Childbirth is considered as the most challenging psychological event in a woman’s life. It has a major effect on women’s lives with long-term positive or negative impacts. Cultural, religious, and socioeconomic differences can affect women’s perception about normal vaginal delivery (NVD) experience. Therefore, it is necessary to explore the primiparous women’s perception about it.This qualitative study, with a descriptive content analysis approach, was conducted in Kashan, a city in the center of Iran. Purposive sampling was used to recruit the participants of the current study. Data was gathered by semi-structured interviews during 24 h after normal vaginal birth among primiparous women. The sampling started from June to October in 2016. Interviews continued until data saturation which was achieved in the 14th interview but for assurance, it continued until the 17th one.The following three main themes were extracted “immersion in stress”, “pain, the essence of NVD” and “strategies for situation management”. Furthermore, seven subthemes were obtained including ‘loss threat’, ‘stressful context’, temporary impairment in physiologic harmony, paradoxical emotions, self-management, emotional support, and spiritual support.This study showed that stress and pain were two highlighted issues in NVD process. Increasing women’s awareness about NVD process, familiarizing the primiparous women with the simulated delivery room, accompanying these women for emotional support, and providing spiritual support can be effective in situation management to make the child delivery a pleasant and satisfying experience. Birth is the most challenging physiological and psychological events in the women’s life , 2. ChilThe first child’s birth and the choice of delivery type are considered as the most important events for the primiparous women. The normal vaginal delivery (NVD) as a normal physiological process has many benefits for both the mother and the child . Today, Based on the evidence, religious, cultural, and socioeconomic factors influence the perception of delivery and childbirth . Aziato In recent years, the rate of cesarean section is 48% in Iran that has increased to 87% in some private hospital , most ofThe reason why the rate of cesarean delivery has increased so dramatically in Iran is not entirely clear. It is important to know what has happened over the recent years. What has changed that despite the religious context in Iran, the tendency of primiparous women with no prior birth experience is less likely to NVD? Exploring women’s perception about normal childbirth experiences can enable policy-makers to identify the factors removing undesirable and negative experiences of childbirth and thus facilitate a pleasant childbirth experience for mothers through educational and structural interventions. In addition, through the recognition of women’s perception of NVD, societies can be directed towards a positive understanding of vaginal delivery, which can ultimately lead to maternal health promotion. Pazandeh et al. (2017) stated that improving the quality of care and creating a positive experience of NVD with minimal complications should be the primary goal of health care providers . TherefoA descriptive qualitative design using a content analysis approach was conducted to extract the experience of Iranian women’s experience regarding normal vaginal delivery. Data gathering lasted from June to October 2016. The context of data gathering was a state hospital in Kashan, a city in the center of Iran.The Institutional Review Board and the Research Ethics Committee of Kashan University of Medical Sciences (Project No. 93230) approved the study protocol. Permissions were also obtained from the hospital data authorities.The participants were informed about the aims, the importance of the study and withdrawal from the study at any time. They were also assured about the confidentiality of the provided data. The names of all participants were changed into codes while transcribing the interviews and the data related to each interview was kept in a safe place. All participants signed an informed written consent before taking part in the study.The participants were selected with a purposive sampling among primiparous women in postpartum ward. The present study was conducted 24 h after vaginal birth and before discharging from the hospital . Data gathering lasted from June to October 2016. Inclusion criteria were 19- to 34-year-old primiparous women with no history of psychological disorders, gestational age of 37–40 weeks, cephalic presentation, and no history of abortion, and ectopic pregnancy. However, the use of drug for induction, and the deterioration of mother’s status and the need for extra care constituted the exclusion criteria. The primiparous women with no labor experience were selected for this study because based on evidence, the previous experience of labor in the multipara women can affect perception, feelings, and the choice of the delivery type .Face-to-face semi-structured interviews with open-ended questions were conducted to explore the detailed perception of primiparous women. The main questions of the interview guide included “Would you please explain about your experiences of NVD?”, “How did you perceive NVD?”, “How did you feel when you were in the delivery room?” and “Can you talk about your experiences when the baby was delivering?”Then, the researchers explored more about the participants’ perceptions by using probing questions such as “Please explain more about it” or “Could you please give us an example?”, and “What do you mean by this?”The interviews were conducted by the first author in one or more sessions. An interview guide was developed in this study, shown in the supplementary file 1. All interviews were conducted in Persian in a quiet and private room in post-partum ward. The length of each interview lasted from 30 to 50 min. Interviews continued till data saturation i.e. repetitive data with no extraction of new conceptual codes. Data saturation was achieved in the 14th interview based on the consensus between all researchers. However, for more assurance, the interviews continued until the 17th one but no new codes were obtained.(22). Data analysis was conducted concurrently with data collection, so each interview was followed by data analysis in the same day. In order to do so, the interviews were transcribed verbatim and read several times to reach an overall understanding of women’s perspectives on normal vaginal birth. Meaning units, including words, sentences or paragraphs relevant to women’s perceptions of NVD were extracted and labeled with codes. Then, the codes were sorted into clusters of themes and sub-themes based on their similarities and differences. Finally, themes or expressions of latent content were obtained (24). An example of analysis phases is shown in Table Qualitative content analysis study was used to achieve a rich description of the phenomenon of interest in a natural context The credibility of the data was established through peer check and member check. Peer checking was conducted by two expert supervisors from Kashan University of Medical Sciences to verify the coding and categorization process. For member checking, some interview drafts were returned to the participants to verify the correct perceptions. In order to promote the transferability, the researchers focused on clarification, reflexivity, and neutrality. Furthermore, the demographic characteristics of the study population were described in detail. The researchers attempted to increase the conformability through keeping all the documentations at all stages and providing exact reports in order to generalize the results for further studies .Totally, 17 primiparous women took part in the study. The age of the participants ranged from 19 to 34 years old. Furthermore, the majority of participants were living in an urban area with average income, different educational level, and medical insurance. As illustrated in Table “Immersion in stress” is the most important theme identified from the participants’ responses. This theme consists of two sub-themes including ‘loss threat’, and ‘stressful context’.The category of ‘Loss threat’ was the most common experience of NVD among the primiparous women. This sub-theme comprised four clusters of sub-themes including ‘fear of damage to the infant during childbirth’, ‘fear of abnormal infant’, ‘fear of death’, ‘fear of damage to genital organs’.The participants declared that most of the concerns were due to words of others and past experiences.“My neighbor’s daughter had a NVD last year and because of the baby’s head injury, his brain was damaged and he would be paralyzed for the rest of his life. I’m afraid of having giving birth because of the risk of injury to baby” (participant 3). Another participant stated: “My sister had difficulty in sitting because of excessive rupture in the perineum during NVD”(participant 2).As one participant said: “I was very afraid of the delivery room. I had never experienced such an environment before. Nothing was familiar to me. I was afraid of staff and special equipment in the delivery room; I was even afraid of the smells and green colors of the walls”(participant 8). Another mother added: “I was horrified by the screams of the women who were giving birth. These screams made me more stressed. I would have preferred an environment with no disturbing noises”(participant 11).Many of the women’s concerns were related to being in a strange and unfamiliar environment. The participants described the delivery environment full of noises, annoying sounds, unpleasant feelings, stress, pain and loneliness and an environment without intimacy. One of the participants mentioned: The second effective element which was related to “stressful context” was “concerns induced by the words of others”. It was due to being influenced by others’ comments and experience. Indeed, it was an imagination created by others. It seems that not only did the maternal experience of NVD not create a pleasant/positive picture for primiparous women, but it also presented a terrifying image about normal childbirth.Occasionally, these concerns induced by the words of others were so intense that resulted in the imposed unrealistic inability to do NVD in women. Also, the presence of other women who were shouting due to labor pain in delivery room was a source of induced concern for primiparous mothers.“Two of my grandmother’s babies died during normal delivery. My mom and my aunt had a difficult NVD, all of which worried me”(participant 9).A major part of concerns was inevitable in normal delivery process. These concerns might alter women’ self confidence and self-esteem, and even might destroy them. One of the participants said: “Everyone who wants to talk about NVD starts straight with its pain.”(Participant 2). The pain of normal labor is different from any other pains. It seems that you cannot imagine a normal delivery without pain. “Sometimes we hear about painless labor, but I think it is just a slogan. I cannot believe that there is any normal delivery without pain”.(Participant 4).This theme showed that pain is an integral and inseparable component of NVD. It means that NVD without pain is impossible. One participant stated it: This theme included two sub-themes: “temporary impairment in physiologic harmony” and “paradoxical emotions”.I felt short of breath and they gave me oxygen. However, it did not help me and I had a sense of choking”. “My pain was so severe and persistent that I lost concentration”. (Participant 1).The majority of participants experienced vomiting, shivering, dyspnea, amnesia, fatigue, thirst, lack of concentration and loss of control. It is supposed that the physiological harmony of the body is temporarily impaired during the NVD process. As one of the participants added, ““The pain of NVD was so horrible that I felt I was going to die soon”.(Participant 3).Moreover, some women felt these painful and difficult conditions as awful as feeling of imminent death. One participant said: “This process was painful, but it had a sweet ending”. (Participant 2). Another participant stated: “This made me able to tolerate the horrible pain when I thought my baby was going to be born at the end of labor pain”. (Participant 5). Another woman said: “I experienced all the emotions that you can’t imagine, once I was screaming, groaning, moaning and crying and another time I was laughing. It was a very difficult time for me but as soon as I saw the baby, I felt it was worth it. That’s the most beautiful and wonderful moment.” (Participant 15).This sub-theme was divided into two clusters of subthemes: pleasant experiences and unpleasant experiences. Most participants explained a combination of pleasant and unpleasant experiences simultaneously which created paradoxical emotions. Some of participants described that the unpleasant experiences of NVD were accompanied by a sweet feeling of motherhood, the feeling of having a healthy normal infant, and the feeling of success and accomplishment. One of the participants said: Women during NVD process develop and adopt various strategies to manage this situation. This theme contained three sub-themes: ‘self-management’, ‘emotional support’ and ‘spiritual support’.“you are mainly responsible for the birth of your baby. We are merely facilitators” (Participant 13). Another participant said: “A midwife told me, if you want to have an easy and comfortable child birth, you must be calm and cooperate with me”. She also said: “do not shout and just take a deep breath to save your energy”. I did what she said, but in the delivery room, there was a woman who did not listen to her midwife and she failed in NVD. Eventually, she was transferred to the operation room for cesarean section (Participant 3).The participants believed that self-management in NVD is a useful factor for situation management. They considered themselves as responsible people for achieving the desired success in NVD process. One of the participants quoted one of the midwives who had said “The presence of a person like mother, sister, spouse, or a friend is very effective and peaceful)” participant 6).The participants said that the need for emotional support was not limited to health care providers (HCPs); if their spouse, mother, and sister had attended there, they would have felt more comfortable and satisfied. They also added the presence of their family members facilitated the pain relief, the tolerance to difficult condition and eventually caused the feeling of pleasant experience. One participant stated: Spiritual support is the third sub-theme of “strategies for situation management”. Spiritual support originates from religious beliefs of participants, especially from their faith in God and holy people.when I had pain, I prayed and I felt I gained more power to tolerate the severe pain” (Participant 2). Another participant added “during labor pain, I called God and holy people repeatedly, I felt less pain and I could handle the pain more easily” (Participant14). Most participants believed that faith in God promotes self-esteem and self-actualization. Some of them even believed that labor pain is an opportunity for spiritual growth and a way to connect to God. One of the participants asserted: “Muslims believe that the sins of women will be forgiven during labor pain”. (Participant 6).One of the participants mentioned: “This qualitative study aimed to explore the primiparous women’s experiences of NVD process. “Immersion in stress” was considered as the main theme of the present study. “Immersion in stress” was associated with two factors including loss threat and stressful context. ‘Fear of damage to the infant during childbirth’, ‘fear of abnormal infant’, ‘fear of death’, ‘fear of damage to genital organs’ were the sources of stress in the present study. In line with the previous studies, our findings indicated that the women in labor were excessively concerned about their infants and maternal complications during the normal childbirth , 25–28. What is inferred from the participants’ statements is that they described the delivery environment as an unfamiliar and noisy place, an environment full of pain, fear, anxiety, and without intimacy and friendship. Screaming and shouting of other women who are giving birth in this environment worsen the fear and the anxiety. Khatony et al. 2019) argued that one of the reasons of fear during delivery is related to the hospital environment and low quality of care  argued t. Akadri The result showed that hearing bitter experiences of other women regarding NVD process was the main source of concern in the primiparous women in this study. Latifnejad Roudsari et al. (2015) argued that these birth stories are mostly associated with unpleasant aspects of childbirth, such as psychological anxiety, fear, severe pain, and inappropriate interventions . These nAnother important experience associated with NVD process was severe labor pain which converted the pleasant feeling of delivery into unpleasant experiences. Women described labor pain as the most horrible pain that they had ever experienced. Majority of studies also describe labor pain as the most severe pain experienced by women , 9, 36. . As the pain deteriorates, the mother becomes closer to the baby. In other words, this unpleasant feeling of pain is associated with a sweet ending to having a baby. Callister et al. (2003) maintained that the labor pain differs from the acute or chronic pain of a disease, trauma, and surgical procedures. This pain is worthwhile for women because it bestowed the gift of motherhood to them [In addition, paradoxical emotions along with pain were experienced by the participants during NVD process. They described labor pain so severe that disturbed the physiological harmony of their body. Boryri et al. (2016) stated that labor pain decreases women’s energy, power and control of the situation . What se to them .The current study showed that even though the pain is the essence of NVD, the women attempted to use various strategies to manage the situation. Thomson et al. argued that owing to multi-dimensional nature of labor pain, women with different socio-cultural backgrounds have to use various coping strategies to adapt with this condition . Self-maEmotional support is another effective approach for situation management. Kozhimannil et al. (2013) concluded that the emotional support provided by “Doula” can relieve the labor pain, increase the satisfaction, and create a pleasant experience and positive outcome , 43. DouSpiritual support was considered as the main approach for situation management among Iranian women. It seems that this concept is originated from religious context in Iran because as mentioned before the majority of Iranian women are Muslim. Based on the evidence, Faith in God is a connection to the superior power that enhances the feeling of control and intrinsically gives power to women . MutmainThis study used a descriptive content analysis approach that employed individual in-depth interviews to explore the perception of primiparous women of NVD process. Although the qualitative approach generated a deep insight into the phenomenon under study, the recruitment of only 17 women from an urban community who were Muslim made the generalization of findings to all primiparous women in Iran difficult. It is assumed that women living in different religious context would have different experiences about vaginal birth process.This study showed that stress and pain were two highlighted issues in NVD process. Increasing women’s awareness of NVD process and what they experience during this process, familiarizing the primiparous women with the simulated delivery room, accompanying these women for emotional support, and providing spiritual support can be effective in situation management to make the child delivery a pleasant and satisfying experience.Additional file 1.


Commercial surrogacy is a highly controversial issue that leads to heated debates in the feminist literature, especially when surrogacy takes place in developing countries and when it is performed by local women for wealthy international individuals. The objective of this article is to confront common assumptions with the narratives and experiences described by Indian surrogates themselves.This qualitative study included 33 surrogates interviewed in India  who were at different stages of the surrogacy process. They were recruited through five clinics and agencies. This 2-year field study was conducted before the 2018 surrogacy law.Surrogates met the criteria fixed by the national guidelines in terms of age and marital and family situation. The commitment to surrogacy had generally been decided with the husband. Its aim was above all to improve the socioeconomic condition of the family. Women described surrogacy as offering better conditions than their previous paid activity. They had clear views on the child and their work. However, they declared that they faced difficulties and social condemnation as surrogacy is associated with extra-marital relationships. They also described a medical process in which they had no autonomy although they did not express complaints. Overall, surrogates did not portray themselves as vulnerable women and victims, but rather as mothers and spouses taking control of their destiny.The reality of surrogacy in India embraces antagonistic features that we analyze in this paper as “paradoxes”. First, while women have become surrogates in response to gender constraints as mothers and wives, yet in so doing they have gone against gender norms. Secondly, while surrogacy was socially perceived as dirty work undertaken in order to survive, surrogates used surrogacy as a means to upward mobility for themselves and their children. Finally, while surrogacy was organized to counteract accusations of exploitation, surrogates were under constant domination by the medical system and had no decision-making power in the surrogacy process. This echoes their daily life as women. Although the Indian legal framework has changed, surrogacy still challenges gender norms, particularly in other developing countries where the practice is emerging. Who else comes to become a surrogate?” Simran (S29)However, most surrogates declared that they had no specific financial problems but needed extra money:More money! And if the body can help [someone]!” Nisha (S23)“Who doesn’t want more money in this world?” Prachi (S15)“Surrogates showed clear intentions as to how the money earned would be used (Table n = 17/33), for day-to-day expenses (n = 14/33), to pay family debts (n = 10/33) or to get the family its own place to live (n = 9/33).Some of the surrogates ( Nisha S2“Who doesn = 6/13 surrogates interviewed on this issue). They explained that they became surrogates so that their daughter would not need to do so:“Financial problems have to stop with me” Devika (S21)If the daughter became a surrogate that would mean, according to them, that she also was in a financial crisis . Answers to the question “would you recommend surrogacy to your daughter in the future?” attest to the desire for upward social mobility.Half of the women would not advise their daughter to become a surrogate “It’s like renting a car” Pushpa (S19)“Some surrogates declared:I only want to do the job” Namrata (S12)“The job is done” Dipti (S32) and Hasina (S33)“Nevertheless, 10 surrogates declared that they would like or would have preferred to have some news, to see the child or at least to have a photo, just to be sure that the product of their work, the child, was healthy and looked happy , explaining that:” Dipti S2 and Hasn = 17/18) would recommend it to another woman (Table n = 12/15) declared that they would not repeat the experience because the medical procedures were physically too painful and it was too hard living away from family and children (for those who were away from home during pregnancy). Surrogacy was indeed perceived as a “one-time shot”:A one-off opportunity” Pushpa (S19)“A parenthesis in life” Meera (S04)“An incident that happened in life” Asma (S08)“Although Ananda (S25) stated that she had “no fears, only interests”, nearly half of the surrogates (n = 18/32) declared that they had some apprehension or difficulties mainly related to delivery and cesarean delivery. The narratives on job difficulties thus largely related to the physical aspects.Surrogacy was usually described as a positive experience. Most surrogates (an Table . Howevern = 14/26) mainly because they looked healthy, or because of their personality (n = 5/26), such as being cooperative, their status as a mother and wife (n = 12/26) or their reproductive history  (n = 6/26). Simran (S29) had difficulty in finding intended parents because she did not meet physical criteria: she was considered too thin and not able to carry a possible twin pregnancy.Similarly, according to some surrogates, intended parents chose them on the basis of physical criteria (n = 19/21) emphasized that surrogacy was a preferable option to their previous job (Table n = 14/21) and had better working conditions (n = 5/21).Of the 21 surrogates who had previously been in wage-paid employment (Table ob Table . They deSabina (S27) explained that when she was working in a jewelry shop, she used to go back home late (after working extra non-paid hours) and drivers used to harass her. Another surrogate, Devna (S28), declared that her previous job, in a hospital, was more tiring and stressful. Kajal (S10), who had worked in catering, declared that she was regularly harassed and that there was not this kind of abuse with surrogacy. Nichita (S09) explained that in her previous job in a hospital, she had to take care of and serve others, whereas now other people were taking care of her.It is not a difficult job, you just need to rest” Kuchi (S14).“For the first time in their life, surrogates had peaceful days, they did not have to manage a home, they did not have to serve anyone, and they received full attention from medical doctors, professionals, their husband and rich intended parents. It was unusual for them to benefit from such extra care.Overall, surrogates explained that:n = 14), eight were in a surrogacy home, two were staying in their own home, and four were in temporary accommodation .Surrogates are generally kept away from their family and neighborhood. Among the women who were pregnant (n = 30/30) stated that among their relatives and in their neighborhood, surrogacy was associated with extra-marital relationships (Table n = 28/33) had told no one (except close family) about their surrogacy commitment “People judge it badly but nobody helps” Kasi (S30)The majority of surrogates wanted greater awareness in society. This demand could explain why they welcomed our study, hoping that it would spread more information on surrogacy.Surrogates were convinced that they were not doing anything wrong but, according to them, society thought differently. They explained that Indian people are quick to pass judgement but:The surrogates explained that people who condemn them for doing sinful, dirty work are only ignorant, and so are not entitled to judge them. Two women explained that educated people understand and accept the process of surrogacy, but illiterate people think it is immoral . Some of them declared that surrogacy allowed them to do something good in their life: helping a childless couple whom they thought were in distress, or being a better mother by investing in their own children’s future.n = 12/15) did not keep a copy. According to medical doctors, no copy was left with the surrogates for confidential reasons . Surrogates explained that they had to do everything the doctors asked them to do. This condition was sometimes written into the agreement.Surrogacy is sealed by a contract between surrogates, intended parents and medical doctors. In our study, 23 surrogates had signed the surrogacy contract.n = 18/21) declared that they had no preference regarding the age, marital status, religion or nationality of the intended parents:I can serve anybody” Ananda (S25).“Only one surrogate, Devna (S28) explained that she was wondering how the intended parents would behave toward her as they belonged to a higher caste. Some surrogates declared that they were aware of hierarchical relationships. Some criticism was expressed of the relationship with doctors because surrogates “are poor and illiterate” . Others criticized medical doctors’ lack of confidence in them, for instance not allowing them to see the child after birth.Surrogates did not choose the intended parents, and they made no demand to do so. The majority of surrogates  declared for instance that, through surrogacy, she developed some skills such as communication skills through the numerous appointments with medical doctors and agency managers. This positive experience may also be linked with the medical care, unrelated to pregnancy, that some of them received, like Sushmita (S03) who had eye surgery to correct a squint.. Finally, we showed that surrogacy as it is experienced and described relates to specific gender norms in India. Our study findings validate some preconceptions and deconstruct others, revealing social and gender paradoxes in surrogacy practice in developing countries such as India.Based on surrogates’ narratives, we present new insights into Indian women’s lived experience of how surrogacy impacts upon their own perceptions of their role as women, spouses and mothers, revealing a complex reality. On the one hand, surrogates’ narratives echo existing criticisms expressed in the literature and in political debates regarding lack of autonomy, economic exploitation and need of money. On the other hand, however, their narratives simultaneously reveal a consciousness of their working conditions and social situation, and some empowerment and benefits of being surrogates. In the remainder of the discussion, we describe how our findings can be seen as pivoting on four paradoxes, echoing the surrogacy controversies in feminist literature. The first paradox is related to the issue of “non-choice” in committing to surrogacy. The second deals with the low moral standards associated with surrogacy in India, giving the women’s feedback and experience of this occupation. Thirdly, another paradox concerns the emotional and bodily involvement of surrogatesThe first paradox deals with the reasons why women commit to surrogacy. It is commonly assumed that in developing countries where surrogacy is commercial, only poor women in immediate need of money commit to it. In our field study, most surrogates interviewed did not appear to be in desperate poverty. The median income of the surrogates interviewed was 10,000 INR 140 euros] which was well above the Indian family median income 0 euros wThe financial motivation for surrogacy observed in our study is in line with all other studies in India, as well as with studies in Israel where it is also paid . This isIn our study, the majority of surrogates had previously been in wage-paid employment whereas in the general Indian population, only 42% of women are in paid employment . SurrogaFacing the need for money and sometimes financial crisis and debts, women had to find strategies, not necessarily to survive but to live better. Surrogacy appears as an option to earn a large sum of money that would be impossible with any other work. They considered that using their reproductive body was a better alternative than other wage labor available for women in India.Surrogacy thus appears as a strategic and thoughtful choice to improve living conditions. Our empirical data do not sustain the hypothesis that it is an economic non-choice for surrogates. A question that remains unexplored is the impact of surrogacy on the surrogates’ life. Does it lead to better economic and daily life conditions? More social studies are needed, especially over the long term, to evaluate the impacts of such a practice on surrogates’ living conditions, on their children’s future and on their conditions as women.The second paradox concerns the moral condemnation of surrogacy. In the “public imagination”, surrogacy is considered as immoral because it is associated with commercialization of motherhood and with sex work . In IndiSurrogacy is not an accepted practice in the surrogates’ community and may lead to stigmatization , 38, 55.Stigmatization is not necessarily specific to surrogacy, but it is intensified here as the woman’s body is directly involved. People are not aware of new reproductive technologies and would therefore think that surrogates had to have a sexual relationship with a man other than their husband. Amrita Pande drew a parallel between surrogacy and “dirty work” , based oWhen surrogates explained that people were not familiar with the process of in vitro fertilization, they placed themselves apart. They now knew that it was possible to have babies without sexual intercourse and they were aware of medical advances, which was not the case of their relatives. They felt that by becoming surrogates they were becoming part of a modern and knowledgeable society, exactly as was observed with institutionalized delivery and use of modern contraception .Condemnation of the condemners” is a classic mechanism observed among dirty workers to counterbalance the social stigma of their job [The surrogates explained that people who condemn them for doing sinful, dirty work are only ignorant, and so are not entitled to judge them. “heir job . SurrogaA third paradox appears regarding the maternal bond. As noted in the introduction, some scholars, especially essentialist feminists, point out that there is an inevitable attachment of pregnant women to the fetus. The surrogates described a clear affective but detached attitude to the future child, and defined surrogacy as a physical activity more than an emotional one.We observed no kind of maternal bond, which is consistent with other findings in India  and obselabor of love” and explained that surrogacy is not very different from “many already accepted practices which separate genetic, gestational, and social parenting, such as artificial insemination by donor, adoption, wet-nursing, and day care” [Elizabeth Anderson compared surrogacy to a “ay care” . For Eilay care” . They drThe surrogates we interviewed approached surrogacy as a physical job. They disembodied their belly, as in Teman’s study in Israel . Teman sSurrogacy is often described in the literature as reinforcing gender inequalities. Indeed, we observed that women become surrogates in order to respond to gender constraints as mothers and wives. However, paradoxically, by becoming surrogates they go against gender norms through which women are assigned to one man (the husband), one family (family-in-law), and are not encouraged to have wage-paid employment. Indian women are assigned to maternity, children and the household , 54.Surrogacy was perceived by the women we met as a new way to generate income, without creating suspicions or threatening the reputation of the family (as the surrogacy was kept secret) and thus to take care of their family. At the same time, surrogacy appears as a respite from women’s workload. Surrogacy stems simultaneously from gender constraints and from the will to go beyond gender constraints.Through our interviews with surrogates, intended parents and medical doctors, we confirm the lack of autonomy, liberty and decision-making power of surrogates regarding pregnancy, delivery and the entire process, as has been observed in other studies conducted in India  but unliThe lack of complaints is consistent with gender norms and with women’s daily life in India: Indian women are permanently under the control of their family and husband, with limited decision-making power and limited mobility , 62. SurThis domination and submissiveness are reinforced by the fact that surrogates belong to a lower class than medical doctors and intended parents, in a society that is traditionally strongly hierarchical and unequal, where power and autonomy depend on social class and economic resources . The conMedical doctors and intended parents tend to counteract the image of exploitation. For them, surrogacy is a win-win situation: childless couples go back home with a child while surrogates earn a large sum of money. Medical doctors explained that they kept the surrogates away from their homes to protect them from stigmatization, while preparing the women for a better life by organizing English or computer lessons, as is clearly shown in Gudenus’s documentary in Anand . Intende“how women both exert power and are subject to it” [In this context, however, and as far as it can be judged based on our interviews, surrogates were not forced to enter into the surrogacy process. We had the impression that they did not want to portray themselves as submissive women, nor as vulnerable women and victims. They described themselves as women taking control of their destiny, taking the few options available to fulfil their responsibilities as spouses and mothers. These women have deconstructed the usual image of Indian surrogates as vulnerable and exploited women. Surrogacy clearly shows t to it” .In feminist literature, surrogacy is described either as a survival strategy, as dirty work denigrated by the women’s peers, as exploitation by medical doctors and intended parents, or as a reproductive right and an opportunity for upward social mobility. Empirical data make it possible to go beyond the theoretical field. From our research based on surrogates’ narratives, the reality of surrogacy in India appears to lie between the two extremes and to embrace these antagonistic features.As in other developing countries where commercial surrogacy is flourishing, India has a significant reserve of reproductive workers because of gender norms and gender inequality that generate unfavorable conditions for women . Surrogastatus of pure alienated victim” p. 53 [The economic, social and political context, especially the gender norms, of a given society may lead to possible paradoxical situations, including for women themselves. It is commonly assumed that women in developing countries are vulnerable, and that they are forced to commit to sex work or outsourced reproductive labor because of economic and gender constraints , 20, 68.m” p. 53 : this woThe social and especially the gender paradoxes that we have analyzed here with transnational and commercial surrogacy echo the social paradoxes of globalization related to migration, sex work and care activities , 71. GloCare activities, such as childcare, and domestic work or sex work are generally performed by economically disadvantaged local women or immigrant women. The choice to become a nanny, a domestic employee or a sex worker may rely on “flawed consent” p. 71 . But sucGender paradoxes are therefore not specific to surrogacy, but rather are common to women’s outsourced activities in global society. Interestingly, they seem to be exacerbated when these activities directly deal with the body of poor women, as is the case of surrogacy.Additional file 1. Guidelines for interviews with surrogates.


The Free Energy Principle (FEP) is currently one of the most promising frameworks with which to address a unified explanation of life-related phenomena. With powerful formalism that embeds a small set of assumptions, it purports to deal with complex adaptive dynamics ranging from barely unicellular organisms to complex cultural manifestations. The FEP has received increased attention in disciplines that study life, including some critique regarding its overall explanatory power and its true potential as a grand unifying theory (GUT). Recently, FEP theorists presented a contribution with the main tenets of their framework, together with possible philosophical interpretations, which lean towards so-called Markovian Monism (MM). The present paper assumes some of the abovementioned critiques, rejects the arguments advanced to invalidate the FEP’s potential to be a GUT, and overcomes criticism thereof by reviewing FEP theorists’ newly minted metaphysical commitment, namely MM. Specifically, it shows that this philosophical interpretation of the FEP argues circularly and only delivers what it initially assumes, i.e., a dual information geometry that allegedly explains epistemic access to the world based on prior dual assumptions. The origin of this circularity can be traced back to a physical description contingent on relative system-environment separation. However, the FEP itself is not committed to MM, and as a scientific theory it delivers more than what it assumes, serving as a heuristic unification principle that provides epistemic advancement for the life sciences. The Free Energy Principle (FEP) inspires one of the most comprehensive frameworks for the study of complex adaptive systems. Originated by Karl Friston and colleagues, it spans active research in several life science fields under the overarching principle of internal free energy minimization. For this reason, the FEP can be counted among contemporary attempts to understand complex systems through variational principles—see e.g., ,2,3,4 foThroughout the last two decades, FEP formalism has been presented with technical aspects that may prove threatening for the uninitiated. Admittedly, changes to notation and symbols can misguide readers, hence FEP papers typically include tables with mathematical definitions of key concepts and figures that help visualize the underlying schema. Nevertheless, the theory increasingly appears as a promising and encompassing framework to study living systems, both dia- and syn-chronically, and has already been considered in the literature as a grand unifying theory (GUT) The advantage of such factorization is that, in terms of probability distributions, a Markov blanket renders internal states conditionally independent of external states. Additionally, sensory states are not influenced by internal states and active states are not influenced by external states . In otheparticular states as Since blanket states also belong in system characterization and partake of system dynamics, one may still consider the whole set of system or ure 1 in . MoreoveThe FEP framework thus assigns a probability distribution for the particular states, ure 2 in  for detaWhen dealing with the different terms of the steady state solution, there is some freedom in how to identify them. For instance, in keeping with the factorization of particular states as internal and blanket degrees of freedom, “the mechanics of internal and active states can be regarded as perception and action, where both are in the service of minimizing a particular surprisal” . One key tenet of the FEP framework outlined here refers to the distinction made between the probability distribution of things and the probability distribution about things. This is because the system must hold “beliefs about external states that are parametrized, represented, encoded or coherent with internal states”. What facts support such a bold claim? Basically the fact that, thanks to factorization via the Markov blanket—which makes external and internal states directly independent—there must be a 1:1 relationship between a system’s average internal state and a probability density over its external states: “The mapping between the expected  internal state (for any given blanket state) and a conditional density over external states  inherits from the conditional independencies that define a Markov blanket” . In its Turning back to probability distribution We see now that, in keeping with formalism and its interpretive possibilities, internal states stand in not just for themselves, but also represent what the system believes about the outer world. In other words, the probability distribution n (4) in . ConsequIf we turn back to system dynamics, as described in Since sensory states do not directly depend on the system’s internal states, it will seem like the latter are trying to minimize exactly the same quantity, namely the surprisal of states that constitute the system. Such autonomous states can be equated with action and perception seeking to minimize surprisal or its upper bound, free energy. One might also deem minimization of particular surprisal as maximization of the value of the system’s state or a sort of “generalized homeostasis”. However, to avoid getting ahead of myself, here I will focus on criticism from the organicist perspective, which raises serious doubts about the ability of physics to adequately represent organisms and their behaviors. On the one hand, organicists accuse FEP theorists of too quickly ascribing FEP framework properties and tools to organisms. Do free energy, surprise, and optimization exist as biological properties in complex adaptive systems? One could bring such concerns to the general problem of representation in scientific theories, which affects topics beyond the FEP framework, although obviously exceeds the scope of this paper.On the other hand, organicists heavily criticize the FEP’s crucial assumption about ergodicity over the system’s span of existence. This assumption might lead towards insufficient characterizations of the organism’s phenotype and defining properties. Admittedly, FEP theorists always introduce the caveat of applying formalism to well-defined, steady phases of the system’s life because, by definition, the FEP framework cannot deal with processes like death. Ergodicity “only holds over certain temporal scales for real organisms that are on a trajectory from birth to death”  and extrinsic (referring to belief states)—how should such probabilities be consistently interpreted? Are interpretations of probabilities as physical propensities compatible with interpretations of probabilities as cognitive inferences at all levels? If, as Colombo and Wright argue , FristonUnderstandably, critiques reviewed in the last section prompt discussion on the FEP’s philosophical interpretations found at the end of . In thatTo recap, due to the Markov blanket factorization used for the system and from the existence of k},{al}) , assume ee e.g., ,49.) p aeometry” .Complexity becomes a matter of temporal depth, with time scales as grey zones—without clear-cut thresholds—which nevertheless allow us to distinguish between different kinds of systems. Self-organization is simply implied by quick convergence on minimal free energy whilst complex adaptive systems present an adaptive response to changes in their environment that “will look as if they are selecting their long-term actions on the basis of an expected free energy”. Humans, for instance, will possess “deep generative models that see far into the future; enabling a move from homoeostasis to allostasis and, effectively, the capacity to select courses of action that consider long term consequences”. Inasmuch as the system does have temporal depth, it needs to implement estimates of the changing environment through a changing generative model. Hence, within the FEP framework, intentional behavior looks like uncertainty resolving, information seeking, epistemic foraging . HoweverFriston and colleagues adopt MM as the better metaphysical position to support the FEP framework. MM can be summed up in these two affirmations: “(1) Fundamentally, there is only one type of thing and only one type of irreducible property … (2) All systems possessing a Markov blanket have properties that are relevant for understanding the mind and consciousness: if such systems have mental properties, then they have them partly by virtue of possessing a Markov blanket” . Of courThe crucial argument draws on the inter-theoretical relationship between the two possible (considerations of) information geometries  dualism but—were that the case—the latter could not explain the existence of minds and consciousness by leveraging properties entailed by the existence of a Markov blanket, even if such properties are identified with protophenomenal properties . PropertNot surprisingly, MM fares better in the company of metaphysical accounts from neutral monists. The former might be considered a specific version of the latter “in which basic entities are intrinsically neither mental nor physical”—the last two qualifications being two conjugate ways of describing existing stuff. Nevertheless,  warn agaWhat other options are available? MM can ground other versions of reductive materialism, namely a physicalist interpretation. One might thus assume that such choice is motivated by physics’  ability to explain the dual aspect of the system’s information geometry. In reality, “[t]here are no additional, non-reducible properties, which are necessary to explain the mind and consciousness; between some non-conscious and conscious systems, there is only a gradual difference”. An implicit recourse to sorites paradoxes—arising from vague predicates—thus transpires when claiming vagueness for consciousness: “If consciousness is a vague concept (as suggested by our interpretation of Markovian Monism), then the right structure and functions can be metaphysically sufficient for consciousness, even if adding just a bit of structure and function to any uncontroversially non-conscious system does not make it conscious” . Even thThe previous section surveyed some philosophical tenets related to MM as the supposedly best ontology for the FEP, while hinting at its potential problems. In this section, I will endeavor to make explicit some FEP assumptions as a comprehensive scientific program to deal with life phenomena and demonstrate the sense in which said assumptions invalidate the MM perspective. This section aims to show that, contrary to criticisms of the FEP’s attempt at being a GUT on behalf of epistemic pluralism , one shoAssuming the validity of the system/environment partition through a Markov blanket—first circularity—the FEP framework’s central hypothesis is that systems do represent the outer world via their internal states—second circularity. This hypothesis is at the core of the correspondence between ee e.g., . For an ee e.g., ,51,52,53ee e.g., , pp. 206The FEP’s internal representations take on a probabilistic nature. Information is encoded and computed through probability density functions or approximations thereof: “This treatment assumes that the system’s state and structure encode an implicit and probabilistic model of the environment” .Sure enough, the FEP framework exploits the powerful feature of variational methods to tackle statistical inference problems as optimization problems . supervene on the same internal manifold”. If “[i]t is tenable to associate physics  mechanics with the intrinsic information geometry” [Friston and colleagues’ reference to the emergence and coexistence of a duality, intrinsic and extrinsic, in information geometry is extremely illustrative. Through the free energy minimization procedure, “belief updating and statistical thermodynamics both eometry” , the logBe that as it may, supervenience is the philosophical concept used to allow for the dual aspect of the systems’ internal basic stuff. As is well known, the explanatory power of supervenience is also highly controversial, though supervenience is usually deemed a good ally of physicalism  rIn other words, the FEP suffers from circularity because it a priori assumes conditions that are to be maintained. No novelty can emerge without further assumptions within this model. For Friston and colleagues, “A particle or person is never ‘off’ their manifold—they just occupy states that are more or less likely, given the kind of thing they are” . Still, In short, the contextuality of system/environment separation always lurks behind any would-be fundamental theory of life and sentience, and the FEP framework is not immune to that. The FEP deserves credit for showing how “action and perception look as if they are minimizing a particular entropy” . Yet, itNonetheless, in as far as its limitations are acknowledged, such circularities need not result in a drawback for the theory. The FEP might be circular, but, in moving around a circle whose foundations are accepted, it provides epistemic gain through a unified principle featuring homeostatic-like phases in living systems’ complex phase space. There, any system characterized as possessing a Markov blanket “can be cast as performing some elemental form of inference—and possessing an implicit generative model” . As a goThroughout the previous sections, this paper has submitted the FEP framework  to profoMM was presented and reviewed in this paper by making explicit the FEP’s implicit assumptions, which Friston and colleagues insufficiently disclosed . In part


Worldwide, the population is aging rapidly; therefore, there is a growing interest in strategies to support and maintain health and well-being in later life. Although familiarity with technology and digital literacy are increasing among this group, some older adults still lack confidence in their ability to use web-based technologies. In addition, age-related changes in cognition, vision, hearing, and perception may be barriers to adoption and highlight the need for digital tools developed specifically to meet the unique needs of older adults.The aim of this study is to understand the use of technology by older adults in general and identify the potential barriers to and facilitators of the adoption of health information technologies (HITs) to support the health and well-being of older adults to facilitate implementation and promote user uptake. In addition, this study aims to co-design and configure the InnoWell Platform, a digital tool designed to facilitate better outcomes for people seeking mental health services, to meet the needs of adults 50 years and older and their supportive others  to ensure the accessibility, engagement, and appropriateness of the technology.Participants were adults 50 years and older and those who self-identified as a supportive other . Participants were invited to participate in a 3-hour participatory design workshop using a variety of methods, including prompted discussion, creation of descriptive artifacts, and group-based development of user journeys.Four participatory design workshops were conducted, including a total of 21 participants, each attending a single workshop. Technology use was prevalent, with a preference indicated for smartphones and computers. Factors facilitating the adoption of HITs included personalization of content and functionality to meet and be responsive to a consumer’s needs, access to up-to-date information from reputable sources, and integration with standard care practices to support the relationship with health professionals. Concerns regarding data privacy and security were the primary barriers to the use of technology to support mental health and well-being.Although HITs have the potential to improve access to cost-effective and low-intensity interventions at scale for improving and maintaining mental health and well-being, several strategies may improve the uptake and efficacy of technologies by the older adult community, including the use of co-design methodologies to ensure usability, acceptability, and appropriateness of the technology; support in using and understanding the clinical applications of the technology by a digital navigator; and ready availability of education and training materials. The global population is aging rapidly. Within the next 40 years in Australia, for example, one-third of the population will be aged 50-65 years and a further quarter will be 65 years and older . The ecoThe international literature indicates that approximately two-thirds of adults aged 65 years and older report internet use ,4, and tHITs are being developed rapidly for improving the delivery of mental health care for both consumers and health professionals and for facilitating improved self-management of care . To thatImportantly, in a study of older adults N=221) presenting to a specialized memory clinic for concerns regarding new-onset cognitive decline and/or mood symptoms, most participants 198/209, 94.6%) reported that they would find it useful to be able to access a website designed to support healthy aging, including physical health and cognition, self-management of existing conditions, and routine tracking of changes in health outcomes over time. Similarly, most respondents also reported interest in a website designed to specifically measure mood-related concerns and changes   GP…teaching you the things you need to tell your specialist” (Workshop 2). However, there was some concern that the misinterpretation of information might be a barrier, recognizing a “risk of creating a device that leads people to self-diagnosing” (Workshop 2) and that generic information may not have much benefit if it is “not personalised” (Workshop 3) and “only answers a silly little thing” (Workshop 3).The ability to find up to date interaction with health care, potentially as a “referral to a specialist” (Workshop 1), a way to “fast track the system…direct you to service” (Workshop 1), or a tool to enhance the care provided by a health professional, that is, “If I brought it in and showed it to her, she’d probably work collaboratively with me.” [Workshop 2]). Recommendations and interventions were also a desired feature, with ideas including “interventions to do balance exercises” (Workshop 1), “video training about how to do a guided [meditation] session” (Workshop 3), and “virtual group sessions” (Workshop 3). However, the potential for error was cited as it was recognized that there is an inherent “risk with assuming that feeding information in means the outcomes will be right” (Workshop 1). Participants wanted there to be an a credible source or was endorsed by health professionals, highlighting the need for the content to be “developed by an organisation that is already trusted” (Workshop 2). Similarly, a digital tool was viewed to lack the credibility of a health professional, thereby potentially preventing use as participants were not interested in “replacing GPs or specialists” (Workshop 2). The potential for a digital tool to be impersonal was also referenced as a barrier, particularly for older adults who “could be more isolated…need someone that cares…the connection is still important” (Workshop 1). Participants indicated that they would be more likely to use this type of tool if it came from diagnosis, participants reported an interest in prevention and risk reduction or “something that would keep me away from the doctor…preventative but also health generative…keeps you healthy and active” (Workshop 1). Goal setting was a potential motivator of use, with participants noting that users “would establish goals after going through a level of entering information” (Workshop 1) and recognizing that “goals could change as you go through” (Workshop 1). On the other hand, competition was referenced as “demotivating…don’t want people to fail and say I won’t look at that again” (Workshop 1) and “a huge problem…a goal isn’t a goal unless there’s a success or failure measured” (Workshop 1).Although there was minimal reference to the need for the tool to be able to provide a user with a access to health care, particularly for individuals in remote areas where “distance becomes a disability” (Workshop 1), helping “people not feel isolated when they are physically isolated” (Workshop 2). Empowering users was also referenced as an important component, with a need for a strength-based approach because “older people are told you can’t do that anymore…celebrate what they are doing” (Workshop 1). Although referenced infrequently, participants indicated that they were more likely to use a digital tool that had a good user experience and design. Furthermore, it was recommended that users would benefit from education and training resources, “information on how to use it – a tutorial or mind map…give people an idea of what kind of help they could get” (Workshop 3). This may be particularly relevant for older adults with poor digital literacy as “people will always be left out if it is on a computer” (Workshop 1) or for those who experience anxiety related to help seeking, where the technology should not be “too daunting” (Workshop 1). However, neither of these barriers were reported to be personal concerns for the participants.It was widely recognized that a digital tool has the potential to improve digital divide is crucial when considering technology use among older adults, as there may be barriers to access  that preclude their engagement with web-based tools, including for, but not limited to, information and entertainment purposes and for the purposes of improving and maintaining health and well-being.Our results align with previous findings that older adults routinely engage with a range of technologies, including computers, mobile phones, eBook readers, and tablets. Importantly, the preference for smartphones highlights a change in device use among older adults. Although previous studies have found that the use of home computers was nearly universal in a sample of older adults (93%), the use of smartphones was far less frequent (52%) . The prefeeling healthy) and the capacity to fulfill one’s goals and carry out activities of one’s choice. However, there was also recognition that illness or disability and well-being are not mutually exclusive; rather, there is a need for personal awareness and acceptance of self. The fulfillment of basic life needs, namely, safety in one’s surroundings, connection to others, and resilience  were also referenced. Importantly, participants noted that stigma can detract from well-being as it may be a barrier to seeking and accessing help for mental health problems. The factors of well-being identified by participants align with the 6 components of the Ryff model of psychological well-being [Participants generally conceptualized well-being as an absence of illness  technology subsidies for low-income consumers, (2) user-friendly technologies appropriate for consumers with physical disabilities and cognitive impairment; and (3) demonstrations and training opportunities for consumers who might not otherwise have the opportunity to learn how to use available technologies [The disruption caused by the COVID-19 global pandemic has resulted in a greater need for and reliance on digital health care for screening, treatment, and ongoing maintenance of health. To this end, HITs offer a viable alternative for those who prefer or are required to use digital health care due to health concerns  and geographic, transport, or mobility constraints. One of the marked discrepancies between our study and others that have investigated technology use for health-related purposes by older adults relates to familiarity with and confidence in using technology. Although this was not a personal concern among our participants, a lack of familiarity with technologies has frequently been cited as a potential barrier to adoption for older adults , specifinologies .Furthermore, health services are also encouraged to consider the addition of a digital navigator to their care team to improve the uptake and implementation of HITs within care . The rolImportantly, many of the features and functions suggested by participants for the digital tool align with the core principles underpinning the design and development of the InnoWell Platform, which include increasing access to standardized, broad-based assessment; identifying and tracking consumer needs; matching those needs with personalized care options; and enhancing the quality of care provided to consumers . AlthougDespite the willingness to engage with HITs, data privacy and security concerns were frequently referenced as barriers to use, which aligns with previous user-centered work in this area . This isImportantly, the results of this study have translated to a configuration of the InnoWell Platform specifically tailored to older adults. The broad-based assessment, for example, has been modified to reflect areas of health that are particularly relevant to older adults, including cognition and pain, and to incorporate assessment tools specifically designed for the older adult community (as opposed to tools used in configurations of the InnoWell Platform designed for young people or veterans). All informational materials provided within the InnoWell Platform are appropriate for older adults. For example, fact sheets are provided regarding the benefits of physical activity or the health impacts of excessive alcohol use for older adults. Furthermore, the care options embedded within the InnoWell Platform have been revised to reflect the needs of older adults, such as recommendations for apps for cognitive training, medication management, and cardiovascular health. The design and development of additional features and functionality of the InnoWell Platform based on the information gathered in this study are currently under consideration for inclusion in the next iteration of this innovative HIT., 50-64 years vs 65-80 years).This study has some limitations that are important to note. All participants in this study were regular users of technology with high levels of digital literacy. As such, the accessibility, engagement, and appropriateness of technology for novice users or those who do not have easy access to technology could not be explored. In addition, only 2 supportive others were included in the participant sample, thereby limiting any conclusions that can be drawn about the features or functions of HITs that may be appropriate specifically for this user group. Finally, to promote patient privacy, no demographic information was collected from participants; therefore, we were unable to comment on factors such as age range, highest level of education, or occupational status . This also precludes the ability to investigate differences in technology preferences based on age , regarding the quality, usability, and acceptability of the functionality of the prototyped InnoWell Platform. Eighteen participants have enrolled in this study to date, and results are expected to be submitted for publication in early 2021. The findings will inform the iterative redesign and development of the InnoWell Platform before the implementation within an older adult health service setting. Furthermore, participant feedback will also be used in the design and development of other HITs for the older adult community, such as gamified cognitive tests to assess and monitor cognitive functioning over time and multifaceted, interactive web-based interventions to support and maintain mental health and well-being.