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Surrogate Role In Nursing

Surrogate Role In Nursing

Over the last few decades, assistive reproductive technology has advanced significantly. Despite advancements, people may still use a surrogate to bear and birth a child. Surrogacy, while an altruistic act, has become commercialized in recent years, raising several ethical and legal concerns. Nurses provide sensitive, advocacy, compassion, and confidentiality to surrogates, infants, and intended parents throughout their journey. The purpose of this article is to investigate the implications of surrogacy for individuals, families, nations, and health care.
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 not available; 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. There is a scarcity of research on the pragmatic, emotional, and ethical aspects of surrogacy. This paper examines the practice of surrogacy and its implications for families and health care 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)).
4 Third-party reproduction is defined by the American Society for Reproductive Medicine as when genetic information is provided by someone other than the intended parents (gamete donation) and/or 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 will be raised by the intended parents. 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 cryostored). If a couple has a history of failed in vitro fertilization attempts, 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.
Surrogate Role In Nursing
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 egg from 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 both 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 supply. 10

Surrogate Selection
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 medical, family, and obstetric histories available

Is given the go-ahead by a medical professional to carry on a healthy pregnancy.

Teman outlined four stages that are required for a successful surrogacy arrangement: dividing, connecting, separating, and redefining.

12 When the surrogate creates boundaries between herself and the baby, this is referred to as dividing. Berend13 explains that when a surrogate enters into 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 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 the surrogacy process as heroic, rather than shameful or upsetting. 12 Because surrogacy is such an intimate process, some people seeking surrogates may choose a family member as a donor and/or 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 Using a family member as a surrogate or donor, on the other hand, can greatly 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 individual retains autonomy in decision-making. 8 If a familial surrogate is unable to 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 especially difficult in these situations because the familial surrogate may see the child frequently. 8

The Difficulties of Finding a Surrogate
It can be difficult 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 counseling services, and facilitating the payment process for the surrogate’s services. 15,16 These organizations allow practitioners to avoid the financial, administrative, and legal aspects of surrogacy.

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 in order 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, particularly poor 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 take into account the child’s specific 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 endangering family structure

Religious objections to surrogacy while supporting adoption

Regulations are lacking.

The presence of the surrogate may be perplexing to the child as he grows older.

Surrogacy for same-sex couples or individuals

Keeping the child’s genetic/donor information hidden

Custody battles

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 in place to protect both the surrogate and the intended parent (s). Legal agreements or contracts are required in order 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 has a significant impact on 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 properly care for the child after birth. A strong, trusting relationship between the surrogacy triad members allows them to promote each other’s best interests. 25

Implications for Health-Care Professionals
Surrogacy affects health care providers in a variety of ways, including practice, education, and research. To determine health risks and provide adequate preventative health care, a thorough history must be taken. 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, as well as 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 provide support to 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 health care professionals to improve clinical practice and provide the best possible care to the surrogacy triad. 27

Implications for Neonatal and Women’s Health Nursing
Surrogacy not only affects the intended parent(s), the surrogate, and the child but also affects the neonatal nurses who care for the child involved. Clinical decision making in the NICU can be difficult in the context of surrogacy, where the legal guardianship of the child is not always clear. NICU nurses face several challenges in caregiving and identifying “the right person” for making care decisions. 28 Clinicians face the following challenging questions: Can the surrogate mother make decisions about the baby or only intended parent(s)? When does the relationship between the surrogate and child end? Can the surrogate mother breastfeed the child following the birth? Who can give consent for procedures or surgeries? Who can visit the newborn in the NICU? 28 Policies or answers may not exist in a hospital system to clarify these questions. It is essential for nurses to refer to the surrogacy contract and collaborate with a multidisciplinary team, including social workers and legal professionals. 9, 28 To ensure the best outcome for the surrogacy triad, an agreement should be arranged beforehand regarding labor and delivery and any postdelivery care in the NICU that may be required. 29, 30

Both physicians and patients have guidelines for surrogacy created by the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine, but no similar guidelines exist for nurses.

29 This indicates a need for health care facilities to have policies and protocols in place for nurses, according to their jurisdiction’s current stance on surrogacy. However, not every jurisdiction has a clear stance, and the surrogacy agreement may have been created in an outside jurisdiction, complicating this process.

Nurses may be caught in the middle of a dispute on custody rights if a member of the triad refuses to adhere to the surrogacy agreement. In traditional surrogacy, often the surrogate will have the right to provide consent if she has not yet given up custody or consented to adoption. 28 In gestational surrogacy, the rights of the surrogate are not as strong, depending on the jurisdiction, because the child is not genetically related to the surrogate. 28 Sometimes a local court may assign a guardian to make the legal decisions regarding the child temporarily until legal guardianship is determined. 28

Evidence shows that breastfeeding provides important health benefits for both the mother and the child and is promoted by neonatal and maternity nurses, but it is rarely discussed in terms of the surrogacy triad.

17, 29 Nurses working with a surrogacy triad need to provide alternative choices to traditional breastfeeding such as the surrogate donating her breast milk for the child postdelivery, the intended parent(s) using donor milk from a regulated milk bank, inducing lactation in the intended mother, or deciding to feed the child with infant formula over breast milk. 17 Staff education and clear guidelines will help nurses focus on their priority: providing quality care to all within the surrogacy triad. 25 Clear guidelines will identify the right approach to address these emerging issues.

Future \sSurrogacy is both an expanding business and a revolutionary reproductive option that can be utilized to empower women. Women aspiring for high professional accomplishments may choose to find a surrogate so that they may fulfill their desire to be a parent without experiencing problems associated with pregnancy. Other women may choose to become a surrogate as a form of employment to earn money while staying at home.

More regulations may emerge to stipulate the conditions, services, and rights of all parties involved within the surrogacy triad. The child’s rights may include knowledge of his genetic makeup. Overall22suggested a screening process for the intended parent(s) before any contracts are created to ensure that all potential children born via surrogacy are placed with responsible and capable caregivers. Technology makes it possible for children wishing to identify their donor parent to explore their genetic roots. Future regulations may make it more difficult for intended parent(s) to utilize cross-border surrogacy as legal challenges may occur when bringing the child back to their home country. The surrogate’s rights and safety may become better protected by regulations created in the future.

Surrogacy is a complex and emotional process for all involved. Surrogates face the medical and health factors associated with pregnancy, delivering a child, and letting go of the child after the delivery. This act can be altruistic or commercial in nature. Guidelines for surrogates, donors, and intended parent(s) exist in some places but are not standardized. Clear, strong, and international guidelines for surrogacy are important for maintaining the social cohesion and emotional health of all involved. These guidelines will lead to less exploitation of the poor and fewer legal battles regarding children born with unpredicted disabilities. Education and clear guidelines for neonatal nurses can help them identify the right parties for consent and care decisions, and provide optimum care to the members of the surrogacy triad, particularly the babies.

The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.

No commercial support or sponsorship was provided for this educational activity.
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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.

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