5.

DISCUSSION

After having data analyzed, it will be discussed in this section regarding the support and contradictory to other studies with this study of quality of life between normal vaginal delivery and cesarean section.

5.1

Socio demographic characteristics of respondents Majority of respondents in this study dominated by Malay as Kelantan is a state which

having Malay as the largest population. It has been stated in study of Kelantans Human Development Progress and Challenges by Richard Leete (2004) that Kelantan is populated with 95% of Malay, Chinese 3.8%, Indian 0.3% and others with 0.9%. However, this study only comprises of Malay, Chinese and others which are Siamese and not including Indian. Mean of age of participants involved in this study is ranged form 31.55 to 32.14. As being stated in the study of Richard Leete (2004) female adults mostly aged around 35 39 but for reproductive age, the second largest population for female adult is around 31-34. There is no respondent who never attended school since the inclusion criteria is including literate which is able to read and write in Malay language and only 13% of populations never attending school by 2000 (Leete, R. 2004). For NVD mothers, half of respondents having attended school and also college with 50% respectively while most of CS mothers attended for school and the rest attended college and post graduate study. Since this study is being done in university area, tertiary education can be commonly found.

Employment status for respondents with both NVD and CS are mostly dominated by housewife, followed by employees, self employed and students. Employed female is nearly equal to unemployed female in population by 2000. In socio economical status, still the income 2000 dominated the study for having the largest number particularly for CS, followed by income raged 2001-3000 and lastly income >3000.

5.2

Difference in quality of life between Normal Vaginal Delivery (NVD) and Cesarean

Section (CS) Analyzed data indicates there is no significant difference between those two methods of delivery. The components of quality fall in 6 parts of domain which comprises of overview perception towards life, satisfaction towards life, physical domain, psychological domain, social domain and environmental domain. All the domains indicate higher score for NVD mothers compared to CS mothers except for overall perception towards life which results in CS mothers having better perception towards life. However this positive thinking does not correlate with the score in psychological domain in which the NVD mothers hold higher score. The results also contradictory with the study by Torkan et. al (2009) on postnatal quality of life in women after normal vaginal delivery and cesarean section in which mothers with cesarean section having more improvements (better score) on mental heath related quality of life (Torkan et. al, 2009). There are some studies in 1980s which women significantly to be depressed after cesarean delivery rather than after vaginal delivery (Clement, S., 2000). However in recent study show that there is no significant association between cesarean section and postpartum depression

but low mental score seems significantly associate with postpartum depression (Sword, W., 2011). It suggested that low mental score gaining by cesarean mothers might lead to postpartum complications that may affect post natal quality of life. In physical domain, NVD mothers found to have higher score compared to CS mothers who showed better improvements and recovery rate. Similarly finding found in study by Torkan (2009) as normal vaginal group showed more improvements on physical health related quality of life. One study by Lilford et al suggested that fourfold higher risk of mortality associated with caesarean section compared to vaginal delivery when other contributing medical factors were excluded and the risk of death from caesarean section was approximately 1 in 4000, but this was in a population whose maternal mortality rate was four times higher than that in the United Kingdom at the time of the trial (Jackson, N. & Paterson-Brown, S., 2001). The complications and particularly maternal morbidity that might be met by the mothers after cesarean section has been studied by Liu and the Maternal Health Study Group of the Canadian Perinatal Surveillance System report on a population based cohort study of all women in Canada (excluding Quebec and Manitoba) who gave birth between April 1991 and March 2005, inclusive which results in the overall risk of severe maternal morbidity in cesarean group was 3.1 times compared to planned vaginal delivery group (Liu, S. et al., 2007). Whereas for social domain and environmental domain both having higher score in NVD mothers compared to CS mothers. After effect experienced by mothers was affected by the delivery method itself as women who delivered by cesarean were also more likely to report a loss of the optimal birthing experience, feelings of powerlessness and lack of control, and to report that they had a terrible or traumatic experience (Lobel, M. & DeLuca, R. S., 2007). Social support from surrounding especially husband, partner and family is indeed important as one

study revealed women with adequate social support scored >70 for each of the WHOQOL-BREF domains (physical health, psychological health, social relationships and environment) (Webster, J. et al., 2010). That suggested importance of close relationships on maternal quality of life in the first months following childbirth (Webster, J. et al., 2010) and are consistent with previous reports that show a mediating effect of social support in other areas of womens lives, such as survivors of domestic violence (Beeble et al., 2009) and following still birth (Cacciatore et al., 2009). Overview perception towards health for NVD mothers having lower score than CS mothers instead NVD mothers having better score compared to CS mothers in aspect of life satisfaction. This finding showed that CS mothers view health in a better way compared to NVD mothers. Meanwhile in satisfaction of life aspect, one study on maternal satisfaction of mothers with NVD and CS in which both groups have underwent both methods of delivery found NVAC group was more satisfied than CSAV group with NVAC group having 74% satisfied with their method of delivery and only 50% CSAV group satisfied with cesarean delivery (Dunn, E. A. & OHerlihy, C., 2004). These mothers also prefer to have vaginal delivery for subsequent pregnant.

5.3

Association of Educational Level with Quality of Life

The association between two variables found to be insignificant association with P value more than 0.05, consistent with the study by Prause, W. et al. on effects of sosiodemographic variables on health related quality of life which indicated that level of education showed no significant influence on quality of life index score of single items consisted of ten items (Prause

et al., 2005). This finding is also in contrast with the study in Tanzania (Wyss et al., 1999) where people with formal education scored lower than people with higher education (Prause et al., 2005). Similarly finding found in study described by Regidor et al. (1999) in which perceived health status declined with decreasing educational level, thus the lowest scores were found in persons with the least education. In physical domain, the result of the study showed that people with lower education (school) rated higher score than people with higher education (college/university, post graduate study). In one study on 145 women diagnosed with breast cancer (Skrzypczak et al., 2009) that higher educated female seem to be more inclined to social avoidance and more severely affected by fatigue. The result is corresponded with the finding in psychological domain which the higher education women have, the lower scored they gained.

5.4

Association of Socioeconomic Status with Quality of Life Unlike what may be predicted, the result showed there is no significant association

between socio economic status and quality of life. It is contradicted with study on effects of sosio demographic variables on quality of life when it suggested socio economic characteristics seems to play an important role in determining the health related quality of life of one person (Prause et al., 2005). The result is also in contrary to the study on 186 lung cancer patients by Montazeri et al. (2003) described that patient with lower socio economic status had more health problems, less functioning and more symptoms compared to affluent patients (Montazeri et al., 2003). However in aspect of perceptions towards health, the score is correlated to the socio economic status with the highest score was scored by high socio economic women (income

>3000) and the lowest had by lower socio economic women (income <2000). This result is in good agreement with many studies (Prause et al., 2005; Cai et al., 2011; Montazeri et al., Wyss et al., 1999). According to Arntzen & Andersen., 2004, educational attainment is the social variable that often displays the largest socioeconomic differential. Unlikely, the result of this finding revealed there is no correlation between educational level and socio economic status in view of perceptions towards health. In contrast of other studies, one study on 90 men underwent radical prostatectomy (Mark et al., 1999) found that education is independent predictor to cause the worse quality of life following treatment after adjusting age and income.

5.5

Correlation of Age with Quality of Life The result of finding showed that there is no significant association between age and

quality of life, contradicted with the finding of study on Austrian population aged over 14 years old (Prause et al., 2005) which described the dependency of age on health related quality of life with age is inversely proportioned to health related quality of life. Based on study, the increasing of age declined the QoL with age group 15-24 having the best score, in contrast the lowest score in index score and all items scored by aged >49 (Prause et al., 2005). This finding is supported by another study which results in youngest age group having best score compared to the oldest age group for physical functioning domain in Medical Outcomes Study 36-item Short Form (SF36) (Hopman et al., 2000). However in various study age was being categorized to find out its differences in group. This study do not obtain the similar results as other studies probably due to the age of participant involved in this study basically from 19 to 40 years old with mean of age is 31.85. There is no obvious age of difference in age group. Most of studies had big age difference with

19 as the minimum age and 60 as the maximized age which might cause the study to have a relevant association with quality of life of persons. However following another study psychological well being seems to be significantly dependant on physical well being in which provides adequate information regarding personal biological and maternal conditions. The study done revealed that quality of life evaluations are not diversified by age (Skrzypczak et al., 2009) as one study shows that older woman having lower risk of cancer-induced depression than younger ones (Osowiecki & Kompas, 1999) and another study showed that older patients had a significantly higher anxiety level than their younger counterparts (Stpie, 2007).