Mothers for Others: An Interpretative Phenomenological Analysis of Gestational Surrogates’ Child Relinquishment Experiences

Abstract

Background:

Previous studies have shown that surrogates reported high satisfaction with the surrogacy process and no psychological difficulties as a result of child relinquishment. However, the experiential dimension of child relinquishment is an understudied area.

Objective:

This study sought to provide a more detailed portrait of gestational surrogates’ child relinquishment experiences and the meanings they give to this experience.

Method:

Semistructured interviews were conducted with 3 women who experienced commercial gestational surrogacy for the first time. Interview transcripts were transcribed and analyzed using interpretative phenomenological analysis.

Results:

Three superordinate themes were generated from the transcripts: (1) undertaking an act of altruism, (2) going through a different kind of motherhood, and (3) promoting a positive body image.

Conclusion:

Such insights can provide essential knowledge for mental health professionals who are interested in the development of psychological support tailored to promote a smooth emotional transfer of the baby from the surrogate to the intended couple.

Introduction

The path to parenthood is not always straightforward. Publicly available data indicate that infertility affects at least 50 million couples globally (1). Such reproductive failure is considered a major life crisis that brought about psychological consequences to couples (2). Yet, there is hope for infertile couples. As reproductive options advance, infertile couples now have a variety of options to have a child, as long as they have the financial capability to do so. Surrogacy is one of the many assisted reproduction technologies for infertile couples. By definition, surrogacy is a process whereby a woman (the surrogate) offers to carry a baby through pregnancy on behalf of another person or couple and then hand over the baby to the intended parent(s) once it is born. (3). There are 2 main types of surrogacy: traditional (the surrogate acts as both the egg donor and the surrogate for the embryo) and gestational (the embryo is developed using both the biological father’s sperm and the biological mother’s egg). Additionally, surrogacy can be commercial or altruistic. Commercial surrogacy is where a surrogate mother accepts financial compensation for carrying the baby, whereas altruistic surrogacy involves a surrogate mother carrying the baby for no monetary gain (4). Due to the controversial nature of surrogacy, gestational surrogates in a commercial surrogacy agreement are still considered an understudied and underserved research population (5).

Previous psychological research related to surrogacy commonly takes 3 major paths (6): attitudes toward surrogacy, motivations for becoming surrogates and seeking surrogates, and psychosocial aspects of surrogacy. Studies on attitudes toward surrogacy have accounted that assisted reproductive technology has been viewed as a controversial way of procreation (7 –9). However, recent data indicate that there has been a significant increase in support for commercial surrogacy (10). Studies on the motivations for becoming surrogates have generally reported that women’s decision to become surrogates are primarily motivated by altruistic reasons than monetary gains (11,12), and motivations for seeking surrogates are predominantly driven by the desire to have genetic relation to the child (13,14). With regard to the psychosocial aspects of surrogacy, existing studies have confirmed that surrogates reported high satisfaction with the surrogacy process and no psychological difficulties as a result of child relinquishment (15 –18). From the literature review, it is evident that the experiential dimension of child relinquishment is an understudied area. Therefore, the aims of the study are to undertake an in-depth exploration of gestational surrogates’ personal and subjective experience of relinquishing a baby in commercial surrogacy and to explore the meanings which they attach to this experience; produce awareness that may usefully inform mental health professionals in their work with gestational surrogates.

Method

We utilized a qualitative method, embracing a phenomenological-hermeneutic research design to gain a detailed portrait of gestational surrogates’ sense-making process with regard to their child relinquishment experiences. Specifically, interpretative phenomenological analysis (IPA) was used to have a conceptual and structured approach in conducting this qualitative exploration (19). This approach is mainly suitable for understudied and subjective research where sense-making is important (20).

Participants

Using a snowball sampling procedure through social media, 3 women who acted as gestational surrogates volunteered to participate in this study. All participants were financially compensated for being surrogates. Furthermore, participants reported that they did not personally know the intended couples prior to the surrogacy arrangement. Pseudonyms were used to preserve participants’ identities (Table 1).

Table 1.

Participant Details.

Participant	Age	Location	Nationality	Marital Status	Number of Surrogate Births	Number of Surrogate Children	Number of Own Children
Angelina	32	Athens, Greece	Filipino	Separated	1	1	1
Marie	30	California, USA	American	Married	1	1	1
Audrey	32	Maryland, USA	American	Married	1	2	3

Procedure

Ethical approval was obtained from research ethics committee of the University of San Carlos. The entire data collection process of this study was accomplished via an online interview method using Skype (21). We scheduled the interviews convenient for the participants in order to create a comfortable environment for them to privately express their thoughts and feelings regarding the subject matter. Before the interview began, informed consent was obtained from the participants. To maintain the privacy and confidentiality, we asked permission to record the interview through the use of an audio and screen recorder and assured that all signed informed consent forms, interview recordings, and anonymized transcripts were kept in a secure location (ie, accessible only to the authors of the study). More importantly, we formulated semistructured form of interview questions in accordance with the practical guide of IPA (22), which sought to explore various aspects of the participants’ child relinquishment experiences ranging from broad questions such as “Could you describe what happens in a surrogacy agreement?” to more specific matters such as “How do you feel when you handed over the baby to the intended couple?”

Data Analysis

The recordings of the interviews were transcribed verbatim. In accordance with the IPA guideline, the first transcript was analyzed thoroughly and repeatedly reading to ensure that interpretations were valid and contextualized in participants’ narrated accounts. As we went through the first transcript, we noted anything interesting or relevant about what the participant said. These notes were then analyzed to identify emergent themes and look for connections between them. Lastly, a final table of superordinate themes was constructed after all transcripts have been reanalyzed by the interpretative process.

Results

Three superordinate themes were generated from the transcripts.

Undertaking an Act of Altruism

All of the participants recollected the act of handing over the surrogate babies to intended couples after birth as an altruistic experience. By definition, altruism refers to any action that is intended to increase another person’s welfare (23). The participants expressed that they felt fulfilled and overjoyed knowing that they have helped infertile couples fulfill their dreams of having a child:

I am able to see the family have their biggest dream come true. And I was able to help them do that. I know that I helped make this family whole, and whether those children ever know it or not, my heart does. And that’s all that matters. (Audrey)

After the delivery, the thought that you’ve helped the intended parents and seeing the smile on their faces…unexplainable feelings inside my bones. (Angelina)

Another definition of altruism is any action aimed to benefit another, even when this action risks possible sacrifice to the welfare of the actor (24). One participant emphasized that she is putting the needs of the infertile couple before her own, even if it causes her discomfort. She did not mind the hassle, as long as she is able to help the infertile couples:

In a good way, it reminds me again that everything I did was so that they could hold their baby. So, it’s very comforting to know that even though you’re having discomfort sometimes, it’s worth it for that family because, for the rest of their lives, they’re going to be grateful for what you and your family have done for them. (Marie)

Going Through a Different Kind of Motherhood

Participants acknowledged that they are going through a different kind of motherhood. From the beginning, they were fully aware that they are contracted to become surrogate mothers of the intended couples’ baby as specified in the legal agreement by the surrogacy agency. Accordingly, the surrogates expressed that relinquishing the baby is not difficult at all since they have honored the contract to become the temporary mothers for the surrogate baby:

I honored my contract that after the delivery, I assume no rights for the baby. So, I think of the baby as theirs (intended parents) and I was just the temporary mother of the baby for 9 months. (Angelina)

I didn’t have any issues relinquishing them. It never felt like they were mine to give. I was just holding them temporarily. All the paperwork and everything was done before we even got to the hospital by the surrogacy agency. So it was good because I wasn’t having to deal with the paperwork and stuff right after birth. I was just the surrogate mother, that’s all. (Audrey)

In addition, participants were able to relinquish the surrogate baby with no psychological difficulties because they were able to differentiate natural motherhood from surrogate motherhood:

It was different because with your own child, you’re planning. Like is it gonna be a boy, is it gonna be a girl, what are you gonna name it, how are you gonna tell everybody, how do you want to do the room, saving up money. But when it’s a surrogate baby, you’re not doing any of those things. You’re just pregnant, and that’s it. (Marie)

I still talked to the babies, but it was different. I didn’t know what they would be named, so I would just call them little boy or little girl. There was certainly less affection from my husband to the babies than there had been when I was carrying my own. But my children were affectionate. We all liked to touch my belly and feel the babies move. It just wasn’t a strong emotional attachment. I didn’t spend time imagining what they would look like and who they would resemble. We didn’t think up names and go pick out cute clothes. (Audrey)

Encouraging a Healthy Body Image

Body image refers to people’s attitudes, beliefs, and perceptions of their own body (25). The participants shared how the experience of relinquishment has encouraged them to perceive their bodies in a positive way. These women have developed a deep appreciation for what their bodies are capable of doing:

It makes me appreciate my body more than I did. I’m very proud to be a woman. I’m very proud to be able to say that I’ve helped that family and able to appreciate my body and my health. (Marie)

It takes a strong woman and courage to become a surrogate. Being pregnant for nine months then after giving it to others. That’s the best of all, on my journey. I have no psychological issues after delivery and relinquishing the baby. I did not have postpartum depression after it. I am proud of myself. (Angelina)

One participant reported how the child relinquishment experience has regained her body confidence after a miscarriage:

Sounds silly, maybe, but it made me really love and appreciate what my body could do. After my own miscarriage, I had some really hard feelings about my body. I felt let down by it. Having my own son helped, but even that labor didn’t go well and I had to have a C-section. I think the experience really helped boost my confidence in my own body again. I loved how positive I felt about my body, and my heart felt good. (Audrey)

Discussion

This study adds to the literature on surrogacy through its focus on the meaning and experience of relinquishing a baby in commercial surrogacy through the application of IPA. Although previous quantitative and qualitative studies have established, in a very general manner, that most surrogates express no psychological difficulties after relinquishing the babies, our research provides a detailed portrait of the gestational surrogates’ child relinquishment experience and the meanings they attributed to this experience. The participants of this study brought up personal and subjective meanings in relation to their experience of relinquishment, which was central importance to the successful transfer of the baby to the intended couples.

The findings of this study reiterate the strong perception of relinquishment as a prosocial action meant to aid infertile couples and to offer them the opportunity of parenting. We believe that paid surrogacy can still be an altruistic experience for gestational surrogates. Assumption of financial compensation as the “real reason” for participating in paid pregnancy is problematic. This assumption preserves the idea that surrogates are not “normal” and “natural” women (26). Surrogates should be viewed as normal or natural women who are capable of internally motivated to empathize with infertile couples. The participants in this study are also mothers to their own children; thus, they understand the pain of being childless. In line with the empathy-altruism hypothesis, if people have strong empathic concern for others, they will help them, regardless of what they can gain from it (27,28). Recent cross-cultural research confirmed that surrogate mothers have a high emotional empathy, which might help surrogates imagine they will be able to help an infertile couple (29). Rather than classifying gestational surrogates’ motivation as altruism or monetary gain, commercial gestational surrogacy should be construed as a prosocial action, which is a complex mixture of both intrinsic (altruism) and extrinsic (monetary) motives.

The findings of the study also bring to light how gestational surrogates manage their social identities as “natural” mothers in the process of gestating and relinquish the child. Consistent with Teman’s findings (30), surrogates undertake the psychological process of disembodiment in which they separate the surrogacy pregnancy from their presurrogacy pregnancy self-identity. In addition, the agencies’ prenegotiation terms have psychologically ensured them that they fully understand their roles as a surrogate mother. A thorough briefing of the contract appears to be quite successful in assisting surrogates to achieve a cognitively consonant state during and after the relinquishment of the baby (31). Hence, the commercial approach of gestational surrogacy appears to facilitate the psychological detachment process among the gestational surrogates (ie, when surrogated prepared to distance themselves emotionally from the baby) (32).

Lastly, the findings of this study draw attention to the body image experiences of the 3 women who undergone commercial gestational surrogacy. Although the women tend to have high levels of body image dissatisfaction after childbirth (33,34), the participants’ experience of child relinquishment has become a transformative event that generated positive perceptions of their bodies. It has been argued that being a surrogate is a profound experience that allows women in altering and transforming their psychic structure in a direction they desire and fulfilling ideal images of themselves (35). Although no research has specifically explored pre- or postpregnancy body image experiences of surrogates, the findings of this study provide an insight into the unique body image experiences for women who undergone gestational surrogacy. The experience of relinquishment carries personal and relational meanings, which were of central importance to the women’s sense of self and subjectivity.

Reflexivity

We recognized that our own beliefs and opinions about surrogacy might have influenced the entire research inquiry process. On a personal note, we firmly believe that it is unfair for a woman to carry a baby for intended couples and get nothing in return. Women should be fairly compensated for their commitment to helping intended parents as well as the physiological demands of pregnancy. As researchers, we have assumed an epistemological position that views motherhood as a social construct rather than a purely biological phenomenon. Thus, this led us to explore gestational surrogates’ experience of relinquishing a baby and interpret the meanings they give to this experience.

Conclusion

Overall, this study illustrates the sense-making process that characterizes gestational surrogates’ relinquishment experience in commercial surrogacy. Particularly, the findings of this study contribute to the limited literature on the experiential dimension of commercial gestational surrogacy by offering a detailed portrait of the sense-making process that makes the relinquishment of the baby a successful event for surrogates. For this reason, the findings of this study have implications for patient support. First, the finding of the study accentuates the importance of presurrogacy counseling, which ensures not just the legal, but the psychological contract between surrogates and intended couples. Second, gestational surrogates’ ability to manage their identities during and after the surrogacy process can provide crucial knowledge for mental health and medical professionals who are interested in the development of psychosocial support tailored to ensure a successful transfer of the baby from the surrogate to the intended couple. Lastly, psychologists who are interested in helping gestational surrogates at risk of postpartum depression may create an intervention approach that fosters healthy body image experiences.

Author Biographies

Austin P Ferolino is a lecturer in Psychology at the University of San Carlos.

Mia Angelica D Camposo received her Bachelor of Science in Psychology at the University of San Carlos. She is a registered psychometrician.

Karla Christianne L Estaño received her Bachelor of Science in Psychology at the University of San Carlos. She is a registered psychometrician.

Jessa Marie R Tacbobo received her Bachelor of Science in Psychology at the University of San Carlos.