Should a Country’s Maternal Mortality Rates Impact Selection for an International Gestational Surrogacy Journey?
As I have written many times before, I am a staunch advocate for strict regulations when it comes to assisted reproductive technology (ART), especially gestational surrogacy.
However, there are no universal regulations for gestational surrogacy and so there are variations in how it is conducted around the world.
While the United States is often lauded as the ‘gold standard’ for compensated gestational surrogacy given its high standards of medical and legal frameworks, I have previously written about how the U.S. is financially out of reach for many queer intended parents (IPs) (https://www.babymoonfamily.com/original-articles/ivf-and-surrogacy-abroad).
Therefore, there is an increasing number of queer IPs who are embarking on journeys in countries in Central and South America and Asia. I have also written about how I believe any surrogacy journey can be made into an ethical journey, regardless of the geography (https://www.babymoonfamily.com/original-articles/ethical-surrogacy-abroad).
One aspect to an ethical journey that I did not previously consider was maternal mortality.
Gestational carriers (GCs) are incredible women who have the greatest of intentions in their motivations to help IPs, but their generous act still comes with the risk of pregnancy. This risk varies greatly in different countries around the world.
For this article, I wanted to share some statistics from the World Health Organization (WHO) and the U.S. Centers for Disease Control (CDC) on maternal mortality. From these data, I want to discuss two questions:
Should this factor into queer IPs' decision to embark on a journey in a certain country?
Should we change our perspective on how we view certain countries for gestational surrogacy journeys?
Maternal Mortality Rates (MMR) Around the World
According to the WHO, approximately 800 women died every day in 2020 from preventable causes related to pregnancy and childbirth - meaning that a woman dies around every two minutes (1).
The goal is to reduce the maternal mortality rate (MMR), which is the number of maternal deaths per 100,000 live births, to 70 by 2030.
For the purposes of this exercise, I wanted to compare MMRs across three different categories of country:
Reference country
Established countries for international gestational surrogacy
Increasingly popular countries for international gestational surrogacy
As a reference country, I wanted to use the country I am currently living in: Sweden. While Sweden does not allow for compensated gestational surrogacy, like all countries within the European Union, it is a good reference for MMR given that it is highly developed and has a national healthcare system that is often regarded as one of the best in the world.
With that being said, the MMR for Sweden in 2020 was 5.
Now, let’s compare this to the MMR for the established countries for international journeys, both of which are the ‘gold standards’ for either altruistic or compensated gestational surrogacy.
For altruistic journeys, Canada is the go-to destination, and Canada in 2020 had an MMR of 11.
The leader for compensated journeys, the United States, had an MMR of 21 in 2020.
I was surprised to learn how high the MMR was for the United States. Upon further research, I found that there is huge variability between states. The CDC compiles its own report for MMR by state, and in 2021, the range went from the lowest of 10.1 in California to the highest of 43.5 in Arkansas (2).
In general, the southern states such as Arkansas, Mississippi, and Alabama all had extremely high MMRs.
While too complicated to get into in this article, the fractured, privatized medical system of the United States demonstrates the huge variability in care that people can receive across the country, with significantly worse outcomes for racial and ethnic minorities and lower socioeconomic classes.
Already, these data for the established destinations are not what I expected. Given the reference of Sweden, Canada and the best U.S. state of California have twice the maternal mortality rate. If you use the average MMR across the entire U.S., it is four times higher than Sweden, and if you have a GC who gives birth in a southern U.S. state like Arkansas, the rate is over eight times higher.
Obviously, there are a number of factors that play into maternal mortality, and GCs are medically screened and optimized for surrogacy. Therefore, their risk is inherently lower than the average pregnant woman who may have risk factors like gestational diabetes or have a higher rate of developing life threatening complications like eclampsia.
However, these MMR numbers also reflect the expertise and capability of a country’s healthcare system. The more advanced and more universally accessible care is, the better the outcomes. So, even if a GC is medically screened and cleared, she will still have to deliver in a medical system that may not be highly successful with regard to maternal health.
Moving to the countries with increasing popularity for international gestational surrogacy, these can be further subdivided into two geographic regions: Americas and Asia.
In the Americas, we have Mexico, Argentina, and Colombia. These are all destinations that due to lower costs have become increasingly popular for international journeys. The MMR for each of these countries from 2020 are: Mexico with 45, Argentina with 59, and Colombia with 75.
Putting aside the reference country, even comparing these to Canada and the United States, the MMRs for these countries are between two and seven times higher.
Lastly, in Asia, I wanted to look at the countries of Georgia and Thailand. Although Thailand is not yet open to international gestational surrogacy, news earlier this year suggests that it may change soon (https://www.babymoonfamily.com/original-articles/thailand-reopens-international-surrogacy).
These countries are close to the United States and each other, with Georgia having a MMR in 2020 of 28, and Thailand having a MMR of 29.
How Should These Maternal Mortality Rates Impact an International Journey?
With these numbers in mind, I want to go back to my initial questions around the impact that these numbers can or should have on planning an international gestational surrogacy journey.
As I have written about before, my husband and I chose the U.S. as our destination for a number of reasons (https://www.babymoonfamily.com/original-articles/beginning-surrogay-journey). However, I am a bit surprised at how high the MMR for the U.S. as a whole is. We are working with a fertility clinic and agency in California, but we may match with a GC who lives in another state. While her care will occur in California up through the start of her 2nd trimester, she would ultimately deliver in another state with a higher maternal mortality rate. This is not something we considered before.
I think there is also a lot of judgment and bias towards the countries emerging in popularity for international journeys that their medical care and systems are not ideal. However, the MMR in 2020 for Thailand and Georgia are very similar to the average U.S. So, should we really be so critical of these medical systems?
Lastly, I think these numbers do suggest a need to reflect if someone is considering a journey in Mexico, Argentina, or Colombia. These are national averages, but given how high they are, I would strongly consider doing extensive research on the fertility clinic, agency, and hospital where your GC will deliver if you are considering a journey in these countries. These MMR statistics can be different in different regions, cities, or even hospitals, but I believe the WHO statistics demonstrate that more diligence is required if you are on a journey in one of these areas in order to try and ensure the safety and well-being of your GC and your child.
No journey is risk free, but in order to have an ethical journey, it is important to do everything in your power to mitigate and minimize the risk to all parties involved.
While these WHO and CDC data and statistics analyze all deliveries and maternal mortality, it would be interesting if there could be more research that is specific to GCs. In a future article, I plan on reviewing a recent scientific journal article around GCs’ risk for elevated blood pressure and/or post-delivery bleeding. This is an example of medical research that is specific to GC outcomes and will help us to better understand if there are medical differences between GC and routine pregnancies in order to better address potential complications for future journeys.
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