surrogacy: the parents' story

Psychological Reports, 2002, 91,201-219. O Psychological Reports 2002

SURROGACY: THE PARENTS' STORY '

CHRISTINE B. KLEINPETER

Calijornia Slate Uniuersiq, Long Beach

Summary.-This qualitative study explored the experiences of 26 parents who were involved in surrogate parenting arrangements in a Califomia-based surrogacy program. Participants were mostly white (n =23), married (n = 25), females (n =24), with high levels of education and income. The mean age at the time of the first child's birth was 39 yr. (SD=5.06). The majority of parents reported having one (n=10) or two ( n = 8 ) children. All subjects reported inlertility as their reason to explore surrogacy as a method of building a family. 18 participants chose in uitro Eertilization as their method of conception. Telephone inteniews explored their decision-making, method of fercilizarion, their relationship with [heir surrogate, and the support chat they received during the surrogacy process. Results indicate that parents were able to anticipate some pitfalls prior to their experience but did not realize the importance of other potential difficulries. A conceptual model is presented with implications for helping professionals.

In the past 50 years, options for couples with f e d t y problems have expanded (Moe, 1998), due in part because women tend to wait longer to have children than they did in the past. Fert~Lity treatment can correct some of the causes of inferthty either through surgery or medications (Weigel, Auxier, & Frye, 2000). However, because the quality of a woman's eggs de- teriorates as she ages, this longer wait may be one contributor to infertility. Female ferthty peaks by age 25 and falls throughout the remainder of a woman's reproductive life (Dutton, 1997). Two generations ago, couples with fertility problems could remain childless or they could adopt. Currently, infertile couples can choose the use of various methods of assisted reproductive technology.

In recent years, there has been a revival of interest in the procedure of using a surrogate mother to help infertile couples have a child. In the 1980s, usually the surrogate provided her own eggs for artificial insemination using the sperm from the prospective father (Dutton, 1997). There was a genetic h k to the husband, but not to his wde. The wife then adopted the child, and the surrogate and her husband reltnquished parental rights to the child (Fischer & Gillman, 1991). This method is called traditional surrogacy.

By the 1990s, in vitro fertilization where the egg and semen are ob- tained from the commissioning couple (or from anonymous donors), and the

'This stud was supported by a Professional Development Grant from the Office of the Dean, College o? Health and Human Services, California State University, Long Beach. Address enquiries to Christine B. Klein eter, Psy.D., Long Beach Department of Social Work, Califor- nia Stare University, 1250 ~ d f l k e r Boulevard, Long Beach, CA 90840-0902.

2 02 C. B. KLEINPETER

resultant embryo is implanted into the surrogate mother, was possible (Brins- den, 1999). Newer variations are GIFT (gamete intrafallopian transfer) or ZIFT (zygote intrafdopian transfer), similar procedures in which the transfer is done at an earlier stage (Moe, 1998). In this case, the surrogate only performs the function of gestation for the couple, without having a genetic h k with the child. A court order may be used to identdy the legal parents, but adoption is unnecessary in most states (Dutton, 1997). This method is called gestational surrogacy or host surrogacy. The surrogate mother typically receives a fee of $10,000 or more for the delivery of the child (Schwartz, 2000). The couple typically pays about $40,000 or more for legal, medical, psychological, and program services fees (Dutton, 1997).

There are many reasons why couples choose surrogacy over adoption (Schwartz, 2000). In some cases the d e may have eggs but cannot carry a child, such as after a hysterectomy or other medical problem that prevents gestation. Using the gestational surrogacy method, the couple can have their own biological child. Some men desire to carry on their family lineage; and if their wives are infertile, they would prefer to have a biological link to their child using traditional surrogacy. This was the case with the Stern-White- head Baby M contract, as Wdiam Stern had lost his family in the Holocaust (Schwartz, 1991). In other instances, the couple may feel they are minimiz- ing the possibility of substance abuse effects or HIV infection in the child, which might not be possible in an adoption. The couple may feel they have more control over their potential parenthood by using surrogacy than they would have if they had chosen adoption. Some couples have been rejected by adoption agencies due to age or other factors. Finally, some couples reject adoption due to lack of availability of or lengthy waiting period for a healthy infant.

The purpose of the present study was to explore the experiences of parents who built their family through surrogacy arrangemenrs. Previous research has explored the experiences of surrogate mothers (Hohman & Ha- gan, 2001); however, the experiences of the parents have not been explored to date. An understanding of the issues involved in surrogacy arrangements -

from the parents' perspective may assist those who work with infertile couples in their decision-making process.

It is estimated that about 8-10% of couples worldwide experience inferthty (Lass, 1999). The World Health Organization defined inferc~lity as a failure to conceive after unprotected intercourse for a period of one year (Appleton, 1999). Approximately 90% of couples w d achieve pregnancy in the first year and 95% in 2 years (Lass, 1999). Although the prevalence of infert~Lit~ has remained constant in the last two decades, attendance of pa-

SURROGATE MOTHERHOOD, INFERTILITY 203

tients for fertility treatment has increased dramatically (Lass, 1999). About one million couples use infertility clinics each year (Dutton, 1997).

Infertility has physiological, psychological, and sociological implications. Couples often experience stress that may lead to mental disharmony, marital and sexual problems, and even divorce or ostracism from the wider family unit (Appleton, 1999). Reactions to infe&ty may create a developmental crisis for couples (Eunpu, 1995). Robinson and Stewart (1996) have described the reactions of initial shock and denial, followed by grief, depression, loss of control, anger, guilt, loss of self-esteem, and a sense of failure. Society strongly h k s a woman's femininity and maturity to her status as a mother (Anderson, Dimidjian, & W e r , 1995). Research indicates that more than 50% of infertile women reported a decrease in overall self-confidence following the news of impaired ferulity (Sabateh, Meth, & Gavazzi, 1988). Although each member of the dyad may attribute the possibhty of infertility to self, women are more likely than men to shoulder the blame (Draye, Woods, & Mitchell, 1988). Regardless of the reason, the couple may experience significant stress, both individually and interpersonally (Weigel, et af., 2000).

Surrogacy has been accepted as an answer to certain forms of infert~lit~ for centuries. While surrogacy dates back to Biblical times (Harrison, 1990), the first "reported" surrogacy was in 1954 (Schmukler & Aigen, 1989). In 1988, the Office of Technology Assessment (OTA) found that approximately 600 babies had been born to surrogacy arrangements, with about 100 being born each year (OTA, 1988). Anecdotal informac~on indicates that about 10,000 infants had been born to surrogacy arrangements by 1994 (Ragone, 1994). Questions about the legal and mental health ramifications and the numbers of births have escalated quickly since that time (Schwartz, 2000).

The most commonly used form of surrogacy coday, gestational surrogacy using IVF, has additional potential medical, ethical, and emotional considerations for couples. Many pregnancies using IVF have three or more fetuses and are at extremely high risk for preterm birth, increased neonatal mortality, and significant long-term neurologic morbidity (Goldenberg & Jobe, 2001). Also, to enhance the chances of having one or two healthy babies, selective reduction in fetal number is an option to be weighed by couples that may present ethical or religious conflicts. When the couple feels that they have completed their family, there is a final ethical consideration of how to handle the unused embryos. The introduction of cryopreservation he . , embryo freezing) in the 1980s provided a temporary solution; however, the number of embryos going into the freezers exceeds the number being used after thawing (Appleton, 1999). This issue has raised many ethical, legal, and religious concerns that aLl hinge on when, exactly, life begins (Dut- ton, 1997). Ln the United States a few states ban the intentional destruction

204 C. B. KLEINPETER

of pre-embryos; therefore, it is important for couples to d~scuss this issue at the time of decision-malung regarding the number of eggs to harvest, ferti- lize, and implant in the IVF treatment. Also, decisions need to be made regarding the fate of the embryos in the case of death of the parents or divorce of the couple.

The outcome of using IVF often results in multiple births (Spillman, 1999). Multiple births rose by 26.6% between 1973 and 1990 (Luke, 1994). Klotzko (1998) reported that since 1971, the number of multiple births in the U.S. has quadrupled. In 1998, one in every six infants born to women 45-49 years of age and one in every three births to women 50-54 years of age were born in a multiple delivery (Ventura, Martin, Curtin, Mathews, & Park, 1998). The two most common medical issues associated with multiple births are the frequent necessity of cesarean sections and the complications that come with premature birth (Weigel, et al., 2000). Splllrnan (1999) found that mothers who underwent a cesarean section found their postnatal period more difficult, and delivery of multiples tended to be more physically and emotionally stressful than single-birth delivery. Hay, Gleeson, Davies, and Lorden (1990) reported that 37.5% of couples reported that having twins put a great deal of stress on their marriage, postpartum depression was five times more common, and anxiety rates were three times more k e l y than with single deliveries. Akerman, Hovmoller, and Thomassen (1997) found that famdies were often inadequately informed that all triplets will be born prematurely and that there are often bonding challenges associated with a premature child. Robin, Cahen, and Pons (1992) reported that 73% of families are faced with extreme financial stressors following multiple births.

The other difficult outcome of using TVF treatment is the fdu re rate. Although success rates have improved in the past 20 years with technologi- cal advancements, Brinsden (1999) described a 33% chance of spontaneous abortion. The author further stated that couples often feel guilt for the surrogate having to experience a miscarriage, while the surrogate often feels guilt that she has lost the hard-won pregnancy of the genetic parents.

Parents who choose surrogacy typically have undergone numerous fertility treatments and spent thousands of dollars in this quest (Dutton, 1997). Couples may have refinanced their home or taken out second mortgages to finance the cost of surrogacy arrangements. Their ages range from the late 20s to early 50s, although most are over age 35 and tend to be from upper and middle classes (Dutton, 1997).

Sample This quahtative study explored the experiences of 26 parents who were

involved in surrogate parenting arrangements in a Cahfornia-based surrogacy

SURROGATE MOTHERHOOD, INFERTILITY 2 05

program. This program was founded in 1991 by a former surrogate mother. No formal license or training is necessary in Cahfornia to open and operate a surrogacy program. Couples and potential surrogates are recruited through advertisement or are referred by inferthy specialists. Participants were mostly white (n = 23), married (n =25), and female (n =24). Most had consider- able education, five participants held bachelor's degrees, and 13 had attended graduate school. Twenty-one of the participants reported a household income over $80,000.00 annually, with only two reporting household incomes ranging from $30,000.00-$79,000.00, and three who deched to report income. The mean age at the time of the first child's birth was 39 yr. (SD= 5.06). The majority of parents reported having one (n= 10) or two (n=8) -

children. The majority of participants reported Protestant (n=9) or Jewish (n = 8) religion. Religious participation varied; eight participants indicated that they attended weekly services, nine indicated participating in religious activities only on holidays, and three indcated no religious involvement. De- mographic data are located in Table 1.

The surrogacy program sent letters introducing the study, and participants were asked to return a form indcating if they were interested in being interviewed. FoUow-up letters were sent to nonrespondents.

Ninety-seven parents in the United States had participated in the surrogacy program by spring of 2000. Thirteen couples (13.4%) had dropped the program because they had been unsuccessful in getting pregnant. Eighty- four parents were qualdied to participate and were sent letters introducing the study. Eleven letters were returned stating the family had moved with no forwarding address. A total of 26 parents were interviewed for this study (out of 73), giving a response rate of 36%, which is somewhat low. The response rate may be low due to the length of time that had passed for couples who participated early in the program, i.e., 10 years prior, which made it ddficult to contact them.

Data Collection All interviews took place over the telephone, required about one hour,

and were audiotaped, with later transcription. The data collection period took place over a 9-mo. period. The interviews were conducted by a research assistant who held a master's degree in social work. A semistructured interview guide was used, divided into several sections. The parents were asked to dscuss their decision-making process to use a surrogate program, their motivations, and how their famllies were involved in the decision. So- cial support from their families, friends, and professionals during the pregnancy was explored, as well as relationships with their surrogate. The current relationship with their surrogate was also explored. The participants were asked demographic questions as well as for information regarding their pregnancy, i.e., method of ferthzation and reason for infertdity.


TABLE 1 DEMOGRAPHIC DESCRIPTORS OF PARTICIPANTS ( N = 2 6 )

n YO Sex (n=26)

!Male 2 Female 24

Race ( n = 26) White 13 Nonwhite 3

Marital Status (n =26) Married 25 Decltned to state 1

Household Income ( n =23) 530,000-59,999 1 $60,000-79,999 1 $80,00&99,999 4 > %100,000 17

Rehgion ( n = 24) Protestanc 9 Jewish 8 Catholic 2 AtheisdNone 3 Other 2

Religious Involvement ( n =24) Weekly 8 Bimonthly 3 Monthly 1 Holidays/rarely 9 None 3

Number of Children ( n =26) 0 2 1 11 2 8 3 3 4 1 5 1

Note.-Age at birth of first child: M=39.1 yr., SD=5.1, range 29-50; number of children: IM= 1.8, SD= 1.16, range 0-5.

Analysis Quantitative variables were analyzed using SPSS-PC. Transcripts from

the interviews were read and then coded to develop themes and categories. Grounded theory techniques were used to develop a conceptual model (Strauss & Corbin, 1990). The inductive approach to understanding was used to allow for unexpected outcomes rather than to confirm or dtsconfirm a research hypothesis. This technique allowed for open-ended interviews which enabled participants to tell their stories.


RESULTS AU participants reported infertility as their reason to explore surrogacy

as a method of building a family. Inferdry and pregnancy data are located in Table 2. The reasons for infertdity were multiple miscarriage (n = ll), hysterectomy (n = 5 ) , inability to conceive (n = 5 ) , cancer (M = 2 ) , wife's age (n = 2) , and hepatitis C (n = 1). Most of the participants (n = 18) chose in uitro ferthzation (IVF) for conception; thus, there was a high rate of multiples in the group (three sets of twins and two sets of triplets). The 26 parents had 38 babies, with six of the parents participating in the program twice. Thus, for this study, 32 different surrogacy experiences were dscussed. Also, several of the parents had other biological, step, or adopted children in the family, and two participants reported having no children at the time of the interview as their surrogate was pregnant.

TABLE 2 PREGNANCY/INFERTILITY DATA OF PARENTS ( N = 26)

n %

Reason for Infertility (n = 26) Multiple miscarriage 11 42.3 Hysterecrorny 5 19.2 Inab~liry to conceive 5 19.2 Cancer 2 7.7 Hepatitis C 1 3.8 Declined to state 2 7.7

Fertilization Method (n = 26) In uitro 18 69.2 Artificial insemination 8 30.8

Baby Delivered (n = 38) Single 23 60.5 Twins (3 sets) 3 23.7 Triplets (2 sets) 2 15.8

Number of Surrogacy Arrangements (n = 26) One 20 76.9 Two 6 23.1

Conceptual Model

The parents' experiences with the surrogacy process were placed in a hierarchical model, with those responses most often given placed in Tier 1, responses next most often given placed in Tier 2 , and responses least often given placed in Tier 3 . As seen in Table 3, the following areas were explored: motivation, concerns about surrogacy, worst experiences, best experiences, surrogates' qualities, relationship with surrogate, and social support.

Motivatrbn

In this sample, there was a strong desire for participants to have a ge-


TMLE 3 MODEL OF P ~ N T S ' EXPERIENCES WITH SURROGACY ARRANGEMENTS

Response Motivation Concerns Worst Best Frequency Experiences Experiences

1 Genetic h k Financial cost Fertilization period Childlchildren 2 Avoid adoption Miss pregnancy Lack of control Birth experience

Wanting a family Lack of trust in Financial costs surrogdte missing pregnancy

Fear of burrogate Medical difficulties miscarriage Surrogate relation-

ship 3 Avoid miscarr~ngc Impact on surro- Decision-making Relationship with

Avoid pregn~ncy/ gate family regarding surro- surrogate and health complica- gacy family tions Receiving a gift

Surro ate's Surrogate Contact Surrogate Contact Social Support ~ u a t t i e s During Present

1 Physical health Monthly 4-6 times per year Family Emotional health Friends

2 Married, supportive Weekly Annually or Support groups spouse monthly*

Altruistic motivation Will relinquish the

child Good relationship

with couple 3 Successful pregnan- Daily

cies Shared philosophical views

Physical character-

No contact since Indj\~idual/couples birch psychotherapy

istics

h'ofe.-Response frequency: l=most often, 2=next most often, 3=least often. 'An equal number of subjects responded with either annually or monthly.

netic link to their children. All of the husbands in these 26 surrogate arrangements were the biological fathers of the chrld/children. The wives were the biological mothers of the child/children in 15 of the surrogate arrangements; the surrogate was the biological mother of the childlchildren in eight, and a donor egg was used in three of the arrangements. The participants reflected on several motivations includmg a desire for a genetic h k to their children (n= 16), a desire to avoid some of the potential pitfalls with adoption (n =9) , wanting a family (n =7) , and a desire to avoid medical complications associated with pregnancy or miscarriage (n=3). Some participants focused on a strong desire to have a family and were open to both surrogacy and adoption (n=3). Most participants gave more than one answer. Some examples of couples who desire a genetic hnk to their child follow:

SURROGATE MOTHERHOOD, INFERTLLITY 209

If I wanted a biological child, I had no option. I couldn't carry my own baby but I kept getting pregnant. I had nine miscarriages. My husband and I wanted a family and we really did not want to adopt.

I had had children by a previous marriage and during that marriage I had a hysterectomy because I had cervical cancer. When I met my current husband, he had not had any children. . . . W e wanred to have children and that was one of the things that we were looking forward to together.

Well I was more inclined to adopt. I just felt that that was a good option. I think that there are a lor of children that need to be in good homes. My husband had never had children and wanted to be the biological Father.

Some examples of couples who were trying to avoid potential pitfalls of adoption follow.

I was told that I could not get pregnant again. My husband and I had our hearts set on having a family.. . we come from a very traditional family chat doesn't really have an open mind about adoption and so this was a way to get around the issue of grandkids for our parents and we could still have a Family.

We were older than most couples. I was in my late 40s. W e thought that if we had gone the adoption route, not too many young 18-year-old pregnant girls were going to pick a couple our a g e . . . we teared that we would not be selected. . . . Also, about 5% of surrogate mothers change their minds versus 40% of adoption oriented birth mothers change their minds. So it just seemed to us like a safer, more secure, more guaranteed route.

An example of a couple strugghg with medical issues follows.

My wv&e had a pretty serious cancer. We had the choice of either trying to have her get pregnant on her own-but if she was pregnant, then there wasn't anything they could d o about the cancer during the time of h e pregnancy. The risk to my wife's life wasn't worth it. We were crazy to have a family at the time but there were ocher ways. W e knew of this [surrogacy], and we know of adoption and either way it was fine For us. I felt that I had more control in the process [surrogacy], over adoption.

Concerns About Surrogacy

All of the participants addressed the concerns they had regarding the surrogacy arrangements. Most of the parents had more than one concern. The financial impact of the surrogacy arrangements was mentioned by 10 of the participants. The legal concern regarding whether the surrogate mother would relinquish the child to the couple was brought up by seven parents. Six participants expressed concern that they would not be able to carry their own child, and five indicated concerns that the surrogate would not take care of herself, i.e., following doctors' orders, proper diet. Five participants expressed concern that the surrogate would not conceive or that she would miscarry. Two participants mentioned concern about the surrogate, such as responsibhty for providmg emotional support to the surrogate and concern regarding any negative impact that the surrogacy experience may have on the surrogate. Some examples of financial concerns follow:

I think initially it was the legal issues. . .would there be any way that the surrogate could claim the child as her own . . . then that kind of settled down, then it was the Financial issue. . . . How were we going to finance this operation?

The cons were the expense; it's ridiculously expensive and nor covered by insurance which I think in the future the insurance companies should come around and start covering some of costs. . . also the Fact that I wasn't going to be carrying the baby myself and that I wouldn't go through the experience of being pregnant.

Trusting the surrogate to take care of herself and the unborn child, and to rehquish the child to the couple was expressed by several couples. Some examples follow:

You don't know if you could find someone that could actually create a child within her and then actually birth it and give it to you. The unknown, you know you had to relinquish all control. Most people make a child the old fashioned way, and you actually are bringing a third person into your very prjvate place.

It might take a long time to find the right person. And it was scary. In trusting that much faith in another person that we barely knew.

The cons were worrying about w d she [the surrogate] take care of herself, is she going to drink, do drugs, or go riding crazy rides at Disneyland?

An example of a participant who dealt with the loss of the pregnancy/delivery experience follows:

Letting go of the fact that I would not be able to carry my own child; once I got to that point, having someone else carrying our genetic baby was fine versus adopting where you get a baby that you don't know anything about.

Worst Experiences Participants reported the worst experiences related to the surrogacy ar-

rangements. Most participants reported more than one aspect. Six participants related that the most difficult part was the fertdization period. They reported concern regarding fdu re to conceive on the part of the surrogate and a tense period of waiting. Four participants indicated the lack of control regardmg the surrogate's behavior was the most difficult. Equally reported by three participants were financial concerns, missing being pregnant, mehcal difficulties, and relationships with the surrogates. Two participants reported the most dkficult aspect was making the decision to engage in surrogacy arrangements. Some examples of the waiting period follow:

The uncertainty of il it is going to be successful or n o t . . . the anxiety that builds up about it not working again and again . . . you get in this kind of cycle of just expecting it not to work.

Waiting for a surrogate. It took 6 months and did not work out. That was quite difficult.

Two participants described the feelings of not being able to carry one's own child: Feeling out of control. Feeling like she [the surrogate] had all the control over the baby's health, and I did not have control.

SURROGATE MOTHERHOOD. INFERTILITY 211

You always wish that you could have done it yourself.. . . When I'm with a bunch of women and they're all comparing their pregnancies and their births and there's that part o l the process that I wasn't the major player in, and I would have loved knowing what that fdc like and seeing the changes in my body.

One participant described the financial stress involved:

Parents need to be aware that there's no set amount [money]. It seems to always be more. You know, d they [surrogates] quit working it will cost you more. You need to know up front if the s~~rrognre is a working person, what is her salary, and what i t would cost if she has to go on bed resr I t can create financial stress if all of a sudden you have to pay the time she misses for work.

Best Experzences

The most often reported best aspect of the surrogacy experience was having a baby ( n = la) , followed by the experience of birth (n=7) . Three participants indicated that the relationship with the surrogate and her family was one of the best aspects of the surrogacy experience. Two participants indicated that the experience of receiving a gift (i.e., the baby) was one of the best aspects of the surrogacy experience. Following are some examples of participants' responses regarding their child/children:

The best pan is having this incredible child who came from so many people putting positive energy together and that those people are still in touch with each other.

Getting our beautiful children. And having your own child. That was it [the best part1 for me.

Following is an example of one participant's reaction to the birth of the child:

The birth was such a miracle in every way, and it was so profound. The experience of what the surrogate did was just so magnified. The gift that she gave us is one that I d never forger

Examples of relationships with the surrogate and her family follow:

We've developed a really strong bond, actually a good ftiendship. It's something that will keep going for a long rime. We feel like we will be friends with them for life.

What happened was exactly what I wanted, which is that the birth mother and I have 3 terrific relationship and we keep in regular contact and get together with the kids.

Following are two participants' feelings about receiving a precious gift, i.e., [he child:

1 will never get over that gift, that's the best part. . . . In the end i r comes back to a human being doing something that is extraordinary for somebody else.

That any woman would do rhis for somebody else is unthinkable. 1 mean to put a price on it, really you couldn't. A million dollars, ten million, there's really no price you can pay someone to do rhis. . . . I t ' s a miracle that someone would be wihng to do this.

Relationship With the Surrogate The relationship with the surrogate was explored at the time of the sur-

rogate arrangements and currently. Because some parents lived in other


states, contact was only by telephone other than perhaps a first meeting and at the child's birth. Nineteen participants described their relationship with their surrogate during the pregnancy. Most of the parents described having positive relationships with their surrogate, including being grateful for what the surrognre had done. In addition to the positive feelings expressed, many also ind~cated some areas of confict. The types of confict encountered gen- erally related to the parents' perceptions that the surrogate was not doing all she could do toward the health of the baby, e.g., poor diet, ignoring bed- rest orders. While the surrogate was pregnant, most parents (n=9) had monthly visits with her usually at doctors' appointments. Some parents had more contact, five indicated having weekly contact, and three indicated having daily contact. Because some lived out of town, they had telephone contact more often than face-to-face contact. Some of the most positive relationships were described as follows:

It was wonderbl. W e talked every dinner. We would calk for about an hour

We were a great match. We had a tremendous amount in common. We liked each other. It was like meeting a friend. I t was good chemistry.

She was llke a sister. I really felt that close to her. She called us the first time the baby kicked. She shared everything. I t was just wonderful.

Some of the conhcted relationships are described below:

She was supposed to be in bed, and she went off to Sea World and did all these things.. . s o it definitely got to be stressful because I started not to trust her.

I t was sort of a love/hate relationship. I feel really bad saying this but I wish I had known that she would be like this, and we \vould have used a different surrogate. I am so grateful to her for carrying our baby but I feel she made the pregnancy a lot of grief. She was up and down in her moods all the time, and I never knew where I stood with her. Sometimes she would be just so nice and then other times she'd just fly off the handle. I was scared for the health of the baby during the pregnancy.

I had some ~nrernal struggles about what should that relationship be like, was I doing enough, was I t a l k ~ n ~ \\j~th her enough. I felt Wte I owed this person the world, that no amount of money could possibly compensate her, and yet there was this age difEerence and economic background ddference. W e just really didn't have anything in common so it was a constant struggle just trying to figure out what that relationship would be and keep it on an appropriare level.

Relationships with the surrogates tended to taper off over time. Twenty- three participants described their relationship with their surrogate after the birth of the child/children. At the time of this study, five parents described seeing their surrogate once per month, six participants saw their surrogate 4 to 6 times per year, and five parents reported seeing or contacting their surrogate annually. Usual contact was described as sending annual holiday cards, birthday cards, or pictures of the children. Five participants stated that they d ~ d not see or contact their surrogate very often. Two participants

SURROGATE MOTHERHOOD. INFERTILITY 2 13

described no contact since the birth of the child. Following are some examples of the current relationships the participants have with their surrogates:

We have a really good relationship. I consider her a sister, and 1 will always be in touch with her from here on out.

I talk with her every three or four months. In the beginning we talked more but I think for both of us it was just easier to let things rest for a bit and go our own directions.. . .And for me it's lund of like you want to forget about chat part of your life and enjoy your children rather than thinking about your infert~lity all the time.

We speak every 6-8 weeks. I guess I thought that we would be speahng more earlier on and then taper off but she pretry quickly didn't seem to need it.

I don't know where we stand right now. We had a bit of a falling our on the phone a couple of months ago. She wanted to come over, and I had a lot of problems going on at that time and she got upset thinking that I didn't want her to see our baby so we had a few words at that time.

Ir has become less and less. And, actually, as time goes on that feels more comfortable to me. It feels like that was the way it was supposed to go.

Surrogates' Qualities Participants described the qualities that they were looking for in choos-

ing a surrogate. Most parents described more than one quahty. The most important quahty in this study was physical health, which was stated by 15 parents. Also endorsed by many participants was emotional health ( n = 9 ) . Several parents indicated that they wanted a surrogate who was married and had a supportive spouse (n=6) . Five parents indicated that they wanted a surrogate who was motivated by altruism. Four participants indicated that

they were looking for a surrogate who would have a good relationship with them. Four parents also indicated that they wanted to be sure that the surrogate would rehquish the child. Other surrogate characteristics mentioned by parents were successful pregnancies (n =3) , shared their philosophical views ( n = 2 ) , and ~hysical characteristics (n =2). Some examples of desired surrogate quahties were:

It was going to be a gestadonal carrier only. I was concerned that rhe person would stay healthy during che pregnancy, not smoke, not drink, not do things that I wouldn't have done if I were pregnant. 1 also wanted someone mho \\,as married and who was going to have support from her spouse because I felt that she W ~ S p ~ n g to need this h d of support. I wanted somebody who obviously I thought would nor have a problem relinquishing che child. I wanted somebody who I felt was mentally stable and healthy.

To have the same views on che number of babies that she would accept to carry. . . . We didn't believe in selective reduction.. . . We didn't want to put in more than three embryos, we were hoping for twins, but we would deal with triplets.

I think I needed to know that she was going to really take care of herself and in doing so would be taking care of the baby. That she was going to psychologically be able to deal wlth the fact that she was going to carry a child that was not going to be hers and that she was probably not going to have any really serious long-term relationship with.


Social Support

Family.-Twenty-five participants described the support that they received from their famhes. Twelve participants described their famihes as being supportive, while two described their famhes as being nonsupportive, and 11 described mixed reactions from fanlily members regarding their involvement in suriogacy arrangements. Examples of supportive responses were:

In both cases, the fam~lies were supportive. They came from scientific backgrounds so they were very accepting of the idea of what was going to go on . I think my Family, more so than my wife's family, was very interested in the fact that it [the baby] was going to be biologically ours. I'm not quite sure what my family would have thought about adoption o r an egg donor program.

My mother has given us a third of the money to d o this and has been really supportive and actually made a maternity dress for our surrogate. My father just kind of says okay. He 's almost 70, and he doesn't quite get it, but he's not against it.

My parents were very devastated when I was younger, chinking that I would never have children. Now we have triplets. They think it's an amazing process.

Some examples of nonsupportive responses:

My mom just had a hard time with it, I think. Even the first time she saw my daughter-my surrogate was Mexican-American-she said, "Oh, she's got olive skin." My wze and I are both Caucasian so it was very obvious what she was saying.. . . T h e y didn't end u p coming for the birch and that h d of hurt me too, I wished they would have.

They wanted a grandchild, they got a grandchild but they were not involved.. . . They're jerks. They have always been jerks.

At one point she [mother-in-law] made a redly horrible comment, and I was s o shocked that I literally couldn't respond . . . it was hurtful. . . . I t was really disappointing because she is a very educated woman and her husband was a doctor. She comes from the midwest and I just found that their values are just very diFferent from ours.

Some examples of mixed responses were:

Incredibly supportive. . . .Just worded. Like something would backfire and hurt me. . . . Once I brought the baby home, they couldn't believe it.

Athough she was supportive, my mom was a little worried. She didn't want me to go through aU the fertility treatments and be disappointed.

I think they were a little nervous about how it would work out until it was completely a done deal. There was always a question because they didn't know her [the surrogate] and did not have the time to trust her that I had.

Friends.-Twenty-one participants described the response from their friends regarding their involvement in surrogacy arrangements. Nineteen participants described supportive responses from their friends. Only two participants described mixed responses from friends, and no participants described nonsupportive responses from their friends regarding the surrogacy arrangements. Some supportive examples were:


[They were] 100 percent supportive. No negativity. We were kind of braced for somebody ob- jecting to it on moral grounds. . . we Figured that we must know somebody that is like that, but fortunately if we did we didn't know abour it.

[Husband] and I are very open people and so people felt that they could ask questions that could help answer their concerns. I think thar helped them to be more supporuve because they didn't have a lor of worries abour what we were doing. But morally, no one had a problem with it.

Some examples of mixed responses:

Three of my friends had adopted so felt it was very gutsy, bur they maybe were a little jealous but basically fabulous.. . .Jealousy is a hard thing to deal with in life. I tried to emphasize the positive within their lives.

People have questions all the time and the questions in most people's mind is what happens if the surrogate won't give your baby back. There are contracts to make sure that's not going to happen.

There are people that feel you are helping the world more by adoption, and thar rhere are all these children out rhere to be adopted, but the fact is char's not true. It's difficulr to find children to adopt. . . . O n e or nvo people thought it was sort of selEish to go to this length [surro- gacyl.

Professzonal.-All of the participants were asked about their anxieties and doubts during the process as well as who provided support to them. Most participants identified seelung support from family or friends. Some participants also mentioned that they attended support groups or received psychotherapy. Six participants attended support groups and four participants received individual or couples psychotherapy. Of those who used professional support, participants described support groups as more helpful than psychotherapy experiences. The majority of the sample ( n = 16) reported no involvement in support groups or psychotherapy, although several of the participants identlfied a need for additional support. Examples follow of the identified need for support:

Being the client couple you really can't complain about anything. You have to be the positive one that kid of holds everything together. To keep things flowing easily, financially, legally, spiritually, I mean the whole thing. And when there is not relief from that, where you can call somebody to complain, where it won't backfire on you was hard to find.

I really d o believe that i t would be nice to have more client couple support.

Drscussro~ The participants were similar to those in other surrogacy programs with

respect to age, ethnicity, marital status, and income (Dutton, 1997). Like other surrogacy programs, the couples in this study chose surrogacy over adoption due to the wife's inability to carry a child, hysterectomy, or medical problems which prevent gestation (Schwartz, 2000). Participants in this study reported a strong desire to have a biological hk to their child, which is also consistent with the findings of Schwartz (2000). The most often re-

216 C. B. RLEINPETER

ported religious affihations in this study were Protestant ( n=9) and Jewish (n=8) , which is interesting because many Protestant religions do not support reproductive technology and Jewish authors report mixed opinions on the subject (Dutton, 1997). However, nearly half ( n= 12) of this sample attended religious services rarely or not at all.

In this sample there were a large number of multiples, three sets of twins and two sets of triplets, which is consistent with the literature on the use of in vitro ferthzation (Spillman, 1999). Also mentioned by participants was the need for cesarean sections and the incidence of premature birth, which is reported to occur more frequently with multiple births (Weigel, et a/., 2000).

The relationship with the surrogate was described as being both one of the best and worst experiences by participants. Participants described the qualities that they were l o o h g for in a surrogate. The most often reported qualities were physical and emotional health. The intensity of the relationship between the surrogate and couple has been documented elsewhere (Hohman & Hagan, 2001). Participants described the lack of control they felt over issues of diet and following doctors' orders such as bed-rest as being important in affecting the outcome of their relationship with their surrogate. If she did not protect their unborn child as they felt she "should have", then the relationship was jeopardized. Also, if the couple and surrogate did not have similar ideas regarding the intensity of the relationship, i.e., lund and amount of contact, participants described being disappointed with the relationship.

Participants described the contact they had with their surrogate both ac the time of the pregnancy and currently. During the pregnancy, most had contact monthly. Many had contact by telephone due to living long dis- tances from their surrogate. Participants reported that the amount of contact diminished over time following the birth, which is consistent with the literature (Dutton, 1997). Most important in the responses of the participants was not the actual amount of contact but that the surrogate and couple agreed on the desired amount of contact. Dutton (1997) stated that couples and surrogates need to be clear about their expectations of one another.

Participants were asked about the social support that they received during the surrogacy arrangements. Most participants reported that they received support from their family and friends. Some participants received support from support groups or were involved in psychotherapy. Although most participants turned to family (n=25) for support, only 12 described the response they received as supportive. Eleven described the responses they received as mixed. Parents of the participants shared many of the origi- nal concerns of the participants, whether the surrogate would conceive, carry the child, and relinquish the child as promised. Participants' parents ex-


pressed concerns that their children, i.e., the participants, would be harmed in an emotional, financial, or legal way. The friends of participants were supportive in 19 of the cases. A few of the mixed responses from friends reflected some of the same concerns regarding potential harm to participants.

Ten participants received professional support in the form of a support group or individual or couples therapy. Although the services of these indi- viduals and groups were not evaluated in this study, the participants who attended a support group (n = 6 ) seemed to be more positive in their comments than were those (n =4) who engaged in individual or couples psychotherapy. Some of the comments reflected the importance of gaining information from others and sharing a common difficult experience, referred to as curative factors in group therapy literature (Yalom, 1995). Participants dis- cussed both the fertilization period and the delivery of the child or children as being stressful times in the process. Also, relationships with the surrogate and her family and coping with medical ddficulties were identified as poten- tially stressful issues.

Most of the parents in this sample reported having an overall positive experience. Of the 26 parents who participated in an interview, six had used a surrogate mother twice. Although many of the participants correctly antici- pated potential areas of concern, such as financial cost, loss of experiences of pregnancy and birth, and lack of control over the surrogate's behavior, many did not anticipate the importance of medical difficulties or a conflict- ed relationship with their surrogate when and iF these issues arose. The negative aspects experienced by some of the participants may have resulted due to a lack of preparation for these potential pitfalls. Fortunately, the antici- pated concerns with legal difficulties, particularly a surrogate challenging the parents for custody of the child, did not occur with any of the participants. This may be due to the fact that this surrogacy program provides surrogate screening, surrogate support groups, and legal contracts that cover those areas of potential difficulty.

This study is limited in generaLzabhty, in that only one surrogacy program was chosen for study. This program has a philosophy of altruism and may attract famhes who are motivated similarly. Subjects were volunteers and may not be representative of the characteristics of all parents who participated in the surrogacy program, particularly those who were unhappy with their experiences. The low response rate might have created a bias toward those parents who had a positive experience. Further investigation into the characteristics and experiences of parenu involved in surrogacy arrangements is warranted and could lead to bercer understandmg of the psychological implications for families and service providers. Further questions include how these experiences may be similar to b r Merent from the experiences of tnfertile couples who adopt, whether the outcomes change were this study


repeated with a large sample which included participants from many different surrogate programs throughout the country, and how satisfaction may vary by stage of participation in surrogate parenting arrangements.

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Books.

Accepted June 24, 2002

surrogacy: the parents' story

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