The psychological well-being and prenatal bonding of gestational surrogates

Altruistic help or taking advantage of the situation? Social representations of surrogate motherhood

Concerning Europe, the lay public, mainly in Central regions, still lacks information about what surrogacy is and how the process works in practice. It is one of the most controversial methods of assisted reproduction precisely because it goes against traditional social norms and ideas about the conception of life. The main aim of our study was to map the social representations of lay people that are formed in internet discussions. We focused on discussion forums over a time span of the last 10 years, from 2013 to 2022. We were also interested in whether perceived risks or benefits formed the core of social representations. Through a reflexive thematic analysis, we identified two distinct constructions of social representations of surrogacy, finding that value settings in terms of liberalism and conservatism appear to have the greatest influence on the anchoring and objectification of surrogacy.

Case Report: I feel like a mother to other babies: experiences and perspectives on bereavement and breastmilk donation from Vietnam

There is a growing recognition globally that care regarding lactation following a perinatal death needs to potentially offer the opportunity for maternal donation. This article discusses this experience and perspectives from a human milk bank (HMB) in Vietnam. This is a descriptive exploratory case study that has a long tradition in both the social and health sciences. Triangulated data collection involved a review of video data, interview data with the donor, and data review for the Da Nang HMB, a Center for Excellence in Breastfeeding. We found that although it is common for mothers in Vietnam to donate breastmilk to HMBs, it is less common for this to occur following perinatal loss. We offer a descriptive case study of the maternal loss of twins and a subsequent choice to donate for approximately 1 month to the Da Nang HMB, the first HMB in Vietnam. We discuss four reasons derived from this case regarding donation following perinatal loss. (1) A strong motivation to donate breastmilk when aware of the service, (2) donating breastmilk helped her deal with grief, (3) family members supported her through this tough time and supported her decision, and (4) health staff supported her decision. While human milk sharing (e.g., wet nursing) has been practiced in Vietnam, breastmilk donation from bereaved mothers has neither been discussed nor well-researched. Because maternal grief is complex and individual, deciding to donate breastmilk is a personal decision that needs to be supported, without creating guilt for those who do not wish to donate.

Commercial Surrogacy: An Overview

OBJECTIVE

 Surrogacy is the process in which a woman carries and delivers a baby to other person or couple, known as intended parents. When carriers are paid for surrogacy, this is known as commercial surrogacy. The objective of the present work is to review the legal, ethical, social, and cultural aspects of commercial surrogacy, as well as the current panorama worldwide.

METHODS

 This is a review of the literature published in the 21st century on commercial surrogacy.

RESULTS

 A total of 248 articles were included as the core of the present review. The demand for surrogate treatments by women without uterus or with important uterine disorders, single men and same-sex male couples is constantly increasing worldwide. This reproductive treatment has important ethical dilemmas. In addition, legislation defers widely worldwide and is in constant change. Therefore, patients look more and more for treatments abroad, which can lead to important legal problems between countries with different laws. Commercial surrogacy is practiced in several countries, in most of which there is no specific legislation. Some countries have taken restrictive measures against this technique because of reports of exploitation of carriers.

CONCLUSION

 Commercial surrogacy is a common practice, despite important ethical and legal dilemmas. As a consequence of diverse national legislations, patients frequently resort to international commercial surrogacy programs. As of today, there is no standard international legal context, and this practice remains largely unregulated.

"Only My Husband and My Doctor Know. And You, Girls": Online Discussions of Stigma Coping Strategies for Russian Surrogate Mothers

(1) Background: Gestational surrogacy is the most common type of surrogacy today. Although technologically well-developed and legal in many countries, it challenges and even contradicts the basic traditional concepts of family, motherhood, and gender roles. In the present study, we examined the types of stigma coping strategies surrogate mothers discussed in an online support group in post-Soviet Russia. (2) Method: We conducted a qualitative thematic analysis of 15,602 posts on a Russian-language online support group for surrogate mothers. (3) Findings: group members discussed four types of coping strategies: stigma internalization, stigma avoidance, group identification, and stigma challenging. Nevertheless, these strategies varied across the surrogate motherhood stages. Group members advised each other on specific strategies to use to cope with the state of discreditable (invisible) stigma (i.e., during the first few months of their pregnancies), with different strategies for when the pregnancies became visible and they risked becoming discredited people. Furthermore, group members disclosed that they used these strategies even when they returned to their previous family and work routines. Theoretically, our findings challenge Goffman’s classic theoretical dichotomy and coping research concerning discreditable (invisible) and discredited (visible) stigma. (4) Conclusion: Our findings indicate that surrogate mothers anticipate experiencing stigma and therefore plan for it by discussing potential coping strategies in the online group. Moreover, any intervention designed to cater to the needs of surrogate mothers must, therefore, take into consideration the social needs of their entire family.

Prenatal attachment: using measurement invariance to test the validity of comparisons across eight culturally diverse countries

Studies in high-income countries (HICs) have shown that variability in maternal-fetal attachment (MFA) predict important maternal health and child outcomes. However, the validity of MFA ratings in low- and middle-income countries (LMICs) remains unknown. Addressing this gap, we assessed measurement invariance to test the conceptual equivalence of the Prenatal Attachment Inventory (PAI: Muller, 1993) across eight LMICs. Our aim was to determine whether the PAI yields similar information from pregnant women across different cultural contexts. We administered the 18-item PAI to 1181 mothers in the third trimester (Mean age = 28.27 years old, SD = 5.81 years, range = 18-48 years) expecting their first infant (n = 359) or a later-born infant (n = 820) as part of a prospective birth cohort study involving eight middle-income countries: Ghana, Jamaica, Pakistan, Philippines, Romania, South Africa, Sri Lanka and Vietnam. We used Multiple Group Confirmatory Factor Analyses to assess across-site measurement invariance. A single latent factor with partial measurement invariance was found across all sites except Pakistan. Group comparisons showed that mean levels of MFA were lowest for expectant mothers in Vietnam and highest for expectant mothers in Sri Lanka. MFA was higher in first-time mothers than in mothers expecting a later-born child. The PAI yields similar information about MFA across culturally distinct middle-income countries. These findings strengthen confidence in the use of the tool across different settings; future studies should explore the use of the PAI as a screen for maternal behaviour that place children at risk.

The social paradoxes of commercial surrogacy in developing countries: India before the new law of 2018

BACKGROUND

Commercial surrogacy is a highly controversial issue that leads to heated debates in the feminist literature, especially when surrogacy takes place in developing countries and when it is performed by local women for wealthy international individuals. The objective of this article is to confront common assumptions with the narratives and experiences described by Indian surrogates themselves.

METHODS

This qualitative study included 33 surrogates interviewed in India (Mumbai, Chennai and New Delhi) who were at different stages of the surrogacy process. They were recruited through five clinics and agencies. This 2-year field study was conducted before the 2018 surrogacy law.

RESULTS

Surrogates met the criteria fixed by the national guidelines in terms of age and marital and family situation. The commitment to surrogacy had generally been decided with the husband. Its aim was above all to improve the socioeconomic condition of the family. Women described surrogacy as offering better conditions than their previous paid activity. They had clear views on the child and their work. However, they declared that they faced difficulties and social condemnation as surrogacy is associated with extra-marital relationships. They also described a medical process in which they had no autonomy although they did not express complaints. Overall, surrogates did not portray themselves as vulnerable women and victims, but rather as mothers and spouses taking control of their destiny.

CONCLUSIONS

The reality of surrogacy in India embraces antagonistic features that we analyze in this paper as "paradoxes". First, while women have become surrogates in response to gender constraints as mothers and wives, yet in so doing they have gone against gender norms. Secondly, while surrogacy was socially perceived as dirty work undertaken in order to survive, surrogates used surrogacy as a means to upward mobility for themselves and their children. Finally, while surrogacy was organized to counteract accusations of exploitation, surrogates were under constant domination by the medical system and had no decision-making power in the surrogacy process. This echoes their daily life as women. Although the Indian legal framework has changed, surrogacy still challenges gender norms, particularly in other developing countries where the practice is emerging.

Postdelivery adjustment of gestational carriers, intended parents, and their children

Surrogacy raises a number of concerns about the psychological adjustment of the surrogate, the parents, and the child. Despite surrogacy becoming more common, research into the postdelivery psychological adjustment of the individuals involved has lagged far behind. This review examines research on the psychological adjustment of surrogates and their children. It then presents findings from studies assessing parents' psychological health and parent-child relationships, and children's adjustment within families formed through surrogacy. Finally, it examines how children born through surrogacy feel about their birth and toward their surrogate. Overall, studies have shown good psychological outcomes for surrogates, parents, and children, but research is still very limited, particularly in relation to the geographical location of the research, the ages of the children studied, and the lack of longitudinal projects. Different forms of surrogacy now exist under the umbrella term of "surrogacy." There is now greater diversity in terms of who is using surrogacy, their motivations for using it, whose gametes are used for the pregnancy, and how a surrogacy arrangement is managed. There is therefore a need for future studies to examine the consequences of these different forms of surrogacy on the postdelivery psychological health of surrogates, surrogacy parents, and their children.

Prenatal Attachment and Perinatal Depression: A Systematic Review

Pregnancy is a period of complex bio-psychological changes, during which the development of an attachment bond to the fetus takes on a central role. Depressive symptoms are common during this period. Both symptoms of depression and low levels of prenatal attachment are related to negative outcomes in caregivers and infants. Following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement, this systematic review analyzes and systematizes 41 studies concerning the association between prenatal attachment and perinatal depression. The majority of the studies reported a significant association between the two. Specifically, prenatal depressive symptoms were found to be negatively associated with prenatal attachment. Furthermore, lower levels of prenatal attachment were related to higher postnatal depressive symptoms, although fewer studies assessed this association. While these results were found across different populations, conflicting findings emerged, suggesting they should be interpreted with caution, particularly in male samples and in non-normative pregnancies (e.g., high-risk pregnancies, medically assisted pregnancies, and pregnancies with previous perinatal losses). These results are clinically important for the perinatal screening process and for implementing preventive and treatment programs. However, future studies are needed to further confirm and generalize these results.

"The Miracle Mothers and Marvelous Babies": Psychosocial Aspects of Surrogacy - A Narrative Review

Surrogates are described in literature as true angels “who make dreams happen.” On the other hand, surrogacy has also been surrounded by several psychosocial controversies. In this review, we have made an attempt to encapsulate this topic from the multiple perspectives of individuals who are involved in the surrogacy cycle. We present to the readers the various outlooks and dilemmas of the clinicians, patient parties contracting for surrogacy, the child born out of surrogacy, and the intricate role of the mental health professionals in surrogacy arrangements. The review also throws light upon the psychosocial issues in connection to the evolving Surrogacy practices in Indian and in the Western world.

An ethical comparison of living kidney donation and surrogacy: understanding the relational dimension

BACKGROUND

The bioethical debates concerning living donation and surrogacy revolve around similar ethical questions and moral concepts. Nevertheless, the ethical discourses in both fields grew largely isolated from each other.

METHODS

Based on a review of ethical, sociological and anthropological research this paper aims to link the ethical discourses on living kidney donation and surrogacy by providing a comparative analysis of the two practices' relational dimension with regard to three aspects, i.e. the normative role of relational dynamics, social norms and gender roles, and reciprocity. Based on this analysis, we derive conclusions for the framing of living organ donation and surrogacy in ethical theory and practice.

RESULTS

First, our analysis emphasizes the relevance of acknowledging the complex relational implications of living kidney donation and surrogacy. Underestimating this relational dimension may not only lead to individual crises but endanger existing as well as newly emerging familial relationships. Second, we point out differences in the normative assessment of social norms and gender roles in the ethical debates about living kidney donation and surrogacy. In particular, we show how different evaluations of altruism affect the understanding of autonomy in both contexts. In addition, we sensitize for biased perceptions of gender roles. Finally, we argue that challenges resulting from unresolved reciprocity are an issue in living kidney donation and surrogacy independent of whether the exchange of body parts or bodily services is framed as a gift or commercial exchange. By pointing out the limits of financial compensation, we stress the relevance of non-material, relational rewards as potential remedy.

Parents' relationship with their surrogate in cross-border and domestic surrogacy arrangements: comparisons by sexual orientation and location

Objective

To study heterosexual and gay couples' relationship with their surrogate and their disclosure decisions when the surrogacy arrangement was completed domestically compared with internationally.

Design

Cross-sectional study.

Setting

Not applicable.

Patient(s)

Participants were 40 gay couples and 76 heterosexual couples who had domestic surrogacy in the United Kingdom (UK) (n = 38) or international surrogacy in the United States (n = 58) or Asia (20). Most (75%) of the children were aged <4 years.

Intervention(s)

Online surveys containing open-ended and multiple-choice questions.

Main Outcome Measure(s)

Experiences of finding a surrogate, relationship with the surrogate, and disclosure to the child were examined among UK parents who had undergone surrogacy in the UK, United States, or India/Thailand.

Result(s)

Parents who had surrogacy in the UK and United States felt very involved in the pregnancy compared with those who had surrogacy in Asia. Couples whose surrogacy was completed in Asia were less likely to want contact with their surrogate after the birth and were also less likely to have any current contact with the surrogate. Parents who had surrogacy in the UK and United States described positive relationships with their surrogate. Gay couples intended to tell their child about surrogacy more than heterosexual couples.

Conclusion(s)

The specific country where couples conducted their surrogacy arrangement (i.e. United States, UK, or Thailand/India) was associated with how involved they were in the pregnancy and their contact with the surrogate over time. Limitations of the study include use of survey methodology and that the representativeness of the sample is not known.

Regulating surrogacy in Europe: Common problems, diverse national laws

Despite the diverse legal approaches towards surrogacy in Europe, there are common socio-legal arguments attempting to legitimise it amongst the European Union member states. Regardless of the prevailing regulation in each country, surrogacy in general is confronted with common criticisms and faces similar obstacles. For instance, the operative definition of altruism is put under question in countries where altruistic surrogacy is permitted. Surrogacy is also considered an attack on a woman’s dignity and a risk to children’s welfare. Behind such claims, however, rests the common yet unsubstantiated belief in a natural maternal instinct. Furthermore, a clear misunderstanding about the bonding theory still persists. Common debates around surrogacy in Europe show us that, beyond the national margin of appreciation, surrogacy challenges basic definitions of motherhood, filiation and family. These challenges are deeply permeated by gender stereotypes which partially explain the national similarities among the legal diversities.

Surrogacy and ethics in women with cancer

Women diagnosed with gynaecological cancer may face unwanted loss of fertility as well as all the other life-changing issues with which cancer and its treatments are associated. The decision to harvest and store gametes has to be made before commencement of treatment, and advances in these techniques have made this successful. Fertility sparing therefore must be discussed and offered at an early stage post diagnosis. Surrogacy is currently an evidence-based method of assisted reproduction, with mainly desirable outcomes for the commissioning mother, surrogate and child, without impacting on the cancer treatment and long-term survival. Surrogacy is therefore ethical as long as the autonomous rights of both the commissioning mother and gestational carrier are equally observed, they both have equal legal protection and due attention is paid to the short- and long-term welfare of any resulting offspring.

The psychological well-being and prenatal bonding of gestational surrogates

STUDY QUESTION

How does the psychological well-being and prenatal bonding of Indian surrogates differ from a comparison group of mothers?

SUMMARY ANSWER

Surrogates had higher levels of depression during pregnancy and post-birth, displayed lower emotional connection with the unborn baby, and greater care towards the healthy growth of the foetus, than the comparison group of mothers.

WHAT IS ALREADY KNOWN

Studies in the West have found that surrogates do not suffer long-term psychological harm. One study has shown that surrogates bond less with the foetus than expectant mothers.

STUDY, DESIGN, SIZE, DURATION

This study uses a prospective, longitudinal and cross-sectional design. Surrogates and a matched group of expectant mothers were seen twice, during 4-9 months of pregnancy and 4-6 months after the birth.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Semi-structured interviews and standardized questionnaires were administered to 50 surrogates and 69 expectant mothers during pregnancy and 45 surrogates and 49 expectant mothers post-birth. All gestational surrogates were hosting pregnancies for international intended parents.

MAIN RESULTS AND THE ROLE OF CHANCE

Surrogates had higher levels of depression compared to the comparison group of mothers, during pregnancy and post-birth (P < 0.02). Low social support during pregnancy, hiding surrogacy and criticism from others were found to be predictive of higher depression in surrogates post-birth (P < 0.05). Regarding prenatal bonding, surrogates interacted less with and thought less about the foetus but adopted better eating habits and were more likely to avoid unhealthy practices during pregnancy, than expectant mothers (P < 0.05). No associations were found between greater prenatal bonding and greater psychological distress during pregnancy or after relinquishment.

LIMITATIONS, REASONS FOR CAUTION

All surrogates were recruited from one clinic in Mumbai, and thus the representativeness of this sample is not known. Also, the possibility of socially desirable responding from surrogates cannot be ruled out.

WIDER IMPLICATIONS OF THE FINDINGS

As this is the first study of the psychological well-being of surrogates in low-income countries, the findings have important policy implications. Providing support and counselling to surrogates, especially during pregnancy, may alleviate some of the psychological problems faced by surrogates.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by the Wellcome Trust [097857/Z/11/Z] and Nehru Trust, Cambridge. K.K. is the Medical Director of Corion Fertility Clinic. All other authors have no conflict of interest to declare.