Functional recovery after cesarean delivery: a prospective cohort study in rural Rwanda

When medically indicated, cesarean sections (c-sections) can be lifesaving for both mother and baby (WHO 2015). C-sections are the most common surgical procedures performed among women and in most LMIC facilities, the most common surgical procedure performed [1]. Furthermore, recent years have seen a rapid increase in c-section delivery rates, both in high-income and low- to middle-income countries (LMICs) [2, 3]. C-section delivery itself is associated with short- and long-term changes in a woman’s physical health, including altered functional status i.e. ability to carry out daily activities of life [4]. Recovery after c-section may have a lengthy trajectory [5] and better understanding of postpartum functional outcomes is key to informing clinical management and designing interventions that can optimize postpartum wellbeing.

As the backbone of households, many women are expected to maintain their duties, including day-to-day household management, care for their new infants and other children, marital and social relationships, or participate in community activities within a short period after childbirth [5, 6]. In rural and resource-constrained settings, particularly where large proportions of the population are agrarian or subsistence farmers [7, 8]; this context may also necessitate women to return to strenuous work shortly after childbirth [9, 10]. Functional recovery and resumption of routine activities after c-section, if not addressed, could have a long-term effect on a woman’s physical and emotional health, as well as have implications on the financial impact on a family after childbirth.

Currently, there is limited empirical evidence that describes functional recovery after c-sections, particularly in sub-Saharan Africa [11]. The available literature on post-c-section recovery focusses on postoperative clinical signs and symptoms complications, with little attention on functional abilities and the general wellbeing of women. However, women delivering via C-section even without complication may face physical discomfort for weeks, which may limit their ability to function in their daily lives and mobility [12, 13]. This has been demonstrated in studies from Sudan, China and India, where women that pain after c-section affected their ability to care for their newborns and problems related to mobility, self-care, or ability to perform usual activities through the first postoperative month [14, 15]. While there are no reported risk factors for poor post-c-section functional status, parity, duration of surgery, and preoperative depression have been shown to predict persistence of pain and to negatively affect recovery [16, 17].

In Rwanda, 17% of women nationally and 11% of rural women deliver via c-section (National Institute of Statistics of Rwanda (NISR) [Rwanda], Ministry of Health (MOH) [Rwanda] and ICF & International, 2015) [18]. While some studies have reported high rates of surgical site infections (SSIs) after c-section, ranging from 3%-17% [19‐22], there is paucity of data assessing functional recovery among women who undergo c-section in rural Rwanda. This study reports functional status and predictors of poor functionality among rural Rwandan women through the first month post-cesarean delivery.

This study was conducted as part of a large prospective cohort study designed to evaluate the feasibility, acceptability, and diagnostic efficacy of photo-enhanced screening for SSI diagnosis following cesarean delivery, and included data collected on c-section patients at three different time points: day of discharge (approximately post-operative day (POD) 3), POD 11 (± 3 days), and POD 30 (± 1 day).

A total of 639 women were included in the study, with 511 (80.0%) having follow up at all three time points, 548 (85.8%) with follow up at two time points, and 602 (94.2%) with only one follow up. Most women were between 20 and 34 years old (n = 477, 74.6%), with 56 (8.8%) under 20 years and 106 (16.6) over 34 years (Table 1). The majority of women lived with a partner (n = 536, 83.9%). Most (n = 543, 85.0%) were farmers and the median self-reported annual household income was US$1,624 ($1,133, $2,675), with 72 participants (11.3%) belonging to the lowest rank of Ubudehe categories. The median travel time from the woman’s home to the health center was 30 min (IQR: 15, 60) and 40 min (IQR: 5, 60) from health center to the hospital. Primipara accounted for 40.4% (n = 258) of women, and 264 women (41.4%) had one or two previous births. Approximately 30% of women (n = 188) had a prior c-section delivery.

Nearly all women (n = 600, 94.1%) had an urgent or emergency surgery. The indications for c-section were: fetal factors only (n = 213 (33.8%), maternal factors only (n = 177, 28.1%), prior c-section (n = 140, 22%) and combined fetal and maternal factors (n = 100, 15.9%). Nearly half of all women (n = 290, 46.5%) had surgery length ranging between 30 to 45 min, 189 (30.3%) had a surgery length of less than 30 min, and 65 (10.4%) had a surgery length of greater than an hour. Over 60% (n = 361) of participants had a hospital stay greater than three days (Table 1).

Table 2 summarizes the five dimensions of functional status of patients at POD 3, POD 11 and POD 30. The majority of women were able to move independently at the time of hospital discharge (n = 518 of 622, 83.3%), at POD 11 (n = 499 of 589, 84.7%) and at POD30 (n = 500 of 549, 91.0%). Participants reported the lowest level of functionality in the dimension assessing ability to perform usual activities, with 50.8% (n = 316 of 622) of women reporting total inability to perform usual activities at hospital discharge and 15.6% (n = 86 of 551) at POD 30. At POD 30, 368 (out of 551, 68.6%) women reported needing help to perform usual activities, 268 (out of 551, 48.6%) reported poor or very poor overall health status, and 80 (14.5%) reported needing help to self-care. The functional status was poor for 54.0% (n = 333 of 617) and 26.8% (n = 147 of 548) of women at POD 3 and POD 30, respectively. Of the 147 women with poor functional status documented at POD 30, 78 (53%) had reported poor functional status at POD 3, while 79 (47%) had good functional status at POD 3 and deteriorated over the following month.

Women who stayed in the hospital longer than three days after delivery were more likely to report poor functional status at POD 30 compared to those who stayed three days or fewer (p = 0.024, Table 3).

Those with a poor functional status had a significantly lower monthly income [poor functional status: $37.6, IQR: ($28.3, $62.4); good functional status: $45.4, IQR: ($30.3, $70.6); p = 0.04)]. In the final reduced model (Table 4), surgery duration, intraoperative complications, and income remained the only significant factors. Patients whose surgery duration ranged between 30 to 45 min had 85% increased odds of reporting poor functional status at POD 30 compared to those with surgery duration of less than 30 min (aOR = 1.85, 95% CI: 1.15, 2.95). Women with any documented intraoperative complications had 3.12 times higher odds of poor function compared to women without complications (aOR = 4.12, 95% CI: 1.09, 15.57). For every US$100 increase in monthly income, there was a 38% decrease in the odds of reporting poor functional status at POD 30 (aOR = 0.62, 95% CI: 0.40, 0.96).

Our study is one of a few assessing the overall functional status of c-section patients a month after surgery in LMICs. We found a high proportion of poor functionality at discharge, which was sustained through the first month, with approximately one in four women reporting poor function at POD 30. Surgery duration of between 30 to 45 min, report of any intraoperative complications and lower annual household income were significant independent predictors of poor physical functional status at POD30.

Our rates are comparable to one study including women from Malawi, Kenya, and Jamaica, where 18% of women had poor function at six weeks postpartum [30]; however notably, our studies used different tools to measure physical functionality and included women despite the report of complications. For example, a study in Iran measured functionality as a single dimension of the health-related quality of life questionnaires, excluded women with complicated child birth or with poor neonatal outcomes, and reported an average functionality score of 53% at 2 months post-cesarean, with higher scores reflecting better physical functioning [31].

In our study, mobility was the fastest dimension to improve after c-section, with over 83% of women reporting full mobility at POD 3 and rising to 91% at POD 30. This aligns with findings from other LMICs where 93% to 98% of c-section patients reported good mobility through the first month following surgery [15, 32]. Despite high mobility, women reported poor ability to perform usual activities, with only 16% of women returning to full abilities by POD 30. Similarly other studies have demonstrated that tiredness and fatigue are common post-c-section and may impede early resumption of activities in these patients [33, 34]. However, it is also possible that some activities, including farming activities or intensive housework such as carrying water or older children, should not be immediately resumed as extreme physical activity or heavy lifting may impede safe recovery after cesarean delivery [35]. Unfortunately, rural lifestyle and limited family assistance can impose heavy work on women, even when they still have low abilities to perform activities. In rural Rwanda, women reported that family support with activities subsided after the first week of delivery; thereafter women were exposed to heavy workload [36]. Similarly in rural South Africa, women reported that even though they had planned to take longer time off, they had to engage in paid work, in addition to home and child care activities within the first two weeks of surgery, as aa result of limited assistance at home [37]. Such early exposure to increased workload may exacerbate fatigue and slow down timely recovery after c-section.

We found that women with a longer surgery duration and intraoperative complications were more likely to report poor physical function compared to shorter and non-complicated surgery. Surgery length has previously been shown to varies by health providers and by intraoperative complications [38‐41]. Despite controlling for intraoperative complication, it is possible that surgeries with longer duration represented more complex cases of women with pre-existing medical co-morbidities, and it is these unmeasured factors that impacted recovery, rather than the surgery length itself i.e. there are other unmeasured confounding factors [42‐45]. For example, the existing pathway in Rwanda requires laboring women to present at health centers before being referred to district hospitals for a C-section delivery (when indicated) could result in further complexities of cases during transportation to district hospitals and inherent delays [46]. In our study, 94.1% of c-section were indicated as emergent or urgent. These complex pregnancies and exacerbated labor anomalies in of themselves may be related to the course of postoperative recovery we documented, rather than the surgery length. Improvement in referral systems and decentralizing obstetric emergency services to health centers to enhance timely access to c-sections for medically indicated cases could result in fewer complications and unnecessarily long c-section surgeries potentially resulting in improved return to normal function [47, 48].

Women with lower annual household incomes had worse physical functional outcomes at POD 30. This association could be explained in the context of poor health outcomes previously reported among poor postpartum women. Poverty has been associated with poor postpartum nutritional status [49, 50], incidence of SSI [22, 51] and poor post-natal care [52]. A study in Ethiopia reported that irrespective of mode of delivery, women with low income were almost half as likely to seek postpartum care [53], and a study in Iran found that rural women who did not receive enhanced postpartum follow-up reported poor functional status at six weeks postpartum [54]. Financial hardship faced by poor women in our study could affect post-discharge follow-up and care, and in turn could impede their ability to recover fully. Moreover, financial stress in low-income households are known to elevate the risk of postpartum depression [55, 56], which also affects postoperative recovery [57, 58]. Thus, interventions to mitigate financial hardships should be explored in the future.

Our findings has several implications. We found that one in four women reported poor functional outcomes at POD 30. Developing strategies to improve the functional recovery for women after c-section could thus have substantial impact on improving physical and emotional wellbeing for families in the postpartum period, as well as potentially mitigate the financial impact of childbirth by c-section on families. Indeed in this same cohort we have previously reported that 6.4% and 27% of women experienced impoverishing and catastrophic expenditures, respectively due to hospital expenses alone, without consideration of the impact of lost economic productivity [59]. Both upstream and downstream strategies should be considered to help aid in the return to normal functional during the postpartum period. For example, increasing evidence points to changes in pre-operative and post-operative management, such as enhanced recovery after surgery (ERAS), leading to significant reductions in length of post-operative stay and time to mobility [60, 61]. However, evidence to date suggests ERAS procedures have yet to be implemented in many resource-limited settings. In Rwanda specifically, existing and well-established systems such as antenatal care clinics at health centers and community health worker systems could be explored as additional channels for implementing components ERAS, alongside clinical teams at district hospitals where surgeries are performed.

We note a number of limitations of this study. First, there was no available validated measurement for functional status for women delivered via c-section; nevertheless, we used individual dimensions pulled from different validated health-related quality of life tools to build a multifaceted measure of functionality. As noted, our choice to use this measure improved study feasibility however, this has limitations around comparing our data to other studies using available tools such as the WHODAS or EQ-5. Secondly, some recruited participants (8.6%) could not be reached by phone on POD 30, although several attempts were made. Loss-to-follow-up is possibly associated with the poorest women, who have limited access to a telephone, or those with postoperative morbidities seeking care outside their community or preventing access to or use of a phone, including but not limited to postpartum depression. As such we may have underestimated the level of poor functional status at POD 30. Thirdly, we did not have a control group to ascertain whether the reported functional status was attributable to c-section specifically, or could be attributed to childbirth more generally, and challenges around child care in the postpartum period. Fourth, there was no data on physical functional status before c-section which could have been useful in estimating the toll of c-section delivery on functionality and what constitutes return to baseline levels of functional status. Fifth, our last point of follow up was at POD30, which may represent a time frame too early in the post-operative period to expect return to normal function. Further studies assessing function further out from surgery will be needed to assess for the long term implications of c-section and its indications on the trajectory of functional recovery. Sixth, our functional outcome tool did not include aspects of postpartum mental health. Thus, our estimate of functional outcome may be underestimate given the potential influence postpartum depression may have on postpartum functional recovery. Further research should explore the development and validation of a concise functional recovery tool specific for C-section patients, and these tools should include the dimension of postpartum depression. Such development could include testing and validation against larger and more robustly used tools such as the WHODAS Lastly, it is possible that women did not have clarity of which activities they should resume or not resume during the first month after surgery because in Rwanda, currently there is no educational protocol to inform c-section women with their post-cesarean recovery. However, we believe that this did not severely affect our results because functionality was measured as a multidimensional outcome.

The present study provides evidence that a quarter of rural Rwandan women sustain poor physical functional status up to a month after cesarean delivery. Particularly, women from low income households, women who experience intraoperative complications, and women with longer surgeries were more vulnerable to poor functionality. Specific attention should be paid to these women during follow-up. Functional status assessments, monitoring and support to functional recovery should be included in post-partum care. Guidelines for postpartum care providers and women should be developed and address physical aspects of functionality, including resumption of usual activities, physical activities and body energy during post-partum period. We believe that these findings hold significance in other rural LMIC settings. Given rising global c-section rates, future research is needed to develop and validate a comprehensive measure of post-cesarean functionality. Further research into functional outcomes after c-section in other LMIC settings should be considered as well as research into peri-operative interventions that may improve and speed up return to normal functionality.