City University, London Family and Child Psychology Research Centre, Northampton Square, London EC1V 0HB, UK
1 To whom correspondence should be addressed. e-mail: F.J.Maccallum{at}city.ac.uk
![]() |
Abstract |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Key words: commissioning couples/surrogacy
![]() |
Introduction |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The relationship between the commissioning couple and the surrogate mother is crucial to the success of the arrangement. The surrogate mother may be either a relative or friend of the commissioning couple, or may have been unknown to them prior to the surrogacy arrangement. Some argue that surrogacy with a previously unknown surrogate mother is potentially problematic (Warnock, 2002), since to some extent all of those involved are depending on trust between strangers. In other forms of assisted reproduction involving an unknown third party such as donor insemination or egg donation, the donor generally remains anonymous. However, in surrogacy cases, a bond must be established between the previously unknown surrogate mother and the commissioning couple, a relationship described by the founder of one UK surrogacy agency as a forced friendship (Brazier et al., 1998
). On the other hand, surrogacy with a known surrogate mother presents the possibility that a relative or friend will be pressured into being a surrogate mother, and that this will complicate the dynamics within the family to a damaging extent. Indeed, in Israel it is illegal for the surrogate mother to be a relative of the commissioning couple (Benshushan and Schenker, 1997
).
Whether the surrogate mother is known or unknown, potentially difficult issues arise associated with the involvement of the commissioning couple in the pregnancy and the birth, the handing over of the child to the commissioning couple and, importantly, the continuing contact after the birth between the surrogate mother and the commissioning couple. Professional advice about this contact is equivocal with the British Medical Association stating that "... while some people report benefits arising from maintaining contact between the parties after the birth, this will not suit everybody" (British Medical Association, 1996).
To some extent, the continuation of contact between the family and the surrogate mother will depend on whether the commissioning couple intend to disclose the facts of the surrogacy arrangement to the child. The disclosure or non-disclosure of the use of assisted conception is an area of much debate. Studies of families created by gamete donation have found that the large majority of parents do not intend to disclose the method of conception to the child (Brewaeys, 1996; 2002), although there is some evidence of a tendency towards greater openness in recent years (S.Golombok et al., unpublished data). van den Akker (2000
) studied 29 women at various stages of surrogacy arrangements and found that all but one of them (97%) said they would disclose the surrogacy to their child, suggesting that surrogacy families are more open than families created through other methods of assisted reproduction. However, more than half of this sample had not yet completed the surrogacy arrangement successfully.
It has been suggested that secrecy about the conception method will damage family relationships with a consequent negative impact on the childs psychological development (Baran and Pannor, 1993; Daniels and Taylor, 1993
; McWhinnie, 2001
)and there is some evidence that difficulties may arise when individuals discover their donor conception in adulthood (Turner and Coyle, 2000
). Also, evidence from research on adoptive families shows that children are more likely to develop emotional and behavioural problems when their parents do not communicate openly about the adoption (Howe and Feast, 2000
). Insofar as the surrogacy situation resembles adoption, it could be argued that children are likely to fare better when the surrogacy is disclosed to them from a young age.
As yet, there is little empirical research on the consequences of surrogacy or the experience of going through a surrogacy arrangement. In terms of child development, a review by Serafini (2001) found no verbal or motor impairment in children born after IVF (full) surrogacy at age 2. A small number of studies have been published that interviewed commissioning couples about the experience of surrogacy. From a sample of 20 commissioning parents, Blyth (1995
) reported that in all cases it had been agreed that the commissioning mother would be present at the birth of the child, all parents believed that the child should be told about the surrogacy arrangement and all intended to maintain contact in some form with the surrogate mother. However, the sample included only eight sets of couples with children, and the age of the children at interview was not reported. In addition, all the participants were volunteers recruited through the UK surrogacy agency Childlessness Overcome Through Surrogacy (COTS) so cannot be considered an entirely representative sample, as not all commissioning couples have contact with COTS. Other studies in the UK (van den Akker, 2000
) and the USA (Ragoné, 1994
) have also used samples that include commissioning couples who have not yet become parents.
The aim of the present study was to obtain systematic information from a representative sample of surrogacy families in the UK with a child aged 1 year old. This paper focuses on commissioning couples reports of their experience of the surrogacy arrangement. In addition to reporting on the sample as a whole, comparisons have been made between those couples who knew the surrogate mother previously and those who did not, and between those arrangements involving full surrogacy and those involving partial surrogacy. Findings relating to the quality of parent-child relationships in surrogacy families are reported elsewhere (Golombok et al., 2003
).
![]() |
Materials and methods |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The mean age of the 42 mothers studied was 35 years, with the mean age of the fathers being 40 years. There were almost equal numbers of girls and boys in the group (22 boys and 20 girls) and the mean age of the children was 10.5 months. A total of 60% of the families had only one child, 31% had two children and 9% had three children. The socioeconomic status of the families was measured by the occupation of the parent with the highest-ranking position according to a modified version of the Registrar Generals classification (OPCS and Employment Department Group, 1991) ranging from 1 (professional/managerial) to 4 (partly skilled or unskilled). Seventy-six per cent of families were in the professional/managerial bracket, with the remaining families equally split between the skilled non-manual and skilled manual categories.
Measures
Researchers trained in the study techniques visited the families at home. Data were obtained from the mother and the father separately by tape-recorded interview. Interviews were conducted with 100% of mothers and 69% of fathers.
The semi-structured interview focused on the couples recall of five areas that related to their past and current experience of going through a surrogacy arrangement and each variable was rated according to strict standardized coding criteria.
Motivations for surrogacy
Information was obtained from mothers on their infertility history; i.e. how long they had been trying for a child, what diagnosis they had been given for their infertility and what first caused them to consider surrogacy. Both mothers and fathers were asked why they had opted for surrogacy rather than other fertility treatments, and whether the decision to pursue surrogacy had been reached jointly by the couple. The financial burden put on the couple by the surrogacy arrangement was also assessed.
Details about the surrogate mother
Mothers were asked for details about the surrogate mother, including whether she had been known to the couple prior to the arrangement. If the surrogate mother was known, information was obtained about; (i) who first suggested she act as a surrogate mother, and (ii) what role she would have in the childs life. If the surrogate mother was previously unknown, information was obtained about; (i) how the couple first contacted her, (ii) how long they had known her before going ahead with the surrogacy, and (iii) what role she would have in the childs life. The type of surrogacy that had been used (i.e. full or partial) was also ascertained.
Experience of surrogacy during pregnancy
Parents were questioned on their retrospective recall of feelings about the pregnancy, including any anxieties and concerns, and responses were rated according to one of four categories: happy, mild apprehension, mixed feelings and high anxiety. This was assessed separately for recollections of the beginning and the end of the pregnancy. Both mothers and fathers were also asked about the quality of their relationship with the surrogate mother at the beginning and the end of the pregnancy. Relationship quality was rated according to one of three categories; harmonious, dissatisfaction/coldness, major conflict/hostility. In addition, the frequency of contact between the couple and the surrogate mother at the beginning and the end of the pregnancy was established from the mothers interview. Frequency of contact was coded into four categories; more than once a week, once a week to once a month, once a month to once every 3 months or not at all.
Experience of surrogacy after birth
Data were obtained about the handing over of the child to the commissioning parents, including when this took place, who decided when it should take place and whether either the surrogate mother or the couple had doubts at this point. Mothers were asked about the frequency of contact since the birth between the surrogate mother and the couple, and about the frequency with which the surrogate mother had seen the child. Frequency was coded as before, with the addition of an extra category for those couples who had seen the surrogate mother once or twice only since the birth, which may be the case if they had only met in court for the granting of the parental order. Both mothers and fathers were questioned about their current relationship with the surrogate mother (rated in the same way as relationship during pregnancy) and also on their feelings about the surrogate mothers involvement with child, which was rated as positive, negative or ambivalent. Where there had been no contact between the couple and the surrogate mother, reasons for this lack of contact were ascertained. Couples were also asked whether they would recommend surrogacy to other couples experiencing fertility problems.
Openness about surrogacy
Mothers were asked about the extent of their disclosure to family and friends about the surrogacy arrangement, and their reasons for disclosure or non-disclosure. Reasons for disclosure were rated by coding the following variables as yes or no, according to the mothers responses: (i) wanted to share experience; (ii) no reason not to tell; (iii) to avoid disclosure from others; and (iv) no choice but to tell.
Both mothers and fathers were questioned about whether or not they intended to tell the child about the surrogacy and, if they intended to do so, at what age they planned to start this disclosure and what their reasons were for disclosure. As for disclosure to family, the following variables were coded as yes or no: (i) child has right to know; (ii) to avoid disclosure from others; and (iii) no reason not to tell.
All statistical comparisons between known and unknown surrogate mother arrangements and between full and partial surrogacy arrangements were made using 2 analyses.
![]() |
Results |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
|
|
In the main, mothers considered the decision to try surrogacy as either a joint decision between the couple (48%, n = 20) or as being more their decision than their husbands (43%, n = 18). Only 9% of mothers felt that their husband had at first been keener to attempt surrogacy than they had been. Data from the fathers followed a similar pattern, with 59% (n = 17) feeling it was a decision made jointly and 28% (n = 8) feeling that their wife had been the instigator. The remaining 13% (n = 4) of fathers reported that they had initially been keener than their wife had been. By the time the couples started treatment, the large majority (81% of mothers and 90% of fathers) felt that both partners were equally keen on surrogacy.
When asked about the financial burden caused by the treatment, two-thirds of couples (66%, n = 27) felt there had been no strain, while 27% (n = 11) reported some strain, requiring a general cutting down on expenses in order to afford the treatment. Seven per cent of couples (n = 3) reported there had been a definite financial burden, requiring measures such as taking out loans or borrowing from family, but these couples all used full surrogacy which involves potentially costly IVF cycles.
Details about the surrogate mother
Of the 42 couples, 69% (n = 29) had not known the surrogate mother prior to the arrangement (see Table II). Of the remaining 31% (n = 13) of surrogate mothers, 17% (n = 7) were family members of the commissioning mother and 14% (n = 6) were friends of the couple. For the known surrogate mothers, the suggestion that she act as a surrogate mother for the couple had come from the surrogate mother herself in 77% (n =10) of cases, from other people in 15% (n = 2) of cases and from the commissioning mother in just one case (8%). Regarding the future role of the surrogate mother, in 77% (n = 10) of known surrogacy arrangements, the couple and the surrogate mother agreed that she would play no special role beyond that appropriate to her relationship status with the child e.g. as aunt or family friend. For the remaining 23% (n = 3) of the arrangements, it was agreed that the surrogate mother would play a special role, e.g. as the childs godmother.
|
A total of 62% (n = 26) of the arrangements involved partial surrogacy and 38% (n = 16) of arrangements involved full surrogacy.
Experience of surrogacy during pregnancy
Table III shows parental recall of concerns for two stages of the pregnancy retrospectively. At the start of the pregnancy, 72% (n = 30) of mothers and 81% (n = 22) of fathers were categorised either as happy, indicating no concerns, or as having mild apprehension, where the parent was predominantly happy or excited but had some slight concerns, for example, about how the pregnancy would progress. A higher proportion of mothers than fathers (26% versus 15%) recalled themselves as having mixed feelings but their orientation towards the pregnancy was still positive, and very few parents were rated as having high anxiety where anxiety was the predominant feeling about the pregnancy. By the end of the pregnancy, the general trend for both mothers and fathers was a move towards more positive feelings. Concerns about pregnancy were compared between those with known and unknown surrogate mothers and between those with full surrogacy and partial surrogacy. No significant differences were found for either comparison
|
Throughout the pregnancy, the large majority of mothers (79%, n = 33) saw the surrogate mother at least once a month. Fathers had less contact with the surrogate mother, with only 55% (n = 23) seeing her at least once a month. Three fathers (7%) did not see the surrogate mother at all during the pregnancy. Frequency of contact did not change from the start to the end of the pregnancy for mothers or fathers. Comparing known surrogate mother cases to unknown (see Table IV), parents who knew the surrogate mother had more frequent contact with her throughout the pregnancy than those who did not (e.g. at start of pregnancy, mothers: 2 = 25.48, P < 0.005; fathers:
2 = 18.62, P < 0.005). There was no significant difference in the frequency of contact according to the type of surrogacy, i.e. full or partial.
|
|
Where there was no contact between the family and the surrogate mother, this was most likely to be either by mutual agreement or because the surrogate mother did not want contact. There were no reported cases where the primary decision to stop contact was that of the parents.
Couples who knew the surrogate mother had seen her more often since the birth than couples who had not known the surrogate mother previously (mothers: 2 = 32.25, P < 0.005; fathers:
2 = 22.68, P < 0.005, see Table IV), but there were no significant differences between the two groups in the quality of the current relationship between the parents and the surrogate mother. Nor were there any differences in the frequency of contact, or in the quality of the current relationship with the surrogate mother, when couples in full surrogacy arrangements were compared to those in partial surrogacy arrangements.
When asked if they would definitely recommend surrogacy to others, 93% of mothers (n = 29) and 97% (n = 28) of fathers said that they would, with only one mother stating that she would not recommend it.
Openness about surrogacy
All of the commissioning couples had told both maternal and paternal grandparents about the surrogacy arrangement, although one couple had not done so until after the childs birth. When asked for their reasons for disclosure, many mothers gave more than one response resulting in a total number of responses of greater than 100% (see Table VI). The most common reasons given for telling families were: (i) 53% (n = 22) of couples wanted to share the experience with the family, (ii) 48% (n = 20) felt there was no choice but to tell, either because it would be obvious that the mother was not pregnant or because the family was aware that it was impossible for the mother to become pregnant, and (iii) 36% (n = 15) saw no reason not to tell. The majority of the couples families had reacted either positively or neutrally to the news, with only 7% (n = 3) of couples reporting any negative reaction from family. There were no differences in the reactions of family depending on whether the surrogate mother was known or not, or on whether the surrogacy was full or partial. All of the couples had also told at least one friend.
|
![]() |
Discussion |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Media reports of surrogacy have often focused on situations where the relationship between the surrogate mother and the couple has broken down, resulting in conflict and, in extreme cases, the surrogate mother applying for custody of the child, for example the baby M case (New Jersey Supreme Court, 1987). However, in this study, relationships were found to be generally good, with little sign of conflict during the pregnancy. A few couples reported having felt some dissatisfaction with the relationship in the past, for example feeling that the surrogate mother was over-exerting herself whilst pregnant, but there was no instance of this causing serious friction between them. Commissioning mothers seemed to have been more involved than did fathers with the surrogate mother during the pregnancy in that they saw her more frequently, often accompanying her to all medical appointments, and in all cases the surrogate mother was happy for the commissioning mother to be present at the birth. This is in line with Ragonés (1994
) assertion that, in the families she studied, the role of the father during pregnancy was de-emphasized while the commissioning mother formed a strong bond with the surrogate mother and was very involved in the pregnancy. It is possible that sharing the pregnancy in this way can help the commissioning mother to feel connected to the unborn child and, in the case of partial surrogacy, to come to terms with the fact that she is not the genetic mother of the child.
It has been suggested that contact with the surrogate mother after the birth might be detrimental to the family, but this does not seem to be confirmed by the findings. Nearly two-thirds of the commissioning mothers had regular contact with the surrogate mother and the large majority of parents, even where there was not regular contact, felt that their relationship was still good. There is little evidence in support of the theory that commissioning mothers may feel insecure about the surrogate mothers involvement with the child, since nearly all of the commissioning mothers were positive about this and felt that their child would benefit from it.
It should be noted that this report is based on the commissioning couples reports only, and it is possible that they were attempting to present the situation in the best possible light. This is particularly true in light of the fact that, for some variables, couples were reporting on their memories of experiences taking place over a year ago, and may have chosen not to recall the negative aspects. The surrogate mothers perception of the arrangement may be very different, or the surrogate mother may have encountered problems that she did not share with the commissioning couple. For example, in Blyths (1994) interviews with 19 surrogate mothers, five of the women studied expressed sorrow and distress about parting with the child, which the commissioning parents may not have been aware of. Therefore, in the current study the surrogate mothers themselves were interviewed where possible and data was obtained on the experience of 34 surrogate mothers (V.Jadva et al., unpublished data).
All of the couples intended to disclose the facts about the surrogacy arrangement to their child at a fairly young age. This follows the pattern seen in previous studies of surrogacy (Blyth, 1995; van den Akker, 2000
). In this respect, surrogacy families seem to be behaving similarly to adoptive families, where current practice is for parents to be open with the child about the adoption from as soon as the child can understand, rather than to families created through other forms of assisted reproduction, where parents tend not to be open with their child about the nature of their conception. Surrogacy families are also like adoptive families in their readiness to disclose the childs origins to their family and friends. This may be due to the fact that, as for adoptive families, the absence of a pregnancy means that the commissioning couple cannot pretend that they have had the child through natural conception. Thus, the wish expressed by some families created through gamete donation to present themselves as a normal family is not an option in the case of surrogacy. Parents did not seem to see surrogacy as something to keep secret, as shown by the large numbers who reported that there was no reason not to tell the child or others.
Interestingly, there were very few differences found between the arrangements where the surrogate mother was unknown to the couple and those where she was a friend or relative. Despite couples and unknown surrogate mothers having to trust each other when they were still relative strangers, their relationship was no less likely to be harmonious than that of couples and known surrogate mothers. The fact that commissioning couples waited on average 4 months before starting treatment suggests that both the surrogate mother and the commissioning couple were carefully considering the situation rather than hurrying into an alliance whilst still unsure Attempts to conceive began slightly sooner after meeting in partial surrogacy arrangements than in full surrogacy arrangements, possibly for practical reasons, but there was still an average of 16 weeks between the first meeting and the first insemination attempt. In situations where the surrogate mother was a relative or friend, there was little evidence of the surrogate mother being coerced by the couple, since in over three-quarters of cases, the suggestion had come from the surrogate mother herself.
In terms of the type of surrogacy used, there were no significant differences for any of the aspects of surrogacy studied between full and partial surrogacy arrangements. This suggests that the presence or absence of a genetic link between the commissioning mother and the child does not affect her experience of surrogacy or her feelings about the surrogate mother. This result is in line with other types of assisted reproductive technology involving gamete donation where the absence of a genetic link between the mother and the child does not appear to affect her feelings about motherhood (Golombok et al., 1999). Similarly, adoptive mothers of children adopted in infancy have positive attachments towards their infants (Singer et al., 1985
).
Warnock (2002) described surrogacy as "an extremely risky enterprise and liable to end in tears". The findings of this study provide no evidence to support this claim. In fact, despite the potentially difficult nature of surrogacy, commissioning couples generally perceived the surrogacy arrangement as a positive experience and one that they would recommend to other people. However, it must be remembered that the children in these families were still in infancy so it is not yet known what the experiences and feelings of commissioning couples will be as their children grow older and develop the capacity to understand the circumstances of their birth. Nor is it known how the relationship between the commissioning couple and the surrogate mother will sustain and develop over time. This study represents the first stage of a longitudinal investigation in which families will be followed up to try to address these questions. It is only through such studies that the impact of surrogacy on families can be properly understood.
![]() |
Acknowledgements |
---|
![]() |
References |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Benshushan, A. and Schenker, J.G. (1997) Legitimizing surrogacy in Israel. Hum. Reprod., 12, 18321834.[Abstract]
Blyth, E. (1994) "I wanted to be interesting. I wanted to be able to say Ive done something interesting with my life": interviews with surrogate mothers in Britain. J. Reprod. Infant Psych., 12, 189198.
Blyth, E. (1995) Not a primrose path: commissioning parents experiences of surrogacy arrangements in Britain. J. Reprod. Infant Psych., 13, 185196.
Brazier, M., Campbell, A. and Golombok, S. (1998) Surrogacy: Review for Health Ministers of current arrangements for payments and regulation (Cm. 4068) Department of Health, London, UK.
Brewaeys, A. (1996) Donor insemination, the impact on family and child development. J. Psychosom. Obstet. Gynecol., 17, 113.[ISI][Medline]
Brewaeys, A. (2002) Review: Parent-child relationships and child development in donor insemination families. Hum. Reprod. Update, 7, 3846.[CrossRef][ISI]
British Medical Association (1996) Changing conceptions of motherhood. The practice of surrogacy in Britain. British Medical Association, London, UK.
Daniels, K. and Taylor, K. (1993) Secrecy and openness in donor insemination. Politics Life Sci., 12, 155170.[ISI]
Golombok, S., Murray, C., Brinsden, P. and Abdalla, H. (1999) Social versus biological parenting: Family functioning and the socioemotional development of children conceived by egg or sperm donation. J. Child Psychol. Psychiat., 40, 519527.[CrossRef][ISI][Medline]
Golombok, S., Murray, C., Jadva, V., MacCallum, F. and Lycett, E. (2003) Families created through a surrogacy arrangement: Parent-child relationships in the first year of life. Dev. Psychol., in press.
HFEA (1993) Code of Practice. Human Fertilisation and Embryology Authority, London, UK.
Howe, D. and Feast, J. (2000) Adoption, search and reunion. The Childrens Society, London, UK.
Lee, R. and Morgan, D. (2001) Human fertilisation and embryology: Regulating the reproductive revolution. Blackstone Press, London, UK.
McWhinnie, A. (2001) Gamete donation and anonymity. Should offspring from donated gametes continue to be denied knowledge of their origins and antecedents? Hum. Reprod., 16, 807817.
New Jersey Supreme Court (1987) In the case of baby M.
Office of Population and Census Statistics (OPCS) and Employment Department Group (1991) Standard Classification of occupations. Her Majestys Stationery Office, London, UK.
Ragoné, H. (1994) Surrogate Motherhood: Conception in the heart. Westview Press, Oxford, UK.
Serafini, P. (2001) Outcome and follow-up of children born after in-vitro fertilization-surrogacy (IVF-Surrogacy) Hum. Reprod. Update, 7, 2327.
Singer, L.M., Brodzinsky, D. M., Ramsay, D., Steir, M. and Waters, E. (1985) Mother-infant attachment in adoptive families. Child Dev., 56, 15431551.[ISI][Medline]
Turner, A.J. and Coyle, A. (2000) What does it mean to be a donor offspring? The identity experiences of adults conceived by donor insemination and the implications for counselling and therapy. Hum. Reprod., 15, 20412051.
van den Akker, O. (2000) The importance of a genetic link in mothers commissioning a surrogate baby in the UK. Hum. Reprod., 15, 18491855.
Warnock, M. (2002) Making babies: Is there a right to have children? Oxford University Press, Oxford, UK.
Submitted on January 9, 2003; accepted on February 27, 2003.