Minckas, Nicole; (2023) Experience matters: women's experience of care during facility-based childbirth. A mixed-methods study on postpartum outcomes. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Background: The poor treatment women are receiving during facility-based childbirth is an escalating global issue with potentially adverse postnatal consequences. My thesis aims to enhance understanding of these consequences, with a focus on postnatal care-seeking behaviour, maternal mental health and breastfeeding patterns in Tucumán, Argentina. / Objective: I sought to investigate the impact of mistreatment during childbirth (MDC) on postnatal outcomes and explore the influence of individual, interpersonal and societal factors on this relationship. / Methods: Employing a pragmatic epistemological framework, I adopted a mixed-methods approach. First, a systematic review of existing literature on mistreatment and its postnatal effects provided a comprehensive foundation for my research. Subsequently, I conducted semi-structured interviews and focus group discussions with women from an underserved community in Tucumán to gain qualitative insights. To complement this, I carried out a prospective cohort study with women who delivered in a public maternity hospital. Data analysis involved using the capability, opportunity, motivation, and behaviour (COM-B) model, directed acyclic graphs, and factor analysis to examine behavioural impacts, association pathways, and operationalisation of MDC. Multivariable models were applied to measure the association between MDC and postnatal outcomes. / Results: The study revealed that MDC should not be operationalised as a single construct, as women perceive breaches of quality of care differently from direct physical or verbal abuse. Health literacy, social support and self-esteem were identified as psychosocial confounders in the relationship between mistreatment and postnatal outcomes. Only 26% of women in the cohort study in Tucumán accessed postnatal care, with incidences of postpartum depression and anxiety of 67% and 21%, respectively. No statistically significant association was found between MDC and care seeking behaviour, although a possible trend emerged suggesting the women experiencing physical or verbal MDC could be more likely to seek care than those who were not mistreated. / Conclusion: Several exploratory hypotheses are presented to explain the trend suggesting that women who are verbally or physically mistreated are more prone to seek care after birth. Additionally, three concrete contributions emerged from this work: 1) the need to differentiate the conceptualisation of MDC from its operationalisation when assessing postnatal effects; 2) the importance of integrating psychosocial factors into the theory of change when designing effective interventions, and 3) the urgency of enhancing postnatal care access to improve maternal and newborn health outcomes, regardless of women’s childbirth experiences.

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