Obstetric quality of recovery: A weak surrogate measure of psychological distress and psychological wellness for cesarean delivery parturients—A prospective observational study
Restricted accessResearch articleFirst published online November, 2025
Obstetric quality of recovery: A weak surrogate measure of psychological distress and psychological wellness for cesarean delivery parturients—A prospective observational study
The obstetric quality of recovery score (ObsQoR-11) is a widely used self-report assessment in obstetric settings following cesarean deliveries (CD). However, this measure may not assess psychological variables as originally intended, which may inform quality care. The primary aim of this study was to explore the relationship between ObsQoR-11 and validated scales that measure peritraumatic distress and psychological wellness. 220 Canadian patients who underwent scheduled or unscheduled CD (mean age = 35.00 years, SD = 4.18) completed self-report surveys assessing: obstetric quality of recovery, peritraumatic distress, and psychological wellness. ObsQoR-11 exhibited significant but weak correlations with peritraumatic distress and psychological wellness. Peritraumatic distress and psychological wellness are independent constructs that should be measured separately in clinical practice outside of routine assessments using ObsQoR-11. As there was low convergent construct validity with these two measures, these psychological assessments may assist in providing additional assessments of holistic outcomes following cesarean delivery.
AdamsTBeznerJSteinhardtM (1997) The conceptualization and measurement of perceived wellness: Integrating balance across and within dimensions. American Journal of Health Promotion11(3): 208–218.
2.
AmyxMPhilibertMFarrA, et al. (2024) Trends in caesarean section rates in Europe from 2015 to 2019 using Robson’s Ten Group Classification System: A Euro-Peristat study. BJOG: An International Journal of Obstetrics and Gynaecology131(4): 444–454.
3.
AspariARLakshmanK (2017) Effects of pre-operative psychological status on post-operative recovery: A prospective study. World Journal of Surgery42(1): 12–18.
4.
BankerJELaCoursiereDY (2014) Postpartum depression: Risks, protective factors, and the couple’s relationship. Issues in Mental Health Nursing35(7): 503–508.
5.
BartRIshakWWGanjianS, et al. (2018) The assessment and measurement of wellness in the clinical medical setting: A systematic review. Innovations in Clinical Neuroscience15(9–10): 14–23.
6.
BattershellMVuHCallanderEJ, et al. (2023) Development, women-centricity and psychometric properties of maternity patient-reported outcome measures (PROMs): A systematic review. Women and Birth36(6): e563–e573.
7.
BentonMSalterATapeN, et al. (2019) Women’s psychosocial outcomes following an emergency caesarean section: A systematic literature review. BMC Pregnancy and Childbirth19(1): 1–24.
8.
BhattacharyaPKDekaKBarmanB, et al. (2023) Validity and Test-retest Reliability of perceived Wellness Survey among geriatric population: A community-based study from North Eastern India. Journal of the Association of Physicians of India71(3): 14–17.
9.
BhiladvalaCFrench-O’CarrollRDadkhahY, et al. (2022) Factors driving the difference in quality of recovery scores between scheduled and unscheduled Caesarean delivery patients. British Journal of Anaesthesia128(3): e219–e221.
10.
BlackmoreERRubinowDRO’ConnorTG, et al. (2013) Reproductive outcomes and risk of subsequent illness in women diagnosed with postpartum psychosis. Bipolar Disorders15(4): 394–404.
11.
BowyerARoyseC (2018) Approaches to the measurement of post-operative recovery. Best Practice & Research Clinical Anaesthesiology32(3–4): 269–276.
12.
BrandãoTBritesRNunesO, et al. (2020) Anxiety and depressive symptoms during pregnancy, perceived control and posttraumatic stress symptoms after childbirth: A longitudinal mediation analysis. Journal of Health Psychology25(13–14): 2085–2095.
13.
BreslauN (2002) Epidemiologic studies of trauma, posttraumatic stress disorder, and other psychiatric disorders. The Canadian Journal of Psychiatry47(10): 923–929.
14.
BrunetAWeissDSMetzlerTJ, et al. (2001) The Peritraumatic Distress Inventory: A proposed measure of PTSD criterion A2. American Journal of Psychiatry158(9): 1480–1485.
15.
Center for Substance Abuse Treatment (2014) Understanding the Impact of Trauma. National Library of Medicine. Available at: https://www.ncbi.nlm.nih.gov/books/NBK207191/ (accessed 2 March 2025)
16.
ChazapisMWalkerEMKRoomsMA, et al. (2016) Measuring quality of recovery-15 after day case surgery. British Journal of Anaesthesia116(2): 241–248.
17.
CiechanowiczSHowleRHeppoletteC, et al. (2019a) Evaluation of the Obstetric Quality-of-Recovery score (ObsQoR-11) following non-elective caesarean delivery. International Journal of Obstetric Anesthesia39: 51–59.
18.
CiechanowiczSSettyTRobsonE, et al. (2019b) Development and evaluation of an obstetric quality-of-recovery score (ObsQoR-11) after elective Caesarean delivery. British Journal of Anaesthesia122(1): 69–78.
19.
CiechanowiczSJKeJXCSharawiN, et al. (2023) Measuring enhanced recovery in obstetrics: A narrative review. AJOG Global Reports3(1): 100152.
20.
ClappMABarthWH (2017) The future of cesarean delivery rates in the United States. Clinical Obstetrics and Gynecology60(4): 829–839.
21.
ClementS (2001) Psychological aspects of caesaren section. Best Practice & Research Clinical Obstetrics & Gyaecology15(1): 109–126
22.
CohenJ (1988) Statistical Power Analysis for the Behavioral Sciences, 2nd edn.New York, NY: Routledge.
23.
CurcioNTurnerEDLeonardK, et al. (2022) The role of resilience and spirituality in recovery following cardiac surgery. Baylor University Medical Center Proceedings35(4): 420–427.
24.
DalyDHigginsAHannonS, et al. (2022) Trajectories of postpartum recovery: What is known and not known. Clinical Obstetrics & Gynecology65(3): 594–610.
25.
DennisC-LFalah-HassaniKShiriR (2017) Prevalence of antenatal and postnatal anxiety: Systematic review and meta-analysis. British Journal of Psychiatry210(5): 315–323.
26.
DeplaALPluutBLamain-de RuiterM, et al. (2023) PROMs and PREMs in routine perinatal care: Mixed methods evaluation of their implementation into integrated obstetric care networks. Journal of Patient-Reported Outcomes7(1): 26.
27.
DiguistoCSaucedoMKallianidisA, et al. (2022) Maternal mortality in eight European countries with enhanced surveillance systems: Descriptive population based study. BMJ379: e070621.
28.
GjerdingenDKFrobergDGFontaineP (1991) The effects of social support on women’s health during pregnancy, labor and delivery, and the postpartum period. Family Medicine23(5): 370–375.
29.
GouinJPKiecolt-GlaserJK (2011) The impact of psychological stress on wound healing: Methods and mechanisms. Immunology and Allergy Clinics of North America31(1): 81–93.
GrisbrookMADeweyDCuthbertC, et al. (2022) Associations among caesarean section birth, post-traumatic stress, and postpartum depression symptoms. International Journal of Environmental Research and Public Health19(8): 4900.
32.
GuJKarmakar-HoreSHoganME, et al. (2020) Examining cesarean section rates in Canada using the modified Robson classification. Journal of Obstetrics and Gynaecology Canada42(6): 757–765.
33.
Hahn-HolbrookJCornwell-HinrichsTAnayaI (2018) Economic and health predictors of national postpartum depression prevalence: A systematic review, meta-analysis, and meta-regression of 291 studies from 56 countries. Frontiers in Psychiatry8: 248.
34.
HarariMJWaehlerCARogersJR (2005) An empirical investigation of a theoretically based measure of perceived wellness. Journal of Counseling Psychology52(1): 93–103.
35.
InekweJNLeeE (2022) Perceived social support on postpartum mental health: An instrumental variable analysis. PLoS One17(5): e0265941.
36.
JagodnikKMEin-DorTChanSJ, et al. (2024) Screening for post-traumatic stress disorder following childbirth using the Peritraumatic Distress Inventory. Journal of Affective Disorders348: 17–25.
KountanisJAMuzikMChangT, et al. (2020) Relationship between postpartum mood disorder and birth experience: A prospective observational study. International Journal of Obstetric Anesthesia44: 90–99.
39.
LamersSMABolierLWesterhofGJ, et al. (2011) The impact of emotional well-being on long-term recovery and survival in physical illness: A meta-analysis. Journal of Behavioral Medicine35(5): 538–547.
40.
Leahy-WarrenPMcCarthyGCorcoranP (2012) First-time mothers: Social support, maternal parental self-efficacy and postnatal depression. Journal of Clinical Nursing21(3–4): 388–397.
41.
LianaPSimaRCarpD, et al. (2018) The psychosocial impact of vaginal delivery and cesarean section in primiparious women. Journal of Mind and Medical Sciences5(1): 70–74
42.
LopezUMeyerMLouresV, et al. (2017) Post-traumatic stress disorder in parturients delivering by caesarean section and the implication of anaesthesia: A prospective cohort study. Health and Quality of Life Outcomes15(1): 1–13.
43.
MarmarCRWeissDSMetzlerTJ, et al. (1996) Stress responses of emergency services personnel to the Loma Prieta earthquake Interstate 880 freeway collapse and control traumatic incidents. Journal of Traumatic Stress9(1): 63–85.
44.
MayopoulosGAEin-DorTLiKG, et al. (2021) COVID-19 positivity associated with traumatic stress response to childbirth and no visitors and infant separation in the hospital. Scientific Reports11(1): 13535.
45.
MilgromJSchembriCEricksenJ, et al. (2011) Towards parenthood: An antenatal intervention to reduce depression, anxiety and parenting difficulties. Journal of Affective Disorders130(3): 385–394.
46.
MolinaGWeiserTGLipsitzSR, et al. (2015) Relationship between cesarean delivery rate and maternal and neonatal mortality. JAMA314(21): 2263.
47.
MoralesJFGomezACarvalhoJ, et al. (2024) Quality of recovery after unplanned and planned cesarean deliveries: A prospective observational study using the Obstetric Quality of Recovery-10 Tool. Anesthesia & Analgesia139(4): 754–760.
48.
MylesPSWeitkampBJonesK, et al. (2000) Validity and reliability of a postoperative quality of recovery score: The QoR-40. British Journal of Anaesthesia84(1): 11–15.
49.
NaciHIoannidisJPA (2015) Evaluation of wellness determinants and interventions by citizen scientists. JAMA314(2): 121.
50.
NegronRMartinAAlmogM, et al. (2013) Social support during the postpartum period: Mothers’ views on needs, expectations, and mobilization of support. Maternal and Child Health Journal17(4): 616–623.
51.
OatesM (2003) Perinatal psychiatric disorders: A leading cause of maternal morbidity and mortality. British Medical Bulletin67(1): 219–229.
52.
O’ByrneLJBodundeEOMaherGM, et al. (2022) Patient-reported outcome measures evaluating postpartum maternal health and well-being: A systematic review and evaluation of measurement properties. American Journal of Obstetrics & Gynecology MFM4(6): 100743.
53.
PrinceMPatelVSaxenaS, et al. (2007) No health without mental health. The Lancet370(9590): 859–877.
54.
RazurelCKaiserBDupuisM, et al. (2013) Validation of the antenatal perceived stress inventory. Journal of Health Psychology19(4): 471–481.
55.
RydingELWijmaBWijmaK (1997) Posttraumatic stress reactions after emergency cesarean section. Acta Obstetricia et Gynecologica Scandinavica76(9): 856–861.
56.
SharawiNKlimaLShahR, et al. (2019) Evaluation of patient-reported outcome measures of functional recovery following caesarean section: A systematic review using the consensus-based standards for the selection of health measurement instruments (COSMIN) checklist. Anaesthesia74(11): 1439–1455.
57.
SheaAJumahNAForteM, et al. (2024) Guideline No. 454: Identification and treatment of perinatal mood and anxiety disorders. Journal of Obstetrics and Gynaecology Canada46(10): 102696.
58.
SimpsonMCatlingC (2016) Understanding psychological traumatic birth experiences: A literature review. Women and Birth29(3): 203–207.
59.
SmithsonSMirochaJHorganR, et al. (2022) Unplanned Cesarean delivery is associated with risk for postpartum depressive symptoms in the immediate postpartum period. The Journal of Maternal-Fetal & Neonatal Medicine35(20): 3860–3866.
60.
StarkPAMylesPSBurkeJA (2013) Development and psychometric evaluation of a postoperative quality of recovery score. Anesthesiology118(6): 1332–1340.
61.
SultanPJensenSTaylorJ, et al. (2022) Proposed domains for assessing postpartum recovery: A concept elicitation study. BJOG: An International Journal of Obstetrics & Gynaecology129(1): 9–20.
62.
SultanPSadanaNSharawiN, et al. (2020) Evaluation of domains of patient-reported outcome measures for recovery after childbirth. JAMA Network Open3(5): e205540.
63.
TrostSLBeauregardJLSmootsAN, et al. (2021) Preventing pregnancy-related mental health deaths: Insights from 14 US Maternal Mortality Review Committees, 2008–17. Health Affairs40(10): 1551–1559.
64.
WillrothECOngADGrahamEK, et al. (2020) Being happy and becoming happier as independent predictors of physical health and mortality. Psychosomatic Medicine82(7): 650–657.
