Parenthood at birth, protection before pregnancy: A clinician's case for surrogacy reform

As MPs debate legal parenthood from birth, new evidence on the risks of gestational surrogacy should strengthen the case for reform, not derail it. The answer is a regulated UK pathway that identifies and mitigates risk well before conception.

Today (7 September 2026), MPs will debate a petition signed by more than 113,000 people calling for intended parents in surrogacy arrangements to be recognised as their child's legal parents from birth (see BioNews 1337).

Under current UK law, the surrogate is the legal mother at birth and intended parents must then apply for a parental order, often taking six to 12 months. The petition focuses on that delay, but it raises a much wider question: can Parliament recognise intended parents from birth while protecting the surrogate before pregnancy?

The Law Commissions' 2023 draft Bill shows how those two aims can coexist. Its proposed domestic pathway would confer parenthood from birth only after preconception safeguards, including medical and criminal record checks, counselling, independent legal advice and a welfare assessment, overseen by an HFEA-regulated non-profit surrogacy organisation (see BioNews 1185a and 1185b). Agreements would remain unenforceable, and the surrogate would retain control over her pregnancy and the right to withdraw consent. Protection is not exchanged for recognition; it is a condition of it.

In every gestational surrogacy arrangement I oversee, my clinical decision-making is profoundly influenced by one fact: the surrogate is my patient. She has the embryo transferred into her uterus, carries the pregnancy and bears the medical risk. Intended parents' hopes are real, often after years of infertility or loss, but they are not the ones undergoing the treatment or carrying the pregnancy. The ethical and clinical priority must follow the patient who is.

A recently published systematic review merits careful attention. Comparing gestational surrogacy against the same women's earlier spontaneous pregnancies, they report approximately 2.4 times the relative risk of pre-eclampsia or gestational hypertension, 4.7 times the risk of gestational diabetes and 3.2 times the risk of preterm birth. Clinicians cannot omit these findings when counselling prospective surrogates.

The authors are clear that the evidence was sparse: four studies used US agency or clinic data, and two were non-peer-reviewed conference abstracts. The only study reporting age found the surrogacy pregnancies occurred almost five years later than the spontaneous conceptions on average. No study compared gestational and genetic surrogacy in the same woman, and crucially, the authors could not establish whether any excess arose from genetic dissimilarity, embryo creation, the hormonal preparation used for embryo transfer, or something else entirely.

They also make a point that deserves wider attention, addressing the claim circulating in anti-surrogacy campaigning material that surrogate pregnancy carries three times the risk of severe complications. Its origin is unclear, and they conclude that it appears to rest on a comparison with unassisted natural conception. The Ontario cohort study usually cited found severe maternal morbidity in around eight percent of gestational-carrier births, four percent after IVF and two percent after unassisted conception. IVF is the clinically appropriate comparator, and its authors concluded that eligibility guidelines were not always strictly followed. That is an argument for better regulation, not for the prohibition of surrogacy.

Other research has reported higher rates of hypertensive disease, postpartum haemorrhage and preterm birth, although much of it is retrospective and inconsistent. A Canadian study found a modestly higher incidence of newly diagnosed mental illness, while a small UK longitudinal study found generally positive wellbeing and no widespread long-term psychological harm.

When counselling and consenting a prospective surrogate and intended parents, both the potential risks and the limits of the evidence should be laid out clearly so that informed consent can be taken. It is also worth saying plainly that the obstetric concerns raised in this recent review relate to donor egg conception, rather than to all surrogacy arrangements. The same data should perhaps be considered when counselling any woman carrying a pregnancy conceived with donated eggs.

In a well-governed HFEA-licensed clinic, the surrogate is assessed independently and offered time without the intended parents present. Clinicians should review original obstetric and GP records, and any history of previous gestational or postpartum issues, including mental health, may require investigation or specialist preconception advice. A previous uncomplicated pregnancy is reassuring, but never guarantees another.

Specialist counselling should be offered to the surrogate, with or without her partner, and then jointly with the intended parents. It must explore physical and psychological risks, coercion, financial vulnerability, pregnancy loss, fetal anomaly, termination, selective reduction, multiple pregnancy, disability, relationship breakdown and support after birth. Divergent views are not necessarily grounds to refuse treatment, but they demand further discussion. The surrogate must understand that decisions about antenatal testing, treatment, termination, and the mode and place of birth remain hers alone, and cannot be contracted away.

These safeguards begin well before embryo creation, typically at the first consultation with the surrogate, and they are effective. HFEA data show that the multiple birth rate in UK surrogacy treatment fell from 14 percent in 2013–17 to five percent in 2018–22. Embryo number is the clearest modifiable obstetric risk in this population, and single-embryo transfer should be the default throughout IVF care, not just surrogacy.

But the HFEA's remit only covers fertility treatment, not the arrangement, the pregnancy or the birth. It does not reach home insemination, and it has no reach at all beyond our borders. In the USA, for example, the American Society for Reproductive Medicine (ASRM)'s 2022 recommendations for gestational carrier practice are detailed and thoughtful, but they note that the Food and Drug Administration does not require surrogates to be screened at all. The thorough screening of donors, intended parents and surrogates that the HFEA requires of a UK clinic as a condition of licence, the ASRM can only advise.

If the debate in Parliament results in surrogacy reform being indefinitely postponed, surrogacy will not disappear; informal arrangements and treatment abroad will continue, and so will the risk, in settings where no British regulator can verify how a surrogate was recruited, assessed, treated or supported, and what screening, if any, took place of the embryo transferred to her uterus.

Drawing on my clinical experience, I would make three practical recommendations. Only the first requires Parliament; the other two could be delivered now.

• First, make the preconception safeguarding pathway for surrogates mandatory, for clinics and for anyone seeking legal parenthood from birth.
• Second, establish a UK outcomes registry with the HFEA linking gestational surrogacy treatment to obstetric, neonatal and longer-term surrogate outcomes; the ESHRE Ethics Committee has already said surrogacy should sit within national registries. Without one, we cannot answer this review's question as we lack our own data.
• Third, I would like to see the Royal College of Obstetricians and Gynaecologists develop a Green-top Guideline on assessing potential surrogates: identifying obstetric red flags, defining when multidisciplinary review is required, and guiding risk reduction, pregnancy surveillance and maternity handover.

Having cared for women who take these risks on behalf of others, I believe the new evidence should change what clinicians say, assess and record. However, it should not be used to question a woman's capacity to make an informed choice, or to justify leaving an outdated legal framework untouched.

Today, MPs will debate when legal parenthood should begin. But there is a second question they should settle alongside it: when should protection for the surrogate begin? My answer, as a clinician, is that it must begin long before pregnancy does, in the first conversation she has in a fertility clinic.