A life-saving endeavor: The meanings and strategies of coping in patients with ectopic pregnancy in Iran

Aim of this study was to explore the experienced coping strategies by patients with an ectopic pregnancy in order to ameliorate the quality of treatment. This is a qualitative study based on a phenomenological tradition in which data were collected through semi-structured and in-depth phenomenological interviews with twenty-five married women, experienced ectopic pregnancy. Data were analyzed through an interpretative phenomenological analysis. “Life-saving endeavor” was the main theme that emerged from the participants’ experiences. It refers to a set of strategies used by women to cope with Ectopic Pregnancy. Life-saving endeavor consists of four subthemes, that is ‘submission to destiny’, ‘the blue sky after the storm’, ‘karma; the world’s supervisor’ and ‘setting foot on earth’. The results of this study reveal that women with ectopic pregnancy have implemented various strategies to cope with this complication of pregnancy, based on their life worldviews and beliefs. However, only those women who had a realistic angle to the disease were able to adapt to life again. As a result, accurate identification of these strategies and real comprehension of their life experiences by medical care providers, and applying positive experiences including a realistic attitude promotion to the other patients are recommended.


Introduction
Ectopic pregnancy (EP), also called extra uterine or tubal pregnancy, as the best known cause of female mortality in the first trimester of gestation, is one of the most significant emergencies in pregnancy which often requires rapidly runnable intervention. Each pregnancy implants outside the endometrial cavity is defined as an EP (Jurkovic and Salman 2016). Nowadays, the incidence of EP is on the rise, to such extent that includes 1-2% of all pregnancies and 10-20 per 1000 live births (Ozan and Thomas 2018). According to the World Health Organization (2018), high-risk pregnancies including EP account for nearly 75% of all maternal deaths. Moreover, prevalence of EP varies among different countries. In the United States, among women hospitalized for EP, mortality increased from 0.29 to 1.65 per 1000 between 1987and 1991and 2010(Lisonkova et al. 2019). This complication of pregnancy has also increased in Iran over the past decade estimated 1.9% of per 1000 pregnancies in the years prior to 2006 and 3.7%, per 1000 pregnancies after 2006 (Hasani et al. 2016).
Recent studies have shown that an early pregnancy loss, including EP, can trigger post-traumatic stress disorder (PTSD) moderate to severe anxiety and moderate to severe depression (Farren and Jalmbrant 2016;Imperial College London 2020), and it will be the most traumatic event in women's life which might be prolonged until the end of their lifespan. Although, the way a person faces a stressor has the crucial impact on mental health, should an individuals' belief system is unable to make sense of the trauma or assist the individuals in interpretation of the event, trauma can raise several newfound questions about the existence of God and meaning of life (Slater Courtney et al. 2015).
Several studies have been conducted to EP focused on risk factors, symptoms and treatment (Brown 2015;Kirk et al. 2014;Yuk et al. 2013), however, no study was found investigated women's lived experiences with EP and their narratives even in Iranian texts. Therefore, a holistic treatment or management of EP requires considering not only physical but also psychosocial and cultural aspects of the complication and designing and conducting it more emic and qualitative studies. By providing effective strategies based on evaluating the patients' perspectives, medical staff could be able to enhance the quality of care and treatment.
Hence, this study was conducted to explore understanding, experience and coping strategies of the married women with EP. Coping strategies refer to women's conscious effort and skills to solve personal and interpersonal problems and tolerate traumas related to the consequences of EP. These strategies are based on women's attitude, which means a mixture of belief and emotion that predisposes a person to respond to other people, objects, or institutions in a positive or negative way (Coon and Mitterer 2006). According to Islamic law (the Sharia), as the official religion of Iran, it is not permitted to get pregnant without marriage in this country. Hence, if unmarried women with EP should refer to the healthcare center, they will not be supposed to be honest in their talks about their complications, emotions and feelings. Additionally, according to a common beliefs in Iran, married women are expected to have children, and this can be considered a kind of social compulsion. Therefore, it is another plausible reason that this phenomenological study has focused on the understanding and narratives of married women experienced EP.
In the context Iran, as a sharia-driven society especially after the 1979 Islamic revolution, gender is amongst main social oppressions and acts as a source for institutional/ structural discrimination. Hence, it plays a decisive role in social relationships and lives of people including girls and women. According to the family law of Iran after the revolution (Mir-Hosseini 1993), the first official marriage for girls of any age group is allowed only with the official and legal permission of her father. After marriage, many of a woman's desires, including working, having economic independence, continuing her education, and leaving the country, even for holiday, depend merely on her husband's legal permission. As becoming a mother, all the rights of children, a son up to the age of 18 and a daughter before marriage, belong to their father. Under Iranian laws, if a woman is infertile or unable to give a birth, her husband will be allowed to leave and divorce her, at any time as he wishes. In addition, if a man becomes widower, his wife's assets will go directly to him, but if a woman becomes a widow without a child, only a quarter of her spouse's property will belong to her and the rest to the man's family. Hence, the dominance of such Islamic patriarchal and androcentric values and rules in the context of Iran, which directly affects the formation of a woman's identity, can give her this impression that having children means to protect the family and inability in childbirth means losing her matrimony, and in some cases, even lead to identity crisis (Alamin et al. 2020).
On the other hand, from medical viewpoint, the goal of EP treatment is only to save the women's lives from death, and medical care providers are surprisingly silent on losing pregnancy or impaired fertility in the future, due to assisted reproductive technologies (ART) can be used later. Thus, from a bio-political point of view, the patient could be impressed that her desire is inconsistent with the goal of treatment, and her illness is not understood by the medical care providers. In this case, along with the dominance of Islamic patriarchal culture in the society, this stereotype can be shaped that she is a passive being who never has the power to make decisions for herself (Osanloo 2009).

Methodological Approach
This study set out to comprehend understanding of participants and constructing knowledge through the conceptualization of individuals' experiences, by taking a qualitative approach and using the Interpretative Phenomenological Analysis (IPA) method. IPA is a qualitative research approach committed to the examination of how people make sense of their major life experiences. It is phenomenological by nature as it is concerned with exploring experience in its terms (Smith et al. 2009).

Participants and Setting
This study was conducted in Alzahra educational and care center in Rasht, north of Iran after obtaining the necessary permissions from the Department of Research and Treatment and the authorities of the hospital. Through purposeful sampling, twenty-five married women, who were definitely diagnosed with EP, in different ages and different treatment methods, were purposefully recruited to take part in this study. Demographic details of all participant women are reported in Table 1.
The participants were informed that the study was designed to explore how they looked at EP and, what they have done to deal with mental, psychological, socio-cultural and physical experiences of their pregnancy complication. Hence, discovering similarities and dissimilarities of these experience would make us able to offer suggestions for improving the quality of the treatment. Also, they were given such information that participation in this research is completely voluntary and they do not have to participate in this research. If they refuse to participate in this research, they will not be deprived of the usual diagnostic and therapeutic care, and their therapeutic relationship with the medical center and the treating physician will not be impaired. Even, after agreement to participate in the study, they could leave the study at any time as they wish, by informing the main researcher, and this decision will not deprive them of the usual medical services. Their collaboration in this research was such that only one face-to-face and private phenomenological interview were conducted with them. They talked about the experiences, events and all the feelings, hopes and motivations they had during their treatment process in the hospital, honestly. The interviews were lasted 30 min to an hour and were conducted at any time and place they preferred. This cooperation had no financial, physical, psychological or time costs for participants, and if they incurred any expenses for any reason, the main researcher compensated them.

Ethical Considerations
Permission to carry out this study was obtained from the ethi c a l c o m m i t t e e o f U n i v e r s i t y o f T e h r a n ( R e f : IR.UT.Rec.1395003, 6 March 2017) and relevant authorities of the hospital in Rasht, which is the capital city of Gilan province. All participants signed voluntary informed consent and were also ensured about confidentiality and freedom to withdraw from the study at any time. Time and place of interviews were arranged with those who agreed to participate. The main researcher (first author) of this study obtained permission of all participants to perform and audio taped the interviews, formally. The confidentiality of information and the patients' rights was guaranteed as the name and personal information of interviewees was not mentioned in tapes and transcripts. All tapes, transcripts and information sheets were given special codes and were kept separately to protect their anonymity.

Data Collection and Analysis
The data collection phase was started in April 2017. The main strategy of data collection was phenomenological interview. Interviews were conducted by main researcher of this study with over a nine-year experiences in infertility research and clinical studies on maternal mental health. Besides, about one year before this work was carried out, the main researcher witnessed her sister's experience with EP, and she had being lived with patients with EP at the hospital for almost a month. This paved the way to conduct this study to explore Iranian women's experience with EP through their own interpretation. With this background, first of all, she expressed her sister's story to express her empathy sense, and ensure the patients that she could understand what and how they would talk about. While exploring and explaining in detail about EP and medical treatment process, she has always been neutral in participants' interpretation or their emotional expressions.
Following three pilot interviews, the data was collected from semi-structured, in-depth and face to face interviews with twenty five participants. All interview sessions were conducted in a private place at the hospital. The duration of the interviews varied from 30 to 60 min (Sum: 1195 min & Average: 45 min). At the beginning of interview, the participants were asked first main question; "How did you make sense of getting EP for yourself??' and then, the second guide question was "What have you done to deal with feelings, emotions and physical impact of your pregnancy complication?" Further probing questions were used to clarify participants' descriptions and to attain more information during interviews; such as, was there anyone who would help her in this process? What was the social-mental impact of the medical care staff? What was your family's behaviors during treatment and how did they react to EP? ...
Most of the interviews were audio-recorded in MP3 format and transcribed verbatim in Persian language prior to the next interview. Just a few participants did not allow their voice to be recorded, so the interviewer had to take notes of dialogs and emotions. Sampling continued until data saturation. During all interviews and data analysis, the verbal and nonverbal reactions of participants were under consideration. As each transcript was prepared, it was simultaneously analysed by the researchers (both authors) using holistic, selective and detailed approaches of Interpretative Phenomenological Analysis (IPA). In the holistic approach, each transcript was read as a whole to create a phrase that grasped the meaning of the whole experience of the participant. Following that, by the selective approach, the principle researcher read each transcript several times and looked for phrases from the participants that appeared particularly essential or revealing about a Assessed by occupational status and income level of participants the studied phenomenon. Then, these phrases were highlighted to identify themes from the early concepts. Finally, in detailed approach, the principle researcher went back to the transcripts and examined each sentence for meaningful units. The formulated meanings were interpreted and the sub-themes were identified. The sub-themes were clustered into themes. The final themes were reviewed and revised with the supervisors of the research team and were integrated into a comprehensive and main theme. All transcripts in this article were translated from Persian language to English by the authors who were fluent in both English and Persian languages. In sum, iteratively-interlocked phases of data collection and analysis took place, between April 2017 and April 2018.

Results
Given the special socio-cultural context of Iran, it seems that desires for and having children in Iranian families, especially in more traditional and religious ones, is considered a necessity. In the pronatalist societies in the Middle East and North Africa (MENA) region including Iran, "women's desire for children" can be seen as easily and clearly linked to the gendered structure of society and to governmental policies and politics that keep those patriarchal structures in place (Inhorn and Patrizio 2015;Riley and Brunson 2018). If this necessity in some way leads to a failure, it will become a kind of longlasting grief for them. So that childless marriages are deemed fruitless and time-wasting marital life.
"As old saying, a barren woman is just like a fruitless tree. A tree that doesn't have fruit will be cut down some day because its presence and absence are not important to anyone. But the fruit trees will be taken care, since they are useful for humans" (Maryam, 27 years old).
Besides, according to the research findings, infertility and sterility are more defined and understandable among Iranian families compared to EP. EP is considered to be an unknown and weird phenomenon that makes people's judgments different and more difficult to some extent. As declared by the women, when they announced the results of their positive pregnancy test with pride and honor to those around, as if they had been showing their success in proving their existence, however, it was a duty from society's point of view. But after two weeks, with the onset of symptoms and definitive diagnosis of EP, that existential idol suddenly broke and embarrassment substituted their pride and honor. They looked at their bodies morbidly, as if they had an unknown disease which never known its existence. This was even more difficult for those who experienced impaired fertility after treatment. Feelings of emptiness and anonymity as a woman who will never be able to give birth to a child, they blamed themselves with such statements that they had useless bodies. Hence, they may experience a multilevel stigma including public and selfstigma because of EP and this may even infer to deprivation from their local community.
"Where I live, it's very important to have a child. But the worst thing is that if folk understand you can't give birth a child, or you are involved with infertility, they will not invite you to their religious ceremony, because they think that the presence of a woman like you is inauspicious for the bride. That's why I didn't even tell my sister-in-law I had EP when I was hospitalized. I just said I had a cyst so that no one could talk behind my back" (Fatemeh, 30 years old).
From the analysis of the interviews conducted, and to find out what the participants have done to cope with EP, more than 150 primary codes were extracted. These codes were decreased gradually by removal overlapping codes and finally, four themes emerged. The master them, "Life-saving endeavor", accompanying four themes are explained by using some direct quotations from the participants. A summary of the themes extracted from the data analysis is presented in Table 2.

Life-Saving Endeavor
To cope with the new situation, the first and the most critical question emerged in the individuals' mind was: "what happened to me?" Lack of adequate information on therapeutic methods, getting scattered data on the Internet, inaccurate awareness by people around and dissatisfaction with medical services, inferred to so many terrible challenges.
"I had pain a lot and didn't know what's going on? Lots of questions I had and lots of thoughts stuck to my mind which could definitely kill me … I just thought about what I could do" (Fatemeh, 15 years old).
The patients' demand for further information about their health conditions was extremely noticeable, and it did not matter at what age group or from what social class they were. Concerns about the happened tragedy, made the prevailing distress the same for everyone with any educational level, to such extent that its continuation made them to improvise an acceptable cause, to be convinced. All these efforts done by the patients which were based on their life philosophical beliefs, named; "life-saving endeavor" included; 'submission to destiny', 'the blue sky of the storm', 'Karma; the world's supervisor' and 'setting foot on earth'.

Submission to Destiny
Beginning with the disease onset, the patient had encountered confusion to the extreme. Among with lots of reasons surrounded her mind, there was no sign of her willpower. So, inevitably the event had been considered as a part of her destiny. From some patients' point of views, there was no way to get out of it but submission, so that they could cope with their illnesses. In such circumstances, the patient believed that the entire universe, from the daily circulation of the sun and moon to all parts of daily life, have been previously made up by God, a creator whose willpower is higher than anybody else, and human willpower has no effect on their life. This is the plan of human creation.
"Nothing can do... All these fruitless and repetitive efforts can only make you tired ... Fatigue helps people to give up on the events. They will become more and more silent day by day, and will no longer have the patience to make sure that one day they will rebuild everything with their own hands. The future, which gradually deprives people of any hope, leaves no choice but to surrender." (Soheila, 38 years old).
It should be noticed that this sort of thought had a benefit for the patients. They were going to find the cause out of themselves, so by submitting to destiny, not only exonerated from any negligence but also were gifted a peaceful mind.
"I asked myself, what if it was my fault!? But it wasn't. Some things are in people's destiny and some things are not. Like a kid that there is no one in mine and no choice …" (Maryam, 25 years old).
Submission to destiny inclines to religious tendencies to some extent, however, is different in the fact that denotes stripping of one's will.

The Blue Sky after the Storm
To some participants, what had happened was just like a terrible storm. As all people know the blue sky will always appear after the storm, some patients attempted to look at EP through a positive attitude. They believed that whatever would happen in people's lives had a goodness inside, even though, had been come in wicked appearance. Regarded to this thought, the most important reason for everything to happen is God. If God wants something to happen, it will be certainly benefited, because God never wants anything against the creatures and mankind.
"I said to myself if the baby was born and then died it would have been worse... or what if it had been born and had an intellectual or physical disability? I really thank God, he certainly knows something that I don't." (Najme, 34years old).
Additionally, through this attitude, every illness not only is not bitter and painful, also has a message of blessing that individuals must attempt to perceive. It did not matter how much their positive outlooks were related to the event, what the matter was that how much it could give them peace of mind.
"Well, people always say we should see the glass half full. I also tried to look at the situation this way. Before it would happen, I didn't have many friends and always felt lonely. In the hospital, there were more than eight other patients with EP in one room. We met each other, and made good friendship. I got their phone numbers to keep in touch later. If I didn't experience EP and hospitalize accordingly, I couldn't make such good friends. I thought it was a gift in my life and that's why I could tolerate the situation to complete my treatment" (Maryam, 30years old). As a merit, the participants believed that by optimistic thinking the treatment process could be managed by themselves and proceed as well as possible.

Karma; the World's Supervisor
From this point of view, the patients mentioned themselves as the centerpiece of all causes. Those who looked at EP this way believed that the earth was round. This means that the whole world is based on human actions and whatever people do, will be turned back to them some day. Whatever people gain in their lives is because of what they have done before. The consequence of big-hearted man is admiration and the fruit of evil, punishment. Good deeds contribute to good karma and happier rebirth, and bad deeds lead to bad karma and bad rebirth.
"The first thing I remembered was the abortion I had last year. Those days, I thought it's too soon to have a kid, saying I hadn't lived in pleasure enough. Everyone said; it's a sin. I knew I would compensate for it some days. I deserved it." (Helia, 30 years old).
So, everything that happens in our lives has a reason and it is nothing but ourselves. This is the rule of Mother Nature and no one is exempt and cannot escape.
"As my memories told me, I had been used to blaming women who couldn't give birth a child, saying that it was their own fault, they have certainly done something and haven't taken care of themselves. They were irresponsible about their pregnancy. It is true that said if you weren't in people's shoes, you wouldn't be able to judge them. What happened to me was the result of my own thought and behavior. It just happened for me to profoundly understand, it wasn't something that could easily blame someone for. " (Zahra, 27 years old).

Setting Foot on Earth
Setting foot on earth, reflects that there are different facts on earth; some are visible and some are not. Some have been discovered and some are still out of human knowledge, however, absence of evidence is not evidence of absence. According to this viewpoint, whatever happens, is deemed as the emergence of a new reality. Hence, a complication like EP is a reality that was accepted by the patient at first. Then, this fact was realized that it had been discovered by researchers and physicians before, so that the patients must be referred to the hospital for treatment and there was nothing to be worried about. "I thought I had a Cyst, as the doctor said, but then... EP was diagnosed, which was late... I had lost one fallopian tube. Although, it was an unfortunate, what I could see was a disease, and that's all. It's neither my fault nor someone else's. Something that could have happened to anyone. It's terrible, I know, but... it is not such thing to say there is no cure for. Just death is not curable". (Zahra, 27 years old).
In this view, science is a web of causes, effects, and solutions and the world is rules-based ordered. Diseases are caused by other facts and the treatment methods are the other realities that should be discovered. Therefore, if human's knowledge has the power to discover it or not, it will not make any contradiction to the concept of the reality. Women with higher education were belonged to this group.
"First, I called my boss to take a leave of absence, then asked my mother, to take care of my daughter. So... got the doctor's recommendation letter and went to the hospital. The healing process started but… it was late ... and I had lost one of the fallopian tubes. I can't say who was blame for, or it is ridiculous to look for blame in these circumstances. It's just a disease. I exactly have done the same things I must, and it's not the end of life. It had its own solution and medical staff knew what to do." (Afsaneh, 30years old).
Examining the themes derived from the research findings, perceived that the strategies used by patients to cope with EP were based on four key factors that shaped their philosophical approach to the life and its end. These key factors included willpower, religion, spirituality and science, and Fig. 1 compares how much the extracted themes were influenced by them.
At first glance, it is obvious that the willpower is the dominant key factor among all themes, except 'Submission to destiny.' This preference can be rooted from the fact that belief in willpower could totally influence the patients' minds, determining how to look at the disease and how to respond to it. The outstanding example can be mentioned is, those women who were in favor of 'the blue sky after storm,' believed that they were free to look at the disease with positivity glasses and control the treatment process in the best way.
On the other hand, religion can be seen as a common contributor to 'submission to destiny' and 'the blue sky after storm,' and spirituality as the primary factor in 'karma; the world's supervisor.' In comparing religion and spirituality, it must be said that religion, is a specific set of organized beliefs and principles, which is directly in connection with God and shared by a community or group of people, While, spirituality is the patients' own experiences of the divine and an individual practice with having a sense of peace and purpose (De Blot 2011). Thus, the patients who looked at the disease with religious glasses reckoned that EP was part of God's laws that were applied in their lives. Although, those who did not believe in their own willpower, considered themselves convinced of submission to destiny, others, in addition to the divine laws, presumed their willpower to be a God-given tool to deal with circumstances. Hence, in terms of Karma; the world's supervisor; it's the law of attraction, people get what they give.
Finally, science was regarded to any scientific information and public awareness which was able to answer all questions related to the disease. Science along with willpower were the basis of the attitudes of those categorized in the setting foot on earth, and could help the patients keep going to accept the reality and cope with treatment consequences.

Discussion
This study aimed to explore meanings, lived experiences and coping strategies of married women with EP in north of Iran. Findings of the study reveal that having a child, as a part of self-identification, is a necessity in Iranian Islamic and patriarchal culture. Hence, an early pregnancy and reproductive loss in any way including EP affect women's sexual functions and fertility, this can lead the patients to a personal and family crisis and then post-traumatic stress disorder. This necessity has been dramatically important and influential in Iranian context that even having an academic education or higher socioeconomic status could not moderate its impact on women's attitudes toward their body (body image) and their identity. However, EP as the same as any pregnancy loss can be experienced in different ways, depending on age and frequency of abortions. In other words, the older the patients, the more concerned they were with their fertility status and future being. Additionally, as Boynton observed, if the patient had more than one loss, she might react differently for each one (Boynton 2019).
In order to overcome this sorts of crisis and adapt to the new situation, the patients needed to open a path towards self-awareness that allows them to understand how this happened and what they could do?! As the findings of Krosch and Shakespeare-Finch (2017) revealed, failure to compromise with the disease caused several physical and mental problems and made it more difficult to control the side effects of the treatment. Moreover, the experience of participants in this study showed that it is a process that ends to self-discovery and acceptance of the new conditions of life by the patients. Hence, coping strategies, named 'life-saving endeavors', can be explained in four themes of 'submission to destiny', 'the blue sky after the storm', 'karma; the world's supervisor', and 'setting foot on earth'.
Theme of 'Submission to destiny' seems to be referred to a fatalistic approach to the life. Faith to fate and disbelief in self willpower, is a kind of monotheistic religion point of view and unquestionable obedience rooted in the traditional and religious culture of Iranian people. Researchers who have investigated in the role of fatalism in health problems believe that fatalistic statements routinely are made by lay people right alongside statements endorsing the efficacy of health behaviors (Keeley et al. 2009). Those patients who supported this strategy suggested that this unquestionable obedience to destiny may be the result of the same patriarchal culture of the society that determines what a man and a woman are, and there is nothing but the boundaries of this definition.
On the other hand, as Jones (2018) asserted, fatalism is a common outlook among women who are trying to get pregnant. Even as for fatalism, it is vain to use of contraception due to if getting pregnant is in person's fate, it will be certainly fulfilled. Our participant women in this study believed that taking a fatalistic approach to EP had given them peace of mind, since it neither impose the responsibility for what had happened, nor the consequences on them. However, this approach failed to help patients' self-esteem to recognize themselves as the efficient members of the community, and to provide them with the needed satisfaction to adapt to the life  Fig. 1 Comparison of the themes derived from the main theme; Life-saving Endeavor again. As this peace of mind did not make difference in the way that the society looked at them, in the form of a woman who could not give birth a child. Some studies confirmed that despite fatalism might be primarily a coping response to illness or complication, release patient's stress and achieve them relative peace, it indicates the medical care system mistrust, and this miss-or less-trust in the medical care system is associated with poorer physical and emotional and subjective wellbeing in the society (Bustillo et al. 2017).
In terms of 'the blue sky after storm,' we found a positive a p p r o a c h w h i c h w a s t w o f o l d ; ' P o l l y a n n a ' a n d 'Pollyannaism'. Through the Pollyanna attitude, positive thinking acknowledges both negative and positive events but emphasizes on the positive aspects rather than the negative one. Pollyanna can be considered as a healthy strategy for thriving in the world (Kaur and Chadha 2016). Furthermore, positive thinking as a strategy to cope with a disease is accompanied by a strong religious root that helps patients refine their thoughts, concentrate on problems and make decision in the future. In this term, one of the effective findings in tolerating and compatibility is the participants' attitude towards the disease as a divine test. Believing in the existence of God in all aspects of life and this belief that God will be always with them, gave the patients hope for treatment and improve their health, again. The obtained results in this research, confirmed the previous researches regarding the constructive effects of optimism in coping with diseases. (Testoni et al. 2016).
Regarding Pollyannaism refers to a positive bias in which participants ignore or avoid dealing with negative events by just looking for the goods (Maltin and Stange 1978). Optimistic bias tends to prevent individuals from taking on preventative measures for good health (Branstrom and Brandberg 2010). Due to the fact that the optimistic bias could influence on decision-making and infer in preventive behaviors, individuals underestimated the risk of the disease and even after reading an article about its risk factors, they were still less concerned about it. Iranian women seemed to consider optimistic bias equal to deceiving themselves. Effort to filter their eyes and see only what they like was the same as suppressing the realistic aspect of their human being. Those who took such an approach may have been apparently pleased and relaxed-minded, but since there were still a list of unsolved problems, they had involved with new internal contradictions.
Karma, as a religious doctrine could influence on women's attitudes by emphasizing responsibility. Some Iranian married women announced that they got used to making sense of their tragedies by karma, and then re-adapt to the changed reality. Recent studies showed, Karma not only restores one's faith in a just world but also provides a very convincing and socially reasonable explanation for a host of undesirable events (Dalal 2015). Since the patients mentioned karma as a doctrine, emphasizes on the relation between willpower and certain results, so that it can be argued that this concept is overlapped with determinism. Deterministic thinking held this viewpoint that individuals are less in control, and more responsible for the events of their life.
Although such thinking which considers personal actions to be the main cause of events, seems logical to some extent, because it can provide a reasonable thinking path before doing anything, applying it in dealing with a disease such as EP, defined as a pregnancy disorder with some probable risk factors, not only is a reality distortion, also empowers the patriarchal ideologies of Iranian society. According to the research findings, blaming women for losing their pregnancies while they needed emotional support more than ever, caused many mental distresses. Iranian researchers approve that deterministic thinking, known as one of important cognitive distortions, has a significant correlation with immature defense mechanisms, risky behavior, anxiety, and depression (Soleimani Sefat et al. 2017). Therefore, this type of thinking could led one to feel unduly anxious, depressed or other psychological disorders.
Considering the theme of 'Setting foot on earth', some patients expressed that having a scientific view of the disease helped them to understand it. They believed that the only way to know a disease was through medical science, which could answer all patients' questions and concerns. Such knowledge can be explained both by the physician and by the patients themselves in various scientific sources. This attitude is reminiscent of realistic thinking. Realists believe that the world exists independently of human understanding, and that human understanding can be a part of the outside world. The correct statements describe something of the real world as it is. Realists believe that theory can be true even if no one believes it.
From this point of view, there is no optimism about ectopic pregnancy, it is not in the patient's destiny, and no one is to blame for. It is a completely neutral view that look at the disease and its cause, separated from one's existence. As previous studies showed, provided reasonable details and indepth knowledge made the patients able to have a realistic approach to miscarriage (Chaloumsuk 2013). Following that, rational adaptation and accepting the reality of the disease are the most significant factors. Homogeneous Studies conformed that how realistic and hopeful information can be combined in physician-patient interactions (PPI) and lead to better adaptation even at the end of life (Oosterveld-Vlug et al. 2017). In general, wisely coping with EP helped the patients to extricate from thinking about the complications of the disease. Rational dealing importance were confirmed in the present study (Wallace et al. 2017).
Finally, the findings of this study revealed that the age variable could not make a difference between patients in selecting coping strategies. Besides, the dominance of Islamic religious and spiritual tendencies in the post-revolutionary Iran had paved the way for all people from multiple socioeconomic status to experience fatalism, optimistic bias and karma, in similar ways. However, education along with information literacy was the single factor that helped some patients to take a realistic approach in order to have a different experience from others. This, coupled with the fact that living in modern families, and away from any traditional thinking, allowed the patients to cope with the new situation and return to the normal life, even in spite of the impaired fertility.

Conclusion
In general, the prevailing Islamic culture in contemporary Iran has played a decisive role in women's feelings about their own bodies, as they see themselves as merely women for fertility. However, the experience of a group of studied women showed that with the aid of academic education and information literacy, which are the achievements of modernity, they were able to have a more realistic vision of the disease and successfully complete the treatment process with no mental distress. Patients' experience suggests that by the awareness of modern world achievements can be freed from the bondage of traditional and religious ideas which infer diseases as a part of human destiny and actions, and this is a part of the mission could be accomplished by the medical care providers.
This unique experience leads us to conclude that when the sharia-based dogmatic structures or arrangements of the society determine the mentality of individuals towards their bodies, the best way to deal with these unchangeable structures is to get a deep understanding of the notions that govern patients' minds and subjectivities. Perceiving the patient's own literature and understanding using emic research methods including IPA could help improve the quality of treatment, especially in the area of mental health.
The findings of the study can be used to design and implement effective care for patients with EP in the areas of medical management, education and practice. Also, the generated knowledge in this research can be beneficial for all researches to explore new horizons regarding this phenomenon and can be used as a guide of holistic care of patients with the other diseases or complications.
Since it is not legally permitted to get pregnant without marriage in the contemporary Iran, this study was merely conducted in married women living in Rasht, north of Iran and this is indeed the most important limitation of this research. Hence, it is recommended to design and carry out similar studies on meaning and experience of women with EP in contexts and settings with the exception of the MENA region. As there are many difficulties for the patients' adaptation, a deep comprehension of their experience by a health care team including similar patient and reflecting the healing experience to other patients can be recommended.