribution was not confirmed, the non-parametric statistical analyses were used using the Kruskal-Wallis test and the Mann-Whitney test, respectively. The p-value of <0.05 was considered statistically significant. For the estimation of reliability we used Cronbach alpha estimates of internal consistency.
Ethical approval
The study was approved by the Ethics Committee of the Žilina, Slovakia (Number EC: 02937/2020/OZ-01). The data collection was anonymous, and all participants expressed their willingness to be included in the study, attaching their informed consent.
Results
Based on the total number of points, high QoL was recorded in 52.93% of women, very good in 41.48%, good in 5.34% and not very good in 0.25% of women.
The average QoL score achieved was 18.79±5.04, which represents a very good quality of life (Table 1).
Table 1:
QoL of pregnant women
| Quality of life | N | % |
|---|---|---|
| Excellent | 208 | 52.93 |
| Very good | 163 | 41.48 |
| Good | 21 | 5.34 |
| Not very good | 1 | 0,25 |
| Total | 393 | 100 |
Based on the total score, the QoL was evaluated as excellent (9–18 points), very good (19–27 points), good (28–36 points), not very good (37–45 points)
The highest mean scale scores, which represent a lower quality of life, were found in the following questionnaire items: physical changes (2.47±0.93), satisfaction with social life (2.38±0.99), concerns of childbirth management failure (2.36±1.14) and a necessity for physical activity reduction (2.32±1.14) (Table 2).
Table 2:
Descriptive characteristics of individual items of the QOL-GRAVquestionnaire
| Questions (QOL-GRAV) | 1 | 2 | 3 | 4 | 5 | x | SD | Med |
|---|---|---|---|---|---|---|---|---|
|
| ||||||||
|
N
% |
N
% |
N
% |
N
% |
N
% |
||||
| Restrictions related to physical changes | 56 14.25 | 154 39.19 | 134 34.10 | 42 10.69 | 7 1.78 | 2.47 | 0.93 | 2 |
| Restrictions related to psychical changes | 166 42.24 | 145 36.90 | 66 16.79 | 12 3.05 | 4 1.02 | 1.84 | 0.88 | 2 |
| Concerns about household care failure | 190 48.35 | 126 32.06 | 51 12.98 | 24 6.11 | 2 0.51 | 1.78 | 0.93 | 2 |
| Concerns about failure to deliver the foetus successfully | 167 42.49 | 130 33.84 | 44 11.20 | 36 9.16 | 13 3.31 | 1.97 | 1.10 | 2 |
| Concerns about birth giving failure | 103 26.21 | 130 33.08 | 95 24.17 | 45 11.45 | 20 5.09 | 2.36 | 1.14 | 2 |
| Necessity to restrict physical activity | 110 27.99 | 131 33.33 | 89 26.65 | 44 11.20 | 19 4.83 | 2.32 | 1.14 | 2 |
| Satisfaction with partnership | 198 50.38 | 139 35.37 | 46 11.70 | 6 1.53 | 4 1.02 | 1.67 | 0.82 | 2 |
| Satisfaction with social life | 69 17.56 | 179 45.55 | 77 19.59 | 63 16.03 | 5 1.27 | 2.38 | 0.99 | 2 |
| Satisfaction with adaptation to pregnancy | 103 26.21 | 213 54.20 | 53 13.49 | 20 5.09 | 4 1.02 | 2.01 | 0.83 | 2 |
1 – not at all; 2 – moderate; 3 – average; 4 – very; 5 – to a great extent
Statistically significant differences in the QoL of pregnant women were demonstrated according to education (P=0.008), course of pregnancy (P=0.001), support from healthcare professionals (P=0.003) and concerns about COVID-19 (P=0.001).
Statistically significant differences in the QoL of pregnant women were not demonstrated according to age (P=0.494), trimester (P=0.390), parity (P=0.177) and child planning (P=0.143) (Table 3).
Table 3:
Predictors of QoL
| Age (yr) | N | % | Mean (SD) | Median | P |
|---|---|---|---|---|---|
| 18–20 | 12 | 3.05 | 16.67 (±5,82) | 15.50 | |
| 21–30 | 236 | 60.05 | 18.75 (±4,91) | 18.00 | |
| 31–40 | 141 | 35.88 | 19.09 (±5,18) | 18.00 | |
| 41–50 | 4 | 1.02 | 17.00 (±4,90) | 17.00 | 0.494a |
| Education | |||||
| Primary | 5 | 1.3 | 16.00 (±4,06) | 18.00 | |
| Secondary | 166 | 42.2 | 18.02 (±5,10) | 17.50 | |
| University | 222 | 56.5 | 19.43 (±4,93) | 19.00 | 0.008a |
| Trimester | |||||
| 1st | 45 | 11.45 | 19.42 (±5.05) | 19.00 | |
| 2nd | 69 | 17.56 | 19.41 (±5.06) | 18.00 | |
| 3rd | 279 | 70.99 | 18.54 (±5.02) | 18.00 | 0.390a |
| Parity | |||||
| Primiparas | 120 | 30.54 | 18.19 (±4.88) | 18.00 | |
| Multiparas | 273 | 69.46 | 19.05 (±5.09) | 18.00 | 0.177b |
| Child planning | |||||
| Yes | 315 | 80.15 | 18.59 (±4.92) | 18.00 | |
| No | 78 | 19.85 | 19.60 (±5.45) | 19.50 | 0.143b |
| Course of pregnancy | |||||
| Without problems | 313 | 79.64 | 18.00 (±4.57) | 18.00 | |
| With problems | 80 | 20.36 | 21.89 (±5.59) | 21.50 | 0.000b |
| Partnership | |||||
| Yes | 385 | 97.96 | 18.74 (±5.02) | 18.00 | |
| No | 8 | 2.04 | 21.38 (±5.53) | 21.50 | 0.163b |
| Support from health professionals | |||||
| Yes | 237 | 60.31 | 18.01 (±4.38) | 18.00 | |
| No | 156 | 39.69 | 19.97 (±5.71) | 19.00 | 0.003b |
| Concerns about COVID-19 | |||||
| Not at all, moderate | 220 | 55.98 | 17.72 (±467) | 17.00 | |
| Average | 122 | 31.04 | 19.30(±4.89) | 19.00 | |
| Very, to a great extent | 51 | 12.98 | 22.18 (±5,28) | 22 | 0.000a |
aKruskal-Wallis test;
bMann-Whitney U test
Discussion
According to the studies that examined the QoL of women with physiological pregnancies using QOL-GRAV (16–18), the QoL was at a very good level, which correlates with the findings of our study (Table 1). We assume that knowledge of how a particular pregnant woman evaluates the quality of her life during physiological pregnancy could lead to a significant increase in the effectiveness of pregnant women care and their subjective well-being provided by healthcare professionals.
The physical area is the most affected QoL domain during pregnancy (19,20), which is comparable to our results. The highest mean scale values were recorded in the questionnaire items of pregnancy-related physical changes that limited most women (Table 2). It is important to comprehend and adapt to the normal physiological changes that occur during pregnancy. Practicing physical activity during pregnancy is also related to physical area. Several studies (21, 22) have shown insufficient physical activity in pregnant women, which is also confirmed by our results, according to which most women reduced their physical activity during pregnancy. Regular physical activity during pregnancy is not only safe for the mother and foetus, but also improves key pregnancy outcomes. A positive relationship between physical activity and the QoL of pregnant women has been demonstrated (23). In the light of these findings, it is essential to inform and motivate pregnant women to exercise regularly as this might enable them to improve their physical and mental well-being.
Another research item with the recorded higher average scale values was the item related to satisfaction with social life. It must be emphasized that a woman, though being pregnant, still constitutes an integral part of a community. It would be appropriate to create a comprehensive model of care for pregnant women, which would also foster their social life interactions. Also, the higher average scale values were in the item on concerns about the childbirth management failure, which were expressed by the majority of respondents. The fear of childbirth seems to be related to the emotional well-being of women, stress, and impact on daily life (24).
The connection between education and the QoL of pregnant women has been demonstrated (6, 11). Education as a significant predictor of QoL has also been shown in our study. An interesting finding is the lower QoL for women with university education, then for women with secondary education and the highest for women with basic education, which may be influenced by the perception of lower self-concept during pregnancy in women with a higher education (Table 3). This has been confirmed by a study (25), showing that pregnant women with higher education were more affected by low self-esteem. On the contrary, another study (17) has concluded that the more educated women were, the more satisfied they were with their quality of life.
Problems during pregnancy such as nausea, fatigue, pelvic / back pain have been shown to be related to the lower QoL of pregnant women (9, 26). The course of pregnancy has been proved to be another significant predictor of QoL in our study (Table 3). Those women who showed problematic pregnancies in our research reported the following most common problems: fatigue, nausea, low back pain. More severe nausea can affect the daily social lives of pregnant women, as well as their relationships and QoL (27).
Support from healthcare professionals has been shown to be another important predictor of the QoL of pregnant women (Table 3). Every woman has the right to dignified and respectful health care during pregnancy. It is possible to identify vulnerable women in the prenatal period and subsequently implement supportive or educational interventions that would lead to better health outcomes as well as better QoL in the short-term period (14). When providing care for pregnant women, it is important to focus not only on physical but also psychosocial factors in terms of supporting pregnant women to successfully manage the changes, to maintain overall health and mental well-being. Healthcare professionals can play a significant role in improving the QoL of pregnant women through their professional approach, awareness and positive support for pregnant women. Individual and holistic support for a pregnant woman and her relatives provides a basis for planning and implementing measures to improve the health-related QoL (28). Concerns and fears related to the pandemic have been shown to be negatively related to the QoL of pregnant women (29). Concerns about COVID-19 have been identified in our study as another significant predictor of the QoL of pregnant women (Table 3). The change in lifestyle due to COVID-19 infection has put a psychological burden on pregnant women because they have been more exposed to anxiety and uncertainty during pregnancy than ever before. Ravaldi et al. (30) examined the psychological effects of a pandemic on pregnant women and found a significant change in their expectations regarding pregnancy and childbirth, as well as an increase in their fears and anxieties, especially if they had psychological difficulties in the past. In another study (31), women were particularly concerned about the risk of COVID-19 infection and the subsequent complications involving themselves as well as the foetus, and were more likely to complain of insufficient prenatal support. In connection with pandemic as well as other socially risky periods, it is important for healthcare professionals to place emphasis on prenatal support, effective communication and specially to strengthen interventions to support the mental health of pregnant women.
Other predictors such as age, trimester, parity, pregnancy planning (17, 26), partnership (3) have also been found to be related to quality of life. These, however, were not statistically significant in our study.
The given results and findings are to be interpreted with respect to thecertain limitations inherent to the nature of our research. In our case, it was a purposive sampling of participants, as a result of which it is possible to interpret and generalize the conclusions only to the research sample group. Further study limitations can be seen in the uneven distribution of the research sample when comparing quality of life, which could have distorted the results. Some other factors (e.g. socioeconomic) may have played a more important role in assessing QoL than those which we have examined. Despite these limitations, we believethat the study has come to challenging and compelling results for our socio-cultural space. The results of this study may be inspiring for healthcare professionals in prenatal care as well as for policy makers as a basis for proposing appropriate interventions in order to improve the QoL of pregnant women and their children, whose health should be considered one of the health services’ priorities.
Conclusion
Despite the proven positive results found in the QoL of pregnant women, it is desirable to stimulate the healthcare professionals to further explore the QoL also in the group of women with physiological pregnancy, which is important in planning individual and specific mother and child care aimed at improving health-related quality of life. Given the proven predictors, it is important to focus on women with higher education, with problems during pregnancy, to emphasize support from healthcare professionals, and to pay an increased attention to women in connection with the COVID-19 pandemic. Assessing the QoL of pregnant women and implementing innovative practices can streamline and support evidence-based humanised care.
Journalism Ethics considerations
Ethical issues (Including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors.
Acknowledgements
We would like to thank all healthcare professionals – the doctors, nurses and midwives who somehow took part in our research and enabled us to conduct research in their gynaecological clinics, as well as the respondents who participated in the research study.
This study was supported by project KEGA016UK- 4/2021 Standardized Patient in Midwifery.
Footnotes
Conflict of interest
The authors have no conflicts of interest to declare.
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