Motherhood as a Double-Edged Sword: A Phenomenological Exploration Into The Lived Experiences of Incarcerated Pregnant Women

The global number of women in prison has increased in recent years. Some of these incarcerated women experience pregnancy. Pregnancy in prison has a great impact on the experience of mothers and can affect women’s role in motherhood. This study aimed to understand the meaning of motherhood in pregnant prisoners. The present qualitative research was carried out using a descriptive-interpretive phenomenology via interviews with 11 pregnant or early postpartum women in prison. The participants were purposefully selected from incarcerated pregnant women in 2020 in Iran. Six-step Van Manen’s phenomenological approach was used for data analysis.

mothers can't play a maternal role. Since incarcerated mothers themselves are confused about the challenge between criminal behavior and maternal duties, prison restrictions also put these women under increasing pressure and unable to be ideal, complete, or even normal mothers. In fact, the confrontation between criminal and maternal role on the one hand and the feeling of stigma and discrimination, social isolation, loneliness, the prison environment, and culture; on the other hand, has changed the concept of motherhood in the minds of women in prison (9). The relationship between maternal identity and feelings, which result in communication with the child, is very strong. Based on Olds et al (2016), motherhood is de ned as "having a feminine sense of self "and this identity is created when mothers' feelings are respected, valued and understood. He believes that motherhood is the result of one's own feeling and that feeling is inseparable from the living world which one experiences (10). In the interviews with mothers in prison in the western United States, many women talked about their maternal worries and anxieties in prison; include: tolerating the stresses of lack of proper care and welfare facilities for their children, inappropriate treatment of prison staff, being chained and handcuffed in front of their children or while they are in their arms, complications which result from childbirth and breastfeeding (11), compliance with strict prison rules (12) and most importantly, fear of separation from the child and concern about the effect of prison on his/her health and future. The results of these interviews show that mother's experience in prison causes anxiety, sadness, and lack of motivation, and these women need help adapt (13). Since pregnancy is the beginning of motherhood, its initial experiences play an important role in forming the maternal identity (14). Studies about maternal identity in prison showed that women in prison are caught between two identities of mother and prisoner and try to separate two identities.
Separate either their motherhood from the world of prison or their imprisonment from motherhood's world. Findings' uniqueness in this area suggests the need for further evaluation in this area, as the feelings experienced by incarcerated mothers are different from other experiences of incarceration (15,16). Since one of the challenges faced by pregnant prisoners is related to their maternal feelings, the discovery and recognition of this phenomenon in the criminal justice system and the context and environment in which the prison is located are among the issues, which needs to be addressed. Also, because giving voice to the incarcerated pregnant women are always the richest and best way for understanding the experience of motherhood among pregnant prisoners (17), using phenomenology, it could be possible to easily re ect the meaning of experiences and emotions of these women from a different perspective. This approach helps to gain a deeper understanding of the phenomenon under study, and to grasp its meaning and interpret it (18). Since the experience of motherhood is related to the speci c social and cultural context of each society, individual responses to this phenomenon can be varied in different social contexts, based on different cultural norms (19). On the other hand, little research has been conducted in different countries on the experience of motherhood in pregnant prisoners (13,16,20,21).

Aims
To the best of our knowledge, in Iran, no report on understanding the experience of motherhood in prison was found in the literature. Therefore, this study aimed to understand the meaning of motherhood in prison based on the experiences of incarcerated pregnant women.

Design
Descriptive-interpretive phenomenology adopted by Van Manen (1997) was the methodology used in designing the present study (22). In the phenomenological research, researcher tries to understand the lived experiences of participants. Van Manen tried to provide phenomenology in a contemporary and modern way in six steps, Which was followed in the current work (23). The effort to understand descriptive -interpretive phenomenology begins with the researcher's orientation towards a phenomenon and its return to its nature .The researcher moves towards the lived experience that made it and asks" ,What is this experience like. The researcher, as an active participant, is immersed in research and phenomena and frequently returns to phenomena, data and texts. In phenomenological research, the researcher clari es several assumptions that govern the research and potentially what can be discovered (24). The main researcher explained her assumptions and understanding of the phenomenon in order to understand the hidden meaning in the participants' experiences.

Setting
The study was conducted at Central Prison of Mashhad (Vakilabad Prison), Iran. This prison currently houses approximately 700 women. Forty to 50 inmates are pregnant at any given time. The prison is comprised of twelve resident buildings with security levels ranging from low to maximum.

Participants
Participants were selected to enter the study using a purposefully method with a strategy of maximum diversity. Eleven participants ranging in age from 21 to 42 years (mean age: 32 years were recruited. One woman was pregnant for the rst time. Two women were pregnant for the second time; however, one of them, her rst pregnancies was an abortion. The other eight women had each been pregnant between two and ten times. Of these pregnancies, individual participants had birthed between one and eight living children (Four participants were currently living with their child). Nine participants intended to raise this child upon their release from prison and two planned to place her newborn to state welfare organization.
The length of incarceration ranged from one month to 6 years.

Data collection
After obtaining permission for main researcher to attend women's ward of Central Prison of Mashhad, interview process began, but before it, this study aimed to explain the participants and written consents were achieved. Sampling duration was from August 2019 to May 2021. Necessary explanations were provided regarding the right to participate in the study or refuse it, and con dentiality principle of information. The interviews began in a semi-structured way with questions about why participants are incarcerated, and continues with questions such as "How did you end up in prison"? In addition, questions like "What is the experience of being a mother in prison like? What does it mean"? The interviews lasted from 30 to 50 minutes. Following the law of non-recording of interviews in prison, researcher was forced to take notes during the interviews. Sampling was continued until data saturation in phenomenon eld. The sampling became persevered until no new information could be added to the codes and data saturation concerning the examined phenomenon became reached. The researcher used narrative anecdotes during the interview to further re ect on the methodology of studying and analyzing data. MAXQD10 software was used to facilitate data management.

Data analysis
Data analysis was conducted primarily based totally on the research activities: 3 to 6 in van Manen's methodology. Within the holistic approach, every transcript turned into rereading several times, and after a well-known understanding became derived, the researchers formulated their perceived sense of the transcript as a descriptive text. Then, the descriptive textual content turned into once more reviewed numerous times, and an one-or two-phrase review of the textual content turned into written the use of a phenomenological approach. Subsequent, the phrases or statements that would unfold the phenomenon in query have been written down according to the selective approach, for that reason allowing the extraction of thematic sentences or paragraphs. Within the detailed approach, the researchers study the transcripts line through line after which extracted key phrases or terms related with worrying for incarcerated mothers. After the thematic phrases have been extracted, the basic contents of every interview have been in comparison with the ones of preceding ones to discover similarities. The contents were then categorized into subthemes primarily based totally on their similarities and interrelationships.
The subthemes had been additionally integrated in line with their interrelationships, from which the main themes emerged.
One of the research activities recommended by van Manen is balancing the research context by considering parts and whole (22). Given the signi cance of this issue, the researcher did a reciprocating motion between the whole and the parts via way of means of bearing in thoughts the pursued the research question in any respect tiers of a study.

Trustworthiness of Findings
To meet the standards of orientation, strength, richness ,and depth in relation to the quality of qualitative studies (23), the rst author tried to establish a good relationship with women in prison and gain their trust. Furthermore, she tried to discover meaning behind data by studying the data regularly and repeatedly. Lincoln and Guba's criteria including credibility, dependability, con rmability, and transferability were also considered (24). The opinions of research team members were applied in obtained documents. Hermeneutic participatory discussions among researchers were also used to increase data credibility. Besides, the experience of research team in the eld of qualitative research and clinical practice helped to provide more credibility to the study. For more reliability, we tried to explain and analyze data in more details. For veri cation, the text of some interviews along with codes and topics were provided to supervisor (who is a faculty member and an experienced qualitative researcher) and she approved the process. All documents were reviewed and approved by three other faculty members outside the eld of study. To maintain the transferability, we tried to provide detailed explanations of context and ndings so that readers can decide whether to apply this knowledge in another context. Province. In addition to obtaining written consent, participants were reassured that they could stop and leave the interview process at any time they wished.

Results
"Motherhood, as a double-edged sword" was a theme, which emerged in relation to the experience of motherhood in prison. This theme tells the story of a mother being imprisoned in a dual world, in which mothers are torn among motherly feelings for their child and motherhood anxiety and cannot be sure of their future and that of their child. This theme consists of two sub-themes, "Moving in a circle between togetherness and separation" and "Being subject to ambiguous and illusory thoughts". The summary of emerged theme and sub-themes are shown in Table 1.

Moving in a circle between togetherness and separation
This theme describes the feelings and instinctive response of women in prison to the experience of motherhood. This concept refers to the emotional con icts of women in prison with the child inside them. When these women realize the existence of their child, this connection and closeness immerse them in a range of different emotions, but in the desperation of reaching and separation, they are forced to accept a feeling, justi cation, and conclusion. This theme consists of two themes of "From alienation to oneness with the unborn child" and "Perpetual trepidation about being separated from the child".
From alienation to oneness with the unborn child For many women, motherhood in prison was a kind of confrontation with positive and negative feelings towards someone who has not yet been born. In fact, this concept illustrate a complex and deep passage of the feelings of women in prison, who spent their entire pregnancy inside the prison and had no mentality about the outside world except for their limited insight.
The feelings of imprisoned mothers were owing in a circuit from the bitterness and poison of alienation and disinterest in the child to the sweetness of intimacy and attachment with him /her and were constantly repeated.
A 26-year-old pregnant participant who is the mother of three daughters says that she suffers from the lack of love and affection for her son's fetus and her unwillingness to communicate with him. She does not know if the reason for this apathy is due to a change in her living environment or a change in her child's gender: "I do not like him at all. I like my daughters who are out of here very much. However, I do not like this boy. I do not know, maybe because he is a boy, I do not like him. Unlike the previous ones, I do not talk to him at all. "Only when he moves, I realize he is still alive." (Participant 3, G3L2).
For another participant, motherhood is not associated with any affection. In fact, she did not want to be involved in any feelings about her child. The hardships and sufferings of imprisonment caused her to nd it unreasonable to spend her emotions thinking about having a child and caring for him/her: "I do not have a special feeling for her. I honestly suffered so much here that I do not think about these feelings and such things anymore, and it does not matter to me at all. I was like this during my pregnancy. I was forced to hug her when I gave birth because I don't want her." (Participant 6, 38-years-old, G3P3) Some women expressed a sense of alienation from the creature, which grows in their womb. They believed that prison covers their motherly feelings and they are strangers to their children. They had no desire for her, and what they do, as a mother was only a matter of duty: "I feel she is not my baby. It is not my skin, esh and blood. I felt the same way when I was pregnant, as if someone else's baby was in my womb." (Participant 4, 31-years-old, G3A1P2) For another participant, motherhood was a mountain of responsibility on her shoulders and brought her new problems. They thought that when a child is born, the problems of the prison would be less visible compared to the di culties they are facing with in the current circumstances.
"I feel I have a great responsibility. Because this child does not have a father, I have the responsibility on him all the time, I do not want to be dependent on anyone, but raising a child alone is very di cult here, pregnancy in prison is very di cult, but when your baby is born, it gets harder. " (Participate 7, 21-yearsold, G1P1) For some individuals, life in prison was like a box full of regrets and dreams, but they loved so much the child inside them and their motherly instinct was so strong that it neutralized all these miseries and dissatisfactions.
"I watch the whole day until nightfall, and the lights are turned off so I can be alone with my child. Perpetual trepidation about being separated from the child The separation from the child was interpreted as one of the biggest prison pains for mothers. Interviews with pregnant mothers were conducted while each of them was waiting for expected separation from their child. Some of these women were planning for their separation, and some were desperately waiting for a forced separation. They all expressed their concern about the separation of child, whether this separation becomes a reality or not. The common expressions used by these women evoked fear, doubt, and anxiety. The unpredictability of the status of their sentence and the uncertainty of the time of their release was a lever of pressure for separation. Although the instability about punishment and freedom is a common experience in prison, it is undoubtedly the most stressful part of pregnancy for these women.
Participant No. 5, whose release status was unknown, revealed the stress of night and her insomnia because of thinking about her child and imagining a future of growing up without his mother: "I'm anxious…, I cannot sleep at night. I always think about my child, how long he will stay with me, and what will happen to him if I am not released. "(38-years-old, G2A1) Many women were at a crossroads of doubt and uncertainty. They did not know what decision make for their child, keep them, or leave them to welfare organizations, in the circumstances that they have forced to sentence their child to life. They thought that if they put him in a welfare organization, they make the child entrapped in loneliness, and if they keep him, they lock the child in their own world in prison.
Participant No. 2, while promising early release, did not know what would happen to her child: "I think about him a lot. To put him in a welfare organization, to be going to a big place that ... is a sin. Sometimes I think that I want to give him to a welfare organization at all so that one day he will feel like me that there is no family at all. "That's why I might have to keep him in jail." (28-years-old, G3L2) Participant No. 4, who had just given birth, was anxious about permission to keep her child in prison. She believed that she has to take care of her child, because outside the prison environment he would suffer from loneliness: " I'm very stressed, I do not know if they will let me keep the baby to myself or not. I just want to keep him to myself, because I do not have anyone outside to take care of. " (31-years-old, G3A1P2) For women who could keep their child with them for up to two years legally, the idea of separating from their child after that period was very painful. The thought of being separated from a part of their being causes them to accept the hardships of caring for a child but not to be separated from him: "I do not even imagine that my child will be separated from me. I know that I can legally keep him with me for up to two years, but I know how di cult it is to take it away from me. It does not matter how many children you have. "It is very di cult to do it." You are ready to keep him in this environment, but he will not leave you." (Participant 1, 35-years-old, G7D2P3A2)

Being subject to ambiguous and illusory thoughts
The notion of motherhood was lost for some women in prison. For some women, becoming a mother might be easy in prison, but motherhood was di cult. For women in prison, motherhood was the beginning of overwhelming concerns. This theme consisted of two themes of "Grappling with obscure dreams of giving birth" and" Belief in an honorable defeat".
Grappling with obscure dreams of giving birth Some women in prison went to bed with anxiety about childbirth and slept through nightmares.
"I constantly sleep with the stress of childbirth, I am always afraid that one night, I will be in pain and no one will help me. One of the women who was pregnant here gave birth so late that her baby was born in the salon here, and there was no one to help her." (Participant 6, 40-years-old, G3P3) For participant No. 5, who was only 10 weeks pregnant, the idea of giving birth in prison was a painful memory for a lifetime: "I cannot accept to stay in prison and give birth here at all; it becomes a bad memory which stays with me all my life, so I try my best to get out of prison before giving birth." (38-years-old, G2A1) Women in prison faced a sense of lack of control over their pregnancy and childbirth. They did not know where to give birth, who will give birth to them, who will support them, and what will happen to them and their baby. They complained that they are forced to suffer from the cold and unsympathetic behavior of the escort o cers when they go to hospital: "I want my body to be in control, I do not want anyone to constantly growl when I am going to give birth to get an ambulance." (Participant 3, 26-years-old, G5L3D1) Feeling of being unable to have a normal delivery and passing the labor without any support and companionship and lack of choice in the mode of delivery were other mental concerns of women who experienced shortly the phenomenon of motherhood. They frightened of the behavior of hospital staff, to the extent that they felt they are endangering their lives by leaving them or their baby to them: "I was constantly worried about being able to give birth naturally. I kept telling our doctor I could not. Especially since I was afraid of the attitude of staff at the hospital, I did not want to leave myself to them and put my baby in danger." (Participant7, 21-years-old, G1P1) For some persons, the fear of childbirth and the unknown issues as well as their loneliness made them scared and angry: "I was very, very scared before I gave birth, but now I'm just angry, that I have no one and I'm alone here." (Participant 1, 35-years-old, G7D2P3A2) Fear of childbirth is doubled for women in prison when they think they are pregnant in bed and chained, in which case it is unknown to them whether they are in labor or in severe physical and mental pain. It may be easier to die, or at least wish for death, than to endure the pain of being chained: "I know that if I want to go out of prison for childbirth, they will handcuff and tie me. At times like this, you do not know whether to take your pain or the pain of handcu ng and tying, as if the pain of childbirth doubles when I think about it. "It's better to die. It is much better when a person can easily give birth without a bracelet." (Participant 8, 41-years-old, G6L5) Belief in an honorable defeat The manifestation, which is usually presented of motherhood, is always heartwarming and desirable. It is very proud that one can have a living being in one's womb and consider oneself as two people instead of one, but the motherly moments of women in prison were full of accepting fruitless efforts in performing motherly duties, because of the lack of prison facilities. It did not give them permission to provide what they are trying to provide for their child, only possibility they had was the unconditional love they could give their child: " I think I can never be a good mother to her. I always feel that I cannot do my job the way I want to as a mother, because there is nothing you can give your child, there are no facilities and only thing I can do is to love him." (Participant 2, 28-yrears-old, G3L2) Being born requires self-sacri ce and effort. One life is formed in exchange for the loss of another life. For some participants, a mother in prison was the opposite, that the prison wall overshadows the image of the mother in front of child, causing the child to be ashamed of mother and to blame her: "I'm worried that these memories will linger in my child's mind, his mother was a prisoner and spent his childhood here in prison because of me. I do not want him to be ashamed of me as a mother when he grows up." (Participant 1, 35-years-old, G7D2P3A2) Although women in prison did not forget that motherhood has its own beauties, they frightened that the child will ignore their tireless sacri ces, which they endured in prison to get the same bit of beauty. These women did not want their daughter or son to one day build a wall between what they felt in prison or the forced separation they endured, and to base their future relationship: "I want my child to remember that his mother endured so much hardship because of him and made this sacri ce for him. Everything I did was just for my child." (Participant 2, 28-yrears-old, G3L2) Some mothers, despite all di culties which childcare brings to them in prison, did their best in this direction, to the extent that the law and circumstances allowed them to do so, but for a moment. It turns out that they were forced to donate their child to a family member outside the prison against their will, and if they were deprived of this blessing, they have to leave the child in the hands of a welfare organization. Separating from mother to child may be di cult, but it was thousands of times more painful for the mother.
"I will keep my child with me for as long as I am allowed for two years, but then if someone is not willing to accept him, I will have to give him to a welfare organization. Although it is di cult for a child to be separated from his mother, it is a thousand times harder for me. "I do not want my relationship with him to be ruined." (Participant 11, 32-years-old, G2L1)

Discussion
This study aimed to identify and understand the meaning of motherhood in prison. "Motherhood, as a double-edged sword "was the main theme and "Moving in a circle between togetherness and separation" and "Being subject to ambiguous and illusory thoughts" were two sub-themes describing the phenomenon of motherhood in the prison. Regarding the main theme of the present study, the meaning of motherhood for women in prison was to wander in a world where, on the one hand, there is hope and enthusiasm for bonding and fear of separation from the child they are looking forward to, and on the other hand, anxiety and hidden fear of maternal unknown issues ahead. In fact, the mother's experience in prison can be compared to a double-edged sword. According to other studies, there are in fact two distinct perspectives on the narratives of the experience of motherhood in prison: on the one hand, children are a source of hope for incarcerated mothers and motivation to cope with imprisonment (7) and on the other hand, the existence of children and their efforts to become mothers becomes a place of anxiety and guilt (25).
According to the theme of "Moving in a circle between togetherness and separation", many women in prison cannot easily communicate with the child on their way. They rst grapple with the inner challenges and turmoil of various emotions, which bind them together, and then face a predictable separation from their child. Studies showed that imprisonment could drastically alter, disrupt, or even end a mother's experience. There are mothers in society who abandon their children for various reasons, but in prison, some women have less empathy and tolerance for their children and are more inclined to leave their children. Prison restrictions have a more negative and destructive effect on the feelings of these women as mothers by inducing emotions such as guilt, failure, stigma, shame, and stress (6, 26, 27). The results of psychological studies indicated that the experience of motherhood in prison imposes more emotional distress on women in prison (28). This psychological distress and confrontation of criminality and motherhood in prison affect women's perceptions and feelings as a mother. Despite all prison restrictions, some women in prison talk about the joy of motherhood. The motherly feeling may be only main motivation for these women to cope with the di culty of separating from child, enduring the daily hardships of imprisonment, and focusing on the future. These women talk about the strong feeling of the need to establish and maintain an emotional connection with their child in prison and how this feeling acts as a catalyst for accepting the role of mother (29). Based on various policies and laws, imprisoned children are separated from their mothers immediately after delivery until shortly thereafter. It causes women to be constantly anxious and stressed about the separation from their children (30). Prison philosophy is based on the concept of separating individuals from society for the safety of others (31).
For imprisoned mothers, it means that part of their punishment is that they are physically and emotionally separated from their children (32).
Under sub-theme of "Being subject to ambiguous and illusory thoughts", women in prison have trouble imagining themselves as ideal mothers. By fear and anxiety, they constantly imagine themselves in a nightmare of childbirth or nd their mother's clothes very inappropriate and ugly. Nevertheless, they sel essly strived to overcome their shortcomings and limitations and offer their child, albeit a simple but not complete, role as a mother in prison. Lockwood (2018) considers prison as a threat to the formation of the mother role. He believes that women in prison face many challenges to create motherly meaning (6). Sykes (2007) stated that the image of women in prison of motherhood is very different and contrasting with the image of a free woman in the society of motherhood (33).
Because many correctional facilities are unable to provide maternity care, pregnant women are transferred to out-of-prison hospitals for delivery. Although there are different policies regarding using bracelets and bindings, most women prisoners are chained to a maternity bed and are forced to give birth in these circumstances (34). Such a scene accompanies the beginning of the maternal season for pregnant women in prison. The physical and emotional stress in icted on them at the moment of delivery and violence in icted on them play a role in disturbing their sense of self-esteem and the image of motherhood in front of them.
For these women, the ideals of "being a good mother" are not realized in prison. The identities of imprisoned mothers are buried in layers of supervision and judgment. These people, who have already been labeled as delinquent and deviant, cause mothers to be known as sel sh and thoughtless women who do not do their job of caring for their children properly (35). Childcare has two ambiguous meanings for imprisoned mothers, one is "care for" and the other is "care of" (36). "Caring for" refers only to the aspect of responsibility and physical performance of maternal duties towards child. While, "care of" is related to the emotional aspect of care and refers to the love and affection of mother even in the context of prison. Thus, the con nement can completely change the mother culture and turn it into a special model of care (37). These two separate meanings often obscure motherhood in prison literature. Since the distinction between duty and love is not clear to imprisoned mothers, they underestimate their motherly performance and nd themselves incapable of ful lling their ideal and perfect motherly role, thus increasing their sense of guilt and ine ciency. Moreover, women in prison are concerned about the impact of prison on their child's fate and future. They feel that they cannot rush to the aid of their child when problems arise, that they are far away from him or her, and that they cannot directly monitor his or her development and take useful action in this regard (30).
In the interviews with mothers in prison, they talked about the fate and future of their children and how prison deprived them of their motherly power and affected their children's lives (38). These women believe that they do what they can to do their job; inside and outside the prison (32) but the structures and policies of the penal system have always attacked their efforts and actively overshadows their motherhood (38).

Limitations
Exploring maternal phenomenon in prison and bringing the voices and experiences of these marginalized mothers to the fore is the strength of this study. However, the existence of internal rules and regulations of the prison regarding the presence of the researcher in the women's ward is one of the notable limitations. Besides, the themes, which emerge in the present study, re ect the experience of a small group of incarcerated mothers, so future research should seek to examine the consequences in a multifaceted way, regardless of the social and selective biases, which limited our research.

Implications For Practice
This study's ndings can affect society's perception of women who become mothers in prison or mothers who are forced to separate from their children. This study's results rea rm the vital role of supporting women in prison. Therefore, if in prison mothers want to be successful in their role and relationships with their children, institutions and organizations are needed to support them.

Conclusion
The emerged themes in this study re ect the experience of motherhood in prison. The ndings and the review of existing literature showed that a mother in prison is a picture of that world. The combination of all confusing emotions results in nothing but confusion for prisoner's mothers. These mothers may look like other mothers who live freely in society, but inwardly they nd themselves a confused and desperate mother. Although, unlike the outside world, motherhood in prison is not as tied to the sacred realms of phenomenon as it should be, it is still beautiful. It is a story that requires endless courage because every concern grows exponentially in the world of imprisoned women. Province. Participants signed an informed written consent, in which they assured that all information provided would be kept strictly con dential and anonymous. Additionally, they were guaranteed that they have the right to withdraw from the study whenever they wished without prejudice.

Consent for publication
Participants were assured that the anonymous of all information provided would be safeguarded in any publication of the results of this research in reputable academic publications. In addition, they were informed that their written narratives published in the articles could be freely available on websites or in print and may be translated to other languages and they have the opportunity to read the manuscript.

Availability of data and materials
The datasets used and analysed during the current study is available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests.

Funding
The present article is a part of a doctorate dissertation the rst author (Somayeh Alirezaei) in Reproductive Health, which is nancially supported by Mashhad University of Medical Sciences, Mashhad, Iran under grant number of 980109.
Authors' contributions SA and RLR provided the concept and designed the study. SA carried out the interviews, initial data analysis and draft manuscript. SA and RLR collaborated with further data analysis, the interpretations and drafting of the manuscript. All authors read and approved the nal manuscript.