Quality of recovery and associated factors of among mothers undergoing cesarean section under spinal anesthesia at Wachemo University, Nigist Eleni Mohammed Memorial Comprehensive Specialized Hospital, Ethiopia, 2025: A cross sectional study

Technical Summary: Quality of Recovery and Associated Factors Among Mothers Undergoing Cesarean Section Under Spinal Anesthesia

Problem Statement
Cesarean section (CS) is a critical intervention for reducing maternal and neonatal morbidity, yet a significant proportion of mothers experience delayed or poor postoperative recovery. While spinal anesthesia is the preferred technique due to its safety profile and facilitation of mother-newborn bonding, it does not eliminate postoperative complications such as pain, nausea, vomiting, hypotension, and psychological distress. These factors can adversely affect physical comfort, functional recovery, and maternal satisfaction. Despite the importance of recovery quality as an indicator of perioperative care effectiveness, evidence regarding the specific predictors of poor recovery following CS under spinal anesthesia remains limited, particularly within the Ethiopian healthcare context. This study addresses the gap in local evidence by assessing the quality of recovery and identifying associated factors among mothers undergoing CS under spinal anesthesia.

Methodology

• Study Design and Setting: An institution-based cross-sectional study was conducted at Wachemo University Nigist Eleni Mohammed Memorial Comprehensive Specialized Hospital in Hossana, Southern Ethiopia, from January to March 2025.
• Population and Sampling: The study included 415 mothers who underwent CS under spinal anesthesia. A consecutive sampling technique was employed. Participants were excluded if they required conversion to general anesthesia, were admitted to the ICU, had severe psychiatric illness, or declined participation.
• Data Collection: Data were gathered within 24 hours post-surgery using a structured interviewer-administered questionnaire, patient chart reviews, and the Obstetric Quality of Recovery (ObsQoR-10) tool. Pain severity was assessed using the Numerical Rating Scale (NRS).
• Variables:
  • Dependent Variable: Quality of recovery, categorized as "good" (score ≥ median) or "poor" (score < median) based on the ObsQoR-10 total score.
  • Independent Variables: Socio-demographics, obstetric factors (e.g., labor duration, type of CS), intraoperative factors (e.g., hypotension, blood loss), and postoperative factors (e.g., pain, PONV, anxiety, ambulation, feeding).
• Analysis: Data were analyzed using SPSS version 26. Bivariable and multivariable logistic regression analyses were performed to identify factors associated with poor recovery. Statistical significance was set at p < 0.05.

Key Results

• Recovery Status: Of the 415 participants, 324 (78%) experienced good postoperative recovery, while 91 (22%) experienced poor recovery. The mean ObsQoR-10 score was 76.4 ± 12.8.
• Risk Factors for Poor Recovery: Multivariable logistic regression identified the following as significant independent predictors of poor recovery:
  • Postoperative Pain: AOR = 3.84 (95% CI: 2.11–6.98).
  • Delayed Ambulation: AOR = 3.27 (95% CI: 1.81–5.92).
  • Emergency Cesarean Section: AOR = 2.91 (95% CI: 1.61–5.24).
  • Postoperative Nausea and Vomiting (PONV): AOR = 2.76 (95% CI: 1.52–5.01).
  • Intraoperative Hypotension: AOR = 2.67 (95% CI: 1.49–4.79).
  • Postoperative Headache: AOR = 2.61 (95% CI: 1.32–5.14).
  • Delayed Oral Feeding: AOR = 2.54 (95% CI: 1.41–4.56).
  • Anxiety: AOR = 2.43 (95% CI: 1.36–4.35).
  • Prolonged Labor: AOR = 2.18 (95% CI: 1.24–3.84).
• Protective Factors:
  • Postoperative Analgesia: Mothers receiving analgesia were 59% less likely to have poor recovery (AOR = 0.41, 95% CI: 0.22–0.76).
  • Adjuvant Use in Spinal Anesthesia: The use of spinal anesthesia with dexamethasone and tramadol adjuvants was associated with a 52% reduction in the odds of poor recovery compared to spinal anesthesia alone (AOR = 0.48, 95% CI: 0.25–0.91).

Key Contributions
The study provides a comprehensive assessment of maternal recovery quality using the standardized ObsQoR-10 instrument in a low-resource Ethiopian setting. It identifies a broad spectrum of modifiable and non-modifiable factors influencing recovery, ranging from clinical interventions (analgesia, adjuvants) to perioperative management strategies (early ambulation, feeding, hemodynamic stability). The research highlights the specific impact of emergency surgery and prolonged labor on recovery outcomes, offering data-driven insights for local clinical practice.

Significance and Claims
The authors claim that while the majority of mothers achieve good recovery, a significant minority (22%) experience poor outcomes that require clinical attention. The study emphasizes that optimizing perioperative care is essential for improving maternal outcomes. Specifically, the findings suggest that:

1. Multimodal Management: Adherence to Enhanced Recovery After Surgery (ERAS) principles, including effective pain control, PONV prevention, and early mobilization/feeding, is critical.
2. Anesthetic Optimization: The use of spinal anesthesia adjuvants (dexamethasone and tramadol) and rigorous management of intraoperative hypotension can significantly enhance recovery quality.
3. Targeted Care: Special attention should be directed toward mothers undergoing emergency CS or those with prolonged labor, as they are at higher risk for poor recovery.

The paper concludes that implementing these strategies can improve postoperative recovery, maternal comfort, and satisfaction with care. The authors acknowledge limitations, including the cross-sectional design (precluding causal inference), the 24-hour assessment window (potentially missing longer-term complications), and the reliance on self-reported subjective variables. They recommend future prospective, multicenter studies with extended follow-up periods to validate these findings and assess long-term functional recovery.