The human cost of unregulated commercial surrogacy

In one of last week’s blogs, I looked at the burgeoning commercial surrogacy industry in Nepal.  Interest groups there were concerned that the lack of regulation left vulnerable and disenfranchised women at risk of exploitation.  Reference was made to the Indian experience, and how the absence of a legal framework left Indian surrogate mothers ill-protected.

The extent of the vulnerability of surrogate mothers in India is highlighted in a recent report from the Centre for Social Research (CSR).  The Centre is a non-profit, non-governmental organisation based in New Delhi working to empower Indian women and help protect their fundamental rights and freedoms.

India has long been a popular destination for prospective parents from Australia, the UK and elsewhere seeking to have a child through surrogacy.  CSR estimate that the resulting surrogacy industry, which is flourishing in the absence of legal protections, is worth about US$2 billion.

Looking to see whether the industry was as deeply exploitative as feared, the CSR undertook a survey of 100 surrogate mothers and 50 commissioning parents in Mumbai and New Delhi. 

CSR’s report, “Surrogacy Motherhood:  ethical or commercial?” summarises the trends emerging from that survey.  Even taking into account the relatively small sample size, those trends are alarming, and include the following: 

Ø                  surrogacy agreements between the surrogate mother and the commissioning parents were normally signed in the second trimester, after the pregnancy had been confirmed. 

Ø                  most surrogate mothers were not given a copy of their agreement and were not aware of its terms.  "The freedom of the surrogate mother is an illusion," says the report.

Ø                  surrogacy agreements rarely addressed issues relating to the health and wellbeing of the surrogate mother.  Where they did, it was usually only incidental to the health of the child she was carrying. 

Ø                  if a congenital defect was detected in utero, or the child was not of the preferred gender, it was often chemically aborted, and often without the surrogate mother's consent or knowledge.  According to the report, "There have been instances where the contracting individual has specified the sex of the baby, refused to take the baby if it was not born normal and filed a suit against the surrogate saying she had broken the contract."

Ø                  surrogate mothers were paid about 1% or 2% of the fees charged by the clinic.  Where the pregnancy was terminated, or the commissioning parents refused to take the child, the surrogate was often only paid half of the agreed fee.  Some surrogates were paid nothing.

Ø                  the actual payment received by the surrogate mother ranged from between 2.1 and 4 lakh of Rupees (between about £2,300 and £4,350), depending on where the arrangement was undertaken. 

 

Compare this with India’s average per capita income – in February 2013, this was estimated to be 68,750 Rupees (£750).  So, whilst only a fraction of what clinics are earning, a surrogate mother can earn the national average annual income many times over from a single pregnancy. 

Ø                  the fate of children born with congenital defects was unclear.  Only 6% of commissioning parents in New Delhi and 26% in Mumbai said that they would take the baby regardless.

Ø                  there was an increasing trend to use more than one surrogate mother. Commissioning parents looked upon it as a more economical option, since some clinics offered “2-mothers-for-1-guaranteed-pregnancy” discounts.

Ø                  most surrogate mothers stayed in hostels or shelters during the pregnancy to avoid the stigma of being a surrogate and to avoid being infected with STIs during pregnancy.

Ø                  many commissioning parents are ethnically Indian themselves, living in Western countries where surrogacy was illegal.

 

The report includes some appalling anecdotes about the extent of the oppression rife in the surrogacy industry.  In one instance: 

"a shocking case of surrogacy was unearthed in the Bombay International Airport, where a foreigner couple went for surrogacy in India only for organ transplant for their sick child in their country."

Unsurprisingly, the resounding recommendation is for a clear legal framework.  There was insufficient protection for the surrogate mother’s health, or to protect her from exploitation. 

“Surrogacy arrangements have made child a ‘saleable commodity’, and complications have arisen regarding the rights of the surrogate mother, the child and the commissioning parents.  As there is no legal provision to safeguard the interests of the surrogate mother, the child, or the commissioning parents in India, looking at such an issue from commercial or business point of view has complicated the matter further.”

Further research was required, the report concluded, to assist in initiating legal provisions to properly regulate surrogacy practices and protect the interests of the surrogate mother and, crucially, the child.

At which point (and at the risk of sounding like a broken record) I return to one of my favourite topics from recent weeks …

 

I looked in a blog a few weeks ago at European research on whether a standardised surrogacy framework within the EU was achievable.  A similar piece of research is underway via the Hague Conference, with a correspondingly broader scope. 

Those with experience of transnational surrogacy in any capacity – commissioning parents, surrogate mothers, legal advisers, etc – are invited to share them by contacting the Hague Conference’s Permanent Bureau.  Legal professionals with relevant practical experience are invited to complete a Questionnaire online.  Responses close at the end of September 2013.

The Indian research demonstrates that, only by identifying the nature and extent of the issues that arise due to current surrogacy practices, can a properly formulated legal, medical and ethical framework emerge. 

Nepal's booming trade in commercial surrogacy

Within Asia, India has long been a popular destination for prospective parents from Australia, the UK and elsewhere who seek to have a child through surrogacy.  Commercial surrogacy in India is booming, and the government there is struggling to regulate what has become an industry.

The exponential growth of commercial surrogacy appears now to have spread to India’s neighbour, Nepal.  Human rights organisations doing research on commercial surrogacy in Nepal point to a marked increase in such cases.  This is particularly so along the Terai (or Madhesh) region on the shared Indian / Nepalese border.

Initial research on behalf of NAWHRD has identified the border areas of Nepalgunj, Biratnagar and Jhapa (amongst others) as fast turning into attractive destinations for commercial surrogacy.

The organisation’s chairperson, Renu Raj Bhandari, has called upon the Nepalese authorities to pay attention to the phenomenon and to regulate it.

“India is already a world hub for surrogacy arrangements. And because of long standing ties between India and Nepal, it can be assumed that women in Nepal are and will continue to become increasingly sought as gestational surrogates, too. 

“In the preliminary phase of the research we are conducting we have found that some areas in the Tarai belts have already attracted service seekers”.   

A local human rights activist and advocate, Meera Dhungana, agrees:

“Poverty is the basic reason behind thriving business of commercial surrogacy in India. We know the status of poor women in Nepal. If we expect to act only after the problem grows, many women are going to be exploited badly.”

Surrogacy always throws up complicated legal and ethical issues, and international surrogacy all the more so.  The Nepalese experience demonstrates that the wave of surrogacy as a global phenomenon continues to crest.  I looked in a recent blog at European research on whether a standardised response to surrogacy within the EU was achievable.  A similar piece of research is underway via the Hague Conference, on a broader scale. 

Those with experience of transnational surrogacy in any capacity – commissioning parents, surrogate mothers, legal advisers, etc – are invited to share them by contacting the Hague Conference’s Permanent Bureau.  Legal professionals with relevant practical experience are invited to complete a Questionnaire online.  Responses close at the end of September 2013,

 

Those considering surrogacy – whether as commissioning parents or surrogates – should seek specialist advice as early in the process as possible.  If there are potential problems with a surrogacy arrangement, early identification and management will help ensure a positive outcome. 

The kids are alright? The behavioural health of children born through surrogacy

Children born using surrogacy may face greater adjustment problems than their peers. 

This seems to be the conclusion of a longitudinal study conducted by Professor Susan Golombok, of the Centre for Family Research at Cambridge University. 

Writing in June’s issue of Journal of Child Psychology and Psychiatry, Professor Golombok observed:   

“Surrogacy children showed higher levels of adjustment problems than children conceived by gamete donation at age 7. 

“Signs of adjustment problems could be behaviour problems, such as aggressive or antisocial behaviour, or emotional problems, such as anxiety or depression.”

The research was more positive about other types of assisted reproduction, including IVF with donated eggs and sperm.

The sample breakdown for Professor Golombok's study

The study involved thirty families who had used a surrogate, thirty-one who had used egg donation, thirty-five who had used donor sperm, and fifty-three who had conceived naturally.

Professor Golombok acknowledged that the results had some limitations because of the relatively small sample size.  She also conceded it was possible that reproductive donation mothers might have skimmed over some of their children’s difficulties.

Parenting was assessed at age three by a standardised interview and by questionnaire measures of anxiety, depression, and marital quality.  The children’s adjustment was assessed at ages 3, 7, and 10 using a Strengths and Difficulties Questionnaire (SDQ).

 

The study found that candour and openness about the mechanism of their conception did not necessarily make the children’s lives easier, at least at age 7.  Parents who had kept their child’s origins secret showed elevated levels of distress.  However, maternal distress had a more negative impact on children who were aware of their origins.

Remarking on this, Professor Golombok said: 

“… contrary to expectations, it was children who were aware of the circumstances of their birth and whose mothers were distressed who showed greater adjustment difficulties, conceivably because they felt less secure when faced with their mother’s emotional problems.”

She concluded that “the absence of a gestational connection between parents and their child may be more problematic for children than the absence of a genetic relationship.” 

As surrogacy becomes increasingly popular as an alternative for parents unable to conceive naturally, studies like Professor Golombok’s will prove vital to ensure that the particular needs of the children born are identified and properly met.

International Surrogacy - Is a global response achievable?

A report published this week examines the legal structures relating to surrogacy across the EU Membership.

The report, commissioned by the European Parliament, was written by academics from the Université Paris, the University of Glasgow and the LSE.

It is a compendious document, weighing in at over 380 pages.  Much of that consists of an analysis of surrogacy law and practice in jurisdictions around the globe:  Australia, Belgium, Bulgaria, Germany, Greece, Italy, the Netherlands, Romania, Russia, South Africa and Spain.

A harmonised approach to surrogacy within the EU Membership looks still to be some way off.  In many EU Member States, surrogacy is illegal.  In others, there is no legal provision for it.  The report’s authors conclude that a principal aim of any EU response should be to go beyond dispute management and manage surrogacy as an international practice.  It should provide certainty on the legal parenthood of the child and his or her entitlement to move to and settle in the home country of the commissioning parents.

One of the key problems with the reform of surrogacy is that there is only limited data available about the phenomenon.  The report recommends that   improved systems be put in place routinely to record relevant information about surrogacy arrangements and outcomes across all countries.

Surrogacy is in fact on the agenda on a broader scale.  It is an issue that the Hague Conference on Private International Law is currently considering.  Whilst the EU (self-evidently) is limited to the twenty-eight Member States in Europe, the Hague Conference has global application.  One needs to look no further than the success of the 1980 Hague Abduction Convention for an example of just how effective some of the treaties emanating from the Conference have been in managing issues affecting families internationally.  That particular Convention now operates as between some eighty Contracting States, a number set soon to increase once Japan and others come on board.

In 2011, the Council on General Affairs and Policy of the Hague Conference invited the Permanent Bureau to intensify its work on the private international law issues surrounding the status of children, with emphasis on the broad range of issues arising from international surrogacy arrangements.

In 2012, the Council asked the Permanent Bureau to continue the current work under the 2011 mandate and further prepare and distribute a Questionnaire in order to obtain more detailed information regarding the extent and nature of the issues being encountered in relation to international surrogacy arrangements.  The Permanent Bureau will present its final Report to the Council in 2014.

As identified in the EU study, empirical data is key.  The Permanent Bureau of the Hague Conference is looking for input from those who have been involved in international surrogacy arrangements, either in a personal or professional capacity.  Those with experience of such arrangements should contact the Permanent Bureau to ensure that the Report is as comprehensive as possible when presented next year. 

The Permanent Bureau is particularly seeking information from legal professionals with relevant practical experience in this field at an international level.  A Questionnaire directed to such individuals has been prepared and can be completed online.  Responses close at the end of September 2013, in order to allow the Permanent Bureau time to consider the responses and factor them into the Report.

 

For those considering embarking on a surrogacy arrangement, especially one with an international dimension, expert legal advice may prove crucial to a successful outcome.  But that advice needn’t cost the earth, and a fixed-fee arrangement ought to be appropriate in many cases.

The line of succession and LGBT monarchs

Parliament is currently debating the Succession to the Crown Bill.  The proposed law is intended to update rules on succession to the throne of the United Kingdom of Great Britain and Northern Ireland. 

If passed, the Bill will (amongst other things) do away with the delightfully quaint concept of primogeniture, namely that a monarch’s firstborn son becomes King irrespective of whether there is an elder daughter.  It will also repeal the prohibition on a person succeeding to the Crown if he or she marries a Roman Catholic.

But what, pray tell, if a future Queen was a lesbian?  What if her child – born through surrogacy – were included in the line of succession?

These are the issues that blindside me at 3:30am many mornings….



Act of Settlement 1701



And I’m not alone.  Thankfully, some equally perspicacious Peers in the House of Lords raised just these questions during the Bill’s Report Stage last week. 

As matters currently stand, the law governing succession means only an heir to the body is included in the line of succession.  Featuring in the Act of Settlement 1701 and the Acts of Union 1707, that phrase was intended to mean a direct biological descendent of the monarch. 

Lord True, a Conservative Peer, proposed changes to the Bill that would make it crystal clear that an heir to the body could only be the product of a heterosexual marriage.  As the Hansard account of Report Stage shows, Lord True was sufficiently vexed about “emerging legislation for same-sex marriage and the techniques of surrogate childbirth” that he proposed removing a child born to either from the line of succession. 




Elton John
(no relation of Lord Elton)

 

His was not the lone voice in the wilderness:  Lord Elton (tragically not John), a former Conservative minister whose wife is aide to the Queen, supported the proposal.

Said Lord True:

“What happens if we have a lesbian queen in a same-sex marriage who conceives using an egg implanted with donor sperm?  The law should be clear, but this is a question that has not been thought through in the Bill.”

He was only assuaged when he received confirmation existing laws meant only a Royal child born to heterosexual parents would be included in the line of succession.



Lord True didn’t go quietly, however, prophesying, “This may seem fanciful or long in the future, but I believe Parliament should reflect on it … I believe the question will inevitably arise.”

Richard I -
A gay man

So what if it does?  Will it really matter if a future King or Queen has a child with his or her same-sex partner / spouse via surrogacy?  Is it the surrogacy point that is the problem?  It must be, because it’s not as if LGBT individuals are unheard of in the Royal lineage.  William II (William Rufus) of England is widely recognised as gay.  He died without issue, but the proposals of Lords True and Elton (not John), if taken to their natural conclusion, would hold his children less entitled to succeed to the throne because of their father’s sexual orientation.  Likewise, on all counts, Richard I (the Lionheart). 



A gay or bisexual man (depicted here
as King James VI / I)



Edward II (he of the apocryphal red-hot poker inserted up his anus) had five children by Isabella of France.  He, too, is thought to have been gay.  Are his children any less entitled to participate in the line of succession by virtue of their parents' wedding having a whiff of lavender about it?  Or is the line of succession saved because he entered into a sham marriage? 

And let’s not forget James I of Great Britain, described alternatively as either gay or bisexual.  He had seven children with the woman who might or might not have been his “beard”, Anne of Denmark.  His sexuality did not end the line of succession. 



None of the nay-saying deals with the elephant in the room, namely that hereditary monarchy is unfair and elitist.  A much more relevant debate would be whether, in a modern and democratic society, anybody should be expected to defer to another simply because of accident of birth.  Given the absurdity of that system enduring, I wonder whether we don’t have better things to worry about than whether a future monarch is born to a gay King or lesbian Queen. 

In the meantime, I’m confident Lords True and Elton (not John) can rest a little easier knowing their concerns about the demise of the monarchy due to the problems visited by same-sex relationships are more “Chicken Licken’” – unwarranted fears the sky is falling - than founded in reality. 

The Succession to the Crown Bill is scheduled for its Third Reading in the House of Lords on 22 April 2013.

Here’s to the happy day when we see our first Queen and her Queen Consort, or King and his King Consort.

Surrogacy arrangements: Who pays the piper?

In my native Australia, two women from Queensland are campaigning for surrogacy costs to be subsidised by the Australian taxpayer.

Melissa Delaware, 35, and Jillian Spears, 40, cannot bear children following their respective battles with cancer which required the removal of their uteruses.  They are each trying for a child using a surrogate mother.

The Australian publicly funded universal health care system is called Medicare.  It allows Australian citizens and permanent residents to receive subsidised treatment from medical practitioners, nurse practitioners and allied health professionals.  Medicare covers the lion’s share of the treatment fee, and patients then pay the balance. 

IVF is provided under Medicare, irrespective of the patient’s income, the number of cycles and whose genetic material is used.  However, Medicare does not presently cover any of the expenses incurred by a Commissioning Parent seeking to have a child through surrogacy.

The two women say this is discriminatory and are petitioning the Australian Federal Government to change the regulations.  Mrs Delaware said while babies born through surrogacy were recognised for tax purposes and paid parental leave, any treatment leading to their birth was not recognised by Medicare.

"Any other woman could do this four times for the same money we're spending on just one cycle," said Mrs Delaware.  "A woman without a uterus or the ability to carry a pregnancy for medical reasons is treated less favourably than other women who can."

Figures show a single cycle of IVF in Australia incurred out-of-pocket expenses of between AU$3,400 (£2,350) and AU$4800 (£3,300).  Mrs Delaware expects her costs to reach more than AU$50,000 (£34,400).

On top of these IVF costs, Commissioning Parents using surrogacy also face legal and counselling costs and their surrogate's health, insurance and travel costs.

Mrs Delaware estimated the average cost of legal surrogacy to be around AU$60,000, (£41,200). 

A spokesman for the Federal Health Minister said the Australian Government would consider the matter.

So much for the Australian angle – what about the situation here?  Well, as in Australia, surrogacy in the UK can be costly.  Whilst commercial surrogacy is illegal, it is perfectly proper – and common – for expenses to be paid to the surrogate.  The precise payment made varies, but tends to range from about £7,000 to £15,000.  There is no upper cap on the amount that may be paid, but an English Judge asked to make a Parental Order following a surrogacy arrangement is likely to need some persuading that expenses exceeding £15,000 were reasonable. 

It may appear cheaper to enter into a surrogacy arrangement overseas, but the costs associated with then dealing with some of the complications that such arrangements tend to bring may make this a false economy.  These include:

·                    the child’s nationality, if born abroad to a non-British / EU citizen;

·                    the child’s entry clearance – if not an EU national, he or she will need a visa to enter the UK;

·                    different approaches abroad to the commercialisation of surrogacy – in some countries, payments in addition to expenses are legal and required;

·                    the fact that a surrogacy arrangement might be enforceable abroad but not in the UK, and

·                    differences between countries about who is treated as a surrogate child’s legal parents.

On top of the costs payable to the surrogate, if the surrogacy is performed at a HFEA-licensed clinic, there will be additional fees for the IVF procedure – between £15,000 and £20,000. 

Last, there potentially are the legal fees associated with obtaining a Parental Order, which I considered in a recent blog.

It might be possible for some of the costs associated with the IVF procedure to be met by the NHS.  However, the provision of IVF treatment varies across the country.  It often depends on local policies.  Priority is often given to childless couples.  In many areas Primary Care Trusts (PCT) refuse to fund surrogacy-IVF because the resulting embryo will be implanted in the womb of a surrogate.  Guidance from the National Institute for Health and Clinical Excellence (NICE) states that where the reason for infertility is known, patients should be fast-tracked for NHS-funded IVF treatment.  However, the Guidance goes on to exclude surrogacy from its remit. 

Following a trawl through Google, I’ve not been able to find any private health care insurance that would cover the costs of IVF treatment (although most will fund investigations into the underlying causes behind an inability to become pregnant).

At present, much as in Australia, there is no entitlement to look to the NHS for a contribution to the surrogacy expenses. 

The commercial reality is that many Commissioning Parents here have to save or borrow (either through personal loans or by mortgaging property) to meet both treatment costs and surrogacy expenses.  Another common option is to rely on credit cards.

Should we be more ready here to fund the IVF procedures associated with surrogacy arrangements on the NHS?  There is force behind the line taken by Mesdames Delaware and Spears in Australia, namely that treating women (and the funding of their IVF) unable to carry a child for medical reasons differently is inherently discriminatory. 

To those who have been through the surrogacy experience, I’d love to hear:

·                    who your PCT was, and their attitude towards NHS funding of the IVF, and

·                    what arrangements you had to make to fund the process.