Semi structured interviews were conducted on 20 postpartum mothers from the outpatient department of Sitaram Bhartia Institute as a preparatory step prior to the survey. These involved asking the mothers to identify the most important positive and negative areas of their lives and to rate their importance in the post partum period through open ended questions. This was intended to study the comprehensibility of the concept and to formulate a list of areas perceived to be important. All interviews were video recorded and reviewed. It was noted that all interviewed women identified only 2 to 5 areas after much suggestions and prodding by the counsellors. The women were noted to have conceptual difficulty in identifying any areas or aspects of life which were positively affected by the delivery. In light of the findings of the pilot study, existing literature on the subject was reviewed and it was decided to adapt the index to the Indian setting, possibly at the expense of limiting its comparability to other settings. In an attempt to keep the index as simple as possible we decided to follow the scoring and spending point specifications for patient generated index presented by Patel et al . In accordance with the same specifications it was decided to restrict the number of areas identified to six, to keep the scoring points at 10, to allow 12 spending points and to allow the mother and child counselors to administer the index if requested by the subject. To further simplify the concept for administration we decided to allow use of words like problems/areas/issues with the suggested list (as most of the comments were negative or neutral and this was judged to be easier to understand) and to seek 'spending points' in terms of what they wanted to improve the most.
This survey was conducted by two stage cluster randomised sampling to recruit postpartum women who delivered in the last 6 months. In stage 1, two colonies each from 3 predefined strata based on MCD classification of property tax – High (A, B), Middle (C, D) and Low (E, F, G) were selected by simple random sampling . In stage 2, a sequential house-to-house survey was conducted in each selected colony using one of four random directions till all houses were linearly covered or a minimum 50 subjects from the colony meeting the selection criteria and willing to participate in the survey were identified. Details of the study design and sampling have been reported earlier . Selected subjects were then given a date and time for questionnaire administration within 2 weeks of the initial visit. Women who delivered a live viable newborn (after 28 weeks) in last 6 months were included in the survey. Women to whom the survey questionnaire could not be administered (unable to communicate, seriously ill, physical/mental disability), women with major illnesses- cardiac, renal, hepatic, intestinal, neurological disease requiring continuing treatment or has required hospital admission for > 1 week prior to recruitment (within the last one year) and women who had delivered outside Delhi were excluded. A detailed written consent was sought from the subjects. No incentives were given other than free test results of haemoglobin, blood pressure, weight and height measurements (data not presented). The project was approved by the institutional ethics committee.
A standardized pretested questionnaire was administered to the mother which included their age, obstetric history, place and mode of delivery. The complete survey included an assessment of the quality of delivery care services (data not presented), cost of maternity care (data not presented) and a third section on postpartum QOL. The questionnaire was translated into Hindi and back translated into English to allow administration in either language. The QOL section included three related parts. One included the Mother Generated Index (see additional file 1), the second included direct questions on acute and chronic postpartum physical problems (see additional file 2) and the third section included the Edinburgh Postnatal depression Scale (EPDS) (see additional file 3). Details of profession, education and income were also recorded to enable classification of socioeconomic status according to the inflation adjusted (wholesale price index) Kuppuswamy scale (KS) i.e high socioeconomic class (HSEC), middle socioeconomic class (MSEC) and low socioeconomic class (LSEC). A separate consent was sought before administration of the QOL and depression related questions.
The Mother Generated Index is a single sheet three step questionnaire. In step 1 the mother was asked to specify up to five areas of her life that had been influenced/affected by having had a baby. In addition a sixth row is provided to represent all other aspects of life that are not captured in the first five areas. In step 2, she was asked to give herself a score out of 10 for each of these areas. The average of these scores gave the primary index score (PIS) (max = 10; lower PIS ~poorer quality of life). In step 3, she was asked to allocate 12 spending points to improve any one or more of these six areas of life. They were asked to distribute these points in any manner they chose but could not use more or less than 12 points. This was to see the relative importance of potential improvement in the six areas. The overall score also known as the secondary index is calculated by taking weighted sum of each area as specified in example in see additional file 4. The secondary index score (SIS) ranges from 0–10 where 0 reflects that "reality most falls short of patients hopes and expectations" and 10 is the "greatest extent to which reality matches expectations".
Edinburgh postpartum depression scale is depression screening tool with a ten question rating scale with four choices per questions scored from 0 to 3. The maximum possible score is 30 and subjects with a score of ≥ 13 are considered to have likely depression while those with a score of ≥ 10 are considered to have possible depression. As specified EPDS is a screening tool and is not confirmatory. The tenth question on the scale classifies the frequency of suicidal thoughts into 'Yes, Quite often, Sometimes, Hardly ever and Never'.
Data entry and analysis was done using Epi-info2002 and SPSS v 13.0. Complex samples procedure of the SPSS was used to adjust the results for the two stage stratified cluster design of the survey (inter and intra cluster variation). Complex sample linear regression models were used to study the relationship of baseline factors with the primary and secondary index score.