Some see it as the ultimate selfless act.
Emma was potentially losing her life on the table.
But surrogacy, carrying a child for someone else, is also a fast-growing global trade. One that’s transforming ideas about family.
The legal definition of family is changing over time.
What’s driving this boom in the baby business?
I’ve done, I believe, over 8,000 surrogate cycles in my career.
Outlawed and hated in many countries.
The inside of a woman’s body is being used as a workplace.
How can surrogacy be better policed and its children better protected?
Good morning.
Hi. How are you?
I’m feeling excited, a little bit nervous.
Jessica has signed up to provide the gift of life.
And this is just giving us permission to place the embryo into your uterus. Just print, sign and date right there.
Jessica is a surrogate and she has no genetic link to the embryo which is about to be implanted into her.
I love being able to help someone to be able to have a family that they’re not able to on their own.
Gestational surrogacy as it’s known, is now significantly more common than surrogates using their own eggs. Jessica’s doctor, David Smotrich, is one of its leading practitioners.
David Smotrich
Those of us who do a lot of surrogacy find that gestational surrogacy is a better approach and it makes it much easier in terms of everybody involved. The genetic makeup of the child is something that is very, very concerning for the overwhelming majority of couples that we work with.
Jessica has had to pass stringent medical and psychological vetting procedures.
Who is driving you home today?
Er, my husband will be picking me up.
Okay.
And most Californian agencies require surrogates to be mothers already.
For my kids, I’ve always told them, “Mom’s babysitting” so the have always known that the baby that I am carrying is not ours.
So we’re going to take you back and just get started, okay. Show time.
David Smotrich
All the testing that we’re doing on her and her body actually is for another couple.
He’s so cute.
David Smotrich
Alrighty. It’s nice that they’re awake.
That couple are Nima and Hamish. Based in Australia, they are the ‘intended parents’, as they’re often called.
In Australia it’s very difficult to adopt. Surrogacy sort of felt like really the only reliable option in terms of having a child.
The embryo implanted inside Jessica was made using Nima’s sperm and an egg from an American donor.
Hello.
Jessica has already given the couple a son, Hugo. Now, they’re hoping she’ll add a baby girl to the family.
David Smotrich
Jessica, are you ready?
I’m ready.
David Smotrich
Okay, going to feel my fingertips first and then speculum, okay? Here we go.
California, so often at the forefront of new technologies, has become the surrogacy capital of the world.
David Smotrich
I’ve done over, I believe, over 8,000 surrogate cycles in my career. We’ve helped couples in over a hundred different countries become families. If you look at the screen behind me, we’re going to show you the actual embryo that we are going to transfer.
Back in 1998, David was one of the first doctors to help same-sex couples become parents through surrogacy.
David Smotrich
This is my trial catheter, and covering you up.
Some may say you can’t put a price on having a family but here in California they do. Intended parents usually pay between $110,000 to upwards of $200,000 for surrogacy services. And surrogates like Jessica can earn between £30,000 and $60,000.
Do you want to stop and make your appointment for Monday?
Yes please.
When you’re a first time surrogate, you obviously don’t know if IVF is going to work for you. So, as you go onto a second one, the pay increases because obviously they know that you can carry this baby with no issues. Think about everything that we are putting our body through to be able to have this baby.
For Nima, the transactional nature of the relationship with Jessica is part of the appeal.
I see it as a win-win. She is doing something amazing for us, able to earn some money through it to help her own family and has made the decision herself.
The number of children born to surrogacy globally is unknown. Data only exists for some countries such as Britain and this shows a small but increasing number of parental orders, transfers of custodial rights from surrogates to intended parents. But globally, the surrogacy industry is estimated to be worth over $14 billion in 2022, a figure that may rise as high as $130 billion over the coming decade. Same-sex couples wanting children are one of the key drivers of this growth. In Britain, for example, about half of all intended parents are gay.
The legal definition of family is changing over time which means that the definition of family is now accepted as being more than just the, you know, mum, dad and 2.5 children.
But there’s another perhaps more significant factor making the surrogacy business grow. Declining fertility rates amongst the heterosexual population. Women are now choosing to start families later in life and this carries a higher risk of infertility.
The World Health Organisation recently produced a report that said up to 17.5% of people will be affected by infertility in their life. So that’s one in six people. So if you are infertile, if you have a burning desire to have a family, you generally have tried everything else, you’ve tried IVF, your last resort is surrogacy.
The surrogacy industry has also benefited from celebrity limelight as the Paris Hiltons of this world keep up with the likes of Khloe Kardashian.
Khloe Kardashian
When I went to the hospital, I really think that was the first time it really registered. You’re like okay, we’re having a baby.
Even if such famous parents are usually living in a different financial reality from most.
Sam Everingham, Global Director, Growing Families
Well it might be inspiring and it gets news, it’s certainly not the norm for most people going through these processes who haven’t got the money or the status.
What’s especially striking about the surrogacy business is how globalised it’s become. Here’s why. Relatively few countries allow surrogates to be expressly paid for the labour of carrying a child, for example, Georgia, Ukraine and certain states in America. However, this kind of commercial surrogacy is against the law in many more countries like China, Germany, Turkey, France and Italy. That means residents of these countries wanting a surrogate have to look abroad to countries where surrogacy is allowed.
The transnational business of surrogacy is very fluid. Originally, India was the popular destination. The Indian Government then said no, we’re not going to allow foreigners to come in and use our population for surrogacy. And it was shut down in Thailand, then it went to Laos.
We’re seeing an increasing trend for countries in Europe particularly to turn their laws against surrogacy and to forbid their citizens from engaging in it.
Opposition to surrogacy often comes from the religious Right and Conservative politicians. In Italy, one politician has even compared surrogacy to child abuse.
Federico Mollicone
It’s a serious crime, in my opinion more serious than paedophilia.
On the other side of the political spectrum radical feminists are often equally opposed, if for different reasons.
Julie Bindel
It’s a financial trade. Therefore there’s huge amounts of exploitation because the inside of a woman’s body is being used as a workplace.
It’s not just hostility and laws which push intended parents to seek surrogates overseas, it’s hard economics too. For those unable to afford services in America, other countries offer lower cost alternatives. In Greece, prices start at around $88,000, while in Georgia it’s less than half that, although in 2024 foreigners will be banned from surrogacy services there.
Before the Russian invasion, Ukraine was a global surrogacy hub offering affordable prices to customers from rich countries.
Sam Everingham, Global Director, Growing Families
Ukraine almost by accident had laws that allowed foreigners to be named on the birth certificate. There was a large number of high quality IVF clinics popped up. It also has a very large population so there was no shortage of surrogates to meet that demand.
There are babies from America, Italy, Spain, Britain, China, France, Germany as well as from Bulgaria.
Before the war, Ukrainian surrogates were producing over 2,500 babies each year, mostly for foreigners, with half of that demand coming from China where surrogacy is banned.
The war has since reduced demand, although it’s also forced aspiring parents to take unusual measures.
Sam Everingham, Global Director, Growing Families
People will go to extreme lengths to be united with their child. Wealthier returning parents were engaging security teams with armoured vehicles to take them into Ukraine and to Kiev to pick up their baby and take them out.
The rise in IVF, cheap air travel and online marketing have all allowed low cost surrogacy agencies to expand across the world but there is a dark underbelly to this industry. In countries as widespread as Guatemala, Laos and Kenya surrogacy is neither banned nor permitted under law. In these places the industry is unregulated and raising concerns.
Naipanoi Lepapa, Investigative Journalist
The surrogacy industry is really growing and it’s growing so fast.
Naipanoi Lepapa is a journalist in Nairobi who exposes the human cost of failing to regulate surrogacy.
Naipanoi Lepapa, Investigative Journalist
If you use surrogates in my country there are no laws around this practice. This means surrogates are not protected and some are exploited. I have met surrogates who have been intimidated, who have been forced to have abortions and then they are defrauded out of their money.
In a country where 27% of the population lives below the poverty line of just over $2 a day, agencies prey on vulnerable and illiterate women in slums, like this one in Dandora. Naipanoi discovered one victim who miscarried at five months but was left with the dead foetus inside her for days and left crippled for life.
Naipanoi Lepapa, Investigative Journalist
Instead of immediately removing the foetus, the agent told her he was going to look for someone who is going to operate on her, so it took a whole week. She’s always in pain, she can’t do anything. She’s still struggling.
To add insult to injury, this surrogate was never even paid.
Naipanoi Lepapa, Investigative Journalist
You only get paid when you produce a baby but when you miscarry, you’re not paid anything.
Naipanoi is on her way to meet another victim.
Naipanoi Lepapa, Investigative Journalist
Today I am meeting a woman who says she was asked for sex in exchange for work as a surrogate.
This woman agreed to be filmed, provided her identity is protected.
Naipanoi Lepapa, Investigative Journalist
Some surrogates have said that they have been asked for sex. Did it also happen to you?
Yes, it happened to me, yes. And I came to realise that that man is sleeping with almost every girl. Since I had no option, I did it because he was promising me he is going to shape my life.
She was recruited as a surrogate through Facebook and was promised a life-changing $4,500, roughly two years earnings but she was given no medical advice.
The didn’t ask me to sign anything before the embryo transfer so I was not concerned about all those things, all I was praying for is that the process got through well, I get pregnant so I can get the money.
It is considered good practice to transfer only one embryo to reduce the risks to both mother and baby. This woman endured the transfer of four embryos without choice. Three of the embryos implanted successfully and rather than risk triplets, the agency chose to abort one. She was later forced to have a caesarean section to deliver twins and is still owed over half her money.
They operated on me. I felt like running away. I have never experienced that kind of pain. I couldn’t move, I couldn’t do anything.
Naipanoi Lepapa, Investigative Journalist
Why do you think CS are performed on surrogates?
They don’t care about surrogates. They just want to remove the babies.
Life is much riskier for surrogates in poor countries like Kenya where for every 100,000 births, an estimated 530 women die. By comparison, in the EU, that figure is just 6.
The surrogacy market within poor countries is often driven by foreign demand. So what, if anything, can be done to address this global problem of exploitation of surrogates? Banning surrogacy is not the answer.
Just as Human Rights Law says, you cannot tell a woman that she has to have an abortion or that she can’t have an abortion. The same principles apply to surrogacy. It is the individual woman’s choice whether and how she uses her reproductive system.
Perhaps a better idea would be to make surrogacy legal and well-regulated in more places.
Sam Everingham, Global Director, Growing Families
The fact that surrogacy is such a transnational business is very problematic. It will be much better if countries could come to terms with the fact that their nationals do require surrogacy and they could put the laws in place in their own countries to allow much easier access to surrogacy at home.
In Britain, one survey found that two-thirds of intended parents chose to go overseas for surrogacy because they felt laws were unfavourable to them at home. After birth, it can take half a year or more for intended parents to become legal guardians of their surrogate children.
How many shirts are you bringing?
Err, three.
Campaigners like Alan White and his partner, Nic have contributed to law reforms that will make this process quicker. Alan is Chair of the Board of Surrogacy UK, a non-profit advocacy and support group.
Alan White, Chair of the Board, SurrogacyUK
The law changes will make things more secure for all parties involved in surrogacy. Surrogates, under the current law, they are the legal parents of a child born through surrogacy, so actually they carry a tremendous amount of risk in the process.
Ooh what’s up with you?
Nic
It is a bit bonkers in comparison to other people’s experience that you know, you wouldn’t expect someone to turn up when your child is six months old and decide whether you can keep him or not.
What was that?
Broccoli.
Are you messy?
The couple are about to take their surrogate-born child, Jago, on holiday for the first time.
Let’s go, let’s go, let’s go.
But even though he is five months old, Jago is still legally not their child.
Don’t eat your feet.
I think you look nice.
Until a parental order is granted by the courts, in legal terms Jago’s surrogate, Emma, will be left holding the baby.
Emma
So you’d sit him between your legs and need to put some toys in front of him. I knew I was legally his parent and I knew that my husband, he would have to go on the birth certificate, which is completely not right either.
In Britain, surrogates like Emma cannot be paid but can receive pregnancy related expenses. It’s sometimes known as the altruistic model and in Emma’s case, it may be hard to find a worthier example of that term.
Emma
I ended up delivering Jago and then immediately after, bled quite a lot, so I had to be rushed to theatre.
After the birth, Emma had a big postpartum haemorrhage. The room suddenly filled with twenty medical staff, crash trolleys, all the stuff that you don’t want to see. Emma was potentially losing her life on the table.
The midwifery team started talking to Emma about having to do things to save her life and it was, it was horrible.
Emma’s six children and her husband nearly lost her, all so that Alan and Nic could become parents.
There’s no way you can thank someone for that, you just can’t, it’s impossible.
There just aren’t the words. Holding him for the first time and realising that this is your child, that you’re responsible for his happiness and it’s amazing.
Yeah, it is, it is.
Emma
I never saw it as a massive deal, to be honest. To somebody else who couldn’t have children, I’ve got all the bits to help, so why wouldn’t I help?
As well as Britain, other countries using the altruistic model include Canada and Australia. Supporters say forbidding surrogates to charge direct fees for childbearing reduces the risks of exploitation. However, critics point out the altruistic model is far from a catch-all solution to global surrogacy’s problems.
And when we look at who’s involved in surrogacy, it’s generally lawyers, doctors, nurses and they’re all getting paid for their services. The only person who’s not being paid for their services is the surrogate who is doing, let’s face it, most of the labour. Pun intended. I would like to see minimum and maximum amounts of compensation for surrogacy, psychological evaluations of all the parties before they embark on surrogacy, there should be mandatory requirements for legal advice.
Regulating such a global business is an enormous challenge and in the often heated debate about this the outcomes of surrogate children can sometimes get forgotten.
There is an argument that children born by surrogacy are somehow disadvantaged. The research doesn’t support that. We know that children born via surrogacy do as well as the children born in other ways.
A recent study suggests that telling surrogate born children about their origins early in life can help. 7% of mothers who did this before their child turned 7 reported problems in family relationships, compared with 22% who disclosed after the age of 7.
So the aim is to hear your views on surrogacy law.
At the University of Leicester in Britain, Dr Katherine Wade and her colleagues have analysed children’s views on surrogacy laws. They gathered quantitative and qualitive information by talking to children born through surrogacy.
Dr Katherine Wade, Lecturer in Law, University of Leicester
We wanted to stop this process of always making assumptions about how children might feel and actually ask them how they do feel.
This is a simulation of the team’s focus group research.
Dr Katherine Wade, Lecturer in Law, University of Leicester
Should children born through surrogacy be told that they were born this way?
I put yes, you can discover a new part about yourself.
It’s good to know early because if you find out, you could get a bit angry at your parents for not telling you.
Be wondering why you weren’t told and wondering if there was something wrong with it.
In many countries, including Britain, you can usually only find out the identities of your egg and sperm donors but not, in most cases, your surrogate.
Dr Katherine Wade, Lecturer in Law, University of Leicester
Should children born through surrogacy know who their surrogate was?
Yes, because you could be related to them.
There’s no reason to not know. It’s just creating mysteries. It’s just creating a problem.
We have our surrogate in our lives and it’s nice to have them around, it’s like a little bit of an extended family.
Although circumstances are different for individuals, this information can help each to develop what is termed their narrative identity.
Dr Katherine Wade, Lecturer in Law, University of Leicester
People are forming integrated life stories throughout their life. It means that you should try to disclose this information to children throughout their childhood.
Katherine and her team’s research has fed into forthcoming reforms to laws in Britain. This will include a mandatory register where from the age of 16, you can trace nearly everything about your genetic origins, from your surrogate to overseas donors. Somes states in Australia have a similar law.
That is the gold standard when children can learn their genetic origin stories.
What’s in the best interests of the child is a good starting point for thinking about how to better police the global surrogacy industry. With demand rising rapidly, getting surrogacy right matters more than ever.
We’re not going to be able to stop surrogacy so let’s instead regulate it so that it is a worldclass system that respects the rights of all parties who are involved.
Hi, I’m Mian Ridge, a correspondent on The Economist Britain desk. If you’d like to read more about surrogacy, please click on the link and if you’d like to watch more of our learn more of our Now & Next series, please click on the other link. Thanks for watching and please don’t forget to subscribe.