This study provides insight into single mothers’ different perceptions of discrimination and abuse when they sought maternal healthcare services at the public healthcare facilities in Tunisia. These experiences might reflect not only the bad quality of maternal healthcare services, but also how health system’s practices translate the social stigmatization surrounding single motherhood to the clinical encounters. Stigma along with other social difficulties contributed to a negative self-perception among the participants linked with being a single mother.
Abusive practices experienced by women during childbirth in the present study align with the different forms of abuse highlighted in previous studies conducted in low and middle income countries including neglect, discriminatory practices and physical and verbal violence [6, 8, 9, 13, 43–47]. Some of the aspects of low quality maternal care brought up by the participants in this study, such as inadequate episiotomies and dirty facilities, were also outlined in previous studies performed in low and middle income countries [45, 46]. Our study adds to this literature by investigating the phenomenon of abusive and disrespectful care among a marginalized group in the society and by connecting this phenomenon to a broader socio-cultural context using the intersectional approach [6, 8, 9, 13, 43–47].
To the best of our knowledge, this is the first health research paper from Africa to explicitly apply intersectionality to the study of women’s experiences of childbirth. In a recently published paper Larson et al. [48], called for more applications of the intersectional approach to health systems research in low and middle income countries. This intersectional approach might allow for new perspectives in understanding health systems’ deficiencies by considering the different social stratifiers of childbearing women and health workers as interlocked and mutually constructed.
Single mothers’ social locations as underprivileged
In this study, the participants’ experiences and self-perceptions cannot only be explained by being single mothers. The participants have multiple identities: they are women, poor, low educated and single mothers. According to the intersectional approach, the effects of these factors are not additive but multiplicative, intertwined and directly affect the lived experiences of individuals [32]. As seen in this study, becoming a single mother might be associated to socio-economic marginalization, while at the same time single motherhood can further reinforce marginalization through the loss of social support and the burden of childbearing alone.
The negative symbolic image of single mothers in Tunisia is constructed through the patriarchal gender order that values women’s virginity and prohibits extra-marital sexual relationships [23]. Socio-cultural norms connected to religious beliefs play a determinant role in shaping this symbolic image through the concept of “Haram” frequently mentioned by the participants when they referred to their pregnancies outside of marriage. The symbolic image of single mothers was mirrored in the social stigmatization experienced by the participants. Stigma seems to also be embedded in the public institutions, and reflected in the emergence of a paternalistic approach in dealing with single mothers as mirrored in the social workers’ attitudes towards some participants. Stigma might have contributed to reinforcing the marginalization of single mothers as stigma can engender the loss of status for the stigmatized person. With lower status in the society’s hierarchy, the stigmatized person can experience many forms of inequalities and disadvantage including inequalities in access to socio-economic opportunities, education, and even in interactions with people [49].
Disrespect and abuse faced by single mothers during childbirth
In Tunisia, there are no clearly written punitive policies against single mothers at the public healthcare facilities. Nevertheless, health workers’ abusive and discriminatory practices against single mothers were mentioned frequently by the participants, suggesting that these practices are a systematic issue, rather than any individual’s or group of individuals’ behaviors.
Most of the participants in this study stressed being targeted by health workers’ abuse because of their marital status. However, disrespectful and abusive care was also perceived as a common practice at the maternity wards and was linked to some deficiencies in the healthcare system. These nuanced perceptions of disrespectful and abusive care as well as the multiple identities exhibited by the study participants suggest diverse explanations for the participants’ negative childbirth experiences.
Violence, discriminatory and moralistic attitudes faced by the participants might be repressive practices used by the maternal healthcare providers to discipline single mothers from a moral perspective. Moral prejudices have been identified as one of the drivers of abusive care during childbirth, especially in low and middle income countries [8, 9]. Thereby, health workers are “social actors” contributing to sustain the ruling social and moral norms in a given society [47].
The abusive practices described by the participants in this study can be explained by unequal power relations between the women and the maternal healthcare providers [8], where gender as well as socio-economic status play an important role. Power relations are not only reflected in the moral prejudices towards women but also in the process of medicalization of childbirth itself, which disempowers women during the delivery and restricts their agency [50, 51]. During this process, violence and neglect can be used by the maternal healthcare providers, placed in an authority position, to punish certain women’s attitudes considered a menace to their authority such as not adhering to their instructions [2, 45]. Some of the rough attitudes can even be integrated in the obstetric training which can lead to the normalization of abuse [8, 52].
The unequal power relations might be also explained by the privileged position occupied by the health workers regarding access to education and social status compared to the participants. Women’s social class can affect healthcare providers’ attitudes. Poor women and lower-educated women, such as the ones in our study, may be subjected to abusive treatment during childbirth more often than wealthier and better-educated women [8, 50]. This might be relevant not only to the study participants but also to single mothers in general in this setting as according to the national survey conducted in 2014, 55.9% of single mothers had basic education and 21.1% had secondary education, only 1.8% of them had university education [22].
Taking into account the intersectional approach, we argue that the participants had experienced these different forms of power relations simultaneously. The single mother’s social location as underprivileged contributed largely in framing these unequal power relations. However, not all the childbirth experiences that participants recounted were of abuse or moral judgments. A few positive experiences were also described such as being assisted during the delivery by health workers whom were perceived as caring and supportive. These experiences indicate signs of resistance from certain maternal healthcare providers who contested the dominant social discourse of discrimination against single mothers. Resistance to the prevailing power relations also emerged from the participants themselves who tried sometimes to overcome their vulnerability in front of the health workers.
The practices of maternal healthcare providers are complex phenomena determined not only by the health workers’ characteristics and beliefs but also by factors at the organizational level of the health system [9]. Poor working conditions, heavy work load, and shortage in financial resources and equipment can lead to the demoralization and the dissatisfaction of health workers [8, 9]. Some of these factors such as heavy work load and inadequate equipment were brought up by the participants in the present study. The dissatisfaction of healthcare providers can affect their attitudes and contribute to aggravate the abusive care experienced by women at the healthcare facilities [8, 53]. Accountability mechanisms within the health system, for example, those that provide women with channels for registering complaints, might contribute to decreasing the risk of disrespect and abuse during facility-based childbirth [8].
The social construction of the single mothers’ self-perceptions
Women’s self-perceptions as mothers are commonly generated from their ideal about motherhood and their real life experiences as mothers. While the ideals about motherhood are strongly stamped by the gender relations in a given society, the daily experiences of mothering depend on multiple factors including gender, religion and socio-economic status. Based on these factors, motherhood can be empowering or disempowering [54, 55].
In this study, the participants’ self-perceptions are marked by the negative image of single mothers in the society. Stigma and discrimination can affect people in different ways including internalizing stigma [56]. The internalization of stigma might explain some aspects of the participants’ self-perceptions such as guilt and shame. The acceptance of the negative stereotypes by the stigmatized people can also reduce their ability to resist their discrimination [49]. This might explain the limited ability of the participants to challenge the discriminatory practices of the maternal healthcare providers. The participants’ feelings of guilt might also be explained by their sense of failure to comply with the normative image of motherhood in Tunisia, an image that only exists within marriage [23]. These feelings of failure were reflected in the numerous repetitions of the word “mistake” in the participants’ discourses while describing their pregnancies outside of marriage. Our study also shows that the participants construct their self-perceptions as single mothers in isolation from their partners evoking an invisibility of men in most of their accounts.
However, participants not only expressed feeling of guilt and shame, but also a positive feeling of strength. Motherhood can be considered a “creative project” that encompasses defying the traditional assumptions about mothering [57]. In this sense, the participants’ choice to keep their children despite the difficulties encountered can be considered a form of challenging the hegemonic ideals about motherhood in the society.
Methodological considerations
Measures to ensure the trustworthiness of the study
Several measures were taken in the present study to ensure trustworthiness [58]. Triangulation of researchers from different disciplines and with different levels of familiarity with the setting was used to enhance the credibility of the study by involving two of the authors in the different stages of designing the study protocol and analyzing the data. This allowed the combination of a cultural insider perspective together with an outsider perspective which adds to the trustworthiness of the study. To strengthen the transferability of this study, a detailed description of the context of the study was provided. To enhance dependability, the study adopted an emergent design throughout the research process which contributed in making single mothers’ voices more visible. To strengthen the confirmability, an inductive approach was used to develop the codes which entailed putting the pre-understanding of the phenomena studied “between brackets” [59]. The quotations were also used as a way to enhance confirmability. Collecting notes during the interviews was used to maximize both dependability and confirmability.
Study limitations
This study has limitations. We included all women regardless of the date of the delivery and the duration of the interviews because the participants provided a detailed description of their childbirth experiences. Nevertheless, this could have affected the way they recalled their experiences. The sample size was also restricted due to the limited data collection period and the sensitivity of the topic i.e., single mothers’ childbirth experiences that did not allow for recruiting a larger number of participants. However, in the final interviews similar issues and ideas started to emerge and we considered that the gathered information was enough to answer our research questions. As part of the data analysis process, the transcripts were translated from Arabic to English. Some information and nuances might have been lost in the translation process. Moreover, it was not possible logistically to share the findings of this study with the participants in order to revise and confirm our interpretation. This restricted our ability to follow-up on the different experiences recalled by the participants. Nevertheless, other measures were taken to ensure the trustworthiness of the present study as clarified above.
Only women who benefited from the organizations’ services were involved in the study. While the participants shared some profile characteristics with single mothers presented in the national survey for example having a low level of education and being unemployed, we do not claim that our study captured the multiple realities of single mothers’ experiences in Tunisia. The participants in this study might be those most in need of these organizations’ services; or might be better off compared to other single mothers in Tunisia because they benefited from the organizations’ support. Being supported by the organizations might have influenced the signs of resistance expressed by the participants in this study. Nevertheless, as single mothers are considered a stigmatized and hard to reach group in Tunisia, recruiting the participants through NGOs was considered more feasible for a first study exploring the childbirth experiences of single mothers in this setting. This also allowed to ensure receiving support from these NGOs in case some issues arose during the interviews. Moreover, in the present study, we wanted to focus on single mothers’ experiences as a group, rather than focusing on the intracategorical differences between these women. This choice led to portraying single mothers as a homogenous group, while this might not be the case. Furthermore, it seemed that the participants in this study perceived that some health workers were more empathic towards them compared to others. It would have been interesting to examine in-depth whether health workers’ attitudes differ according to their professional roles. Further research is needed to probe the different aspects of a variety of single mothers’ childbirth experiences and to compare and contrast these experiences.
Our study captured single mothers’ experiences and perceptions of the quality of care they received during childbirth. While it is important to highlight the perceptions of the participants as services users, we cannot claim for sure that they were subjected to abuse because they were single mothers. The participants’ perceptions might be the combination of different features of vulnerability which cannot be disentangled, and implying the use of intersectionality. Further research is needed to explore the practices of maternal healthcare providers towards different groups of women in Tunisia. Both qualitative and quantitative research is needed to assess the burden of abusive care and to gain insight into different experiences of women during facility-based childbirth. Examining maternal healthcare providers’ perceptions and experiences is equally important to be able to address the issue of disrespectful and abusive care during childbirth.
While our study applied intersectionality to examine single mothers’ experiences, it would also be interesting to explore the partners’ (men) experiences grounded in the same socio-economic and cultural context. Scholars [60] suggested applying intersectionality not only to understand women’s underprivilege encounters but also to gain an insight on how men’s experiences are constructed.