Abstract
The purpose of this study was to explore surrogate women’s experiences of stress during the surrogacy process in India. We interviewed 15 women who had been a surrogate for an international couple at least once in their lives. The following themes emerged: stress regarding (1) physical health, (2) psychology well-being, and (3) the well-being of surrogates’ families and children. Transnational surrogates may experience more physical and psychological stress during pregnancy because their children and families continue to depend on them for support. Social workers must minimize the physical and emotional effects of surrogacy through counseling and psychosocial support.
Introduction
Infertility and involuntary childlessness affect countless individuals and couples worldwide. In total, an estimated 40.2–120.6 million women aged 20–44 years, living in a married or consensual relationship, fail to conceive after 12 months of unprotected sexual intercourse, and of these, 12–90.4 million are likely to seek medical help (Boivin et al., 2007). A wide variety of reproductive medical procedures – commonly known as assisted reproductive technologies (ARTs) – exist to provide infertile couples or individuals with help in achieving conception. In the United States alone, ARTs make up a multibillion dollar industry estimated to be worth more than US$3bn a year (Spar, 2006). Treatments can include, but are not limited to, in vitro fertilization (IVF), fertility drugs, donor gametes, and surrogate carriers.
Over the past decade, the popularity and growth of the ART industry has increased tremendously in high-income countries. However, couples and individuals from these nations often seek out services abroad, primarily in low-income nations. Indeed, medical tourism related to infertility treatment is one of the most common medical procedures identified by medical tourism companies (Alleman et al., 2011). Transnational surrogacy is included in this roster of treatments in which a woman, often from a low-income country, contractually agrees to carry and deliver a child for another individual or couple, often from a high-income country, who will raise the child. Intended parents in these transnational arrangements are often motivated to seek services in low-income countries due to low costs, high accessibility, and low oversight (Kirby, 2014; Nelson, 2013; Shenfield et al., 2010).
India regularly ranks among the most popular destinations for medical tourism (Alleman et al., 2011), and in the last two decades an entire industry has been created to provide medical services at low cost to a global consumer base (Parks, 2010). Since the legalization of commercial surrogacy in India in 2002, transnational surrogacy has become a thriving national industry (Chang, 2009). The transnational surrogacy industry in India is rumored to be a US$445m a year business and is said to have more than doubled between 2007 and 2009 alone (Haworth, 2007; Sehgal, 2008). A large proportion of citizens from high-income nations have traveled to India for infertility treatment (e.g. reproductive cell donation, surrogacy, birth, and delivery) for several reasons. Foremost, commercial surrogacy is substantially cheaper in India. While the cost of commercial surrogacy may exceed US$100,000 in other parts of the world, the cost in India is a third of that amount (ranging between US$10,000 and US$35,000 and possibly less; Pande, 2011; Whittaker, 2011). Additionally, India is more desirable than other Global South countries because many Indians speak English, and advanced medical technologies are available (Chang, 2009). Yet almost 15 years after India first legalized commercial surrogacy in 2002 (Chang, 2009), the Indian Ministry of Health and Family Welfare, through its Department of Health Research, passed legislation – the Assisted Reproductive Technology Regulation Bill of 2014 – recommending it be illegal for women to become surrogate mothers for international couples (Assisted Reproduction Technology Regulation Bill of 2014). If this bill is passed into an Act, surrogacy will be banned in India for international couples.
Arguments have been posed for and against transnational surrogacy by practitioners and policy makers; however, most research on surrogacy is limited to Western settings, such as the United States, the United Kingdom, and Canada, and provides conflicting evidence. For example, Blyth (1994) and Ciccarelli (1997) suggest that surrogate mothers in Western contexts may experience significant emotional distress, such as depression, stress, anxiety, and regret, regarding the transfer of the child from surrogate to intended parent(s). However, Ciccarelli and Beckman (2005) provide evidence that there is little psychological impact on women or children in domestic surrogacy arrangements. However, to our knowledge, there is no scholarly documentation of these effects in non-Western contexts, such as India. Research shows that surrogates have been found to feel less attached to the fetus during pregnancy than nonsurrogates (Fischer and Gillman, 1991; Ragone, 1996) and to experience different attitudes toward pregnancy from nonsurrogates (Baslington, 2002; Ciccarelli, 1997; Ragone, 1996). However, again, there are no studies that have examined the emotional responses of non-Western surrogates. Finally, there are no studies to our knowledge that have investigated how the emotional and physical stress of surrogacy impacts the surrogate woman.
We present findings from a qualitative study conducted among surrogate women in one fertility clinic in Gujarat, India. The purpose of this study was to understand surrogate mothers’ experiences of emotional and physical stress during surrogate pregnancies and how this tension impacts their lives.
Methodology
Study setting and population
We analyzed data from a qualitative study conducted to explore women’s experiences of transnational surrogacy. In-depth interviews were conducted in one fertility clinic in Gujarat India, during December 2012. The fertility clinic personnel assisted in participant recruitment and provided private and secure spaces in the clinic to conduct the interviews. In total, 15 women participated in the study.
Procedures
Since the topic of transnational surrogacy is relatively new and exploratory in nature, qualitative methodology was deemed most appropriate to conduct this research. This methodology brought about an in-depth understanding of the issue and highlighted the voices of the surrogate mothers. An interview guide (in English) was developed for this research study and subsequently was translated into Hindi and Gujarati. The interview guide contained several questions on demographics (i.e. age, marital status, number of children, and education), entry into surrogacy, motivation for being a surrogate, as well as questions about experiences as a surrogate. The interviews were semi-structured, and the participants could choose to speak on any area of particular relevance to them.
Participants were recruited for participation in the study through a staff member at the clinic. Women were recruited with the clinic’s permission, and the clinic was fully aware that a staff member was assisting with participant recruitment. The staff member contacted women who had previously been surrogates for international couples, and a verbal script was utilized to recruit participants. If a woman was interested in and willing to participate in the study, the staff member invited the woman to the clinic for an interview. All interviews were conducted in a private room at the fertility clinic. The staff member and/or clinic did not determine who was interviewed, rather any woman who had been a surrogate for an international couple, was interested in participating, and had the availability to participate in an interview at the clinic was invited.
Interviews were conducted by the first author of this article in Gujarati and Hindi. On average, each woman was interviewed for between 40 and 50 minutes. Interviews were recorded upon the participant’s consent and translated from Gujarati/Hindi to English.
Due to cultural norms and the high rate of illiteracy among participants, it was neither appropriate nor standard practice to require participants to sign actual consent forms. Consent was established through verbal communications and subsequent participation in the study. This informed consent technique revealed that participants had a clear understanding of the study, an appreciation for the invasiveness of the questions, and were willing to proceed despite risks involved with discussing sensitive information about themselves. To protect participants’ privacy, all interviews were conducted in a private and secure room within the fertility clinic. Only the researchers were present, and no content of the interviews was shared with the clinic, unless the surrogates themselves openly disclosed their conversations. Recruitment continued until saturation was reached. Each surrogate was compensated with 500 Indian rupees (Rs.) as travel reimbursement for participating in the study.
The aforementioned study procedures were approved by the Institutional Review Board (IRB) at The Ohio State University and the University of Utah. In India the social sciences IRB is not formalized yet, and there are no official approvals given. However, as social scientists we are concerned about the protection of human subjects, and we attend to this as an important element of conducting our research.
Data analysis
We used a narrative approach to analyze the in-depth interviews (Padgett, 2008). Specifically, the constant comparative method (CCM) was used to examine similarities and differences across respondents and narratives (Padgett, 2008). Following the procedures outlined in Straus and Corbin (1990, 1997), analysis consisted of four steps. First, interviews were transcribed and translated into English. Transcription and translation were performed by a researcher fluent in Gujarati, Hindi, and English. Second, analysis involved reading the qualitative data line by line and open coding to reveal similar categories. This step was conducted independently by two researchers. Third, the researchers discussed significant categories and identified emergent themes. A provisional list of codes and coding themes were compiled and applied to each interview. Finally, matrices were developed to uncover relationships between themes. Quotes were assembled to highlight each theme.
Results
Participant characteristics
The majority of the participants were illiterate women between the ages of 21 and 30 years. Most women had been a surrogate approximately three times in their life, although many had been egg donors almost double that amount. Participants were all married and had at least one biological child of their own. The birth of at least one biological child was a requirement for surrogates prior to participation in this surrogacy program in Gujarat. Many of the women reported their husbands to be unemployed or underemployed, and some reported problems in the home (such as their husbands abusing alcohol). The majority of the participants reported being from a very low socioeconomic background and had little to no formal education. The commissioning parents were from the United States, Japan, Canada, Australia, England, Japan, India, and Madagascar.
Qualitative findings
Three critical themes emerged related to stress: (1) stress regarding physical health, (2) stress regarding psychological well-being, and (3) stress regarding the well-being of surrogates’ families and children.
Physical health
All participants expressed anxiety over the state of their physical health. Several surrogates reported taking medications prior to the pregnancy to prepare themselves for surrogacy and described poor health before the surrogate pregnancy. In describing the consequences of surrogacy on her employment, Participant 2 stated, I took several medications to prepare myself for the pregnancy, because I was physically not very strong. I also had a caesarian section so that caused some problems. It has just been one month so I am still recovering, but have to return to work.
Many participants reported that if they were not physically ready for a surrogate pregnancy, they would instead substitute with egg donation. Participant 4 said, I came here today because I am currently on medications to prepare my uterus for a second time being a surrogate. After the first time my husband asked me to do a second time, but my physical health was not good enough so I had to wait this long. In the meantime, I donated eggs 4 times and got some money for that.
Interestingly, most women who participated in egg donation reported the process to be painful, yet the women continued to donate eggs due to the financial compensation: Participant 7: I did egg donation 3 times. [I received] around 7 to 8 thousand rupees each time. Egg donation pay is decided by the doctor based on quality and quantity of the eggs donated. It is very painful, the injections, but I take medicines that the doctor gives. Participant 3: Whenever I got sad, I would think about my children and the money. The egg donation was very painful, but every time I did it I got 6 to 7 thousand rupees.
Additionally, most of the women who reported negative health consequences associated with surrogacy and egg donation conversely reported portraying the work positively to other women. For example, Participant 6, who is also a surrogate recruiter for the clinic, said early in her interview, I have been an egg donor for seven times. Egg donation was extremely painful and I had to be on many medications … and then I did surrogacy, because it was the way to make more money. So I decided to do that instead. Money is the only reason that I do this.
But she then says later, The madam has told us that this is good work. We are also helping someone else. So that is the way that I tell other women that they should do this work. When I recruit women I tell them they would be taken care of like you never have before.
The women would also express that what they were engaging in was an honorable cause, yet would keep the surrogacy from their friends and family for fear of stigmatization. Finally, the women reported that they do experience pain, but they largely keep this information to themselves. For example, Participant 9 said, After delivery there are some problems everyone has, but no one talks about them. But the doctor gives lots of medicines to help us recover.
Psychological well-being
All participants expressed that surrogacy was emotionally challenging to various degrees. The majority of the women lived in a surrogate hostel away from their families and communities, with other women who were also surrogates, during their surrogate pregnancy. This was done to make sure they followed a proper diet during pregnancy, and to keep their pregnancy a secret due to the social stigma attached to surrogate pregnancies. Living away from their children was reported as a top concern of many surrogates. For instance, Participant 2 stated, I was in the surrogate home. It was very difficult to be without my son … Every day I was thinking if I am suffering so much, the money I earn will make it worth it. The money will be saved and used wisely, because it has come from much suffering.
Similarly, women reported that the surrogate homes posed everyday challenges that were often difficult to handle: Participant 9: I had to live in the surrogate home. That was very good because of all the things provided there. But it was also a challenge because there were all these women and duties, and I didn’t feel well so it was also a challenge … At the home there was a lot of complications. We all had to keep in mind we were only there for temporary time. There was only two bathrooms, so we all had to adjust and deal with issues. Participant 10: When I was in the surrogate home, I didn’t learn any activity. I just sat there. There were many difficulties but when I had them I just thought of the money. Participant 11: It’s a good thing, but it’s very difficult to stay without family for so long. And also keeping it secret from them. But how else can one make so much money?
While at the hostels, most surrogate women reported that the emotional distance from their own children was the hardest part, but necessary for the surrogacy process and financial compensation. The women also noted the perceived benefits of staying in the surrogate hostel, such as for their health, a successful pregnancy, and secrecy from their families or communities: Participant 13: I did not like staying in the surrogate house. I constantly wanted to go back home to my children. But the poverty of our house would have been bad for my pregnancy. It was safer to stay in the surrogate house. Participant 2: I had to stay in the surrogate home because the people in village would ask about how I got pregnant, especially with no husband. Also, we are so poor. It would be hard to ensure good health. Participant 6: I stayed in the surrogate house because my home situation is so bad, and we are so poor, it would have not been good. We also live so far away from [the clinic].
Some of the women discussed their emotional attachment to the surrogate fetus. For some women, the emotional attachment to and separation from the child were a part of the process and they reported no concerning psychological issues surrounding the surrogacy. For other women, the attachment to the pregnancy was amplified by prolonged breastfeeding. Participant 1 stated, It was initially very weird because the kids looked very like the American parents, and I felt an attachment to them, but I knew that I had to give them. Two and a half months I was breastfeeding the first time. The second time, I was only breastfeeding for one month. This made the attachment increase, but ultimately I had to let go. The first time the parents came after 2 months, because of a Visa issue, so the attachment was higher that time.
Similarly, Participant 4 noted that although surrogate pregnancy is similar to a biological pregnancy, it brings about different emotions and motivations. She said, I am doing it only for the money. If there was not money involved I don’t think any woman would do this. Even though everyone gets pregnant it is very difficult when you have to carry someone else’s child. All day I thought about the money. When I had my own child I never had those feelings.
Surrogates’ families and children
The majority of women noted the difficulties the surrogate pregnancy caused for their families and children. As noted earlier, the most difficult part of the surrogacy was spending time away from their own children: Participant 4: I was not interested [in surrogacy], because I didn’t know how this is possible and I didn’t want to spend time away from my 10 and 9 year-old kids, but my husband said this is a way to get out of our poverty.
While being away from their children was hard, the surrogacy largely provided most women with an income and the ability to send their children to school: Participant 5: I really care about my kids’ education so that is why I did the egg donations and surrogacy. Those are extremely painful even though it was a short time. Participant 10: I didn’t want to really do [surrogacy], but when I thought about the money I had no other choice. Without that money, I would not have gotten our family together and our house and I was ensuring my child’s education. Participant 15: I used the money for many so many good things. My kids are in school. My husband had surgery for kidney stones. I have done so much good with the money.
Regardless, all of the surrogate women faced criticism in their communities for the surrogacy: Participant 16: It was for a noble cause. When people would get angry I would ask if they were buying my house, or giving my kids school and after a while they stopped saying things to me.
Discussion
We observed that surrogate women experience physical and psychological stress to various degrees. This stress may be amplified by extenuating circumstances at home (such as leaving children), in the surrogate hostel, and from previous poor health. Although all the women reported strain from the surrogate pregnancy and processes, most pointed out the benefits that surrogacy provided for themselves and their families. For example, most surrogates noted how the income provided them with a means to send their children to school. Indeed, most women that participated in this study had engaged in surrogacy and egg donation for the clinic multiple times. Nonetheless, the physical and emotional effects of surrogacy must be minimized by providing counseling and psychosocial support to protect women and their families. Given the recent change in legislation around surrogacy in India, it is critical to examine stress among surrogate mothers. Should the new legislation be ratified, even though Indian women will no longer be able to be surrogate mothers for foreign couples, they will continue to be surrogates for Indian couples living all across the world. Thus, women will continue to suffer from similar stressful situations that are indicated in this article as surrogate mothers, and the legislation needs to focus on providing social services and support to women during and after pregnancy.
Informed consent involves self-decision by the patient to undergo medical treatment and utilize the relevant services after all the facts, risks, and recommendations have been presented to the patient (American Medical Association, 2006). Surrogates in low-income countries tend to be poor and mostly illiterate. Therefore, the threshold for consenting to a procedure must be higher than that typically necessary (Deonandan et al., 2012). Scholars have noted that, oftentimes, no efforts are made to determine whether surrogates comprehend the information they receive or whether they receive much information at all (Crockin, 2013; Kirby, 2014). To ensure that all surrogate women understand the complexity of the risks associated with surrogacy, including the social and emotional risks, additional measures must be taken to communicate these threats and guarantee informed consent.
Women in low-income nations may not be granted the same freedoms as are women in the Western world. Reproductive choice, personal autonomy, and privacy are not necessarily transferable in an international setting in which different cultures and traditions exist (Knoche, 2014). The surrogate woman’s husband, children, or other family members may need to be involved in the decision, as it will also impact their lives and may influence the woman’s decision to become a surrogate (Deonandan et al., 2012). Considering the cultural context in which a woman’s informed consent is obtained is important in future intervention research.
The care of a surrogate woman while pregnant should be important not only to the intended parent(s), but also to the clinic by whom she is employed. Yet clinics often practice different models of health care, and some neglect to consider the psychological health of the surrogate (Deonandan et al., 2012). We found that the women often live in surrogate hostels away from their families, altering their familial and social duties, and possibly leaving other family members in charge of these responsibilities. If not taken into consideration by the clinicians and other parties involved, these changes place further burden upon the surrogate. Fertility clinics should put measures in place to ensure that not only is the surrogate cared for during the pregnancy, but that her family’s well-being is also considered.
Engaging in ART services, specifically treatments needed for surrogacy and egg donation, can pose health concerns for women, such as hypertension and preeclampsia (Knoche, 2014). However, there is little empirical data on the long-term health impacts of surrogacy and egg donation on women. In this study, women reported that procedures often result in pain and ‘other’ unspecified issues, but it cannot be known how these issues continue to impact their physical and social abilities. Intervention efforts should work to minimize long-term risks to women’s functionality after engagement in surrogacy services.
We found that women report conflicting levels of attachment to the fetus during pregnancy and similar attitudes towards the pregnancy as a biological pregnancy. This conflicts with previous research in that some scholars have found that surrogate women are often less attached to the pregnancy (Fischer and Gillman, 1991; Ragone, 1996) and experience different types of attitudes (Baslington, 2002; Ciccarelli, 1997; Hagan, 2001; Ragone, 1996). Future research should seek to understand the emotional attachment that commercial, gestational surrogates experience in developing contexts and how this contrasts with altruistic surrogates in high-income nations.
Limitations
Our work was not without limitations. The sample of participants was drawn from a fertility clinic in which all of the women had once been gestational surrogates and some had ongoing relationships with the clinic. For example, some women were employed at the clinic performing general housekeeping duties and some were engaged in other reproductive services (i.e. gamete donation). Other women still kept in contact with clinic staff for possible future employment opportunities. It is possible that due to these ties with the clinic, the women did not speak openly about their experiences. Furthermore, the staff member assisting with recruitment may have recruited only women that she had a relationship with, rather than the entire population of surrogates who were employed at the clinic. Surrogates who may not keep in contact with the clinic or clinic staff may have described the surrogacy experiences more negatively; therefore, the findings of this study cannot be generalized to all surrogates employed at this facility or other facilities providing similar gestational surrogate services. However, we ensured the utmost privacy when conducting all interviews at the fertility clinic, and no persons (other than the researchers) had knowledge of the content of our conversations. Future studies should make cross-comparisons in and between surrogacy clinics to explore the similarities and differences in women’s experiences.
This study was cross-sectional in nature. The participants were only interviewed at one point in time about an experience that is likely to have a lasting and evolving impact. Therefore, no causal conclusions can be drawn from this study regarding the effect of surrogacy on women’s physical and emotional health and well-being. Future research should investigate the long-term impacts on women who choose to become surrogates in low-income countries.
We also recommend research on understanding the perceptions of the surrogate mothers regarding the recent ban on international surrogacy in India. The data for this study were collected prior to the ban on international surrogacy, and it will be important to see how women are being impacted by the ban. Since surrogacy was indicated to be an income-generating option for women, it will be important to see how the women who have been surrogates in the past and those who wanted to be surrogate mothers in the future perceive the ban on international surrogacy in India.
Implications for social work
In India and other countries where transnational surrogacy is on the rise, social workers can play an active role in providing counseling and psychosocial services to surrogate women. Social workers are uniquely adept to address the intrapersonal and interpersonal stressors that surrogate women may experience before, during, and after a surrogate pregnancy. Long-term, rather than short-term, interventions are needed to support women. Furthermore, social workers from all countries can advocate on behalf of surrogate women, intended parents, and surrogate children to ensure that policies are created which comprehensively address the needs of all who are involved.
Social workers in Western or high-income countries can guide intended parents who wish to seek out surrogacy abroad. Intended parents should be made aware of the risks for themselves, but especially for the surrogate women. Educating intended parents on the realities of transnational surrogacy may provide a deeper awareness of the needs of a surrogate.
Footnotes
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.