Experiences, psychological health, and prenatal bonding of surrogate mothers: a longitudinal study

Background: Globally there is limited information on the long-term psychological health of surrogate mothers. Power differentials between surrogates and intending parents and the commercial aspect of the surrogacy arrangement raise concerns regarding the psychological health of surrogate mothers, specifically in low-income countries. In India, cross-border commercial surrogacy became a 6-billion-dollar industry between 2002-2017.
Aim and methods: The current study explores the psychological well-being and prenatal bonding of surrogates in comparison to a matched group of expectant mothers in India who had children for international intending parents. Surrogate mothers were interviewed at three time points: during pregnancy, four to six months post-birth, and five years post-birth. Studies in the West have found that surrogates do not suffer long-term psychological harm and often keep in touch with the parents and the surrogate child. Semi-structured interviews and standardized questionnaires were administered to 50 surrogates and 69 expectant mothers during pregnancy, 45 surrogates and 49 expectant mothers 4-6 months post-birth, and 19 surrogates 5 years post-birth.
Results: While overall psychological health did not significantly differ for the surrogates over the three time points, surrogates had higher levels of depression compared to the comparison group of mothers, during pregnancy and post-birth. Low social support during pregnancy and stigma associated with surrogacy from others were found to be predictive of higher depression in surrogates a few months post-birth. Regarding prenatal bonding, surrogates interacted less with and thought less about the fetus but adopted better eating habits and were more likely to avoid unhealthy practices during pregnancy, than expectant mothers. Importantly, attachment with the unborn baby during pregnancy was not significantly associated with greater psychological distress during pregnancy or after relinquishment. Nearly half of the surrogates did not meet the intended parents and only one third met the newborn. None of them met the child at the time of delivery.
Impact: This is the first study of the psychological well-being of surrogates in low-income countries. Both quantitative and qualitative findings have important policy implications for low-income countries where surrogacy industry remains unregulated.