STORK checklist proven effective for measuring postpartum recovery

The Stanford Obstetric Recovery Checklist (STORK) is effective for measuring outpatient postpartum recovery, according to a recent study published in JAMA Network Open.¹

Screening in large populations is often performed through patient-reported outcomes measures (PROMs), making them the standard method for measuring recovery after childbirth. However, experts have noted difficulties in measuring postpartum recovery because of its unique and complex characteristics.²

“A PROM designed and validated for use at the 6-week obstetric outpatient follow-up clinic visit could be useful for clinicians to facilitate discussion and counseling,” wrote investigators.¹

Developing the STORK PROM

The Delphi method may be used to reach consensus among experts about a certain topic, leading to the development of new condition-specific PROMs. Therefore, investigators conducted a study to create a global outpatient postpartum recovery PROM using Delphi consensus across multidisciplinary stakeholders and patient representatives.

The STORK was developed across 3 phases, the first being identification of existing questions relevant to postpartum recovery. This was accomplished through a systematic review, in which items were selected from a list of 16 PROMs.

Afterward, STORK items were chosen using the Delphi method between January 11 and April 12, 2021. Sixteen stakeholders were included on the panel, from fields including obstetrics, maternal-fetal medicine, postpartum recovery, pain, epidemiology, psychiatry, sleep, nursing and midwifery, and PROM development.

Finally, feedback on STORK items was obtained through cognitive debriefing interviews with 10 postpartum patients. The STORK was then tested in English-speaking women aged over 18 years, with all modes of delivery and anesthesia modes included. Recruitment occurred 12 to 36 hours after delivery.

Assessment of postpartum recovery

Postpartum recovery quality was assessed at baseline, as well as weeks 2, 6, and 12 postpartum. Demographic, medical, obstetric, and anesthetic data were collected at baseline, while PROMs were completed at each follow-up time point using REDCap software (Research Electronic Data Capture, version 14.1.4; Vanderbilt University).

PROMs completed included the 47-item STORK PROM using a 5-point Likert scale and the validated EuroQoL Five-Dimensions Three-Levels (EQ-5D-3L). Psychometric STORK properties at 6 weeks postpartum were reported as the primary outcome. This outcome was assessed through validity, reliability, responsiveness, and feasibility.

There were 500 items in the first round of the Delphi process, 165 in the second, and 47 in the third. Participants were aged a mean 33.3 years, with 1% being American Indian, 14% Asian, 7% Black, 14% Hispanic, 0.4% Pacific Islander, 63% White, and 3% other races and ethnicities. Sixty-two percent of patients responded after 6 weeks.

Structural validity and score correlations

Structural validity was reported for STORK when defining dimensions with a 4-factor model including dimensionality, model fit, item and scale properties, and differential item functioning for key groups. Differences in performance at baseline vs week 6 were found for interest in sexual activity and aches and pains-related items.

A correlation between STORK scores and EQ-5D-3L scores of ρ = −0.67 was reported. Additionally, STORK successfully differentiated between patients with good vs poor recovery, with a median STORK score of 151 indicating good recover and 129 indicating poor recovery.

Reliability and responsiveness of STORK

Consistency was also found for individuals in the lowest and highest postpartum recovery percentiles. Additionally, reliability was found for STORK, with a Cronbach of α = 0.92, interitem correlation of r = 0.20, and split-half reliability of ρ = 0.98.

STORK scores increased across 12 weeks, indicating responsiveness. Increases between baseline and week 12 were 19% after spontaneous vaginal delivery, 31% after operative vaginal delivery, 27% after scheduled cesarean delivery, and 20% after nonscheduled cesarean delivery.

Implications and looking forward

These results indicated STORK as a valid, reliable, and responsive PROM for measuring global postpartum recovery. The clinical utility of this tool may be determined through future research.

“Future studies are needed to evaluate the clinical utility of STORK by comparing it with standard care for evaluation of outpatient postpartum recovery and to evaluate its performance in different patient groups, languages, and health care settings,” wrote investigators.

References

1. Sultan P, Pandal P, Murthy A, et al. Development and validation of the Stanford Obstetric Recovery Checklist (STORK): A Delphi consensus and multicenter clinical validation study. JAMA Netw Open. 2025;8(4):e255713. doi:10.1001/jamanetworkopen.2025.5713
2. Ciechanowicz S, Setty T, Robson E, et al. Development and evaluation of an obstetric quality-of-recovery score (ObsQoR-11) after elective caesarean delivery. Br J Anaesth. 2019;122(1):69-78. doi:10.1016/j.bja.2018.06.011