Women who decide to be surrogates, like intended parents, enter these arrangements for different reasons and to meet different needs. They might be motivated by a chance to alleviate poverty or establish greater financial security for themselves and their families, or they might want to help people who are unable to conceive children unassisted, or both.
Intended parents, as well as the larger public, generally don’t know very much about the lives of surrogates or the conditions to which they are subjected during their pregnancies. Most information about international commercial surrogacy is filtered through intermediaries who have a financial stake in these arrangements. This makes it difficult to get a full and accurate picture of the different health, financial, and human rights issues surrogates face.
The current global economy has created “hubs” around the world where international commercial surrogacy thrives. These hubs tend to function in countries with large populations of economically or socially marginalized women who have few options for financial stability. Several states in the United States are also destination hubs for international commercial surrogacy due to lack of regulation and a robust fertility industry.
Surrogates are often exposed to troubling practices and risks once they have agreed to a surrogacy arrangement. They may be particularly vulnerable once a pregnancy has been established. Some examples of conditions surrogates may face when there are inadequate safeguards in place for their health and rights include:
- Denial of contact with or information about the intended parents before, during, and after pregnancy — even if both parties desire it.
- Requirements to live in dormitory-style housing with little privacy
- Denial of the freedom to leave their assigned housing or spend time with family, friends, and community unsupervised
- Pressure to sign a contract in a language they do not speak, read, or understand
- Coercion to undergo an unnecessary cesarean section so the delivery can coincide with the intended parents’, physicians’, or intermediaries’ schedules
- Expectation to undergo multiple embryo transfer to increase the chance of pregnancy, which could endanger their lives or the lives of the resulting children
- Denial of or inadequate access to postpartum care
- Misleading or inadequate information about medical risks or the amount of compensation and when it will be received; or not being compensated in full or at all in the event of miscarriage, termination of the pregnancy, or stillbirth.
Here is some additional information about some of the conditions surrogates may face in countries with a robust surrogacy industry.
Freedom of Movement and Unrestricted Access to Family
Staying physically active, socially engaged, and emotionally connected are hallmarks of a healthy pregnancy. In some places, surrogates are restricted from leaving the surrogacy residence at will and remain isolated from their families (including their children) and communities through the pregnancy. Intended parents can advocate for contract provisions, or at least agreement from agencies, to allow the surrogate unrestricted and unsupervised access to her family and community.
Single Embryo Transfer Versus Multiples
An intended parent’s desire for a child — and a clinic’s motivation for success — means that surrogates are often expected to undergo multiple embryo transfer to increase the chance of pregnancy. Multi-fetal pregnancies have implications for the health of women and children. To reduce risks related to multiple births and avoid the need for “selective reduction,” intended parents can request one embryo transfer per cycle, as suggested by the U.S.-based National Perinatal Association, the World Health Organization, and other respected bodies.
Decisions about Remaining or Not Remaining Pregnant
It is crucial to respect a surrogate’s decisions related to her body and her pregnancy, including her decision either to terminate the pregnancy (and withdraw from the contract) or to see it through despite intended parents wanting otherwise. Thorough conversation in advance is critical so that both parties understand the implications and expectations attached to decisions that will be made or altered. This conversation must cover decision-making in the event of detected genetic conditions of a fetus.
Vaginal Births Versus Cesarean Sections
Surrogates should not be contractually required — or pressured — to undergo scheduled non-medically indicated cesarean sections. Delivery by cesarean section is often made a condition of surrogacy contracts to ease scheduling and maximize birth numbers at the clinic or to accommodate intended parents who wish to attend the birth of their child.
Cesarean sections can save lives when medically needed. However, they are invasive abdominal surgeries and present risks that are not associated with vaginal births. In addition, because many surrogates return to communities in which obstetrical care is limited or absent, they can be at serious risk during subsequent vaginal births after a cesarean delivery.
Postpartum Follow-Up and Care
Postpartum support seems the exception rather than the norm for surrogates. Free medical care for at least three months after a birth can help assess and manage risks. Psychological support services — to help recover from relinquishing a child, cope with lactation, re-assimilate with family, and resist any social stigmatization — are also important. It is recommended that intended parents include provisions for postpartum care in the contract, pay for services in advance and, if possible, follow up with the clinic or the surrogate.
Contracts and Informed Consent
Often, surrogates do not speak or are not conversant in the language in which the contract is written (generally English or the intended parent’s native language). In such cases, she signs the document and, by doing so, agrees to the contract conditions without actual informed consent. By insisting on bilingual contracts (in languages in which gestational mothers and intended parents are fluent) and the presence of an interpreter during all discussions, intended parents can take a significant step towards true informed consent.
Intended parents can play an important role in creating conditions to minimize health risks and safeguard human rights for surrogates, and hold clinics accountable for the quality of care they provide. They can insist that specific provisions be included in the contract to safeguard the health and rights of the surrogate.
See Surrogacy360’s tool Principles and Standards for Engaging in International Commercial Surrogacy for recommendations to intended parents on choosing a surrogacy arrangement that safeguards all parties.