Among the eleven mothers participating in this study, 2 (18%) were employees and 9 (81%) were housewives. 4 (36%) were primigravida and 7 (63%) were multigravida. In terms of level of education, 4 (36%) had high school diploma, 3 (27%) had education less than high school diploma and 4 (36%) had bachelor’s degrees.
The Emergent central theme was "The mother with smeary-death life" consisting of three subthemes: "Distorted psyche on a journey to death", "physical destruction due to an ominous event ", and the "vicissitudinous life of the back-to-life mother". These sub-themes, in turn, involved 12 additional sub-themes that emerged from 38 common meanings. The common meanings were obtained from 1200 codes (Table 2).
Distorted psyche on a journey to death
"I put my clothes up, sat down on the floor, to cool down my body. Then, I was dizzy. It was like I was there, but my head was dizzy as if my brain was moving away from me. At that moment, I thought that I wouldn't live anymore and that was the last moment of life ".(P3)
The statemnets of the majority of mothers shows they experienced physchological impacts which were due to the conditions which exposed them to risks Such exposures were often made up of "exposures with unpredictable news", "encountering unpleasant real events" and "perceived threat of danger".
Some mothers said that they had psychological reactions, such as shock and wishing to go unconscious in the face of unpredictable news concerning their problem. Furthermore, factors such as doctors' surprise at the mothers’ survival indicated to them that they were in a serious danger. A 24-year-old mother with abdominal distension and bowel perforation after emergency cesarean, says:
"Keep the mother here for a minute (with emphasis), you (the husband) are responsible for her death. She said every minute counts for her. She said 'I wonder how she has survived this long'".(P7)
Another mother who has had a hysterectomy due to Placenta Accreta hemorrhage says:
"At that moment, I asked my anesthesiologist to just anesthetize me earlier so I wouldn't see what was going to happen. They said that if they were to open my stomach, blood would spray out. Even they were all worried andnervous. It was very, very painful."(P1)
The theme of "outcome of the fight with the death courier" suggests that thinking about death and the presence of the angel of death disrupted most mothers' thoughts after they go close to death and overcome e critical conditions and emergencies. This theme consists of the succeeding sub-themes of "rejecting the existing reality", "compulsory progression in the irreversible path", "stress" and "fear".
"Rejecting the existing reality" was described by a 31-year-old mother suffering from severe preeclampsia, kidney failure, and had to undergo dialysis forever as follows:
"I was saying to myself, 'All these people give birth, and there's no problem. Why should I have a problem? What's the reason? I couldn't take it'.(P8)
A 28-year-old mother who was forced to undergo emergency treatment despite fetal death due to advanced lung cancer says:
"I kept saying, 'Let my baby be born and I'll wait another two months until it's complete.' But they said no. As I said, I was forced to do so, and this compulsion was crushing my spirit pretty much".(P6)
A mother with experience of fear and cardiopulmonary failure, who had to go to a well-equipped hospital in the city, says:
"It was a long way. I was scared, even though we came by plane. But they said it was your responsibility then. I was panicked at that moment. It was a pretty grave situation at that moment, and that horror is still in my mind."(P6)
The next subtheme that emerged from the long-term psychological impacts of most NMM' statements is "depression". Typical symptoms of depression, such as guilt, despair, uninterrupted crying, extended sadness and grief, loneliness, irritability, and aggression, are most evident in these mothers' life experiences. Here are some instances of mothers speaking about different symptoms of depression:
"I was crying and saying, 'I want to die, just let me die. Why are you doing this to me?'(P7)
"I was really shattered. It was incredibly hard for me. No matter who checked on me or what happened; I would only cry (she cried). I couldn't control myself at all and felt very bad."(P1)
"Well, it's really hard to be alone (she cries). Well, I felt lonely in the hospital for some days. It was tough for me, and I felt abandoned."(P6)
"I was a little shyer. I'm much more outraged now. You know, I have gone offensive, fighting over everything right away with my brother and my sister; with my mom. ... I get angry about everything." (P4)
"I feel so guilty for not choosing a good hospital for childbirth, and I blame myself."(P11)
Another long-term psychological complications, derived from many participating mothers' experiences, was "post-traumatic stress". This theme emerged in three sub-themes, namely "disturbing thoughts about death", "hyper-arousal of death symbols" and "avoiding the shadow of death". A 43-year-old mother who had a hysterectomy due to maternal morbidity presented her experience of disturbing thoughts:
"After removing the uterus, I thought it was going to happen again with the slightest bleeding. When I went to the doctor, he would say, 'you no longer have a uterus. You have had it removed. What are you afraid of now?' And I would tell him, 'I can't help with it, I imagine the same thing is going to happen again'.(P1)
Another mother with a two-month history of intensive care in the hospital due to kidney failure with hyper-arousal of death symbols experience says:
"For example, just this week, my mother-in-law is going to have her back operated. The thought of those angiocathes, ampoules, doctors, nurses, and their behavior ravages me. I cried so much, I was even more worried for her than even the others and her children".(P3)
Avoiding the shadow of death was displayed by many mothers as avoiding what is reminder of death. In this respect, a mother with a history of three times abdominal laparotomy and then a hysterectomy says:
"I avoid seeing myself in the mirror. I don't want to look at my stomach now because it looks so bad. For example, I hate myself every time I go to the bathroom. I try not to see my belly in the mirror". (P7)
Physical destruction due to the ominous event
In this research, mothers who almost died but survived suffered from short-term and long-term maternal morbidities, which were constantly recurred in their lived experience. Because these mothers have undergone life-saving interventions, including blood and platelet transfusions, repeated surgeries, prolonged hospitalization, hemodialysis, and other paraclinical procedures. Although survived, these mothers have experienced physical destruction and short-term and long-term injuries. Physical destruction due to the ominous event theme implies that the tragic death accident is intermingled with the positive birth event. This theme emerges in three sub-themes, including "Physical degeneration in the path of death", "Persistent Physical decadence," and "Losing Apparent Acceptance". "Physical degeneration in the path of death" depicts the first physical failures that happened short time from MNM event. A mother who has been bedridden in ICU with cardiac and kidney failure for a long time expressed her experience of physical degradation:
"I would sleep in sitting positions and couldn't breathe at all. They had to keep giving me an oxygen mask all the time. Until one day, they consulted with the cardiology section, and they took me there for an echocardiography. There, they came to realize that only 17% of my heart worked, and it could stop beating at any moment. They quickly said that I must be moved to the cardiology section. Then I was in the cardiology ICU. I was there for three weeks".(P8)
"Persistent physical decadence" indicates that persistent physical morbidity such as hearing or memory loss or organ failure remain a mother's lifetime physical burden. A mother who has been in ICU for one month because of neurological failure and coma says:
"I can't walk now. I have no balance. I have no eyesight either. I am blind now. I couldn't see anywhere after recovery. I had lost my short-term memory too and now I'm starting to remember little by little"..(P4)
"Losing Apparent Acceptance" means that in addition to organ failure, the mother does not have the previous acceptance in terms of appearance and aesthetics, and persistent physical morbidities have affected her physical beauty. A mother who is currently experiencing abdominal dialysis owing to kidney failure says:
"I have now sewed a cloth and stretched its top and bottom for my abdominal catheter and skin to be unseen. I wear it permanently. I don't want anything to be seen. I wear a dress that hides my belly when I go to parties. After all, my body has changed in terms of aesthetics. It is very hard to see my appearance messed up like this"..(P8)
The vicissitudinous life of the back-to-life mother
The experiences of the participants in this study show that not all mothers who came to the hospital intending to give birth return with the same previous conditions. Rather, they are discharged after experiencing the most severe and indescribable conditions, with new living conditions different from former ones. These issues force them to live a vicissitudinous life. This sub-theme itself has emerged in six further sub-themes, revealing the new conditions directing the mother's life. These sub-themes include "Deviating from the direct road of everyday life", "Shadow of disaster on mother's acquaintances", "Ambiguity of the future", "Social distancing", "Sacrificing wealth for health" and "surrendering oneself to divine fate".
The "Deviating from the direct road of everyday life" subtheme that was engaged in the all mothers lived experiences, was derived from the six common meanings mentioned in the following. One of these common meanings is the demand for permanent and exhausting follow-up of the therapeutic process that is tiring to the mother. A 23-year-old mother with neurological failure says:
"Well, it is hard for one to always be sick and keep going to the doctor and the hospitals. Until now, I've had three brain angiographies. These things put me off work and life". (P4)
Some mothers, due the chronic psychological problem, feel that their life is not normal, so constantly strive to reduce created outcomes.
After a hysterectomy, a mother says:
"Most importantly, I couldn't eat at all. Nothing would go down my throat. My doctor said she was depressed. If I hadn't gone to the doctor to get treatment, I wouldn't have been able to pull myself together".(P5)
Some other mothers stated it was quite time-consuming to return to normal life. Regarding the theme of "Late normal-life obtaining", a 43-year-old dialysis mother says:
"I would wash clothes, but I didn't feel like collecting them back. Dishes would be stacked, and house works remained undone. Until I got dialysis, things started to improve a bit. I got better and my energy recovered".(P10)
Most mothers stated that they could not perform normal life activities and that their physical and psychological changes had upset their everyday routine. A mother with a two-month history of coma says:
"I haven't cooked since then. But it's been about two weeks since I managed to take bath by myself. Also, it has been around a month that I can go to the bathroom by myself". (P4)
About depending on the help of others, according to the doctor's advice, these mothers cannot independently manage life duties as before. Thus, someone must steadily support and aid them.
"The doctor told me to take an absolute break this year. I can't lift more than two kilos. I can't even hug my baby" (P7), says a mother with a bowel perforation and mesh abdominal wall insertion. The subtheme "Trying to quench the baleful reality of life" suggests that some mothers, notwithstanding the complexity of home affairs and duties, try to somehow demonstrate their previous strengths, and cover the catastrophic reality of life behind a wholesome look, until they quenching the extent of the existing disaster. A 31-year-old dialysis mother says:
"I have to do my responsibilities by myself now. Some people see me from the outside and say, 'Oh, don't let her work' but I have to do my work, go to the doctor, go to dialysis, get parties, do house cleaning independently. This is my life routine. I can't ask for help from others every day".(P8)
The "Shadow of disaster on mother's acquaintances" subtheme, derived from the statements of many mothers, designates that the bothersome incident that happens to the mother affects her husband, family, parents, and her previous children, its negative effects are imposed on those around her, unwantedly. The outcomes of this event directly affect her marital life. Some aspects of hurt marital relationships include sexual relationships, childbearing behavior and decisions, and psychological responses, such as depression and stress in the spouse. Some mothers stated that this directed to marital intimacy and positive emotional outcomes between the couple. A dialysis mother speaks of her sexual relationship change, "Our intercourse was simply cut off for nearly eight months. Even now it's very low and about once a month".
Another mother with a daughter and emergency hysterectomy, speaks of changing future childbearing decisions:
"My husband and I weren't on speaking terms for a while. Because he wants a boy and I have no uterus to have a baby. All our earlier arrangements to have a baby changed".(P11)
Spouse's negative psychological responses were manifested in different forms. A mother with an emergency hysterectomy experience says:
"My husband is depressed now. Insofar as when the name of the hospital comes up, he feels pretty bad. He doesn't want me to talk about those bad memories anymore".(P7)
"Shading of the ghost of death over families" was one of the common meanings of this sub-theme. A mother with a history of three months in an ICU says:
"our entire village was touched by my illness. My uncle, dad, and mom got depressed. The entire village was weeping for us." (P2)
Another dimension of this ambiguity, especially in times of emergency and MNM crisis, was the worries about their dears' and children’s future after their deaths.. A mother with heart failure says:
"I'm always worried for them (parents, spouse, and children), I'm not worried about myself at all. I always say, 'mommy, daddy what have you been through?!, what did you do back then in similar situations?' I keep saying 'oh my God if I am not here anymore, what is going to happen to them?" (P8)
The next theme, "Social distancing", depicts the social burden that this event puts on their lives, and they are unwilling to have healthy communication with other because of different physical and psychological reasons. In this regard, a 23-year-old mother says:
"My connections with others have become much less and I speak less. I am no longer in touch with my friends. I told them not to call me anymore because I don't feel like talking".(P3)
The other theme is "Sacrificing wealth for health": these mothers have spent all their money and financial savings of their marital life to achieve their previous health, and they have suffered an economic fatal blow. The incident imposes tremendous costs of hospital and paraclinical measures, tests, medication, and so on. A mother with a three times history of ICU says:
"We had a piece of land and a house and two cows. My husband sold them because of my situation. There was no more money left until my husband was forced to sell my gold without me knowing. Now my father is supporting us mostly".(P7)
The subtheme of "surrendering oneself to divine fate" indicates in mothers' experiences, surrender to fate has never been ignored and resorted to God to reach their previous health and wellbeing. A 23-year-old mother who had undergone hysterectomy following severe PPH speaks about her husband's reaction to her illness, "When I was discharged from ICU, he was in Imam Reza shrine, sitting there until the very morning and crying and praying, 'Imam Reza, I want my wife from you'. (P7)
These mothers practice spiritual methods and closeness to God to bring about greater adjustment to tolerance and acceptance of the hardships of life. About the common meaning of attention to spirituality, a dialysis mother says:
"Well, for example, I recite the Qur'an at the same time as dialysis and I think of God. I try to make even the dialysis somewhat spiritual. Remembering God will help me to cope better with dialysis".(P8)
Finally, the conclusion from the mothers' experience shows that all aspects of the lives of mothers who have suffered an MNM event due to maternal morbidity have been smeary-death. Plus, encountering death and its adverse outcomes leave a negative psychological, physical, economic, and social experience for the mother, had been deviated her from the direct path of normal life.