title: "Is the doctor God to punish me?!" An intersectional examination of disrespectful and abusive care during childbirth against single mothers in Tunisia.
abstract: BACKGROUND
  Disrespectful and abusive treatment during childbirth is a violation of women's right to dignified, respectful healthcare throughout pregnancy and childbirth. Although reports point out that marginalized groups in society such as single mothers are particularly vulnerable to abusive and disrespectful care, there is a lack of in-depth research exploring single mothers' encounters at the maternal healthcare facilities, especially in Tunisia. In Tunisia, single mothers are particularly vulnerable due to their social stigmatization and socio-economic marginalization. This study examines the self-perceptions and childbirth experiences of single mothers at the public healthcare facilities in Tunisia.
  
  
  METHODS
  This study follows a qualitative design. Eleven single mothers were interviewed in regard to their experiences with maternal healthcare services and their perceptions of the attitudes of the health workers towards them. The interviews also addressed the barriers faced by the participants in accessing adequate maternal healthcare services, and their self-perceptions as single mothers. The data were analyzed using an inductive thematic approach guided by the feminist intersectional approach. Emergent codes were grouped into three final themes.
  
  
  RESULTS
  Three themes emerged during the data analysis: 1) Experiencing disrespect and abuse, 2) Perceptions of regret and shame attributed to being a single mother, and 3) The triad of vulnerability: stigma, social challenges, and health system challenges. The study highlights that the childbirth experiences of single mothers are shaped by intersectional factors that go beyond the health system. Gender plays a major role in constructing these experiences while intersecting with other social structures. The participants had experienced disrespectful and discriminatory practices and even violence when they sought maternal healthcare services at the public healthcare facilities in Tunisia. Those experiences reflect not only the poor quality of maternal health services but also how health system practices translate the stigma culturally associated with single motherhood in this setting. Social stigma did not only affect how single mothers were treated during the childbirth, but also how they perceived themselves and how they perceived their care.
  
  
  CONCLUSIONS
  Ensuring women's right to dignified, respectful healthcare during childbirth requires tackling the underlying causes of social inequalities leading to women's marginalization and discrimination.
authors.affiliation: Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, 901 87, Umeå, Sweden. amroussia.nada@hotmail.com.
authors.forename: Nada
authors.initials: N
authors.lastname: Amroussia
authors.affiliation: Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, 901 87, Umeå, Sweden.
authors.forename: Alison
authors.initials: A
authors.lastname: Hernandez
authors.affiliation: Department of Community Nursing, Preventive Medicine and Public Health and History of Science Alicante University, Alicante, Spain.|CIBER of Epidemiology and Public Health, Barcelona, Spain.
authors.forename: Carmen
authors.initials: C
authors.lastname: Vives-Cases
authors.affiliation: Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, 901 87, Umeå, Sweden.
authors.forename: Isabel
authors.initials: I
authors.lastname: Goicolea
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D036861:Delivery, Obstetric / Q000523:psychology* / Q000592:standards*; D005260:Female; D006268:Health Facilities / Q000592:standards*; D006801:Humans; D008427:Maternal Health Services / Q000592:standards*; D036801:Parturition; D005791:Patient Care / Q000941:ethics / Q000592:standards*; D011247:Pregnancy; D011369:Professional-Patient Relations; D036301:Qualitative Research; D057545:Social Stigma; D011795:Surveys and Questionnaires; D014416:Tunisia; D014933:Women's Rights; D055815:Young Adult
keywords: Abusive care; Childbirth; Disrespectful care; Intersectionality; Maternal health; Qualitative thematic analysis; Single mothers; Tunisia