International Journal of Obstetric Anesthesia 49 (2022) 103235

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International Journal of Obstetric Anesthesia

journal homepage: www.elsevier.com/locate/ijoa

Original Article

Validation of an obstetric quality of recovery scoring tool (ObsQoR-11) after

elective caesarean delivery in a developing country: a prospective
observational study
S. Kumar a, V. Ashok a,⇑, D. Jain a, A. Arora b, A. Singh b, P. Sikka b
a
Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
b
Department of Obstetrics and Gynaecology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

A R T I C L E I N F O A B S T R A C T

Keywords: Background: The obstetric quality of recovery scoring tool (ObsQoR‐11) was developed and validated in the
Caesarean delivery, elective United Kingdom for use after elective and emergency caesarean delivery. Quality of recovery scoring tools val-
Developing country idated in one country may not be valid in other countries with significant cultural, socio‐economic and linguis-
Quality of recovery tic variations. The aim of the current study was to validate a Hindi version of the ObsQoR‐11.
Methods: In this prospective observational study, 100 parturients who underwent elective caesarean delivery
in a tertiary care obstetric referral university hospital in North India were asked to complete a Hindi version
of the ObsQoR‐11 scoring tool 24 h after surgery. The performance of the Hindi version of ObsQoR‐11 was
assessed using measures of validity, reliability, and feasibility.
Results: The Hindi version of ObsQoR‐11 correlated moderately with the global health visual analogue scale
(r=0.45, 95% CI 0.27 to 0.59; P <0.0001) and discriminated well between good and poor recovery (mean
(SD) score 84.6 (9.4) vs 75.0 (11.2); P <0.0001). The reliability and internal consistency were moderate
(Cronbach’s alpha=0.66; Spearman‐Brown Prophesy Reliability estimate=0.57) with good repeatability (intr-
aclass correlation coefficient 0.85, 95% CI 0.69 to 0.93; P <0.0001) and no floor or ceiling effects. All parturi-
ents completed the questionnaire in a (median (IQR) time of completion of 3 (1.5 – 5.5) min).
Conclusion: The Hindi version of the ObsQoR‐11 questionnaire is a promising scoring tool to evaluate quality of
recovery after elective caesarean delivery. Further research is needed to evaluate the Hindi tool in other insti-
tutions in India as well as in other languages.

Introduction ObsQoR‐11 questionnaire contained items derived from four clinically

Recovery after caesarean delivery is a multidimensional process
that is dependent on a range of patient, anaesthetic and surgical fac-
tors. Measures of postoperative outcome usually focus on morbidity
and mortality, which do not necessarily describe the patient’s experi-
ence or quality of recovery (QoR) after surgery.
While scoring tools like the QoR‐40 and QoR‐15 have been devel-
oped and validated to evaluate recovery outcomes in patients undergo-
ing non‐obstetric and same‐day surgical procedures,1,2 until recently
there has been no validated scoring tool to assess recovery after cae-
sarean delivery. For the first time, Ciechanowicz et al.3 developed
and evaluated an obstetric quality of recovery score (ObsQoR‐11) for
specific use in parturients who had undergone elective caesarean
delivery. As a modified version of the earlier QoR‐40 survey, the
relevant dimensions of good postoperative quality of recovery, includ-
ing physical comfort, emotional state, physical independence and care
of the newborn, and pain. Notably, the ObsQoR‐11 includes key items
such as the ability to care for, and nurse, the newborn. These are
important components of good patient outcomes after childbirth.
The ObsQoR‐11 scoring tool was subsequently validated in non‐
elective caesarean delivery.4
Self‐reported QoR after anaesthesia and surgery is often difficult to
assess as it is frequently affected by cultural, educational and socio‐
economic factors. Patients’ self‐perception of their health is likely to
depend on their expectations about what is ‘normal’, as well as the
knowledge about their health and health problems.5 The ObsQoR‐11
scoring tool is in the English language, developed and validated in par-
turients in the United Kingdom; as such, it might not be directly appli-

⇑ Correspondence to: Dr V Ashok, Department of Anaesthesia and Intensive Care, Level 4, Nehru Hospital, PGIMER, Chandigarh 160012, India.
E-mail address: vighneshmmc@gmail.com (V. Ashok).

https://doi.org/10.1016/j.ijoa.2021.103235
Accepted 24 October 2021
0208-5216/© 2021 Elsevier Ltd. All rights reserved.
S. Kumar et al.
cable to childbirth in Indian institutions, which have a significantly
more challenging environment that includes lower literacy levels,
greater poverty, and varied cultural and religious beliefs.
We conducted this study to validate the ObsQoR‐11 scoring tool in
women after elective caesarean delivery in a single institution in India,
with the hypothesis that the ObsQoR‐11 developed and validated in
the United Kingdom would not be valid in a demographically different
setting such as India. The reliability and the feasibility of the ObsQoR‐
11 scoring tool to measure patient‐reported outcomes were also
evaluated.
Methods
This prospective observational study was conducted in a tertiary
care obstetric referral hospital in Northern India after institutional
ethics committee approval (NK/6235/Study/750, Institute Ethics
Committee, Post‐Graduate Institute of Medical Education and
Research, Chandigarh, India, September 2020). The hospital and the
peri‐operative anaesthesia protocol followed for elective caesarean
deliveries is described in Supplementary Material 1.
Study participants
Women scheduled for elective caesarean delivery under either neu-
raxial or general anaesthesia, aged ≥18 years and who could read and
understand the questionnaire in Hindi were eligible for inclusion in
the study. Women who could not read and understand Hindi and those
who declined to participate in the study were excluded.
Study design and conduct
Translation of the English version of the ObsQoR‐11 questionnaire
to Hindi was performed as per the guidelines recommended for cross‐
cultural adaptation of health‐related measures.6 The English version of
the ObsQoR‐11 was translated by two independent bilingual speakers
(Hindi and English) to Hindi and subsequently back‐translated by two
other independent bilingual speakers (Hindi and English) to ensure
accuracy of the translation process. The Hindi version of the
ObsQoR‐11 questionnaire was further reviewed by bilingual medical
experts before being piloted on a sample of 12 parturients scheduled
for elective caesarean delivery. The questionnaire did not need any
further modifications after the pilot study (Supplementary Material 2).
Recruitment and data collection
The study patients were recruited consecutively by the anaesthesia
senior registrar (SK) or consultant (VA), based on their availability.
Written informed consent was obtained from the study participants
at the time of recruitment. Relevant demographic and clinical data
of the study patients were collected at the time of study enrolment.
The participating women were requested to complete the Hindi ver-
sion of the ObsQoR‐11 questionnaire 24 (±2) h after the completion
of surgery, rating each item of the questionnaire on an 11‐point Likert
scale (0–10). The researchers were available at the patient’s bedside in
case the participants faced any difficulty in completing the question-
naire. The participants were also asked to rate their global health sta-
tus on a 100 mm visual analogue scale (VAS) anchored on the left with
‘worst imaginable health state’ and on the right with ‘best imaginable
health state’. All data were recorded on a standardised paper data col-
lection form and were subsequently transferred to a Microsoft Excel
spreadsheet with patient details anonymised.
2
International Journal of Obstetric Anesthesia 49 (2022) 103235
Outcomes measured
The performance of the ObsQoR‐11 scoring tool was assessed using
measures of validity (convergent, discriminant, content), reliability
(internal consistency, split‐half reliability, test–retest reliability and
floor/ceiling effects) and feasibility as described by the COnsensus‐
based Standards for the Selection of health Measurement INstruments
(COSMIN) group.7
(i). For convergent validity the ObsQoR‐11 scores were correlated
with the 100‐mm global health status VAS scores. Discriminant
validity was assessed by comparing the 24‐h ObsQoR‐11
scores of patients who had ‘good’ or ‘poor’ recovery, defined
by global health status VAS scores of ≥70 mm and <70 mm,
respectively. For content validity, the ObsQoR‐11 scores were
correlated with factors that could have a potential effect on
the parturients’ quality of recovery after caesarean delivery.
These included length of hospital stay, maternal age, maternal
education levels, maternal occupation, parity, American Soci-
ety of Anesthesiologists physical status score, and the type of
anaesthesia received.
(ii). Reliability of the ObsQoR‐11 tool was assessed by evaluating
the internal consistency using Cronbach’s alpha and split‐half
reliability using the Spearman‐Brown Prophesy Reliability esti-
mate. The test–retest reliability was assessed by repeating the
ObsQoR‐11 questionnaire on a convenience subset sample of
25 patients 60 min after the first completion, and evaluating
the intra‐class correlation coefficient.
(iii). Feasibility was assessed by evaluating ease of recruitment, suc-
cessful completion of the paper forms and time taken to com-
plete the ObsQoR‐11 scoring tool.
Statistical analysis
Data were presented using measures of central tendency and mea-
sures of dispersion. Normality of data was tested using the Shapiro‐
Wilk and Kolmogorov‐Smirvov tests of normality. Normally dis-
tributed data were compared using the Student’s t‐test, while skewed
data were compared using the Mann‐Whitney U test. Correlation
analysis was done using Spearman rank coefficients (r). The null
hypothesis was rejected if the two‐tailed P‐value was <0.05. All sta-
tistical analyses were done using IBM SPSS statistics software, ver-
sion 27.0.
The ObsQoR‐11 score had not yet been validated in a non‐English‐
speaking setting and data regarding patient‐reported QoR after cae-
sarean delivery from Asian countries were lacking. A convenience sam-
ple size of 100 was chosen based on previously published studies
evaluating the ObsQoR‐11 scoring tool.3,4
Results
The study was conducted from October 2020 to March 2021. One
hundred patients recruited completed the study and the returned
paper forms were complete with no missing data. The patient demo-
graphic, obstetric and anaesthetic details are presented in Table 1.
The most common indication for caesarean delivery was previous cae-
sarean delivery and not suitable/willing for a trial of labour after cae-
sarean. Most of the caesarean deliveries were performed under
neuraxial anaesthesia employing a single‐shot subarachnoid block
with bupivacaine and fentanyl. The individual items of the ObsQoR‐
11 scoring tool are summarised in Table 2. The mean (SD) global
health status VAS score and ObsQoR‐11 score were 69.4 (11.4) mm
and 81.0 (11.0), respectively.
S. Kumar et al. International Journal of Obstetric Anesthesia 49 (2022) 103235

Table 1 Table 3
Patient, obstetric, and anaesthetic characteristics (n=100) Content validity of the ObsQoR-11 scoring tool

Variables Variable Spearman’s correlation coefficient [r (95% CI)] P-

value
Age (years) 30.4 (4.7)
Weight (kg) 70.8 (10.3) Maternal age 0.007 (−0.189 to 0.203) 0.94
Maternal education: school/graduate/postgraduate 47/40/13 Parity 0.077 (−0.120 to 0.269) 0.44
Maternal occupation: employed outside the home 12 Maternal education −0.108 (−0.297 to 0.090) 0.29
Parity: 0/1/2/3/4 22/43/31/2/ Maternal occupation −0.079 (−0.271 to 0.118) 0.43
2 ASA-PS 0.179 (−0.018 to 0.362) 0.07
ASA-PS: 2/3 95/5 Type of anaesthesia −0.026 (−0.221 to 0.171) 0.84
Length of hospital stay (days) 4 (3-5) Length of hospital stay −0.016 (−0.212 to 0.180) 0.87
Anaesthesia for caesarean delivery: neuraxial/ general anaesthesia 95/5
Pre-existing medical conditions (n) 16 CI: confidence interval; ASA-PS: American Society of Anesthesiologists phys-
Endocrine 13 ical status score.
Cardiac and/or cardiovascular 5
Neurological 1
Musculoskeletal 3 (iv). Feasibility. The median (interquartile range) time for comple-
Others
tion of the study questionnaire was 3 (1.5–5.5) min.
ASA-PS: American Society of Anesthesiologists physical status score.
Values are mean (SD), median (1st to 3rd quartile), or number.
Discussion

Primary outcome: ObsQoR-11 validity
(i). Convergent validity. The ObsQoR‐11 scores had moderate cor-
relation with the 100 mm global health status VAS scores
(r=0.45, 95% CI 0.27 to 0.59; P <0.0001).
(ii). Discriminant validity. The ObsQoR‐11 scores were higher in
women with ‘good recovery’ (n=63) compared with those with
‘poor recovery’ (n=37) (mean (SD) score; good recovery 84.6
(9.5), poor recovery 75.1 (11.2), t(98)=−4.5, P <0.0001).
(iii). Content validity. The ObsQoR‐11 did not correlate with the
length of hospital stay, maternal age, maternal education levels,
maternal occupation, parity, American Society of Anesthesiolo-
gists physical status score or the type of anaesthesia received
(Table 3).
Secondary outcomes: ObsQoR-11 reliability and feasibility
(i). Internal consistency and split‐half reliability were moderate
(Cronbach’s alpha, 0.66; Spearman‐Brown Prophesy Reliability
estimate, 0.57). The inter‐dimension correlation matrix for
ObsQoR‐11 is described in Table 4.
(ii). Test re‐test reliability was good (intra‐class correlation coeffi-
cient 0.85, 95% CI 0.69 to 0.93; P <0.0001).
(iii). Floor and ceiling effect. No participant had an ObsQoR‐11 score
of 0 (lowest) or 110 (highest), which was well within the
acceptable limit of <15%.
Table 2
ObsQoR-11 individual items score (Q1-Q11) across four dimensions
ObsQoR-11 items
Dimension 1 (Physical comfort)
Q3: Nausea or vomiting
Q4: Dizziness
Q5: Shivering
Dimension 2 (Emotional state)
Q6: Comfortable
Q11: Feeling in control
Dimension 3 (Physical independence and care of newborn)
Q7: Mobilise independently
Q8: Hold baby without assistance
Q9: Feed/nurse baby without assistance
Q10: Personal hygiene/toilet
Dimension 4 (Pain)
Q1: Moderate pain
Q2: Severe pain
a
Total possible score is 10 for each question.
In this study of women undergoing elective caesarean delivery, we
demonstrated that the ObsQoR‐11 scoring tool performed moderately
well. While the discriminant validity and feasibility of the tool were
good, the convergent validity and reliability of the scoring tool were
moderate. The content validity of the scoring tool was, however,
limited.
The ObsQoR‐11 scoring tool was developed and evaluated for elec-
tive caesarean deliveries at a single centre study in the United King-
dom.3 The researchers reported a moderate strength of correlation
between ObsQoR‐11 score and the global health status numerical rat-
ing scale (r=0.44).3 Consistent with these findings, we report similar
convergent validity of the ObsQoR‐11 scoring tool in the current study.
A threshold value of >0.6 has been recommended for correlation stud-
ies evaluating scoring tools in health science.8 While the ObsQoR‐11
correlation with the global health VAS score reported in the current
study was less than this threshold, the upper limit of the 95% CI of
the correlation coefficient nearly reached 0.6, suggesting possible util-
ity of the ObsQoR‐11 scoring tool in measuring QoR after caesarean
delivery in our setting. In agreement with earlier studies,3,4 we demon-
strated that the ObsQoR‐11 scoring tool had good discriminant valid-
ity, being able to distinguish between parturients with ‘good’ vs ‘poor’
postoperative recovery. In contrast, the reliability of the ObsQoR‐11
scoring tool in our setting was only moderate, warranting further
inter‐dimension analysis.
Postoperative quality of recovery involves several domains which
were recognised during the development of the QoR‐40 scoring tool.
Myles et al.1 defined five clinically relevant dimensions which encom-
pass quality of postoperative recovery, including physical comfort,
emotional state, psychological support, physical independence and
pain. Inter‐dimension analysis, in our study, demonstrated that the
Mean (SD)a correlations between the domains of the ObsQoR‐11 scoring tool with
the global health VAS score and ObsQoR‐11 score varied from poor to
good. The items pertaining to the dimension of ‘physical independence
9.3 (1.4)
8.9 (2.1) and care of newborn’ had the highest correlation with the global
7.3 (2.7) health VAS score and ObsQoR‐11 scores, indicating the importance
new mothers place on the need for self‐sufficiency and their role as
7.6 (1.8) the caregiver for the newborn. The pain dimension had the lowest
7.5 (1.5)
strength of correlation with global health VAS score. Of interest is
7.2 (1.6) the observation that, despite the items in the ‘pain domain’ having
7.6 (1.8) the lowest scores in the ObsQoR‐11 scoring tool, there were no statis-
7.3 (1.9) tically significant correlations between postoperative pain and QoR
7.1 (2.2)
measured using the global health VAS score and ObsQoR‐11. It has
4.6 (2.4) been shown that patient reporting of pain varies significantly across
6.6 (2.9) cultures and is likely to be influenced by ethnic and cultural differ-
ences.9 In our setting, we found that parturients considered postoper-
ative pain as part of normal recuperation after surgery, which probably

3
S. Kumar et al.
Table 4
Inter-dimension correlation matrix for ObsQoR-11 following elective caesarean delivery
ObsQoR-11 dimensions VAS ObsQoR- 1 – Physical comfort
11 (n=3)
1 – Physical comfort 0.21 0.5 –
2 – Emotional state 0.37 0.73 0.2
3 – Physical independence and care of 0.43 0.77 0.16
newborn
4 – Pain 0.15 0.43 0.11
VAS: visual analogue scale. Each dimension consists of several items (denoted as n), as described in Table 2. All values expressed as correlation coefficient, r.
explains the lack of correlation between the pain items of the ObsQoR‐
11 scoring tool and the global health VAS scores.
The reliability and repeatability of the Hindi version of the
ObsQoR‐11 scoring tool was comparable to that reported in the studies
from the United Kingdom.3,4 No participant refused to complete the
questionnaire and the time taken to complete the Hindi version of
the questionnaire was comparable to the times reported in earlier
studies.3,4
The ObsQoR‐11 belongs to a family of scoring tools referred to as
patient‐reported outcome measures (PROMs). The PROMs have shown
to be useful modalities to critically evaluate the health system in terms
of the quality of care provided.10 However, the use of validated PROMs
in pregnancy and childbirth is limited.11 Self‐reported outcome mea-
sures are influenced by socio‐economic, cultural and linguistic factors,
amongst others.12–14 Patients’ perception of their own health and
recovery depends on which aspects of the recovery he/she considers
a ‘problem’, as opposed to aspects that are considered ‘normal.’ Hence,
caution is advised in attempting to use PROMs developed in the Wes-
tern world in countries in Asia and Africa.5,15
To the best of our knowledge, our study is the first to attempt to
validate the ObsQoR‐11 scoring tool in an Asian country with signifi-
cant demographic, socio‐economic, and cultural differences compared
with the United Kingdom, where the scoring tool originated. There is a
need for sustained efforts to improve maternal healthcare delivery in
settings like ours. As a means of evaluating the quality of maternal
healthcare being provided, the ObsQoR‐11 tool could enhance service
provision, thereby encouraging parturients to attend hospitals to give
birth safely.
We acknowledge that the study has some important limitations.
Our study was performed in a single centre in Northern India which
may have an implication on the generalisability of our findings. India
is a vast country that is culturally and linguistically diverse. While sim-
ilar study findings could be expected in other regions of Hindi‐
speaking India, the same may not hold true for other regions of the
country.
In the past year, the ObsQoR‐11 questionnaire has been modified to
the ObsQoR‐10 tool which has been successfully validated after vagi-
nal and caesarean deliveries.16–18 In addition to changes in the ques-
tionnaire layout, the items regarding moderate and severe pain were
combined into a single pain item. The ObsQoR‐10 tool scoring tool
was, unfortunately, not available to us during the development of
our study protocol. We had anticipated some possible confusion
amongst our patients regarding the items concerning moderate and
severe pain. Hence, we were available at the bedside to clarify this
while the questionnaire was being filled. It is possible that our study
participants might have answered the pain items differently had we
used the ObsQoR‐10 tool, so the pain outcomes and the pain dimen-
sion correlation reported in our study should be interpreted with
caution.
In summary, we have evaluated the Hindi version of the ObsQoR‐
11 scoring tool to measure QoR following elective caesarean delivery
in a single centre in Northern India, and the preliminary findings are
encouraging. Despite some limitations in internal consistency and con-
4
International Journal of Obstetric Anesthesia 49 (2022) 103235
2 – Emotional state 3 – Physical independence and care of 4 – Pain
(n=2) newborn (n=4) (n=2)
–
0.68 –
0.12 0.12 –
tent validity, the scoring tool performed well with regards to its con-
vergent and discriminant validity and was found to be feasible and
reliable. More research is needed to validate the Obs‐QoR scoring tool
after vaginal and caesarean delivery, and in other languages.
Funding
This research did not receive any specific grant from funding agen-
cies in the public, commercial, or not‐for‐profit sectors.
Declaration of interests
The authors report no conflicts of interest.
Acknowledgement
The authors wish to thank all the parturients who participated in
this study.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.ijoa.2021.103235.
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