Assessment of functioning and disability of postpartum women: a study based on the International Classification of Functioning, Disability and HealthABSTRACT
The puerperium begins soon after placental expulsion, with local and systemic changes in the woman’s body. This transition is associated with the woman’s functioning. The International Classification of Functioning, Disability and Health (ICF) underlie the application of the biopsychosocial model. This study investigated the functioning and disability of postpartum women in the immediate, late, and remote puerperal subperiods. This is a cross-sectional, observational, quantitative study. An anamnesis form was applied with sociodemographic, anthropometric and obstetric data and with questions related to the ICF. The self-administered 36-item WHODAS 2.0 was applied to investigate disability. Qualitative variables were described by frequency and percentage distribution and quantitative variables with descriptive statistics. For group comparison, Kruskal-Wallis and Dunn’s post hoc tests were applied with 5% significance. A total of 82 postpartum women participated in the study. We obtained 32 ICF categories, with structure and function being the most frequent. In WHODAS 2.0, for total sample and for each puerperal subperiod, the (D5) domain – Activities of Life – was more compromised. When comparing domains with puerperal subperiods, immediate puerperium showed less disability, differing from remote puerperium and late puerperium for cognition 10.42 (p=0.0365) and participation 18.75 (p=0.0197). The (D2) domain – Mobility – showed a difference between late puerperium and remote puerperium, with remote puerperium having less disability 17.50 (p=0.0212). Based on the diversity of filled-in items in the ICF, it is concluded that functioning can be affected in the puerperium, and disability may be presented at all times.
Keywords
International Classification of Functioning; Disability and Health; Postpartum Period; Women’s Health; Physiotherapy
RESUMO
O puerpério inicia logo após a dequitação da placenta, ocorrendo modificações locais e sistêmicas no corpo da mulher. Essa transição está associada com a funcionalidade da mulher. A Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF) fornece a base para aplicação do modelo biopsicossocial. O estudo investigou a funcionalidade e incapacidade de puérperas no período puerperal imediato, tardio e remoto. Trata-se de um estudo transversal observacional de caráter quantitativo. Aplicou-se uma ficha de anamnese com dados sociodemográficos, antropométricos e obstétricos e com perguntas relacionadas à CIF. Para investigar a incapacidade, aplicou-se o WHODAS 2.0 de 36 questões autoadministrado. As variáveis qualitativas foram descritas por distribuição de frequência e percentuais, e as quantitativas com estatística descritiva. Para comparação de grupos, aplicaram-se os testes de Kruskal-Wallis e post hoc de Dunn com 5% de significância. Participaram do estudo 82 puérperas. Obteve-se 32 categorias da CIF, sendo estrutura e função a mais frequente. No WHODAS 2.0, na amostra total e para cada momento do puerpério, o domínio (D5) – Atividades de Vida – obteve maior comprometimento. Ao comparar os domínios com momentos do puerpério, o imediato apresentou menor incapacidade, diferenciando-se do remoto e tardio para cognição (10,42 – p=0,0365) e participação (18,75 – p=0,0197). No domínio (D2) – Mobilidade –, ocorreu diferença entre o puerpério tardio e o remoto, sendo que o remoto apresentou menor incapacidade (17,50 – p=0,0212). A partir da diversidade de itens preenchidos na CIF, conclui-se que a funcionalidade pode ser afetada no puerpério, podendo apresentar incapacidade em todos os momentos.
Descritores
Classificação Internacional de Funcionalidade; Incapacidade e Saúde; Período Pós-Parto; Saúde da Mulher; Fisioterapia
RESUMEN
El periodo de puerperio empieza tras el alumbramiento de la placenta, provocando modificaciones locales y sistemáticas en el cuerpo de la mujer. Esta transición se asocia con la funcionalidad de la mujer. La Clasificación Internacional de la Funcionalidad, la Discapacidad y la Salud (CIF) proporciona la base para la aplicación del modelo biopsicosocial. El estudio investigó la funcionalidad y la discapacidad en puérperas durante el periodo puerperal inmediato, tardío y remoto. Se trata de un estudio transversal observacional de carácter cuantitativo. Se aplicó una ficha de anamnesis con datos sociodemográficos, antropométricos y obstétricos con preguntas relacionadas con la CIF. Para investigar la discapacidad, se aplicó el WHODAS 2.0 de 36 cuestiones autoadministrado. Las variables cualitativas se describieron por distribución de frecuencia y porcentajes, y las variables cuantitativas se describieron con estadística descriptiva. Para comparar los grupos, se aplicaron las pruebas de Kruskal-Wallis y post hoc de Dunn con significación del 5%. Participaron en el estudio 82 puérperas. Se obtuvieron 32 categorías de la CIF, siendo la estructura y función la más frecuente. En el WHODAS 2.0, en la muestra total y para cada momento del puerperio, el dominio (D5) –Actividades de Vida– obtuvo el mayor compromiso. Al comparar los dominios con momentos del puerperio, el inmediato presentó menor discapacidad, diferenciándose del remoto y el tardío para cognición (10.42 – p=0.0365) y participación (18.75 – p=0.0197). En el dominio (D2) –Movilidad–, hubo diferencia entre el puerperio tardío y el remoto, siendo el remoto el que presentó menor discapacidad (17.50 – p=0.0212). Con base en la diversidad de ítems rellenados en la CIF, se concluye que la funcionalidad puede verse afectada en el puerperio, y puede presentar discapacidad en todos los momentos.
Palabras clave
Clasificación Internacional de la Funcionalidad, la Discapacidad y la Salud; Periodo Posparto; Salud de la Mujer; Fisioterapia
INTRODUCTION
The puerperal period begins after placental expulsion and can be subdivided into three subperiods: immediate puerperium, late puerperium, and remote puerperium 1 . In the puerperium, there are involutive manifestations of the organs and systems in relation to the physiological return to the pre-pregnancy state, in addition to numerous psychic and emotional changes and adaptations 1 , 2 . This period represents a time of behavioral, sociocultural and economic transitions, which intensify maternal demands 1 . Despite intense changes in the maternal sphere, Holanda et al. 3 report that the figure of the mother is neglected, with exclusive focus on the newborn. Therefore, it is important to understand the biopsychosocial context in which this woman is situated and uniquely assess its possible influences on her health, well-being and functioning.
As for the context of functioning, the International Classification of Functioning, Disability and Health (ICF) has the potential to cover aspects of the individual’s functioning, disability and health condition, associated with a biopsychosocial model 4 , 5 . The ICF considers functioning as a result of the individual’s interaction with the environment context and personal factors, which are assessed by means of a set of domains and conditions that include activities performed, as well as participation 6 . The health care transition, informed by ICF-based functioning, facilitates the establishment of therapeutic objectives and appropriate interventions, enabling an overview of the resources needed to improve specific aspects of functioning 7 . Furthermore, to measure disability, we note the World Health Organization Disability Assessment Schedule version 2.0 (WHODAS 2.0) as an instrument that measures the health and disability of populations 8 , which fully addresses the ICF and can be applied to all diseases, including physical and mental disorders 4 . In the puerperium, the ICF approach is particularly important due to the numerous factors that can affect the daily lives of postpartum women. Somatic complaints are common in this period and are related to physiological changes and physical demands associated with pregnancy, childbirth and babycare 9 . The ICF, on which WHODAS 2.0 is based, shares the expanded view of the biopsychosocial health status 8 . Personal factors, activity and participation can be obstacles or facilitators within the condition of puerperium 10 .
In this context, the ICF is an important resource in clinical practice, covering various segments of women’s health, taking into consideration all aspects involving postpartum women. Thus, the objective of this study was to examine and measure the functioning and disability of women in the immediate, late, and remote puerperal subperiods.
METHODOLOGY
Study design and population
This is an observational, cross-sectional study of a quantitative nature, with the target audience being postpartum women. For sample size, we considered a 95% reliability, a 0.7 prevalence, and a 0.1 sampling error, obtaining a sample size of at least 81 participants 11 .
Selection criteria and location
Data collection was conducted online on the Google Forms platform. The study included women in the immediate, late or remote puerperal subperiods (up to six months), aged over or equal to 18 years, whose fetuses were born alive, literate, and with internet access. The exclusion criteria applied to puerperal women in the following conditions: multiple fetuses pregnancies; newborns hospitalized in the Intensive Care Center; stillborn fetuses; abortion; puerperal women who required hospitalization.
Data collection instruments
An anamnesis form prepared by the authors was applied to trace the social, anthropometric and obstetric profile, including questions related to the ICF domains to categorize their functioning. Thus, a summarized list was structured with the set of specific codes for the health condition, according to the frequency of answers related to ICF categories.
To study disability, we used the self-administered 36-item WHODAS 2.0 instrument. WHODAS 2.0 has been translated and adapted into Portuguese 10 and contains 36 items distributed into six domains (Cognition; Mobility; Self-Care; Getting Along; Life Activities; Participation) 12 . In addition, there are questions (H1, H2, and H3) that assess the impact of difficulties faced by participants in their lives 10 , 12 . To calculate scores, we used the Excel calculator made available on the World Health Organization website 13 . The metric of the scores ranges from zero to 100, and higher values indicate a higher degree of disability 12 .
Statistical analysis
Data were tabulated in the Excel program and statistical analysis was performed in the R program (version 4.2.1). Descriptive statistics were used to analyze the profile of the characteristics of the puerperal women. To compare the three puerperal subperiods between the WHODAS 2.0 domains, we applied the Kruskal-Wallis test and Dunn’s post hoc test, adopting 5% significance.
RESULTS
A total of 82 postpartum women participated in the study and were classified according to their puerperal subperiod, namely: 20 in the immediate puerperium, 18 in the late puerperium, and 44 in the remote puerperium. Regarding the place of residence, according to state: 64.7% lived in Amapá, 12.2% in Rio Grande do Sul, 6.1% in São Paulo, 4.9% in Santa Catarina, 3.7% in Pará, 2.4% in Goiás, 2.4% in Paraná, 1.2% in Maranhão, 1.2% in Minas Gerais, and 1.2% in Espírito Santo. Other sample characterization variables are available in Table 1 .
Regarding functioning, a summarized list with the corresponding codes was prepared based on the participants’ answers regarding the questions that addressed the ICF domains. We observed 32 categories, namely: 23 categories in structure and function, seven categories in activity and participation, and two categories in environmental factors ( Table 2 ).
Disability traced by WHODAS 2.0 showed, in the general sample, impairment in all domains, with D5 being the most compromised both in the general sample and in the puerperal subperiods ( Table 3 ).
Another variable contained in the WHODAS 2.0 questionnaire relates to three questions referring to the effect of difficulties that help examine disability by means of frequency and duration expressed in days. In general, the question that presented the highest number of days on which participants had difficulties was H1, and the lowest was H2. In addition, we observed that the immediate puerperium obtained the lowest values as to the number of days with difficulties, and that the late puerperium presented the highest values ( Table 4 ).
WHODAS 2.0 questions H1, H2, H3 on the number of days when difficulties affected the lives of postpartum women (descriptive analysis mean ± standard deviation)
When comparing the WHODAS 2.0 domains in relation to puerperal subperiods, the immediate puerperium obtained a lower significant median in domains D1 and D6. This suggests that the function of cognition and participation in the immediate postpartum subperiod has less impairment of functioning compared to the other subperiods. In the D2 domain, the remote puerperium showed a lower significant value in relation to the late puerperium, showing that mobility improves in the remote puerperium ( Table 5 ).
DISCUSSION
This study sought to examine and measure the functioning and disability of women in the puerperal period. For functioning, we used the ICF categories based on participants’ answers and, for disability, we used the WHODAS 2.0 questionnaire, which has already been used in the puerperal public 14 , 15 . In the puerperium, there are physical, emotional and social transformations that are part of the biopsychosocial experience of women 16 . In addition, this period may be related to physical and mental dysfunctions 17 . To this end, the ICF manual recommends that, in order to trace a functioning profile, all its components should be considered, and for that it suggests WHODAS 2.0 and summarized lists as one of the approaches 8 .
This study enabled categorizing the functioning of postpartum women into 32 categories in the ICF domains, compiling a summary list that covers impairments, limitations and restrictions. This allowed the observation that the categories differed according to puerperal subperiod; however, most of them were related to the domain of structure and function. Another study 16 sought to determine the ICF categories that would be essential to classify functioning from the perspective of physiotherapy, compiling a list with 53 categories (26 structure and function; 12 activity and participation; 15 environmental factors; and nine personal factors) 16 . Comparing the list of the present research and the list prepared by physiotherapists, there is a similarity of approximately 60% for the results found, that is, more than half the answers of postpartum women in this study were compatible with the findings of the list prepared by physiotherapists.
As for the disabilities of postpartum women for the total sample, according to the WHODAS 2.0 score, all presented some amount of disability. When observing by domain, the D5 domain obtained a higher overall mean both for total sample and for puerperal subperiod, that is, there was a higher level of disability in issues related to difficulties in daily activities 12 . In the study of Godoy et al. 18 , it was found that most puerperal women alternate between domestic and paid activities, assuming full responsibility within the family life, often having to reconcile such activities without a support network.
When analyzing disability between puerperal subperiods, we observed a lower disability in the D1 domain referring to cognition in the immediate puerperium compared to the late puerperium and remote puerperium. Postpartum women undergo a process of remodeling of structures responsible for maternal behavior, triggering changes in cognition 19 . Hormonal, anatomical and physiological changes in the brain and sleep, in addition to psychosocial changes, determine variations in cognitive functioning 19 . Moreover, some studies differ as to the puerperal subperiod in which cognitive changes occur; however, there are authors who suggest that better cognitive performance usually occurs in the first days after childbirth 20 - 22 , corroborating the findings of the present research, since the immediate puerperium obtained lower values.
The D6 domain, which refers to social factors, presented the second highest overall mean in the total sample, and the immediate puerperium presented a significant decrease compared to the other subperiods, reaching a lower level of disability. According to Finlayson et al. 23 , postpartum adaptations may be associated with major changes in the routine of puerperal woman, including social and relational adjustments due mainly to the prioritization of the newborn’s needs. This change may be the result of increased difficulty in performing activities that previously did not require as much effort, such as household chores, self-care and leaving home 19 .
The D2 domain showed a significant difference between the late and remote puerperal subperiods, and the late puerperium presented higher disability in mobility. Burti et al. 24 report that, in addition to musculoskeletal complaints, acute pain is frequent, resulting in a difficulty in mobility in the postpartum period. In addition, the difficulty in mobility may be associated with the type of delivery, since most of the puerperal women in this study reported having undergone cesarean section, and the slow recovery of this process can cause pain and reduced mobility 15 ; thus, functionality in the remote puerperium tends to be better.
Another outcome observed in WHODAS 2.0 was the effect of difficulty expressed in days through questions H1, H2 and H3, indicating that the late puerperium had a higher average of days in the three subperiods mentioned. A better postpartum quality of life is directly associated with a social support network, helping to find ways to deal with the physical and psychological challenges of this period 25 . However, the effects of postpartum difficulties are still poorly elucidated, requiring more specific research.
As a limitation of the study, w expected to reach a mixed sample of the Brazilian territory; however, there were regions with few responses.
FINAL CONSIDERATIONS
The puerperal period is a time of major and intense anatomical, physiological and biomechanical changes, affecting the disability and functioning of women, which can be demonstrated by the significant diversity of filled-in items in the ICF categories, with the structure and function category being the most indicated. As for disability, we observed in the sample studied that there was impairment in all domains. Although each puerperal subperiod poses unique challenges, observing the general sample in the WHODAS 2.0 total score, there was no difference between the subperiods (immediate, late and remote). However, when observing by domains, the immediate puerperium showed better results, differing from the remote puerperium and late puerperium in the domains of cognition (D1) and participation (D6). In the mobility domain (D2), there was improvement in the remote puerperium compared to the late puerperium.
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Financing source:
nothing to declare
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Approved by the local Research Ethics Committee under CAAE No. 65178722.0.0000.0003.
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This article was extracted from the Physical Therapy Program Final Paper by Marina da Silva Moraes and Francisco Farias Feitoza, entitled Avaliação da funcionalidade e incapacidade de puérperas: um estudo baseado na Classificação Internacional de Funcionalidade, incapacidade e saúde [Assessment of functioning and disability of postpartum women: a study based on the International Classification of Functioning, Disability and Health], defended on June 28, 2023.
