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The blog of the Wilson Center's Environmental Change and Security Program
  • Dot-Mom

    Putting a Price on Reproduction: The Global Surrogacy Market

    September 6, 2016 By Aimee Jakeman

    The first baby conceived through in vitro fertilization (IVF) was born in 1978 and revolutionized alternative family building strategies. As IVF has become more widely available in the years since, the focus of many families who cannot conceive or carry a baby to term – the Centers for Disease Control and Prevention estimates there are 6.7 million such women in the United States alone – has shifted from adoption to surrogacy. However, this endeavor remains very expensive; prohibitively so for many. Commercial surrogacy can cost up to $70,000 in the United States, except in the seven states where it is illegal. Yet if couples are willing to outsource to another country, surrogacy can cost much less.

    A global trade between families from developed countries and women from developing countries is growing, raising questions about the reproductive rights of poor, marginalized women and how to institute effective regulation and oversight. The commoditized reproductive capabilities of a poor woman in South Asia, Latin America, or Eastern Europe can cost as little as $12,000, according to a study by Karen Rotabi and Nicole Bromfield in Women’s Studies.

    “Total Lack of Autonomy”

    India, once the largest global surrogacy market due to its lenient regulations, started closing its doors to foreigners seeking surrogate arrangements in late 2015. Now families seeking a surrogate abroad look to countries such as Cambodia, Guatemala, and Ukraine (though only for heterosexual, married couples in Ukraine’s case). These countries have little to no regulation when it comes to surrogacy, which reduces the costs for commissioning parents and alleviates the complications associated with legal red tape.

    Minimal regulations are a perk for the commissioning couples, but leave the women serving as surrogates extremely vulnerable to exploitation. “While surrogacy can be seen as enhancing reproductive freedom for the commissioning mother to have a genetic child, and for a surrogate mother to utilize her reproductive capacities for altruistic or financial reasons, surrogacy arrangements are ripe with possibilities for women’s reproductive freedom to be violated,” write Rotabi and Bromfield.

    “‘Prospecting’ is being carried out by husbands, fathers, brothers, or other family or community members”

    “The power divide among these women, the sophisticated organizations that are developing the services, and the consumers (relatively wealthy couples and individuals) is such that human protections are an absolute imperative.”

    Surrogacy can provide women in developing countries with a life changing amount of money. Rotabi and Bromfield found that surrogates in India were paid $5,000 per child on average – the equivalent of 10 years’ worth of wages for a rural woman. However, there are often few alternatives. They found many global surrogates have only more oppressive forms of work as their other choices, including sex work. In some cases, surrogates do not have a choice at all. “‘Prospecting’ is being carried out by husbands, fathers, brothers, or other family or community members (including recruiters),” write Rotabi and Bromfield, “who may entice and/or coerce the women.”

    Many global surrogacy agencies require women to live in dormitory-style housing throughout the duration of the pregnancy, ostensibly to ensure access to nutritious foods, clean drinking water, and high quality antenatal care. But experts have raised concerns regarding the “total lack of autonomy” surrogates are subjected to, writes Priya Shetty in a special report for The Lancet.

    Maternal Health Implications

    Though detailed statistics are lacking, there are indications this trend is on the rise, and there are important maternal health implications beyond the power dynamics at play. Ninety-nine percent of maternal deaths occur in developing countries, and surrogacy only serves to exacerbate the chances of poor women encountering a life-threatening complication.

    One of the most dangerous aspects of surrogacy is the increased likelihood of bearing more than one child. During IVF it is often recommended that more than one egg is implanted at a time in the hopes that at least one will “stick” and develop into a fetus. This practice leads to a greatly inflated number of multiple births as compared to non-IVF pregnancies.

    A multiple gestation pregnancy poses serious risks for the surrogate and fetuses. “Even a twin pregnancy strains organs such as the liver, kidneys, and thyroid” in the mother, writes Shetty in The Lancet. There is a higher possibility of a premature birth, which increases the potential for many health problems too. “One-third or even one-half of infant mortality is due to complications of prematurity, and a large contributor to prematurity is infertility treatment,” writes M. M. Tieu in an article on the ethics of surrogacy for The Journal of Medical Ethics.

    Cesarean section is also more likely with a multiple gestation pregnancy, a complex surgery associated with a variety of risks, such as wound infection, increased bleeding, and elevated risk of problems during future pregnancies. Even women who aren’t carrying multiple fetuses are more likely to face problems after a Cesarean. Rotabi and Bromfield found surrogates face a higher risk for Caesarean not only because of the possibility of a multiple gestation pregnancy but in order to make the timing convenient for commissioning parents.

    Women living in crowded conditions and separated from their families are also more likely to manifest mental health issues that can have a harmful impact on the surrogate and fetus. Once the surrogates deliver, many face postpartum depression as any special treatment from their employers stop. Approximately 20 percent of women in developing countries experience post-partum depression following delivery, which can lead to severe mental problems, including suicide.

    Can It Be Done Right?

    The complications cropping up around the global surrogacy market are not necessarily an argument against surrogacy writ large, but for more oversight over a potentially very damaging trade. The American Society of Reproductive Medicine recommends surrogates should undergo thorough screening of their physical and mental health history and complete counseling before and throughout the duration of the pregnancy on topics such as their right to make choices about their bodies and more. They also recommend counseling continues after birth as a preventative measure against postpartum depression and other mental health issues.

    The challenge lies in placing a quantitative value on women’s reproductive capabilities

    This type of high quality care and monitoring is feasible when the commissioning parents are paying up to $70,000 (i.e., in the United States), but when the cost is up to five times cheaper in the developing world, there are simply fewer funds and quality services available.

    India has responded by making it more difficult for foreigners to get visas to collect children and, just this August, proposing a complete ban on commercial surrogacy. A law put forth by the governing Hindu nationalist party would allow only “altruistic surrogacies” for childless Indian couples that have been married at least five years, are not capable of having children, and have a “close relative” who can be the surrogate.

    An ideal solution is likely somewhere in between a complete ban and a freewheeling market. Regulation “will likely take years to develop and adopt,” writes Erica Davis in the Minnesota Journal of International Law. In the meantime she recommends countries model surrogacy laws after adoption laws. For instance, “adoptive parents are required to work with accredited adoption service[s]” and if future “accredited [surrogacy] agencies comply with an overall regulatory scheme, this type of rule would function to protect all parties from exploitation.”

    Ultimately, the challenge lies in placing a quantitative value on women’s reproductive capabilities. This has the potential to be exploitative, particularly in the absence of regulation, and threatens the health and wellbeing of women whose bodies are deemed less valuable due to their race, class, socioeconomic status, or country of origin. Tieu argues that surrogacy as it currently exists “requires the subordination of the welfare of the surrogate and [the fetus] in favor of the commissioning parents desires to have a child.”

    Davis quotes University of Michigan law professor Margaret Radin: “We can both know the price of something, and know that it is priceless.”

    Sources: Affilia, Human Reproduction, The Indian Express, Journal of Medical Ethics, Journal Sentinel, The Lancet, Mayo Clinic, Minnesota Journal of International Law, The Washington Post, World Health Organization.

    Photo Credit: A surrogate mother rests in a temporary home for surrogates in Anand town, India, September 2013, courtesy of Mansi Thapliyal/Reuters.

    Topics: demography, Dot-Mom, economics, featured, global health, human rights, India, livelihoods, maternal health, poverty, U.S.
    • f2473627

      all surrogacy should be banned! even altruistic surrogacy creates a market niche with payments under the table and expensive gifts! it cannot be regulated nor can coercion be proved except in the most extreme cases!

    • Megan

      I don’t think so in fact. This procedure has already existed. This is a reality. It is difficult to ban such powerful machine. And banning surrogacy we create “market niche with payments under the table” for sure. It is good when this issue is regulated properly. In this case all the issues and details are written in the law. In fact many people need surrogacy. And they conduct it even if at home it is banned. They go abroad to use ART legally. It means people do not want to violate the law. They go to Ukraine, to America and so on to have surrogacy there. I understand there are people who are against surrogacy. But I think this issue must be thought out in details. Nevertheless everyone has the right for his own opinion.

    • Melissa

      Surrogacy is a very profitable business. It can be said about Ukraine as well as about USA and other states. Every year, Ukrainian clinics attract thousands of foreigners. They come from countries where it is prohibited by the law or costs crazy money. The cost of such services ranges from 20 to 45 thousand dollars in Ukraine. The surrogate mother gets only a tenth part of that amount. Despite this there are more than enough willing to bear and give birth to another person’s child. I am infertile and cannot conceive. Therefore I know this issue very well. I was in some countries where surrogacy is legal. I tried to find the best one where I could have surrogacy legal. And I must note that it is a huge business. Despite this fact it is needed business. And such countries as Ukraine for example propose good price for surrogacy.

    • Anna

      The main incentive is strong poverty of Ukrainians. More often surrogates are from regions. It can be understood why it is so. There is high unemployment and relatively low wages in regions. If you go to online forums devoted to surrogacy, you can see that most of the candidates come from small towns and district centers. They are middle-aged and independently raise their children. As a rule, the difficult financial situation encourages women to surrogacy. But there are no ads from women wanting to do it for free. But do you think it is easy to bear a child for other people. Now I am on the eighth month of pregnancy. And it is not easy as you can think. Especially it is not easy in financial terms. I think it can if it is made in an appropriate way. It is a great opportunity for poor women to earn money. I see nothing bad in this way.

    • Alla Chernova

      I was a surrogate mother for one European couple. I had a program in Ukrainian biotexcom fertility clinic. After all, what should I do? I had two own children and Have no husband. I must take care of them and provide them proper life conditions. Clinic where I was paid for all examinations and all I need in the hospital. Being a surrogate I had not to pay money. But I had an opportunity to earn funds for my children. And where must I get them? I live alone together with babies. Children’s father left us during my second pregnancy. He just disappeared in an unknown direction. And after delivery I needed money to support newborn child. I couldn’t have full time work. The reason is there is no one to sit with kids. I saw on women’s forum ad for surrogate mothers and agreed. It was my real help and salvation.

    • BriannaJ

      I know that in Ukraine for example, where surrogate motherhood is legal and very often conducted for foreigners, surrogate mother cannot have biological connection with the child she will carry for infertile couple. And according to the law surrogate mother has no rights and obligations towards this child. It means that in such case as we can read in this article children became orphans having a father. Surrogate mother has no right towards this child and biological father does not want to take them. I wonder what will he feel when this children will be born because as I understand this surrogate mother will give them birth anyway. If they conducted the program in the fertility clinic workers of this medical center must help to solve this problem – to talk to this mediocre-father, to explain the situation and what it will be in the nearest future. Of course it is awful and difficult situation. The main thing is that children have good family and care. Maybe this man will understand, realize his mistake and change his opinion…

      • Alexis

        Yes, I also was in Ukrainian fertility center. And both my husband and I were satisfied with the service and medical result of our surrogate motherhood program. We were in the biotexcom center for human reproduction. And we easily found it in the internet after one of our friends recommended us this clinic. Examining the information we got to know that in fact a great number of British children were conceived via surrogacy. And it is not just empty words but official statistics. In the UK only non-commercial surrogacy is allowed by the law. And it means that surrogate mother does not receive money for her great help. As for me it is unfair. As a result in the UK infertile couples face the problem of surrogate mothers lack as it is difficult to find a woman who will agree to bear a child just for free. Therefore infertile families go abroad in particular in Ukraine in order to use legally assisted methods of reproductive medicine. Ukrainian center for human reproduction biotexcom is extremely popular medical center among many infertile people from Germany, France, Great Britain, Italy, and Spain. And even America. Firstly people are a little bit afraid of Ukraine due to the fact that it is a third world county, and in addition there are military actions in the Eastern part of Ukraine. Nevertheless visiting this country and especially its capital Europeans can see a great and positive picture – extremely beautiful state, friendly people, and high level of reproductive medicine.

        • Melissa

          Ukraine is a country which the majority of Europeans are afraid to go especially with the aim to use methods of reproductive medicine. Ukraine is behind in the European development in general. Visiting this state foreigners have the impression that they got in a time machine and flew many years ago. Bumpy roads that make impression you get into a turbulence zone. Public transport that extremely needs replacement due to their old age and not always a European quality of services. But it has the most loyal legislation concerning surrogacy. UK couples usually go to Ukraine because they find their needed services and conditions. It must be noted that about a year ago it was much harder to receive official registration in the UK after child’s birth in Ukraine via surrogacy. Earlier parents should wait about six months in order to register their child. Now the waiting time had been reduced to two months. The UK legal solution for resolving parenthood in surrogacy cases is a parental order. This is a court order which makes the intended parents the legal parents of the child. Once a parental order is made, the birth will be re-registered to record both intended parents as the legal parents, and a new birth certificate will be issued. Before leaving Ukrainian clinic, parents receive surrogate mother’s official deny declaration. It confirms surrogate mother has no rights and obligations concerning child she gave birth.

    • BriannaJ

      Surrogacy is a real help for thousands of infertile. They need this procedure and use it. Another thing is how it is conducted. In such countries as India it is awful. But in such as Ukraine for example surrogacy is on legal level. It is conducted appropriately and has good results. As of surrogates they agree to be surrogate for own wish. Lack of money forces them to do it. I do not understand people talking about children’s sale. What kind of sale they talk about. It is not clear for me. You know surrogate mother carrying a baby receive payment. She does not sell something her own. She just carries genetic material of another people. In addition she has to leave job place for some time. Surrogate pregnancy is hard and honest work. Childbirth takes place on a huge desire of his biological parents. Money is like a compensation and non plus ultra. Meanwhile government does nothing to help them. It can only ban the process which helps surrogates to earn some money.

    • JannaCrm

      When we married I was already 34 and my husband was 39. It was my first marriage, and I wasn’t quite yet ready for children. So we waited a little over a year to begin trying with the thought that we should probably start, as we weren’t getting any younger. To my disappointment, it wasn’t going to be that easy. The only abnormal thing was that I had been spotting slightly mid-month for the past couple of years, which I thought might have something to do with hormonal imbalance of some sort, but neither my gynecologist, nor my naturopath were too concerned about this. My husband never got his sperm count tested, but other than the possibility of a problem on his end, there was no reason we should not be getting pregnant. We decided that although we really wanted a child, we were not prepared to go the route of fertility treatments or IVF, and had resigned ourselves to the attitude “whatever happens, happens…”. So we had found clinic in Ukraine. The sum of money we get is was enough to meet our costs. In that country the girls are very beautiful and well-educated. So the demand on their reproductive cells and surrogacy service is also very high. I just want to thank Biotex clinic’s stuff and this site for making our dream come true. I am 100% positive I would not have gotten pregnant without their help. And it truly feels like a miracle.

    • Patricia

      No amount of money could come close to the value of my child. And buying babies is abhorrent. Buying access to women’s bodies to act as surrogates is also intensely unpleasant. But altruistic surrogacy raises far less questions – and yet, as the article highlights, it’s also riddled with difficulties. Personally I’d like to see surrogacy only allowed in situations where there is a family connection between the surrogate and the intentional parents. If you’re completely out of female relatives, and there’s nobody whom you have a good enough relationship to discuss it with, maybe you could look to well-known clinic. This suggested you doctor or someone who use its service. My closest friend has been in Ukrainian reproductive center In Kiev. She told that it is one of the best among European similar facilities. It was a great conditions there – legality, good price, all-inclusive package of services which she used. Clinic even gave her guarantee that she would leave the medical center only with a baby. I remember she told that she didn’t find such guarantee in any other clinic nor in Canada. Therefore she believed them and started the program. She got pregnant after the second in vitro fertilization. She gave birth in time and the baby is healthy and beautiful.

    • Aurora

      I believe that ART medicine has a lot of benefits. First of all, if it can involve incomes to the country. And the second, the ART will help childless couples to have a baby. That`s why I don’t understand why some countries have a banned surrogacy. I think, if surrogacy mother goes on that, it is her conscious decision. Unfortunately, our family faced this problem. The wife of my brother couldn`t have children. My husband and I also tried to find a solution from their situation. And they managed to cope with their infertility issue in Ukraine by using surrogacy. So, now I am convinced that ART medicine should exist in the modern world. Because it might help many infertile couples.

    • Hanna

      I know that with science most people are now able to have children but I fell it’s just selfish. There are thousands of orphans around the world who are up for adoption and to spend what is over $3000 just to get a surrogate doesn’t sit right with me. Also the most successful surrogate agencies happen in foreign countries like one in Ukraine I recently read about. It’s called Biotexcom and they were involved in a huge scandal with selling babies. I don’t know if it’s true. But they appeared in numerous scandals before so…Child birth can take a lot out of a woman physically speaking so knowing that a woman went through that just to give birth to a child she will never see again doesn’t seem right.

    • https://www.ivfconceptions.com Neelam Chhagani

      The issues with surrogacy services is that in some countries it is not strictly regulated. The lax laws can make it easy for the manipulative people to mis-use it. If done correctly with clearly defined laws, surrogacy can be a life changing experience for a childless couple.

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