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   Table of Contents      
ORIGINAL ARTICLE
Year : 2015  |  Volume : 20  |  Issue : 2  |  Page : 255-262

Iranian Azeri women's perceptions of unintended pregnancy: A qualitative study


1 Department of Nursing, Medical Sciences Faculty, Tarbiat Modares University, Tehran, Iran
2 Department of Reproductive Health, Faculty of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Date of Submission05-Feb-2014
Date of Acceptance02-Sep-2014
Date of Web Publication24-Oct-2017

Correspondence Address:
Dr. Roghaiyeh Nourizadeh
Faculty of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran
Iran
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Source of Support: None, Conflict of Interest: None


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  Abstract 

Background: Many women, throughout their life cycle, experience unintended pregnancy and its subsequent induced abortion. Nonetheless, women's perceptions of this phenomenon - particularly in countries prohibiting elective abortion - are poorly known. The aim of this study was to explore Iranian Azeri women's perceptions of unintended pregnancy.
Materials and Methods: This was a conventional content analysis study conducted in Tabriz, Iran. The data were collected through 31 semi-structured interviews with 23 women who had recently experienced an unintended pregnancy. The study participants were recruited using the purposive sampling method. Sampling started in March 2013 and continued until reaching data saturation, i.e. till August 2013. Data analysis was carried out concurrently with data collection. MAXQDA 10.0 software was employed for managing the study data.
Results: The study data analysis process yielded the formation of three main themes including negative effects of unintended pregnancy on daily life, fear of being stigmatized with violating social norms, and abortion panic, which in turn constituted the broader overarching theme of "threat supposition." In other words, following an unintended pregnancy, the study participants had experienced different levels of fear and threat depending on their personal, family, and socio-cultural backgrounds.
Conclusions: Women perceive unintended pregnancy as a challenging and threatening situation. An unintended pregnancy can threaten women's lives through social deprivations, growing instability, and putting both mother and baby at risk for physical and psychosocial problems. On the other hand, an unsafe illegal abortion could have potentially life-threatening complications. To cope with such a situation, women need strong social support. Healthcare providers can fulfill such women's need for support by developing pre-abortion counseling services and providing them with professional counseling. Also, strengthening women's support system by policy-makers is recommended.

Keywords: Abortion, Iran, qualitative research, unwanted pregnancy, women′s experience


How to cite this article:
Mohammadi E, Nourizadeh R, Simbar M. Iranian Azeri women's perceptions of unintended pregnancy: A qualitative study. Iranian J Nursing Midwifery Res 2015;20:255-62

How to cite this URL:
Mohammadi E, Nourizadeh R, Simbar M. Iranian Azeri women's perceptions of unintended pregnancy: A qualitative study. Iranian J Nursing Midwifery Res [serial online] 2015 [cited 2022 Dec 4];20:255-62. Available from: https://www.ijnmrjournal.net/text.asp?2015/20/2/255/153775


  Introduction Top


Unintended pregnancy (including both unwanted and mistimed pregnancy) is one among the most important issues of reproductive health. [1] From 1995 to 2008, the unintended pregnancy rate reduced by 17% worldwide; nonetheless, about 41% of all pregnancies - 4 out of 10 pregnancies - are unintended. [2]

In Iran, the rate of unintended pregnancy decreased from 37% in 1992 to 21% in 2009 and has remained constant since then. [3] About 73.3% of Iranian families use different types of contraceptive methods; [4] however, none of the contraceptive methods is reliable. Consequently, families still experience unintended pregnancies. Lifetime abortion rate in Iran is estimated to be one per four women. [5]

The challenges of unintended pregnancy and subsequent induced abortion involve individuals' values and beliefs. [6],[7] Porter highlighted the importance of religious beliefs in dealing with unintended pregnancy and recommended further studies on this subject area in different ethnic and religious groups. [8]

About 98% of Iranians are Muslims, mainly Shiites. Moreover, the Iranian regime is Islamic. In Islamic jurisprudence, induced abortion has been prohibited; accordingly, induced abortion is clearly illegal in Iran. However, since 2003, severely high-risk pregnancies have been allowed to be terminated before the ensoulment of the fetus, i.e. before the 19 th week of last menstrual period, with the permission of Iranian Forensic Medicine Organization. [9] Accordingly, the illegality of induced abortion in Iran can affect Iranian women's perceptions and experiences of unintended pregnancy.

Most of the studies on women's experiences of unintended pregnancy have been conducted on unmarried teens. [10],[11],[12],[13],[14] On the other hand, studies on married women have focused mainly on women's coping strategies and post-abortion psychological problems. [15],[16],[17],[18],[19] The Center for Disease Control and Prevention (2009) reported that as women's perceptions and experiences of unintended pregnancy and induced abortion are poorly known, examining the effectiveness of healthcare services provided to women experiencing unintended pregnancy as well as developing new care plans for them are difficult. [20] Consequently, exploring women's experiences of unintended pregnancy and induced abortion in different socio-cultural contexts is a matter of great importance.

In Iran, many studies have been conducted on the causes and the outcomes of unintended pregnancy and induced abortion; [21],[22],[23],[24] however, Iranian women's beliefs, attitudes, and experiences surrounding unintended pregnancy and induced abortion are still poorly known. To prevent illegal induced abortions, clarifying women's perceptions of unintended pregnancy is crucial. The study was conducted to explore Iranian Azeri women's perceptions of unintended pregnancy.


  Materials and Methods Top


This was a conventional content analysis study. The aim of the conventional content analysis approach is to study and explain poorly known phenomena. [25] The study setting was all the public and private health clinics as well as private gynecologists' and midwives' offices located in Tabriz. Tabriz is one of the five biggest cities of Iran that is located in northwest of the country. People in Tabriz are mainly of Azeri ethnicity and speak Turkish. The study population consisted of all the women having a recent unintended pregnancy who either had decided to continue their pregnancy (and were in their last 4 months of it or had delivered in the past 40 days) or had electively aborted it recently (in the previous 6 months). The women who were candidates for obtaining therapeutic abortion and women with established diagnosis of psychological disorders were excluded from the study. The participants were selected through purposeful sampling method from 10 different districts of Tabriz city, according to their socioeconomic status. Totally, 31 face-to-face unstructured interviews with 23 women were conducted from March to August 2013. The main interview question was, "What were your feelings and concerns about having an unintended pregnancy?" Then we employed probing questions to delve into the participants' perceptions. Sampling and data collection were continued until reaching data saturation, i.e. until the generated concepts and categories were fully developed and refined and no new data was obtained from the interviews. [26] The main and the follow-up interviews lasted for 45-80 and 15-20 min, respectively. Interviews were conducted in a counseling room located in the study setting and recorded using a digital sound recorder. Four participants withheld consent to record their voices. Consequently, we made note of their narratives. The interviews were transcribed verbatim and reviewed several times to get a basic sense of participants' perceptions. [27] Data analysis was carried out concurrently with data collection. Initially, the transcripts were coded using participants' words or authors' formulated concepts. Then, the generated codes were compared with each other and were categorized according to their differences and similarities. The generated categories were also compared with each other and were categorized into higher-level categories and themes. MAXQDA 10.0 R250412 from VERBI software was used to assist data analysis and organization. [Table 1] shows how meaning units, codes, and sub-categories formed one of the main categories of the study.
Table 1: Meaning units, codes, and sub-categories of "fear of life difficulty and instability' category


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Using several strategies such as maximum variation sampling, member checking, prolonged engagement with the study subject matter, and establishment of an effective communication with the study participants [28] helped improve the credibility of the study findings. In the member-checking process, three participants were asked to check the congruency between their own perceptions and the generated concepts and categories. On the other hand, the peer-checking technique was employed to enhance the dependability of the study findings. The audit team comprised two of the study authors who were experts in qualitative data analysis. They recoded all the interviews and supervised the study. To guarantee the confirmability of the study findings, bracketing was done to prevent preconceptions from affecting the processes of data collection and analysis. Finally, transferability of the present study was ensured by rich description in order that other researchers can conduct similar projects and compare the findings.

The Ethics Committee of Shahid Beheshti University of Medical Sciences, Iran, approved the study. The aim of the study was clearly explained to the study participants and accordingly, their questions and concerns were addressed. Both participation in and withdrawal from the study were completely voluntary. Moreover, the confidentiality of the participants' personal information was guaranteed. The participants were also informed how to access the study findings. Finally, immediately before each interview, a written informed consent was obtained.


  Results Top


The study participants consisted of 13 women with unwanted pregnancy and 10 women with mistimed pregnancy, between the ages of 18 and 48, of which 10 women had decided to abort and 13 women had continued to term. The participants had between zero and four children. Five participants had education up to high school, 6 participants had obtained diploma, and 12 participants had some level of college education. Eleven participants made reference to employment, and only 3 of the 23 participants were university students while unintended pregnancy was detected. Five participants had reported a previous history of induced abortion.

The study data analysis process yielded 214 primary codes, 17 sub-categories, 8 categories, 3 main themes, and the central overarching theme of "threat supposition" [Table 2].
Table 2: A summary of findings


Click here to view


Negative effects of unintended pregnancy on daily life

The first theme of the study was the negative effects of unintended pregnancy on daily life. The participants equated unintended pregnancy with deviation from their normal life routines and also with a potential threat to them. They referred to their coming baby as an uninvited guest and a major challenge that could result in disturbed tranquility, life instability, and social deprivations. The four sub-themes of this theme included fear of life difficulty and instability, social deprivations, negative maternal and child outcomes, and inability to fulfill parental commitments and responsibilities.

Fear of life difficulty and instability
"Threatening family stability and growing instability" and "inability to fulfill multiple roles: Role conflict" constituted a great part of the experiences of the participants, so that one of the women's concerns of unintended pregnancy was the possibility for encountering financial pressure and difficulty. Participant no. 2 stated:
"I felt I would experience financial problems; I was afraid of potential financial problems." (obtained elective abortion)

Factors such as tenancy, unemployment, home-office long distance, marital conflicts, and uncertainty over the prospect of marital life in young newly married couples heightened the participants' fear of growing instability after encountering an unintended pregnancy. On the other hand, the perceived difficulty of rearing subsequent little babies, as well as the perceived difficulty of fulfilling multiple conflicting parental and social roles had brought the study participants into role conflict. Interviewee 3 stated:
"I am an employee. When I got pregnant, I (with her face turned sour) remembered the difficulties of rearing and taking my children to nursery." (obtained elective abortion)

Social deprivations

The second perceived negative effect of unintended pregnancy on women's daily lives was the probability of suffering from social deprivations. The participants thought that their unintended pregnancy would interfere with their academic and occupational promotion and limit their participation in social activities. Participant no. 5 stated:
"I wanted to continue my education at university. I felt that a new baby would cripple me and consequently would hamper the pursuit of my education at PhD level." (obtained elective abortion)

Other aspects of social deprivations induced by unintended pregnancy were the restriction imposed on social interactions, recreational activities, and the freedom to travel as well as the inability to attend parties. One of the women said:
"With two babies, you should do without many things including recreations and parties. You may know that Turk men pass on the childrearing responsibilities to their women; two babies could largely confine me." (P. 7; continued her pregnancy)

Inability to fulfill parental commitments and responsibilities

Another negative effect of unintended pregnancy on women's daily lives was inability to fulfill parental commitments and responsibilities (for the previous children). Women who had either several babies or two subsequent little babies were more worried about being unable to successfully fulfill their parental commitments and responsibilities. A participant (no. 22) said:
" I became pregnant soon after the previous pregnancy. I told myself, 'My poor daughter!' She is still being breastfed." (obtained elective abortion)

Being unable to fulfill the coming baby's emotional and financial needs, as well as being unable to build a high-quality life for him/her were among the other concerns of women over their unintended pregnancy. One woman explained the issue as follows:
" I know that I can only fulfill the needs of my current two babies and not of a third one. Therefore, giving birth to the third baby would be some sort of mercilessness." (P. 9; obtained elective abortion)

Negative maternal and child outcomes

Negative maternal and child outcomes formed another aspect of the participants' perceived negative effects of unintended pregnancy on daily life. An unintended pregnancy may happen at older ages, while a woman is using contraceptive methods or certain types of medications, or is undergoing X-ray studies. All of these conditions have teratogenic potential and may put every fetus at great risk for developing health problems. Consequently, the participants noted that they were worried about their fetus's health status. One of the women stated:
" I am too old to pregnancy; my baby may be born with mental retardation at this age, which can potentially ruin my life." (P. 2; obtained elective abortion)

Besides being worried about their fetus's health, the participating women were also worried about their own health. For example, women with underlying illnesses felt that pregnancy could aggravate their condition. Moreover, older women were worried about age-related pregnancy complications. A participant (no. 3) said,
" Well, other dangers also threatened me. Pregnancy at ages above 35 years is usually considered as high-risk and can be associated with pregnancy-induced hypertension." (obtained elective abortion)

Fear of being stigmatized with violating social norms

The second theme of the study was the fear of being stigmatized with violating social norms. Two sub-themes of this theme included "violating childbearing norms' and "the social taboo of abortion."

Violating childbearing norms

An important dimension of violating childbearing norms was related to the social restrictions of childbearing. In other words, becoming pregnant while having two to three children, very soon after marriage, or at older ages had given the study participants a sense of violating childbearing norms. Consequently, the participants were worried about the negative outcomes of violating childbearing norms. As the childbearing pattern reflects the couple's socio-cultural class, violating childbearing norms could lower their social prestige. One woman remarked:
" I was greatly concerned with people's sarcastic talks. Both of us (my husband and I) were worried about other's outlook (toward us). It seemed as if a repulsive force was saying to us, 'You are not anymore eligible for childbearing.' I thought of others' opinion about such a big 17-year gap between our second and the coming children. Well, people would think that we are probably of a lower social class that did not take into account such important considerations. (You know that) usually villagers plan their pregnancies as such." (P. 3; obtained elective abortion)

In some instances, the fear of others' blame and derision had been so great that the participants, at the early stages of pregnancy, had preferred to hide their pregnancy and isolate themselves socially. Participant no. 17 expressed as follows:
" I was afraid of people's sharp tongue. I avoided going to my parents' home and attending ceremonies because I thought people would humiliate me. I refrained going out to avoid people's talks." (continued her pregnancy)

The other dimension of violating childbearing norms was related to the prevalence of the only-child practice in some Iranian families, which in turn made the continuation of the second pregnancy difficult. As participant no. 5 noted:
" My husband's family disapproved every woman who gave birth to her second baby. Generally, they do not agree with childbearing. In such an unsupportive environment, giving birth to a second baby was not so much admirable." (obtained elective abortion)

The social taboo of abortion

Another dimension of social norms violation stigma was related to the social taboo of abortion. An important strategy to get rid of the fears and difficulties of an unintended pregnancy was to obtain an induced abortion. However, relatives' and friends' disagreement with abortion was in turn the additional source of fear and anxiety for the study participants. Fear of others' opposition to abortion had compelled the participants to hide their pregnancy and abortion from relatives and friends. As one of the women noted:
" I feared my mother, sister, and mother- and father-in-law would notice my pregnancy and my intention to abort it. I was sure that if they noticed, they would prevent me from abortion. One of my problems was that I needed to hide it from others because I feared they would prevent me from obtaining abortion. You know, abortion is against both our religion and tradition. Our public also has a negative attitude towards it." (P. 1; obtained elective abortion)

The other dimension of the social taboo concerning abortion was related to its illegality. Due to lack of social support for abortion and its illegality, the participants were worried about having access to abortion services. As one woman stated:
" I had to obtain abortion - an illegal, hard-to-access abortion. I was extremely worried. I had a big fear - fear over the fate of my pregnancy. I did not know what I had to do and where I had to go to obtain abortion. I felt extremely stressed out about managing the situation." (P. 5; obtained elective abortion)

Abortion panic

The third theme of the study was the panic over abortion. Women's abortion panic differed according to their moral and religious beliefs as well as past direct and indirect experiences. This theme consisted of two sub-themes including "infringing belief and value systems" and "fear over difficulty and adverse effects of abortion."

Infringing belief and value systems
"Moral and religious dilemmas" and "fear of punishment" were some of the major experiences of unintended pregnant women. Most of the participants had encountered moral and religious dilemmas. Consequently, they had experienced pangs of guilt and conscience. The severity of their feelings depended on the firmness of their religious beliefs and commitments. Participant no. 1 said:
" I had a twinge of guilt because I did not want the baby and hence decided to terminate my pregnancy. My deliberate cruelty towards that baby was a twinge. Many things began to flood my mind. For example, I thought I was ignoring the God's favor; it was maybe some sort of ingratitude. I felt extremely guilty - both ethically and religiously. Our religion strongly disapproves of abortion. I did not want to increase the burden of my guilt." (obtained elective abortion)

Some of the participants believed that abortion was equal to deliberate murder and could result in afterlife punishment. One of the participants (no. 16) stated:
" I remembered this verse of the Holy Quran, 'When the buried-alive female infant is asked, for what sin she was killed?' Then, I was scared. I thought that my baby would ask me in doomsday, for what sin did you kill me, mum?" (continued her pregnancy)

Women were also reluctant to obtain abortion because they believed that it was against God's will and could result in worldly punishment. Participant no. 4 expressed as follows:
" I dreaded the worldly punishment of abortion. I thought God would curse and chastise my husband, my children, and me in this world. I dreaded something wrong might happen to my children." (continued her pregnancy)

Fear over difficulty and adverse effects of abortion

When thinking about abortion, most of the participants had experienced fear and anxiety over its difficulty and pain. Participant no. 7 said:
" I had heard that abortion is too difficult, even more difficult than delivery. Therefore, I dreaded abortion." (continued her pregnancy)

On the other hand, women were greatly concerned with the adverse effects and complications of unsafe illegal abortion. Participant no. 23 stated:
" My husband insisted on obtaining abortion. However, I dreaded being permanently sterile; I dreaded the adverse effects of abortion." (a recently married young woman who had obtained elective abortion)

The three main themes of the study - negative effects of unintended pregnancy on daily life, fear of being stigmatized with violating social norms, and abortion panic - generally reflected participants' perceived threat and fear of unintended pregnancy outcomes and complications. These themes constituted the broader overarching theme of "threat supposition." It was a common theme emerging from the experiences of both those women who had continued with their pregnancy and those who had obtained elective induced abortion. In other words, participants in both groups had experienced different levels of fear and threat depending on their personal, family, and socio-cultural backgrounds. Threat ran through all the participants' narratives. For example:
"I did not want that (pregnancy). It was endangering my job security. But I also had an inner feeling of fear - fear of killing a living being." (P. 15; continued her pregnancy)


  Discussion Top


The aim of this study was to explore Iranian Azeri women's perceptions of unintended pregnancy. Study findings revealed that women perceived unintended pregnancy as a threat. Other studies also reported the same finding. [29],[30]

The participating women were mainly worried about continuing with an unintended pregnancy because of life difficulty and instability, inability to fulfill parental commitments and responsibilities, negative outcomes for mother and baby, social deprivations, and violating childbearing norms.

Fear of life difficulty and instability was one of the most remarkable perceptions of women about unintended pregnancy. In other studies, [6],[23],[24],[31],[32],[33] different dimensions of the above-mentioned threat, such as the perceived financial burden of unintended pregnancy, uncertainty over the prospect of marital life, and perceived role conflicts, were among the most common factors contributing to the obtainment of elective abortion.

Another important finding of the study was the women's fear over the inability to fulfill parental commitments and responsibilities. Hoogen reported that unintended pregnancy challenges women's perception of "being a good mother." In that study, women had a holistic family-oriented outlook - rather than a one-dimensional fetus-oriented one - toward motherhood and believed that a good mother is responsible for the welfare of the whole family. [34] In a study conducted on 11 Mexican immigrant women, Wilson also reported that women's main reason for pregnancy planning was to create a better life and future for their children. [35]

In this study, the participants were also concerned with social deprivations induced by unintended pregnancy and subsequent childrearing. This finding implies the great need of women of reproductive age for social support. Consequently, strengthening women's support system as well as providing them with better educational and employment opportunities throughout and after their pregnancy are recommended.

Another finding of the study was the women's fear of negative outcomes of unintended pregnancy for themselves and their baby. Fear of maternal health problems has also been reported in African sub-Saharan area and southwest Asia; however, the fear of birth defects has been reported only in some studies conducted in Asia. The main reason for such fears is probably women's lack of health information as well as their limited access to modern screening tools for identifying birth defects in developing countries. [36] These findings confirm the importance of healthcare providers' role in providing education and counseling to women experiencing an unintended pregnancy. Efficient counseling and strong social support alongside comprehensive birth defect risk assessment can help decrease the rate of unsafe illegal abortions.

Another aspect of the participants' perceptions of unintended pregnancy was the fear of violating childbearing norms. In 1980s, population control policies under the slogan "Daughter or son, two children are enough" was adopted in Iran. Accordingly, having only one or two children gradually became an accepted norm. The adverse long-term effect of the aforementioned policies was the increment of elderly population in the country. Accordingly, the Iranian population policy has been recently reversed into encouraging frequent childbearing. However, the only- and two-child traditions are still dominant in the Iranian society. Consequently, the participants considered having two or more children as a clear violation against this tradition and a potential damage to their social prestige. This important finding implies that abortion is not performed in a social vacuum; rather, the society's cultural climate can sometimes prevent women from continuing an unintended pregnancy. Other studies conducted in Iran also support the effect of public attitude toward the number of children on the acceptance of and adaptation with an unintended pregnancy. [23],[37]

Another type of threat perceived by the participants was related to the barriers to abortion. Legal obstacles to abortion and subsequent inaccessibility to safe abortion services, as well as the complications of an unsafe backstreet abortion were the other sources of fear and anxiety for women. Moreover, the participants were extremely concerned with the important others' probable opposition to abortion. The findings of another study conducted in Iran also revealed that legal obstacles and negative social attitude to elective abortion increased the severity of the threat perceived by women having an unintended pregnancy. In that study, women weighted their ability to obtain abortion against political obstacles and others' reactions. [23] Lie et al. also reported that inadequate social and emotional support could result in women's fear and anxiety over illegal abortion-induced sterility and death. [6]

The study findings also demonstrated that when thinking about aborting an unintended pregnancy, the participants had experienced pangs of guilt and conscience and fear over worldly and afterlife punishment. Other studies also highlighted the moral and religious dilemmas over abortion. [6],[24],[32],[38] Fear of worldly punishment and probable God-inflicting damage to other family members were among the most important inner feelings of women. Other studies have reported such findings less frequently. [39] This can be attributed to the prevailing cultural and ideological climate in Iran.

An important limitation of this study was the reluctance of women having unwed, unintended pregnancy to participate in the study. Consequently, these women's experiences and perceptions of unintended pregnancy remain unknown. Significant knowledge gap in this area in the country deserves further investigations.


  Conclusion Top


Pregnancy and childbearing are inherently interesting experiences that guarantee the continuation of human race; however, when happening unintentionally, women perceive it as a real threat to their personal, familial, and social life. An unintended pregnancy can threaten women's lives through depriving them of educational and employment opportunities, interfering with their ability to fulfill parental responsibilities, imposing financial burden on them and growing instability, and even by putting both mother and baby at great risk for serious physical and psychosocial problems. On the other hand, an unsafe illegal abortion would have potentially life-threatening complications. Accordingly, women experiencing an unintended pregnancy definitely deserve strong social support. Healthcare providers and policy-makers can fulfill such women's need for support by developing pre-abortion counseling services and providing them with professional counseling.


  Acknowledgment Top


We appreciate the research field and participants for their participation in the study.

 
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Abstract
Introduction
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