At first findings of the qualitative study were showed, and then the reproductive health care program for surrogate mothers were introduced. The qualitative study conducted with 26 participants (9 surrogate mothers, 12 care providers, and 5 maternal health policy makers). The age range of the surrogate mothers was 28-38 years, and in term of marital status, 5 were divorced and 4 were married (Table 1).
Table 1: Surrogate mothers' demographic characteristics
Participants' codes
|
Education level
|
Ovule/ embryo donation history
|
Number of surrogacies
|
Number of children
|
P1
|
High school
|
1
|
1
|
2
|
P2
|
Diploma
|
0
|
1
|
1
|
P3
|
Elementary school
|
0
|
1
|
1
|
P4
|
High school
|
3
|
2
|
1
|
P5
|
Elementary school
|
1
|
1
|
2
|
P6
|
Elementary school
|
1
|
1
|
2
|
P7
|
Secondary school
|
1
|
1
|
1
|
P8
|
University student
|
0
|
1
|
1
|
P9
|
Elementary school
|
0
|
1
|
3
|
Qualitative data analysis resulted in the extraction of 1836 codes and 11 subcategories and 4 main categories as presented in Table 2.
Table 2: Categories of the analysis of participants' description of surrogate mothers' health care needs
Subcategories
|
Main categories
|
Special surrogacy health care
|
Extra care for surrogate mothers
|
Need for caregiver at home
|
Care for inhibition of lactation
|
Legal and health consideration of surrogacy
|
Educational training
|
How introducing surrogacy to their children
|
Improving communication skills with intended mothers
|
Promotion of surrogate mothers' mental health
|
Psychological support
|
Support surrogate mothers in fetal attachment concerns
|
strengthening their resiliency for overcoming surrogacy difficulties
|
Judgment and stigma of surrogacy
|
Protecting against surrogacy`s social and familial consequences
|
First category: Extra care for surrogate mothers
Data analysis indicated that surrogate mothers needed extra care, including “Special surrogacy health care ", "Need for caregiver at home ", and "Care for inhibition of lactation ".
1-1- Special surrogacy health care
Analysis of participants' descriptions indicated that, in addition to routine pregnancy care before, during, and after pregnancy, surrogate mothers need special care, such as comprehensive physical-mental health screenings, psychological readiness assessment for surrogacy acceptance and ensuring the confidentiality of information about surrogacy. Furthermore, some providers emphasized the surrogacy is a high risk situation and need to increase the frequency of care and mothers' round-the-clock access to services. In this regard, a midwife working at the infertility center said:
"A woman who is going to have a surrogacy should have a complete health assessment. In terms of overall health; and all aspects of her health should be confirmed" (p19).
Most surrogate mothers did not attend to public health centers and childbirth preparation classes because they have to hide their surrogacy and were under pressure for cesarean from care providers and intended parents; hence, they expressed different needs for cesarean delivery and aftercare.
"I had vaginal deliveries for my first two children, but they now said that I have to go for cesarean section! It is very difficult for me to have surgery; I do not have anyone to take care me after surgery. Also I have to take care of my two children by myself! (p6)
1-2 Need for caregiver at home
Most surrogate mothers had to rest and restrict activity for a variety of reasons, such as anxiety and tenderness for maintaining the pregnancy, the intended's parents' insistence, and care providers' recommendations. On the other hand, they did not receive any support from family and friends because of pregnancy concealment; hence, they needed a caregiver at home during and after pregnancy. A surrogate mother said: "I had both bleeding and hyperemesis in early pregnancy. They (intended parents) didn't come to help me at all. My family didn't know about my pregnancy. I needed someone to take care of me and do the housework" (p8).
In addition, these mothers were unaccompanied if they needed to be hospitalized because their families were unaware of their pregnancy; hence, they needed an educated companion in the case of hospitalization.
1-3 Care for inhibition of lactation
One of the different care needs of surrogate mothers was to inhibition of lactation. Based on the agreement between the surrogate mother and the intended parents, and the health providers' emphasis, the infant was separated from the surrogate mother immediately after delivery. Therefore, mothers needed to receive adequate care and education about how inhibition of lactation.
A reproductive health expert said: "Surrogate mother are forced to immediately separate from the baby and stop breastfeeding. These mothers experience severe and prolonged breast engorgement and pain during inhibition of lactation. Therefore, a decision on inhibition of lactation should be taken at the end of pregnancy and surrogate mothers should be prepared for it. Also after child birth, sufficient care should be given in this subject “(p28).
Second main categories: Educational training
All participants emphasized the importance of educating surrogate mothers about the legal and health consideration of surrogacy, introducing surrogacy to their children and improving communication skills between intended mothers and surrogate mothers.
2-1- Legal and health consideration of surrogacy
Surrogacy candidates stated that they had poor and ambiguous information about surrogacy, and suggested receiving the adequate education about legal and health aspects before the surrogacy.
A surrogate mother said: "The first day I came (to infertility clinic), they (care providers) asked me to sign the contract. It was written in a way that I didn't understand, but I signed. I wish they had explained the terms and articles of the contract" (p1).
2-2- How introducing surrogacy to their children
The findings indicated that most surrogate mothers did not disclose the true nature of surrogacy for their children and told their children that the pregnancy belonged to themselves, and after childbirth, told their children that the baby had died. The majority of surrogate mothers were unaware of the proper way to inform their children about surrogacy and expected that counselors would assist them in managing information and the way to introduce this challenge to their children.
A surrogate mother said: "I told my 14-year-old son that I was pregnant and she (the fetus) was his sister, but (after childbirth) I told him that she died, he became so upset. It would be better if counselors told these issues to mothers before starting the surrogacy" (p2).
2-3- Improving communication skills with intended mothers
During pregnancy, the surrogate and intended mothers had great interaction with each other on financial, social, emotional, and health issues, but they were often unable to meet each other’s expectations due to lack of communication skills; hence, strengthening the communication skills was a need of surrogate and intended mothers.
A surrogate mother said: "I liked intended mother come to see me, asking about my status and her child, but she did not come. I became upset and it bothered me. I liked she came and saw her fetus growth ". (p 9)
Third main categories: Psychological support
Participants emphasized on psychological support which divided into three subcategories: promotion of surrogate mothers' mental health; support surrogate mothers in fetal attachment concerns; and strengthening their resiliency for overcoming surrogacy difficulties
3-1- Promotion of surrogate mothers' mental health
All care providers emphasized on frequent assessment and promotion of surrogate mothers' mental health before surrogacy to after childbirth. All surrogate mothers also expressed need for mental health counseling.
An obstetrician said: "A psychiatrist and psychologist should verify volunteers' mental health before surrogacy, so that they will not regret after the embryo transfer and during the pregnancy. Furthermore, any mother should be visited during pregnancy and after childbirth according to her mental health concerns" (p4).
3-2- Support surrogate mothers in fetal attachment concerns
Attachment to the fetus and infant was a main concern of surrogate mothers. Despite the fact that all mothers knew that they had to separate from the baby after birth, they were worried about their attachment to the fetus and sad about the prospect of separation. They needed to talk to their counselor repeatedly about their feelings and get guidance on how to manage their emotions. A surrogate mother said:
"When I was pregnant, I knew" that the baby was not mine, but I had a motherly feeling. I talked to baby at night. I had chosen a name for her and called her name. I told her that you should go, and I shouldn't love you, but my heart was full of sadness and I cried" (p9).
3-3- strengthening their resiliency for overcoming surrogacy difficulties
In the present study, all surrogate mothers had surrogacy for financial reasons; hence, strengthening their resiliency for overcoming difficulties of this period, adapting to complications of pregnancy, and reinforcing altruistic motivations were necessary.
A psychiatrist said: "All surrogate mothers hope to get a good wage. It seems that this period would be easier to tolerate if the surrogate mother's motivations are altruistic "(p10).
Most surrogate mothers did not attend public health centers and childbirth preparation classes, which could help them adapt to pregnancy, because of concealment, and on the other hand, care providers and intended parents put pressure on mothers for elective caesarean section and immediate separation from the baby, making pregnancy difficult full of tension fur these mothers.
For most surrogate mothers, this pregnancy was a frustrating experience; hence, some of them were reluctant to repeat surrogacy.
A surrogate mother said, “I promised myself this would be my last time. I accepted surrogacy with hope of 20 million tomans, but they gave it gradually and it was not clear what the money was spent on. I had to cut all communications due to concealing my pregnancy. I didn't dare go to the clinic to ask a question or take care of myself. They forced me to have a cesarean section and then they gave up me after birth" (p7).
Fourth category: Protection against surrogacy`s social and familial consequences
Many surrogate mothers were exposed to social and familial consequences, such as judgments and stigma of surrogacy and family disturbances.
4-1- Judgment and stigma of surrogacy
The analysis of participants' description indicated that surrogacy was a social stigma which causes surrogate mothers to hide the true nature of their pregnancy and limit their social relationships. Divorced mothers were more exposed to blame and taboos for their surrogacy
A surrogate mother said, "In my husband's family, they would dishonor me if they knew that I was carried a pregnancy for another woman. They said that I made a mistake for money and how heartless her husband was, so I said that it was my pregnancy and my baby, but I was very worried about revealing the secret. I didn't know what to do. I went to have cesarean section delivery alone and said that the baby died!" (p7).
4-2- Family disturbances
Surrogacy affected marital relationships and childbearing planning. Most surrogate mothers avoided sexual intercourse during surrogacy because of concerns about the possibility of harm to the fetus. A surrogate mother said: "During pregnancy, I was afraid of intercourse (for fetal health). My husband accepted it, but he was frustrated and angry" (p3).
Most surrogate mothers had 1 or 2 children of their own and were planning to have another child/children of their own after the surrogacy, but complications and consequences of surrogacy damaged their childbearing planning. A surrogate mother said:
"After surrogacy, I haven’t been able to get pregnant for a few years. I had cesarean delivery in my first birth, and then for surrogacy. Now I want to have a baby myself, I'm worried that my cesarean number will increase" (p4).
For developing reproductive health care program, research and guidelines were analyzed thematically. These findings were integrated with results of the qualitative study; and the draft of the surrogate mother reproductive health care program was designed; then appropriateness of each proposed care was assessed by a two- rounds Delphi technique RAND Appropriateness Method (RAM). Furthermore, the surrogate mother reproductive health care program was developed in four sections, pre-pregnancy health screenings and legal counseling; dedicated care from embryo transfer to pregnancy confirmation; psychological support; prenatal care until delivery; and follow-up postpartum care. This program offered the inter-professional teamwork with obstetrician, midwife, reproductive health specialist, psychologist, psychiatrist and legal consultant who were qualified in the field of surrogacy in addition to professional skills. Midwives/reproductive health professionals can coordinate the team with the ability to play Multi-professional roles.
The first part of the care program included health screening, volunteer legal counseling and preconception care. First an early interview was conducted with a surrogacy volunteer to examine her conditions and motivation then her physical, mental and social readiness for pregnancy were assessed and she was screened for chronic illness, high risk behaviors, sexually transmitted diseases (STDs), and psychological disorders. After that, Psychological and legal surrogacy counseling was performed in women.
In the second part of the care program, the surrogate mother was prepared to transfer the embryo and the home caregiver was introduced to her. If the embryo transfer was successful and pregnancy was confirmed, the third part of the care program was provided with psychological support, specialized prenatal care and planning for delivery. Psychological counseling and care was provided to enhance resilience, respond to children's curiosity about surrogacy, fetal attachment concerns, and manage interaction with the intended parents.
The fourth part of this care program included the postpartum follow-up care that included the routine care, help surrogate mother for inhibition of lactation, and supporting them after leaving the baby through psychological counseling. Mental health screening and planning follow-up counseling were necessary. Family planning counseling and sexual function improvement were performed. Two months after delivery, screening was performed for hypertension, diabetes, mental health, and other surrogacy consequences; and the care program would end and they referred to health center for continuing routine reproductive health care.