Are Surrogates More at Risk of Mental Health Issues?
As a physician, researcher, and intended dad, I am always in favor of more research related to surrogacy.
However, I believe that research has to be well done and unbiased.
I was excited to find an article in JAMA Network Open last month that used real world data to compare mental health outcomes of mothers and surrogates after their delivery (1).
This is a great topic, and more data is needed to really understand if there are unique mental health challenges for surrogates. Unfortunately, I have several issues with the publication that I will discuss in this article.
Overview of the Study
The study was a real world data study, which means that the authors used publicly available medical health records. In this case, the medical records were from patients in Ontario, Canada. This gave them access to a tremendous amount of data, including over 1.2 million births during the period from April 2012 to March 2021.
However, it’s important to note that real world data means that they had access to the records, not the patients or any other information. Therefore, they had no way to question the patients about their experience or the physicians about their diagnosis. Also, the authors used a combination of emergency room visits, hospitalizations, and outpatient visits for a formal mental health diagnosis. There was no criteria that the diagnosis had to come from a psychiatrist or mental health professional. Nothing against my ER colleagues, but they will be the first to tell you that mental health diagnoses are not their forte. This study design calls into question how strongly the results should be interpreted.
The results leveraged the following pregnancy data from 767,406 women:
748,732 (97.6%) were by unassisted conception
17,916 (2.3%) by IVF (without surrogacy)
758 (0.1%) by gestational carriage or surrogacy
The authors focused on 2 comparisons for their primary endpoint of new-onset mental health diagnosis:
Comparison 1: Gestational carriage vs unassisted conception
Comparison 2: Gestational carriage vs IVF (without surrogacy)
While the authors corrected for maternal age, income quintile, urban residence, obesity, smoking, parity (the number of times a woman has given birth), and hypertension (high blood pressure), there are aspects to the groups that could not be controlled for. Also, the groups are extremely skewed when it comes to numerical representation as surrogacy was 0.1% of all pregnancies.
The main results showed an increased rate of mental health with gestational carriage in both comparisons:
Comparison 1: New-onset mental illness occurred in 236 gestational carriers (6.9 per 100 person-years) vs 195,022 women with unassisted conception (5.2 per 100 person-years).
Comparison 2: New-onset mental illness occurred among 236 gestational carriers (6.9 per 100 person-years) and 4704 women receiving IVF (5.0 per 100 person-years).
The authors concluded that gestational carriers (GCs) or surrogates are more likely to be diagnosed with mental illness during and after pregnancy. I cannot refute this statement given the statistics above, but as I have stated, the design is limited and this conclusion seems strong given the type of data and analyses that were done.
However, I think the main aspects of this study are that it highlights some critical flaws in the Canadian surrogacy system, the poor background the authors seem to have about surrogacy in general, and the fact that over 5% of all women suffered mental health issues during and after pregnancy.
Canada’s Gestational Surrogacy is World Class, But This Study Highlights Serious Flaws
Canada is the leading destination for international, altruistic surrogacy. While overall and compensated surrogacy is globally led by the United States, Canada has a robust clinical, surrogacy, and legal framework for altruistic surrogacy. This was reviewed in a previous Gay Dad Reporter article where the surrogate experiences were discussed in different countries around the world.
I thought one of the main reaonss Canada had this reputation was because they had strict criteria for surrogate screening, but this study highlights that there are significant issues with this system.
Canada has Guidelines for Third Party Reproduction from 2016 (2) that describe the screening requirements for surrogates:
Age below 45
BMI below 30 mg/kg2 is preferable but up to 35 mg/kg2 is allowed
Immunization titers (e.g. Rubella, varicella)
Uterine cavity screening (e.g. Sonohysterogram)
The rest of the process is up to ‘clinical judgement’ to screen out potential surrogates with health factors that could increase obstetrical risk. There are also no mental health requirements or guidelines.
The goal of surrogacy is to minimize risk for all parties involved, so I would hope that Canadian physicians would be strict with their ‘clinical judgement.’ However, this study shows that is not the case, given the conditions the surrogates were diagnosed with before pregnancy:
Obesity: 36.1%
Smoking: 1.7%
Diabetes: 1.6%
Hypertension: 3.2%
Mental health: 19%
The mental health percentage was calculated from the number of GCs who were excluded from the study because they already had a diagnosis but still were gestational carriers. The percentages of the other health issues are for the GCs who were included in this study.
This percentage of surrogate mental health diagnoses prior to pregnancy is extremely high. Also, every other listed diagnosis adds considerable risk to the pregnancy. I would argue that none of the health issues listed above should be allowed for surrogates.
Canada’s 2016 guidelines are almost a decade old, and they need updating to have more comprehensive and strict physical and mental health criteria to qualify someone to be a gestational carrier.
The Authors are Not Well-Informed about Surrogacy
The authors were primarily concerned with new-onset mental illness, but they asked other questions when analysing the data.
One of the questions was: What is the effect of maternal-child separation on mental health?
However, to try and answer this question, they compared surrogates to mothers who have had their children taken away from them.
This is not a comparison that should be made. GCs or surrogates are not mothers. They do not want to be mothers to the child they give birth to. They are performing an amazing service to help someone become a parent. They are already a parent to other children.
The fact that the authors asked this question, and then in the conclusion stated that ‘a potential risk factor for new-onset mental illness among gestational carriers include the emotional effect of separation from the newborn’ is not only unscientific but laughably ignorant and biased.
Studies have shown that most surrogates maintain good relationships with the intended parents (IPs) and children after birth. This analysis does not take this into consideration but rather assumes that the surrogates are mourning the loss of the child in a similar way to actual mothers who are not with their own biological children. It’s not a comparison that should ever be made and shows the authors have approached this topic with an inherent bias.
Are We Missing the Point: Mental Health after Any Pregnancy Needs More Attention
The final challenge I have for this study is the overall rates of mental health diagnoses for women during and after pregnancy: 5% or more.
This is huge.
I know this study wanted to focus on surrogate mental health, but as I have stated, I think the real world data design is not strong and the authors appear to have inherent bias towards surrogacy based on their line of questioning.
That being said, the authors should have concluded that the Canadian healthcare system needs to focus more on all women during and after pregnancy, rather than just gestational carriers. While statistically significant, 5% of all women compared to about 7% of surrogates is not a massive difference.
Also, it’s critical to point out that even the 7% new-onset mental health diagnosis in GCs is much less than averages of postpartum depression. Postpartum depression is common. As many as 75% of women experience ‘baby blues’ (or non-serious mental health changes) after delivery. Up to 15% of these individuals will develop postpartum depression, with 1 in 1,000 women developing postpartum psychosis (3).
This study’s diagnoses are likely an underrepresentation of mental health challenges during and after pregnancy, and to address this we need to remove the stigma of mental health during this life stage. Pregnancy and becoming a parent are huge life changes, and it seems like women are not getting the support that they need.
As for future studies that could actually help address the gap in knowledge regarding surrogacy, comparisons should have more context than real world data in medical records. This process is complicated and not standardized, so distilling it down to diagnosis codes does it a disservice. Studies need to be more robust to account for the complexities and variables that occur in every journey.
However, one thing is clear regarding gestational carriers in Canada, and that is the screening process should be updated to be more comprehensive, standardized, and strict in order to safeguard the surrogacy process in Canada.
If more surrogates are allowed to carry with pre-existing medical issues, complications will increase, putting them and the babies at risk. More negative stories around surrogacy could lead to rolling back of surrogacy practices in Canada. Surrogacy must be done right in order for it to continue.
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