Hidden in plain sight: Validating theory on how health systems enable the persistence of women’s mistreatment in childbirth through a case in Tanzania

Mistreatment in childbirth has been identified as a concerning pattern reproduced and normalized in health systems globally. To address mistreatment, social theory is required. Mistreatment as normalization of organization deviance holds promise as a nascent theoretical framework but requires further validation. The theory posits that a health system distorted by resource scarcity and production pressures causes meso-level actors to seek workarounds and ration services. Emphasis on biomedicine leads providers to ration emotion work leading to mistreatment. A qualitative theory-driven approach was applied to verify and expand nascent theory using qualitative data from a study in Tanzania. The data included eight focus group discussions and 37 in-depth interviews involving 91 individuals representing community and health system stakeholders. Data were analyzed deductively and inductively using the theory’s framework while allowing for new constructs. Participants’ perspectives largely supported key constructs within and relationships among the different levels of the system elaborated in the original theory. New elements that were identified included moral distress experienced by providers, managers coping with dual roles as managers and providers and the dynamics of women’s families in the service interaction. Greater detail on the regulatory environment showed challenges in monitoring mistreatment due to structural secrecy and the nature of mistreatment. Further theory testing in different contexts and types of health systems is needed. Advancing this theory and others will uncover the systemic factors enabling mistreatment towards solutions to ensure a respectful experience during childbirth for women and their newborns, and providers struggling in overburdened and under-resourced health systems.