Fact sheet: Surrogacy and violence against women

First of all, we should define what surrogacy is in order to clarify that it’s social practice and not a medical technique. Surrogacy is the practice of recruiting, with or without payment, a woman to carry one or more children, whether or not conceived with her own eggs, with the aim of giving them to one or more persons who wish to be designated as the parents of these children.

In the 1980s, surrogacy was based on artificial insemination, but since the 2010s, IVF (in vitro fertilisation) has become the norm. Surrogacy consists on eight different stages :

1. Selection of the surrogate mother. Signature of contracts
2. 2a. Selection of oocytes and sperm (the oocytes used are often selected from a “catalog” of women)
   2b. Preparatory stage (preparing the endometrial cavity of the surrogate mother to receive the embryo or embryos, multiple screenings)
3. Fertilisation in vitro and pre-implantation diagnosis (organizing In Vitro Fertilisation, testing and selecting the embryos to be implanted, even carrying out sex selection)
4. Embryo transfer into the womb of the surrogate mother
5. Pregnancy confirmation
6. Pregnancy monitoring
7. Delivery and handover of the child to the people who commissionned the baby
8. Process of transferring the parentage from the surrogate motther to the commissioning people.
   

Although only one stage of surrogacy involves medically assisted reproduction, this technology is still wrongly classified a medical technology. Surrogacy is a social practice, not a medical technique. It does not treat anyone, neither the surrogate mother, who is chosen for her good health, nor the commissioning parents.

Surrogacy falls within the spectrum of reproductive violence, alongside practices like the trade of oocytes (eggs), forced pregnancy and sterilisation, and ban on contraception and abortion.

Surrogacy inherently involves a trifecta of violence against women: medical, psychological, and economic.

 

We advocate for its inclusion as a form of violence against women in all international instruments to dismantle this exploitative practice.

Medical violence and surrogate pregnancies

The information regarding the health risks women face in surrogacy is limited, as this issue is seldom examined from a feminist perspective. Even if it is an important health issue there are no official records neither of clinics dealing with surrogacy, nor of children born from surrogacy, even less of surrogate mother death, injury or illness, and of children being left over by commissioning people. What we know for certain is that the weight of the physical and health risks in surrogacy (whether called ‘altruistic’ or ‘commercial’) falls solely on women.

Different studies show that IVF pregnancies are associated with higher risk of adverse obstetric outcome and should be handled as high risk pregnancies. These risks are very well known as it has been studied for “Double Donation IVF”, IVF carried out with egg and sperm^[1] “donation”, but there are also a few studies focusing on surrogate mother^[2].

In addition, the mother’s health is at risk at all stages of the surrogate pregnancy:

Hormones to prepare the uterus prior to the embryo transfer

At the preparatory stage of surrogacy, as it is not a natural pregnancy, hormones (estrogen and progesterone) are administered so that the endometrial develops in the uterus and thickens up to 7 mm to receive the embryo.

Over Medicalisation to ensure the success rate in the embryo transfer

Clinics, to satisfy the commissioning people have two goals to achieve : That the pregnancy is only induced by the IVF embryo and that the best success rate is reached as promised in the clinics advertising.

Birth control pills and Lupron are meant to prevent that any premature ovulation of the surrogate could interfere with the transferred embryo. Lupron (most common brand of Leuprolide) was originally prescribed for prostate cancer, it is also used as a puberty blocker. The side effects of Leuprolide are documented to produce increased intracranial pressure^[3].
Also, to ensure that the body of the surrogate is clear of all infections, antibiotics (Doxycycline, Tetracycline^[4]) are prescribed a few days prior to the transfer.
There might also be a prescription of Medrol^[5], a low-dose steroid to suppress the autoimmune system of the surrogate, intended to avoid possible rejection of the embryo.

Most of these medications are unnecessary and prescribed, not as a concern for the surrogate mother’s health, but to increase the chance of successful embryo implantation and therefore improve the clinic business.

Monitoring the pregnancy with unnecessary screenings

With the same goal in mind, which is to reassure the commissioning parents and to achieve the best success rate, surrogacy agencies may request antenatal screening at any point during the process. In fact, the surrogate mother must not only comply with all the conditions outlined in the contract, but also with additional conditions imposed by the agencies and any discretionary conditions set by the commissioning parents.

It includes ultrasound scans, screening tests for Down’s syndrome, Edwards’ syndrome or Patau’s syndrome such as amniocentesis, that carries a chance of miscarriage^[6].

Specific health problems due to surrogacy

Babies conceived through in vitro fertilisation (IVF) with commissioned embryos (not genetically related to the surrogate mother) and carried by surrogate mother had higher rates of preterm birth, low birth weight, and complications in the surrogate mother such as gestational diabetes, hypertension, and placenta previa, compared to babies conceived naturally and carried by the same woman^[7].

Surrogacy carries a known risk factor for preeclampsia due to the “paternal effect.” This effect describes how a woman’s prior exposure to a man’s sperm can actually reduce her risk of preeclampsia during a subsequent pregnancy with his child. Conversely, the risk is thought to be higher when carrying an embryo completely unrelated to the surrogate mother, l^[8]. This works as a kind of immune reaction to the foetus after about 20 weeks of pregnancy^[9]. Pre-eclampsia is among the major complications that account for nearly 75% of all maternal deaths^[10]. Without immediate treatment, pre-eclampsia may lead to a number of serious complications, including: convulsions (eclampsia), HELLP syndrome (Hemolysis, Elevated Liver enzymes and Low Platelets) and the pregnant woman is admitted to hospital. A caesarean section is performed urgently at the slightest sign of worsening in the mother or foetus which already suffers from slow growth due to receiving less oxygen and fewer nutrients than it should. The foetus will be born prematurely.

According to The Helsinki Birth Cohort Study “People born [born as premature babies] after pregnancies complicated by preeclampsia or gestational hypertension are at increased risk of stroke. The underlying processes may include a local disorder of the blood vessels of the brain as a consequence of either reduced brain growth or impaired brain growth leading to “brain-sparing” responses in utero. Women who develop pre-eclampsia in pregnancy have higher levels of cardiovascular risk factors, including raised blood pressures, serum cholesterol concentrations, and hyperinsulinemia, and are at increased risk of cardiovascular disease in later life”.^[11]

Multiple embryos: a risk for the surrogate mother

As twins are less expensive than two surrogate babies, there is a trend towards ordering twins ( from 5000 $  to 7000 $ for additional foetus). For gay couples, a special demand has developed: each twin is produced from the sperm of one of the partners.^[12]

The American Society for Reproductive Medicine^[13] has issued guidance for the limits to the number of embryos to be transferred during IVF cycles. This document aims to promote singleton gestation, reduce twin gestations, and eliminate high-order multiple gestation.

According to the European Perinatal Health Report, 2015-2019^[14] “Compared to singleton pregnancies, multiple pregnancies (twins, triplets, or higher order multiples) pose greater risks for mothers and babies. Women with multiple pregnancies are more likely to develop complications, such as preeclampsia and gestational diabetes, and give birth by caesarean section than women with singleton pregnancies. Preterm birth is also much more common, over 50% in multiples versus 6-7% in singletons, and risks are higher for other adverse

perinatal and childhood outcomes, including stillbirth, neonatal and infant mortality, low birth

weight, congenital conditions, and cerebral palsy.

The surrogacy business made by clinics do not consider these guidelines nor ensure the safety of surrogate mothers. They allow people to commission twins (cheaper cost for commissioning people) and to improve the success rate, usually transfer several embryos and then perform what is called “embryo reduction” or “selective termination”, which is in fact a selective abortion.

Abortion. hijacking of women’s right to self-determination

Most surrogacy contracts (called surrogacy arrangements) deal with who will decide about “termination or selective termination”, a carefully coined term used instead of abortion.This decision is up to the commissioning people, justified by the fact that they are the ones who pay and should therefore be able to decide^[15]. This is a clear violation of women’s rights and falls under “forced abortion”, an obvious violence against women.

Delivery: Unnecessary C-sections

Risks persist even after pregnancy concludes, particularly regarding the modes of delivery in surrogate pregnancies, with a notable prevalence of caesarean sections (C-sections).  C-sections are often imposed on surrogates without medical necessity, at the request of those who commission them: it allows them to plan and attend to the birth. They also express the idea that a caesarean section prevents the surrogate from developing a bond with the child.

Studies have shown the disparity between C-section deliveries between surrogate pregnancies and non surrogate pregnancies. In fact, women with surrogate pregnancies were three times more likely to deliver via C-section compared to vaginal delivery^[16]. It is important to recognize that a C-section is a significant surgical procedure, as it is developed to prevent or treat life-threatening maternal or foetal complications^[17]. In addition, surrogate mothers who have undergone more than three C-sections, whether for surrogacy or previous spontaneous  pregnancies, face an increased risk to their own future fertility with issues such a uterine rupture.

Prior C-sections can increase a woman’s risk of uterine rupture during a future pregnancy. This risk is especially dependent on two factors: the number of prior C-sections and the kind of incision made in the uterus during the earlier delivery. Studies show that roughly 1% of women with one prior C-section experience uterine rupture, compared to 3.9% of women who have had more than one^[18].

Surrogacy agencies exploit price variations in their detailed budgeting guides to account for the different health risks women face. They prioritise profit over women’s well-being, as evidenced by their business model that depends on women’s bodies being at risk. The following image details the financial cost commissioning parents have to pay in the event of a catastrophic medical outcome for the surrogate mother, such as the loss of a reproductive organ or a full hysterectomy^[19].

Lactation, another way to exploit surrogates  

Some contracts may include breastfeeding the baby. After the birth, the surrogate will pump breast milk for the surrogate and send it to the intended parents for a set price ($200 to $300 per week)^[20]. Otherwise she is invited to donate it to a milk bank or to suppress lactation.

Death of surrogate mothers

A veil of secrecy surrounds the mortality rate of surrogate mothers. Reliable data is scarce, likely due to a lack of transparency from surrogacy agencies and confidentiality clauses binding family members. As a result of this information blackout, it is impossible to quantify these situations and it is difficult for surrogate mothers to be fully aware of the risks associated with surrogacy.

Tragic cases documented on GoFundMe, like those of Brooke Lee Brown^[21] and Michelle Reaves^[22], offer a glimpse into the dangers that lurk beneath the surface of this clinic business. Beyond the glossy brochures, a critical narrative about surrogacy is emerging. In the US, for example, a network of surrogate mothers, egg donors, and feminist activists have joined forces to expose^[23] the exploitation inherent of surrogacy in an attempt to fight its legislation in the New York state.

Public discourse and media coverage should prioritise uncovering these risks, not shy away from them. Only with comprehensive, independent studies can we gain a complete picture of the different types of violence that women are exposed to in this practice.

While the lack of monitoring and traceability from States and third parties entities is undeniably concerning, studies have emerged.  In India, Sheela Saravanan shows that surrogate mothers are constantly confronted with death, the death of their fellow surrogate mothers and the death of their babies.^[24]

The study concludes boldly that India witnessed widespread human rights violations against surrogate mothers and that the reason for these women exposing themselves to these risks is exclusively “for money”. It is important to highlight that foreign couples and non Indian residents formed the bulk of the commissioning people in India. In the aforementioned study, two women were reported to have died while the author conducted these interviews, one of them was a surrogate mother and the other was an ovocite donor: their deaths were never made public by the clinic.

Psychological violence and surrogate pregnancies

Our understanding of the physical effects of surrogacy on women is limited, but data on the psychological impact is even scarcer. This lack of knowledge underscores a form of violence often overlooked.

Surrogate pregnancy should be considered as a high-risk emotional experience in addition to being a high-risk pregnancy since many surrogate mothers face negative experiences^[25]. Studies have revealed that surrogate mothers often lack emotional attachment, whether positive or negative, towards their pregnancy. This detachment mechanism serves as a means to dissociate themselves and avoid or reduce feelings of loss at relinquishment of their babies^[26].

According to another study, pregnant surrogates start their pregnancies with an overwhelming sense of “risk” and a high degree of surveillance. As their pregnancies progress, they face considerable emotional turmoil, constantly navigating the conflicting narratives of detachment from the foetus and the need to form a sufficient attachment to nurture and give birth to a healthy baby^[27] for the commissioning people.  

The reality of this violence in surrogacy cannot be denied. Some contracts drafted by lawyers and offered by surrogacy agencies anticipate this by including terms that surrogate mothers must agree to.

Figure 1: Section 5.09 “Assumption of the Medical and Psychological Risks”

Figure 2. “Payments to Gestational Carrier

1.a $1,000,00 after receiving two positive HCG blood tests confirming pregnancy and ultrasound confirmation of a foetal heartbeat, to be mailed within ten (10) business days of the ultrasound.”

Economic violence and surrogate pregnancies

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