The impact of obstetric violence on postpartum quality of life through psychological pathways

Table of Contents

Procedure and participants

The current cross-sectional study was carried out on 385 mothers who gave birth from January to May 2022 using a convenience sampling method.

The protocol of this study was approved by the ethics committee of Isfahan University of Medical Sciences (IR.MUI.NUREMA.REC.1401.039). After explaining the study aims, written consent and verbal assent were obtained from all participants, and they all ensured that their participation was voluntary, confidential, and anonymous.

The inclusion criteria were as follows: (a) Iranian nationality (b) passing 4 to 6 weeks after childbirth, (c) not having problems in speaking, listening, and writing in Persian, (d) not using psychiatric medications according to self-report, (e) a healthy baby, born on time and without any abnormalities, (f) Not having a recent stressful event such as divorce, death of family, and (g) willingness to participate in the study. We also excluded the women who were admitted to the hospital after childbirth and those who had their babies admitted to the hospital in those 4–6 weeks.

Measures

Demographic and reproductive data

First, a checklist of sociodemographic and obstetric questions including women’s age (years), type of childbirth (vaginal, caesarean section), educational level (Primary school, Secondary school, Diploma, University) gravidity (number), parity (number), occupation (housewife, employed), residency (rural, urban), having planned or unplanned pregnancy.

Postpartum quality of life (PQOL)

The PQOL questionnaire was developed by Zhou et al. for assessing postpartum quality of life. This scale consists of 40 questions and 4 main dimension: child care (questions 1–8), physical function (questions 20–9), psychological function (questions 21–28), and social support (questions 29–40). Participants will answer each question on a five-point Likert scale from 0 to 4. The total score ranges from 0 to 160, with higher scores reflecting better conditions. The validity and reliability of this scale have been confirmed in the Iranian population¹⁸. Cronbach’s alpha coefficient indicated good overall internal consistency (0.88) and by dimensions: child care (0.70), physical function (0.78), psychological function (0.71), and social support (0.70).

Self-esteem

The Rosenberg Self-Esteem Scale was used for assessing Women’s self-esteem. This scale consists of 10 statements about overall feelings of self-worth or self-acceptance, to which participants respond on a 5-point Likert scale (ranging from 1 = “strongly disagree” to 5 = “strongly agree”). Higher scores represent high self-esteem. This questionnaire has good validity and reliability among the Iranian population (internal consistency = 0.83)¹⁹.

EPREVO (experiencias de parto relacionadas a violencia obstétrica)

This instrument was developed by Kirsten Falcon et al. in Ecuador to determine the criteria for obstetric violence²⁰. This scale contains 35 questions and is scored on a two-level scale (yes = 1, and no = 0). After adaptation, 4 questions were excluded from the questionnaire due to cultural issues. The total score was between 0 and 31, and a higher score indicates higher obstetric violence. First, to check the validity and reliability, after obtaining the consent of the instrument designer, the questionnaire was translated into Farsi. To check content validity and face validity, the questionnaire was given to 15 faculty members of the midwifery department, experts’ opinions were received qualitatively, and suggested changes were applied to the questionnaire. The questionnaire was provided to 20 mothers, and the face validity of the scale was also checked from their perspective. The reliability of the tool was determined by the test-retest method and the internal consistency was evaluated with Kuder-Richardson value. In our study, this value was equal to 0.80, which indicated good internal consistency. The details of validity and reliability were reported in another paper, that is under review.

Post-traumatic stress disorder (PTSD)

The Post-traumatic Stress Disorder Checklist (PCL-5) is a 20-item self-report questionnaire based on DSM-5 diagnostic criteria for assessing the severity of PTSD symptoms over the past month. This scale contains four subscales: re-experiencing (items 1–5), avoidance (items 6–7), negative alterations in cognition/mood (items 8–14), and alterations in arousal and reactivity (items 15–20). The respondent rated each question on a 5-point Likert scale from 0 (not at all) to 4 (extremely), and the final score is normally between 0 and 80. The validity and reliability of this questionnaire are well documented (Cronbach’s α = 0.92)²¹.

Depression, anxiety, and stress scale-21 (DASS-21)

For detecting and classifying negative emotional states, the short form of the Depression, Anxiety, and Stress Scale-21 (DASS-21) questionnaire was used. This scale contains 21 questions and consists of three subscales including stress, anxiety, and depression with seven questions for each domain. Each question was rated on a 4-point Likert-type scale (0 = did not apply to me to 3 = applied to me very much), and the total score for each domain was calculated by doubling the initial sum of the scales. The total score was calculated by adding the three domain scores, with higher scores indicating negative emotional states. The validity, and reliability of this questionnaire was approved for the Iranian population (Cronbach’s α = 0.94)²².

Data analysis

Path analysis was used to assess the predictive effects of independent variables on postpartum quality of life. This method is applied to assess how much of the total effects of independent variables on the dependent variables occur directly or indirectly. Also, this method determines and tests the causal relationship between included variables.

For running the path model, the normality assumption of quantitative data was approved using the Shapiro test. The Pearson correlation test was used for evaluating the correlation between variables, and a p-value more than 0.05 considered as normal distribution of data.

Based on the previous similar articles, a conceptual model (Fig. 1) was designed, and included variables in the path diagram, and defined relationships between variables were based on the logical and theoretical analyses. In this conceptual model, we considered obstetric violence as the only independent predictor, postpartum quality of life as a dependent variable, as well as other variables as mediators.

Path analysis was performed using LISREL software ver.8.8 to test the specified pattern of causal relationships between variables. The acceptable model was determined after checking of Goodness of Fit test. The Root means a square error of approximation (RMSEA), Adjusted Goodness of Fit Index (AGFI), Confirmatory Factor Analytic (CFI), and Chi-square/df (Degree of Freedom) was used for evaluating the model fitness. RMSEA values less than 0.08, Chi-square/df lower than 3, AGFI more than 90, and CFI more than 0.95 indicate a good fitting model. T-values more than + 2 or less than − 2 were considered statistically significant²³.

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