Book Review: Birthing a Mother

Birthing a Mother is a study of surrogacy arrangements in Israel. Elly Teman describes the complexity of these arrangements, paying particular attention to the relationship that develops between surrogates and intended mothers (1). Although Teman focuses her attention on Israel, she also discusses the situation in other countries, mainly the USA and UK. This discussion forms part of a comparative analysis which is used to highlight particular aspects of the Israeli experience.

One thing that is clear is that Teman has largely encountered positive experiences of surrogacy, something she has previously discussed in BioNews (2). In that article, she highlighted the importance of trust between surrogate and intended parents, especially the intended mother. She also stresses this point throughout the book. Surrogacy arrangements based on strong relationships between surrogate and couple, particularly the intended mother, can be a positive and empowering experience for all parties. It is usually when this relationship breaks down that problems arise.

After reading the book, I feel another important factor in the success of surrogacy arrangements in Israel is the clear legislative provisions that govern them. This is something policy makers in the UK should be mindful of, especially given many of the recent controversies encountered here (3). The relationship between surrogates and intended mothers is given solid foundations in Israel by having clear legislative provisions in place, standard contracts, and professionals trained to be aware of how to handle these arrangements. Teman highlights at various points in the book how these provisions ensure the safety and welfare of all parties to the arrangement, which is not something that always happens in countries with less clear provisions like the US and UK (4).

This is not to say, however, that surrogate/intended mother relationships can be reduced to a simply contractual exchange. The successful surrogacy experiences that Teman documents run much deeper. By focusing exclusively on the commercial and contractual elements of surrogacy arrangements, we risk overlooking more significant features of how these relationships develop. Indeed, as surrogacy relationships progress, we see a clear shift in relations from one of commerce to one of kin.

Surrogacy has a long history and has been subject to much controversy and debate in the UK and other countries. It challenges our perceptions of maternal roles and also our perception of maternal nature. Surrogates have, in the past, been viewed as cold or in some way emotionally void in their capacity to relinquish the child they have gestated (and presumably bonded with) for the duration of the pregnancy (5). In this book, Teman dispels this myth as she reveals the complexity of the roles that surrogates fulfil during pregnancy.

A striking feature of the book is the intensity of the relationship between the intended mother and the surrogate. For the arrangement to result in a positive experience, the two women must embark on a shared reproductive enterprise. They often describe the pregnancy as 'our pregnancy'. They become a 'we' to the exclusion of others. To assist the intended mother's experience of pregnancy, the surrogate 'disembodies the belly, relegating it to a space that is linked to her body but separate from it'.

Legislation in Israel places strict conditions on who can act as a surrogate. She must be single and already have birthed at least one child. This means that the surrogate will be in many ways marginalised in a society that still places a high value on traditional family forms. Most of the surrogates 'were struggling as single mothers to support their children'. In Teman's study she describes how these women can use their surrogacy experience as an empowering process. They achieve 'agency through objectification'.

This is consistent with other ethnographic studies showing that 'women engage in self-objectification and self-medicalisation as a form of agency'. These surrogates feel empowered by their capacity to reproduce naturally. And it is through their 'nature' that medical technology is mobilised. And as well as being controlled by technology, the surrogates often use technology to facilitate their control by, for example, having a caesarean section rather than a vaginal delivery.

'It would… be devaluing the surrogates' creative choreography of connections and disconnections to say that she is passively fragmented by technology and by the state. Instead, it is through the divisions… that the surrogate is able to realign the innovative form of maternity that she has created with nature and culture, with her personal goals, and with the pro-natalist national ideology of maternal service to the nation'.

Surrogates view the approval process and subsequent IVF attempts as a test and view themselves as heroic warriors. The military language used by the surrogates reflects the pro-natalism of the society they live in. Like military service, child bearing is seen as a national obligation for female citizens. The power that comes from their capacity for 'natural' child bearing is strongly valued by these women. Teman found that sometimes, if pregnancy fails to be achieved during a proposed surrogacy arrangement, a surrogate would try to become pregnant naturally shortly after to reaffirm her power and identity as natural child bearers.

There are also instances in the book where technology is subversively used to facilitate and empower the surrogate and intended mothers in their respective roles: 'While the ultrasound may, arguably, demote the body of the pregnant woman to a secondary order significance, the technology also enables the surrogate to promote the intended mother's experience to a privileged position. Indeed, if visualisation technologies such as the fetal ultrasound have been critiqued for exposing the interior of the pregnant woman's body to visual inspection, leaving her bodily boundaries thoroughly transparent, in surrogacy, it is this transparency that enables the intended mother to conceptualise the fetus apart from the surrogate and to access the role she covets'.

There are places in the book where I felt a definite uneasiness about how the metaphor of 'agency through objectification' worked in practice. A story is told about a surrogate Orna who has three failed attempts at embryo transfer. Her surrogacy contract will be terminated after a fourth failed attempt. It is clear Orna is strongly personally invested in succeeding in the surrogacy process. She views it as a personal test. Therefore, without any medical guidance, she doubles her dosage of hormones (both injection and oral) for this last cycle. She presents at her doctor's surgery with sky-high hormone levels and is admonished by the clinician for her actions and the danger she has put herself in.

This is not the end of the story, however. Orna then insists the doctor implant double the embryos he had in previous cycles. This meant implanting the eight remaining embryos. The story, thankfully, has a happy ending, but I was uncomfortable with it because it is presented as Orna controlling the medical process. This is also a case of someone clearly endangering herself to fulfil a role of 'maternal service'. Her identity and self-perception are so tied up in this reproductive enterprise, there is no consideration given to the danger she may be subjecting herself to. What seems even more worrying is that the clinician in this case was happy to help her.

Another issue that also struck me as problematic is that, during the course of the surrogacy, all the medical records are kept in the intended mother's name. The surrogacy is documented in a file under the intended mother's name and 'the surrogate is represented by a page in the intended mother's file'. This is an important part of the process of delineating the maternal role outlined above. It allows the intended mother to effectively manage the pregnancy and, indeed, Teman notes that many surrogates react negatively if such management does not occur.

This filing system, therefore, seems to be a strategy that worked well for the most part. There is only one documented example in the book of this process creating problems. Regardless of whether it is accepted practice, it seems to me problematic. While the process of alienation from the belly and womb might be an important part of the gestational process for surrogates, the physical reality remains. It is the surrogate who will feel the physical symptoms of many of the test results sent to the intended mother and kept in a file in her name.

It is interesting that the exception to general acceptance of this practice was an arrangement involving a surrogate who had a PhD and was a birth educator. This surrogate defied 'any typecasting' and was an exception among the surrogates Teman described in the book. Teman summarises the situation as follows: 'Her reaction to the discovery that her intended mother was being treated by the medical system as the primary pregnant patient brings the agency of surrogates who do comply with this categorisation into sharp relief. Allowing the intended mother to assume this role is not just part of the surrogate's distancing repertoire but also an offering: an act of relinquishing control over a particular aspect of surrogacy in support of the intended mother's identity-building process'.

The surrogate is usually of a lower socio-economic status through a combination of being unmarried, less educated, and having a lower income. Therefore, it could equally be suggested that this situation also raises questions about the power relationships between surrogates, intended parents, and clinicians. At times, I felt that it would have benefitted the book overall if some of these negative readings of the situations were given more consideration. It would not necessarily have detracted from the overall positive picture of surrogacy that Teman describes and would have improved the analysis overall.

There is no way that I could hope to do justice to the wealth of issues that Teman covers in this book and I have only touched on a few. Birthing a Mother is a fascinating and worthwhile study. I would recommend it to lay academic readers with an interest, not just in surrogacy, but in assisted reproduction more generally. The analysis is interesting, of high quality and the book is also full of useful references for further reading.

Buy Birthing a Mother: The Surrogate Body and the Pregnant Self from Amazon UK.