Gestational mothers, like intended parents, enter surrogacy arrangements for different reasons and to meet different needs. They might be motivated by the desire to help others or by extreme poverty or for greater financial security for themselves and their families.

The public does not have much insight into the lives of gestational mothers or the conditions that they are subjected to during their pregnancies. Much of the information on international commercial surrogacy is offered by go-betweens with a financial stake in these arrangements. It can, therefore, be difficult to get a full and accurate picture of the different health, financial, and human rights issues.

Who Is Most At Risk?

In a global economy, poverty has created the kind of hardship that allows surrogacy to thrive — as an option for gestational mothers that can be paid to carry and birth children for others. This has created international “hubs” around the world, in countries with large populations of economically or socially marginalized women who are easy to recruit because of their financial vulnerability.

Gestational Mothers in Old and New “Hubs”

Prejudice against certain groups of women in India — based on their religion or caste, for example –- has long reduced their ability to find work and fulfill their and their families’ basic survival needs. In 2012, Sama, a nonprofit organization focused on women and health in India, released a report noting that “new markets” such as international commercial surrogacy “have opened up for [women’s] sexual and reproductive labour.”

As the Centre for Social Research also reported in 2008, most women who opt to become gestational surrogates do so due to a lack of education and unemployment. They need money to subsist — money for food, rent, and school tuition for their children. Both reports provide important detail on the lives of gestational mothers in many parts of India and the context for their decisions.

Commercial surrogacy in Mexico, another popular hub, has relied on a mix of middle-class women and those drawn to the possibility of earning more money than what most jobs offer. For the latter, their vulnerability has left them open to abuse, as Jo Tuckman writes in The Guardian:

“While some Mexican ‘surrogacy journeys’ progress smoothly, there are horror stories of unscrupulous or mismanaged agencies stealing money and eggs, subjecting pregnant women to psychological abuse, and cutting corners on their payments.”

Following the recent passage of laws restricting commercial surrogacy in India and Thailand, the practice is now on the rise in Vietnam. According to a representative of the Institute of Social Development Studies in Vietnam, one of Our Bodies Ourselves’ global partners, most gestational mothers live in rural areas and are poor.

This may not always be the case. Gestational mothers -– in countries mentioned above or places like the United States and Eastern Europe -– can belong to better socio-economic indices, and many may enter surrogacy relationships for reasons other than poverty.

Nevertheless, all gestational mothers seem exposed to concerning practices and risks, like the ones described below, once in a surrogacy arrangement.

Health Risks

There is much debate around international commercial surrogacy and the health risks involved. These range from risks generally associated with, and monitored during, any pregnancy — hypertension, gestational diabetes, and preeclampsia for example — to others that are specific to practices within surrogacy arrangements. This includes:

  • Hormone treatments that artificially prepare gestational mothers to carry embryos: These treatments can have many side effects, similar to treatments used on egg providers to boost their egg production.
  • Mandatory and medically unnecessary cesarean sections: Abdominal surgery to remove the child from the uterus carries well documented risks, including mistaken surgical cuts to the woman and child, infection, and severe and/or long-term pain in the pelvis area or cite of the cesarean cut. Most gestational mothers receive inadequate care during a slow and complicated recovery from this procedure. During subsequent deliveries, especially VBACs or vaginal birth after cesarean section, many are at grave risk of uterine rupture and conditions such as placenta previa (when the placenta covers the cervix), placenta accreta (when the placenta grows into the wall of the uterus), or placental abruption (when the placenta separates from the uterus before birth). Research also indicates that women that have had cesarean sections are more likely to have trouble becoming pregnant again.
  • Multiple embryos implanted to increase success rates: Carrying and delivering multiple embryos puts women at increased risk of hypertension, preeclampsia, gestational diabetes, and postpartum hemorrhage according to the American College of Obstetricians and Gynecologists (ACOG). They also note effects on the child.

For readers interested in more information about cesarean sections, Childbirth Connection is a very helpful and easy-to-use resource. ACOG’s report on “Perinatal Risks Associated with Assisted Reproductive Technology,” which was published in September 2016, also provides a comprehensive overview of concerns and considerations. The report concludes with a strong recommendation for single embryo transfers.

Intended parents can play an important role in minimizing some of these health risks and holding clinics accountable to the quality of the care they provide. Via the contract, for example, they can insist a gestational mother be allowed to birth vaginally — a safer option — unless otherwise indicated by her or her medical provider. Intended parents can also agree to a single embryo transfer, thereby avoiding risks linked to multiple births or the need for a selective reduction. This procedure to reduce the number of pregnancies is often suggested as a helpful preventative; in the context of commercial surrogacy, however, it is often done regardless of a gestational mother’s preference and not always for medical reasons.

Contract and Payment Issues

On the legal front, one of the main concerns involves contracts. In certain places, such as India, Mexico, and Vietnam, gestational mothers may not be able to read the contracts they sign. This means they cannot give informed consent.

Even if gestational mothers can read the contracts, most have little or no negotiating power. This is because of their economic need and because they might be forbidden or unable to hire lawyers and medical providers to represent their interests. This exposes them to many risks, from the medically unsafe practices listed here to staggered payments and forced surrender of parental rights and attachments.

In addition to the issue of legal contracts, gestational mothers often receive less payment than initially promised or nothing at all. This can occur in the case of miscarriage or birthing a child with a disability.

Like some intended parents who pay large sums of money to go-betweens and never receive the child they have been promised, gestational mothers also lack legal protections.

Isolation From Family and Society  

Other conditions with potentially lasting impact on gestational mothers and their families include:

  • Unethical and aggressive recruitment tactics that can escalate to public harassment.
  • Dormitory-style living arrangements with constant surveillance to regulate food consumption, medication, and activity level.
  • Restricted movement outside the hostel.
  • Restricted contact with family members, including biological children and partners.

None of this is made easier by limited or heavily supervised contact between intended parents and gestational mothers –- often mandated to minimize the chances of forming bonds, even if some bond is desired –- and the isolation some experience when they return home to friends and family who may not know about the surrogacy or stigmatize gestational mothers for their decision.

However problematic the living arrangement, given the isolating nature of the experience, it may at the very least offer some gestational mothers companionship, community, and support during the pregnancy. Having said that, the toll of these restrictions and imposed isolation from family is impossible to quantify, but can be avoided if intended parents insist clinics allow gestational mothers unrestricted –- and preferably unsupervised -– access to the outdoors and their loved ones.

Surrogacy360 aims to bridge information gaps by documenting how international commercial surrogacy is practiced and how it affects everyone involved in the surrogacy relationship.

We hope all parties will join our efforts to promote best medical practices and transparency. Without collective involvement, there is no way to ensure that expanded reproductive options are available for everyone — and, at the same time, guarantee sound medical care and fair work conditions for those who make these options possible.

Top photo: Adrian van Leen