Surrogacy – wish fulfilment or exploitation? A guest blog by Dr Rebecca Steinfeld, Senior Policy Officer for Health, Maternity Action

Surrogacy is a polarising issue. For some, it embodies true altruism – a woman realising the dreams of others by birthing their baby, with all the medical risks, and physical and emotional toll, that can come with pregnancy, birth and, ultimately, handing over a baby. Sprogcast’s interview with David Gregory-Kumar is a touching example of how surrogacy can help gay couples to become parents, as is the heart-warming story recently aired on BBC 2’s series The Baby Has Landed of Paul and Craig Saunders, whose work friend Mel carries their twins.  

But that is not the whole the story. For others, surrogacy is inherently exploitative and unethical. They say it makes children commodities, and disadvantaged women “breeders.” Some even compare surrogacy to prostitution, and argue “womb rental” be the term used.  

This debate is not abstract.  

The Law Commission is in the process of a review of existing surrogacy laws in the UK entitled "Building Families Through Surrogacy: A New Law." Their proposals include a new pre-conception agreement and related pathway, as well as changes to the types and level of payments for surrogate mothers. The goal is to bring forward a Surrogacy Bill in 2021 that will constitute the first legal reform to surrogacy law in the UK since the Surrogacy Arrangements Act 1985.  

We at Maternity Action, along with a number of feminist organisations, submitted responses expressing our concerns about law reform in this area. Our concerns focus on the process of the consultation, barriers to accessing it (the consultation document was 502 pages long and had 118 questions!), and the extent to which surrogate mothers' rights and experiences are being taken into account.  

But beyond the specifics of the consultation, there are several other serious issues at stake in this debate. These include potential power imbalances between surrogate mothers and intended parents, the risks of pregnancy and birth taken on by the surrogate mother, and human rights concerns that may crop up during a surrogate mother’s antenatal, intrapartum and/or postnatal care. It is crucial to acknowledge and reflect on these difficult areas in any discussion of surrogacy.  

Surrogates may be vulnerable to exploitation as there is often socioeconomic inequality between surrogate mothers and intended parents. Intended parents tend to be older, wealthier, better educated and employed in higher status jobs than surrogate mothers. Though there does not appear to be any research exclusively considering the demographic characteristics of surrogates in the UK, evidence from other studies indicates that the majority of women who act as surrogate mothers are substantially less well-off, less powerful and less endowed with status than the majority of intended parents.

Though there may be some exceptions to this pattern in what are known as “traditional” or “altruistic” surrogacy arrangements – such as a sister carrying a baby for her brother/sister – these arrangements account for the minority of surrogacy arrangements. Plus, there may be other power imbalances in these familial arrangements, and economic inequalities may still exist.  

There are inherent risks involved in pregnancy and birth for the surrogate. Emeritus Professor Susan Bewley, a retired consultant obstetrician with direct, first-hand experience of many UK surrogates contends that there are documented medical and psychosocial risks to surrogacy. All pregnancies carry physical and mental health risks to pregnant women, ranging from trivial to very severe (sepsis, pre-eclampsia, haemorrhage and maternal death for the woman; abnormality, prematurity, stillbirth, brain damage, infant death for the baby). For untested first-time mothers, or primigravidae, these risks are entirely unknown, and the Law Commission rightly asked whether primigravidae should be allowed to be surrogates.   

Risks for the surrogate may be higher if she, or another woman, are involved as egg donor, which involves undergoing ovarian stimulation, egg extractions and a small risk of the serious complication of ovarian hyperstimulation syndrome. The surrogate may have many appointments, drug treatments, invasive procedures and timed embryo transfer. More importantly, she is at a significantly increased risk of developing pre-eclampsia. If it is a twin pregnancy, she is at increased risk of every complication barring postmaturity. Pre-eclampsia and multiple pregnancy, which remain high in the UK IVF sector, both increase the risk of prematurity, with possible lifelong health consequences for the child.  

On a perinatal mental health level, although many surrogates are keen to hand over the baby, there are a lot of dramatic hormonal events in the first days and weeks after birth, and some find that handover triggers or exacerbates perinatal mental ill-health conditions, like postnatal depression or postpartum psychosis.   

Finally, surrogates may experience coercion from intended parents during their antenatal care or birth. In their consultation response, the Woman’s Place UK said “it is not difficult to imagine a scenario where the mother may find it difficult to make choices which prioritise her own health and wellbeing if the intended parents are in the room with her, even if they do not actively put pressure on her to prioritise the welfare of the foetus. Or in a scenario where a scan reveals a foetal anomaly, the pregnant woman may feel unduly pressured to conform to the intended parents’ wishes regarding continuing or terminating the pregnancy if they are present in the room when the scan takes place.” As these scenarios suggest, the surrogate mother’s rights to dignity and bodily autonomy may be subtly undermined by the known wishes or momentary reactions of the intended parents.  

Given the current policy climate and controversy around surrogacy, it’s crucial that public discussion of this issue includes the fullest range of perspectives. As well as hearing moving stories from intended parents about how surrogacy enabled them to overcome biological or social infertility to realise their dreams of becoming parents, we also need to hear from a range of surrogate mothers. That includes those whose experiences have not been so rosy, and who instead encountered challenging power imbalances between themselves and the intended parents, or who felt that their human rights were subtly or overtly undermined during their pregnancy or birth, or who suffered unexpected physical or emotional repercussions. There are two sides to this story, and both must be told.  

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