Womb to let

An Israeli social anthropologist describes the process of surrogacy, which enables couples to be parents by relying on a hired stranger.Since Israel’s pathfinding surrogacy law – the first in which government supervises women being paid to gestate the embryos and deliver the babies of couples unable to have their own – was passed in 1996, about 350 children have been born. A few heartwarming stories about childless couples becoming parents and some sensational ones about surrogates who regretted their role have hit the media, but there has been no objective assessment of how the law has been implemented and how it affected those involved.

At least until now. A comprehensive, 361-page, English-language masterpiece on surrogacy by an Israeli social anthropologist, Dr. Elly Teman, has just been published by the University of California Press (www.ucpress.edu/books/pages/11401.php). Academic and well-researched, moving and sensitive, Birthing a Mother: The Surrogate Body and the Pregnant Self concludes that the law was well designed and is being fairly implemented.

Around the world, some feminists have denounced surrogacy for allegedly taking advantage of the women who bear the babies, while others have claimed it is “abnormal” for a surrogate to forgo a baby she carried, even if it was not her biological child.

Although Teman writes in the world’s first “ethnographic study” on the subject that “surrogacy does have the potential to exploit women..., the voices of surrogates counter automatic presumptions of exploitation by showing that a majority achieve a degree of appreciation through surrogacy that they do not get otherwise from partners or from society at large.”

At the same time, despite fears of opponents, Teman found that surrogacy arrangements in Israel did nothing to erode the nuclear family; instead, it reflected Israel’s conservative approach to reproduction and reflected the pro-birth ideology of a mostly Jewish society facing dangerous enemies.

Teman, who was born in Brooklyn, New York and raised in Portland, Oregon, was brought to Israel as a teenager. After completing her military service and traveling in the Far East, she began her studies at the Hebrew University, where she completed a doctorate in social anthropology.

SHE FIRST became interested in the topic about two years after the law was passed, and soon after the delivery at Haifa’s Rambam Medical Center of the first surrogate children – girl and boy twins – in February 1998. As a graduate student in anthropology, she worked as an interpreter for visiting US law Prof. Kelly Weisberg, who came to Hebrew University to do research about her own book, The Birth of Surrogacy in Israel. One day, Teman accompanied Weisberg to an interview with “Yael,” who as a woman who could not carry her own embryos to delivery lobbied for the law; she and her husband later contracted a single woman to carry their baby. Teman writes in her book ($55 hardcover/$22 softcover) that although she had never given such a situation much thought, she was “profoundly touched” by Yael’s personal story and became good friends with her, ultimately deciding to devote eight years to interviewing many of the surrogates and “intended mothers.”

Her book is the result of 43 in-depth, formal conversations with 26 surrogates and 45 interviews with 35 intended mothers; most of these encounters took place in the interviewees’ homes, and often included looking at home videos and photo albums. In some cases, she spoke to both the surrogate and the woman who was to take home the baby. She was also in touch with some of the intended mothers and surrogates during the pregnancy and after the births, and in contact in person or by e-mail with “two-thirds” of those involved in Israeli surrogacy arrangements between 1998 and the end of 2005. The academic nature of the work is demonstrated by her 60 pages of notes and bibliography.

Teman and her husband Avi currently live in Philadelphia with their two children, Uriel and Rachela, while she is working as a research fellow at the Penn Center for Integration of Genetic Healthcare Technologies at the University of Pennsylvania. They intend to return home to Israel after concluding her postdoctoral work.

CONTRARY TO the image of surrogates as being desperate women who undergo the implantation of embryos of a couple just for the roughly $25,000 payment, Teman found that about 30 percent were Israeli middle-to lower-middle-class who worked at a steady job, owned cars and lived in pleasant homes. They usually lived with boyfriends and decided to be a surrogate to provide “extras” for their family. About half were lower-class single parents, divorced, widowed or never married, who thought the money would give them a “financial push forward.” The rest, said the author, lived in delapidated apartments in poor areas and thought surrogacy would be a better way to pay their bills than, say, selling a kidney. Teman said the economic and class differences between Israeli surrogates and intended mothers were quite a bit smaller than their counterparts in the US, where surrogacy is arranged privately and for much higher sums. The would-be surrogate must be currently unmarried, have at least one child of her own, must not have miscarried or delivered prematurely, and be free of psychological or physical problems.

UNLIKE COMMERCIAL arrangements in other countries where surrogacy is not illegal, the intended mothers are not rich career women who want children but don’t want to be bothered (or become “misshapen”) by pregnancy. All of them have undergone many failed in-vitro fertilization (IVF) cycles, miscarried many times and were born without or lost their uterus due to disease. Some had no healthy ova of their own and had to obtain donor eggs to be fertilized by their husbands’ sperm. Under the law, all intended parents have to be heterosexual and married, with the written agreement approved by a Health Ministry committee and recognized by a court. No Muslim or Christian Arabs have been surrogates or intended parents, as Islamic law prohibits surrogacy, and strong stigmas surround the practice in the Christian Arab community, Teman writes. However, a homosexual couple recently petitioned the High Court to give the Knesset the authority to allow them to apply as well.

The contract worked out by the two parties includes many details, possibly including whether the surrogate can work or smoke, and what she may not eat or do during the pregnancy, what happens if she miscarries or the baby is born defective, how she is paid, and other important details. While the pre-surrogacy supervision is stringent, the state avoids intervention during most of the pregnancy. But at delivery (either vaginal or in many cases by cesarean section), the baby is whisked off and given to the intended mother (who sometimes is hospitalized in the maternity ward) and her husband, while the surrogate is rolled into the gynecology department until her discharge. The baby immediately and officially becomes the natural child of the couple (who like the surrogate receive a maternity allowance) and is entered into their identity cards.

Teman stresses that while the Orthodox religious establishment in Israel might have been expected to fight legal surrogacy, opposition was overcome by Judaism’s highly positive views of having children and using almost any means to achieve this. Added to this imperative is Israel’s national culture of increasing the population.

Surrogacy and taking home one’s biological baby are described by many participants interviewed as powerful experiences that change lives. “And that’s why I say, I didn’t just give birth to a baby; I gave birth to a mother,” declares Tamar, a surrogate, even before the volume’s text begins. “I always say my mother gave birth to me the first time; she gave me life. But my surrogate gave me life the second time,” says Shlomit, an intended mother.

The IVF procedure and embryo transfer are quite complicated, requiring a series of rather painful hormone shots in the buttocks of the biological mother to ripen her ova, which are fertilized in a glass dish by her husband’s sperm. The surrogate too undergoes shots to coordinate her reproductive system with that of the biological mother so her uterus will be maximally prepared to receive the embryo(s).

IN A VERY interesting chapter, the author explains that the surrogates she interviewed have a different vocabulary and use special metaphors for parts of their bodies to separate themselves from the commissioning couples’ fetuses. One called herself an “oven that bakes the bread for hungry people. I just help them... Like if my friend needed a loan, I would save from my own food, and I would give her a loan. Would they then say I am being used?” Another surrogate said she was “someone with a womb, a good womb ... I just held [the fetuses] in my belly, like an incubator... I was their incubator for nine months... And the second that they were born, I finished the job and that was it.

Many of the surrogates described their commissioned pregnancy as very different physically from when they bore their own child – little or no nausea or food urges, for example. It was as if their womb belonged to someone else, and their emotions toward the fetus were nonexistent. In no case did any surrogate chronicled by Teman express a desire to keep the baby they had delivered.

The relationships between surrogates and intended parents were often very close, especially between the women. Some said they would do anything for the biological mother and felt the need to update her daily on what she felt so that the mother – who could never become pregnant – would be able to “experience” it. Some of the commissioning mothers developed symptoms of pregnancy – even high levels of pregnancy hormones – as a way of entering their future role. They invariably fondle the belly of their surrogate to feel fetal movements and hear the heartbeats and drive the surrogates to tests and spoil them. Sometimes even the father is allowed by the surrogate to be present for vaginal ultrasound scans, not to mention the birth. But in some cases, the relationship becomes very sticky, and Teman describes cases in which the couples develop severe psychological dependence and make too many demands, forgetting the boundaries of the surrogate’s self. Yet some surrogates also worry about the sudden disconnection from the couple, fearing they will lose them as friends. Surrogate e-mail forums and Web sites often carry such stories and give advice to avoid the minefields.

Teman notes that the law has its drawbacks, including the directive that surrogates must be single women, that gay couples and single persons cannot hire surrogates, and that intended mothers must first have made repeated IVF attempts to prove their candidacy. “However, the legislation also protects surrogates, couples and the resultant child. The government ensures that parties are diligently screened and that all contracts are valid.” It is the quality of the surrogate’s relationship with the couple that largely determines her satisfaction with the experience. The Israeli surrogacy law, minus some of the restrictions required by Jewish law, could serve as a model for other countries, the author concludes.