The HRQoL of women with preeclampsia improved over time from 6 to 12 weeks. However, the overall HRQoL of postpartum women with preeclampsia was significantly lower at 6 and 12 weeks of the postpartum period compared to normotensive women. We identified significant contributing factors for postpartum women’s HRQoL as women with severe features of preeclampsia, preterm birth, and early neonatal death. At 6 weeks of the postpartum period, the physical domain, psychological domain, social domain, and environmental domain were identified as contributing factors to lower HRQoL among women with preeclampsia. At 12 weeks of the postpartum period, the physical domain, psychological domain, and social domain were identified as contributing factors to lower HRQoL among women with preeclampsia.

The HRQoL of women with preeclampsia improved over time from 6 to 12 weeks. This finding agreed with other studies that found HRQoL improved over time from 6 to 12 weeks postpartum [4, 29, 30]. This could be due to a lower physical HRQoL that may continue for up to 6 weeks or more, and a lower mental HRQoL may continue for up to 12 weeks after preeclampsia [30]. Our study results contradict the finding of a study that indicated that, at 12 weeks postpartum, women had recovered mentally, physically, and psychologically, which was reflected in their improving HRQoL [8].

Women with severe features of preeclampsia were found to be significantly associated with lower HRQoL. This finding was similar to other studies that found women with severe features of preeclampsia reported significantly lower HRQoL at 6 weeks of the postpartum period [4, 31]. After severe features of preeclampsia, HRQoL improved for physical/bodily pain, and social functioning. However, some women still reported low mental scores at 12 weeks postpartum, which was associated with the admission of their children to the neonatal intensive care unit or the death of their child [2, 3]. Similarly, women with preeclampsia who reported postpartum depressive symptoms noted they decreased over time from 36% at 6 weeks postpartum to 25% at 12 weeks [4].

Preterm birth showed a negative effect on HRQoL among postpartum women with preeclampsia. This finding was similar to other studies that found preterm birth was found to have a significantly higher effect on a lower HRQoL among postpartum women with preeclampsia compared to women who did not have preterm birth [32, 33]. Furthermore, preterm birth in postpartum women with preeclampsia is associated with feelings of helplessness, fear, and worry about the health of the baby, which may affect postpartum HRQoL [32, 33].

Early neonatal death showed a negative effect on the HRQoL among postpartum women with preeclampsia. This finding was supported by findings of other studies in which early neonatal death was found to be a significant contributing factor to lower mental HRQoL among women with preeclampsia [34, 35]. The same study also showed that early neonatal death was found to have a significant effect on the differences in the prevalence of postpartum depressive symptoms [35].

At 6 weeks of the postpartum period, the general HRQoL was found to be significantly associated with the lower HRQoL of women with preeclampsia compared to normotensive women. This finding was similar to the findings of other studies that women with preeclampsia had significantly lower scores on a general HRQoL, social functioning, emotional role, and mental health [33, 36]. It has been found that women with preeclampsia may experience negative feelings, including hopelessness, guilt, sadness, tearfulness, despair, nervousness, and anxiety [3]. Screening of pregnant women with preeclampsia may lead to a more timely referral and initiation of psychological treatment.

At 6 weeks of the postpartum period, the general health condition was found to be significantly associated with lower HRQoL of women with preeclampsia compared to normotensive women. This was similar to the findings of other studies noting that pregnancy complications are associated with lower physical, mental, and social health [30, 37]. Speed of thinking and clarity of thought, understanding, and concentration might differ among women with preeclampsia and normotensive women in the postpartum period [4]. Furthermore, sleep disturbances seen in pregnancy may be linked to adverse pregnancy outcomes such as cesarean birth and perinatal deaths among postpartum women.

In the social domain, women with preeclampsia were more dissatisfied with personal relationships compared to normotensive women. This was supported by other studies that indicated that women who had a stable relationship with their partners had a higher HRQoL compared with those who did not [13, 37]. This could be because emotions associated with physical challenges during a complicated pregnancy may affect their relationships at home, with friends and partners.

In the social domain, women with preeclampsia were more dissatisfied with social support from friends compared to normotensive women. This finding was similar to findings of other studies that found women with preeclampsia who got support from partners, family, and friends felt supported in their needs, increasing their capacity to address difficult situations favorably [38, 39]. Lower social support negatively affected the physical, social, and environmental well-being of HRQoL. Furthermore, women with severe preeclampsia are dependent on others and seek help in their daily activities. This more likely affects their HRQoL.

In the physical domain, women who had preeclampsia were more dissatisfied with postpartum sleep HRQoL compared to normotensive women. This was consistent with other studies that found deterioration in sleep quality to be a significant issue for postpartum women with preeclampsia because it can impact physiological, cognitive/behavioral, emotional, and social health [38, 39]. This was also supported by other studies that showed that physical and emotional problems can limit postpartum women’s daily activities and affect their HRQoL [40, 41]. This could be further related to preterm delivery-related stress, sleeping position, physical pain, and difficulty in falling asleep.

At 6 weeks of the postpartum period, women with preeclampsia had a lower psychological HRQoL compared to normotensive women. This finding was similar to findings of other studies that reported preeclampsia was considered to have a significant psychological effect on postpartum women, particularly after severe preeclampsia [40, 42]. Postpartum discomfort could be manifested by psychological anxiety, feelings of sadness, problems in the couple’s relationship, and HRQoL [40, 42]. The psychological support provided by healthcare providers should be aware of both childbirth and the prevention of postpartum anxiety and depression.

In the social domain, women with preeclampsia were more dissatisfied with sexual relationships with partners compared to normotensive women. This was similar to findings of other studies that found deterioration of sexual function in women with preeclampsia in the first 6 weeks impairs postpartum HRQoL [42, 43]. This might show women with preeclampsia desired sex and the extent to which the women were able to express and enjoy their sexual desire appropriately. Sexual expression and fulfillment were described without physical intimacy.

In the environmental domain, lower regular leisure time HRQoL scores were observed among women with preeclampsia compared to normotensive women. This finding is similar to findings of other studies that found that regular leisure time for pregnant women was associated with a reduced risk of pregnancy complications such as stress, hypertension, and better mental, and psychological health [41, 44, 45]. Also, it creates a good opportunity for pregnant women to see friends, do sports, or spend time with their families.

In the environmental domain, women who have financial constraints during pregnancy have a lower HRQoL. This was supported by other studies that found women’s financial problems during pregnancy affected their basic needs such as a healthy lifestyle, transportation, and planning for births in health facilities [33, 45]. Furthermore, women with preeclampsia cannot afford to get adequate service, which might affect their HRQoL in the postpartum period.

Maternal health care providers should be aware of the potential effect of severe preeclampsia on HRQoL and about the potential need for extended postpartum care of women after severe preeclampsia, especially mental and psychological health care services. Women who have had an early neonatal death or whose children were born prematurely may require extra support. Maternal health care providers should be aware that women with prolonged poor postpartum HRQoL after preeclampsia also experience challenges with work and family responsibilities. Therefore, family members should also be informed about potential mental health issues.

A limitation of our study could be recall bias linked to gestational age, which was calculated based on the women’s recall of her last menstrual period. However, women who could not remember their approximate gestational age were given an ultrasound scan. Social desirability could have been present because data were collected in face-to-face interviews, which could have led to socially acceptable answers. This study is not generalizable as it was limited to one region of the country and those who received hospital care. It also only measured short-term morbidity, so the impact of preeclampsia in extended periods of life, including mental, psychological or other important health outcomes.