The characteristics of the participants
Of the 16 women interviewed, the mean ± standard deviation [SD] of age was 31.94±3.90. The age at BC diagnosis among the participants ranged from 20-33 years (mean± SD= 25.81± 3.50). The marital length among participants was 8.56±4.70 years. Eight participants had an academic degree, and four participants were employed. Among 16 participants, only two reported a family history of cancer. Five participants had a unilateral mastectomy, and in additional participants breasts were preserved. The demographic characteristics of participants are shown in Table 1.
In this present study, the data saturation occurred after 14 semi-structured interviews, but for more certainty, two other BC survivors were also interviewed. Initially, 750 codes were extracted and after dealing with them according to the research objectives, the codes were classified into six main categories and 13 subcategories. The extracted categories and subcategories of the research are shown in Table 2.
Category 1: Pregnancy and childbirth problems
This category includes two subcategories of maternal physical health problems and fetal-neonatal health problems.
1–1. Maternal physical health problems
Some of the participants suffered from nervous system problems such as severe headaches, feeling weakness and tiredness, and inability to perform daily activities, and digestive system problems such as hyperemesis gravidarum and stomachache.
A 31 years old woman expressed:
- I had severe headaches during pregnancy. Although I had these headaches before, they only got worse (Participant No. 5)
Feeling weakness, tiredness, and the inability to perform daily activities were other problems reported by most of the participants during pregnancy.
In another 28 years, women stated:
- I had severe body pain during pregnancy and felt weakness in my body despite pf using vitamins and Iron. Although now I am a little better, I get tired and lethargic very soon. Cancer has weakened me and decreased my body tolerance (Participant No. 6).
The hyperemesis gravidarum and stomachache were other complaints reported by BC survivors similar to other pregnant women. In addition, they said that they experienced nausea and vomiting during the adjuvant therapy, experienced these symptoms again after completing treatment was bothersome, and worried them regarding the disease recurrence. In this regard, a 32 years participant shared:
- I had missed the period for two months but I thought my irregular menstruation was due to treatment side effects. Every morning I had severe nausea, and I got upset. My mother said your symptoms look like a pregnant woman. Due to her insistence, I took a test and was pregnant (Participant No. 2).
1–2. Fetal-neonatal health problems
Participants in the research raised maternal concerns regarding fetal health, such as uncertainty about the possible side-effect of oncological treatment on fetal growth and health and fear of miscarriage and fetal abnormalities.
One of the 32-year-old participants said:
- I am worried given I took various drugs during the treatment process, my baby is healthy? He has grown well or was born with defects. What should I do? Although I went for ultrasounds regularly, this stress was with me until delivery (Participant No. 10).
Despite most of the participants reporting that they had a pleasant delivery with a healthy newborn, some of the BC survivors reported neonatal outcomes. One of the 25-year-old woman declared:
- At 34 weeks of pregnancy, my amniotic sac ruptured at midnight. My husband took me to the hospital, I had a cesarean section delivery, and my child was hospitalized in the intensive care unit due to difficulty in breathing (Participant No. 1).
Another participant stated:
- After giving birth, my daughter had hospitalized due to jaundice and I had to stay full time in the hospital with feeling weak (Participant No. 9).
Category 2: Maternal mental health problems
This category consisted of two subcategories of fear of death shadow over life and duality of feeling. Most participants had psychological concerns about their disease condition and their child's future.
2–1. Fear of death shadow over life
Fear of the child's future, fear of disease recurrence, and fear of sudden and early death during pregnancy were reported by participants. One of the participants said:
- When I got pregnant, the first thing I was concerned about was the pregnancy outcome and my fetus status because when I visited the physician, she told me that there was nothing 100% for me (Participant No. 11).
Also, the content of the interview showed that the fear of disease recurrence and death after delivery and motherless child growing up were the most common concerns among participants of this study. In line with this concern, a participant told that:
- I was afraid that when my child was born, my disease recurrence and, I would die soon, and my child would be motherless (Participant No. 2).
Another participant said:
- During pregnancy, when I have heartache with my husband, I always tell him I am afraid that I will die after giving birth, and ask him what he would do then, how would he raise the child without me? (Participant No. 3).
2–2. Duality of feeling
The participants declared that the occurrence of pregnancy after the treatment of BC led to contradictory feelings for them hence, some of them represented the feeling of strength and failure simultaneously and a sense of endless happiness and sadness. Although experiencing motherhood was considered a strength however, fear of inability to breastfeed and the sense of inability to perform motherhood duties were stated as failures among some of the participants. In this regard, a 26-year-old mother said:
- Diagnosis of cancer was a big failure in my life. Although experiencing pregnancy made me hopeful about life but fear of the possible inability of motherhood roles, made me stressed and depressed (Participant No. 13).
Another participant with no history of pregnancy before cancer diagnosis expressed:
- A child is like a valuable thing that a person has and becoming a mother gives me a sense of strength (Participant No. 8, 32-years-old).
Category 3: Social problems
Pregnancy as a stressful event led to social challenges among participants. This category comprised of two subcategories: social isolation and job problems.
3-1. Social isolation
Some participants reported endless loneliness and fear of stigma during the pregnancy. Some of these women reported that experiencing the stigma of infertility during treatment and inducing a sense of imperfection by f and friends, led to social isolation during pregnancy. A 31-year-old woman stated:
- After I became pregnant, I isolated myself from society and distanced myself from all my friends, because I was a sick pregnant mother, and I felt they were treating me with contempt and this bothered me. I felt lonely a lot (Participant No. 13).
Also, another mother said:
- I always heard from familiar that she can't get pregnant after cancer treatment. This stigma of being infertile bothered me a lot. When I got pregnant, I was worried that my baby would miscarry for any reason and they would say that she could not protect her pregnancy (Participant No. 5, 31-year-old).
3-2. Job problems
The participants represented that pregnancy led to losing a job due to the frequent absences from work and difficulty in finding a job due to a history of cancer. A 34-year-old woman with no child before cancer diagnosis regarding the job challenges, declared:
- My physical problems and cancer treatment made me feel so weak that I had to take a lot of leave during my pregnancy (Participant No. 13).
Also, another participant said that a healthy medical history is one of the crucial conditions for working:
- When a person gets sick, she loses all her chances in life (Participant No. 7, 38-year-old).
Category 4: Marital instability
Marital instability is one of the common experiences of BC survivors during pregnancy. This category included two subcategories: sexual problems and fear of losing marital life.
4-1. Sexual problems
Several women reported during pregnancy encountered sexual problems such as a lack of sexual desire, and frigid and compulsive sexual intercourse. Also, some of them declared that they had no sexual intercourse according to the agreement with their husbands during the pregnancy. A 30-year-old participant with no history of pregnancy before cancer said that:
- Although due to the high sexual desire of my husband, I had to have compulsive sexual intercourse sometimes, the frequency of our intercourse decreased considerably, and during the sex, I intended to finish it quickly and I got tired (Participant No. 10).
A 31-year-old woman declared that:
- My husband told me if I have no desire for sexual intercourse during pregnancy, I do not want it either, and we will wait until I feel better psychologically and physically, and then we'll do it (Participant No. 3).
4-2. Fear of losing the marital life
Some participants faced various fears and concerns during pregnancy regarding their marital relationships, such as worried about divorce and fear of their husband's betrayal during pregnancy.
In this regard, a 28-year-old woman with experience of pregnancy expressed:
- During the cancer treatment, my husband's family had a conflict with me and triggered their boy to divorce me due to my illness. Sometimes during pregnancy, I doubted my husband that he might be in a relationship with anyone (Participant No. 6).
Another participant also expressed that:
- I had a problematic treatment period, and my husband was very annoyed. I had an impaired physical condition during pregnancy. I was afraid that my husband would get tired, and I lose my marital relationship and this issue led to severe stress for me (Participant No. 13, 34-year-old).
Category 5: Need to support
Pregnant women, especially women with a history of serious illness such as cancer, need support to pass the stressful event such as pregnancy successfully. The need for a husband's support, need for family's and healthcare provider's support was the most common needs of the participants mentioned in this study.
5-1. Need to husband's support
The majority of women declared that their husband is their life's shoulder and mentioned the considerable miraculous role of a husband's support during their pregnancy. A 36-year-old woman declared that:
- During pregnancy, my husband was as if a mountain behind me, his attention and presence beside me in each gave, give me confidence and a feeling of strength (Participant No. 14).
Another woman who experienced the support of her husband through this period said:
- Every time I was silent, my husband told me "what you're thinking about, tell me, so that your mind calms down" (Participant No. 8, 32-year-old).
5-2. Need to family's support
The emotional and financial support of family was the main support reported by the participants during pregnancy. The presence and accompany of the family during treatment and pregnancy visits, assistance in daily activities, and responsibilities have been declared by the majority of the participants in this research. In line with this subcategory, a 33-year-old participant who experienced pregnancy 6 months after completing of the treatment stated:
- My family was always beside me and followed my health status. They did not let me get tired and think about anything. They told me that you are powerful and you can easily endure any hardship (Participant No. 4).
A 25-year-old participant with history of two abortions before diagnosis of cancer said:
- I had a husband who was unemployed and did not accept any responsibility for me. My family paid for all of my treatment costs and also pregnancy visits and checkup costs (Participant No. 12).
5-3. Need for healthcare provider's support
One of the most critical needs and concerns of patients was receiving informational support regarding the prognosis and complications of cancer during pregnancy. Some of the participants had complaints about the unacceptable level of informative and psychological support of healthcare providers during the pregnancy visits. In this regard, a 30-year-old participant who experienced pregnancy two years after oncological treatment said:
- I expected my doctor to allocate more time for me to answer my questions during pregnancy visits because I had no technical information regarding the pregnancy outcome in BC survivors (Participant No. 10).
Another 38-year-old participant declared that:
- Uncertainty regarding the disease status during pregnancy and the pregnancy outcome due to lack of informational support from physicians led to severe anxiety for me (Participant No. 7).
Category 6: Need to resort to spirituality
The need to resort and trust to God and trusting Imams, Prophets, and the Qur'an in a challenging situation, were essential issues that were reported by some of the participants.
Many reported their disease allowed them to acknowledge and appreciate their life, feel close to God, and believe in God's miracles during their disease and pregnancy made their life meaningful. A 38- year-old woman said:
- Before the diagnosis of cancer, I had an infertility history for several years. When I got pregnant so quickly after the BC treatment, it was like a miracle of the resort and trust Imams for us (Participant No. 7).
In addition, another participant stated:
- Experiencing pregnancy and motherhood is a great blessing. I thank God for this event every day (Participant No. 2, 32-year-old).