Over the last few decades, assistive reproductive technology has advanced significantly. Despite advancements, people may still use surrogates to bear and birth a child. Surrogacy, while a selfless act, has become commercialized in recent years, raising several ethical and legal concerns. Nurses provide sensitivity, advocacy, compassion, and confidentiality to surrogates, infants, and intended parents throughout their journey. This article investigates the implications of Surrogacy for individuals, families, nations, and health care.
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Technological advancements have transformed reproductive technologies, allowing many individuals and couples to realize their childhood ambitions. When reproductive technology fails to produce a baby, a third-party surrogate or donor may be hired. Families may travel across international borders in search of the perfect surrogate. Because of the lack of standardized guidelines across international borders, accurate data on Surrogacy are unavailable; however, 13,380 recorded gestational surrogacy deliveries resulted in 18,400 births in the United States from 1999 to 2013. 1–3 Surrogacy is a medically and emotionally complex process with serious consequences at the individual, familial, social, emotional, financial, political, national, and international levels. Research is scarce on the pragmatic, emotional, and ethical aspects of Surrogacy. This paper examines the practice of Surrogacy and its implications for families and healthcare providers, specifically neonatal clinicians.
What Exactly Is Surrogacy?
Surrogacy is the practice of hiring a woman (the surrogate mother) to become pregnant and bear a child for another couple or individual (the intended parent(s)).
The American Society defines 4 Third-party reproduction for Reproductive Medicine as when genetic information is provided by someone other than the intended parents (gamete donation), and gestation is completed by someone other than the intended mother (Surrogacy). 5,6 Traditional surrogacy and gestational Surrogacy are the two types of Surrogacy. 7 Traditional surrogacy involves a woman becoming pregnant through artificial insemination, carrying a fetus, and giving birth to a child who the intended parents will raise. The child is genetically related to the surrogate in this type of Surrogacy. An embryo is implanted in the surrogate, who will carry and deliver the child in gestational Surrogacy. The child is not genetically related to the surrogate in this case. 8
As shown in Box 1, various combinations of reproductive tissue can be used in Surrogacy. The gamete providers, or the sources of Sperm and oocytes, are not always the intended parents. 7,9
If a donor egg is used, the egg is fertilized in vitro, and the embryo is implanted in the surrogate immediately after fertilization or thawing (if cryo-stored). Suppose a couple has a history of failed in vitro fertilization attempts. In that case, if a woman has a condition that prevents her from successfully carrying a fetus to term, the intended parent is single, or the couple is of the same sex, donated gametes and Surrogacy are typically used. 6,9 Before the decision and procedure, donors, surrogates, and intended parents are thoroughly screened.
Sperm and Egg Fertilization Combinations in Surrogacy
Sperm from the intended father + Surrogate Egg (Traditional Surrogacy)
Surrogate egg + donor sperm (Traditional Surrogacy)
The intended father’s Sperm + the intended mother’s egg (Gestational Surrogacy)
Donor sperm combined with an egg from the intended mother (Gestational Surrogacy)
Donor egg + Sperm from the intended father (Gestational Surrogacy)
Donor sperm + donated egg or embryo (Gestational Surrogacy)
Screening of Potential Gamete Donors
According to the American Society for Reproductive Medicine5 guidelines, an egg donor should preferably be a woman between the ages of 21 and 34 who has undergone a thorough medical examination. A detailed medical history, family history, sexual history, genetic and psychological screening, disease screening (HIV, hepatitis B, and hepatitis C), and substance use are all part of this examination. This screening procedure also applies to sperm donors. 5, 9 When the Sperm and the egg are from donors who chose to freeze their gametes but no longer want or need them, a donated embryo is typically used. The demand for such embryos far outstrips the supply. 10
Before contracting, potential surrogates may be known or unknown to the intended parent(s). A strong relationship between the surrogate and intended parents is ideal and beneficial to the process. 11 Box 2 lists the characteristics of an ideal surrogate.
Ideal Surrogate Characteristics5
Is at least the age of 21
Has previously given birth
Is there a stable social environment?
Her background checks were successful.
Is supported by references
Has values and priorities similar to the intended parent (s)
Is cleared by disease screening, particularly for diseases that will affect her reproductive health or the health of the child (e.g., HIV)
Has a medical, family, and obstetric history available
Is given the go-ahead by a medical professional to carry on a healthy pregnancy.
Teman outlined four stages for a successful surrogacy arrangement: dividing, connecting, separating, and redefining.
12 When the surrogate creates boundaries between herself and the baby, this is called dividing. Berend13 explains that when a surrogate enters a surrogacy agreement, she understands that the child is not hers. The surrogate’s strongest bond is with the intended parent(s) for whom she is providing this loving service. 13 Surrogates typically seek the intended parent(s) with whom they have a connection and wish to establish a relationship. 11,13 During the connecting phase, the intended mother becomes attached to her unborn child and begins to assume motherhood responsibilities. During the separating phase, the intended mother separates from the surrogate mother and assumes full parental responsibility for the child. Finally, in the redefining stage, the surrogate sees her role in Surrogacy as heroic rather than shameful or upsetting. 12 Because Surrogacy is an intimate process, some people seeking surrogates may choose a family member as a donor and a surrogate.
Factors to Consider When Choosing a Familial Surrogate
Using a family member as a surrogate or gamete donor may be a quicker and less expensive way to become a parent. This option also gives the intended parent(s) a genetic connection to the child. 8 On the other hand, using a family member as a surrogate or donor can significantly complicate the surrogacy process. Most fertility clinics do not allow any gamete combination that would result in a child with a genetic makeup suggestive of incest, such as a brother donating his Sperm to his sister. 8 Concerns about familial Surrogacy include undue influence over a person and pressure to perform the act of Surrogacy for another family member. This is especially true in cases where generations are involved. Because of the risk of intimidation from older, authoritative relatives, it is typically considered unethical for a younger woman to be a surrogate for her mother or aunt. 14 As a result, it is critical to ensure that each retains autonomy in decision-making. 8 If a familial surrogate cannot establish or maintain the pregnancy or detach from the child she bears, she may face additional emotional risks, such as resentment from her family members. The latter is challenging because the familial surrogate may see the child frequently. 8
The Difficulties of Finding a Surrogate
It can be not easy to entrust a surrogate with the birth of a family’s future generation, and recommending someone to be a surrogate is outside the scope of clinical practice for a provider. Surrogacy agencies offer services such as maintaining databases of potential surrogates, offering incentives, facilitating contracts, providing support for follow-up tests to confirm pregnancy, arranging legal services, making birth arrangements, providing counselling services, and facilitating the payment process for the surrogate’s services. 15,16 These organizations allow practitioners to avoid Surrogacy’s financial, administrative, and legal aspects.
Surrogacy Across Borders
Transnational gestational Surrogacy, also known as reproductive tourism, typically involves intended parents from one country using a woman from another, typically a low-income country, as a gestational surrogate.
17,18 Cross-border surrogacy may be chosen to avoid complicated legal requirements or high costs in the home country. 17
Social, Legal, and Ethical Issues
One of the most contentious ethical issues surrounding commercial Surrogacy is the risk of exploiting women, inferior women, versus the opportunity for women to provide the “gift of life” for those who cannot do so themselves.
19 Cross-border surrogacy raises the risk of women being exploited because women from low-income countries seek Surrogacy solely to escape poverty17 and are unprotected due to a lack of regulations in these countries. 20,21 Furthermore, with IVF in Surrogacy, sex selection becomes an option and a point of contention among practitioners.
Another aspect of Surrogacy to consider is the effect on the child. Unlike adoption, intended parents are not screened for their ability to raise a child in Surrogacy. Furthermore, the agreement does not consider the child’s needs or emotional well-being. 22 Overall22 contends that because Surrogacy is a monetary exchange for a human being, it is technically a form of slavery. Box 3 contains a list of additional challenges.
Surrogacy’s Social and Ethical Challenges19, 23
Women are being coerced into Surrogacy for financial gain.
Lack of understanding of the consequences of Surrogacy, particularly among women in low-income countries
HIV or other diseases are a possibility.
Surrogacy is viewed as “baby-selling,” and women’s bodies are viewed as “baby factories.”
Artificial reproductive technologies endanger the family structure.
Religious objections to Surrogacy while supporting adoption
Regulations need to be improved.
The surrogate’s presence may perplex the child as he grows older.
Surrogacy for same-sex couples or individuals
Keeping the child’s genetic/donor information hidden
Illegal commodification or trade objects
Intermediaries who connect intended parents with surrogates are known as “surrogacy pimps.”
Surrogacy must be made ethically justifiable by putting safeguards to protect both the surrogate and the intended parent (s). Legal agreements or contracts are required to enforce proper child custody. 7, 21 Regulations governing parental status must be clear in cases where intended parents divorce or refuse to accept the child after birth due to an unexpected outcome in the child (e.g., Down syndrome, unanticipated sex, and so on). 24
Implications for Surrogacy Triad Participants
Surrogacy significantly impacts the surrogate mother, child, and intended parent on an individual level (s). These people comprise the surrogacy triad, a complex and extensive reproductive unit linked by moral obligations. 25 By becoming pregnant, the surrogate mother exposes herself to physical, psychological, and emotional risks, including the risk of miscarriage, ectopic pregnancy, and fetal anomalies. 9 She runs the risk of long-term consequences from the pregnancy and is reliant on the intended parent(s) to care for the child after birth properly. A strong, trusting relationship between the surrogacy triad members allows them to promote each other’s best interests. 25
Implications for Healthcare Professionals
Surrogacy affects healthcare providers, including practice, education, and research. A thorough history must be taken to determine health risks and provide adequate preventative health care. Education about the pregnancy process and its effects on the surrogate and intended parent(s) is an important responsibility, especially for those working in women’s health, obstetrics, maternity, and neonatology. Emotional and social support and communication are critical for the health and well-being of all parties involved. Administrators and clinicians, including bedside nurses, advanced practice nurses, and physicians, must support surrogates and intended parents, especially in cases of loss, child separation, and custody battles. There has been little research on the quality of life, stress, and coping of surrogates and intended parent(s), as well as the ethical aspects of Surrogacy; thus, it requires attention from healthcare professionals to improve clinical practice and provide the best possible care to the surrogacy triad. 27
Nursing Implications for Neonatal and Women’s Health
Surrogacy affects not only the intended parent(s), the surrogate, and the child but also the neonatal nurses who care for the child. Clinical decision-making in the NICU can be challenging in the context of Surrogacy, where the child’s legal guardianship is not always clear. NICU nurses face several challenges regarding caregiving and identifying “the right person” to make care decisions. 28 Clinicians must answer the following difficult questions: Can the surrogate mother or only the intended parent(s) make decisions about the baby? When does the surrogate-child relationship come to an end? Can the surrogate mother breastfeed the baby after the birth? Who has the authority to give consent for procedures or surgeries? Who is permitted to visit the newborn in the NICU? 28 Policies or answers to these questions may not exist in a hospital system. Nurses must refer to the surrogacy contract and work with a multidisciplinary team that includes social workers and legal professionals. 9, 28 To ensure the best possible outcome for the surrogacy triad, a pre-arrangement should be made regarding labour and delivery as well as any post-delivery care in the NICU that may be required. 29, 30
The American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine have developed surrogacy guidelines for physicians and patients, but no such guidelines exist for nurses.
29 According to their jurisdiction’s current surrogacy policy, healthcare facilities should have policies and protocols for nurses. However, only some jurisdictions take a firm stance, and the surrogacy agreement may have been drafted in a different jurisdiction, further complicating the situation.
If a triad member refuses to follow through on the surrogacy agreement, nurses may find themselves in a custody battle. If the surrogate has not yet given up custody or consented to the adoption, she often has the right to consent in traditional Surrogacy. 28 Because the child is not genetically related to the surrogate, the surrogate’s rights are not as strong in gestational Surrogacy, depending on the jurisdiction. 28 A local court may sometimes appoint a guardian to make legal decisions for the child until legal guardianship is determined. 28
Breastfeeding has been shown to have significant health benefits for both the mother and the child, and it is promoted by neonatal and maternity nurses. Still, it is rarely discussed in terms of the surrogacy triad.
17, 29 Nurses working with a surrogacy triad must offer alternatives to traditional breastfeeding, such as the surrogate donating breast milk for the child after delivery, the intended parent(s) using donor milk from a regulated milk bank, inducing lactation in the intended mother, or deciding to feed the child infant formula rather than breast milk. 17 Staff education and explicit guidelines will assist nurses in focusing on their primary goal of providing quality care to all members of the surrogacy triad. 25 Clear guidelines will help identify the best approach to dealing with these emerging issues.
Future Surrogacy is a growing business as well as a revolutionary reproductive option that can be used to empower women. Women aspiring for high professional accomplishments may choose to find a surrogate to fulfil their desire to be a parent without pregnancy complications. Other women may decide to become surrogates to earn money while staying home.
More regulations may be developed to specify the terms, services, and rights of all parties involved in the surrogacy triad. The right of the child may include knowledge of his genetic makeup. Overall22suggested a screening process for the intended parent(s) before creating any contracts to ensure that all potential children born through Surrogacy are placed with responsible and capable caregivers. Children who want to find out who their donor parent is can now do so, thanks to technological advances. Future regulations may make it more difficult for intended parents to use cross-border Surrogacy because legal challenges may arise when the child is returned to their home country. Surrogate rights and safety may be better-protected thanks to new regulations.
Surrogacy is a complex and emotional process for everyone involved. Surrogates must deal with the medical and health issues accompanying pregnancy, childbirth, and letting go of the child after birth. This act may be charitable or commercial. Surrogate, donor, and intended parent(s) guidelines exist in some places but are not standardized. Clear, strong, and international surrogacy guidelines are critical for maintaining social cohesion and emotional health for all parties involved. These guidelines will result in less poor exploitation and fewer legal battles for children born with unanticipated disabilities. Education and clear guidelines for neonatal nurses can assist them in identifying the appropriate parties for consent and care decisions, as well as providing the best possible care to the surrogacy triad members, particularly
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In the nursing theory of Hildegard Peplau, the nurse plays various roles, such as the stranger, teacher, resource, counsellor, surrogate, and leader. In the same way, the patient encounters a stranger every day, and the nurse treats the patient as a stranger. The nurse should provide a setting that fosters trust (Wasaya et al., 2021). The nurse acts as a teacher by sharing knowledge concerning the patient’s needs or interests. In this sense, the nurse serves as a patient’s resource by offering details the patient needs to comprehend a situation or a problem. Therefore, in their capacity as surrogate, nurses support patients by assisting them in comprehending and integrating the meaning of their current circumstances and offering support and encouragement as they attempt to make adjustments.
The nurse serves as a surrogate and works as the patient’s advocate while assisting the patient in defining the domains of reliance, interdependence, and independence. Nursing is therapeutic, according to Peplau, because it is a healing art that aids a patient who is ill or in need of medical attention (Jones & Beauvais, 2022). The interaction between two or more people who share a purpose also makes it an interpersonal process. Together, the nurse and patient develop maturity and expertise in providing care. Leading by example, the nurse encourages the patient to assume full accountability for achieving their treatment objectives. A nurse can also act as a technical expert, consultant, tutor, social worker, safety agent, environment manager, mediator, administrator, record watcher, and researcher. Therefore, the nurse should employ interviewing strategies when speaking with the patient to investigate, comprehend, and effectively address the underlying issue. Since the patient’s level of independence is likely to change, the nurse must also be familiar with the various communication phases.
The resolution phase is the last stage of surrogacy. As a result of the nurse and patient working together to meet the patient’s requirements, the professional relationship has ended. They must end their relationship and cut the links that bind them together. However, this may be challenging for both parties if there is still psychological dependence. The nurse and patient’s connection are broken as the patient drifts away. Both develop more mature beings and find a better emotional equilibrium. Thus, this is how the nursing procedure is being evaluated. The nurse and patient assess the situation based on the objectives specified and whether they were achieved. However, Peplau’s theory has some drawbacks, such as a lack of emphasis on health promotion and maintenance, a lack of consideration for intra-family dynamics, personal space considerations, and local social service resources, the inability to be applied to patients who are unable to express their needs, and some areas that are too general to allow for hypothesis generation.
Jones, J. S., & Beauvais, A. M. (2022). The Education of Nurses During COVID-19—Using Nursing Theory to Help Us Regain Our True North. Journal of Nursing Education, 61(5), 227-228.
Wasaya, F., Zulfiqar, S., & Farhan, A. (2021). A Comparison and Integration of Two Nursing Theories into Clinical Practice: Betty Neuman and Hildegard Peplau. i-Manager’s Journal on Nursing, 11(3), 4.