Representation of a `positive experience' of surrogacy in Yazd, Iran: A qualitative study

Abstract Background The social and cultural challenges facing surrogate mothers have been explored in several studies. However, few studies have discussed the motivations of surrogate mothers, their expressions and interpretations of their lived experiences, and their feelings of personal and spiritual satisfaction. Objective This study aims to present the positive experiences of surrogate mothers from a phenomenological perspective. Materials and Methods Using a phenomenological approach, this study was conducted from September 2020 to January 2021 in the city of Yazd, Iran. Participant observation and semi-structured interviews were used to collect the data among 12 participants with at least 1 experience of surrogate motherhood. Results Our findings showed that, despite having had harsh physical and socio-cultural experiences such as fear of social labeling and stigma, participants felt a kind of inner satisfaction and a positive view of their actions. A core theme found in the study was mothers' satisfaction. The main categories included feminine self-sacrifice and positive rewards. Feminine self-sacrifice included 2 sub-categories: creating happiness and conveying motherly feelings, while positive rewards included good childbirth, family acceptance, and halal income. Conclusion This study showed that surrogate mothers experience conflicting feelings of inner satisfaction and social stigma during surrogacy. Some of those interviewed were willing to go through surrogacy again, but they feared social labeling and stigma, being misunderstood by others who are not fully informed about surrogacy, and being subjected to family and social disapproval.


Introduction
Family is highly valued in Iranian society and the Islamic religion, and the birth of a child plays an important role in strengthening family bonds (1). Both religious and cultural norms and values reinforce such perceptions. That is why Muslim countries, from Morocco to Iran and other Middle Eastern nations can be described as family-oriented communities in which marriage and childbearing are highly valued (2). One of the factors that can weaken the foundation of the family is infertility. In many families, infertility is a major problem that can lead to stressful experiences and serious psychological problems (3).
In recent decades, many successful attempts have been made to treat infertility using assisted reproductive techniques (ART) such as surrogacy.
The absence of a congenital uterus, failure of repeated treatments, recurrent miscarriages, heart diseases, cancer, or abnormal uterine structure are among the reasons for deciding to use this technology (4). ART pose many epistemological and ethical challenges (5,6). They can lead to emotional effects, physical and financial stress, as well as many moral and legal problems (7,8).
Surrogacy is no exception and is a social and cultural lived experience. The development of the embryo can influence the surrogate mother, in particular their perceptions, feelings, and experiences which are not unrelated to the meanings and concepts produced in the mother's social and cultural world.
Several studies have reported that returning the child to the requesting couple after birth can cause emotional distress in the surrogate mother (7,9,10). For those women who leave the baby, there may be a risk of postpartum depression, as well as feelings of anger or guilt (11). However, some studies have reported that most surrogate mothers have a positive experience of surrogacy and do not suffer the psychological consequences of carrying a fetus (12). From a psychological point of view, they do not have problems or discomfort in delivering the child, and most of them have a morally meaningful or positive experience of this action (13)(14)(15). With about 2-3 million infertile couples, Iran is the only Muslim country where ART have been legitimized by the religious authorities (15,16). This has given Iran a unique position in the Islamic world (13). Currently, 61 infertility clinics (24 public and 37 private) operate in several major cities of Iran such as Tehran, Isfahan, Shiraz, Tabriz, Yazd and Mashhad (16). Although previous studies have examined the feelings and motivations of these mothers, there is still a research gap to explore surrogacy within the socio-cultural context of Iran (5,12,13).   (17). In this regard, it can be said that surrogacy should be studied not as an axiom and independent of nature, but as a social structure. If we want to study the issue in-depth, we must use a phenomenological method and field study as well as participant observation.

Materials and Methods
As the name suggests, to collect data and provide valid interpretation through participant observation, the researcher takes the role of a participant in the social life of the people in the place of interest and in relation to the issue(s) being studied. The purpose of participant observation is to study social behaviors, not artificially or in a laboratory, but in a real and natural environment (18,19).
In this study, one of the researchers initially The researcher tried to interview in a quiet and safe environment. All interviews were recorded on a cell phone and then transcribed.
The 7-step Colaizzi method was used to analyze the data (20). At first, the participants' interviews were read and re-read several times so that the researchers could gain a deep understanding of the contents of the interviews. Then the important statements related to each phenomenon were extracted and the meaning of each statement was also extracted. In the next step, the obtained meanings were classified into clusters of themes.
The researcher then obtained a detailed and complete description of the phenomenon. In addition, the researcher tried to provide a network of concepts and themes about the experience of the mothers participating in the research. The last stage of the Colaizzi's method which was carried out was to present the participants with the findings to test the validity of the research; the researchers were able to further determine the reliability of the data through discussing the research findings with the medical staff at the institute to consider the truth or falsity of the data given the staff's judgment, based on their long experience dealing with surrogate mothers (15).
In the present study credibility, transferability, confirmability, authenticity, and dependability were considered during the process of data collection and data analysis in order to promote the reliability of findings.

Results
Most participants in the study had experienced problems such as social rejection of surrogacy feminine self-sacrifice, and b) positive reward, which is divided into several sub-categories (Table   II).

Feminine sacrifice
All participants showed a strong desire to make the lives of other families happy. Although their own lives might have been full of sorrow and grief, they were very happy that they were giving a gift to another family. The lives of these mothers are often not very good and sometimes they even start their lives completely from scratch thanks to this income, which can lead them to success and wellbeing.
It is believed that when a mother's heart is happy and she wishes well from the bottom of her heart, it is enough for this world and the hereafter.
These women say they can prosper day by day and deliver righteous children to society because they believe that if a child grows up with legitimate money, he/she will surely become a righteous person.
However, there are exceptions to the above, and different views were also recorded in this study.

Respondent number 3 said:
"After all, I am a mother and I would like to give them a good child. For 2 yr now, I have been looking for a family that is both financially supportive and happy with my help to them, and I can experience the feeling of being a mother." (This shows that she was eager to make others happy and to transfer the feeling of motherhood to others.) An observation report stated: "A surrogate mother is ready to go to the operation room to implant the fetus. The infertile mother is standing next to her and is very worried.
She keeps rubbing her hands together, worried that she might not get a positive response this time again because this was the second time they were attempting a transfer. But the surrogate mother, even though she is worried and full of stress tells her: Do not worry so much, trust in God. Hopefully, it will be fine this time and you will have a baby".
Another observation report stated: Positive experience' of surrogacy in Yazd, Iran between the mother and the child that there was a good relationship between them, and her mother also said: My son is very careful about me during pregnancy. He's worried. God bless him". The desire to convey this feeling to others Participant 4: "I want to transfer the feeling of motherhood to another. You know, when you become a mother, you no longer belong to yourself"

Transfer of motherhood feeling
Giving motherhood feeling to someone who cannot otherwise be a mother Participant 11: "Because i am a mother myself, i wanted someone else to feel it too. There is a difference between someone who has a child and who does not"

Positive reward
Justification to make surrogacy problems easier Participant 4: "I have easy pregnancy and delivery"

Easy pregnancy
Relieving pregnancy problems Participant 3: "Fortunately, i bear very easily" Informing the older child, as he/she can understand it, and hiding it from other children Children's support of the mother during pregnancy Participant 7: "For the first 3 months i had varicose veins, and my kids were very affectionate because they had accepted that we had no other choice"

Family acceptance
Husband's support Participant 9: "My husband takes care of the child as our child. He says that this is a religious duty" Divine reward Participant 9: "If you just solve one problem for someone, God will solve hundreds of problems in your life" Halal business Participant 2: "It is very important for me that everything is halal and haram in life. When i inquired, i was relieved and told myself that if it was not halal, the court would not approve it

Halal income
Receiving wages as halal act Participant 11: "I was told that they wanted it to be halal, and it is my right to receive payment for it. I did not say anything at all"

Discussion
Surrogacy is one of the technologies that is now available in many parts of the world, Women who have dreamed of becoming mothers and have never become mothers are now hopeful with this technology. In contrast, a mother who could not even afford to buy bread for her child can now support her family and not be ashamed before her child thanks to the income from surrogacy.
As can be seen from the analysis of the interviews, the surrogate mothers felt satisfied with what they had done and even interpreted it as divine merit. The satisfaction of surrogate mothers has also been reported in other studies, which have found that women who perform surrogacy have described this process as a satisfying experience, as many of the surrogate mothers in these studies expressed the experience of uterine donation in words such as "increased self-confidence" or "increased self-respect" (25,26). There are also opposing views, for example which argue that surrogacy abuses women and creates female exploitation, helping men to dominate women (6,27).
This study investigated the reasons why surrogate mothers are happy with surrogacy.
Surrogate mothers gain new strength to continue life as they increase their self-confidence and hope. They gain an altruistic feeling that they can make another person happy and in return earn a halal income that is approved by society.
Many observers believe that the commercial surrogate mother is contrary to medical ethics (26).
In the present study, the majority of respondents received a salary in addition to payment for the relevant costs.  (30). Therefore, it is necessary for the legislator to define the legal provisions for such contracts. Doing so will put an end to differences of opinion as well as assign tasks to the applicant's families and medical centers.
The findings showed that the surrogate mothers considered themselves empowered in society because they have done a great job and given birth to a child for an infertile woman.
The surrogate mothers gained this sense of inner satisfaction through perceptions of divine justifications and good deeds. They have a dual sense of perspectives. On the one hand, they face many problems. They may not be willing to be recognized in society as a surrogate since this practice is not also welcomed in society. On the other hand, they associate their work with spiritual intentions, and in this way, they get rid of fears, sorrows and challenges, and feel inner satisfaction.
They gain a sense of forgiveness, helpfulness, and hopefulness by giving a motherly feeling to others and fulfilling the wishes of others, creating an objective and tangible justification for themselves.
Finally, we believe that the participants were trying

Conclusion
The present study showed that surrogate mothers are happy with their decision for economic, religious and altruistic reasons. Some