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Unintended pregnancy, Abortion, Qualitative research, Iran, What&,rsquo s Known Unintended pregnancy is a prevalent issue in Iran, influenced by a range of cultural, social, and economic factors. Women often face significant emotional challenges and societal stigma, which impact their decision-making regarding whether to continue the pregnancy or seek an abortion. Furthermore, limited access to reproductive health services exacerbates these challenges, highlighting the necessity for targeted interventions to provide better support. What&,rsquo s New This meta-synthesis integrated 22 qualitative studies, which involved over 600 interviews with Iranian women, to explore experiences of unintended pregnancy. Key findings revealed two main themes, &,ldquo Facing an unintended pregnancy&,rdquo (including emotional impact, societal norms, and healthcare access) and &,ldquo The decision-making process&,rdquo (influenced by avoidance behaviors, socio-economic factors, and conflicting beliefs about motherhood and fetal life). IntroductionThe process of becoming a mother is typically celebrated as a joyous occasion for women and their families. However, this is not universally the case. Unintended pregnancy is often a distressing and stressful experience for the entire family, particularly for the mother. 1, As one of the most challenging issues in global reproductive health, it can impose significant physical and psychological stress, as well as substantial social and economic burdens on women, families, and communities. 1,, 2, Studies suggested that higher rates of acceptance towards abortion are often observed among affluent families, women with higher education levels, and those residing in urban areas. 3,- 5, The decision to terminate or continue a pregnancy is one of the most personal and contentious choices a woman can face. This choice is influenced by a complex interplay of social, cultural, and economic factors, as well as individual circumstances. 6,, 7, These factors can constrain autonomy and expose women to significant pressures that ultimately shape their abortion-related decisions. 8, Women&,rsquo s emotional states during pregnancy are closely linked to their behaviors. Facing an unintended pregnancy, women may delay, reduce, or entirely avoid seeking prenatal care services. 4,, 9, This avoidance can lead to unsafe abortions and a neglect of necessary treatments for pregnancy-related complications. Furthermore, maternal anxiety and inadequate social support can contribute to the deterioration of both maternal and fetal health. 6, Evidence indicated that women from lower-income backgrounds and those with less educational attainment experienced higher rates of unintended pregnancies. This trend was particularly pronounced in sub-Saharan Africa, where women with primary and secondary education had 26% and 29% lower likelihood of unintended pregnancy, respectively, than those with no formal education. Furthermore, higher educational levels among male partners were also correlated with reduced rates of unintended pregnancy. 10, High-income nations such as the UK and US exhibited similar patterns, where unintended pregnancies are consistently linked to factors such as inadequate sexual education, lower educational attainment, and poverty. For instance, a UK study highlighted associations between deficiencies in sexual competence and tobacco use, 11, while Finer&,rsquo s research emphasized poverty and adolescent age as significant contributing factors. 12, Unintended pregnancies are the leading cause of induced abortions. 3,, 13, Annually, approximately 56 million abortions occur worldwide, more than half of which are deemed unsafe. These unsafe procedures predominantly occur in regions with restricted access to legal abortion services and contribute substantially to global maternal mortality and morbidity, thereby posing a critical challenge to healthcare systems. 13,, 14, Some Studies demonstrated that financial, social, and gender hierarchies, coupled with restrictive abortion laws, significantly shape women&,rsquo s decisions regarding abortion. 15,, 16, In Iran, the reported prevalence of unintended pregnancy fluctuates between 12.5% and 30.6%. These rates exhibit regional variations influenced by diverse cultural, social, and economic factors. 17,, 18, Qualitative research in Iran illuminates the complex reality of unintended pregnancies. For example, Shahbazi and others and Nourizadeh and colleagues explored how Iranian women navigate intricate decision-making processes shaped by their personal beliefs, familial expectations, and the country&,rsquo s legal restrictions on abortion. 19,, 20, Similarly, Razeghi Nasrabad and others, along with Mohammadi and others, highlighted these women&,rsquo s lived experiences, revealing that unintended pregnancies often evoke profound anxiety and social isolation, particularly within more conservative communities. 4,, 21, Furthermore, studies by Nourizadeh and others and Azadvari and colleagues indicated that Iranian women employed a range of coping mechanisms when faced with unintended pregnancies, which included seeking support from family and friends, and navigating the complexities of accessing abortion services, and were often shaped by the woman&,rsquo s socio-economic status and personal beliefs. 22,, 23, Given the significant prevalence of unintended pregnancies in Iran and the potential impact of cultural, social, and legal factors on women&,rsquo s experiences, a thorough understanding of these issues is crucial. Although numerous qualitative studies on the experiences of unintended pregnancy and abortion among Iranian women exist, a comprehensive meta-synthesis that integrates these findings to illuminate their unique needs and challenges is currently lacking. Therefore, this study aimed to conduct a meta-synthesis to provide an in-depth understanding of Iranian women&,rsquo s experiences regarding unintended pregnancy and abortion, examining the multifaceted cultural, social, economic, and personal determinants that shape them.Materials and MethodsThis study employed a meta-synthesis approach to conduct qualitative data analysis and was approved by the Ethics Committee of Shahroud University of Medical Sciences (code, ID IR.SHMU.REC.1401.153). Inclusion Criteria The inclusion criteria for this study were as follows, &,bull Qualitative and mixed-methods studies that addressed the experiences, decision-making processes, and outcomes related to unintended pregnancy and induced abortion among Iranian women. &,bull Studies published in either the Persian or the English language. &,bull Publications limited to the last two decades (from 2004 to 2024). Exclusion Criteria The exclusion criteria were, &,bull Studies that focused specifically on unintended pregnancy among adolescent populations. &,bull Studies pertained solely to the medical or clinical aspects of abortion procedures. &,bull Studies reported pregnancies resulting from illegal sexual behaviors. Search Strategy This meta-synthesis was conducted to explore and integrate existing knowledge on the experiences of unintended pregnancy, induced abortion, and related decision-making processes. Systematic Literature Search A systematic literature search was performed in the following electronic databases, Scopus, MEDLINE/PubMed Central, Cochrane CENTRAL, Web of Science, Embase, Google Scholar, and Iranian databases (including SID, Iranmedex, Magiran). The search strategy utilized keywords and Medical Subject Headings (MeSH) terms related to the core concepts of &,ldquo unintended pregnancy&,rdquo , &,ldquo induced abortion&,rdquo , and &,ldquo qualitative studies&,rdquo . The search strategy, including four databases and search engines, is outlined in table 1,.DatabaseSearch strategynMEDLINE/PubMed Central#1 (Unplanned pregnancy [Title/Abstract]) OR (unwanted pregnancy [Title/Abstract])) OR (unintended pregnancy [Title/Abstract])5069#2 (Fetal Preservation [Title/Abstract])) OR (Fetal Safeguarding [Title/Abstract])) OR (Fetal protection [Title/Abstract])) OR (Fetal Conservation [Title/Abstract])190#3 (Induce Abortion [Title/Abstract])) OR (Elective Abortion [Title/Abstract])) OR (Therapeutic Abortion [Title/Abstract])11902#4 (Decision-Making [Title/Abstract])) OR (Decision Process [Title/Abstract]) OR (Choice-making [Title/Abstract])8907#5 (Qualitative Research [Title/Abstract])) OR (Exploratory Research [Title/Abstract]) OR (Thematic Analysis [Title/Abstract])8609#5 # 1 AND #2 AND #3 AND #45347Cochrane library#1 &,ldquo Unplanned pregnancy &,ldquo OR &,ldquo unintended pregnancy &,ldquo OR &,ldquo unwanted pregnancy &,ldquo 5395#2 &,ldquo Fetal Preservation &,ldquo OR &,ldquo Fetal Safeguarding &,ldquo OR Fetal Protection&,raquo OR &,ldquo Fetal Conservation &,ldquo 326#3&,rdquo Induce Abortion&,rdquo OR &,ldquo Elective Abortion &,ldquo OR Therapeutic Abortion 18515#4 &,ldquo Decision-Making &,ldquo OR &,ldquo Decision Process&,rdquo OR Choice-making 4078# 5 Qualitative Research &,ldquo OR &,ldquo Exploratory Research&,rdquo OR &,ldquo Interpretive Research&,rdquo OR &,ldquo Thematic Analysis&,rdquo 1334#6 # 1 AND #2 AND #3 AND #4 AND #5639ScopusTITLE-ABS- KEY ((Unplanned pregnancy * OR unwanted pregnancy * OR unintended pregnancy * AND (&,ldquo Fetal Preservation *&,rdquo OR &,ldquo Fetal Safeguarding *&,rdquo OR &,ldquo Fetal protection *&,rdquo OR &,ldquo Fetal Conservation *&,rdquo &,ldquo AND &,ldquo Induce Abortion*&,rdquo OR &,ldquo Elective Abortion *&,rdquo OR Therapeutic Abortion &,ldquo AND &,ldquo Decision - Making *&,rdquo OR &,ldquo Decision Process*&,rdquo AND &,ldquo Qualitative Research *&,rdquo OR &,ldquo Exploratory Research*&,rdquo OR &,ldquo Interpretive Research*&,rdquo OR &,ldquo Thematic Analysis*&,rdquo )896Embase(Unplanned pregnancy *,ti,ab OR unwanted pregnancy *,ti,ab OR unintended pregnancy *,ti,ab) AND (&,ldquo Fetal Preservation *&,rdquo ,ti,ab OR &,ldquo Fetal Safeguarding *&,rdquo ,ti,ab OR &,ldquo Fetal Conservation *&,rdquo ,ti,ab OR &,ldquo Fetal protection *&,rdquo ,ti,ab) AND &,ldquo Induce Abortion*&,rdquo ,ti,ab OR &,ldquo Elective Abortion&,rdquo ,ti,ab OR &,ldquo Therapeutic Abortion*&,rdquo ,ti,ab AND &,ldquo &,rdquo Decision - Making *&,rdquo ,ti,ab OR Decision Process ,ti,ab OR &,ldquo Choice-making *&,rdquo ,ti,ab AND &,ldquo Thematic Analysis*&,rdquo ,ti,ab OR &,ldquo Interpretive Research*&,rdquo ,ti,ab OR &,ldquo Qualitative Research *&,rdquo ,ti,ab)957Table 1.Search strategy in four databases and search engines Data Extraction Data extraction and synthesis followed the seven-step framework for meta-synthesis established by Sandelowski and Barroso. 24, This process involved formulating the research question, conducting a systematic literature review, searching for and selecting relevant studies, extracting data, analyzing and synthesizing the findings, quality control, and presenting the integrated results. The specific information extracted from each study included author names, publication year, study characteristics, methodology, and primary findings. Quality Assessment of Studies The qualitative analysis in this study utilized the Critical Appraisal Skills Program (CASP) checklist. 25, Statistical Analysis The qualitative data analysis process was conducted using MAXQDA software (version 2020 VERBI Software GmbH, Berlin, Germany). This tool supported the systematic organization, coding, and thematic synthesis of the findings across the selected studies. Results Study Selection Process The initial database search identified a total of 7,839 articles. After the removal of 6,852 duplicates, 987 records remained. Following a screening of titles and abstracts, 579 articles were excluded due to their quantitative or cohort study designs or limited full-text access, leaving 396 articles for full-text review. The title screening led to the exclusion of an additional 287 records, resulting in 118 articles assessed for eligibility. Upon full-text review, 77 articles concerning medical and spontaneous abortions, 28 studies on abortion due to fetal anomalies, and nine studies focusing on adolescents under 18 years of age were excluded. Consequently, 22 studies met the final inclusion criteria and were incorporated into the qualitative synthesis. To ensure reliability, two researchers independently assessed articles for eligibility at each stage, with any disagreements resolved through discussion or by consultation with a third researcher. The study selection process is detailed in the PRISMA flow diagram (figure 1,).Figure 1. The flow diagram shows the study selection strategies according to the PRISMA guidelines.The results of this meta-synthesis were derived from the analysis of data collected from 22 qualitative Studies that met the inclusion criteria. The included Studies encompassed 626 individual interviews and 36 group interviews involving women aged 18-45 years. Among the 22 studies, three examined the decision-making process regarding abortion or continuation of pregnancy, 20,, 26,, 27, nine explored women&,rsquo s experiences with intentional abortion and underlying reasons, 4,, 5,, 19,, 23,, 28,- 32, eight examined the experiences of women facing unintended pregnancies, 21,, 22,, 33,- 37, two focused on the consequences of induced abortions, 38,, 39, and one investigated the impact of Iran&,rsquo s new population policy on unintended pregnancies. 40, The characteristics of the included articles are presented in table 2,. Author, year, ReferenceMethods Sampling Method, Sample sizeFindings1Chinichian (2007) 28, Qualitative approach using focus group discussions and individual interviewsA total of 36 focus group interviews were conducted with women from various ethnic groups. Additionally, 54 individuals interviewed healthcare providers involved in intentional abortions.The analysis identified four primary reasons for intentional abortion, rubella vaccination, maternal illness, fetal abnormalities, and unintended pregnancy. Among cases of unintended pregnancy, economic pressures emerged as the most common reason for seeking an abortion, while religious beliefs were the predominant factor influencing the decision to avoid it.2Shahbazi (2008) 26, Qualitative study with a content analysis approach27 semi-structured interviews were conducted with women who had undergone abortions, as well as with religious, political, legal, and academic experts.The main identified themes were social support, adherence to religious principles, belief in the sanctity of life, and aversion to invasive procedures, which were cited as factors deterring abortions.3Abdolahian (2008) 5, Qualitative study with a content analysis approachIn-depth interviews were conducted with 25 women in Tehran who had experienced abortion, aiming to explore the hidden social and cultural norms and values surrounding abortion.The main themes of the study included cultural and institutional motivations for abortion, the impact of social factors, challenges related to contraceptive methods, consequences of induced abortion, psychological and cultural consequences, the taboo surrounding abortion, and the social belief system.4Shahbazi (2011) 19, Qualitative study with a content analysis approachParticipants included 27 experts in religion, politics, and law, as well as healthcare professionals and individuals who had experienced illegal abortions.Five core concepts were identified, factors influencing decisions to reject or terminate a pregnancy, factors affecting the decision-making process, reasons for pursuing or discontinuing abortion, facilitated abortions, and the consequences of abortion.5Mortazavi (2012) 35, Qualitative approach and group discussionsFocus group interviews were conducted with 23 pregnant women in their third trimester, and individual interviews were held with four women who had previously undergone abortions.The results were categorized into four main themes, reasons for unintended pregnancy, reactions of others, the process of accepting unintended pregnancy and reasons for considering pregnancy unwanted.6Shahbazi (2012) 38, Qualitative study with a content analysis approachThe study involved 27 participants, including women who had undergone illegal abortions and healthcare professionals (midwives, psychologists, and relevant physicians).Four primary categories were identified, physical, psychological, socio-political, and legal consequences.7Hosseini Chavoshi (2012) 39, Qualitative-quantitative studyThe study was conducted in two phases. In the first phase, 5,526 married women aged 15-54 from three provinces&,mdash Yazd, Isfahan, and Gilan&,mdash and the city of Tehran were randomly selected, and data were collected regarding pregnancy outcomes and the history of contraceptive use. In the second phase, 200 women who had experienced unintended pregnancies in the past 5 years were randomly selected from Tehran and Rasht. Among them, 40 women who had undergone induced abortions were identified for in-depth interviews. The extracted themes included social and economic concerns, emotional reactions, social stigma, feelings of guilt and distress, insufficient knowledge of the laws, and a need for revising reproductive health policies.8Ebtekar (2013) 30, Qualitative study with a content analysis approachSemi-structured, in-depth interviews were conducted with five married Kurdish women in Sanandaj who had a history of induced abortion.The themes identified included financial difficulties, fear of societal judgment, pressure from partners, physical consequences of abortion, and post-abortion guilt and remorse. 9Motaghi (2013) 29, Qualitative study with a content analysis approachA total of 72 semi-structured interviews were conducted, including eight experts, 28 married women, 10 women engaged to be married with a history of unintended pregnancies or unsafe abortions, and 12 healthcare providers. For wanted pregnancies, reasons for abortion included fetal abnormalities, concerns about fetal health, distrust in diagnostic methods, fetal sex, and lack of decision-making autonomy. In the case of unintended pregnancies, reasons for abortion included socio-economic factors, beliefs and feelings, lack of family planning information, and easy access to abortion methods.10Hatamian (2014) 31, Qualitative phenomenological methodSemi-structured interviews were conducted with 28 married women who had undergone illegal abortions, selected through snowball sampling.The extracted themes included the decision-making process surrounding abortion and women&,rsquo s roles within it, reasons for seeking abortions, and the influence of husbands and others on the decision-making process.11Bayrami (2014) 33, Qualitative study using a phenomenological approach10 in-depth semi-structured interviews were conducted.Experiences of stress, psychological reactions, coping mechanisms, decision-making processes related to abortion due to unintended pregnancy, as well as changes in maternal and spousal roles, daily routines, and societal reactions were the primary and secondary themes identified in this study.12Mohammadi (2014) 32, Qualitative approach with a descriptive-interpretive designUnstructured, in-depth interviews were purposefully conducted with 29 participants.Data analysis revealed two main themes, negative perceptions of the impact of abortion on life and violations of societal norms regarding childbearing, with a central theme revolving around perceived threats.13Kheiriat (2014) 34, Qualitative StudyUsing purposive sampling, in-depth, unstructured interviews were conducted with 30 participants&,mdash 24 with direct experience and six with indirect experience.The analysis revealed several themes, including the shame associated with societal norms around pregnancy, feelings of loneliness and perceived inadequate social support, and fear of adverse pregnancy outcomes. From these themes, twelve subcategories were identified.14Nourizadeh (2015) 22, Qualitative study with a content analysis approachData were collected through 23 semi-structured interviews with 15 women who chose to continue their unintended pregnancies.Data analysis identified four themes, negative and avoidance reactions, societal restrictions on abortion, religious values and beliefs, and post-decisional conflicts.15Peyman (2016) 37, Qualitative study with a content analysis approach In-depth interviews were purposefully conducted with 13 healthcare workers until data saturation was achieved.Data analysis revealed three factors, service delivery system challenges, characteristics of service recipients, and the effectiveness of family planning methods in addressing unintended pregnancies.16Akbarzadeh (2016) 36, Qualitative study with a content analysis approach20 semi-structured interviews were purposefully conducted with participants who experienced unintended pregnancies. The data analysis identified several themes, including embarrassment associated with pregnancy, lack of emotional support, anxiety about the child&,rsquo s future, feelings of guilt, conflict with partners, negative self-perceptions, concerns about divine retribution, financial, social, and relationship problems, and suppression of the logical expectations of other children.17Razeghi (2017) 4, Qualitative study with a content analysis approachData were collected via semi-structured interviews with 50 women divided into two groups, single women (including those without legal spouses or those in the engagement period) and married women with children who sought abortions.The extracted themes included abortion as part of a cost-benefit assessment and the avoidance of potential future risks and harms. 18Nourizadeh (2017) 27, Qualitative- sequential exploratory mixed method31 in-depth semi-structured interviews were conducted with 23 participants.Analysis of the 27 final items identified four strategic factors, justification avoidance, resistance to acceptance, analytical strategies, and confirmation strategies.19Mohammadi (2018) 21, Qualitative content analysisUnstructured interviews were held with 23 women aged 18-48 who had experienced unintended pregnancies.Four themes emerged from the data analysis, disbelief and negative emotional responses, fragile justifications, perceived support, and post-decisional dissonance.20Nourizadeh (2020) 20, Qualitative study29 in-depth semi-structured interviews were purposefully conducted with 23 participants aged 18-48 years. Data analysis identified four core categories, ambivalent resistance, perceived threat, resources and values influencing decision-making, and decision acceptance and confirmation.21Mokhtari Nia (2022) 40, Qualitative grounded theorySemi-structured interviews were held with 23 women with the experience of unintended pregnancies who were selected purposefully.The analysis revealed the following themes, dissatisfaction with government interference, feelings of regret, and experiences of coercion related to pregnancy.22Azadvari (2023) 23, Qualitative grounded theoryInterviews were conducted with 28 women from diverse social groups concerning age and socio-economic status. Data analysis revealed that abortion was understood as a process of confronting fear and making choices.Table 2.Characteristics of the included qualitative studies and the summary of findings Data Categorization The analysis of the included studies revealed two main themes and seven sub-themes related to Iranian women&,rsquo s experiences of unintended pregnancy and intentional abortion. The first main theme, &,ldquo Facing an unintended pregnancy,&,rdquo encompassed emotional-affective fluctuations, societal norms, and access to health services. The second main theme, &,ldquo The decision-making process surrounding unintended pregnancies,&,rdquo comprised avoidance reactions, socio-economic considerations, psycho-social conflicts in the decision-making process, and belief in maternal role and the value of preserving fetal life. These categorized themes and sub-themes are outlined in table 3,.Themes Categories Codes Facing an unintended pregnancyEmotional-affective fluctuations 22, , 31, , 34, - 36, Emotional distress (guilt and shame, depression, feelings of crying, anger, Fear and anxiety hopelessness and depression)Self-hatred towards oneself, partner, fetus |