Hum. Reprod. Advance Access originally published online on July 17, 2007
Human Reproduction 2007 22(8):2287-2295; doi:10.1093/humrep/dem155
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Psychological trait and state characteristics, social support and attitudes to the surrogate pregnancy and baby
Department of Psychology, Aston University, Aston Triangle, Birmingham B4 7ET, UK; Centre for Human Reproductive Sciences, Birmingham Women's Health Care Trust, Metchley Park Road, Edgbaston, Birmingham B15 2TG, UK
Correspondence address. Tel: +44-121-204-4085; Fax: +44-121-359-3257; E-mail: o.vandenakker{at}aston.ac.uk
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Abstract |
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BACKGROUND: Personality differences between surrogate mothers (SMs) who gestate and relinquish and intended mothers (IMs) who commission a genetically related or unrelated baby have been unexplored in the UK. Furthermore, the psychological effects of the arrangement have not been determined in a prospective longitudinal study, making this the first quantitative report of psychological functioning in SMs and IMs.
METHODS: SMs and IMs (n = 81: 61 surrogate, 20 intended) undergoing genetic or gestational surrogacy (4 groups) were assessed by postal questionnaire during the first, second and third trimesters of pregnancy. Those with a positive outcome were assessed again in the first week, at 6 weeks and 6 months post-delivery of the surrogate baby.
RESULTS: There were no significant differences between or within SM and IM groups on personality characteristics. Social support, marital harmony and state anxiety differed significantly (to P < 0.01) between SMs and IMs at different stages of the arrangement. Differences in attitudes towards the pregnancy and the baby were also observed between groups during pregnancy (to P < 0.001), but there was no evidence of post-natal depression amongst the groups studied.
CONCLUSIONS: These results are important because they demonstrate psychological effects of the surrogate arrangement are notable and occur over an extended period of time. It also shows that psychological screening and support prior to, during and following surrogacy is indicated.
Key words: surrogacy/genetic/gestational/attachment/psychology
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Introduction |
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Surrogate practices and policy formation are now established in many countries including the UK (Human Fertilization and Embryology Authority Act, 1990
, section 3 (5); Sharma, 2006). This is despite the fact that surrogacy does not seem to be a publicly desirable option to overcome involuntary childlessness (van den Akker, 2007). It is now nevertheless recognized that ‘Over time, professional opinion has shifted to a position where surrogacy is recognized as an appropriate response to infertility in some circumstances' (DoH, 2006). Surrogacy can be carried out in two different ways. Surrogate mothers (SMs) can use their own oocyte and artificial insemination (SMAI) or the intended mother's (IM's) oocyte and go through the process of embryo transfer (SMET). SMAI therefore relinquish a genetically related baby, whereas SMET do not. IMs similarly can use the surrogate's oocyte and AI using the IMs' husband's sperm (IMAI) or they can use their own oocyte and go through Embryo Transfer (IMET). The former will not give them a genetic baby, but the latter will. Surrogate arrangements using AI are referred to as genetic surrogacy, which does not require the involvement of a clinic. Embryo transfer surrogacy is referred to as gestational surrogacy, which uses technology and interventions carried out in a specialist clinic (ASRM, 1990).
The treatment interventions require that physical characteristics of the couples involved in surrogacy are routinely monitored (van den Akker, 1998, 1999). However, psychological screening of SMs and IMs is relatively neglected in clinical practice. This may be because only a limited amount of social sciences research using standardized questionnaires exists, and because they rarely identify psychopathology, social isolation or stigma in SMs (Franks, 1981; Hanafin, 1987; Mechanic Braverman and Corson, 1992; van den Akker, 2003) or women intending to commission a surrogate to carry a baby for them (IMs) (Blyth, 1995; van den Akker, 2000; MacCallum et al., 2003). However, personality profiles have not been adequately investigated in SMs and IMs in the UK, and these may well be different from population norms because surrogates themselves report that surrogacy takes a special kind of person (Blyth, 1994; van den Akker, 2003). Similarly, IMs may have different personalities from others not initiating surrogate arrangements (as was found by Mechanick Braverman and Corson, 2005 in the USA), and this is therefore also explored in the present investigation. The lack of psychological screening in clinical practice is an important omission, because SMs and IMs may be psychologically challenged or predisposed to perceive events as taxing and may need tailored holistic care and support.
Attitudes towards pregnancy, the fetus and baby can vary enormously between pregnant women (Marteau et al., 1989) and have not been systematically investigated in SMs and IMs. Attitudes towards a fetus are indicative of attachment to the baby post-partum (Rubin, 1984; Reading et al., 1984). Research has already shown that SMs appear to be less attached to the fetus (Fisher and Gilman, 1991), and that surrogates are encouraged by their agency to develop feelings of detachment to the fetus in pregnancy (van den Akker, 2005), reinforcing the need to remain detached during delivery and the first post-natal days (van den Akker, 2007). It was therefore anticipated that a surrogate who is attached to the fetus during pregnancy may be more anxious during pregnancy and depressed post-delivery. It was also expected that an IM who is attached to the fetus during the pregnancy may be more anxious because they will have more to lose if something goes wrong with the pregnancy or delivery, particularly if it is genetically related to her.
Furthermore, because of the timeline and depth of involvement between SMs and IMs it is possible that the surrogate relationship affects both parties' usual sources of social support and their marital relationship, which in turn could affect their mood. Blyth (1994) noted that genetic surrogates do not have the same benefit of clinic involvement as gestational surrogates, which could lead to a significantly worse psychological outcome in genetic surrogates (Fisher and Gilman, 1991; Appleton, 2001; Edelmann, 2004). Perceived social support and quality of the marital relationship were therefore also assessed. Lastly, because the surrogate process is characterized with uncertainty, it is possible the surrogate pregnancy could lead to anxiety in both parties. Although not confirmed using measurable indicators, Reame and Parker (1990) observed increased stress in surrogates towards the end of the pregnancy, labour, delivery and relinquishment. High anxiety in pregnant surrogates can lead to adverse peri-natal outcome (Reading, 1983; Neggers et al., 2000; Mancusco et al., 2004) and is therefore of clinical importance. This study was carried out to provide a long-term (from pre-pregnancy to 6 months post-delivery) prospective account where changes over time could be reliably recorded. Where possible, genetic and gestational SMs and IMs were studied separately because IMs (van den Akker, 2000) and SMs (van den Akker, 2003) appraise the importance of a genetic link similarly. The perceived costs and benefits of AI and ET are opposites, and differences were therefore also expected between gestational or genetic, in addition to intended and surrogate, group factors.
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Materials and Methods |
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Design
This paper reports the results of the quantitative analyses of longitudinal comparative questionnaire data, where genetic and gestational surrogates were compared with independent comparison groups of genetic and gestational IMs. This was part of a larger study involving semi structured interviews carried out pre arrangement and 6 months post-delivery (van den Akker, 2005
), for which ethical approval was obtained.
Materials
A series of reliable and validated questionnaires were used to obtain detailed information about both stable trait and state differences in psychological functioning between these groups of women. Sociodemographic information was obtained and has been reported elsewhere (van den Akker, 2005). The short form of the Eysenck personality inventory (consisting of 12 ‘yes/no’ items for the Psychoticism, Extraversion, Neuroticism and Social Desirability subscales ranging from 0 to 12; EPI, Eysenck et al., 1985), and the state and trait versions of Spielberger's (1970) anxiety questionnaire (ranging from 0 to 80, with high scores indicating high anxiety) were used. Other scales included a measure of Marital harmony (0–84, with high scores indicating severe disharmony; Rust et al., 1988), a Perceived Social Support scale which rates support from parents (useful because of the genetic link in all genetic surrogacy arrangements), family and friends (all ranges 3–15), as well as positive (range 8–40) and negative (range 11–55) support from husband/partner separately (alpha reliability = 0.82; Omer, 1986), the Marteau et al. (1989) Attitudes to Pregnancy the Foetus and Baby scale, which asks respondents to rate both positive (range 0–28) and negative (range 0–21) attitudes to the pregnancy, fetus and baby (indicating positive and negative strength of concerns simultaneously) and worries and certainty about the health and wellbeing of the baby (rated on 0–8 point scales each; which has good predictive validity; Marteau et al., 1992), and the Edinburgh post-natal depression (PND) inventory (range 0–30; Cox et al., 1987).
Participants
Participants were recruited from the UK COTS (Childlessness Overcome Through Surrogacy) agency over a period of 3 years. Consecutively registering (or re-contacting COTS for a new arrangement) SMs and IMs were given a brief explanation of the study by COTS help-liners. Each prospective participant was asked if they were willing to volunteer, and those who did gave permission for the help-liner to pass on the participants contact details to the researcher. The researcher contacted a total of 143 SMs (n = 81) and IMs (n = 62) who were given a detailed explanation about the nature of the study over the phone and were then asked if they would participate. Of the 143 contacted and informed, 46 (19 SMs, 29 IMs) did not volunteer to take part, leaving 95 (66%) who agreed. Fourteen of those who had agreed (1 SM, 13 IMs) were lost as a result of moving house or not returning questionnaires. In total therefore, 81 of those who agreed completed the first questionnaire (61 SMs, 20 IMs). The 61 surrogates consisted of 22 AI and 39 ET surrogates, the 20 IMs consisted of 12 AI and 8 ET IMs. Where possible, data were analysed for the four groups separately. All SMs and IMs had been offered the standard information provided by COTS, including the desirability to talk to a counsellor. None revealed a medically confirmed history of psychiatric illness.
Sociodemographic details and obstetric histories
In line with previous research (Blyth, 1994,1995; Baslington, 1996; van den Akker 2000, 2003) significant differences in age between SM (
= 31.39, SD = 4.90, SE = 0.62) and IM ( = 40.14, SD = 6.03, SE = 1.35) groups were found (t = 6.53, df = 79, P < 0.000). Marital status and parity were not analysed statistically because the data did not meet the conditions for chi squared analyses. However, clear differences between IM and SM groups were evident, with 100% of IMs being married, and 64% (AI) and 67% (ET) surrogates either married or having a partner. All but one surrogate had one or more children and only one AI and three ET IMs had previous live deliveries. Some differences were also evident between SM and IM groups in education, with no surrogate reporting higher education and 25% (AI) and 75% (ET) IMs reporting higher education. Similarly, no surrogate reported being in higher occupational groups versus 25% (AI) and 62% (ET) IMs reporting having high-managerial or professional occupations.
Previous pregnancy complications were determined in surrogates because they were preparing themselves for a new (surrogate) pregnancy. A minority of surrogates had reported problems, high blood pressure (one AI, two ET), excessive sickness (one AI), bleeding (one AI, three ET) and one ET surrogate reported an ectopic pregnancy. Previous delivery problems were reported by 23% AI surrogates and 28% of ET surrogates. Self-reported PND was reported by 18% of AI and 21% of ET surrogates.
Procedure
SMs and IMs were contacted by telephone to ask for participation in this long-term study. They were sent postal questionnaires pre-pregnancy at Trimesters 1, 2 and 3 of pregnancy and again at 6 days, 6 weeks and 6 months post-natally. The data reports on responses from 81 participants who started a surrogate arrangement. The final 6 month post-natal assessments relate only to the 32 who completed post-natal questionnaires, resulting in different pre-pregnancy comparisons from the n = 81 reported at the start (see Table 1 for order of assessments at each time point and attrition over the 3 year study period).
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Data analyses
A series of univariate factorial 2 group (type of mother; SM/IM) x 2 genetic link (AI/ET) analyses of variances (ANOVAs) were carried out to test for significant differences in personality and psychosocial functioning between the four groups: SMET, SMAI, IMET and IMAI. During pregnancy and post-delivery t-tests between combined (AT/ET) SM groups and combined (AI/ET) IM groups were carried out because of the smaller numbers (n < 5) within the latter groups. Separate t-tests on the AI/ET grouping factors (each including SM/IMs) were also carried out to determine commonalities or differences between women opting for genetically linked/not linked surrogate arrangements.
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Results |
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The sample
Seventy four participants completed the first set of questionnaires pre-pregnancy and attrition occurred over time (Table 1). Twenty-six completed the term 1, 26 the term two and 25 the third trimester assessments. Post-natally, 31 completed the 6 days post-natal, 32 the 6 weeks post-natal and 29 the 6 months post-natal assessments. Reasons for attrition included: failure to conceive (n = 27); abandonment of arrangement, usually associated with difficulties with their counterpart (n = 10); surrogate became pregnant with her own baby (n = 1); spontaneous abortion (n = 3); became pregnant but refused to continue with the research (n = 6) and 5 did not respond to further requests. The final 29 consisted of 8 AI, 11 ET surrogates and 7 AI and 3 ET IMs.
Assessment between the 4 groups separately at start of surrogate arrangement
Seventy four participants completed the EPI, trait (n = 73) and state anxiety (n = 66), marital harmony (n = 53) and social support (n = 65) questionnaires prior to the arrangement. Univariate 2 Group (type of mother; SM/IM) X 2 Genetic link (AI/ET) ANOVAs showed no effects or interactions for any of the stable personality variables (see Table 2). No effect for state anxiety pre-pregnancy between SM/IM groups (F(1,66) = 1.05, P > 0.05) or AI/ET groups (F(1,66) = 1.68, P > 0.05) were found either, but there was a significant interaction (F(1,66) = 10.84, P < 0.002) with state anxiety scores highest for IMs using ET and lowest for IMs using AI. However, the opposite was found for surrogates with AI surrogates reporting higher state anxiety than ET SMs pre-pregnancy, reflecting highest anxiety in both groups (SM/IM) when they were using their own genetic material.
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Further univariate factorial 2 group (type of mother; SM/IM) x 2 genetic link (AI/ET) analyses revealed no significant effects or interactions for parental, family or friends' social support (Table 3). However, a main effect for perceived positive social support received from husband/partner was obtained for SM/IM groups (F(1,52) = 4.76, P < 0.05) with IMs reporting more positive support from their partners, but no effect for AI/ET (F(1,52) = 1.62, P > 0.05) or interactions (SMIM x AIET) (F(1,52) = 1.74, P > 0.05; Table 3) were obtained. An additional effect for negative social support from husband/partner was also obtained for SM/IMs (F(1,52) = 5.97, P < 0.01) with surrogates reporting significantly more negative support from their husbands/partners than IMs, but again no effect for AI/ET (F(1,52) = 0.14, P > 0.05) or Interaction (F(1,52) = 2.40, P > 0.05) were observed. Lastly, pre-pregnancy assessments of Marital harmony confirmed a significant effect for marital (dis)harmony (F(1,53) = 8.52, P < 0.01; also shown in Table 3) with surrogates reporting being in less harmonious relationships than IMs but no effect for AI/ET (F(1,53) = 0.08, P > 0.05) or interaction (F(1,53) = 1.18, P > 0.05) was apparent.
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Pregnancy assessments between SM (AI + ET combined) and IM (AI + ET combined) groups at Trimesters 1, 2 and 3
State anxiety during pregnancy
During early (t = 0.24, df = 24, P > 0.05) and middle pregnancy (t = 1.35, df = 24, P > 0.05), no differences between SMs and IMs in state anxiety were observed. However, in the final trimester of pregnancy (Trimester 3), IMs (
= 45.14, SD = 17.46, SE = 6.60) were more anxious than surrogate groups ( = 30.44, SD = 7.83, SE = 1.84; t = 2.95, df = 23 P < 0.05).
Attitudes to the pregnancy, fetus and baby during pregnancy
A number of attitudes to the pregnancy and fetus and worries and concerns about the health and wellbeing of the baby were significantly different between SM and IM groups. In Trimester 1, surrogates had less positive attitudes towards the fetus (t = 5.45, df = 2, P < 0.001) and were less worried about the health and wellbeing of the baby (t = 2.01, df = 23, P < 0.05; Table 4) than IMs. At trimester 2, IMs were significantly more negative about the pregnancy (t = 2.29, df = 23, P < 0.05), the fetus (t = 2.12, df = 23, P < 0.05) and more worried (t = 3.34, df = 22, P < 0.01) but they were also more positive about the fetus (t = 6.65, df = 23, P < 0.001) than surrogates. A similar pattern was observed in Trimester 3, IMs continued to have negative attitudes to the surrogate pregnancy (t = 3.49, df = 23, P < 0.01) and continued to be worried about the health and wellbeing of the baby (t = 2.77, df = 22, P < 0.01), although their attitudes towards the fetus were significantly more positive (t = 5.85, df = 23, P < 0.001) than surrogates. Surrogates are therefore characterized by low scores on attitudes towards the fetus during pregnancy, and if they did express their feelings, they were less positive and less concerned about the fetus. IMs, on the other hand held positive and negative attitudes towards the pregnancy (once this was showing) and some negative attitudes towards the fetus, possibly, because they were significantly more worried about the health and wellbeing about the fetus.
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Social support during pregnancy
The surrogate group showed a number of significant differences in perceived social support from the IMs (see Table 5). During Trimester 1, SMs received significantly less social support from their parents (t = 3.27, df = 22, P < 0.01) than IMs. At Trimester 2, parental social support remained lower for surrogates although this was not significant (t = 1.97, df = 23, P > 0.05). No differences in parental social support were obtained in the final trimester of pregnancy (t = 0.37, df = 23, P > 0.05). As can be seen from Table 5, although no other sources of support were significantly different between groups during the three trimesters of pregnancy, surrogates consistently reported less support than IMs from all sources.
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Post-natal psychological states and social support between SM and IM groups
Post-natally, t-tests were again carried out on the combined SM (AI and ET) and IM (AI and ET) groups (n = 21 SM and 11 IM, respectively) because of the smaller numbers of participants in the subgroups. No differences in PND (t = 0.336, df = 29, P > 0.05) or state anxiety (t = 0.268, df = 30, P > 0.05) were found between SMs and IMs at 6 days post-delivery or at 6 weeks post-delivery (state anxiety t = 0.26, df = 30, P > 0.05 and PND t = 0.59, df = 28, P > 0.05). As was found during Trimester 1, surrogates at 6 weeks post-delivery continued to report being significantly less well supported by their parents (t = 2.33, df = 30, P < 0.05) and reported less positive (t = 2.38, df = 24, P < 0.05) and more negative (t = 2.13, df = 24, P < 0.05) support from their partners (see Table 6). At the final, 6 month post-natal assessment, PND, state anxiety and marital harmony were again assessed, and no differences in PND (t = 0.05, df = 27, P > 0.05) or state anxiety were found (t = 0.30, df = 27, P > 0.05), although surrogates reported higher marital disharmony (t = 2.13, df = 22, P < 0.05) as was reported pre-pregnancy. Surrogates also reported significantly higher negative husband/partner support (t = 2.34, df = 24, P < 0.05) and lower husband/partner positive support (t = 2.32, df = 24, P < 0.05) than IMs (Table 6). These results show that social support from parents and husbands/partners in surrogates is significantly worse than in IMs.
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Pregnancy and post-natal analyses for AI (including SM and IM groups) and ET groups (also including SM and IMs) resulted in fewer group differences than expected. Analyses showed that in the second trimester of pregnancy women using AI (SM and IMs) (
= 8.80, SD = 6.71, se = 2.12) were significantly more negative about the pregnancy than women using ET (SM and IMs) ( = 4.73, df = 3.08, se = 0.79) (t = 2.05, df = 23, P < 0.05). No other significant differences were found. |
Discussion |
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The study was based on a sample of consecutively contacted SMs and IMs, who volunteered to take part in this longitudinal study. The results are therefore generalizable to these populations only. The sample was self-selected, but likely to be representative of SMs and IMs because the majority (66%) agreed to participate. It was impossible to determine differences between volunteers and non-volunteers (because the latter did not make themselves available for study), but COTS help-liners confirmed that in their experience, no clear differences between these were apparent. Drawbacks of a prospective design are high attrition rates, and in studying infertile populations, attrition, lack of cooperation and giving socially desirable responses are not uncommon (McKenna, 1998
). Fewer IMs (32%) were willing to take part than surrogates (75%), possibly because the former needed to use surrogacy (and have reported stigma associated with infertility) whereas surrogates chose to do surrogacy. Attrition, through abandonment of the arrangement (17%) because of failure to conceive (36%) and through a lack of commitment to continue with the research (16%), was high and led to a need for caution with analyses. High attrition of studies using SMs and IMs is consistent with previous research using different samples (van den Akker, 2003). The pregnancy and post-natal data in particular were therefore analysed and presented between—rather than between and within—groups. With regards to the initial factorial group (SM/IM) by genetic link (AI/ET) analyses of psychological traits, no differences between groups were evident suggesting stable personality characteristics (as measured on the EPI and trait anxiety) do not differentiate between women giving up or receiving a genetically related or unrelated baby. These results are reassuring because they provide evidence that any subsequent state differences cannot be attributed to constitutional differences between the groups. Differences in state characteristics were observed during the pre-pregnancy period, in late pregnancy and at 6 months post-delivery, with pre-pregnancy state anxiety higher in IMET and SMAI mothers. IMET mothers use their own oocyte (and embryo) for transfer to the SM; SMAI mothers also use their own genetic material in the surrogate pregnancy. Both these groups may be more anxious because they may feel they have invested most into this arrangement which is characterized by much uncertainty. In the final stages of pregnancy, the prospective IMs were significantly more anxious than surrogates. This is likely to reflect their concomitant increasing attachment and concerns for the health and wellbeing of the fetus. A genetic link and being an IM therefore does differentiate anxiety from other groups, independent of underlying differences in more stable personality characteristics.
Post-delivery, no further differences in state anxiety were observed. van Balen (1996) reported that women undergoing fertility treatment are likely to experience some additional problems in adjustment, causing concern in relation to the parent–child interactions. However, this is not equivocally reported (for a review see, Segev and van den Akker, 2006). In the present study, anxiety was identified during pregnancy, confirming previous reports (McMahon et al., 1997), but this seemed to be absolved in the post-natal period. These issues need to be explored in future research following larger groups of IMs and SMs over a longer time period than was feasible here, allowing separate analyses of pregnancy and post-natal intended AI and ET groups, as it is possible that IMET babies in particular are perceived as more precious than IMAI babies. For the surrogates, anxiety was not high during pregnancy which is clinically reassuring as it provides preliminary data suggesting peri-natal complications, a known outcome of high anxiety in pregnancy (Reading, 1983; Neggers et al., 2000; Mancusco et al., 2004), are unlikely to be the result of anxiety during the SMs pregnancy.
As was shown in Table 4, significant differences between SM and IM groups in their attitudes towards the fetus were apparent during the course of the pregnancy. IMs were significantly more positive about the fetus than the surrogates who were pregnant. They were also more worried about the health and wellbeing of the baby and more negative towards the pregnancy. Since the questions on the positive and negative attitudes differ, it is possible to obtain high scores on both and demonstrate multiple concerns the IMs had about all aspects of the pregnancy and fetus. The IMs' mixed responses appear to be healthy, inquisitive and to show concerns coupled with positive feelings towards the fetus which are likely to reflect an attempt to form a bond or attachment with the fetus (Rubin, 1984; Reading et al., 1984). The IMs' negative attitudes towards the pregnancy could be the result of fear of viability, which dissipated towards the end when the pregnancy was most visible. For surrogates, their consistent middle range scores in attitudes towards the pregnancy is likely to reflect their continued attempts to dissociate meaning to the pregnancy in an attempt to remain detached from it.
The surrogates lack of (positive or negative) feelings about the fetus is probably a deliberate attempt to dissociate themselves from possible attachment. Attachment theory states that attachment in pregnancy tends to be carried over to the baby following delivery (Rubin, 1984; Reading et al., 1984). By not attaching to the fetus, surrogates are developing constructive coping mechanisms towards the baby following delivery, thereby minimising any potential feelings of loss at relinquishment. Fisher and Gilman (1991) had already shown that surrogates are less attached to the fetus, and Blyth (1994) and van den Akker (2000) confirmed this retrospectively. The present study therefore provides additional longitudinal confirmatory data showing that detachment is reported early and maintained throughout the pregnancy, with little variation post-delivery. No differences in the experience of PND were reported.
What was consistently different between groups was the lack of social support from important people in the surrogates lives which were not lacking in the IM groups. The parents of surrogates were less supportive in the first trimester of pregnancy and at 6 weeks post-delivery. These time points are critical, as they involve confirmation of success of the pregnancy and confirmation of ‘success’ of relinquishment of the baby. It is likely that parents may have found it more difficult at these points in time, to accept the fact that the (in some cases genetically related) offspring would not become part of their family and social network. Furthermore, the surrogates studied here were less likely to be in stable relationships than IMs consistent with other research (Blyth, 1994; van den Akker 2003,2005). Unfortunately, for the surrogates who were in stable relationships, social support from husbands or partners pre-pregnancy and post-delivery was significantly less positive and significantly more negative than the husband/partner support reported by IMs. Marital disharmony was also higher in surrogates pre-pregnancy and a year and a half later at 6 months post-delivery. Previous research on Infertile couples undergoing treatment reports variable results, showing, in some cases, improved marital cohesion (Slade et al., 1997; Sydsjo et al., 2002), no differences (McMahon et al., 1997; Klock and Greenfeld, 2000) or increased marital conflict (Gibson et al., 2000; Hahn and DiPietro, 2001). However, these couples are not comparable to surrogates. Further qualitative research may have to be carried out to determine why this lack of support was reported in SMs.
The weaker social support received by surrogates throughout this period suggests continued counselling should be offered to surrogates to monitor their longer term welfare and to support them. Social support acts as a buffer for psychological health, and the identification of shortcomings in social support needs to be addressed as part of the clinical care offered. Blyth (1994) pointed out that gestational surrogates ‘benefit from the full panoply of regulation’ (and clinical care), whereas genetic surrogates ‘operate in a moral and psychological twilight’. This, as Edelmann (2004) points out, could predispose the surrogates to be particularly vulnerable. Further longer term research is therefore needed using larger samples to monitor the long-term outcome in these women separately for AI and ET arrangements, as the type of surrogacy is likely to have an effect on the wider social network of both SMs and IMs.
With one exception, none of the results of pregnancy and post-natal analyses for AI (including SM and IM) and ET groups (also including SM and IMs) were significant, indicating that a genetic link with a baby on its own has no differential effect on psychological state during the surrogate arrangement. Women using AI were significantly more negative about the pregnancy in Trimester 2 than women using ET. It is possible that the AI group consisting of (SMAI) genetic surrogates felt it would help them dissociate from the fetus by being negative about the pregnancy once it had passed the critical first trimester, whereas IMs using AI surrogacy (also included in the AI group) might have associated the (now established) pregnancy with the genetic (or biological surrogate) mother and hence felt negative towards it. Further research is needed to unravel the detailed differences within groups in more depth.
In conclusion, this study has shown that SMs and IMs, who have opposite reproductive needs, are comparable on stable psychological characteristics such as personality and anxiety. The IMs' psychological responses during pregnancy were vigilant and slightly more anxious towards the end when the fetus was visible, viable and nearly born and relinquished to them. The SMs' lack of anxiety and relatively flat response on attitudes towards the pregnancy, baby and fetus during pregnancy is reassuring and suggests their psychological state does not pose an increased risk of peri-natal or surrogate arrangement complications. One area that should be addressed in clinical care is the lack of social support surrogates received before, during and after the arrangement.
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Acknowledgements |
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This work was supported by a generous NHS R&D award made to the author. The views expressed are those of the author, not the NHS.
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References |
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Submitted on April 1, 2007; resubmitted on May 3, 2007; accepted on May 9, 2007.
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