Interviews offered in-depth insight into CBRC attitudes, behaviours, and experiences among a cohort of women living in Italy who had never engaged in CBRC. Social perspectives are critical to understanding the landscape of nuanced reproductive healthcare needs governed by policy and norms [37, 45, 46]. This is true of CBRC and infertility as these are couched within broad frameworks of religion, policy, identity and social acceptability. Prior research  demonstrated women faced obstacles to MAR that facilitated going beyond Italy for treatment and generated feelings of abandonment by the government. Though participants in our study had not experienced CBRC personally, women and couples within their networks had, and our participants highlighted multi-layered considerations of seeking CBRC. Because CBRC is a topic of conversation even among women who have not had these experiences, this suggests social norms and acceptability [15, 16, 47] of infertility treatments and CBRC are important considerations in healthcare choices. Understanding the broad perspectives regarding policy and social norms [15, 16] can better situate CBRC discussions within what is acceptable for Italians and can inform policy change or support for women and couples who desire treatments that are currently illegal or heavily regulated.
The Italian cultural value of the motherhood identity was significant in discussions surrounding infertility perspectives. Motherhood identity emphasizes the importance and respect placed on women who bear children in Italy , resulting in a paradox when considering infertility and CBRC. The importance of motherhood in Italian culture places societal pressure on women, leading to unrealistic motherhood expectations  and lowered quality of life [15, 16]. In cases of infertility, where achieving the goal of bearing children organically is not an option and restrictive policies in Italy make it difficult, women may seek alternative options (e.g., not becoming mothers, CBRC), which may be associated with social stigma or shaming. This pressure placed on women can make it difficult to fulfil the motherhood identity and may tie to the emotional costs and logistical barriers to CBRC. The desire to become a mother, coupled with restrictive policies, represent competing narratives of acceptable choices even among women who had never experienced infertility or CBRC. Thus, women’s voices, including personal experiences and social perspectives, are necessary for creating and implementing supportive policies reflecting the social norms and pressures women in Italy experience.
Despite the separation of church and state , the perception that religious influences pose barriers to women attempting to achieve their desired families remains. Thus, religious influence impacts the social climate and acceptability of MAR, making it necessary for people to travel to less religious or restrictive places to obtain MAR, which may result in monetary and emotional costs, including isolation and shame. The perception of trickle-down effects from religion into Italian policy was an accepted idea among participants, though they had never experienced CBRC. This may present a barrier in encouraging childbearing, as Italy’s notably low fertility rates have sparked efforts to encourage childbearing, such as Fertility Day campaigns . Participants desired more supportive systems to have and raise healthy families; thus, the overarching perspective that religion enhances restrictive policies regarding childbearing opportunities should be addressed in policy, promotions, and campaigns that increase support for women to achieve their family planning goals. Despite laws having changed in 2014, women were still in belief of older laws and regulations. Though participants described the Italian healthcare system as supporting MAR-seeking, compassionate care is limited within the current environment, enhancing women’s perspectives of shame. Therefore, women’s voices should be included in policy to understand and address emotional costs and perceived barriers and create a landscape that supports women’s choices when, whether, and how to have a family within Italy.
Strengths and limitations
Interviews were conducted with women who were comfortable speaking conversational English, which may have limited perspectives and vocabulary, therefore, some insights may not have been adequately captured. Additionally, women in this sample had higher education levels and were employed, which is to be expected from women capable of interviewing in English, thus limiting generalizability to women who may differ demographically and geographically. Interviews may have differed due to the flexibility of a semi-structured interview guide. As this was part of a larger study, not all questions in the interview guide were focused on CBRC and infertility perceptions. Interviews only took place in Florence, limiting generalisability and applicability to other regions of Italy. Despite these limitations, this study allowed us to explore the effects of societal and cultural subjectivism related to CBRC among Italian women. One strength was that the interview guide was reviewed by experts and in-country professionals, ensuring interview question quality and cultural relevance. An additional strength was conducting 30 interviews, which allowed for rich insights into myriad lived experiences and perspectives. Additionally, as part of a larger study on women’s health, CBRC these perspectives were situated in narratives of other related reproductive health conditions, which provided context and rich thought throughout the interview. However, no women in this study had experience with CBRC, which should be explored in a future study among a sample of women who have sought MAR through CBRC.
Implications for health professionals and policymakers
Policymakers and practitioners should address social and cultural perceptions, increase access to safe and effective local care, and empower women in their family planning decisions. In particular, healthcare professionals should discuss the options available for those interested in building a family but who may be struggling with infertility. These should include in-country and CBRC options, so women and couples can be fully informed about the benefits and barriers of each. Furthermore, given the emotional toll that infertility and CBRC have on women, specifically, healthcare professionals should connect those experiencing infertility with mental health resources. Health promotion scholars should utilize social norms, like those discussed in this cohort of women who had not experienced CBRC, to identify barriers to seeking care and discussing infertility and CBRC with close social support systems. By identifying these barriers, they can craft social norming campaigns that reduce the stigma and isolation many women perceive occurring among those experiencing infertility of engaging in CBRC, helping to shift cultural perceptions. Women and couples may, in turn, feel more supported when considering having a family. Finally, policymakers should incorporate social perceptions of CBRC and infertility to lend constituency support for crafting MAR policies that expand the options available for individuals desiring to have a family. This can demonstrate the need for less restrictive policies, and empower women and couples in their childbearing goals.
Future research should explore social opinions about CBRC, including MAR, among single and partnered women with these experiences. Further, to better understand women’s CBRC experiences, inclusion of women’s families and friends may be fruitful to better situate these within the social framework of women’s lives. A focus group methodology conducted in Italian and English may assist in gathering collective perceptions and interpretations, which can further elucidate the social climate surrounding CBRC. Additionally, future research should develop and test social norm campaigns aimed at reducing barriers, like stigma and motherhood identity failure associated with CBRC and infertility, to identify effective opportunities to empower women and couples in achieving their family planning goals. Finally, scholars should explore the perceptions of policymakers on CBRC, including those involved in past and current legislation, to demonstrate facilitators and gaps in creating supportive MAR policies.