Thesis+2016 - Nada Amroussia

"Is the doctor God to punish
me?!!"
Childbirth experiences and self-perceptions of single
mothers in Tunisia
Author: Nada Amroussia
Supervisor/s: Isabel Goicolea
Nr: XXX/Spring 2016

Master thesis, 15/30 credits
Masters program in Public Health, 60 credits or 120 credits
Acknowledgment
I would like to start by expressing my deepest gratitude to the women who participated in
this study. Thank you for trusting me and sharing with me your intimate stories, emotions
and reflections.
To Isabel, I would not only express my acknowledgments, I really owe you this work. This
thesis is the result of joined efforts between us. Thank you for your patience, your
understanding, your brilliant ideas, and for appreciating even small advancements in the
work. And above all, thank you for supporting me this year. By the way, thank you Alison for
introducing me last summer to Isabel.
I would like to express my gratitude to all the staff at the Department of Epidemiology and
Public health for their tremendous efforts to make this master exciting and motivating.
I would like to thank all the staff working in the two organizations "Beity" and "Amal" for
their help and collaboration during the data collection. I am also grateful to Dr. Habiba Ben
Romdhane for providing me data about single mothers in Tunisia.
To my friends in the second year of the master program in Public health, thank you for all the
moments that we spent together: the discussions in the class, the dinners, the parties... This
year was wonderful! I am proud to be part of this big family. I wish you all the success and
the happiness.
To my family, I am always indebted to you. Thank you for your endless support. I am lucky to
have such a great family. I love you!
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Abstract
Introduction: Worldwide, single mothers are considered a vulnerable group in the

society. This vulnerability draws on multiple factors and it is reflected in different aspects of
women's social, economic and health status depending on the context. In Tunisia, single
mothers suffer from social stigmatization and socio-economic marginalization. There are few
studies that have explored the social aspects of single motherhood in Tunisia, but, to the
authors knowledge, the experiences of single mothers with the maternal health services
facilities have not been explored yet. The general aim of this study is to explore the childbirth
experiences of single mothers at the public health facilities in Tunisia.
Methods: The thesis follows a qualitative design. In collaboration with non-governmental

organizations in Tunisia, 11 single mothers were interviewed in regard to their experiences
with maternal health care services and their perceptions of the attitudes of the health workers
towards them. The interviews also addressed the barriers faced by these women in accessing
adequate maternal health care services, and their self-perceptions as single mothers. The
data was analyzed using an inductive thematic approach to generate codes. The development
of themes was guided by a theoretical framework that connects the gender relational theory
and the intersectional approach.
Results: Three themes emerged during the data analysis. The first theme "Health systems
disciplines single mothers" describes the relation between the single mothers and the
maternal health care providers. The majority of the participants were subjected to
discriminatory practices, neglect and even violence inflicted by the maternal health care
providers. Few of the participants described positive childbirth experiences that are
considered as signs of resistance. The second theme "If a woman makes a mistakes once. She
has to pay for the rest of her life" reflects the self-perceptions of the participants as single
mothers. The participants' self-perceptions are multifaceted: they are overwhelmed mothers
living with a persistent feeling of guilt, and they are also challenging and determined
mothers. The last theme "The trilogy of vulnerability" includes: the social stigmatization and
the socio-economic marginalization experienced by the participants as single mothers, and
the situation of the health system described as crumbling by the participants.
Conclusion: The study highlights that 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 health care services at the public health facilities in Tunisia.
Those experiences reflect how the health system translate in its practices the discrimination
and stigma culturally associated with single motherhood in this setting. Social discrimination
and stigma did not only affect how single mother were treated during the childbirth, but also
how they perceived themselves. Thus, ensuring women's right to dignified, respectful health
care during childbirth requires tackling the underlying causes of women's marginalization
and discrimination in many settings where women face the contingency of multiple social
inequities.
Key words: childbirth, single mother, maternal health, abusive care, disrespectful care,
intersectional approach, gender relational theory, qualitative thematic analysis.
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Content
Acknowledgment ................................................................................................................... ii
Abstract ................................................................................................................................... iii
Content .................................................................................................................................... iv
List of maps, figures and tables ........................................................................................ vi
Abbreviation list .................................................................................................................. vii
Introduction............................................................................................................................ 1
A global overview of single mothers and health .................................................................... 1
Single mothers in Tunisia ...................................................................................................... 2
Rationale of the study ............................................................................................................ 3
Aims of the study .................................................................................................................... 4
Theoretical framework ........................................................................................................ 5
Gender relational theory and women's health ....................................................................... 5
Intersectional approach and women's health ........................................................................ 6
Use of the gender relational theory and the intersectional approach in this study ............... 7
Results .................................................................................................................................... 14
Health system disciplines single mothers ............................................................................ 14
"If a woman makes a mistake once. She has to pay it for the rest of her life." .................... 18
The trilogy of vulnerability ................................................................................................... 23
Description of the model ...................................................................................................... 26
Discussion ............................................................................................................................. 28
Single mothers' social locations as underprivileged ............................................................ 28
Health system disciplines the single mothers: maintaining and contesting the trilogy of
vulnerability ......................................................................................................................... 29
The social construction of the single mothers' self-perceptions .......................................... 30
Methodological considerations........................................................................................ 33
Reflexivity ............................................................................................................................. 33
Trustworthiness ................................................................................................................... 33
Implications of the study ................................................................................................... 36
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Implications for further research ......................................................................................... 36
Implications for practice ...................................................................................................... 36
Conclusion ............................................................................................................................. 38
References ............................................................................................................................. 39
Appendices ............................................................................................................................ 49
Appendix 1: Informed consent (English version) ................................................................ 49
Appendix 2: informed consent (Arabic version) .................................................................. 50
Appendix 3: Thematic and interview guides .........................................................................51
Appendix 4: Interview guide (Arabic version) ..................................................................... 52
Appendix 5: Table illustrating the 10 groups formed during the analysis ........................... 53
Appendix 6: Conceptual map with 5 preliminary themes ................................................... 55
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List of maps, figures and tables
Figure 1 :Data analysis from codes to final themes.................................................................. 12
Figure 2: Model-Childbirth experiences and self-perceptions of single mothers in Tunisia .. 26
Table 1:Background characteristics of the single mothers interviewed ................................... 10
Table 2:Table illustrating the analysis process from translated transcripts to final themes ... 12
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Abbreviation list
MENA: Middle East and North Africa
MMR: Maternal Mortality Rate
MDG 5: Millennium Development Goal 5
GDP: Gross Domestic Product
CEDAW: Convention of Elimination of All Forms of Discrimination against Women
WHO: World Health Organization
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Introduction
This thesis explores the childbirth experiences of single mothers at the public health facilities
in Tunisia. It emerges from the findings of my last year thesis that showed that one of the
gaps in the implementation of the reproductive health policy in Tunisia is the presence of
discriminatory practices within the public health system targeting single women.
Single mothers, lone mothers, unmarried mothers, sole mothers and unwed mothers are
different terms found in the literature to refer to women who experience motherhood out of
wedlock or to a broader group of women who experience motherhood in the absence of a
partner (divorced mothers, widows...). In this study, the term single mothers is used to refer
to women who experience motherhood outside the marriage framework. This term is derived
from the translation of the following terms used in Tunisia "mres clibataires" or "
".
A global overview of single mothers and health

Worldwide, single mothers are considered a vulnerable group in the society. This
vulnerability draws on multiple factors and it is reflected in different aspects of women's
social, economic and health status depending on the context.
In high-income countries, a large body of research on single mothers indicates that single
mothers are often economically disadvantaged as they are more likely to suffer from
unemployment and even from poverty. Single mothers' economic vulnerability in welfare
states is explained by different reasons including low education, low social support, hardship
in maintaining a balance between work and child care, discrimination in the labor market
and women unfriendly polices (112). Several studies revealed that single mothers also
suffered from stigmatization. Despite the progress in women's status in high-income
countries, single mothers are still perceived as "deviant" by making irresponsible choices and
challenging the "normative nuclear family". They are also perceived as incompetent
mothers, unable to assume their responsibilities towards their children (2,59). However, it
seems that the stigmatization of single mothers in welfare states is not mainly based on moral
judgments, but rather on an economic concern. Single mothers are accused of being "lazy"
and overwhelming the tax payers by receiving social benefits to sustain their families (6
9,11). The social stigmatization led to the emergence of adverse emotions among single
mothers including guilt, shame and low-self-esteem (5,7,8).
The socio-economic marginalization of single mothers has negative impacts on their health.
Studies revealed that single mothers reported more poor self-rated health compared to
coupled mothers (1,3,10,12,13). Studies also report that single mothers are more likely to
suffer from psychological and mental health problems including high level of stress and
depression (1,2,10,13,14). They are also at higher risk of cardiovascular diseases and poor
health outcomes at the long term (1,10,12,13,15). The relatively limited number of studies on
single fathers revealed that single fathers also have more mental health disorders, poorer
quality of life and worse self-rated health compared to coupled fathers (1618). Nevertheless,
single fathers are less disadvantageous in the society than single mothers. They are less
stigmatized than single mothers; and they are even appreciated for their role in taking care of
the children (2). Moreover, some studies showed that single fathers have better access to
health care services, and less mental health care problems compared to single mothers
(16,18,19).
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In low and middle income countries, research on single mothers are less developed. Single
mothers are also socio-economically marginalized; and they are more likely to experience
poverty (1,2023). Financial hardship can hamper single mothers' access to health services
(24). In low and middle income countries, single motherhood is closely related to another
phenomenon "adolescent pregnancy" which has plenty of negative impacts on the socio-
economic status of the adolescent mother, on her health, and on her child's health (21,25,26).
Nevertheless, sometimes single motherhood can be regarded as an empowering experience if
women can benefit from family support or can have access to more social and economic
opportunities (22,27).
In many low and middle income countries, single mothers can face the contingency of socio-
economic marginalization and stigma related to taboos surrounding premarital sex and that
can lead to violence (1,21,2830). Single mothers can be subjected to discriminatory
practices present even within the health system. Those practices represent barriers to single
mothers' utilization of maternal health care services during the delivery. They, thereby, can
undermine women's health including maternal health (31). This is particularly relevant in
Middle East and North Africa (MENA) region where tight restrictions on women's sexuality
and bodies led to a persistent rhetoric of shame and disgrace surrounding single mothers
(1,30,32). In this context, stigma and discrimination can even result in fatal consequences
such as suicide and honor crime (30,33). In some countries of the MENA region,
discrimination is also embedded in the laws as single mothers can face penal sanctions (34).
Single mothers in Tunisia

Tunisia is a middle-income country located in North Africa and with a total population 11
million. According to the constitution, Tunisia has a republic regime, Arabic is the official
language and Islam is the official religion (35). Life expectancy at birth is 74 for men and 78
for women (36). The maternal mortality rate (MMR) is 44.8 per 100 000 live births (37). Low
quality of maternal health services and regional disparities in access to adequate health care
services are considered the main causes of failure in achieving MDG5 (37,38). Health
expenditure represented 7.1% of the total GDP in 2013 (36). The public sector, the parapublic
sector and the private sector are involved in providing health care services in Tunisia. The
public health sector, considered as the main health care provider, had a capacity of 84% of
total hospital beds and employed 51% of physicians in 2011 (39). Nevertheless, since the
1990s the role of private sector in health care provision has grown. In 20011, the private
sector had a capacity of 12.5% of the total hospital beds and employed 49% of physicians
(39,40). The parapublic sector had only a capacity of 2.4% of total hospital beds. At the public
sector, health care services are provided through a network of 24 university teaching hospital,
33 regional hospital, 109 district hospital and 2091 primary health centers (39).
Gender inequality is persistent in the Tunisian society. Women represent 50.2% of the total
population, while they represent only 25.88% of the total work force (41,42). The
unemployment rate is 15.6% in the population. However, this rate is twice higher among
women (22.6%) compared to men (12.5%) (41). The illiteracy rate is also twice higher among
women (22.5%) compared to the rate among men (12.5%) (42). Gender inequality is also
reflected in the high prevalence of gender-based violence. In fact, 46.7% of Tunisian women
aged between 18 and 64 years old reported experiencing at least one form of gender-based
violence in their life (43).
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One of the most pronounced aspect of gender inequality in Tunisia is single mothers'
situation. Official statistics concerning single mothers and their children are blurred. It is
estimated that more than 1200 to 1600 babies are born out of wedlock every year (34). In
2014, an official survey based on a sample of 732 single mothers registered at the ministry of
social affairs portrayed single mothers as young women, low-educated and having a high
unemployment rate. According to these statistics, 70% of single mothers were aged between
19 and 30 years old and 6.6% were aged less than 19 years old. While 55.9% of these women
had basic education and 21.1% had secondary education, only 1.8% of them had university
education. The statistics also revealed that 43.6% of the single mothers were unemployed,
33.3% were working in service and industrial sectors and only 1.3% were working as civil
servants. It was also stated that most of the registered women were concentrated in big cities
including Tunis district because single mothers from different regions preferred to deliver in
hospitals situated in these cities (44).
Taboos surrounding premarital and extramarital sexual relationships and deep-rooted

patriarchal stereotypes led to the stigmatization and the exclusion of single mothers and their
children (45,46). For a long time, single mothers and their children were considered as
"invisible" by the Tunisian legislation. It was only in 1998 that the law n75 allowed the
children born out of marriages to benefit from a complete identity by receiving the fathers
name (34,47). However, the discrimination is still persistent. CEDAW Committee (48) and
the Committee of the Right of Child (49) urged the Tunisian government to take the
necessary measures to provide an effective protection to single mothers and their children
and to end the discriminatory practices against them.
The social stigmatization and the economic hardship force single mothers to leave their
children in child protection institutions to take care of them (34). In the absence of reliable
official statistics, it is hard to assess the extent of this phenomenon. According to the
National Institute of Children Protection 539 of the babies born from single mothers were
placed in child protection institutions in 2014; 44% of these children were adopted and only
18% were returned to their families (50). While the government has started to provide social
services for children born out of wedlock, single mothers did benefit from a limited support
from the state (34,44). In response to this situation, different initiatives were taken by the
civil society organizations to provide social, psychological and financial support to single
mothers (34).
Rationale of the study

Women's perceptions of maternal health care can have an impact on their future engagement
with maternal health care services, and therefore on their maternal health morbidity and
mortality (5154). Exploring women's childbirth experiences are important in assessing the
quality of maternal health care services from the users' perspective. It can also contribute in
enhancing the quality of maternal care services by bringing women's voices in the core of the
quality improvement process (52,54,55).
Women's perceptions of childbirth experiences are subjective, and can be influenced by

different factors. Health workers' attitudes can be determinant in shaping women's
perceptions of their childbirth experiences (51,55,56). Worldwide, evidence of abusive and
disrespectful treatment during the pregnancy and the delivery in health facilities were well
documented (51,54,57). Accordingly, WHO (54) called for multiplying the research efforts to
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investigate care practices during childbirth as part of the commitment to ensure women's
right to dignified, respectful care throughout pregnancy and childbirth.
As few quantitative studies investigated the quality of maternal health services in Tunisia,
exploring women's childbirth experiences using a qualitative method can contribute in
improving our understanding of the quality of maternal care services (38,58). Furthermore,
few studies were conducted to probe some social aspects of single motherhood in Tunisia
(34,47). However, to our knowledge the experiences encountered by the single mothers at the
maternal health services facilities have not been explored yet. Several studies mentioned that
single women in general faced discriminatory practices while accessing reproductive health
services, mainly abortion and contraception services (59,60). Thus, exploring the childbirth
experiences can also contribute in generating knowledge about the care practices towards
one of the most vulnerable groups in the Tunisian society: single mothers.
Women's perceptions of their childbirth experiences are also influenced by women's

attributes and by the context in which these experiences occurred (55,56). Gender norms can
largely contribute in shaping single mothers' childbirth experiences at the public health
facilities. Hence, applying a gender lens in this study can enable us to gain an understanding
of these experiences.
Aims of the study

General aim
Explore the childbirth experiences of single mothers at the public health facilities in Tunisia.
Specific aims
- Explore the challenges and the barriers faced by single mothers to access adequate maternal
health care services that ensure women's right to dignified, respectful health care during
childbirth.
- Explore how single mothers perceived the attitudes of maternal health care providers
towards them.
- Explore the self-perceptions of the participants as single mothers.
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Theoretical framework
The theoretical framework is based on the gender relational theory and the feminist
intersectional approach. This section starts by presenting the two theoretical approaches and
their implications on research on women's health. It ends with explaining the rationale for
using the theoretical framework in this study.
Gender relational theory and women's health

Connell relational theory defines gender as a social structure built on the "reproductive
arena". The "reproductive arena" constitutes the "bodily site" where social practices are
engaged to construct the "cultural categories men and women". As centered on the
reproductive arena, gender represents a particular pattern of "social embodiment". Social
embodiment reflects the process of incorporating the society in the human body. Thereby,
the human body is considered as an "object of social practice" and as an "agent of social
practice". The body as an object of social practices means that the body is framed by those
practices including the "disciplinary practices" that aims to create a usable "docile body".
The body as an agent of social practices means that the body has capacities and constraints
that can create or inhibit social practices (61,62).
Gender is socially constructed and it operates at different levels: intra-personal level (within
the individual), interpersonal level (between the individuals), the institutional level and
societal level. The organization of gender relations/patterns at the institutional level forms
the "gender regime" which reflects a broader organization of gender relations/patterns at the
societal level: the "gender order" (61,62).
Connell (61) also defines four dimensions of gender relations: "power relations", "emotional
relations", "production relations" and "symbolic relations". Gendered power relations can be
manifested in different ways. They can operate directly through the direct relations between
individuals, or through the state. They can also be repressive to control/"discipline" women
or some forms of masculinities, or productive to "generate identities and practices". Like
power relations, emotional relations can also be manifested in different ways: sexuality,
parent-child relationships, labor emotions...Emotional relations can be hostile such as
homophobia or misogyny or favorable such as emotional attachment. They can be symbolic
or they can generate actions. Production relations concerns mainly the gendered division of
labor, and symbolic relations concern the "meanings" attributed to gender. Gender
symbolism can be reflected in the speech, in the values attributed to some concepts such as
motherhood and femininity, and in cultural expressions (for example films). The four
dimensions of gender relations are not considered as isolated relations but as interconnected
and interweaving relations. Gender relations are context-and time-bound; they are also
unstable. Gender relations can change over time. They can be challenged and resisted.
Gender as a social structure and as a form of social embodiment is constantly shaping

women's social experiences including health experiences. Gender relations are reflected on
how women can experience sexuality, reproduction, motherhood, illness and stress.
Patriarchal gender relations constraint women's ability to take control over their bodies and
their decisions which affect their health status. "Gender relations-approach" to women's
health is a practical tool to analyze how gender relations are incorporated in women's bodies
and thus reflected in their health including sexual and reproductive health. This approach
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can be also used to examine the impact of gender regimes of the institutions including the
health care system on women's health (6164).
Intersectional approach and women's health

The intersectional approach assumes that the social locations of groups and individuals are
determined by intersecting systems of power relations. Power relations are fluid and
dynamic. Their intersections create a complex set of social inequalities experienced by
individuals and groups at different levels (6567). They thereby determine people's degrees
of privilege and underprivilege, inclusion and exclusion, and their specific identities (64,66).
The intersecting systems of power relations are shaped by different categories including
gender, class, ethnicity, disability, sexuality and nation. Those categories are not considered
as separated from each other but as interrelated and mutually constructed. Social locations
are constructed not only by the power relations operating at the macro level but also by the
daily interactions between individuals (6668).
Introduced by black feminist scholars in the 1980s ("Kimberl Crenshaw" in 1989), the
intersectional approach was presented as a useful analytical framework to explore social
phenomena and to deconstruct hegemonies that shape women's experiences. It tries to
explore the power relations constructing women's experiences by placing them in a broader
framework where gender is considered as an intersecting structure of social inequality
(66,67). This approach focuses on the most marginalized groups in the society (64).
Nevertheless, it also recognizes the complexity and the diversity of women's social
experiences. Women with the same social locations can have different individual experience
implying that they can experience social inequalities differently (68). The intersectional
framework was largely used in social sciences studies to investigate different social
phenomena including violence, sexual harassment, women's employment, family,
motherhood and identity (66,68,69).
The intersectional approach is also regarded as "critical praxis" to advance human rights and
social justice. Through recognizing the multiplicity and the complexity of social inequities
undergone by marginalized groups and individuals, this approach is considered as a
practical tool to develop equity-based policies (66,67). As part of its critical praxis' use, the
intersectional approach was incorporated in UN discourse. In it the 58th session report, the
UN Commission on Human rights (70) stressed: "the importance of examining the
intersection of multiple forms of discrimination, including their root causes from a gender
perspective and their impact on the advancement of women and the enjoyment by women
of their human rights".
As health inequity represents a major feature of social inequities, people's health experiences
are also shaped by intersectional systems of power relations. People's different degrees of
privilege and marginalization have impact on their health outcomes. Hence, incorporating
"intersectionality" in the health research is regarded as a challenging and innovative method
to understand and address health inequities (64,66,71,72). It is also acknowledged for its
practicality in designing health interventions applicable to different contexts of the
populations (72). The use of this approach in health research, mainly in qualitative studies, is
constantly growing (73). Women's health experiences including sexual and reproductive
health experiences are conventionally analyzed through a single-gender lens, while other
social structures such as ethnicity and social class are considered as "additive factors". This
approach was criticized as it does not fully capture the complexity of women's health
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experiences. "Gender (...) takes a meaning in relation to other categories" (64). Thus,
exploring other intersectional categories with gender such as ethnicity, class and social
contexts is important to gain an insight how interrelated power relations determine women's
health (64,66,7175).
Use of the gender relational theory and the intersectional approach

in this study
The increasing institutionalization and medicalization of childbirth in modern societies
enhanced a technical medical approach in the childbirth research. Nevertheless, childbirth is
also regarded as a "social phenomenon" constructed by the interaction of different "social
processes" (53,76,77). Childbirth is considered as an example of gendered practices where the
social processes and the body interplay (61). However, childbirth as a social phenomenon
cannot be fully understood without addressing the intersectional and contextual factors
shaping those experiences that are not restricted to the gender (53). In fact, numerous
studies revealed that within the healthcare system, women experienced childbirth differently
according to a complex set of attributes including marital status, socio-economic position,
age, ethnicity and HIV status. Unwed mothers, young and adolescent mothers, poor women,
women from ethnic minorities and immigrant women are more likely to encounter negative
childbirth experiences at the health care facilities. These negative childbirth experiences
range from being subjected to discriminatory and disrespectful attitudes to being subjected
to diverse forms of violence and abuse (31,51,57,76,7883).
While all women are considered as "vulnerable" during childbirth, single mothers in Tunisia
exhibit a greater vulnerability during childbirth due to a double burden of socio-economic
marginalization and gender norms (34,53,54). Hence, applying the gender relational theory
and the intersectional approach can contribute in expanding our knowledge about single
mothers' childbirth experiences.
Childbirth is also part of the overall woman's experiences as a mother. The childbirth
experience can affect women's self-perceptions as a mother. A positive childbirth experience
might improve the woman's attachment to her child, while a negative experience might alter
the woman's self-confidence and her self-performance as a mother. It can also affect her
relation to the baby (53,84). Women integrate motherhood in their identity to construct their
self-perceptions (85). Motherhood identity was addressed from different theoretical
perspectives.
Carreon and Moghadem (86), and Laney et al. (85) argued that the woman's self-perception
as a mother is generated from her ideal about motherhood and her real life experience as a
mother (85,86). The ideals about motherhood are based on the stereotyped images of "good
mothers" in a given society which can be linked to the symbolic representations of women's
sexuality in that society. Not attaining the ideals about motherhood can be frustrating for the
mother, it can also generate a feeling of guilt (61,76,85,86). In Tunisia, Le Bris (87) stated
that marriage is the only legally and socially accepted framework to exercise parenthood
implying that motherhood cannot be exercised out of wedlock. While the ideals about
motherhoods are strongly stamped by the gender order and the gender regime including
patriarchal gender relations, the mothering daily experiences depend on multiple factors
intersecting with gender such as religion, socio-economic status and ethnicity. Based on these
factors, motherhood can either contribute in empowering or disempowering women in the
society (85,86).
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We argue that both childbirth and women's self-perceptions as single mothers are
multifaceted social phenomena centered on the women's bodies. Gender plays a determining
role in constructing these phenomena through intersecting with other social structures.
Hence combining the gender relational theory and the intersectional approach can enable us
to gain a deeper understanding of the self-perceptions and the childbirth experiences of
single mothers.
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Methodology
Study design
A qualitative methodology with an inductive approach and an emergent design is used for
this study (88). The qualitative methodology was used to explore the childbirth experiences
of single mothers at the public health facilities. It contributed in improving our
understanding of how the participants perceived the attitudes of the maternal health
providers towards them. The qualitative methodology also enabled us to gain an insight into
the participants' self-perceptions as single mothers.
Study setting
The study was conducted in collaboration with two non-governmental organizations "Beity"
and "Amal". The two organizations are situated in Tunis district, Tunisia. Tunis district is
formed by four governorates including the capital Tunis. The number of the population in
this district is 2.504 million and the urbanization rate is 92%. The main economic sectors in
this area are service sector (63.5%) and industry (17.7%). The unemployment rate in this
region (16.9%) is slightly higher compared to the national rate (89). Despite the availability
and the accessibility of maternal health services in this region, the MMR is higher in Tunis
district (50.8/100 000 live births) compared to the national rate. This might be due to the
poor quality of maternal health services including delay in the diagnostic, underestimation of
the risk, and a delayed and inadequate treatment (38).
The two organizations "Beity" and "Amal" are non-for-profit organizations. Since 1998, the
organization "Amal" (Hope for the family and children) has provided specific services for
single mothers. The objectives of this organization are to provide a temporary shelter for the
single mothers and their children, providing a legal and psychological support for these
women, ensuring financial support for these women, and facilitating their professional
integration (87). The shelter was created in 2001 with a total capacity 34 beds. Since its
creation, the organization "Amal" has received nearly 2000 single mothers (90). The
organization "Beity" was created in 2013 to address poverty and marginalization among
women living in urban settings. Through this organization women can benefit from social,
psychological and legal assistance services, housing services and professional training
programs (91). The organization does not only target single mothers. However, these women
represents 35% of total services recipients (90). Since its creation, 350 women had benefited
from assistance services and 150 had benefited from training programs (92).
Study participants
The participants were recruited in collaboration with the two organizations "Amal" and
"Beity. First, the two organizations' representatives were contacted; they also received the
study protocols to be evaluated and approved. Through direct meetings, the purpose of the
study, the selection criteria and the data collection method were further explained to the
organizations' representatives. Second, the participants were contacted through these
organizations. Hence, only women who had benefited of their services were involved in the
study. The organizations' employees participated in the selection of the participants. They
were also in charge of contacting the candidates. Participants were purposively selected to
ensure the maximum variability in age and in educational level. Two main inclusion criteria
were used to select the participants: the participant's age and the delivery place. The sample
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includes women who had experienced the delivery at a public health facility; and aged 18
years old or more at the moment of the interview. Moreover, only women who were
psychologically ready to conduct an interview and who voluntary accepted participating in
the study were recruited (see informed consent in appendices 1 and 2). Minor mothers were
excluded from the study for ethical considerations as the parents of these girls were not
available to provide parental approval.
The study included 11 women: 7 women were contacted through the organization "Beity"
while 4 women were contacted through the organization "Amal". The participants age
ranged from 19 years old to 43 years old, with 7 participants aged under 30 years old. A
participant with a university educational level withdrew from the study. The majority of the
participants have basic educational level and were unemployed or working in the informal
sector. Only one participant did not have the Tunisian nationality. The majority of the
participants delivered at a University Teaching Hospital in the capital. The table below
provides a detailed description of the background characteristics of the single mothers
interviewed.
Table 1:Background characteristics of the single mothers interviewed
Interview Participant Age Educational level Employment Place of the Date of

Pseudonym delivery the
delivery
1 Mariem _ Illiterate Missing data Regional Hospital, 2004
Kef
2 Kawthar 19 9th grade Unemployed University Teaching 2013
hospital, Tunis
Primary school
3 Sawsen 40 4th grade Unemployed University teaching - 2006

Primary school hospital, Tunis - 2009
- 2010
4 Amira 43 6th grade Worker University teaching 1991
Primary school hospital, Tunis
5 Sondos 38 6th grade Primary Unemployed Regional hospital, 2008
school Ariana
6 Marwa 27 High school Teacher in the University teaching 2014
diploma kindergarten hospital, Tunis
7 Imen 27 5th grade Unemployed University teaching 2004
Primary school hospital, Tunis 2009*
8 Sahar 22 2nd grade Unemployed Regional hospital, 2015

High school
9 Amani 20 7th grade Unemployed University teaching 2010*
gymnasium school hospital, Tunis 2015
10 Ferdaws 40 7th grade Worker University teaching 2015
Gymnasium school hospital, Tunis
11 Farah 25 High school House University teaching 2015
diploma keeper/cleaner hospital, Sousse
(*) childbirth experience as a married mother
- 10 -
Data collection
Data was gathered through 11 in-depth-interviews guided by a semi-structured interview
guide (see appendices 3 and 4). Four main topics were addressed in the interview thematic
guide: the experiences of single mothers with maternal health care services in Tunisia, the
participants' perceptions of attitudes of the maternal care providers towards them, the
barriers faced by these women in accessing adequate maternal health services, and the
perception of single motherhood among the participants. Semi-structured in-depth
interviews are considered as appropriate method to explore individual experiences and to
address sensitive topics that can be difficult to disclose within the group. They are also useful
in capturing individual emotions and opinions (93). Hence, in-depth interviews were chosen
for data collection in this study to gain an insight into how single mothers describe and
reflect upon their childbirth experiences and to ensure the comfort of the participants.
The interviews were carried out between 21/12/2015 and 4/01/2016. The mean duration of
the interviews is 25 minutes. The interviews were conducted in Arabic, the mother tongue of
the interviewer (the student) and the participants. All the interviews were conducted face to
face; and they were audio-taped. A notebook were used to register additional information
about the participants, some memos and comments. The interviews were conducted at the
organizations' offices. To secure the privacy of the participants and to avoid disturbance,
these interviews were carried out in private rooms.
Data analysis
First, all the interviews were transcribed verbatim. Then, the transcripts were translated from
Arabic to English. This process contributed in enhancing familiarity with the data as
transcripts were read repeatedly during the transcription and translation process.
The translated transcripts were analyzed using an inductive thematic analysis approach.
Thematic analysis is defined as the process of identifying and generating themes within the
data. The inductive approach entails that the process of coding is performed without any
preexisting framework to ensure a strong closeness of the themes to the data (94). First, all
the transcripts were coded line per line by the student using the "OpenCode 4.03 software"
(95). 560 codes were generated during this process. This software was also used to help in
grouping the codes. Codes with close meanings were grouped together to form groups. Ten
groups were generated during this process (see appendix 5).
Then, the extracted codes and groups were examined to look for thematic patterns in the
data. This process was guided by the gender relational model presented by Connell and that
encompasses four dimensions of gender relations: power relations, production relation,
emotional relation and symbolic relation (61). Five preliminary themes emerged during this
process (see conceptual map in appendix 6). To enrich our theoretical perspective, the
intersectional approach was incorporated in the theoretical framework. The five preliminary
themes were discussed and reviewed using the theoretical framework that combines the
gender relational theory and the intersectional approach. The five preliminary themes were
condensed into three final themes (see model in figure 2). The figure 1 below illustrates the
data analysis process from codes to the final themes.
- 11 -
Figure 1 :Data analysis from codes to final themes
During the analysis process, codes and groups were generated according to the principle of
constant comparative analysis. Constant comparative analysis is used in grounded theory
method by comparing incidents to incidents, concepts to incidents and concepts to concepts
(96). The use of the constant comparative analysis method in this study was adapted to
thematic analysis. Fram (97) argued that constant comparative analysis can be used in
qualitative studies that are not based on grounded theory method to ensure an "emic"
(internal) perspective in the analysis. Constant comparative analysis can also ensure that all
the data are analyzed following an inductive approach. The author (97) presented an example
of how to use constant comparative analysis in naturalistic inquiry in the first stage of the
analysis to develop codes and incidents. The theoretical and conceptual frameworks were
used in the second stage of the analysis to determine patterns in the data. In this study,
existed codes were compared to the new emerged codes. The new groups were defined by
comparing them with codes and with other groups. The development and the refinement of
the themes was based on an abductive approach. This approach involved constant back and
forth movements from the codes, the groups and the themes to the theoretical framework
used (94). The constant comparative analysis and the theoretical model ensured combining
both "emic" (internal) and "etic" (external) perspectives in the data analysis (97).
Table 2:Table illustrating the analysis process from translated transcripts to final themes
Text (translated transcripts) Codes Subtheme Final theme
"The doctor...The doctor was rude Being rude to the Physical Health system
when she was making the sutures. patient violence Disciplines single
She was shouting at me and Shouting at the single towards single mothers
screaming...She was beating me on mother mothers
my hips." Being beaten of the
hips
- 12 -
Ethical considerations
Before conducting the study, the study protocol was approved by the two organizations where
the interviews were carried out, and a consent was obtained from the organizations. During
the data collection, the purpose of the study as well as the confidentiality measures were
explained to the participants. They were also informed that their participation was voluntary
and that they can withdraw at any time. A written informed consent was signed by the
participants (see informed consent in appendices 1 and 2). To avoid any kind of ambiguity,
all the participant were informed orally about the content of the informed consent as some
participants were illiterate or with low educational level. The majority of the participants
stressed the importance of not mentioning their names in the study as a measure to protect
their privacy and confidentiality. Thus, we chose to refer to the participant by pseudonyms.
The study was also approved by the National Ethical Committee for Medical Research in
Tunisia.
- 13 -
Results
This section includes the description of the themes and the final model. Three themes
emerged during the data analysis process. These themes are: "Health system disciplines
single mothers", "If a woman makes a mistake once. She has to pay it for the rest of her life"
and "The trilogy of vulnerability". The three themes were placed in a model that tried to
illustrate the different connections between them (figure 2).
Health system disciplines single mothers

This theme describes the relations between single mothers and the maternal health care
providers during the childbirth. It describes the attitudes of health workers towards the
participants and the reactions engendered by these attitudes. This theme includes 4 sub-
themes: "Neglecting and discriminating single mothers", Violence towards single mothers",
"Overcoming fear to contest abuse?" and "Not all health workers are bad!".
Neglecting and discriminating single mothers
While recalling their childbirth experiences, many participants mentioned that they felt
neglected and ignored by the maternal health care providers who did not respond to their
needs. The quotes below reflect some of those experiences:
"They ignored me when I called them. They might be talking to each other about their daily
lives...and when I called them they ignored me".
Sahar-Interview 8
"I don't know with what they were busy...I was screaming that I will deliver... and no one
came to help me. The girl was moving...I was going to deliver...
Sawsen-Interview 3
Some participants also mentioned that they felt not being taken seriously by the maternal
health care providers who did not ask for their permission or their consent before medical
procedures. Moreover, the participants often complained about suffering from hunger, cold
and from post-delivery complications as a result of the neglect. Sawsen (interview 3)
described how she was freezing after the delivery:
"Then, I felt cold...after the delivery...my teeth were chattering. I felt so cold...I was
freezing".
In addition to feeling neglected, many participants mentioned feeling stigmatized by the

maternal health care providers because of their status as single mothers. Some women
expressed how that they felt disregarded and disrespected by the health workers during the
delivery. The participants also stated that they were judged by the health workers who openly
questioned their attitudes and blamed them for having an out of wedlock baby or pre-marital
sexual relationships. The quotes below illustrated some those experiences:
"When, the nurses and interns asked me about the father's name...I explained my situation
(...) and the way they looked at me changed..."
Marwa-interview 6
- 14 -
"Then she (a nurse) said "After committing a sin (Haram), you came here to Tunisia to sort
out your situation!"
Ferdaws-Interview 10
Some participants described feeling treated differently compared to other women. The
discriminatory practices surpassed treating single mothers differently to include denying
access to postnatal health care services as accounted by the following quotes:
"No they didn't ask me to come back. I didn't do anything...nothing! I saw that they told the
other women to come back in prefixed dates but, they didn't do the same for me. I am not
completely healed. Today it's the 4th of the current month but I am not completely cured.
They told all women to come back except me".
"Their services were very bad...I went back the 40th day for follow up; I had pain in my
uterus...They told me that I am not allowed to do the follow up."
Marwa-Interview 6
As they reflected on their childbirth, many participants mentioned perceiving health care
providers negatively. They portrayed them as apathetic, careless, rude and arrogant. The
quotes below illustrate some of these perceptions:
"Thank God, I was registered as a married woman because they (health workers) treated
single mothers badly... in inhumane ways. It's rarely that single mothers can meet someone
who is caring and understanding".
Farah-Interview 11
"In the hospital...the nurses are arrogant".
Sahar-Interview 8
Violence towards single mothers
During the interviews, many participants recounted experiencing different kinds of violence
including physical violence, verbal and psychological violence exerted by the maternal health
care providers. They also expressed their feelings and reflections towards these experiences.
Many participants reported encountering different forms of psychological and verbal violence
when they described their childbirth experiences including being insulted and name called.
The participant Sahar (interview 8) asserted that she was insulted by the midwives:
"When I went there to give birth, they insulted me...you know...the midwives and everyone
there...they were talking to me in a bad manner"
The participants also mentioned how the health care professionals mistreated them and
shouted at them. Some of the women also pointed out being subjected to threats and
menaces from the health care providers who also violated their privacy. For example, Marwa
- 15 -
(interview 6) recalled how midwives took some photos of her during the delivery to
intimidate her:
"Then... when I was screaming because of the pain, the midwives took some photos of me.
They said they were going to take the photos to show them to the director...I don't know
actually what they did with those photos".
Some participants described being subjected to physical violence during the delivery. They
mentioned being beaten on the hips, slapped on the face and having finger marks on their
bodies. The quotes below illustrate some of those experiences:
"The doctor asked the interns and the midwives to leave the room as he found them arguing
with me...One of the midwives slapped me on the face."
Mariem-interview 1
"The doctor...The doctor was rude when she was making the sutures. She was shouting at
me and screaming...She was beating me on my hips. Her attitude was not normal".
Sawsen-interview 3
"They made me suffer so much and they beat me a lot...They forced me to push the baby
out..."
Amani-Interview 9
Violence in its most severe form was experienced by the participant Mariem (interview1) who
accused the health care professionals of stealing one of her baby twins after the delivery in
the hospital. The participant described how she was anesthetized by a nurse just after the
delivery whom she accused of disappearing after taking the child. Throughout the interview,
Mariem (interview 1) described her fruitless efforts to find her son, her despair and her
sadness as accounted by the quote below:
"I wish I can find my son...I wish that my son will come back to me...Every time I see a little
boy, I remember my son (the participant started crying)."
As they reflected on those experiences, some women stated that they felt targeted by violence
because of their status as single mothers. These participants also pointed the concepts of
"punishment" and "discipline" directly or indirectly. Some of these reflections were clearly
articulated in the following quotes:
"They (health workers) behave like that because I wasn't married...According to them...an
unwed mother...an unwed mother does not deserve to live."
Sawsen-Interview 3
"They knew that I didn't have a husband...so they started calling me names".
- 16 -
Overcoming fear to contest abuse?
While describing their childbirth, women expressed different feelings engendered by health
workers' abuse. Some women expressed feeling scared, unsafe, powerless and desperate
when they faced mistreatment inflicted by the maternal health care providers. For example,
Imen (interview 7) described how she felt nervous and confused when the health workers
started shouting at her:
"When I was in the hospital, I didn't know what to do...They were supposed to show me
what to do. But, when I was on the table, they were shouting at me...I felt nervous...so
instead of being calm, I wanted to stand up and move around".
Many participants also mentioned feeling hurt, offended and humiliated as a result of the
health care abusive attitudes as described in the following quotes:
"I didn't forget their words...bad words that hurt. And in my situation, it affected me a
lot...I was sensitive...I didn't like being insulted but I didn't know how to reply to them. I
kept quiet, but I felt offended."
Amira-Interview 4
"No...I didn't come back...I didn't come back to that hospital. They told me that it was useful
to come back for follow-up. But, the most important thing for me was to leave that place
and to escape the humiliation...They humiliated me. I had just wanted to leave, nothing
more".
Mariem-Interview 1
During the interviews, the participants reflected upon health worker's attitudes. The
participants questioned health workers' abuse and expressed refusing being stigmatized,
ignored or mistreated. These participants expressed how that they felt angry and unsatisfied
because of the health workers' mistreatment as expressed below by Sawsen (interview 3):
"Was she there to punish me for my mistake?!!...Is the doctor God to punish me?!!... she is
not God to judge people!!"
Some participants also mentioned that they did not have passive attitudes, and that they tried
to protest against health workers' abuse as illustrated by the following quotes:
"The nurse was screaming and shouting at me...I told her :"that's it, I will leave!"".
Marwa-Interview 6
"I asked her (a nurse) why she said such thing...why she said that I ruined my life...I asked
her what did I do wrong".
Not all health workers are bad!
While most of the participants recalled negative childbirth experiences, a few of the
participants described positive childbirth experiences in the hospital. These women stated
that they felt well treated and satisfied with the maternal health care services. They described
- 17 -
how the health workers support them during the delivery. They also expressed their gratitude
towards the health staff whom they described as responsive, supportive and caring. Kawthar
(interview 2) described her positive childbirth experience by saying:
"At the moment of the delivery, I felt the contractions...It was very painful. The doctors
asked me not to move...There were three doctors with me...and they told me to relax. I had
never felt such kind pain during my whole life. The doctors told me to take it easy. They
gave me an anesthetic. They treated me well...Not all doctors are bad!"
Regardless of their positive or negative child birth experiences many participants pointed out
that health workers had ambivalent attitudes. Their attitudes can be "bad" or "good".
Moreover, although they had painful delivery experiences, some participants acknowledged
meeting health care professionals whom they considered as having friendly attitudes as
asserted below by Ferdaws (interview 10):
"Only one lady was nice to me...she asked me to help them to have a quick delivery."
"If a woman makes a mistake once. She has to pay it for the rest of
her life."
This theme describes the participants self-perceptions and their reflections about their
overall experiences as single mothers. This theme includes four sub-themes "Internalizing
guilt", "From detachment to attachment", "Single motherhood: a burden and a daily
challenge" and "Despair and determination".
Internalizing guilt
The majority of participants considered their out of wedlock pregnancy as a "mistake". The
word "mistake" was redundant in all the interviews as illustrated by the quotes below:
"I made a mistake...and I had my son. My son was born out of wedlock "Haram"..." (The
participant started crying).
Amani-interview 9
"The human being can make a mistake...But, I didn't want to make another mistake to solve
the problem".
Farah-interview 11
Some participants expressed the feelings of regret and guilt for making the mistake of being a
single mother. The participant Marwa (interview 6) mentioned how she felt that she
disappointed her mother when she got pregnant:
"It was actually an... experience... I don't know... a painful experience. And my mother was
disappointed. But, thank God, I stood up for myself and I will not repeat the same thing...it
was a mistake".
Some participants also tried to justify and to make excuses for being single mother including
lacking awareness or feeling distressed. For example, the participant Sawsen (interview 3)
mentioned how she was young and foolish when she had her daughters:
You know...I was young and foolish ... I had another girl "Jouda"...and then "Zouhour".
- 18 -
In addition to feeling guilty, some participants expressed feeling ashamed because their
status as single mothers. The feeling of shame was clearly described by the participant Imen
(interview 7) when she recalled her first child birth experience as a single mother:
"I felt that I had no dignity...I felt ashamed...I was feeling ashamed...and...you
know...people were aware of my situation."
When asked about their overall experiences, some participants asserted that they do not
consider themselves as single mothers. These participants shared with the society the
negative image of single mothers as according to them being single mother is either related to
child abandon or to the sin. Sondos (interview 5) expressed refusing being called single
mother by saying:
"I don't consider myself as single mother...at all. I always say that I am divorced. I have
never said that I didn't have a marriage contract...because I didn't have a baby...and then I
abandoned her".
From detachment to attachment
Pregnancy was not a choice for the majority of the participants who mentioned that they had
unwanted and unexpected pregnancies. The participant Amani (interview 9) explained how
she failed in doing an abortion:
"I didn't do anything...I figured out that was pregnant accidentally...And I took medicines
to have an abortion... but It didn't work."
Moreover, the decision to keep the child was not an easy decision for some participants who
asserted that they hesitated to keep their children. These participants mentioned different
reasons for their hesitation: concern about the family reactions, being not ready to take care
of children, feeling afraid of responsibility and lacking financial means. Some of these
reasons are reflected in the quotes below:
"Honestly, before giving birth to my daughter, I was telling myself: "I should leave her...I
don't need her. I won't give up on family just for a baby.""
"I was thinking if I should keep the baby or not...I was not ready at all to think about
having children".
Imen-Interview 7
Although many participants described their pregnancies as unwanted and their dilemma to
keep their children, most of them mentioned that their emotions towards their babies
changed after the child birth. The participants expressed their attachments and affection
towards their children specially after the delivery. The following quotes capture some of those
feelings:
"Now...my girl is the most important person in my life".
Marwa-Interview 6
"I mean...I feel blessed to have my son with me...he can grow up with me".
- 19 -
Sahar-Interview 8
Single motherhood: a burden and a daily challenge
According to the participants, single motherhood is a multifaceted experience. As part of

describing their self-perceptions as single mothers, the participants mentioned that they
perceived single motherhood as a burden that they had to cope with and a daily challenge
that allowed them to affirm themselves as mothers. In fact, when reflecting about their
overall experiences as single mothers, the majority of the participants used expressions
related to pain and suffering such as "tough experience", painful experience", " I suffered a
lot", "It was not easy for me", "I felt down". Some women also cried during the interviews.
Moreover, many participants expressed how they felt stressed, tired or physically weak and
breathless as a result of their hideous situation. The quotes below capture some of those
feelings:
"I started to smoke...I started to smoke so much because of the stress...It's because this is the
first time for me to live in organizations".
Amani-Interview 9
"I was feeling weak because I didn't eat properly. I wasn't able to stand up...I wasn't able to
do anything. I wasn't living at home...I couldn't eat properly...and I didn't feel relaxed".
Ferdaws-interview 10
However, single motherhood was also perceived by the participants as a positive experience
that brought meaning and joy to their lives. They also related the image of single mothers to
assuming responsibilities as asserted below by Farah (interview 11):
"For me this...this experience taught me the patience. I learned that there some beautiful
things in this life: experiencing motherhood, assuming responsibilities..."
The participants perceived single motherhood as a burden exacerbated by the lack of social
support and rejection. The participants recalled different experiences of rejection including
rejection from their family, their friends, their partners and the society in general. According
to many participants, rejection is a common reaction of parents towards their daughters'
"mistake" as reflected in the quotes below:
"If woman makes a mistake once, she has to pay it for the rest of her life. That's it... she will
pay it...Her family will reject her".
"If the parents know that their daughter made mistake, they will say that they don't want
her anymore like my mother who rejected me in the beginning"
Amani-Interview 9
Furthermore, the participants complained about assuming the whole responsibility of taking
care of their children alone in absence of their partners. In fact, while some participants
mentioned that the role of their partner was restricted to recognize the baby by giving the
child his name. Other mentioned that they were completely abandoned by their partners
- 20 -
before or after the delivery. Few of them mentioned that they were accompanied by their
partner during the childbirth.
Rejection is experienced by the mothers not only in the intimate sphere but in the whole
society and their daily interactions with people as illustrated by the following quotes:
"When I gave birth for the second time, I was talking and joking with other women. But, it
wasn't the case in the first delivery...I felt that all people didn't want to talk to me...They
were gossiping... you know. "
Imen-Interview 7
"The last time, I saw on T.V report on "Tounissia". There were old men, women, girls. They
said "there is no place with us for single mother in Tunisia"."
Marwa-Interview 6
Nevertheless, many participants considered single motherhood as a challenge. The

participants brought up directly or indirectly the concept of challenge" when they described
their experiences. Some participants mentioned that in order to keep their children, they had
to face a lot of pressure from their families, from the health workers or the social assistant to
leave their children or to have an abortion. Some of those experiences are reflected in the
quotes below:
"In the hospital, people asked me to give her but I couldn't...It's true that I am a single
mother but my daughter is a part of me...I can't give her".
Ferdaws-interview 10
"I don't know...I think I was strong when I insisted to keep him (her son) and I challenged
all the people and...I had to challenge my brothers, my family...my dad (RIP)...Yet I was the
only girl in the family, I should had made them proud as they said. "
Amira-Interview 4
Some participants also mentioned that they had to challenge themselves to assume their role
as mothers for the first time and to take care of their children as stated by Farah (interview
11):
"I took time to accept my situation and I started discovering motherhood. I am still not used
to my daughter. Sometimes, I looked at her, I started touching her and I told myself "This is
my daughter...she belongs to me"...I had to learn how to take care of her, how to breastfeed
her..."
Some participants mentioned that single motherhood entails also challenging the social
norms by ignoring the prejudices as reflected in the following quotes:
"The single mother cannot move forward, unless she ignores what people are saying...If she
wants to move forward, she had to put behind her the bad words and the society's
prejudices...so she can advance".
Sawsen-Interview 3
- 21 -
"Ok...I got pregnant...It is my problem! Why other people would be annoyed by my
pregnancy?! If I have a son in "Haram", other people will not be judged for what I did...
they will not. I will be the only person to be judged in front of God...So I am free!"
Amira-Interview 4
Despair and Determination
Single motherhood generated different controversial emotions expressed by the participants.

Some participants mentioned that they felt insecure as other people tried to take advantage
of their vulnerability while others said they felt deprived of their rights to live peacefully and
to restart a new life. Some participants also mentioned suffering from loneliness and
isolation, and feeling desperate and helpless because of the rejection as asserted below by
Farah (interview 11):
"For 9 months, no one knew about my pregnancy: my family didn't know my pregnancy,
my friends also...I lived alone far from them. I suffered during my pregnancy because no
one helped me."
According to the participants, single motherhood is not only associated with the feeling of
despair and loneliness, but also to feeling of strength and determination. Hence, when they
were talking about their motherhood experiences, the majority of the participants stressed
the importance of being strong to be able to face stigma and rejection or to overcome the
daily difficulties as illustrated by the following quotes:
"To survive in the society, the single mother has to impose her presence by her will and her
strength".
Sawsen-Interview 3
"I don't regret having my daughter. She's my family now. Sometimes, I meet many
difficulties in life. Now, she's in the first grade of the primary school. I try my best to be
strong in front of her".
Sondos-Interview 5
Although some participants expressed their concern and uncertainty about their future and
their children future, many of them expressed how they were determinant to move forward.
They highlighted the importance of finding a job and working. The participants perceived the
job not only as a means to sustain themselves financially but also as a means to stand up and
to prove themselves and to be independent as reflected in the following quotes:
"I want to have a loan and start my own business step by step".
Kawthar-Interview 2
"I came to this place to stand up for myself. I don't want to stay at home because I know
that I would not work. I know that I would return to my same old behavior..."
Amani-Interview 9
- 22 -
The trilogy of vulnerability
This theme describes how socio-economic and cultural factors operating at the macro and
micro levels shaped women's childbirth experiences at public the health facilities and their
self-perceptions as single mothers. This theme includes three subthemes "Social
stigmatization", "Socio-economic marginalization" and "A crumbling health system".
Social stigmatization
While describing their experiences as single mothers, the participants reflected on how the
health workers, their families and the society in general perceive single mothers. To refer to
these perceptions, the participants used the expressions "mischievous woman", "bad
woman", "without moral". The concept of "Haram" was also pointed out by the majority
participants while describing the stigmatization that they had faced in the hospital or in the
society as a whole.
According to the participants, the bad image of single mother does not only include being
morally wrong but also being incapable of making decisions and assuming her responsibility
as a mother. For example, the participant Sahar (interview 8) described how she had to
struggle to take her child as the social assistant did not consider her as a trustful mother:
"Actually, I met the social assistant...you know. That's it. I explained to her my situation
and she asked to give her my I.D so I can return and take the baby. I left the I.D for two
weeks...Then, the social assistant said she was afraid that I will abandon the child in the
future or do something bad to him... Because it happened several times: the woman took the
baby with her...and then she abandoned him"
Socio-economic marginalization
Many participants stated experiencing socio-economic marginalization as single mothers and

also before single motherhood. In fact, when the participants introduced themselves, the
majority of them mentioned having a basic education. Some of them also pointed out coming
from poor families.
The socio-economic was related to different forms of violations affecting the participants. In
fact, while describing their situation before their pregnancy, some participants mentioned
experiencing domestic violence. Sondos (interview 5) described how she was obliged to leave
her family at the age of 16 because of the domestic violence:
"When I was 16, I had many problems with my father. They were financial issues...I had
many troubles with my father. In the end, he aggressed me. So, my mother asked me to
leave...mmmh...and I left. We lived in bad conditions...So, I left home at the age of 16".
Some participants also mentioned having a forced marriage, early marriage or adolescent
pregnancy which contributed in increasing their social vulnerability. The quotes below
illustrate some of those experiences:
"She also said that I am still young and that my family made a mistake by marrying me at
the age of 15...Indeed, I got married at the age of 15".
Amani-Interview 9
- 23 -
"I was forced to marry him... you know... I didn't love him or anything. I couldn't live with
him...so I got the divorce...
Sawsen-Interview 3
The cycle of marginalization was reinforced during the pregnancy or after the childbirth. The
majority of the participants mentioned how they struggled to afford necessities, how they
lived in poverty and how they were homeless as part of their experiences as single mothers.
The concern of finding a place where to live was shared by the majority of the participants
who explained that being homeless is mainly related to financial constraints and sometimes
to family rejection. The quotes below illustrate some of these experiences:
"I suffered a lot and I couldn't give up on my daughter. I was materially broken so I left the
house and I had to stay with her in the hospital".
Farah-Interview 11
"How can I take care her? I didn't know organizations as now...I mean...I wasn't aware of
anything...It's not like now I know...Where am I going to live with her?"
Sawsen-Interview 3
Some women mentioned how that they were obliged to rely on the organizations' services to
secure housing and to take care of their children as stated by Amani (interview 9) below:
"They give us clothes here, they give us diapers, they give us milk for the baby.(...) they give
us medicines...they give us a paper to benefit free health care services in the hospital."
A crumbling health system
Many participants complained about the poor quality of health services in the hospital where
they delivered: dirty place, poor quality of the food, lacking equipment, sharing beds in the
maternal health department, bad quality of the sutures, a long waiting time and
inappropriate episiotomy. The quotes below reflect some of these experiences:
"It's not that I want to disparage them...but, in the hospital, you are not supposed to find
mosquitoes or flies...I mean the hospital has to be sterilized...you know. But, there you can
find mosquitoes, flies, trash...I mean...the hospital was very dirty."
Sahar-Interview 8
"We were two women sharing the same bed...Two or three women were sharing the same
bed".
Farah-Interview 11
Some participants also complained about the corrupt practices that existed within the health
system and that included bribery. Several participants mentioned that they perceived bribery
and having contacts as important to ensure that health workers will take care of the patient
and will provide good quality of services as accounted by the quotes below:
"The guard was taking money from all people. I had to pay money to even receive visits
from my mother or my sister..."
- 24 -
Amani-interview 9
"All hospitals in Tunisia are well known...well known...if you give bribery or something like
that they will be pleased to have you and they will provide you good services...If you had
contacts, they will serve you."
Marwa-interview 6
While some participants stated feeling targeted by violence and neglect as single mothers,
others said that these practices are common and normalized in the hospital affecting women
during the delivery regardless of their marital status. For example, the participant Mariem
(interview 1) explained that women were usually subjected to physical violence in the hospital
where she delivered:
"Even married women were treated like that...A woman told me:"you're complaining about
what happened to you But, did you these finger marks?! A midwife slapped me on the
face!"...That lady was married."
Some participants also explained some attitudes of health workers such as lack of
responsiveness and psychological and verbal violence by the heavy workload or by being used
to assist deliveries, as illustrated by the following quotes:
"I can find excuses for the one who assisted me in the delivery and for the doctor. I delivered
by night...so maybe they had many women to assist in the delivery".
" It wasn't because of my situation or something. They treated women in general like that.
The midwives became...I don't know how to say it. I mean...They got used to see women
delivering."
Sahar-Interview 8
- 25 -
Description of the model
Figure 2: Model-Childbirth experiences and self-perceptions of single mothers in Tunisia
The three themes described above are interrelated. Some of the connections presented in the
model are paradoxical and nuanced. The trilogy of vulnerability includes the socio-economic
and cultural factors that shaped both women's self-perceptions and their childbirth
experiences as single mothers. It includes the social stigmatization of single mothers, the
socio-economic marginalization experienced by the participants, and the bad situation of the
health system.
This trilogy of vulnerability had negatively affected the relations between the participants and
the maternal health care providers. This was reflected in the abusive and discriminatory
practices of the maternal health care providers, and in the participants' reactions (fear,
disempowerment...). The attitudes of the maternal health care providers and the reactions of
the participants might have ambivalent effects on the factors presented in the trilogy of
vulnerability. While, abusive attitudes of the health workers and passive reactions of the
single mothers might reinforce these factors; some health workers' friendly attitudes and
certain participants' attempts to resist abuse might contribute in contesting these factors.
- 26 -
The social stigmatization and the socio-economic marginalization might have a role in
altering the participants' self-perceptions as single mothers through internalizing guilt,
feeling desperate...(etc). These negative self-perceptions can contribute in reinforcing the
social stigmatization and the socio-economic marginalization of single mothers. However,
the participants' positive self-perceptions such as feeling strong and determinant can
enhance their ability to challenge the causes of their vulnerability.
The participants' childbirth experiences and their self-perceptions might be also

interconnected. On one hand, the participants' gloomy self-perceptions can weaken their
position in front of the healthcare providers. On the other hand, the negative childbirth
experiences of single mothers might emphasize the participants' feelings of guilt and despair.
However, the negative childbirth experiences encountered by the majority of the participants
did not alter their attachments to their babies to whom they felt more attached and devoted
after the delivery.
- 27 -
Discussion
The themes and the models are discussed in relations to the theoretical framework that
connects the gender relational theory and the intersectional approach. This study shows that
the participants (single mothers) had experienced disrespectful and discriminatory practices
and even violence when they sought maternal health care services at the public health
facilities in Tunisia. Those experiences reflect how the health system translate in its practices
the discrimination and stigma culturally associated with single motherhood in this setting.
Social discrimination and stigma did not only affect how single mothers were treated during
the childbirth, but also how they perceived themselves. However, some signs of resistance
existed.
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. Their experiences are shaped by their social locations as
underprivileged in the society. The single mothers' social locations as underprivileged are
constructed by the intersection of gender reflected in the symbolic image of single mothers in
the society and social class reflected on their socio-economic marginalization. According with
the intersectional approach, the relation between these factors is not additive but
multiplicative. These factors are also interconnected and one can lead to the other (66). This
means that being single mothers might be related to the socio-economic marginalization. In
Tunisia, both contraception and abortion are legal (34). However, the majority of the
participants mentioned that they had unwanted pregnancies that ended by experiencing
single motherhood. According to Bellizzi et al. (98), unwanted pregnancies in low and middle
income countries are related to underuse of modern contraceptives methods which
disproportionally affect poor and low educated women. Nevertheless, it is hard to disentangle
the exact links between the socio-economic marginalization and the unwanted pregnancies
experienced by the majority of the participants. Single motherhood also led to reinforcing the
marginalization of single mothers namely through the loss of social support and the burden
childbearing as mentioned by the participants.
Gender regime and gender order intertwine to frame the negative symbolic image of single
mothers in the society. This image is constructed by the patriarchal gender order that
considered extramarital sex as a taboo and reinforced by the penalization of extramarital
cohabitation (46). Socio-cultural norms connected to religious beliefs play a determinant role
in constructing the symbolic image of single mothers through the concept of "Haram"
frequently mentioned by the participants when they refer to their out of wedlock pregnancy.
The concept of "Haram" means prohibited or forbidden by the religion. It is a "law tattooed
in mind" and manifested on the daily life to restrict some attitudes and behaviors (99). The
symbolic image of single mothers was mirrored in the social stigmatization and
discrimination experienced by the participants who were perceived as immoral and
mischievous by the society.
The social stigmatization and discrimination are also embedded in the public institutions. In
the hospitals for example there are specific and exposed offices to receive single mothers by
the social assistants without measures to secure the women's privacy. Moreover, receiving a
single mother to deliver in the hospital implies that the social assistant has to automatically
inform the police so they can launch their inquiry to determine the identity of the father. This
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represent a source of fear for many single mothers while accessing to maternal health care
services (34). These different measures taken by the state to address single motherhood
contributed in the "institutionalization" of the discrimination and stigmatization of single
mothers in Tunisia. It also led to the emergence of "structural stigmatization" against them.
Structural stigmatization is defined by the incorporation of stigma in the public institutions,
regulations and policies (100,101).
Furthermore, constructing single mothers as irresponsible mothers led to the emergence of

paternalistic approach within the public sector in dealing with single mothers as reflected in
some participants' experiences.
Health system disciplines the single mothers: maintaining and

contesting the trilogy of vulnerability
This study shows that violence, discriminatory practices and moralistic attitudes are
repressive practices used by the maternal health care providers to discipline single mothers
from a moral perspective. Moral prejudices are stated as one of the drivers of abusive care
during childbirth, especially in low and middle income countries (51,79,83). Thereby, health
workers are "social actors" contribute in sustaining the ruling social and moral norms in the
society (102). Based on our theoretical framework, it seems that the maternal health care
providers had incorporated the gendered symbolic image of single mothers in Tunisia as
"immoral" and "deviant" that deserve to be punished and reproduced it in their hostile
emotions and attitudes towards the participants.
Browser and Hill (79) stated that abusive practices experienced by women during the
childbirth are mainly due to unequal power relations between the women and the maternal
health care providers. Gender plays a predominant role in constructing these power relations.
Gendered power relations are not only reflected on the moral prejudices towards women but
also on the process of medicalization of childbirth itself. The medicalization of childbirth is
accused of disempowering women during the delivery by considering their bodies as "soulless
objects". These "soulless objects" are subjected to "a machinery of power" to repair them and
to generate usable "docile bodies" (76,103,104). During this process, maternal health care
providers are placed in authorized positions that enable them to restrict women's agency and
to control their bodies (102,104). In this context, violence and neglect can be regularly used
by the maternal health care providers to punish certain women's attitudes considered a
menace to their authority such as resisting or not adhering to their instructions
(80,80,83,102,105). Some of the rough attitudes such as shouting at the mother can be
integrated in the obstetric training which can lead to the "normalization" of abuse (79,83).
Cindoglu and Sayan-Cengiz (76) asserted that the medicalization of childbirth as a modern
process can also incorporate the patriarchal norms and reproduce them in a modernized
form to take control over women's bodies and sexuality. Our study is an example of how the
patriarchal norms were embedded in the health system and reflected in the abusive practices
faced by the single mothers during the childbirth.
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 (79). Women's social class can affect health care providers attitudes. Poor
women and low educated women are more likely to be subjected to abusive treatment during
childbirth (79,83,106). Health care providers might assume that low educated and poor
women or women coming from rural areas are unable to understand the medical
- 29 -
instructions, and thus to behave properly during the delivery. These assumptions can lead to
excessive use of coercive practices by the health care providers while attending these women
(76,79).
Taking into account our theoretical framework, 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. Their vulnerability especially their social stigmatization might be maintained and
reinforced by the health care providers' hostile attitudes during childbirth. However, not all
the participants were subjected to abuse or moral judgments during childbirth. This confirms
that women with the same social locations can experience social inequities differently which
engender diverse experiences (68). It also demonstrates that power relations are not fixed;
they can change and they can be resisted (61,67). Resistance emerged from the health system
itself and it involved certain maternal health care providers. These maternal health care
providers as "social actors" contributed in contesting the dominant social discourse
discriminating single mothers. Some resistance also emerged from the participants
themselves who tried sometimes to overcome their vulnerability in front of the health
workers.
Mannava et al. (51) argued that the practices of maternal health care providers are complex
phenomena determined not only by the health workers' characteristics and beliefs but also by
the context surrounding these practices. Poor working conditions, heavy work load, and
shortage in financial resources and equipment can lead to the demoralization and the
dissatisfaction of health workers. The dissatisfaction of health care providers can affect their
attitudes and contribute to the emergence of abusive and disrespectful care of women at the
health facilities (51,57,79,83,107). Some of these factors such as heavy work load and poor
equipments were also mentioned by the participants in this study. Women's abuse during
childbirth is considered as an aspect of the poor quality of maternal health care in many low
and middle income countries (56,108). It is exacerbated by the lack of accountability
mechanisms within the health system that can enable women to complain and to report
violations (57,79).
Abusive and disrespectful care during childbirth represents a human rights' violation; it is a
violation of women's right to dignified, respectful health care throughout pregnancy and
childbirth (54). It is also considered a form of violence against women linked to the
persistence of gender inequality in the society (78,83,105). Studies revealed that abusive care
during the childbirth can have adverse effects on women's health and wellbeing. It is linked
to distress, poor-self rated health, posttraumatic stress disorder and sleeping disorders (109
111). It is also associated with maternal mortality and morbidity in low and middle income
countries (79,108,110). For example, neglect as a form of disrespectful care is related to some
preventable causes of maternal mortality such as hemorrhage (108). Moreover, while skilled
birth attendance is considered as an important factor in reducing maternal mortality in low
and middle income countries, abusive care represents one of the barriers to use maternal
health care services in these countries as it contributes in reducing women's trust towards the
health system (31,56,57,78,83,107,112,113).
The social construction of the single mothers' self-perceptions

The participants' self-perceptions are multifaceted: they are overwhelmed and ashamed
mothers; and they are also challenging and strong mothers. The participants' self-perceptions
- 30 -
are strongly marked by the negative image of single mothers in the society. Stigma and
discrimination can affect people in different ways including "internalizing stigma".
"Internalizing stigma" refers to the mechanism of incorporating stigma in the self-
perception of the stigmatized person. The internalization of stigma can manifest in different
forms: low-self-esteem, self-blame, rejecting identity and negative attitudes towards other
stigmatized persons (100,114,115). The internalization of stigma might explain some aspects
of the participants' self-perceptions such as internalizing guilt, rejecting the single
motherhood identity and stigmatizing other single mothers.
Link and Phelan (101) asserted that the acceptance of the negative stereotypes by the
stigmatized people can reduce their ability to resist their discrimination. Hence, the
acceptance of stigma by some participants might contribute in restricting their ability to
challenge the discriminatory practices of the maternal health care providers and their social
stigmatization in general. The participants' feeling of guilt can also be explained by their
sense of failure to comply with the normative image of motherhood in Tunisia. The feeling of
guilt might be reinforced during childbirth by the moralistic attitudes of maternal health care
providers that can represent a feature of "the politics of guilt" (7). Longhurst et al. (7) stated
that "the politics of guilt" that includes how the feeling of guilt is constructed and how it
affects single mothers can contribute in sustaining "gendered" stereotypes and ideals about
motherhood.
The participants did not only expressed feeling of guilt, shame and loneliness, but they also
expressed positive feelings of strength and determination. Probyn (116) argued that the
feeling of shame can induce a process of rethinking one's self which can lead to new attitudes.
This might explain the participants' insistence to overcome their vulnerability and to affirm
themselves through assuming their responsibilities as mothers and also through their
determination to find a job. Oliver (117) pointed out that motherhood can be a "creative
project" that encompasses defying the traditional assumptions about mothering. As part of
discussing the complexity of the choice to be a mother, the author agrees with Lundquist
(118) statement that the process of passing from unwanted pregnancy to wanted pregnancy
reflects some kind of "reproductive freedom". In this sense, the participants' choice to keep
their children despite the different difficulties encountered can also be regarded as a form of
challenging the hegemonic ideals about motherhood in the society.
As part of describing their situation as single mothers, some participants mentioned that they
felt stressed and tired because of their situation as single mothers. Longhurst et al. (7)
asserted that "emotions and affects, (...) are enacted but they are also visceral, embodied
and emplaced through daily practices". The experiences of stigma, discrimination, isolation
and guilt might be embodied by the participants and displayed in their relation to their
bodies. A study conducted to explore the associations between self-assessed health,
motherhood types and gender inequality in 32 countries revealed that lone mothers including
single mothers in Tunisia reported one of the highest levels (odds) of poor self-reported
health compared to other lone mothers. Other studies related lack of social support
experienced by single mothers to poor self-rated health and to reporting depressive
symptoms especially among women suffering from financial hardship (119,120).
Furthermore, studies showed that perceived discrimination which means feeling targeting by
discriminatory practices is one of the determinants of poor self-rated health (121,122).
Perceived discrimination has also negative effects on mental health outcomes including
depressive symptoms, psychological distress and anxiety (123). A study conducted to assess
- 31 -
the effect of perceived discrimination on health when taking into account self-blame revealed
that people who experience discrimination often tend to blame themselves for their
mistreatment. It also showed that both perceived discrimination and self-blame have
negative effects on health including reporting symptoms of poor physical health, anxiety and
depression (124).
We conclude that the model presented in this study could have captured some of the
interconnections between the different themes. While the role of the trilogy of vulnerability
in framing the childbirth experiences and the self-perceptions of single mothers is relatively
clear according to our theoretical framework, the other connections between the themes
need further investigation. More research is also needed to investigate the embodiment of
different adverse emotions and experiences including stigma, guilt, rejection and
discrimination by single mothers.
- 32 -
Methodological considerations
Reflexivity
My pre-understanding of the research topic was based on my overall life experience as a
woman living in Tunisia, on several work published by non-governmental organizations
related to the experiences of single mothers in my country, and on my previous thesis.
Throughout the data collection and the coding processes, I tried to put my pre-understanding
"between brackets" (125). Nevertheless, this was challenging for me as it was my first
experience to conduct a qualitative study.
During the research process, my position oscillates between being an outsider and an insider.
In the data collection, I was an outsider as I am not working in the organizations where the
research was conducted. Moreover, I am not a single mother and I did not experience the
socio-economic marginalization experienced by the participants. This might create a form of
hierarchical relationship with the participants during the interviews which might affect their
responses. However, my position as an outsider allowed some participants to disclose
information that they were not open to reveal to other people including the organizations'
employees. During the analysis process, I might be considered as an insider as I share the
same socio-cultural background with the participants.
My supervisor understanding on the topic was based on her previous researches on women's
reproductive health and rights in different settings including Africa. It is also marked by her
research on the adolescent pregnancy in the Amazon Basin of Ecuador (25). Single
motherhood and adolescence pregnancy share several similarities. Both phenomena reflect
the negative effect of gender inequities on women maternal health in low and middle-income
countries. The choice of the theoretical framework was driven by our beliefs that gender
equity, health as a human right and social justice are inextricably linked. Other researchers
might address the research topic differently. They could also highlighted different results
with the same data.
Trustworthiness
Trustworthiness means that the results of the study worth believing (88). Several measures
were taken in this study to ensure the trustworthiness. These measures were based on the
four criteria to assess the trustworthiness of qualitative study stated by Dahlgren et al. (88).
These criteria are: "credibility", "transferability", "dependability" and "confirmability".
However, these measures were restricted by different challenges encountered during the data
collection and the data analysis. These challenges led to several limitations in the study.
Measures to ensure the trustworthiness
The first criteria to assess the trustworthiness is "credibility" of the study. This criteria judges
the "true value" of the study which reflects its ability to apprehend the different realities in
the phenomenon studied (88). "Triangulation" was used in this study to enhance the
credibility through involving both the student and the supervisor in the research process. My
supervisor was involved in the different stages of designing the study protocol and analyzing
the data. The data analysis process including the development of the model was carried out
through a continuous discussions between us. In this process, I can be considered as
relatively insider because I shared the same socio-cultural background with the participants.
My supervisor is considered as an outsider as she has a Western/European background.
- 33 -
The second criteria to assess the trustworthiness is "transferability". Transferability judges
the applicability of the study findings in different contexts and with different subjects (88).
To strengthen the transferability of the study, a description of the context of the study was
provided including a description of the study setting, the overall socio-economic context in
Tunisia with focusing on gender inequality, and the situation of single mothers in general.
According to Morrow (126) measures to enhance the transferability include also a detailed
description of the research process, the characteristics of the participants and the researcher.
This study tried to fulfill these measures.
The third criteria stated by Dahlgren et al. (88) is "dependability". Dependability is defined
by the ability of the study to account for different changing conditions in the research design.
Dependability assesses the consistency of the study. To enhance dependability, the study
adopted an emergent design throughout the research process. The aims of the study were
reevaluated after the data collection. During the interviews, the participants focused more on
their childbirth experiences which was reflected in the final aim stated. Additionally, during
the data collection, it was clear that the childbirth experiences of single mothers cannot be
understood without exploring the contextual/intersectional factors shaping these
experiences. Hence, more attention was paid to these factors during the analysis which was
reflected in the study findings.
The last criteria is "confirmability" which refers to the ability of the study to ensure the
neutrality in the data. In qualitative studies, we do not pretend to be neutral, we state our
position and we try to let the data talk for itself. In this study, I have tried to make clear my
stand point while reflecting on my position. The study used an inductive approach to develop
the codes which entailed putting the pre-understanding of the phenomena studied "between
brackets" (125). To stay close to the data during the coding process, the transcripts were
coded line by line with using some in-vivo codes (127). 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 and strengths
This study has several limitations. Despite the richness of the data, due to time constraints, I
cannot claim that I reached saturation, and I cannot claim that the study captured the
multiple realities of the childbirth experiences of single mothers in Tunisia. Moreover, only
women who benefited from the organizations' services were involved in the study. The
participants in this study might be considered as better off compared to other single mothers
in Tunisia as they benefited from the organizations' support. This might have an impact on
the signs of resistance expressed by the participants in this study. Despite the limited
duration of some interviews, all the interviews were included in this study regardless of their
duration. The decision to include all the interviews was based on an ethical consideration as
the participants signed an informed consent; and on a scientific consideration as all the
interviewees contributed in providing relevant information related to the aims of the study.
We also included all the women regardless of the date of the birth because the women
provided a detailed description of their childbirth experiences regardless of the dates of the
delivery. This might be explained by MacLellan (53) statement that women are able to recall
negative childbirth experiences even after decades.
As part of the data analysis process, the transcripts were translated from Arabic to English.
While this process facilitated the involvement of the supervisor in the analysis. It also
- 34 -
contributed in losing some information due the translation limits. The translation might
reduce the trustworthiness of the study. Finally, the women's perceptions of maternal health
care can be influenced not only by the quality of care received but also by their expectations
of care (55,56). While this study tried to encompass different aspects of single mothers'
childbirth experiences, the participants' expectations of the quality of maternal care were not
explored.
Despite its limitations, this study can have some strengths. This study tried to bring the
voices of a marginalized group of women in the Tunisian society, and to explore their
experiences regarding access to adequate maternal health services during childbirth. The
childbirth experiences of single mothers in Tunisia were not explored before. Moreover, in
this study, we tried to combine the gender relational theory and the intersectional approach
in the data analysis. Combining the two approaches might allow us to gain a deeper
understanding of how gender relations as interconnected with other forms of power relations
can be incorporated by the health system and reflected in the practices of the health care
providers towards single mothers.
Two recently published papers discussed the use of gender analysis and intersectional
approach in health research. Morgan et al. (128) highlighted the importance of using gender
analysis in health system research to generate evidence for equitable health interventions.
The authors argued that gender relations can be embedded in the health system and affect its
different components including services delivery. The authors suggested some areas of
interests that can be addressed while performing gender analysis in health system research.
For example, they suggested examining how gender affect people's interactions with the
health system including access and utilization of health services with focusing on the most
marginalized groups in the society. Moreover, Larson et al. (129) argued that intersectional
approach can allow the researchers to explore health inequities from a new perspective by
considering the different "social stratifiers" as interlocked and mutually constructed. The
authors stated that the interest on intersectional approach in health research has grown
globally since 2009. However, among 86 published papers only 14 papers were related to low
and middle income countries. The authors called for more applications of intersectional
approach in research on health systems and health inequities in low and middle countries.
We claim that the finding of this study can be applied to other contexts in low and middle
income countries in general and MENA region more specifically. In these contexts, single
mothers might share similar burden of social stigmatization and socio-economic
marginalization which can expose them to abusive practices during childbirth at the public
health care facilities. This burden can also alter their self-perceptions as mothers.
- 35 -
Implications of the study
Some implications for further research and for practice in public health regarding women's
right to dignified, respectful care during childbirth emerge from this study.
Implications for further research

Maternal health care providers' practices are considered as an important element of the
quality of maternal care and a determinant of women's maternal health (56,78,130). Kendal
and Langer (131) stated that the attitudes of maternal health care in low and middle income
countries are considered as one of the areas of the research that had received limited
attention before the post-2015 development agenda. The authors argued that exploring this
area can contribute in producing evidence necessary to improve the quality of maternal care
reduce maternal mortality and morbidity in these countries. This study focuses on one the
most marginalized group in the society. Further research are needed to explore the practices
of maternal health care providers in Tunisia and in other low and middle-income countries
towards different groups of women. Both qualitative and quantitative researches are needed
to assess the burden of the abusive care and to gain an insight to different experiences of the
women during childbirth. Exploring the maternal health care providers' perceptions and
experiences is equally important to address this issue.
Implications for practice

Ensuring women's right to dignified, respectful health care throughout pregnancy and
childbirth requires comprehensive policies to improve the quality of maternal care services
and to place human rights in the core of care practices (57). Both women as service users and
health workers as service providers should be involved in creating and implementing these
policies with special focus on marginalized groups (83). Worldwide, Different initiative were
taken to ensure women's right to dignified care including providing humanized care and
calling for applying the ethic of care in midwifery (53,79,112). These initiatives are part of
patient-centered care approach.
The humanized care was applied in some countries such as Brazil and Benin; and it is based
on the respect of women's dignity and freedom of choice. The humanized care approach
includes improving the communication between the maternal health care providers and the
women during the childbirth, using evidence based techniques and avoiding unnecessary
medical interventions during the childbirth (unnecessary cesarean surgery or episiotomy). A
core of component of humanized care is empowering women during childbirth by providing
adequate information during the antenatal care, and enabling women to make the choice
about care providers and the position during the delivery. This approach was perceived as
beneficial for the women as it reduces abusive care and it increases women's satisfaction. It is
also beneficial for the maternal health care providers as it enhances their motivation and
empowerment (79,112).
Reforming the training of maternal health care is also crucial to avoid disrespectful and
discriminatory practices during childbirth. This reform can include integrating human rights
and sexual and reproductive health and rights in the training on maternal health care
providers (79,83). Ensuring women's right to dignified care also requires allocating adequate
human and financial resources to maternal health (83). Strengthening the accountability
mechanisms and encouraging women to report violations with special focus on the most
- 36 -
vulnerable and marginalized groups can also contribute in reducing abusive practices within
the public health system (79,83,105).
This study demonstrated that women's childbirth experiences can be shaped by different
intersectional factors that go beyond the health system. Ensuring women's right to dignified,
respectful care during the childbirth also requires tackling the root causes of women's
marginalization and discrimination in many settings when women face the contingency of
multiple social inequalities. In Tunisia, the alarming situation of single mothers requires
urgent measures from the state to support these women, to enhance their integration in the
society and primarily to end the institutional discrimination against them. Relying on the
non-governmental organizations services are insufficient to improve single mothers'
situation. While facing the social stigmatization and discrimination seems to be a long term
goal that requires engagement from different components of the society, empowering single
mothers' through access to education, training and economic opportunities can be a key
stone to achieve this goal.
- 37 -
Conclusion
Childbirth experiences of single mothers in Tunisia are shaped by intersectional factors that
surpass the health system. The participants in this study were subjected to discriminatory
practices, neglect and even violence inflicted by the maternal health care providers. These
experiences demonstrate how the health system can incorporate stigma and discrimination
culturally associated with single motherhood in this setting, and reproduce them in the
practices of the maternal health care providers. The participants' childbirth experiences are
also related to their self-perceptions as single mothers. Both participants' self-perceptions
and childbirth experiences as single mothers reflect the multiple social inequities undergone
by these women in Tunisia.
The study findings also suggest that abusive care during the childbirth is a public health issue
that needs greater efforts in research to explore and document different forms of violations
experienced by women at the health care facilities as stated by WHO (54). It is a violation of
women's reproductive and sexual rights that can undermine women's health and wellbeing. It
also represents an aspect of health inequities affecting disproportionally vulnerable groups of
women in the society. Addressing abusive care during the childbirth should be linked to the
global efforts to reduce maternal mortality and morbidity.
The study highlights some sings of resistance that emerged from the health system itself that
involved some maternal health providers, and from some participants who tried to overcome
their vulnerability to consent abusive care. These signs of resistance could be strengthen by
empowering both health workers as services providers and women as service users during
childbirth. Thus, ensuring women's right to dignified, respectful care throughout pregnancy
and childbirth requires efficient and human-right based strategies to improve the quality
maternal health care services. It also requires tackling the underlying causes of women's
marginalization and disempowerment.
Finally, this study highlights the importance of combing the gender relational theory and the
intersectional approach to explore women's health experiences. Gender has a determinant
role in constructing women's health experiences. However, a single-gender lens can be
insufficient to probe the complex and multidimensional aspects of these experiences.
- 38 -
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Appendices
Appendix 1: Informed consent (English version)
Ume University
Department of Public Health and Clinical Medicine, 2015-12-04
Epidemiology and Global Health
901 87 Ume
We would like to invite you to participate as an informant in a study on the experiences of

single mothers in contact with maternal health care services in Tunisia. The questions that
will be asked are related to the experiences of single mothers using maternal health services
in Tunisia, the attitudes of health workers towards single mothers, the barriers faced by these
women in accessing adequate maternal health services and the perception of single
motherhood among the participants. The study is done as a thesis in the Master's program in
Public Health at Ume University.
Data collection for this qualitative study will be done through semi-structured interviews.
Each interview is expected to take approximately 60 minutes and will be recorded to enable
transcription. Only the interviewer, myself, will have access to the recorded interview and it
will be deleted when transcribed. The interview is confidential, which means that your
identity and the information you provide will not be traceable in the finished work.
Participation is voluntary and you can always cancel your participation without specifying the
reasons. You can also refuse to answer certain questions. No compensation will be given for
your participation. You will be able to take part of the finished work if you so wish.
You are welcome to contact me or my supervisor if issues arise.
Sincerely:
Nada Amroussia
Student at Ume University

Department of Public Health and Clinical Medicine
amroussia.nada@hotmail.com 0046 730764807
Supervisor: Isabel Goicolea
Researcher, epidemiology and global health
090-786 54 66
I have read and understood the purpose of the study. I have been informed that the interview
will be confidential. I hereby give my consent to participate in the study.
__________________________________________________________
Name and signature participant
_________________________________________________________
Name and signature student
- 49 -
)Appendix 2: informed consent (Arabic version

,
.
00 .

. .
.
. . .
.
0040070004400 :
0046 907 864 699:
- 50 -
Appendix 3: Thematic and interview guides
Thematic guide
1. The experiences of single mothers with maternal health services in Tunisia

2. The participants perceptions in regard to the attitudes of health workers towards
single mothers
3. The barriers faced by these women in accessing to adequate maternal health services
4. The perception of single motherhood among the participants
Interview guide
The interview will start by letting the participant presenting herself.
1. Could you please present yourself?

2. When did you have your last child? Where did you have your last child?
3. Could you please tell me about your delivery experience of delivery experience?
4. Did you benefit from pre-natal care services? Could you please describe your first
contact with the maternal care services?
5. Did you benefit from post-natal care services? How do you think about these services?
6. Did you face any difficulty in accessing to maternal health services? Could you please
tell us more about these difficulties?
7. What do you think about the health workers attitudes?
8. How do you feel about your overall experience in contact with maternal health
services?
9. How you do you feel about being single mother in Tunisia?
10. (How do you think it influences maternal health services?)
- 51 -
)Appendix 4: Interview guide (Arabic version
- /
- /
)- (
- 52 -
Appendix 5: Table illustrating the 10 groups formed during the
analysis
Group Sub-group Examples of codes

1. violence Physical violence towards single Having marks of violence
mothers Being beaten by the health staff
Being subjected to physical violence
Feeling hurt
Psychological and verbal Insulting the woman
violence Using swear words
Threatening the patient
Name calling
Shouting at the patient
Violating the patient's privacy
Feeling offended
Common attitudes Normalizing doctor's violence
Justifying violence
Considering toughness as a normal
attitude
Not targeting single mothers
2.Stigmatization and moral Feeling humiliated
judgments Feeling disregarded
Feeling not respected
Judging the single mother
Accusing single mother of committing a
sin
Looking differently to single mothers
3. Neglect and low quality of Neglect and lack of Neglecting the single mother during the
maternal health services responsiveness labor
Not asking for patient's consent
Arrogant attitudes of health workers
Ignoring the patient
Neglecting the baby
Not taking care of the patient's
wellbeing
Not being responsive
Unsatisfying services Ineffective communication with the
patient
Lack of equipment
Suffering from hunger
Feeling cold after the delivery
Dirty place
Suffering for surgery complications
Bad quality of the sutures
4. Corruption Giving bribery
Stealing the baby
"Contacts are important"
- 53 -
5. Not all health professionals Being nice to the patient
(workers) are bad! Comforting the patient
Taking care of the baby
Trying to relieve patient's pain
Being treated with dignity
Feeling grateful
Having a nice delivery experience
6. Buffering resources Benefitting from social assistance

Religious beliefs
Appreciating the role of the
organizations
Seeking refuge in the organization
7. Self-perception of single Being a single mother is a Being a single mother is a mistake
motherhood mistake! Admitting committing a mistake
Feeling ashamed
Having out of wedlock pregnancy is
forbidden by the religion
Acceptance of single The single mother is special
motherhood (status) "Sweet experience"
Refusal of single motherhood "I don't feel that I am a single mother"
(status)
8.Social and economic Being homeless
marginalization Being unemployed
Being underprivileged Lacking awareness
(background) Experiencing forced marriage
Experiencing domestic violence
9. being single mother is a "A tough experience"

burden Struggling as a single mother "single mother suffers"
Struggling to afford necessities
Feeling forced to leave her child
Feeling desperate and helpless
Feeling worried about the future
Loneliness, rejection Taking advantages of single mothers

and Isolation Facing social stigmatization
Feeling lonely
Being rejected by the family
Facing insolence
Not enjoying their rights
Being abandoned by the partner
10.Single motherhood is a Feeling attached to her baby

daily challenge Assuming responsibility
Challenging the social norms
Working to prove herself
Surviving requires will and strength
- 54 -
Appendix 6: Conceptual map with 5 preliminary themes
- 55 -

Thesis+2016 - Nada Amroussia

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"Is the doctor God to punish

Author: Nada Amroussia

Supervisor/s: Isabel Goicolea

Nr: XXX/Spring 2016

Introduction: Worldwide, single mothers are considered a vulnerable group in the

Methods: The thesis follows a qualitative design. In collaboration with non-governmental

Abstract ................................................................................................................................... iii

List of maps, figures and tables ........................................................................................ vi

Abbreviation list .................................................................................................................. vii

A global overview of single mothers and health .................................................................... 1

Single mothers in Tunisia ...................................................................................................... 2

Rationale of the study ............................................................................................................ 3

Aims of the study .................................................................................................................... 4

Theoretical framework ........................................................................................................ 5

Gender relational theory and women's health ....................................................................... 5

Intersectional approach and women's health ........................................................................ 6

Health system disciplines single mothers ............................................................................ 14

The trilogy of vulnerability ................................................................................................... 23

Description of the model ...................................................................................................... 26

Single mothers' social locations as underprivileged ............................................................ 28

The social construction of the single mothers' self-perceptions .......................................... 30

Implications of the study ................................................................................................... 36

Implications for practice ...................................................................................................... 36

Appendix 1: Informed consent (English version) ................................................................ 49

Appendix 2: informed consent (Arabic version) .................................................................. 50

Appendix 3: Thematic and interview guides .........................................................................51

Appendix 4: Interview guide (Arabic version) ..................................................................... 52

Appendix 6: Conceptual map with 5 preliminary themes ................................................... 55

Figure 1 :Data analysis from codes to final themes.................................................................. 12

Figure 2: Model-Childbirth experiences and self-perceptions of single mothers in Tunisia .. 26

Table 1:Background characteristics of the single mothers interviewed ................................... 10

MMR: Maternal Mortality Rate

MDG 5: Millennium Development Goal 5

GDP: Gross Domestic Product

CEDAW: Convention of Elimination of All Forms of Discrimination against Women

WHO: World Health Organization

A global overview of single mothers and health

Single mothers in Tunisia

Taboos surrounding premarital and extramarital sexual relationships and deep-rooted

Rationale of the study

Women's perceptions of childbirth experiences are subjective, and can be influenced by

Women's perceptions of their childbirth experiences are also influenced by women's

Aims of the study

- Explore the self-perceptions of the participants as single mothers.

Gender relational theory and women's health

Gender as a social structure and as a form of social embodiment is constantly shaping

Intersectional approach and women's health

Use of the gender relational theory and the intersectional approach

Table 1:Background characteristics of the single mothers interviewed

Interview Participant Age Educational level Employment Place of the Date of

3 Sawsen 40 4th grade Unemployed University teaching - 2006

8 Sahar 22 2nd grade Unemployed Regional hospital, 2015

Text (translated transcripts) Codes Subtheme Final theme

Health system disciplines single mothers

Neglecting and discriminating single mothers

In addition to feeling neglected, many participants mentioned feeling stigmatized by the

"In the hospital...the nurses are arrogant".

Violence towards single mothers

Not all health workers are bad!

From detachment to attachment

"Now...my girl is the most important person in my life".

Single motherhood: a burden and a daily challenge

According to the participants, single motherhood is a multifaceted experience. As part of