Path analysis of the influence of obstetric violence on the postpartum quality of life: the mediating role of psychological factors Running title: obstetric violence and the postpartum quality of life

Path analysis of the influence of obstetric violence on the postpartum quality of life: the mediating role of psychological factors Running title: obstetric violence and the postpartum quality of life | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Path analysis of the influence of obstetric violence on the postpartum quality of life: the mediating role of psychological factors Running title: obstetric violence and the postpartum quality of life Shahnaz Kohan, Desirée Mena-Tudela, Samaneh Youseflu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3848180/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Pregnancy and childbirth as important events in women's lives should be guided based on quality and humanized principles. This study aimed to test a conceptual model considering the interrelated role of obstetric violence, mental health, self-esteem, and PTSD on the postpartum quality of life (PQOL) using path analysis. Methods This cross-sectional study was conducted on 385 parturient women who have given birth from January to May 2022 using the convenience sampling method. Data were collected using a socio-demographic checklist, EPREVO, DASS-21, PCL-5, Rosenberg Self-Esteem Scale, and PQOL scales. Path analysis was applied to generate specified patterns of causal relationships between variables and to determine the type of relationships between predictor and response variables using LISREL software ver.8.8. Results We found that obstetric violence (β= -0.659), self-esteem (β = 0.223), mental health (β= -0.396), and PTSD (β = 0.345) are the main predictors of postpartum QoL. In addition to its direct effect, obstetric violence can impress the PQOL through the effect on mental health (β = 0.0.533), self-esteem (β = 0.222), and PTSD (β = 0.229), indirectly. Conclusion Our finding highlighted the negative effect of obstetric violence on mental health, self-esteem, PTSD, and PQOL. Therefore, it is recommended that policymakers and managers adopt programs to promote respectful maternal care and prevent obstetric violence to prevent the occurrence of adverse effects in parturient women. obstetric violence PTSD self-esteem postpartum quality of life path analysis Figures Figure 1 Figure 2 Introduction Pregnancy and childbirth as important events in women's lives should be guided based on quality and humanized principles. The World Health Organization (WHO) emphasizes the quality of interaction between women and health care providers and considers good interactions as a prerequisite for favorable pregnancy and childbirth outcomes ( 1 ). Most maternal care programs mainly focus on physical safety, while childbirth is an important process with profound personal, emotional, psycological and cultural implications ( 2 , 3 ). Since motherhood is exclusive to the female universe, both gender equality and gender violence should be considered at the core of maternal care ( 2 ). In the care that women receive during childbirth, many of them experience some type of violence, which can manifest as physical, mental, inadequate clinical care, or violation of the principle of their autonomy ( 4 ). Some obstetric situations, such as multiple vaginal examinations, Kristeller's maneuver, episiotomy, cesarean section, and other medical interventions, such as the administration of oxytocin without medical indication, may be invisible forms of violence and human rights violations ( 5 , 6 ). WHO statement has highlighted the elimination of obstetric violence toward women during childbirth because it is in contrast with human rights principles and threatens their right to life, physical, mental and moral integrity, as well as freedom from discrimination ( 1 , 7 ). Despite WHO's emphasis on respectful maternity care, there is strong and growing evidence of the occurrence of disrespectful and violent acts against women in obstetric care facilities; therefore, between 40% and 67% of women in Spain, 31% in Mexico, and 91.7% in Adisababa have experienced obstetric violence ( 8 , 9 , 10 , 11 ), although the variability in these findings may be due to the different methodologies used to measure obstetric violence. The negative feelings caused by these concepts can have short- and long-term effects on physical, sexual, and mental health as well as mother-infant relationships ( 12 ). A high prevalence of postpartum depression, post-traumatic stress disorder (PTSD), failure to properly adapt to the maternal roles, breastfeeding problems and a decrease in the desire to have more children have been reported among those experiencing obstetric violence ( 13 , 14 , 15 ). When the health care provider humiliates, insults, or mistreats the mother, her confidence in infant caring decreases, so it can have a negative effect on their mental health, and quality of life ( 16 ). The birth experience itself can be a painful experience, but if an invisible violence is also imposed on them, it can turn it into a terrible process. This unpleasant experience can affect women's mental health and the quality of the mother-infant relationship ( 17 ). Regarding the importance of obstetric violence on the health of mother and child, this study aimed to test a conceptual model considering the interrelated role of obstetric violence, mental health, self-esteem, and PTSD on the postpartum quality of life (PQOL) using path analysis. Materials And Methods 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, term 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& 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 100, with higher scores reflecting better conditions. The validity and reliability of this scale have been confirmed in the Iranian population ( 18 ). 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 This instrument was developed by Kirsten Falcon et al. in Ecuador to determine the criteria for obstetric violence ( 20 ). 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 ( 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 ( 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 significant ( 23 ). Results Out of 385 women who took part in our study, 152 individuals (42.73%) were in the age group of 20 to 30 years, and 12.8% (n = 46) of them had less than 20 years old-age. The majority of participants (39.94%, n = 143) were primiparous, and 14.8% (n = 53) had more than 3 children. In terms of educational level, 46.6% (n = 74) of the participants had academic level education and about 74.2% (n = 259) of them were housewives. Moreover, 37.71% (n = 135) of pregnancies were unplanned, and 63.4% (n = 227) of women had a vaginal childbirth (Table 1 ). Table 1 Socio-demographic Characteristics of participants. Characteristic n (%) Age Less than 20 years 20–29 years 30–40 years More than 40 years 46(12.84) 152(42.73) 112(31.28) 48(13.41) Parity 1 2 3 More than 3 143(39.94) 84(23.46) 78(21.79) 53(14.80) Type of childbirth Caesarean Vaginal 131(36.59) 227(63.40) Education Primary school Secondary school Diploma University 34(9.50) 67(18.71) 183(51.12) 74(20.67) Occupation Housewife Employed 259(72.35) 99(27.65) Type of pregnancy Planed Unplanned 223(62.29) 135(37.71) Residency Urban Rural 227(65.64) 123(34.63) Table 2 shows the correlation between all variables included in the path analysis. Results showed that PQOL was associated with OV (r=-0.65, p < 0.001), self-esteem (r = 0.39, p < 0.001), PTSD (r=-0.48, p < 0.001), and mental health (r= -0.70, p < 0.001). Table 2 Correlations between obstetric violence, self-esteem, PTSD, DASS, and postpartum quality of life Variables 1 2 3 4 1. Postpartum Quality of Life - - - - 2. Obstetric violence -0.65* - - - 3. PTSD -0.48* 0.23* - - 4. Self-esteem 0.39* -0.22* -0.07 - 5. DASS-21 -0.70* 0.53* 0.36* -0.19* Values are given as Spearman coefficient (P-value) using Pearson correlation test. *p-value < 0.05 PTSD: Posttraumatic stress disorder; DASS-21: Depression, Anxiety, and Stress Scale-21 Based on the conceptual model, the overall goodness-of-fit statistics had perfectly good fitness indices (χ2 = 3.92; DF = 2; χ2 /DF = 1.96; RMSEA = 0.06; CFI = 0.98; GFI = 0.99) (Table 3 ). Table 3 The Goodness of Fit Indices for the Models. CFI* GFI٭٭ RMSEA٭٭٭ Chi-square df Chi-square/df٭٭٭٭ Path N = 385 0.99 0.99 0.06 3.922 2 1.96 *CFI: comparative fit index, ٭٭GFI: goodness fit index, ٭٭٭RMSEA: root mean square error of approximation, ٭٭٭٭Chi-square/df: chi-square to the degree of freedom index. We found that obstetric violence (β= -0.659), self-esteem (β = 0.223), mental health (β= -0.396), and PTSD (β = 0.345) are the main predictors of postpartum QoL. Among variables, obstetric violence had the strongest effect on women’s PQOL. In addition to its direct effect, obstetric violence can influence the PQOL through the effect on mental health (β = 0.0.533), self-esteem (β = 0.222), and PTSD (β = 0.229), indirectly. Mental health, self-esteem, and PTSD were considered mediators. Factors such as obstetric violence and PTSD with indirect effects on mental health can impair the quality of life (Table 4 & Fig. 2 ). Table 4 Path Coefficients for, obstetric violence, self-esteem, mental health, PTSD, and postpartum quality of life of Women during postpartum period. Direct effect* Indirect effect* Total effect* T-value Quality of life Obstetric violence -0.342 -0.317 -0.659 -16.58 Self –esteem 0.223 - 0.223 7.45 Mental health -0.396 - -0.396 -11.02 PTSD -0.245 -0.099 -0.345 -9.95 Mental health PTSD 0.250 - 0.250 5.689 Obstetric violence 0.590 -0.057 0.533 11.919 Self-esteem Obstetric violence -0.222 - -0.222 -4.309 PTSD Obstetric violence 0.229 - 0.229 4.46 Discussion In the current study, the causal relationship between theoretical and applied research topics was evaluated using the path analysis method. Our findings show that obstetric violence, self-esteem, mental health, and PTSD were significant predictors of postpartum quality of life. Among these variables, obstetric violence had the greatest effect on the quality of life after childbirth. Moreover, higher mental health disorders, PTSD, and impaired self-esteem were seen among women who experienced obstetric violence. Our findings are in line with Scandurra et al. study, which shows a significant correlation between mental health status measured using DASS-21, and obstetric violence ( 17 ). Moreover, Martinez-Vázquez et al. reported a higher level of depression among women who had experienced verbal or psycho-affective obstetric violence ( 24 ). The results of a cohort study showed that 18% of women who had mild or severe depression had experienced at least one type of violence and disrespect during childbirth, and physical violence was associated with an increased chance of severe depression ( 25 ). Beck considered factors such as poor communication between mothers and healthcare providers, disrespectful maternity care, loss of control, and autonomy, lack of empathy, privacy, and sense of security, insufficient information, as well as inattention to women’s feelings as psychological trauma ( 26 ). Other studies also link episiotomy and instrumental delivery to poor childbirth experience ( 27 ). Instrumental childbirth was not assessed in this study. This may need to be taken into account in future studies. Previous research showed that positive childbirth experiences, support, good care, physical comfort, and positive emotional experiences decreased acute stress and postpartum depression symptoms ( 28 ). Yeo et al. revealed that childbirth experiences and postpartum depression are the main predictors of women’s quality of life ( 29 ). More research is needed on how these factors are related and the effects they may have on women and their newborns. The way mothers communicate with health care providers is vitally important because these communications are not only a necessary tool to preserve the mother's life, but also women's experiences in these communications can strengthen their self-confidence and sense of comfort, or lead to lifelong psychological damage. In our study, a significant correlation was found between PTSD and obstetric violence. The experience of PTSD symptoms can impair their mental health and has a direct and indirect effect on PQOL. In this regard, Martinez-Vázquez et al. indicated that only verbal, and psycho-affective obstetric violence are associated with PTSD symptoms ( 30 ). Another Iranian study reported a higher PTSD among women who experienced disrespectful maternity care ( 31 ). A traumatic childbirth experience is mainly accompanied by helplessness, fear, and panic, and is subsequently related to a wide range of thoughts and feelings, including vivid memories, nightmares, flashbacks, and irritability, which can have a negative impact on women and their families ( 32 ). A previous study showed that PTSD symptoms have a worse effect on the quality of life during postpartum periods, and a respected birth plan was a protective factor against PTSD ( 33 ). Starting the care of your newborn with poor mental health is an added factor for poor maternal, infant and family outcomes, as well as an added risk factor for postpartum suicide ( 34 ). In our study, self-esteem was a main predictor of PQOL, that influenced by obstetric violence. Impaired self-esteem was seen among those experiencing obstetric violence. In this regard, Raudasoja et al. reported that the childbirth experience has a positive impact on a mother’s self-esteem ( 35 ). Negative emotions such as fear and embarrassment, low self-confidence, and decreased mother-infant bonding were seen following their separation; and a decrease in self-esteem, and autonomy was seen due to the failure to obtain informed consent .( 16 ) Strength and limitation: Whereas numerous studies have highlighted that obstetric violence, PTSD, self-esteem, and mental health contribute to PQOL independently.This study, for the first time, considered these factors in tandem. The main strength of this study is the combination of the assessed domains. The use of developed conceptual models (pathway diagrams) and validated questionnaires (e.g., EPREVO, PCL-5, Rosenberg Self-Esteem Scale, DASS-21, and ) is another strength of this study. Despite the strengths of this study, the results have some limitations. One of the limitations of this study did not consider the effects of other variables which can affect PQOL (such as social supports, economic status, marital relationship, and etc.). It has been suggested that future studies consider these issues. Moreover, considering the mental nature of obstetric violence, this concept is different based on the social and cultural norms of any societiy. A behavior may be defined as violence by the patient, but health care providers consider it part of their routine care, as well as, a behavior may be considered violence by one person, but another may consider it part of their treatment process. Conclusion Our findings highlighted the negative effect of obstetric violence on mental health, self-esteem, PTSD, and PQOL. Considering the mental nature of violence, and its adverse effects on the health of the mother and infant; Sometimes we witness violence, which is mostly without intention, by healthcare providers. Therefore, it is recommended that policymakers and managers adopt programs to promote respectful maternal care and prevent obstetric violence to prevent the occurrence of adverse effects in parturient women. Abbreviations PTSD: post traumatic stress disorder PQOL: postpartum quality of life OV: obstetric violence DASS-21: Depression, Anxiety, and Stress Scale-21 Declarations Ethics approval and consent to participat The study was approved by the Isfahan University of Medical Sciences (IR.MUI.NUREMA.REC.1401.039). All procedures were in accordance with the ethical standards of the Regional research committee and with the Declaration of Helsinki 1964 and it later amendments. Consent for publication: Not applicable Availability of data and materials: The data sets was used and analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests: The authors declare no conflict of interest. Funding: None Authorship contribution statement Sh. K, and S.Y contributed to the conception and design of the study; S.Y did the literature search. S.Y, Sh.K, and D.MT wrote the first draft of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version. Acknowledgments The article is a part of a research project that has been approved by the Isfahan University of Medical Sciences. 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Ann Gen Psychiatry. 2021;20(1):1–8. Fernández IO. PTSD and obstetric violence. Midwifery Today. 2013. Hernández- Martínez A, Rodríguez-Almagro J, Molina-Alarcón M, Infante-Torres N, Donate Manzanares M, Martínez-Galiano JM. Postpartum post-traumatic stress disorder: Associated perinatal factors and quality of life. J Affect Disord. 2019;249:143–50. Lindahl V, Pearson JL, Colpe L. Prevalence of suicidality during pregnancy and the postpartum. Archives of Women’s Mental Health. 2005;8(2):77–87. Raudasoja M, Vehviläinen-Julkunen K, Tolvanen A. Passing the test of motherhood? Self‐esteem development and birth experience in the transition to motherhood: A longitudinal mixed methods study in Finland. J Adv Nurs. 2022;78(12):4246–60. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3848180","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":266193285,"identity":"ce0293fd-0621-410c-9a48-bb29265c8eb9","order_by":0,"name":"Shahnaz Kohan","email":"","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Shahnaz","middleName":"","lastName":"Kohan","suffix":""},{"id":266193286,"identity":"0b6c22fe-be1c-4596-a94e-bcdc0c7218a4","order_by":1,"name":"Desirée Mena-Tudela","email":"","orcid":"","institution":"Universitat Jaume I","correspondingAuthor":false,"prefix":"","firstName":"Desirée","middleName":"","lastName":"Mena-Tudela","suffix":""},{"id":266193287,"identity":"81911790-28da-4e23-8f74-d058dd67d576","order_by":2,"name":"Samaneh Youseflu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzklEQVRIiWNgGAWjYPACORkG9gYGZlK0GPMw8BwgWYtEApFa5Bt4DB/+qDDgMbj5xvBzQYUNA397dwJeLQYHeIyNec4AtdzOMZaecSaNQeLM2Q34tTDwmEkztv0BaTGQ5m07zGAgkYtfC9BhZpI//4Ecdsb4N1FaGA7wmEnwNgC13ABaR5QWg8NsxcY8xwx4JM+klVnznEnjIegX+fbmjQ9/1BjI8R0/vPk2T4WNHH97LwGHMXMYQFkQBg9+5WDA/gCdMQpGwSgYBaMAFQAAPOw+lv4Gd6kAAAAASUVORK5CYII=","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Samaneh","middleName":"","lastName":"Youseflu","suffix":""}],"badges":[],"createdAt":"2024-01-09 12:14:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3848180/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3848180/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49495792,"identity":"b1e271fb-a80d-4f8b-b97c-dd1a0df906dd","added_by":"auto","created_at":"2024-01-11 20:05:35","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":17342,"visible":true,"origin":"","legend":"\u003cp\u003eA conceptual model for the predictors of postpartum quality of life\u003c/p\u003e\n\u003cp\u003eOV: Obstetric violence; PTSD: Posttraumatic stress disorder; SE: Self-esteem, DASS-21: Depression, Anxiety, and Stress Scale-21, PQOL: Postpartum quality of life.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3848180/v1/79fba49e61c0b212ce505c56.png"},{"id":49495794,"identity":"1cf5bc2a-920f-4e4c-8a6e-0f144dd6d55f","added_by":"auto","created_at":"2024-01-11 20:05:35","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":16720,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePath diagram for the predictors of postpartum quality of life\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOV: Obstetric violence; PTSD: Posttraumatic stress disorder; SE: Self-esteem, DASS-21: Depression, Anxiety, and Stress Scale-21; PQOL: Postpartum quality of life.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-3848180/v1/9997e9d1471943f29443327f.png"},{"id":57303072,"identity":"96551cc1-0327-41c3-9b18-85a10626675d","added_by":"auto","created_at":"2024-05-29 00:16:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":561429,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3848180/v1/9a12abf6-2f43-4198-ad48-6f217661a559.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Path analysis of the influence of obstetric violence on the postpartum quality of life: the mediating role of psychological factors Running title: obstetric violence and the postpartum quality of life","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePregnancy and childbirth as important events in women's lives should be guided based on quality and humanized principles. The World Health Organization (WHO) emphasizes the quality of interaction between women and health care providers and considers good interactions as a prerequisite for favorable pregnancy and childbirth outcomes (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMost maternal care programs mainly focus on physical safety, while childbirth is an important process with profound personal, emotional, psycological and cultural implications (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Since motherhood is exclusive to the female universe, both gender equality and gender violence should be considered at the core of maternal care (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the care that women receive during childbirth, many of them experience some type of violence, which can manifest as physical, mental, inadequate clinical care, or violation of the principle of their autonomy (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Some obstetric situations, such as multiple vaginal examinations, Kristeller's maneuver, episiotomy, cesarean section, and other medical interventions, such as the administration of oxytocin without medical indication, may be invisible forms of violence and human rights violations (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWHO statement has highlighted the elimination of obstetric violence toward women during childbirth because it is in contrast with human rights principles and threatens their right to life, physical, mental and moral integrity, as well as freedom from discrimination (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite WHO's emphasis on respectful maternity care, there is strong and growing evidence of the occurrence of disrespectful and violent acts against women in obstetric care facilities; therefore, between 40% and 67% of women in Spain, 31% in Mexico, and 91.7% in Adisababa have experienced obstetric violence (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), although the variability in these findings may be due to the different methodologies used to measure obstetric violence.\u003c/p\u003e \u003cp\u003eThe negative feelings caused by these concepts can have short- and long-term effects on physical, sexual, and mental health as well as mother-infant relationships (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). A high prevalence of postpartum depression, post-traumatic stress disorder (PTSD), failure to properly adapt to the maternal roles, breastfeeding problems and a decrease in the desire to have more children have been reported among those experiencing obstetric violence (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). When the health care provider humiliates, insults, or mistreats the mother, her confidence in infant caring decreases, so it can have a negative effect on their mental health, and quality of life (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe birth experience itself can be a painful experience, but if an invisible violence is also imposed on them, it can turn it into a terrible process. This unpleasant experience can affect women's mental health and the quality of the mother-infant relationship (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRegarding the importance of obstetric violence on the health of mother and child, this study aimed to test a conceptual model considering the interrelated role of obstetric violence, mental health, self-esteem, and PTSD on the postpartum quality of life (PQOL) using path analysis.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\n\u003ch3\u003eProcedure and participants\u003c/h3\u003e\n\u003cp\u003eThe current cross-sectional study was carried out on 385 mothers who gave birth from January to May 2022 using a convenience sampling method.\u003c/p\u003e \u003cp\u003e 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.\u003c/p\u003e \u003cp\u003eThe 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, term 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\u0026ndash;6 weeks.\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eDemographic\u0026amp; reproductive data\u003c/h2\u003e \u003cp\u003eFirst, a checklist of sociodemographic and obstetric questions including women\u0026rsquo;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.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePostpartum quality of life (PQOL)\u003c/h3\u003e\n\u003cp\u003eThe 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\u0026ndash;8), physical function (questions 20\u0026thinsp;\u0026minus;\u0026thinsp;9), psychological function (questions 21\u0026ndash;28), and social support (questions 29\u0026ndash;40). Participants will answer each question on a five-point Likert scale from 0 to 4. The total score ranges from 0 to 100, with higher scores reflecting better conditions. The validity and reliability of this scale have been confirmed in the Iranian population (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). 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).\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSelf-esteem\u003c/h2\u003e \u003cp\u003eThe Rosenberg Self-Esteem Scale was used for assessing Women\u0026rsquo;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 = \u0026ldquo;strongly disagree\u0026rdquo; to 5 = \u0026ldquo;strongly agree\u0026rdquo;). Higher scores represent high self-esteem. This questionnaire has good validity and reliability among the Iranian population (internal consistency\u0026thinsp;=\u0026thinsp;0.83) (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eEPREVO\u003c/h2\u003e \u003cp\u003eThis instrument was developed by Kirsten Falcon et al. in Ecuador to determine the criteria for obstetric violence (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). This scale contains 35 questions and is scored on a two-level scale (yes\u0026thinsp;=\u0026thinsp;1, and no\u0026thinsp;=\u0026thinsp;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.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePost-traumatic Stress Disorder (PTSD)\u003c/h2\u003e \u003cp\u003eThe 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\u0026ndash;5), avoidance (items 6\u0026ndash;7), negative alterations in cognition/mood (items 8\u0026ndash;14), and alterations in arousal and reactivity (items 15\u0026ndash;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 (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eDepression, Anxiety, and Stress Scale-21 (DASS-21)\u003c/h2\u003e \u003cp\u003eFor 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\u0026thinsp;=\u0026thinsp;did not apply to me to 3\u0026thinsp;=\u0026thinsp;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 (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eData analysis:\u003c/h2\u003e \u003cp\u003ePath 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.\u003c/p\u003e \u003cp\u003eFor 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.\u003c/p\u003e \u003cp\u003eBased on the previous similar articles, a conceptual model (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) 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.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePath 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 +\u0026thinsp;2 or less than \u0026ndash; 2 were considered statistically significant (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOut of 385 women who took part in our study, 152 individuals (42.73%) were in the age group of 20 to 30 years, and 12.8% (n\u0026thinsp;=\u0026thinsp;46) of them had less than 20 years old-age. The majority of participants (39.94%, n\u0026thinsp;=\u0026thinsp;143) were primiparous, and 14.8% (n\u0026thinsp;=\u0026thinsp;53) had more than 3 children. In terms of educational level, 46.6% (n\u0026thinsp;=\u0026thinsp;74) of the participants had academic level education and about 74.2% (n\u0026thinsp;=\u0026thinsp;259) of them were housewives. Moreover, 37.71% (n\u0026thinsp;=\u0026thinsp;135) of pregnancies were unplanned, and 63.4% (n\u0026thinsp;=\u0026thinsp;227) of women had a vaginal childbirth (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic Characteristics of participants.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003cp\u003eLess than 20 years\u003c/p\u003e \u003cp\u003e20\u0026ndash;29 years\u003c/p\u003e \u003cp\u003e30\u0026ndash;40 years\u003c/p\u003e \u003cp\u003eMore than 40 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46(12.84)\u003c/p\u003e \u003cp\u003e152(42.73)\u003c/p\u003e \u003cp\u003e112(31.28)\u003c/p\u003e \u003cp\u003e48(13.41)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParity\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003eMore than 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e143(39.94)\u003c/p\u003e \u003cp\u003e84(23.46)\u003c/p\u003e \u003cp\u003e78(21.79)\u003c/p\u003e \u003cp\u003e53(14.80)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of childbirth\u003c/p\u003e \u003cp\u003eCaesarean\u003c/p\u003e \u003cp\u003eVaginal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e131(36.59)\u003c/p\u003e \u003cp\u003e227(63.40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003cp\u003ePrimary school\u003c/p\u003e \u003cp\u003eSecondary school\u003c/p\u003e \u003cp\u003eDiploma\u003c/p\u003e \u003cp\u003eUniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34(9.50)\u003c/p\u003e \u003cp\u003e67(18.71)\u003c/p\u003e \u003cp\u003e183(51.12)\u003c/p\u003e \u003cp\u003e74(20.67)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupation\u003c/p\u003e \u003cp\u003eHousewife\u003c/p\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e259(72.35)\u003c/p\u003e \u003cp\u003e99(27.65)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of pregnancy\u003c/p\u003e \u003cp\u003ePlaned\u003c/p\u003e \u003cp\u003eUnplanned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e223(62.29)\u003c/p\u003e \u003cp\u003e135(37.71)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidency\u003c/p\u003e \u003cp\u003eUrban\u003c/p\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e227(65.64)\u003c/p\u003e \u003cp\u003e123(34.63)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the correlation between all variables included in the path analysis. Results showed that PQOL was associated with OV (r=-0.65, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), self-esteem (r\u0026thinsp;=\u0026thinsp;0.39, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), PTSD (r=-0.48, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and mental health (r= -0.70, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelations between obstetric violence, self-esteem, PTSD, DASS, and postpartum quality of life\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Postpartum Quality of Life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Obstetric violence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.65*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. PTSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.48*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.23*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Self-esteem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.39*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.22*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. DASS-21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.70*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.53*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.36*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.19*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eValues are given as Spearman coefficient (P-value) using Pearson correlation test.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003ePTSD: Posttraumatic stress disorder; DASS-21: Depression, Anxiety, and Stress Scale-21\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBased on the conceptual model, the overall goodness-of-fit statistics had perfectly good fitness indices (χ2\u0026thinsp;=\u0026thinsp;3.92; DF\u0026thinsp;=\u0026thinsp;2; χ2 /DF\u0026thinsp;=\u0026thinsp;1.96; RMSEA\u0026thinsp;=\u0026thinsp;0.06; CFI\u0026thinsp;=\u0026thinsp;0.98; GFI\u0026thinsp;=\u0026thinsp;0.99) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe Goodness of Fit Indices for the Models.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCFI*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGFI٭٭\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRMSEA٭٭٭\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChi-square\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eChi-square/df٭٭٭٭\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePath\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;385\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.922\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e*CFI: comparative fit index, ٭٭GFI: goodness fit index, ٭٭٭RMSEA: root mean square error of approximation, ٭٭٭٭Chi-square/df: chi-square to the degree of freedom index.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWe found that obstetric violence (β= -0.659), self-esteem (β\u0026thinsp;=\u0026thinsp;0.223), mental health (β= -0.396), and PTSD (β\u0026thinsp;=\u0026thinsp;0.345) are the main predictors of postpartum QoL. Among variables, obstetric violence had the strongest effect on women\u0026rsquo;s PQOL. In addition to its direct effect, obstetric violence can influence the PQOL through the effect on mental health (β\u0026thinsp;=\u0026thinsp;0.0.533), self-esteem (β\u0026thinsp;=\u0026thinsp;0.222), and PTSD (β\u0026thinsp;=\u0026thinsp;0.229), indirectly. Mental health, self-esteem, and PTSD were considered mediators. Factors such as obstetric violence and PTSD with indirect effects on mental health can impair the quality of life (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e \u0026amp; Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePath Coefficients for, obstetric violence, self-esteem, mental health, PTSD, and postpartum quality of life of Women during postpartum period.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDirect effect*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIndirect effect*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal effect*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eQuality of life\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObstetric violence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.342\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.317\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.659\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-16.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf \u0026ndash;esteem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.223\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.223\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMental health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.396\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.396\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-11.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePTSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.245\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.099\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.345\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-9.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eMental health\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePTSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.250\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.250\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.689\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObstetric violence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.590\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.057\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.533\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11.919\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSelf-esteem\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObstetric violence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.222\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.222\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-4.309\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePTSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObstetric violence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.229\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.229\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the current study, the causal relationship between theoretical and applied research topics was evaluated using the path analysis method. Our findings show that obstetric violence, self-esteem, mental health, and PTSD were significant predictors of postpartum quality of life.\u003c/p\u003e \u003cp\u003eAmong these variables, obstetric violence had the greatest effect on the quality of life after childbirth. Moreover, higher mental health disorders, PTSD, and impaired self-esteem were seen among women who experienced obstetric violence. Our findings are in line with Scandurra et al. study, which shows a significant correlation between mental health status measured using DASS-21, and obstetric violence (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Moreover, Martinez-V\u0026aacute;zquez et al. reported a higher level of depression among women who had experienced verbal or psycho-affective obstetric violence (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The results of a cohort study showed that 18% of women who had mild or severe depression had experienced at least one type of violence and disrespect during childbirth, and physical violence was associated with an increased chance of severe depression (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Beck considered factors such as poor communication between mothers and healthcare providers, disrespectful maternity care, loss of control, and autonomy, lack of empathy, privacy, and sense of security, insufficient information, as well as inattention to women\u0026rsquo;s feelings as psychological trauma (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Other studies also link episiotomy and instrumental delivery to poor childbirth experience (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Instrumental childbirth was not assessed in this study. This may need to be taken into account in future studies. Previous research showed that positive childbirth experiences, support, good care, physical comfort, and positive emotional experiences decreased acute stress and postpartum depression symptoms (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Yeo et al. revealed that childbirth experiences and postpartum depression are the main predictors of women\u0026rsquo;s quality of life (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). More research is needed on how these factors are related and the effects they may have on women and their newborns.\u003c/p\u003e \u003cp\u003eThe way mothers communicate with health care providers is vitally important because these communications are not only a necessary tool to preserve the mother's life, but also women's experiences in these communications can strengthen their self-confidence and sense of comfort, or lead to lifelong psychological damage. In our study, a significant correlation was found between PTSD and obstetric violence. The experience of PTSD symptoms can impair their mental health and has a direct and indirect effect on PQOL. In this regard, Martinez-V\u0026aacute;zquez et al. indicated that only verbal, and psycho-affective obstetric violence are associated with PTSD symptoms (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Another Iranian study reported a higher PTSD among women who experienced disrespectful maternity care (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). A traumatic childbirth experience is mainly accompanied by helplessness, fear, and panic, and is subsequently related to a wide range of thoughts and feelings, including vivid memories, nightmares, flashbacks, and irritability, which can have a negative impact on women and their families (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). A previous study showed that PTSD symptoms have a worse effect on the quality of life during postpartum periods, and a respected birth plan was a protective factor against PTSD (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Starting the care of your newborn with poor mental health is an added factor for poor maternal, infant and family outcomes, as well as an added risk factor for postpartum suicide (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn our study, self-esteem was a main predictor of PQOL, that influenced by obstetric violence. Impaired self-esteem was seen among those experiencing obstetric violence. In this regard, Raudasoja et al. reported that the childbirth experience has a positive impact on a mother\u0026rsquo;s self-esteem (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Negative emotions such as fear and embarrassment, low self-confidence, and decreased mother-infant bonding were seen following their separation; and a decrease in self-esteem, and autonomy was seen due to the failure to obtain informed consent .(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStrength and limitation:\u003c/h2\u003e \u003cp\u003eWhereas numerous studies have highlighted that obstetric violence, PTSD, self-esteem, and mental health contribute to PQOL independently.This study, for the first time, considered these factors in tandem. The main strength of this study is the combination of the assessed domains. The use of developed conceptual models (pathway diagrams) and validated questionnaires (e.g., EPREVO, PCL-5, Rosenberg Self-Esteem Scale, DASS-21, and ) is another strength of this study.\u003c/p\u003e \u003cp\u003eDespite the strengths of this study, the results have some limitations. One of the limitations of this study did not consider the effects of other variables which can affect PQOL (such as social supports, economic status, marital relationship, and etc.). It has been suggested that future studies consider these issues. Moreover, considering the mental nature of obstetric violence, this concept is different based on the social and cultural norms of any societiy. A behavior may be defined as violence by the patient, but health care providers consider it part of their routine care, as well as, a behavior may be considered violence by one person, but another may consider it part of their treatment process.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur findings highlighted the negative effect of obstetric violence on mental health, self-esteem, PTSD, and PQOL. Considering the mental nature of violence, and its adverse effects on the health of the mother and infant; Sometimes we witness violence, which is mostly without intention, by healthcare providers. Therefore, it is recommended that policymakers and managers adopt programs to promote respectful maternal care and prevent obstetric violence to prevent the occurrence of adverse effects in parturient women.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePTSD: post traumatic stress disorder\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePQOL: postpartum quality of life\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOV: obstetric violence\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDASS-21: Depression, Anxiety, and Stress Scale-21\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participat\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Isfahan University of Medical Sciences (IR.MUI.NUREMA.REC.1401.039). All procedures were in accordance with the ethical standards of the Regional research committee and with the Declaration of Helsinki 1964 and it later amendments.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe data sets was used and analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthorship contribution statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSh. K, and S.Y contributed to the conception and design of the study; S.Y did the literature search. S.Y, Sh.K, and D.MT wrote the first draft of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u0026nbsp;Acknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe article is a part of a research project that has been approved by the Isfahan University of Medical Sciences. The researchers would like to thank the staff of the health center for your collaboration and all mothers for participating in this study.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKatz L, Amorim MM, Giordano JC, Bastos MH, Brilhante AVM. Who is afraid of obstetric violence? Revista Brasileira de Sa\u0026uacute;de. Materno Infantil. 2020;20:623\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhalil M, Carasso KB, Kabakian-Khasholian T. Exposing Obstetric Violence in the Eastern Mediterranean Region: A Review of Women's Narratives of Disrespect and Abuse in Childbirth. Front Global Women's Health. 2022;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChabbert M, Rozenberg P, Wendland J. Predictors of negative childbirth experiences among French women. J Obstetric Gynecologic Neonatal Nurs. 2021;50(4):450\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerr\u0026atilde;o AC, Sim-Sim M, Almeida VS, Zang\u0026atilde;o MO. Analysis of the concept of obstetric violence: scoping review protocol. J personalized Med. 2022;12(7):1090.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYalley AA, Abioye D, Appiah SCY, Hoeffler A. Abuse and humiliation in the delivery room: Prevalence and associated factors of obstetric violence in Ghana. Front Public Health. 2023;11:988961.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnnborn A, Finnbogad\u0026oacute;ttir HR. Obstetric violence a qualitative interview study. Midwifery. 2022;105:103212.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrganization WH. The prevention and elimination of disrespect and abuse during facility-based childbirth: WHO statement. World Health Organization; 2014.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMart\u0026iacute;nez-Galiano JM, Martinez-Vazquez S, Rodr\u0026iacute;guez-Almagro J, Hern\u0026aacute;ndez-Martinez A. The magnitude of the problem of obstetric violence and its associated factors: A cross-sectional study. Women Birth. 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSiraj A, Teka W, Hebo H. 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Int J psychol. 2008;2(2):82\u0026ndash;102.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang H. Structural Equation Modeling. In: Zhang H, editor. Models and Methods for Management Science. Singapore: Springer Nature Singapore; 2022. pp. 363\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartinez-V\u0026aacute;zquez S, Hern\u0026aacute;ndez-Mart\u0026iacute;nez A, Rodr\u0026iacute;guez-Almagro J, Delgado-Rodr\u0026iacute;guez M, Mart\u0026iacute;nez-Galiano JM. Relationship between perceived obstetric violence and the risk of postpartum depression: An observational study. Midwifery. 2022;108:103297.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSilveira MF, Mesenburg MA, Bertoldi AD, De Mola CL, Bassani DG, Domingues MR, et al. The association between disrespect and abuse of women during childbirth and postpartum depression: Findings from the 2015 Pelotas birth cohort study. 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J Adv Nurs. 2022;78(12):4246\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"obstetric violence, PTSD, self-esteem, postpartum quality of life, path analysis","lastPublishedDoi":"10.21203/rs.3.rs-3848180/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3848180/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePregnancy and childbirth as important events in women's lives should be guided based on quality and humanized principles. This study aimed to test a conceptual model considering the interrelated role of obstetric violence, mental health, self-esteem, and PTSD on the postpartum quality of life (PQOL) using path analysis.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis cross-sectional study was conducted on 385 parturient women who have given birth from January to May 2022 using the convenience sampling method. Data were collected using a socio-demographic checklist, EPREVO, DASS-21, PCL-5, Rosenberg Self-Esteem Scale, and PQOL scales. Path analysis was applied to generate specified patterns of causal relationships between variables and to determine the type of relationships between predictor and response variables using LISREL software ver.8.8.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe found that obstetric violence (β= -0.659), self-esteem (β\u0026thinsp;=\u0026thinsp;0.223), mental health (β= -0.396), and PTSD (β\u0026thinsp;=\u0026thinsp;0.345) are the main predictors of postpartum QoL. In addition to its direct effect, obstetric violence can impress the PQOL through the effect on mental health (β\u0026thinsp;=\u0026thinsp;0.0.533), self-esteem (β\u0026thinsp;=\u0026thinsp;0.222), and PTSD (β\u0026thinsp;=\u0026thinsp;0.229), indirectly.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOur finding highlighted the negative effect of obstetric violence on mental health, self-esteem, PTSD, and PQOL. Therefore, it is recommended that policymakers and managers adopt programs to promote respectful maternal care and prevent obstetric violence to prevent the occurrence of adverse effects in parturient women.\u003c/p\u003e","manuscriptTitle":"Path analysis of the influence of obstetric violence on the postpartum quality of life: the mediating role of psychological factors Running title: obstetric violence and the postpartum quality of life","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-11 20:05:31","doi":"10.21203/rs.3.rs-3848180/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2ec5be5f-499e-4b1a-8b3d-5fe2a041150a","owner":[],"postedDate":"January 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-29T00:08:39+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-11 20:05:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3848180","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3848180","identity":"rs-3848180","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}