Motivation and emotion/Book/2018/Surrogate motherhood motivation

Overview


Imagine you find out the happy news that you are pregnant and expecting a baby. Over the weeks you watch as your stomach grows and body changes. You feel increasingly fatigued, you begin to experience morning sickness, your breasts become tender and you are passing urine more frequently. Hormonal changes cause fluctuations in your mood. Visits to the doctor are becoming more regular. As the weeks pass your clothes become tighter until you no longer fit into them. As the baby grows, your uterus increases in size, pushing up on your ribs and causing discomfort. The lack of space causes indigestion and heartburn. You are experiencing more frequent headaches, back ache, and leg pain. As the pregnancy develops you can feel the baby moving around and you notice stretch marks on your abdomen and breasts ("Pregnancy Week by Week Guide - Essential Baby", 2018). You have not had a glass of wine in 40 weeks. The time has finally come and you go into labour. After eight hours of intense contractions, you give birth to a healthy baby. Oxytocin floods your system the minute you lay eyes on your new born child.

Now, imagine that you have to relinquish that baby, because you are a surrogate mother.

This chapter provides current information about what motivates some women to act as surrogate mothers.


 * What is a surrogate mother?
 * Why study surrogate motherhood motivation?
 * What are the different types of surrogacy?
 * What are the different motivations of surrogate mothers?
 * What are the relevant theories that could be applied to better understand surrogate motherhood motivation?

What is a surrogate mother?
A surrogate mother is a woman who becomes pregnant, either through artificial insemination (AI) or In vitro fertilisation (IVF), carries the pregnancy to term, and gives birth to a child for another couple or single person, with the intention of relinquishing that child to the couple or person (Imrie & Jadva, 2014; Tremellen & Everingham, 2016).

Why study surrogate motherhood motivation?
Becoming a parent is a significant milestone and major social role in life. Individuals who encounter barriers in being able to conceive a child often regard it as being a great personal tragedy, involving significant emotional pain and impacting their overall psychological well-being ("Childlessness", 2018). Two options available to overcome the issue of childlessness include adoption and surrogacy. Surrogacy is becoming the preferred option due to the possibility of having a genetic link between parent and child and with adoption becoming increasingly more restrictive (Van den Akker, 2007).

Surrogacy is the oldest and most controversial of reproductive innovations, dating back to biblical times (Ciccarelli & Beckman, 2005). It is impossible to accurately estimate the incidence of surrogacy due to the many informal arrangements that occur (Teman, 2008).

Despite the long history and prevalence of surrogacy, most people are not personally acquainted with surrogates or families created through surrogacy (Teman, 2008). The media therefore becomes the primary source of information in which surrogacy is rarely portrayed in positive and uncomplicated ways (Teman, 2008). Surveys investigating attitudes toward surrogacy indicate that the majority of people disapprove of the practice (Teman, 2008).

The common belief is that surrogate women are exploited, they do not relinquish the child or regret doing so, and suffer from psychological problems as a result (Teman, 2008). In reality, most surrogates report the relinquishment of the child to be a happy event and report no psychological problems as a result of relinquishment (Teman, 2008). These attitudes were shown to remain stable over time through longitudinal studies (Teman, 2008). The majority of surrogates reported high satisfaction with the process and that they would do surrogacy again. Less than one-tenth of 1% of surrogacy arrangements end up in court battles (Teman, 2008).

Another popular assumption is that women are motivated to become surrogate mothers purely out of financial desperation (Teman, 2008). In commercial agreements, this is more commonly the case, however commercial surrogacy is occurring less as it is illegal in most countries (Millbank, 2014). Studies have revealed that the most common motivations for women to become surrogate mothers include the enjoyment of being pregnant, sympathy for a childless couple, and the desire "to do something special". However, these motivations are often sceptically addressed (Teman, 2008).

Addressing the misconceptions about the motivations of surrogate women and their experiences could have significant impacts on psychological research in the field, social policy and public attitudes.

Types of surrogacy
The genetic relationship of the child with the surrogate and commissioning parents is determined by the way in which the egg is fertilised. There are two distinct types of surrogacy: genetic and gestational surrogacy (Van den Akker, 2003).



Genetic surrogacy
Genetic surrogacy, also referred to as traditional, partial, natural or straight surrogacy, involves AI of a surrogate and the child is genetically related to the surrogate mother and donor father (Imrie & Jadva, 2014).

Gestational surrogacy


Gestational surrogacy, also known as full or host surrogacy, involves IVF which results in the child being genetically related to the donor parents and unrelated to the surrogate (Imrie & Jadva, 2014). Gestational surrogacy is viewed as the preferred method as it presents lower risks regarding legal parentage and allows intending mothers to use their own oocyte (Imrie & Jadva, 2014; Van den Akker, 2007).

Commercial surrogacy
Surrogacy arrangements that are motivated by monetary compensation beyond reimbursement for medical expenses is known as commercial surrogacy (Millbank, 2014).

Altruistic surrogacy
Surrogacy arrangements that are motivated by altruistic reasons and do not include any monetary compensation beyond reimbursement for medical expenses (Millbank, 2014).

Surrogate motivations
A single motive is generally not sufficient in explaining why a woman might seek to bear a child for someone else. Research reveals that there is a combination of several needs and desires, with some being more predominant (Goleman, 2018).

Financial gain
"There is nothing wrong with this [ surrogacy ] . We give them a baby and they give us much needed money. It's good for them and it's good for us" (Bailey, 2011).

There are a decreasing number of countries that allow commercial surrogate arrangements to take place. Even in some countries where commercial surrogacy arrangements are legal, a surrogate may be rejected if they are not financially secure (Teman, 2010). This is being done to help avoid exploitation of vulnerable women.

A study on Israeli surrogates found that the women were usually pursuing surrogacy specifically for financial gain. The surrogates' expressed economic goals ranged from paying off debts to providing for their own children's basic needs to saving money for the future. The surrogates in this study fell into three economic classes (Teman, 2010).

30% of the women were described as Israeli middle class to lower-middle class and stated they wanted the money to set aside for their children (Teman, 2010). 50% of the women were described as Israeli lower class, and wanted the money to pay off debts or afford better housing (Teman, 2010). 20% were described as very poor living in low-income areas. These women described the money they earned as surrogates as being a better option at resolving their financial situation compared to other considered options such as selling a kidney (Teman, 2010).

Some surrogate mothers in India describe surrogacy as the opportunity of a lifetime. Many women in India struggle to obtain employment that provides enough income to support their families. For most surrogate women in India, surrogacy is usually motivated by financial gain as the income provided is enough to significantly reduce their financial difficulties and pull their families at least temporarily out of poverty. In Bailey's (2011) article, surrogate women reported that surrogate arrangements allowed them to afford better housing, pay for their children's education, pay their daughters' dowries and grow their businesses.

Women in the United States (US) who disclosed money to be the primary motivation for becoming a surrogate, described surrogacy as being a part-time job which allowed them to be stay-at-home mothers. Being afforded the "luxury" to not have to leave the home on a routine basis to earn money was viewed as a significant benefit to the women and their families (Ragoné, 1996).

Sympathy for childless people
"The best part was giving commissioning parents a daughter. It is a humbling experience. When I gave the baby to the commissioning mother she said: "I'm holding my dream." And that to me summed it all up. I'd given her her dream." (Blyth, 2007).

Surrogate women overwhelmingly report that they are motivated primarily out of altruistic concerns (Ciccarelli & Beckman, 2005; Tieu, 2009; Jadva, Murray, Lycett, MacCallam, & Golombok, 2003; Blyth, 2007). Empathy towards a childless couple is the most frequently cited motivation of surrogate mothers. This motivation has not been found to emerge from direct knowledge of infertility experienced by friends and family but rather a general awareness of the feelings experienced by childless people. Jadva et al. (2003) interviewed 39 surrogate women in order to explore the experiences of surrogate mothers, and found 31 (91%) women reported their motivations of surrogacy was "wanting to help a childless couple" and only one woman stating payment as the motivating factor. Additionally, 11 women in Blyth's (2007) study specifically recounted that the "best part" of being a surrogate mother was the "pleasure and joy given to the commissioning parents".

Enjoyment of being pregnant
"One of the things that attracted me to surrogacy was the opportunity to have a pregnancy and birth without the responsibility of having a child to bring up after it” (Blyth, 2007).

The enjoyment of being pregnant was an additional motive of surrogate mothers commonly referred to across studies (Teman, 2008; Blyth, 2007; Jadva et al., 2003; Ciccarelli & Beckman, 2005). In the study by Jadva, et al., (2003) 15% of the surrogates reported enjoyment of pregnancy as the reason for opting for surrogacy, making it the second most common motivation after wanting to help a childless couple. In Blyth's study (2007), nine out of the 19 surrogate women specifically mentioned their motivation was due to the enjoyment of pregnancy.

"I find pregnancy and birth easy, I actually like pregnancy, although I don't want anymore of my own children" (Van den Akker, 2003).

Obtaining a sense of value and achievement
"I wanted to do something that was out of the ordinary and that made me a little bit special ... because I haven't got a lot of confidence. I'm not a mathematician or anything like that, I'm not a world-class model, and just normal. And I didn't want to be normal, I wanted to be interesting. I wanted to be able to say, I've done something interesting with my life" (Blyth, 2007).

Also mentioned across the literature is the motivation to become a surrogate mother in order to obtain a sense of value and achievement (Blyth, 2007; Teman, 2008; Jadva et al., 2003). Out of the 34 surrogate mothers in the study performed by Jadva et al., (2003), 6% of the surrogate women reported this as their primary motivation. This motivation is less frequently reported compared to sympathy for a childless couple and enjoyment of being pregnant.

Reparative motives
"Having had two miscarriages of my own, I felt I would like to help a childless couple" (Van den Akker, 2003).

Some women have revealed that feelings of guilt towards previous miscarriages, abortions or adoptions motivated them to become a surrogate mother (Tieu, 2015). For instance, in a study by Ragoné, 26% of prospective surrogates had previously had an abortion and 9% had given a child up for adoption (Tieu, 2015). However, the majority of studies have found little evidence of reparative motives of surrogate mothers (Teman, 2008).

Self-determination theory
Proposed by Ryan and Deci (2000), the Self-Determination Theory (SDT) represents a broad framework for the study of human motivation and personality. The theory focuses on people's inherent growth tendencies and innate psychological needs (Ryan & Deci, 2000). SDT suggests these innate psychological needs are the basis for human self-motivation and personality integration (Ryan & Deci, 2000). According to SDT, humans have extrinsic and intrinsic motivations. Extrinsic motivation is driven and regulated by performing activities for the attainment of a certain outcome based on external pressures and control (e.g., rewards and punishments) (Reeve, 2015). Intrinsic motivation refers to when people take part in activities and seek out challenges purely for the enjoyment of the activity itself (Reeve, 2015).

Also specified are three basic psychological needs that are considered to be central to optimal functioning and personal well-being (Ryan & Deci, 2000). These include autonomy, the need for personal endorsement and sense of independence in the initiation and regulation of behaviour (Reeve, 2015). Competence, the need to interact effectively with the environment by exercising skills and mastery in challenges (Reeve, 2015). Finally, relatedness, the need to establish emotional attachments and connected relationships with other people (Reeve, 2015). While there is no research that has applied SDT to surrogacy, the theory could assist in explaining surrogate motherhood motivation.



Researchers who have used standardised psychological tests to assess surrogate mothers conclude that surrogate women are more likely than the general population to be non-conformists, self-sufficient, and independent thinkers who are less affected by social proscriptions and sanctions (Busby & Vun, 2010). The behaviour of women who choose to become surrogate mothers for altruistic reasons is therefore suggestive of being autonomous as their decision is not bound by Western assumptions of motherhood or influenced by the often negative portrayal of surrogacy in the media (Teman, 2008).

One of the motives revealed by surrogate mothers is the enjoyment of being pregnant (Busby & Vun, 2010). This is an indication that women who disclose this as their primary motive have been pregnant before and feel competent in their ability to do so again for someone else. Additionally, many surrogate agencies ensure that prospective surrogate mothers meet a set of requirements including that they have given birth to a child of their own, experienced uncomplicated pregnancies and deliveries and have had a full-term pregnancy and delivery (Van den Akker, 2006). These requirements are regarded as evidence of competence to become a successful surrogate mother.

Positive feelings regarding the surrogacy process is reported by many surrogate women due to the strong bonds and friendships formed with the intended parents (Teman, 2008). A number of studies have confirmed that surrogate mothers tend to form relationships with the commissioning couple rather than the baby (Imrie & Jadva, 2014; Jadva et al., 2003). During the pregnancy and after the birth of the child, relationships with the intended parents largely determines the surrogate mothers' level of satisfaction with her experience (Ciccarelli & Beckman, 2005). The relationship surrogate women have with the intended parents satisfies the need for relatedness.

Intrinsic vs. extrinsic motivation
Intrinsic motivation appears to increase for women who feel sympathetic towards a childless couple, when they have experienced uncomplicated, successful pregnancies in the past, and when meaningful relationships are formed with the intended parents.

Extrinsic motivation appears to increase for women living in countries where commercial surrogacy arrangements are legal, when women have a family to support, and are experiencing financial hardships or significant debt and where alternative employment opportunities are scarce.

Theory of planned behaviour
The theory of planned behaviour (TPB) provides a framework to identify the primary behavioural, normative, and control beliefs impacting behaviours (Montano & Kasprzyk, 2015). First proposed by Ajzen (1991) the TPB states that autonomous and motivated behaviours are a result of intentions. Additionally, the TPB posits that intention is determined by one's attitude toward the behaviour, the pressure to perform that behaviour (subjective norm), and perceived behavioural control (competence in performing the behaviour) (Ajzen, 1991).

While the TPB has not been applied to surrogate motherhood motivation in the research literature, the table below highlights how the TPB could be used to explain the factors that motivate women to become surrogate mothers for altruistic reasons.

Table 1. Application of the TPB principles to surrogate motherhood motivation:

Table 1 demonstrates the way in which expectations are used as motivation to engage in a particular behaviour. Surrogate women have the expectation that by becoming a surrogate mother they are performing an altruistic act of helping a childless couple and, as a result, may obtain a sense of achievement and self-worth that will be supported by others. Additionally, surrogate women expect that the pregnancy and birth will occur without difficulty or complications.

Conclusion
This book chapter explored the motivations of surrogate mothers. Research highlights a variety of motivations of surrogate mothers, including financial gain, sympathy towards a childless couple, enjoyment of pregnancy, obtaining a sense of value, and achievement and reparative motives.

Women who pursued surrogacy for monetary gain commonly reported experiencing financial issues, along with difficulties supporting their families and acquiring alternative employment. In these cases, becoming a surrogate mother was motivated by an external reward which was the income provided by surrogacy.

Sympathy towards a childless couple and enjoyment of pregnancy emerged as the two most frequently cited motivations to become a surrogate mother. A significant majority of surrogate women who were motivated by internal rewards reported surrogacy to be a positive and fulfilling experience. It is possible that greater insight into the motivations of surrogate mothers could be gained by applying the SDT and TPB. These theories in relation to surrogate motivation warrant further investigation in future research.

Understanding the motivations of surrogate mothers could have significant implications for psychological research, public attitudes and social policy.