Introduction

Many studies have found infertility to be very stressful. Involuntarily childless people are usually completely focused on various options for acquiring a child [1, 2] and preferably one who is biologically related to them [3]. Increasing access to assisted reproductive technologies (ART) has opened new path to obtaining genetically related children. Although gestational surrogacy has been around since the 1980s, it is still controversial because it requires the physical participation of a third party who carries the child for the couple. Due to disparate country-specific legislation on surrogacy and varying access to infertility treatments, cross-border reproductive care (also known as reproductive tourism) is a growing phenomenon [4, 5].

Discrepancies in the regulation of surrogacy show its contested status as a reproductive method. In many industrialised countries surrogacy is banned (e.g. France, Germany, Italy, Spain, and some states in the U.S.), while other countries allow altruistic surrogacy or impose certain regulations on the practice (e.g. the U.K., the Netherlands, Greece, Australia, and South Africa) [6, 7]. In Sweden, surrogacy is partly unregulated but this situation is under review by the government and might change [8]. Israel has created an internal state-funded market in which only Israeli commissioning parents are permitted to have children through Israeli surrogate mothers, thus disallowing reproductive tourism [9]. California is unique as an area where surrogacy arrangements are organised through agencies with little state interference [6]. India is well known for having turned surrogacy into a multi-million dollar market serving couples from all over the world [10–14]. It has accordingly been called ‘a transnational hub for surrogacy’ ([15] p.14).

To a great extent the international debate on surrogacy revolves around the concept of exploitation. As used here, we define exploitation as ‘the taking of unfair advantage such that one individual or party gains at another’s expense’ ([15] p.25). Critics of commercial surrogacy in a global reproductive market highlight inherent power inequalities between commissioning parents and surrogate mothers [13, 16, 17]. Transnational surrogacy has therefore been described as a ‘reproductive supermarket’, in which ‘industrial wombs’ or ‘outsourced wombs’ are marketed and ‘baby-selling’ takes place (e.g. [18, 6]). Critical voices contend that the global fertility market is structured along class, ethnic, and racial lines, and that capitalist logic leads to exploitative relationships between poor women in low-income settings and wealthy commissioning parents [6, 11, 19]. Also in Sweden this view is notable in the media, especially among feminists. There is, however, no unified feminist position, either internationally or in Sweden: some feminists condemn all forms of surrogacy as a commodification of women’s reproductive capacity and as exploitative per se, while others believe women should have the democratic reproductive freedom to enter into surrogacy contracts [12, 20–25]. In India there is even a discourse describing surrogacy as an opportunity for empowerment for the surrogate mothers because of the possibility of a significant financial benefit for themselves [24, 26].

Similarly, there are divergent views on the medical consequences of surrogacy. There are some who highlight the increased risks to which surrogate mothers are exposed because of hormonal treatments, multiple gestations, and unnecessary caesarean sections [12, 27, 15]. Others report that the close medical surveillance during surrogate pregnancies makes those pregnancies less likely to bring severe complications (e.g. [28]).

The key issue being debated is whether surrogacy should be construed in terms of opportunity and choice, or inequality and exploitation [29, 23, 10, 30]. Some claim that it is a win-win situation for surrogate mothers and commissioning parents alike, in settings such as India [27]. Others argue that the relationship between commissioning parents and surrogate mothers is never purely contractual but has an inescapable ethical dimension with unequal social powers [29].

There is no legal regulation of ART in India. Only non-binding guidelines exist. According to governmental guidelines, a surrogate contract should be drawn up in which the surrogate mother relinquishes all parental rights and agrees to avoid harming herself and the baby. The commissioning parents in turn commit to paying for all costs associated with the surrogacy arrangements and the guidelines also state that the commissioning parents will have full custody of the child immediately after birth [31]. The rapid increase of surrogacy arrangements in India has, however, created a need for legislation beyond unenforceable guidelines. A government bill on ART was drafted in 2008, but has not yet been passed. It has been criticised by Indian scholars for not sufficiently protecting the surrogate mother’s health and interests [32, 33].

Transnational gestational surrogacy is under-researched [15] and there are currently only a few studies of Western commissioning parents’ experiences of using transnational surrogacy. These are mainly included in larger studies focusing on several issues of the surrogacy process [34–37], so we know little of the views and concerns of prospective parents who contract for transnational surrogacy. For the present study we interviewed Swedish commissioning parents who have decided to let women abroad carry their children through surrogacy arrangements. Sweden is conspicuous as one country where the technology enabling surrogacy is unlawful [38], but where the practice is otherwise unregulated. Hence, people who want to have a family by means of surrogacy cannot have clinic-based treatment in Sweden, but can make those arrangements on the global market. As may be expected, such a decision can involve some moral qualms. It has been argued that cross-border reproductive care may work as a ‘safety valve for couples whose moral principles are not represented by the laws regulating their own countries’ ([39] p.20). Commissioning parents who acquire their children by travelling to a country such as India might find themselves implicitly or explicitly accused of being immoral and exploitative (see e.g. Parks ‘calling commissioning couples to task,’ ([29] p.336).

The prevalent discourse on transnational surrogacy as an exploitive activity is not unknown to commissioning couples [23]. The aim of our study was to explore Swedish commissioning parents’ experiences and motivations for using transnational gestational surrogacy and how they construct and negotiate their understanding of this arrangement in the light of the exploitation discourse on surrogacy.

Materials and Methods

Results

Surrogacy was seen as a last resort in seeking to have a child. Many interviewees were affected by media discourses on surrogacy, especially the focus on the vulnerable situation of surrogate mothers. However, when researching surrogacy, they found other sources of information (e.g. internet forums for people using surrogacy) which brought new perspectives that counterbalanced the negative image of surrogacy provided by the media. Couples that had turned to India felt the need to take a stance, many of them critically, on the exploitation discourse. They referred to the financial compensation provided to the surrogate mother as the only opportunity for her to improve her economic situation and embark on a better life. Nevertheless, they also argued for legalising surrogacy in Sweden as that would protect the interests of all parties involved. All quotes below are from commissioning parents using India except one, where it is stated that the commissioning parent had used the U.S.

Discussion

Transnational commercial surrogacy brings out the issue of potential exploitation in light of global socioeconomic inequalities. From the perspective of commissioning parents the practice involves moral qualms and is perceived as a last resort. Interviewees were aware of the exploitation discourse but defied it on the grounds that the Indian surrogate mothers wanted to do this in order to improve their life situation through the financial benefit of the surrogacy arrangement. Instead of commissioning parents seeing their actions as part of an exploitative global business, they focused on the welfare of the individual woman.

The commissioning parents justified their use of surrogacy as contributing to a significant benefit for both parties in the surrogacy arrangement. This kind of narrative is also found in another study on commissioning parents’ perceptions of using transnational surrogacy in India, and is interpreted as contradicting the discourse of exploitation [36]. Similar views on surrogacy are found among agencies in India, emphasising the great financial benefit and empowerment for the surrogate mother [42, 36]. It can then be assumed that commissioning parents in our study also have been influenced by the discourse of agencies. Still, in their contact with the surrogate mother, the commissioning parents tried to gain insight into her situation. Even though they got the impression that their surrogate mother was not exploited, some still had concerns about Indian surrogate mothers’ interests, and worried that these might not always be well protected. This is in contrast to those using surrogacy in Western countries, who had closer contact with the surrogate mother without involvement from agencies, and who did not express any uncertainties about the surrogate mother’s situation.

The ambiguous feelings towards surrogacy, that many of our interviewees explained they had felt before starting the process, are echoed in other parts of the world. Markens [23], who has researched discourses on surrogacy in the U.S., remarks that, although transnational surrogacy is often condoned because of the assumed benefit for the two parties involved, it comes with the awareness that surrogacy activities in India are in need of legal reform. To decrease the risk of exploitation, the parameters of informed consent should be tightened to protect the surrogate mother’s health and social interests. With only guidelines to follow and no regulation, adherence to good ethical medical practice exclusively relies on the ART clinics’ and agencies’ own feelings of responsibility. There are reports about clinics commissioning parents call “nontransparent and ‘fishy’” [36]. This would suggest that the non-exploitative impression that the commissioning parents report in our study might not be an impression they would have got at other clinics and agencies in India.

The agencies’ role in mediating the contact between the surrogate mother and the commissioning parents, led to uncertainties whether protection of the surrogate mother was always fulfilled. This contrasts to surrogacy arrangements in Western countries, where agencies did not have a similar role. However, the surrogate mothers in India benefit financially proportionally more from the arrangement and it can make a substantial difference in their lives at least in the short term, or in the long run for their children receiving better education. This is also an argument among some commissioning parents for choosing India. Some of the participants in our study who rejected the notion of exploitation argued that there is a lack of understanding regarding local context and the motives women have for becoming surrogate mothers. Regarding Western moral views on surrogacy in India, feminist philosopher Alison Bailey states that this approach incorrectly interprets the surrogate mothers’ experiences and ‘raise the specter of discursive colonialism’ ([10] p.716). This standpoint is consistent with that of sociologist Amrita Pande [43–47] who has conducted extensive fieldwork at a surrogacy clinic in India. She has explored the surrogate mothers’ situations and experiences of being part of transnational surrogacy arrangements and argues that the complex realities of poor Indian women must be the starting point for a nuanced debate about surrogacy [44].

Many interviewees using India describe a trajectory in which they went from a negative view of transnational surrogacy that was based on alarming mass-media reports, to more complex and nuanced positions as a result of their dealings with the surrogate mother and understanding of her life situation. This view is reflected in a study by sociologist Shamila Rudrappa, in which she found that the surrogate mothers’ situation as garment workers, prior to entering the arrangements with the surrogacy clinic, were perceived as far more exploitative than being a surrogate mother, which gave more meaning to their lives [48]. The situation of the surrogate mothers can be seen as relatively less exploitative than their former labour situation, according to Rudrappa’s findings.

Regarding the medical treatment and also the actual consequences of the surrogacy arrangement, these aspects were referred to as issues that stirred worry among some of the commissioning parents. The limited contact with the surrogate mother would make it difficult to get knowledge of the surrogate mothers’ well-being and how they are taken care of. In several studies it has been found that the surrogate mothers have not been properly informed about what kind of medical treatment they would get and the risks involved [44, 49, 36], thereby raising doubts to their informed consent [49].

The discourse on exploitation and surrogacy being an ethically questionable practice, influenced the commissioning parents initially, and led to a thorough search for a clinic or a way to minimise the risk for the surrogate mother not be well cared for. In line with this, Banerjee suggests that commissioning parents being more critical of how they use transnational reproduction would have the potential to reduce the risk of exploitation of surrogate mothers [50].

The definition or impact of exploitation is difficult to judge in an Indian context, where certain exploitation also can mean the potential of empowerment. Commissioning parents’ ambiguous views on surrogacy are mirrored in the current discussion on commercial transnational surrogacy in low-income settings, which embodies contrasting perspectives. On the one hand, some argue that ‘the only acceptable solution to international surrogacy in India remains abolition’, citing these activities as inherently exploitative [51]. On the other hand, despite incontestable power imbalances between surrogate mothers and commissioning parents, surrogacy may be a way out of poverty for many Indian women. It can present an opportunity for personal empowerment and increased independence in relation to husbands and families, a fact that complicates viewing the issue solely in terms of oppression and exploitation [50]. It has been shown that there is a strong correlation between an improved socioeconomic situation and positive health outcomes for both individuals and groups [51].‬ However, a stronger emphasis on reproductive rights on behalf of the surrogate mothers in ART clinical routines would be welcome.

The commissioning parents’ expressed uncertainty about the surrogate mothers’ interests not being well protected also led to arguments for allowing surrogacy in Sweden in order to increase the safety for all involved. The desire to reproduce makes people go to great lengths to have children [52], but regulation in the home country, allowing domestic surrogacy, would be offering an alternative of using surrogacy in a context where it could be seen as more ethically acceptable. However, there are still discourses with ethical arguments against all kinds of surrogacy in whatever context it may occur [20]. This method of reproduction would then still risk being questioned in society, and ethical issues would need to be navigated even for domestic use.

The views of commissioning parents are important for a comprehensive understanding of the surrogacy context in all its complexity. A better understanding of commissioning parents’ experiences, decisions, and motives may contribute to future efforts to make improvements in this area.

Conclusion

Our study demonstrates the complex use of transnational surrogacy with colliding discourses. Infertile couples who have engaged in this practice also problematise the widespread exploitation discourse when referring to their encounters with surrogate mothers and the insight gained into their life situations, while they simultaneously argue for a regulation in Sweden.

With the growing phenomenon of cross-border surrogacy, the legal aspects of the mode of reproduction need to be regulated on both national and international levels. The European Society of Human Reproduction and Embryology (ESHRE) and the International Federation of Gynecology and Obstetrics (FIGO) have addressed the exploitation risk in surrogacy in their guidelines for regulating surrogacy, which can be useful in regulating efforts [53, 54]. It is also important, however, to consider commissioning parents’ experiences of using transnational surrogacy and the context-based issues of this reproductive method, as shown in this study. With the Ministry of Justice’s reviewing of the situation of surrogacy, it remains to be seen if there will be an alternative for potential commissioning parents to use surrogacy within Sweden.

Acknowledgments

We are deeply indebted to the informants who openly shared their views and experiences during interviews.