Exploring Swedish single women’s decision to choose motherhood through medically assisted reproduction – a qualitative study

Abstract

New legislation was introduced in Sweden in 2016, giving single women access to medically assisted reproduction (MAR). While Swedish single women’s characteristics and motivations for choosing motherhood through MAR were assessed in our previous pilot survey, their experience of considering and making the decision to undergo MAR has not been assessed through a qualitative approach. Thus, the aim of this study was to explore Swedish single women´s experience of making the decision to choose motherhood through MAR. The study design was a qualitative method with a semi-structured interview guide used for individual face-to-face interviews. Sixteen single women accepted for MAR were interviewed individually during their waiting time to start treatment. Qualitative content analysis was used to analyse the data. The data analyses resulted in three main categories: (i) longing and belonging; (ii) social exclusion and support; and (iii) evaluation and encounter. The overarching theme reflects the decision to become a single mother by choice: motherhood through MAR – an emotional and ambivalent decision to make on your own. In conclusion, to reach motherhood, by giving birth to one’s child and not deviating from the norm as childless, was considered important among these women when making the decision to become a single mother by choice.

Keywords:

• Assisted reproductive technology (ART)
• medically assisted reproduction (MAR)
• motherhood
• single mother by choice
• qualitative study

Introduction

The view on reproduction has changed in Western society, because of changes in norms and values. Today, families can have different structures and children grow up in constellations other than the traditional nuclear family. Meanwhile, women choosing single motherhood continue to challenge norms of both reproduction and the family (Hertz, 2006).

Single women who choose motherhood through medically assisted reproduction (MAR) (Zegers-Hochschild et al., 2017), are older and more well educated and are employed full-time to a greater extent than women in couples with common parenthood (García et al., 2020; Jadva et al., 2009). Most single women applying for MAR have not been married, but have had previous relationships (Salomon et al., 2015). They have discussed their decision to become a single mother by choice with family members and friends (Jadva et al., 2009). However, single motherhood was not their first choice (Birch Petersen et al., 2015, 2016). Most women hope to find a partner in the future with whom to share parenthood (Birch Petersen et al., 2016; Murray & Golombok, 2005; Salomon et al., 2015).

New legislation in Sweden in 2016 made it possible for single women to apply for MAR, through Donor Insemination (DI) and/or assisted reproductive technology (ART) (SoU, 2015/16). Thus, a pilot survey was conducted to investigate the characteristics and motivations of single women applying for MAR in a Swedish context (Volgsten & Schmidt, 2021). Our results indicated that the characteristics of Swedish single women accepted for MAR were in accordance with those of other single mothers by choice: they were older, employed full-time, and well educated. Furthermore, most of the women had previously had long-term relationships, having been married or in a partnership. Single women’s reasons for not having children in previous relationships have been stated as the relationship not being right, not being the right time, and their partner not wanting to have a child (Jadva et al., 2009; Salomon et al., 2015). Motivations for choosing single motherhood through MAR among the Swedish women in the pilot study were that having a child was more important, due to their age, than waiting for the right partner; nevertheless, they still had hoped they would find a partner in the future. However, further questions arose involving choosing motherhood through MAR as a single woman, such as the importance of motherhood to give birth to ones biological child was not assessed in our previous study (Volgsten & Schmidt, 2021).

Since the legislation in 2016 that gave single women access to MAR, these women’s experiences of choosing motherhood through MAR have not been assessed in a Swedish context. Thus, the aim of this qualitative study was to explore Swedish single women's experience of making the decision to choose motherhood through MAR.

Materials and methods

Study design

The methodological approach was a qualitative design with semi-structured individual face-to-face interviews.

Study participants and setting

The participants in this qualitative study were single women accepted for MAR at the Centre for Reproduction at Uppsala University Hospital, Sweden, from August 2016 to December 2017. They had previously participated in a pilot survey and had consented to be contacted for an interview by providing their phone number. A detailed description of the study population’s characteristics has been presented elsewhere (Volgsten & Schmidt, 2021).

The fertility clinic, the Centre for Reproduction, is one of six public clinics in Sweden offering couples, both heterosexual and lesbian and since 2016 single women, subsidised MAR, as six treatments with donor insemination (DI). Two of the insemination treatments can be replaced with one treatment of assisted reproductive technology (ART). For single women, the upper age limit for MAR is 39 years at the beginning of each treatment. The clinic was the first public clinic in Sweden to start investigations for undergoing MAR after the 2016 legislation. Another legislation in Sweden, from 2019, permits embryo- and double donation, and there no longer must be a genetic link to the parent(s) (National Board of Health and Welfare, 2020; SoU, 2017/18). After the investigation, there is a waiting time for the treatment, based on the availability of donor sperm. Single mothers by choice have to have their medical conditions examined by a medical doctor and their psychosocial and social conditions evaluated by a counsellor before being accepted for MAR, according to the Swedish legislation regarding donor sperm. The criterion for psychosocial conditions is the woman’s ability, as a single parent, to provide for the child’s needs (National Board of Health & Welfare, 2016; SoU, 2015/16). After this investigation, and before treatment can start, a donation meeting is held at the clinic, at which the woman is accepted or rejected for MAR. In Sweden, the donor is non-anonymous to the prospective child, who will have access to the donor’s identity from the age of 18 years.

There are no specific governmental support services for single mothers by choice than for other mothers who are single due to divorce or separation. However, as Sweden is a Nordic welfare country, there is free access to subsidised MAR treatment in the public healthcare sector, long maternal leave, salary as social transfer income when on leave, and access to affordable and available day-care of high quality. It is also relatively easy to combine employed work and parenthood, and there are no fees for school or higher education.

Procedure

Recruitment was done in two steps in October 2018. First, an invitation letter was sent to the participants of our previous study with a home address in the county of Uppsala (n = 30), as the interviews were to be face-to-face. These single women had all been accepted for MAR at the public clinic. Second, these women were contacted by the first author (HV) individually by phone about a week after they had received the letter; this provided an opportunity to check for inclusion and exclusion criteria and to book a place and time for an individual interview. The inclusion criteria for the study were that the women were accepted for MAR at the donation meeting and lived in the county of Uppsala. The exclusion criteria were Swedish language difficulties, having had a biological child after MAR, and living outside the county of Uppsala. One woman had moved outside the county, and of the other women, five had cancelled, paused, or completed their treatment and three did not answer or declined participation. Five women had already had a child after MAR. A purposive sample of 16 single women was included and agreed to participate in the study.

Data collection

Individual face-to-face interviews were conducted in Swedish, using open-ended questions from a semi-structured interview guide, developed in Swedish by the first author. Interviews were audio-recorded and transcribed verbatim. Occasional probing questions were asked when further information was needed. All interviews were conducted by the first author in the same non-clinical room at the university hospital between 25^th October and 21^st December 2018. The author is a registered nurse-midwife who has previously worked and conducted research at the same public clinic, but was not employed at the clinic at the time of the study. Participants were asked to sign a consent form before the interview, at which time information was also collected regarding whether the treatment had started and, if so, when and what kind (DI/ART), see Table 1. The interview started after informing the participant that she could withdraw participation at any time during the interview. A pre-tested and revised interview guide covering the following topics was used: (i) life situation when deciding to undergo MAR; (ii) social support and network; (iii) information and questions concerning motherhood; and (iv) other options to have a child. All interviews were audio-recorded, lasted a mean of 35.7 min (range 26–51 min). No repeat interviews were conducted. Field notes, such as non-verbal expressions, silence and sighs and disturbing surrounding, were made directly after each interview (Tong et al., 2007; van Teijlingen & Forrest, 2004). Data saturation was considered to be reached when no more information was obtained (Tong et al., 2007).

Table 1. Background data of Swedish single women accepted for MAR (n = 16).

Age (mean)	36.7
Age (range)	31–40
Started MAR	9
DI	5
ART	4
Pregnancy*	0
Waiting time for MAR (months)	12.5

*At the time of the study.

Data analysis

The interviews were analysed by the first author, inspired by qualitative content analysis (Graneheim & Lundman, 2004). To systematically organise the data into a structured format, the text was divided into shortened meaning units, after several careful readings of the transcribed interviews. A meaning unit is a piece of text with specific content relating to the aim. Units were coded and sorted into subcategories and categories depending on similarities and differences in the content. Two MSc students in Midwifery participated in the data analysis by analysing parts of the transcribed interviews. Thus, the subcategories and categories were checked in cooperation with the students and the second author. To problematise the interpretation, the second author was involved to find other alternative interpretations if considered necessary. Furthermore, the first author, who had previously been working at the clinic, provided insight and knowledge in the research field, a pre-understanding considered important in qualitative research. No software package was used. Data was collected and analysed by sorting subcategories and categories in separate documents in a computer only used for research purposes. To achieve trustworthiness, steps of the data analysis process were checked through triangulation of the data to reach dependability (Graneheim & Lundman, 2004; Tong et al., 2007; van Teijlingen & Forrest, 2004). A rich number of quotes have been presented to substantiate the content and to give the reader an opportunity to interpret some of the findings, in order to strengthen the credibility. Thus, following the criteria for reporting qualitative research (Tong et al., 2007). The study was approved by the Ethics Committee at Uppsala University, Sweden (Dnr 2017; 402).

Results

A qualitative design was used to explore Swedish single women's experience of making the decision to choose motherhood through MAR. The study group consisted of 16 single women, aged 36.7 years (range 31–40) accepted for MAR. Nine of them had started MAR (DI = 5 and ART = 4) and none of them were pregnant at the time of the study. The average waiting period for MAR was 12.5 months, including investigation (Table 1). The data analyses resulted in three main categories and ten subcategories (Table 2), the overarching theme being; motherhood through MAR – an emotional and ambivalent decision to make on your own. Quotations from the individual interviews are presented and labelled with the participants’ code and age.

Table 2. The theme, categories, and subcategories of Swedish single women's experience of making the decision to choose motherhood through MAR.

Overarching theme	Motherhood through MAR – an emotional and ambivalent decision to make on your own
Categories	Longing and belonging	Social exclusion and support	Evaluation and encounter
Subcategories	Longing for a child	Social exclusion and shame	Being evaluated as a “good” mother
	Having a bond to the child	Social support – but no one to share thoughts with	Frustrating waiting time for a donor
	Other options for having a child not considered Not the first choice	Need of emotional support	Expected to find information on your own

Longing and belonging

Longing for a child

The life situation when deciding to have a child by MAR was described as a long-lasting, emotional process that had occupied the single women’s life for an extensive amount of time. The longing for a child had been on their mind for their entire adult life. The experience of wanting to carry a child was described as a physical feeling that was impossible to fight against. A feeling of one’s “biological clock,” and how one’s body was yearning and screaming for a child, was described as both a mental and physical desire:

No, but I’ve always thought that it’s something I want to experience, to carry my child. And all that with your body, this biological clock and how your body cries out for a child, it…I think, it’s such a strong feeling in my body that it’s…It’s not just a wish I have mentally but it also physically ends up there. (A32)

This longing for a child was described among the women as both an illogical and irrational feeling and at the same time a desire for a child as a feeling that the meaning of life is children:

Now I’m getting a bit emotional here. But it’s something that’s extremely illogical, actually. Not rational in any way. Yes, what is longing? No, but I guess it’s some type of feeling that the meaning of life is children, in some way. And you can feel that way to different degrees…But I want to have children. That’s just the way it is. (I 34)

The desire to have a child was experienced as a feeling of longing that did not disappear, a feeling stronger and more important than the longing to find a partner. Among the single women was described to come to a point in life at which you had done everything and fulfilled their dreams, and now the only thing missing was to have a child:

I’m so very tired of just being on my own and thinking about myself and…I’ve had such a huge amount of freedom my whole life, actually. Or yeah, in many ways. So it’s also that I’ve done it all, I’ve realized my dreams in principle…So it also feels like this, why should I…yeah, why shouldn’t I have a child in my life? (C 36)

Feelings of anxiety and emptiness, of something missing in life, and of life being unfair due to not having a child was mentioned among the women’s descriptions of making the decision:

It makes my heart ache a bit. I mean, there’s something missing. Sometimes I cry too, because I feel as if life is just so unfair…And here I am and really want to have a child, and have nothing. Then life feels unfair. No, I mean it hurts. I also want to… (G 31)

A feeling of selfishness in having a child alone as a single mother was also mentioned. Not only would having a child give your parents grandchildren; it would mean that you would be less alone in your old age as a woman described:

It felt so selfish to just say you wanted someone of your own to love. And maybe just have someone so you didn’t…that part when you get old, that you actually have some people…not to take care of you, but maybe who visit you and such. (L 40)

Having a bond to the child

The decision to have a biological child was expressed as a feeling of wanting to have a bond with the child. The experience of going through a pregnancy, of carrying the child, was considered self-evident to most single women, as something to share with other women. This choice was described as the bond that was created with the child:

Yeah, I guess it’s building the bond with the child and the feeling that you’ve carried it and such, I suppose. I don’t know, I’ve never been there so I don’t know how it feels. But I think that’s what it is. That there’s something I’ve made, in that case. It’s certainly not the normal way, but anyway it’s my choice how I’ve done it and how I create it…yeah, I think that would be exciting to experience. (O 39)

A longing to be pregnant was described as both important and at the same time not the most important thing. Fear of losing control and experiencing physical pain during childbirth was also mentioned among the women. Pregnancy was described as a significant part of having a child:

I wish it weren’t the case, but I actually think I have a longing to be pregnant. Even though I have friends who have felt really bad when they’ve been pregnant, nonetheless I have this kind of…Yeah, but just once in life I’d like to be pregnant. Yeah, that’s the way it is. It’s a part of it. It’s not the most important thing, but I’d be lying if I said it wasn’t significant. (I 34)

Motherhood was described as taking care of a child and giving a child unconditional love and being able to give the child a good childhood. Living some kind of family life and creating family-like other families, with family chores, and being there when the child was growing up were mentioned among the women:

Yeah, I mean it entails a bunch of different things. Both difficult and fun things. No, but I…if you connect it to this longing. Yeah, but I actually have a longing for both a baby…I can also long for these absurd things like getting to be on parental leave and just having a baby. But I can also long for, yeah, going on a cycling holiday with a ten-year-old. Yeah, I mean some type of family life. And to be there as someone grows up. (I 34)

Motherhood was also described as becoming more of a woman, reaching adulthood. This feeling was explained as having an understanding of what other women with children experience and as a woman described:

I think I could feel more like a woman, actually, I think. Because now you’re so alone and are kind of only responsible for yourself, and I do exactly as I wish and now I have a very stable life…But it’s kind of not the case that you’re the same as you were before, and then it feels like, yeah, you also want these things that are there in adult life. Having children and being a mother and such. And having all these thoughts. (H 39)

Other options for having a child not considered

The notion that there would not be a child after MAR if the treatment failed was hard to think and talk about. Other available options were not on the single women’s minds. Going to Denmark for MAR was mentioned as an alternative. Adoption was not an option if treatment was unsuccessful as this was an alternative for couples and not considered a possibility for single women in this study, due to economic and age factors. Embryo- or double donation were not options these women considered, who explained that they wanted to undergo MAR first before they decided on the next step in the case of treatment failure. Giving birth to the child was important to single women. Some of the women said they would consider other alternatives if they were the only options left:

I don’t know. I mean, if the situation demanded it…Right now I just feel like I want to have…Because then it’s not my own. Right now I want…I want to have my own, that’s actually my own. But if that’s not possible and I had it…Or have the possibility, then I’d surely take it if it meant I could carry the child and give birth to it. It would in any case be my blood running through it, to be crass. Yes, I guess I would consider it. (E 39)

Not the first choice

The decision to have a child alone, without a partner, was not the single women’s first choice; rather, they described it as having a child before it was too late. Time running out and being left childless if no decision was made were also mentioned. Not having met the right partner, as well as a partner not wanting to have children, were brought up as reasons for not having had a child in previous relationships. Having no future plans involving children was mentioned as a reason for ending relationships. The decision to go through MAR alone was described as a kind of pain due to not being in a relationship:

No, but it’s my decision and I’ll just have to deal with the pain of not being able to be in the relationship I want, or a relationship at all, sort of. I can handle it like that…But kind of knowing, who am I to have a baby? And what happens with me in…I mean, what it is I need to be in a relationship with a child…It won’t be especially easy. But I had sort of something to orient myself to anyway, I knew a bit what was going on. (J 39)

Feelings of ambivalence were mentioned among the single women when making the decision to go through MAR without a partner:

And I also think it’s gone up and down how I’ve felt about it, that when I’d just gotten in the queue I felt like yes, this feels right, oh how nice, now I’m really doing the right thing and it’s going to go well. And I thought it felt really nice, but then it goes a bit up and down and sometimes it can…Yeah, sometimes it can feel like no, am I really going to do this by myself…so I can end up in that a lot and I’ve been going through a period a bit now, of: am I really going to do this alone? (N 33)

At the same time, they mentioned a life situation in which they could take care of a child both emotionally and financially and pride at having made the decision and as a woman described:

I’m proud of myself for making this decision. I feel completely capable of having a child on my own, both emotionally and financially. (C 36)

Social exclusion and support

Social exclusion and shame

Social exclusion, for instance not belonging to the same social context due to being childless, was described among the women:

Because when you don’t have children, you can…what should I say? You’re excluded from certain…You don’t understand…All these types of things. So both a social thing too, I think, is a rather big thing, even though it might sound odd, but…No, I mean you’re not excluded like that, but just…You might gain a better understanding of things and you understand what people are talking about and what they mean, because you yourself can’t have children. You’re not in it, you don’t get it. No matter how much you try to understand… (M 37)

Disappointment, sadness, and discontent were mentioned as feelings the women experienced involving exclusion when other women among both their close family and friends had children:

I feel sad. I can feel discontentment, unfortunately. It’s not beautiful, but that’s how it is. And it’s very much these updates on Instagram or Facebook, that they’re pregnant with their bellies and such. And I just long for when I’m there, that day. Hopefully I’ll get to share that. But when you’re on the other side it’s really tough. And then I’ve done it in different ways. Sometimes I’ve been really destroyed. (A 32)

Single women also spoke of the social norm of having children as well as being judged due to not having a nuclear family. Having a low status was mentioned as a consequence of not having a child. Some women described this situation as something single women had to deal with as childless, creating a feeling of deviating from the norm. Some women also described a kind of shame in deciding to have a child without a partner:

But a bit of shame, actually, in connection with it, that…Yeah, all my friends have partners and children and such, and…Yeah, but perhaps something like this…Feeling like I deviate from the norm…So I think for me it’s been connected to deviating from a norm. (F 38)

Social support but no one to share thoughts with

Social support and encouragement from families and close friends were mentioned when the women had made the decision to undergo MAR. They counted on support and help, such as babysitting, from close family after the child was born. A network of close family and friends supporting when the child was born was described among the women as follows:

And I have lots of people around me who I know would help and be there to support me and such…. (N 33)

At the same time, some women expressed a feeling of fear at being alone and not having a partner waiting at home to share their thoughts with:

That I don’t have someone with me along the way, and also a bit of fear in that. That you…Partly that I’ll be very alone but also that the child doesn’t have some other adult who’s automatically there… (B 37)

When the decision to be a single mother by choice was made a woman described both a relief and a kind of grief to go through the treatment process alone, without a partner:

No, it’s a process and of course a source of sorrow at not…that I choose to do it by myself, that that’s what will happen, the alternative I chose but also perhaps a relief that it was…Okay, but I can do it myself if this is the path I want to take… (N 33)

The lack of a partner led the women to regard as important the support given at the clinic as well as being offered counselling, to have someone to talk with during the waiting time before starting treatment. Some women mentioned that some kind of support, or a call from the clinic, would have been helpful for their mental wellbeing:

Yeah, but I mean your psychological wellbeing is just as important as your physical wellbeing in this process and it’s…I mean you don’t have a natural partner to talk about it with when you do it yourself; instead it’s parents, siblings, friends, and so on. So if you’d had the possibility to go talk to someone that might have been really good, actually, and just gotten a bit of perspective about it. Now I’ve gotten it anyway because I have good people around me, but…you really need to perhaps talk to someone. I don’t know if they offer that. (P 39)

Need of emotional support

Mental wellbeing was experienced among women as involving emotional swings during the waiting time for a donor, or upon a negative pregnancy test after unsuccessful treatment. They mentioned long waiting times of up to a year when there were holidays coming up, and this affected their emotions:

…it’s up and down. It’s very…I don’t think I’ve ever been so unstable. Because it’s a year of strange waiting where you don’t know, will it be a year or will it be six months? Or will it be two years? You have no one…And I’m quite a planner, so it’s very…It may have to do with one’s personality, of course… (M 37)

Some women described that they had not been informed that they could bring someone else, instead of a partner, when they had an appointment or treatment at the clinic. They would have appreciated receiving information from the clinic about different peer-support groups, either at the clinic or elsewhere, such as Internet groups and patient compounds. Meeting with other single women in the same situation as themselves was suggested:

Yeah, perhaps sometimes you have some small circle or something. You could have a discussion group you’ve invited people to. That could also be an alternative, I think. Because, as I said, there are many thoughts and the like that, yeah…it’s not everyone who can understand what you’re going through and what thoughts you have. So I do think that would be good. (H 39)

Evaluation and encounter

Being evaluated as a “good” mother

The meeting with the counsellor for the evaluation of their psychosocial condition was described as strenuous, as the woman did not know what would be brought up. Some women described both preparing by going through the guidelines in advance, and not being prepared when they did not know what criteria would be assessed. Being evaluated alone, without a partner, as to one’s appropriateness as a mother was mentioned in regard to a fear of being doomed if there were a rejection:

…that they don’t think I fit in, that I’m not fit to be a mother. So it’s…Or I don’t really know how but, yeah, if I fit in as a mother then in that way it’s…But I guess it’s always hard when you’re judged in some way if it’s something…Because I want to go through this and then it’s…and I have to jump over this or I have to get myself through this and they’ll approve of me, give their stamp of approval that I should have this. So in that way it’s hard. (N 33)

The result of the meeting with the counsellor, whether or not being accepted for MAR, was sent by mail. Some women expressed that the treatment process could have been described step by step, to give them an overview or as a treatment plan, from their acceptance for MAR until the treatment started, to avoid their experience of such a long waiting time:

Yes, but when you’ve met with the counsellor you’ve in some way…stepped into a programme. Like this, Step 1 is this and you’ll meet with the counsellor on this date and in four weeks it’s time to meet with the doctor and in four more weeks or…then you get an answer. Yes, and I guess that was there of course, but I guess I didn’t know about it, I think. So you went around and waited and then all of a sudden there was a letter with the post. So you were approved, like, “Aha, okay.” But yeah, it felt like you’d…I don’t know…won the lottery. Yeah, it’s almost that you’d have liked to have a telephone conversation but I understand they might not be able to do that. (B 37)

Frustrating waiting time for a donor

After the meeting with the counsellor, the women were not given any information about having to wait for an available donor, which was experienced as frustrating. Not knowing their place in the queue to MAR or how long they would have to wait could have easily been solved with information on the clinic’s website or by giving them information in a phone call. It could thus be explained that there was a lack of donors, and it would make it easier to understand why there was a long waiting time for a suitable donor:

Because I assume that influences how long the waiting time is and when it’s my turn in the queue, what is it…More perhaps in the process how…Now you’ve gone through this, now it’s going to be…You’re going to wait this long because this is how long our queue is and then it’ll be your turn and we’ll find a suitable donor and then we’ll follow these…Whatever they are…the criteria they follow. (N 33)

Thoughts about the donor during the waiting time were mentioned among some women, as what it would be for the child not to know who the father is. The women mentioned wanting to have information on how and by whom the donor was chosen. Prejudice in society was another topic some women brought up, in regard to a fear that the child could be exposed to questions regarding their decision:

There are many questions and many such things that the children are going to be exposed to, that can be difficult for the child but perhaps also for me. And then to also explain to everyone who thinks it’s wrong and thinks it’s egoistical. I think it’s probably those things that are the drawbacks. That there’s going to be a lot from the outside…I think that’s what will be the biggest drawback. Because there are still prejudices in society. (H 39)

Starting a new relationship while waiting for treatment was mentioned and some women wondered whether having a sexual relationship was accepted during the long waiting time, as there was still hope they would find a partner. At the same time, a new relationship was described as a problem, as doing this while waiting for MAR would cause an imbalance in the relationship. Fear of losing one’s place in the queue was also expressed:

And then it ends up like this, or should you meet someone and…yeah, there are a lot of “ifs”. If you meet someone during this time you have to report it, and then you’re taken out of the queue, and then it’s like when do you know you’ve met someone who it’s going to be so serious with? So it ends up like this, yeah…And now it’s quickly approaching, so now it feels like I’m even more unstable. That’s why I’m like this. (M 37)

Questions about if and when having previous partners were assessed by the counsellor, and were considered important among the women when making the decision to undergo MAR. Questions about sexual orientation were not assessed and this question was not considered relevant among the single women:

In that way I think it’s relevant to ask about…yeah, previous partners. When did you last have a partner? And that also perhaps says something about how much you’ve thought through your decision. So I think that’s relevant. But then who I fall in love with or have sex with – I’m not sure that’s so relevant. No one asked me about that. (I 34)

Expected to find information on your own

More customised information, such as folders at the clinic, as information was given was not adapted for non-couples. Most single women perceived the information as directed at couples, and mentioned that some of the healthcare professionals asked about the father or their partner when being at the clinic:

For one thing I’ve been very disappointed that not everyone who sees me knows I’m single. It’s happened a number of times that they’ve asked who the father is… (A 32)

Information about health issues, such as nutrition status, as well as what to avoid, such as alcohol and smoking, before starting treatment was described by a woman:

And I’m a vegetarian and such. But am I getting the nutrition I need? It would’ve been really interesting to have that kind of examination to see if you have any deficiencies you should adjust. Yes, and not drink alcohol. But it was also that I asked, yeah, what should I think about now? Don’t drink alcohol and don’t smoke and all that. Yeah, no, it doesn’t feel like you’ve gotten so much information, you’ve had to ask…it feels like they perhaps assume that you know, that you’re informed. (C 36)

Updated websites and a separate waiting room for single women could have helped in this respect. Some women mentioned not being told of opening hours at weekends or about closing during holidays like Christmas, which was frustrating when the time was running out for MAR due to the upper age limit. Other women expressed that they were comfortable finding information themselves and that it was their own responsibility to do this:

Yes, I guess that’s what I’ve needed, I’ve felt. It’s so easy to find information too. And I think…yeah, it’s prejudice perhaps, but the kind of people who seek this out. I mean, they also have an easy time…it’s people like me, surely. I mean, often highly educated people who have an easy time finding information. So you find the information you need. I absolutely haven’t thought it should be bad information in any way; I’ve gotten what I need. And what I’m curious about…now I’ve read a bit about it, like on the Internet about fallopian tube examination. (K 37)

On the other hand, great thankfulness was expressed among the women, at the healthcare system’s generosity in giving single women the opportunity to undergo MAR:

I mean, sometimes I can imagine that too…That the healthcare system is incredibly generous and you…There are quite a lot of people who have medical problems that persist and persist…Sometimes I also think that we have a society where everything should be possible, everything should be possible to arrange. But I don’t really think it’s that way. Because sometimes I think it can be good to take a step back… (D 38)

Discussion

To our knowledge, this is the first qualitative study to explore Swedish single women's experience of making the decision to choose motherhood through MAR. The overarching theme in the individual interviews reflects the decision to become a single mother by choice being motherhood through MAR – an emotional and ambivalent decision to make on your own.

The longing for a child had occupied the single women’s lives for an extensive amount of time, and the possibility to decide to undergo MAR as a single mother by choice made the transition to motherhood accessible to them. This result is in accordance with another study (García et al., 2020), which cites a long history of motherhood desire in single women before undergoing MAR. A “biological clock” was described among the single women in our study, as both a mental and physical feeling that is impossible to repel. This biological clock as a reason for the choice of single motherhood agrees with other studies (Graham, 2018; Hertz, 2006; Jadva et al., 2009; Ravn, 2017). The women mentioned time running out, one’s age, and being left childless if no decision was made. This result agrees with a Danish qualitative study of pregnant single mothers by choice (Werner et al., 2021). These mothers described ambivalent feelings of anxiety and failure, and on the other hand, a feeling of being capable, as the longing for a child was stronger than the fact that they had no partner. Likewise, Graham (2018) states that the single women were comfortable with their decision to pursue motherhood and at the same time had feelings of anxiety and ambivalence regarding their decision. Feelings of selfishness in making the decision alone were also described by the single women in this study. Becoming a single mother by choice has been described as a selfish choice in other studies (Graham, 2018; Werner et al., 2021).

Having a bond to the child by giving birth to ones child was emphasised among the single women. Going through pregnancy and carrying a child were considered significant among the single women and seen as an experience to be able to share with other women who had children. Motherhood involved giving unconditional love and living a family life like other families with children. Motherhood was also described as becoming a woman, and reaching adulthood. Likewise, the decision to be a mother on one’s own, not giving up on motherhood, identity-defining for women who choose to be single mothers by choice (Hertz, 2006). In another study (Hendriks et al., 2017) genetic parenthood was preferred among most heterosexual infertile couples at their first consultation at a fertility clinic. Likewise, women in heterosexual couples in the same Swedish context (Volgsten et al., 2010) described their childlessness by saying they were not like other women due to their inability to create a family. Thus, among the single women in the current study achieving motherhood as a single mother by choice, and not being childless, was more important than having a partner. This is, in another study, described as the active and positive choice to have a child rather than the active choice not to have a partner (Ravn, 2017).

Other options for having a child if the treatment failed were not considered; the single women explained that they wanted to undergo MAR before deciding on the next step. However, adoption was not considered achievable as a single woman in this study, due to the economical and age factors. Other alternatives, such as double donation, were not considered as this was not the first option, even though it could be considered as an ultimate solution. This explains single women’s choice of motherhood through assisted reproduction rather than adoption, in agreement with other studies, considering the genetic link emotionally significant (Goldberg & Scheib, 2015; Landau et al., 2008). On the other hand, undergoing MAR as a single mother was described in this study as not having been their first choice. In other studies, this result is referred to as “Plan B” for achieving motherhood (Birch Petersen et al., 2016; Engholm Frederiksen et al., 2011; Ravn, 2017; Salomon et al., 2015). Furthermore, some single women in our study also described feelings of grief at having to go through MAR alone as there was no partner involved.

Social exclusion when one is childless, and deviating from the norm, were mentioned by the single women making the decision to undergo MAR without a partner. Societal norms regarding having a family with two parents were one reason, being judged for not having a nuclear family. However, motherhood would give single women a way out of the social exclusion they experienced as childless. Consequently, there was still hope they would find a partner. This result is in accordance with Werner et al. (2021), who state that single women would have preferred a nuclear family, regarded as the ideal family model. Likewise, Graham (2018) describes single women’s decision to have a child alone as deconstructing the ideal of the nuclear family to make the best of single motherhood for the child-to-be. Furthermore, single mothers by choice in a Danish pilot study did not find themselves to be stigmatised or excluded socially but stated that they had an awareness of the prejudice that might exist in society towards single mothers by choice (Steenberg et al., 2021). However, while the single women in this study had support and encouragement from a social network of close family and friends, some women mentioned they had no one to share their thoughts with. They spoke of feelings of being left alone when there was no partner waiting at home, even if they received social support during the process and expected it after the child’s birth as well. The support of close family and friends in the decision-making process and having a family living close by having also been mentioned in other studies (García et al., 2020; Graham, 2018; Werner et al., 2021). A need for emotional support due to the lack of a partner made the need for support at the fertility clinic more important during investigation and treatment. Further, meeting other single women in the same situation at group meetings at the clinic was suggested as an alternative. Similar results, such as the need to be aware of different family structures and provide psychological support, have been found in Swedish two-mother families (Appelgren Engström et al., 2018).

Being evaluated as a mother at the meeting with the counsellor was described as a fear to be doomed if there were a rejection. Not knowing what would be brought up at the meeting was described as stressful. A recent Swedish study (Elenis et al., 2020) showed that 16% of single women, in contrast to 5% of heterosexual couples, were not accepted for MAR with donated sperm, due to conditions noted during the psychosocial evaluation. Being regarded as a “good” mother was important to the single women in this study, in line with Graham (2018), who states that single women feared not being considered a “good” enough mother when the decision was made. However, to avoid the risk of stigmatisation, single mothers by choice need to be seen as good mothers (Wahlström Henriksson & Bergnehr, 2021).

Thoughts about the donor during the waiting time, and what it would be like for the child to not know who its father was were mentioned by some of the single women in this study. This reflection, regarding the absent father, has been brought up in other studies among both single- and two-mother families (Appelgren Engström et al., 2018; Graham, 2018; Werner et al., 2021). Questions about sexual orientation or identity were not raised during the evaluation and were not considered to be important among single women. Our previous pilot study revealed that 18.5% of the Swedish single women applying to MAR had a sexual orientation other than heterosexual (Volgsten & Schmidt, 2021). Thus, indicating that an absent father or male partner could involve a female partner, as described in another study (Weissenberg et al., 2007). This is important for healthcare professionals to be aware of during the treatment process, and a reason to avoid unnecessary questions about a father or male partner.

Furthermore, mental wellbeing was reported to be emotionally strenuous during the long waiting time for a donor to be able to start MAR, not knowing one’s place in the queue or how long one would have to wait. Meetings or calls from the fertility clinic, and more patient information on the clinic’s website, were suggested. Another suggestion was a schedule of the treatment process, described step by step, to give an overview and inform on how to be prepared before the MAR started. The single women expressed that they had to find information on their own; this lack of adequate information and support has also been found in Swedish two-mother families (Appelgren Engström et al., 2018). Likewise, the women in this study mentioned that a lack of information about pre-conception health, such as nutrition, to increase the chance of pregnancy could have been useful. More customised information and the use of apps were requested, as single mothers by choice were a new patient group at the clinic at the time of the study. Examples like updated websites and folders adapted for non-couples were mentioned, as the available information was perceived as being directed at heterosexual couples. Communication of opening hours at weekends and information about closing at holidays were other solutions mentioned when the time was running out for MAR due to a woman’s age.

Conversely, among the single women was also expressed a great thankfulness at having the opportunity to undergo MAR as single mothers by choice, in accordance with a Danish qualitative study by Ravn (2017). Access to assisted reproductive technologies, achievable thanks to the structural societal opportunities in the Nordic countries, make it more possible for single women to become single mothers by choice, compared to the situation in other countries. This made the decision to undergo MAR without a partner easier regarding both conception and childbirth, but also offered better opportunities for raising a child alone as a single mother by choice.

The method used for this study was a qualitative approach, by using semi-structured individual interviews, to explore the single women’s experiences. A strength in qualitative studies is that questions not assessed, or not possible to assess, in a questionnaire can be assessed in face-to-face interviews. Thus, our previous survey made it possible to develop an interview guide with questions not assessed about motherhood and the importance to give birth to a child (Volgsten & Schmidt, 2021). However, a limitation is that a question about when and what to tell the child about the donor was not assessed in our study. Thus, could the question be used in a follow-up study.

A limitation in qualitative studies is considered the small sample size and the difficulty to generalise the results (van Teijlingen & Forrest, 2004) even though a larger sample size may achieve similar results. Therefore, findings in this qualitative study may not be as transferable to other populations or settings as to other Nordic countries with similar access to MAR, public day-care and education as well as maternal leave and high employment rates for women having children. Thus, the extent of the results’ transferability to other settings depends on the settings’ similarities or differences to this study’s context. Furthermore, when using a qualitative design the aim is not foremost to generalise, but to offer insight into a new patient group and to encourage further research within this developing field of assisted reproduction. Given this, our study aimed to explore the decision-making in choosing motherhood by MAR and what motherhood involves for these women. Thus, a strength of this qualitative study is that it explores experiences (van Teijlingen & Forrest, 2004) right after new legislation was introduced, making it possible to explore the experiences of the first single women to undergo MAR in Sweden.

A clinical implication for healthcare professionals meeting this group of single women is that they should have the knowledge and awareness that the process of choosing motherhood through MAR is an emotional and ambivalent decision to make on your own. Thus, offering this patient group emotional support such as support groups, and giving them adequate and adapted information such as up-to-date folders, is of utmost importance. Furthermore, taking the opportunity to offer information about pre-conception health during the waiting time for MAR is another implication for providers of reproductive healthcare.

In conclusion, Swedish single women’s decision to choose motherhood through MAR was considered as an emotional and ambivalent decision to make on your own. To reach motherhood, by giving birth to one’s child and not deviating from the norm as childless, was considered important among these women when making the decision to become a single mother by choice.

Acknowledgements

We are thankful to midwifery students Isabel Ljung and Yasna Lazcano, who participated in the data analysis, and for the fruitful residency through the Bergman Estate foundation when drafting the manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.