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“Not
my
child
to
give
away”:
A
qualitative
analysis
of
gestational
surrogates’
experiences
Samantha
Yee
a,
*,
Shilini
Hemalal
a,b
,
Clifford
L.
Librach
a,b,c,d,e,f
a
CReATe
Fertility
Centre,
Canada
b
Institute
of
Medical
Science,
University
of
Toronto,
Canada
c
Department
of
Obstetrics
and
Gynecology,
University
of
Toronto,
Canada
d
Department
of
Obstetrics
and
Reproductive
Endocrinology,
Sunnybrook
Health
Sciences
Centre,
Canada
e
Department
of
Obstetrics
and
Gynecology,
Women’s
College
Hospital,
Canada
f
Department
of
Physiology,
University
of
Toronto,
Canada
A
R
T
I
C
L
E
I
N
F
O
Article
history:
Received
26
October
2018
Received
in
revised
form
17
January
2019
Accepted
11
February
2019
Keywords:
Gestational
carrier
Surrogate
Surrogacy
Third
party
reproduction
Assisted
reproduction
A
B
S
T
R
A
C
T
Problem/background:
Limited
empirical
data
are
available
on
the
experiences
of
women
who
have
been
a
gestational
surrogate.
Question:
What
are
the
experiences
of
gestational
surrogates
along
the
surrogacy
pathway?
Methods:
Ananonymous
study-specific
cross-sectional
survey
wasused
to
evaluate
participants’
experience
of
being
a
surrogate.
A
total
of
184
Canadian
women
who
were
recruited
from
Canadian
surrogacy
agencies
and
the
Internetcompleted
the
online
survey;
9446
wordswere
collectedfrom 110
participants
who
entered
comments
to
one
or
more
questions.
The
qualitative
data
were
analyzed
through
thematic
analysis.
Findings:
Seven
main
themes,
and
eighteen
interrelated
sub-themes
grouped
under
the
pre-,
during,
and
post-surrogacy
stages
were
identified.
Many
surrogates
viewed
surrogacy
as
a
positive
experience
and
as
something
meaningful
and
impactful
to
other
people’s
lives.
Most
surrogates
had
harmonious
relationships
with
their
intended
parents
and
maintained
on-going
contact
with
the
surrogacy
family
post
birth.
Discussion:
Surrogacy
involves
deliberate
efforts
to
establish
a
trustful
surrogate-parent
partnership
through
relationship
building,
boundary
negotiation,
and
management
of
expectations.
The
compatibility
between
surrogate
and
intended
parents,
regarding
aspects
such
as
communication
and
pregnancy
management
styles,
was
an
important
contributing
factor
to
a
positive
experience.
Conclusion:
Our
findings
provide
a
deeper
understanding
of
participants’
reasons
for
and
motivation
to
be
a
surrogate,
the
relationship
dynamics
with
their
intended
parents
and
the
gestated
fetus
during
surrogacy,
and
their
satisfaction
on
personal
and
relationship
levels
post
surrogacy.
The
findings
would
be
useful
to
mental
health
professionals
in
preparing
new
surrogates
for
the
potential
challenges
along
the
surrogacy
pathway.
©
2019
Australian
College
of
Midwives.
Published
by
Elsevier
Ltd.
All
rights
reserved.
Statement
of
significance
Problem
or
issue
Much
has
been
written
on
policy
debates
surrounding
altruistic
surrogacy
under
the
Canadian
Assisted
Human
Reproduction
Act’s
legal
framework.
However,
empirical
knowledge
related
to
the
experience
of
Canadian
surrogates
is
extremely
limited.
What
is
already
known
Studies
on
the
psychosocial
impacts
of
surrogacy
have
concluded
that
many
surrogates
were
well
adjusted
both
short-term
and
long-term.
Although
available
research
findings
are
primarily
positive,
most
published
studies
were
conducted
in
the
UK
and
the
US
contexts.
What
this
paper
adds
Surrogacy
involves
deliberate
efforts
to
establish
a
trustful
partnership
through
relationship
building
and
management
of
expectations.
We
found
that
surrogates
who
were
partnered
with
like-minded
intended
parents
had
a
good
chance
of
developing
a
harmonious
relationship
that
could
be
long
lasting.
*
Corresponding
author
at:
CReATe
Fertility
Centre,
790
Bay
Street,
Suite
110 0 ,
Toronto,
Ontario
M5G
1N8,
Canada.
E-mail
address:
samantha@createivf.com
(S.
Yee).
https://doi.org/10.1016/j.wombi.2019.02.003
1871-5192/©
2019
Australian
College
of
Midwives.
Published
by
Elsevier
Ltd.
All
rights
reserved.
Women
and
Birth
33
(2020)
e256–e265
Contents
lists
available
at
ScienceDirect
Women
and
Birth
journal
homepage:
www.else
vie
r.com/locat
e/wombi
1.
Introduction
Surrogacy
is
a
form
of
third
party
reproduction
whereby
a
woman
agrees
to
carry
a
pregnancy
on
behalf
of
another
individual
or
couple
who
intends
to
be
the
legal
parent(s)
of
the
resultant
child
born
from
surrogacy.
1
Surrogacy
is
not
only
a
family
building
option
for
intended
parents
who
are
medically
incapable
to
carry
a
pregnancy,
but
also
for
same-sex
male
couples
or
single
men
who
are
unable
to
conceive
or
bear
a
child
for
biological
reasons.
Surrogacy
can
be
gestational
(also
known
as
‘full
surrogacy’)
in
which
there
is
no
genetic
tie
between
the
surrogate
and
the
gestated
surrogacy
baby,
or
traditional
(also
known
as
‘partial
surrogacy’
or
‘genetic
surrogacy’)
in
which
the
surrogate
donates
her
eggs
to
facilitate
a
conception,
either
through
insemination
at
a
fertility
clinic
or
private
arrangement
without
medical
assis-
tance.
2,3
Traditional
surrogacy,
a
practice
that
is
no
longer
offered
by
most
in-vitro
fertilization
(IVF)
programs
in
the
US,
is
also
not
a
favorable
practice
in
Canada
due
to
the
potential
legal
risks
in
parentage
and
unforeseeable
psychological
risks
to
the
surrogate
when
the
same
woman
serves
as
the
egg
donor,
surrogate,
and
birth
mother.
4,5
Surrogacy
in
Canada
is
altruistic
under
the
Assisted
Human
Reproduction
Act
2004
6
;
this
means
that
surrogates
cannot
receive
payment
for
their
participation
but
can
receive
reimbursement
for
expenses
incurred
during
the
surrogacy
process.
Canadian
law
also
supports
‘known’
surrogacy,
in
which
the
surrogate
and
their
intended
parent(s)
were
known
to
each
other
prior
to
surrogacy,
as
well
as
‘unknown’
surrogacy,
in
which
the
surrogate
and
their
intended
parent(s)
came
to
know
each
other
for
surrogacy
partnership
with
no
preexisting
relationship.
While
surrogacy
provides
an
alternative
family
building
option
for
intended
parents
who
desire
biological
children,
the
surrogates
are
exposed
to
potential
maternal
health
risks
related
to
obstetric
complications
such
as
miscarriage,
ectopic
pregnancy,
hypertension,
gestational
diabetes,
premature
birth,
hysterectomy,
placenta
accreta,
and
uterine
rupture.
7,8
It
is
important
to
understand
what
motivates
women to
participatein altruisticsurrogacywhen there are
potential
maternal
health
risks
with
no
financial
incentive
to
be
a
surrogate.
It
has
been
argued
that
surrogacy
violates
the
assumed
maternal
instinct
for
women,
with
ethical
concerns
about
objectification
of
women’s
bodies
and
disembodiment
from
the
pregnancy
experience
9
.
Much
work
has
been
done
in
the
past
three
decades
in
demystifying
surrogacy
through
the
lens
of
women
who
have
been
a
surrogate.
Three
systematic
reviews
on
the
psychosocial
impacts
of
surrogacy
concluded
that
many
surrogates
were
well-adjusted
emotionally
and
psychologically
after
relinquishment.
10–12
Findings
from
longitudinal
studies
examining
the
psychological
well-being
of
surrogates
post-birth
were
also
reassuring.
13–16
The
majority
of
them
did
not
develop
psychologi-
cal
health
problems
post-birth,
including
post-partum
depression
at
six
months,
one
year,
seven
years
and
ten
years
later.
No
significant
undesirable
long-term
outcomes
in
the
domains
of
self-
esteem,
emotional
stability,
or
spousal
and
family
relationships
were
found.
Although
research
findings
are
primarily
positive,
most
published
studies
were
conducted
in
the
UK
and
the
US
contexts.
11
To
our
knowledge,
Canadian
surrogates
rarely
participate
in
research,
except
in
a
Canadian
study
in
which
eight
surrogates
were
interviewed
about
their
spirituality
and
religion
in
the
context
of
surrogacy,
17
and
in
two
international
studies
in
which
a
few
Canadian
surrogates
were
either
interviewed
9
or
surveyed.
18
It
is
not
known
if
Canadian
surrogates
share
similar
positive
experiences
compared
to
the
findings
from
international
studies.
The
lack
of
empirical
data
in
the
experience
of
Canadian
surrogates
to
inform
best
practices
is
disconcerting
when
over
2000
gestational
surrogacy
cycles
had
occurred
between
2013
and
2016
in
Canada,
19
yet
little
is
known
about
the
experience
of
Canadian
women
who
had
been
a
surrogate.
Surrogacy
research
within
the
Canadian
context
is
needed
to
address
this
substantial
empirical
gap.
This
paper
analyzed
the
descriptive
comments
provided
by
Canadian
gestational
surrogates
who
participated
in
a
cross-sectional
survey.
2.
Participants,
ethics,
and
methods
2.1.
Study
design
The
study
design
was
exploratory
and
descriptive
due
to
the
lack
of
empirical
data
on
the
experience
of
Canadian
surrogates.
A
non-probability
convenience
sampling
was
used
to
recruit
gestational
surrogates
from
the
Canadian
surrogacy
community
and
the
Internet.
Participants
of
this
study
were
Canadian
women
who
had
past
or
current
experience
as
a
gestational
surrogate
and
did
not
use
their
own
eggs
for
the
surrogacy
pregnancy.
The
study
protocol
was
approved
by
the
University
of
Toronto’s
Research
Ethics
Board
(#32847).
2.2.
Survey
construction
A
63-item
study-specific
questionnaire
was
constructed
based
on
clinical
experience
and
a
comprehensive
literature
review
of
relevant
areas
in
a
surrogacy
pathway.
The
survey
was
constructed
to
examine
the
retrospective
experience
of
gestational
surrogates
at
different
stages
of
a
surrogacy
process
and
how
they
appraised
their
relationship
with
the
intended
parents
and
surrogacy
child
during
and
post
surrogacy.
In
addition
to
the
two
open-ended
questions
in
the
survey,
textboxes
were
added
to
seventeen
questions
with
which
participants
may
elaborate
on
their
selections
if
they
wished
(Appendix
A).
For
pre-testing
purpose,
the
survey
was
reviewed
by
five
clinicians
specializing
in
assisted
reproductive
services
for
face
and
content
validity,
and
was
subsequently
pilot-tested
by
eight
surrogates
recruited
at
a
fertility
clinic.
Minor
revisions
were
made
based
on
their
feedback
with
regards
to
readability,
formatting,
structure,
clarity
of
questions,
and
inclusiveness
of
options
in
multiple
choice
questions.
2.3.
Data
collection
An
online
survey
tool
called
Fluidsurvey
(www.fluidsurvey.
com)
was
used
for
survey
implementation.
The
cover
page
of
the
online
survey
served
as
the
consent
form
of
research
participation.
Interested
participants
must
have
provided
consent
by
checking
three
mandatory
boxes
to
confirm
that
they
had
understood
the
risks
and
benefits
of
participation
by
reading
the
consent
form,
had
met
the
eligibility
to
participate,
and
had
given
the
consent
to
participate.
Participation
was
anonymous
and
voluntary.
No
personal
identifying
information
was
collected
in
the
survey
or
tracked
by
the
survey
tool.
Recruitment
notices
with
the
survey
hyperlink
were
sent
to
all
the
Canadian
surrogacy
agencies
and
a
list
of
fertility
lawyers
who
specialized
in
assisted
reproductive
law.
Digital
platforms
includ-
ing
Facebook,
Instagram,
chatrooms,
and
message
boards
were
used
to
reach
out
to
potential
participants.
During
the
data
collection
period
from
June
2016
to
February
2017,
approximately
220
people
accessed
the
online
survey
by
clicking
the
hyperlink.
After
excluding
surveys
that
were
partially
completed,
a
total
of
184
completed
surveys
were
used
for
data
analysis.
One
hundred
and
ten
participants
entered
descriptive
comments
to
one
or
more
questions;
9446
words
were
collected
with
an
average
of
51
words
per
returned
questionnaire.
Identification
codes
(S1–S110)
were
assigned
to
these
110
participants.
S.
Yee
et
al.
/
Women
and
Birth
33
(2020)
e256–e265
e257
2.4.
Data
analysis
Qualitative
comments
were
imported
to
Excel
spreadsheets
for
thematic
analysis.
20,21
Investigator
triangulation
was
achieved
by
organizing
the
data,
identifying
recurrent
themes,
and
labeling
the
contents
using
codes
through
an
iterative
process.
The
codes
were
then
reviewed
by
the
research
team
to
inform
the
development
of
commonalities,
emergent
categories,
underlying
sub-themes,
and
interrelated
patterns
using
constant
comparative
methods.
22
Differences
were
resolved
through
revision
and
discussion
until
consensus
was
reached.
The
data
were
then
presented
in
a
thematic
map
of
a
visual
presentation
of
themes,
sub-themes,
categories
and
their
relationships
to
capture
participants’
expe-
riences
along
the
surrogacy
pathway
grouped
by
the
pre-
surrogacy,
during
surrogacy,
and
post-surrogacy
stages.
Quantitative
analyses
were
conducted
using
the
Statistical
Package
for
the
Social
Sciences
(SPSS)
version
24.0.
Descriptive
statistics,
where
applicable,
were
reported
together
with
the
qualitative
comments.
Text
within
double
quotation
marks
indicates
extracts
of
participants’
written
comments.
Participants’
own
words
(with
or
without
double
quotation
marks)
were
used
as
much
as
possible
when
reporting
the
findings.
Identification
codes
are
used
when
reporting
long
extracts
of
participants’
comments.
In
accordance
with
accepted
conventions
for
reporting
results
from
qualitative
studies,
the
terms
‘many’
or
‘most’
refer
to
frequently
reported
comments,
whereas
‘several’,
‘some’,
‘a
number’,
and
a
few’
refer
to
less
commonly
reported
comments.
Text
within
square
brackets
indicates
editorial
notes.
Three
ellipsis
points
(
)
indicates
omitted
text
from
participants’
comments.
In
this
paper,
“surrogacy
children”
refers
to
the
children
who
were
born
through
surrogacy,
whereas
“surrogates’
children”
refers
to
surrogates’
existing
children.
The
legal
parents
of
the
surrogacy
children
are
referred
to
as
“intended
parents”
or
“parents”,
interchangeably.
3.
Results
3.1.
Sample
description
Of
the
184
surrogates
who
completed
the
survey,
91
were
first-
time
surrogates
who
were
at
various
stages
of
an
on-going
surrogacy
journey
at
survey
time,
and
the
other
93
women
had
completed
a
surrogacy
journey
at
least
once
(Table
1).
Table
2
shows
the
socio-demographics
of
184
survey
participants
who
were
involved
in
287
surrogacy
cases.
At
the
time
of
embarking
a
surrogacy
journey,
the
mean
age
of
participants
was
32
(age
range:
21–48);
most
were
in
a
marital
(153
cases,
53.3%)
or
partnered
relationship
(51
cases,
17.8%).
The
vast
majority
of
participants
were
Caucasian
(n
=
173 ,
94%).
One
in
five
participants
had
a
university
degree
(n
=
41,
22.3%).
Thirty-seven
percent
(n
=
67)
reported
their
current
annual
gross
family
income
was
$50K
or
less;
41.7%
(n
=
75)
reported
a
‘very
tight’
or
‘tight’
family
budget
based
on
income
and
expenses.
Of
the
287
cases,
more
than
half
of
the
intended
parents
were
heterosexual
couples
(n
=
158,
55.1%),
the
remainder
were
same-
sex
male
couples
(n
=
113 ,
39.4%),
single
men
(n
=
11,
3.8%),
single
women
(n
=
4,
1.4%),
and
transgender
women
(n
=
1,
0.3%).
Only
21
cases
were
‘known’
surrogacy
involving
friends
(17
cases,
5.9%),
or
family
members
(4
cases,
1.4%).
The
other
266
cases
were
‘unknown’
surrogacy
in
which
participants
met
the
intended
parents
through
an
agency
(225
cases,
78.4%)
and
the
Internet
(41
cases,
14.3%).
3.2.
Themes
and
sub-themes
Three
themes
and
ten
sub-themes
regarding
participants’
views
on
the
Canadian
law
governing
assisted
human
reproduction,
and
their
surrogacy
experience
under
the
legal
framework
were
found
from
qualitative
analysis.
The
three
main
themes
are:
(1)
loop
holes
created
by
legal
uncertainty,
(2)
support
for
an
unpaid
surrogacy
model,
and
(3)
support
for
a
paid
model.
Please
refer
to
Table
3
for
the
illustrative
quotes
supporting
the
themes
and
sub-
themes
related
to
the
surrogacy
law
in
Canada.
As
depicted
in
Fig.
1,
seven
main
themes
and
eighteen
sub-
themes
were
identified
from
analysis
to
capture
the
participants’
experiences
along
the
surrogacy
pathway.
The
findings
are
presented
in
the
following
paragraphs
grouped
under
three
surrogacy
stages:
pre-surrogacy,
during
surrogacy
and
post-
surrogacy.
3.3.
Pre-surrogacy
stage
3.3.1.
Prerequisites
to
be
a
surrogate
All
the
participants
had
given
birth
at
least
once
before
their
surrogacy
commitment;
79%
indicated
that
they
had
completed
their
families
when
they
decided
to
become
a
surrogate.
Many
participants
commented
about
their
uneventful
pregnancy
expe-
rience
and
enjoyment
of
pregnancy,
feeling
that
they
would
not
mind
carrying
a
pregnancy
for
a
third
party.
Their
motherhood
fulfillment
and
the
joy
their
children
brought
to
their
daily
lives
also
made
them
very
empathic
to
people
who
could
not
be
parents
without
receiving
help.
With
the
belief
that
“having
a
child
is
love
in
its
purest
form
and
everyone
deserves
to
have
that
in
their
life
if
they
choose”
(S18),
they
did
not
see
a
reason
for
not
offering
help
when
they
had
the
physical
capacity
to
give
someone
the
gift
of
life:
“Every
day
I
look
at
my
kids,
I
could
not
imagine
how
life
would
be
if
I
were
not
able
to
have
children.
I
am
done
with
having
children
and
I
have
a
healthy
uterus,
so
why
not!”
(S43)
3.3.2.
Motivation
to
be
a
surrogate
Among
the
162
cases
involving
heterosexual
couples
and
single
women
as
intended
parents,
the
reasons
for
them
to
use
surrogacy
were:
‘unable
to
carry
due
to
infertility’
(n
=
116 ,
71.6%),
‘unable
to
carry
due
to
medical
reasons’
(n
=
15,
9.3%),
‘unable
to
carry
due
to
Table
1
Cross-tab
of
past
and
active
surrogates
at
survey
time.
Past
surrogates
a
Active
surrogates
b
Total
number
of
surrogates
Total
number
of
surrogacy
cases
First
time
being
a
surrogate
0
91
(49.5%)
91
(49.5%)
91
(31.7%)
Completed
a
process
once
before
20
(10.9%)
39
(21.2%)
59
(32.1%)
98
(34.1%)
Completed
a
process
twice
before
15
(8.2%)
7
(3.8%)
22
(12%)
51
(17.8%)
Completed
a
process
three
times
before
2
(1.1%)
6
(3.3%)
8
(4.3%)
30
(10.5%)
Completed
a
process
four
times
before
3
(1.6%)
1
(0.5%)
4
(2.2%)
17
(5.9%)
Total
40
(21.7%)
144
(78.3%)
184
(100%)
287
(100%)
a
Past
surrogates
—
women
who
were
not
involved
in
a
surrogacy
process
at
the
time
of
survey.
b
Active
surrogates
—
women
who
were
actively
involved
in
a
surrogacy
process
at
the
time
of
survey.
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33
(2020)
e256–e265
cancer
treatment’
(n
=
21,
13%),
and
others
(n
=
10,
6.2%).
On
a
list
of
6
items,
the
three
most
common
reasons
that
triggered
the
participants’
interests
to
be
a
surrogate
were
‘knowing
someone
who
has
infertility
issues’
(59.2%),
‘knowing
someone
who
has
been
a
surrogate’
(28.3%),
and
‘saw
information
on
social
media
about
surrogacy’
(26.3%).
A
number
of
women
commented
that
they
were
motivated
to
be
a
surrogate
after
witnessing
the
struggles
encountered
by
people
who
desired
a
family
but
could
not
do
so
owing
to
medical
or
biological
reasons:
“So
many
people
have
a
hard
enough
life
and
to
go
through
the
problems
that
come
with
infertility
is
heartbreaking.
I
have
seen
first-hand
how
a
family
struggles
not
bearing
a
child
and
every
person
be
it
straight,
gay,
transgender
or
even
a
different
race
deserves
to
hold
a
child
in
their
arms
that
they
call
their
own.”
(S9)
Some
participants
viewed
surrogacy
as
a
selfless
act
to
help
others
through
“doing
something
big
and
meaningful”
to
alleviate
the
pain
and
suffering
of
childlessness.
In
the
words
of
a
woman
who
commented
on
the
characters
of
surrogates:
“Surrogacy
is
a
true
calling;
it's
not
for
everyone,
but
those
called
to
do
it
are
special
selfless
women,
and
they
should
be
celebrated
and
honored.”
Spiritual
metaphors
such
as
“personal
calling”,
“life
purpose”,
“blessing”,
“gratitude
to
life”,
and
“sacrifices”
were
noted
as
well
when
several
participants
commented
on
what
surrogacy
meant
for
them:
“I
am
grateful
I
have
been
able
to
give
back
to
the
universe
so
to
speak,
for
the
blessings
of
my
own
large
family
that
I
had
wanted
since
I
was
a
child.”
In
another
comment
by
a
participant
who
wrote
about
why
she
was
motivated
to
give
the
gift
of
life
to
those
who
cannot
achieve
it
on
their
own:
“I
knew
I
wanted
to
be
able
to
give
a
couple
the
best
gift
they
could
ever
want
in
life.
I
have
the
working
parts,
I
have
good
health,
why
wouldn’t
I
help
someone
the
best
I
could.”
(S80)
The
altruistic
desire
to
help
someone
through
bearing
a
pregnancy
for
them
as
“a
labor
of
love”
and
“not
for
money
or
prestige”
also
emerged
from
the
descriptive
comments.
As
shared
by
a
woman
who
had
chosen
to
use
surrogacy
as
her
way
to
give
back
to
society:
“Some
people
donate
organs
after
they
pass
or
give
money
to
charity.
I’ve
chosen
to
offer
my
body
while
I’m
healthy
and
vibrant
to
give
the
gift
of
life
and
family
to
a
deserving
couple.”
(S74)
The
gift
rhetoric
of
surrogacy
was
mentioned
by
a
number
of
participants
as
they
reflected
on
what
surrogacy
meant
for
them.
Some
participants
commented
on
their
desire
to
alleviate
the
pain
and
suffering
of
others
who
were
unable
to
have
children,
through
giving
and
serving.
In
a
society
of
give-and-take,
the
act
of
surrogacy
was
their
way
of
expressing
gratitude
to
life
for
“their
good
fortune
to
have
children
without
much
difficulty”.
A
woman
who
was
grateful
for
her
own
pregnancy
and
childbirth
experience
wrote
about
her
reason
to
be
a
surrogate:
“Surrogacy
is
my
way
of
saying
thank
you
to
the
universe
for
blessing
me
with
the
ability
to
have
had
an
amazing
pregnancy
and
birth
experience
without
any
complications.”
(S18)
3.4.
During
surrogacy
stage
3.4.1.
Harmonious
relationship
with
intended
parents
Surrogacy
involves
complex
interpersonal
interactions
be-
tween
the
intended
parents
and
surrogates
during
the
process.
Three
different
types
of
surrogate-parent
relationship
patterns
–
‘harmonious’,
‘neutral’,
and
‘conflictual’
–
emerged
from
analysis.
In
instances
where
the
surrogates
described
having
a
‘harmo-
nious’
relationship
with
their
intended
parents,
strong
emotional
Table
2
Socio-demographics
of
184
participants
at
the
time
of
287
surrogacy
arrange-
ments.
Demographics Frequency
(%)
Age
at
surrogacy
(mean
=
32
5.3;
range:
21–48)
21–25
28
(9.8%)
26–30
98
(34.1%)
31–35
89
(31%)
36–40
54
(18.8%)
>40
18
(6.3)
Total
287
(100%)
Relationship
status
at
surrogacy
Single
45
(15.7%)
Married
153
(53.3%)
Common-law
51
(17.8%)
In
a
non-cohabited
relationship
15
(5.2%)
Separated/divorced
23
(8%)
Total
287
(100%)
Province
of
residence
at
survey
time
Ontario
113
(61.4%)
Alberta
37
(20.1%)
British
Columbia
26
(14.1%)
Saskatchewan
4
(2.2%)
Nova
Scotia
2
(1.1%)
Quebec
1
(0.5%)
New
Brunswick
1
(0.5%)
Total
184
(100%)
Ethnic
background
White
173
(94%)
Non-white
11
(6%)
Total
184
(100%)
Highest
education
at
survey
time
Less
than
high
school
2
(1.1%)
High
school
48
(26.1%)
Community
college
93
(50.5%)
Undergraduate
university
degree
38
(20.7%)
Postgraduate
university
degree
3
(1.6%)
Total
184
(100%)
Number
of
biological
children
at
survey
time
One
35
(19.7%)
Two
74
(41.6%)
Three
45
(25.3%)
Four
or
more
24
(13.5%)
Total
178
a
(100%)
Occupation
at
survey
time
Homemaker
35
(19%)
Self-employed
or
freelancer
4
(2.2%)
Business
owner
or
entrepreneur
22
(12%)
Unskilled
labor
9
(4.9%)
Semi-skilled
labor
9
(4.9%)
Skilled
labor
20
(10.9%)
Skilled
worker
(jobs
without
requiring
a
degree)
46
(25%)
Skilled
worker
(jobs
requiring
a
degree
and/or
license)
37
(20.1%)
Other
2
(1.1%)
Total
184
(100%)
Annual
family
income
at
survey
time
$30,000
33
(18%)
Between
$30,001
and
$50,000
34
(18.6%)
Between
$50,001
and
$70,000
30
(16.4%)
Between
$70,001
and
$90,000
28
(15.3%)
Between
$90,001
and
$110,000
28
(15.3%)
>$110,000
30
(16.4%)
Total
183
b
(100%)
Family
budget
based
on
income
and
expenses
at
survey
time
Very
tight
family
budget
18
(10%)
Tight
family
budget
57
(31.7%)
Modest
family
budget
53
(29.4%)
Comfortable
family
budget
48
(26.7%)
Very
comfortable
family
budget
4
(2.2%)
Total
180
c
(100%)
a
6
participants
did
not
answer
this
question.
b
1
participant
did
not
answer
this
question.
c
4
participants
did
not
answer
this
question.
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e259
connection,
trust,
and
respect
between
parties
were
frequently
mentioned
in
their
comments.
In
the
words
of
a
woman
who
reflected
on
her
bonding
with
the
intended
parents
during
the
process:
“It’s
quite
the
rewarding
process
of
living
vicariously
through
the
intended
parents
emotions.
I
feel
everything
they
feel”
(S47).
Some
surrogates
felt
that
they
had
developed
a
close
emotional
bond
with
their
intended
parents,
as
noted
in
comments
such
as
“I’ve
enjoyed
meeting
my
[intended
parents]
IPs
as
they
feel
like
long
lost
friends”
(S39)
and
“the
best
experience
of
my
life.
I
consider
their
family
to
be
part
of
my
family
now”
(S60).
3.4.2.
Neutral
relationship
with
intended
parents
A
few
participants
approached
surrogacy
as
a
goal-oriented
baby-making
project,
with
a
mindset
of
not
wanting
a
future
relationship
with
their
intended
parents
post-surrogacy.
These
women
commented
that
they
chose
to
work
with
like-minded
intended
parents
who
shared
a
similar
desire
of
not
expecting
ongoing
contact
post-birth.
One
surrogate
explained
why
she
did
not
want
to
have
a
post-surrogacy
relationship
with
the
intended
parents:
“I
don’t
want
to
have
a
relationship
with
the
intended
parents
afterwards.
I
am
helping
women
who
have
struggled
with
infertility
have
a
family.
The
absolute
last
thing
that
the
women
I’m
helping
need
is
a
person
in
their
lives
trying
to
claim
some
sort
of
relationship
with
her
children.
I
want
my
intended
mother
to
be
the
mother
100%.
Not
99%
with
some
creepy
“tummy
mommy”
or
“birth
mother”
as
part
of
the
kids’
lives.
No,
the
mother
deserves
to
be
the
one
and
only
because
she
is
the
one
and
only.
I’m
already
taking
away
something
that
she
would
have
killed
to
do.
.
.
.
Will
we
ever
hang
out
again?
Probably
not,
but
it
doesn’t
matter.
We’ve
shared
something
special
and
it
is
a
wonderful
thing.”
(S42)
3.4.3.
Conflictual
relationship
with
intended
parents
Almost
all
relationships
were
harmonious
at
the
onset
but
some
had
become
more
strained
towards
the
end,
with
tensions
arising
along
the
surrogacy
pathway
due
to
different
expectations
and
pregnancy
management
styles.
For
example,
one
participant
described
how
the
intended
parents’
stress
provoking
communi-
cation
style
posed
physical
and
mental
stress
to
her
pregnancy:
“At
first,
I
felt
like
we
were
friends,
and
this
was
going
to
be
a
wonderful
journey.
As
soon
as
I
was
pregnant,
it
was
all
about
the
baby.
.
.
.
Furthermore,
they
put
so
much
stress
and
anxiety
on
me
that
I
ended
up
with
hypertension
and
migraines
throughout
the
pregnancy.”
(S17)
In
the
words
of
another
woman
who
had
to
set
firm
communication
boundaries
with
the
intended
mother
who
was
described
to
be
intrusive
and
overbearing:
“I
had
to
put
the
brakes
on
with
this
journey
because
she
[intended
mother]
was
becoming
quite
overbearing
.
.
.
I
told
her
that
she
needed
to
trust
me
and
be
less
invasive”
(S38).
Another
participant
who
had
a
difficult
relationship
with
the
intended
mother
wrote
this
comment:
“My
last
surrogacy
journey
was
a
horrible
experience;
the
mother
and
I
didn’t
see
eye
to
eye
on
all
things.
She
didn’t
get
along
with
my
OB/GYN
and
made
things
very
stressful
and
Table
3
Participants’
perspective
and
experience
of
the
surrogacy
law
in
Canada.
Theme
Sub-theme
Illustrative
quote
1.
Loop
holes
created
by
legal
uncertainty
a.
Create
a
black
market
“Although
I
am
following
the
law
and
only
receiving
reimbursements
as
a
surrogate,
I
know
that
there
are
many
women
who
are
getting
around
the
law
somehow
and
making
money.
I
would
love
to
know
the
numbers
for
how
often
this
happens,
and
what
the
government
intends
to
do
about
this
black
market.”
(S100)
b.
Prevent
transparency
“I
believe
surrogacy
is
vital
and
necessary
but
with
our
current
regulation,
systems
are
preventing
adequate
documentation
on
all
aspects
of
surrogacy.
Such
as
how
many
times
donors
have
been
used,
what
side
effects
are
there
using
the
various
combinations
of
drugs.
What
are
the
actual
statistics
on
successful
pregnancies
and
live
births,
along
with
details
to
be
made
available
like
criminal
activities.”
(S26)
c.
Surrogates
being
exploited
financially
under
the
system
“A
lot
of
parties
involved,
I
often
wished
it
was
just
me,
my
partner
&
the
intended
parents
rather
than
all
the
doctors,
lawyers,
agency
reps,
etc.
But
I
understand
their
role
in
the
process
is
necessary.
It
is
frustrating
to
know
the
cost
these
parties
charge
throughout
the
surrogacy
yet
the
surrogate
who
sacrifices
her
body
&
lifestyle
can
be
sentenced
to
hefty
fines
and
jail
time
for
accepting
any
form
of
payment.”
(S74)
d.
Surrogates
being
exploited
financially
by
intended
parents
“I
once
had
to
be
the
mediator
for
another
surrogate
and
her
intended
parents
because
they
were
so
very
mean
to
her
and
did
some
terrible
things.
I
managed
to
get
her
the
help
she
needed
and
for
the
intended
parents
to
stick
to
their
legal
contract.
They
actually
wanted
to
not
pay
for
her
hospital
bill
(she
was
American)
after
she
almost
died
giving
birth
to
their
twins.”
(S38)
e.
Surrogates
being
exploited
by
agencies
“The
unclear
laws/loopholes
in
surrogacy
laws
have
been
frustrating
and
confusing
and
often
leave
me
feeling
taking
advantage
of
by
the
surrogacy
consulting
agency.”
(S79)
2.
Support
for
a
non-
compensated
surrogacy
model
a.
Not
getting
paid
is
feasible
“I
think
it
would
be
important
for
them
to
know
that
‘not
getting
paid’
can
actually
be
done.
Surrogates
are
not
necessarily
out
for
money
(although
some
ARE
[capitalized
by
participant]
and
give
us
all
a
bad
name).”
(S42)
b.
Service
out
of
kindness
“Surrogates
choose
whether
they
want
to
be
a
carrier
or
not.
They
are
not
forced
into
it
and
aren’t
in
it
for
the
money.
In
Canada
it's
illegal
to
compensate
a
carrier
other
than
to
reimburse
them
for
their
lost
wages.
It
is
a
great
service
we
provide
for
these
families
out
of
the
kindness
of
our
hearts.”
(S103)
3.
Support
for
a
compensated
surrogacy
model
a.
Allow
payment
with
a
cap
“It’s
my
opinion
that
surrogates
should
be
allowed
to
receive
payment
for
our
services.
It’s
a
difficult
task,
has
risks
and
affects
our
families.
There
could
be
a
cap
to
the
amount,
exceptions
for
family
or
long
time
friends,
but
at
least
10,000
for
a
regular
pregnancy
would
begin
to
be
fair.
It’s
worth
so
much
more.”
(S96)
b.
Allow
payment
with
measures
in
place
“I
also
think
that
the
law
that
states
surrogates
can't
accept
payment
is
ridiculous.
It’s
a
job.
It’s
hard
as
hell.
You’re
building
a
baby.
You’re
creating
a
family.
You’re
putting
your
life
at
risk.
Not
everyone
is
going
to
do
this
and
I’m
sure
there
will
be
measures
put
into
place
so
it
weeds
out
the
crazies
but
we
need
to
make
it
legal.”
(S38)
c.
Allow
payment
with
enforced
regulations
“My
own
opinion
is
to
commercialize
surrogacy
with
enforced
regulations
and
allow
the
women
who
want
to
do
this
to
go
ahead
without
the
worry
of
financial
consequences.”
(S100)
e260
S.
Yee
et
al.
/
Women
and
Birth
33
(2020)
e256–e265
difficult
for
me
to
the
point
that
I
had
high
blood
pressure
from
all
the
added
stress.
.
.
.
After
I
had
the
babies,
my
intended
mother
didn’t
understand
why
I
did
what
I
did,
she
didn’t
even
come
to
see
if
I
was
ok
after
having
a
C-section,
didn’t
say
a
thank
you
or
even
a
card
thanking
me
for
what
I
had
done
for
her.
To
me
she
is
a
very
very
very
selfish
woman.”
(S53)
3.4.4.
Relationship
with
surrogacy
child
Terms
such
as
“a
host”,
“a
custodian”,
“an
oven”,
and
“a
baby
sitter”
were
noted
in
the
comments
in
which
participants
described
their
role
was
to
“babysit
an
embryo
until
he/she
was
ready
to
meet
their
parents.”
Participants
also
emphasized
that
their
emotional
connection
was
with
their
intended
parents
but
not
with
the
gestated
fetus.
They
downplayed
the
significance
of
a
gestational
link
with
the
surrogacy
child
and
stated
that
they
were
the
“birth
mother
on
paper”
only.
For
example:
“I'm
just
the
oven,
not
genetically
related
to
the
baby”,
and
“I
am
not
the
actual
mother.
It’s
not
my
baby.”
Thus,
their
goal
was
to
help
the
intended
parents
fulfill
their
family
dream
by
gestating
a
baby
for
them,
and
later
returning
the
child
to
their
parents:
“I
am
not
giving
up
my
child;
I
am
growing,
carrying
and
delivering
someone
else’s
child
for
them”
(S74).
In
the
words
of
a
woman
who
explained
why
she
had
no
problem
relinquishing
the
baby
at
birth:
“I
would
like
to
make
it
clear
I’m
in
no
way
giving
the
baby
away,
I’m
just
the
baby
sitter
until
this
little
sweet
heart
is
big
enough
to
go
home
to
their
parents.
He
or
she
was
never
mine
to
keep!”
(S83)
3.4.5.
Support
system
Participants
wrote
about
the
importance
of
having
support
from
friends
and
family
to
withstand
the
stress
associated
with
the
surrogacy
process:
“If
you
don’t
have
good
support
from
the
people
you
care
about
the
most,
don’t
do
it”
(S51).
In
the
words
of
a
woman
who
commented
on
the
importance
of
having
a
good
support
system
in
place
and
why
surrogacy
is
not
for
everyone:
“You
really
have
to
be
in
the
right
place,
mentally
and
emotionally
to
do
it
.
.
.
You
have
to
be
willing
to
make
sacrifices
in
your
own
family
for
the
good
of
the
baby
that
you
are
carrying.
And
you
need
to
be
able
to
do
that
without
resentment.”
(S60)
Of
the
participants
who
had
children
mature
enough
to
understand
what
surrogacy
was
about,
they
commented
on
their
positive
experience
when
telling
their
children
about
their
decision
to
be
a
surrogate.
All
the
written
comments
regarding
children’s
reactions
to
their
mother’s
surrogacy
act
were
either
neutral
or
positive:
“My
kids
are
young,
and
just
think
that
it’s
cool”.
A
few
commented
that
their
children
were
very
open
to
tell
their
friends
about
surrogacy:
“they
tell
everyone
that
the
baby
isn’t
ours.”
In
the
words
of
two
participants
who
wrote
about
how
they
used
surrogacy
as
an
example
to
teach
their
young
children
about
generosity,
kindness
and
selflessness:
“My
5-year-old
son’s
reaction
was
‘this
is
beautiful’
when
explaining
to
him
that
we
wanted
to
help
another
couple
out.”
(S75)“My
kids
have
a
greater
understanding
of
not
only
that
it
isn’t
always
a
case
of
‘mommy
and
daddy
love
each
other
so
they
decide
to
have
a
baby’
and
I
feel
it
also
taught
them
about
selflessness.”
(S30)
Surrogacy
is
a
complicated
process
that
requires
case
coordi-
nation
and
relationship
management,
and
sometimes
even
mediation
when
conflicts
arise
between
different
parties.
For
participants
whose
surrogacy
arrangements
were
coordinated
by
agencies,
they
commented
on
the
support
services
they
received
during
the
process:
“I
originally
expected
the
surrogacy
process
to
be
like
a
business
transaction.
.
.
.
However,
the
staff
helped
me
Fig.
1.
Themes
and
sub-themes
along
the
surrogacy
pathway.
S.
Yee
et
al.
/
Women
and
Birth
33
(2020)
e256–e265
e261
realize
what
an
amazing
spiritual
experience
this
is”
(S64).
A
few
others
commented
that
through
the
agency,
they
were
able
to
access
a
network
of
past
and
current
surrogates
for
social
support,
which
enhanced
their
satisfaction:
“I
did
not
realize
there
is
such
a
big
network
to
support
surrogates
when
I
first
started
the
journey.
I
met
other
surrogates
through
the
agency
and
we
went
to
[a]
retreat
together.
It
is
quite
an
incredible
process
and
is
definitely
eye-
opening
and
transformative.”
(S37)
3.4.6.
Selective
disclosure
Surrogates
used
different
disclosure
strategies
to
protect
their
privacy
and
to
avoid
social
judgement
from
other
people
who
may
not
agree
with
or
may
not
understand
what
surrogacy
is
about.
Participants
commented
that
while
most
people
in
their
network
showed
support
of
their
surrogacy
act,
it
was
often
those
well-
intended
comments
that
offended
them.
For
example:
“‘I
could
never
do
that’
(in
regards
to
growing
the
child
and
then
parting
with
it)
is
a
very
common
sentiment
shared
with
me
and
it
often
made
me
feel
broken
and
cold
as
if
I'm
some
detached
and
unfeeling
person
because
I
can
do
it.
It
was
usually
meant
as
how
strong
I
am
emotionally