The first baby conceived through in vitro fertilization (IVF) was born in 1978 and revolutionized alternative family building strategies. As IVF has become more widely available in the years since, the focus of many families who cannot conceive or carry a baby to term – the Centers for Disease Control and Prevention estimates there are 6.7 million such women in the United States alone – has shifted from adoption to surrogacy. However, this endeavor remains very expensive; prohibitively so for many. Commercial surrogacy can cost up to $70,000 in the United States, except in the seven states where it is illegal. Yet if couples are willing to outsource to another country, surrogacy can cost much less.

A global trade between families from developed countries and women from developing countries is growing, raising questions about the reproductive rights of poor, marginalized women and how to institute effective regulation and oversight. The commoditized reproductive capabilities of a poor woman in South Asia, Latin America, or Eastern Europe can cost as little as $12,000, according to a study by Karen Rotabi and Nicole Bromfield in Women’s Studies.

“Total Lack of Autonomy”

India, once the largest global surrogacy market due to its lenient regulations, started closing its doors to foreigners seeking surrogate arrangements in late 2015. Now families seeking a surrogate abroad look to countries such as Cambodia, Guatemala, and Ukraine (though only for heterosexual, married couples in Ukraine’s case). These countries have little to no regulation when it comes to surrogacy, which reduces the costs for commissioning parents and alleviates the complications associated with legal red tape.

Minimal regulations are a perk for the commissioning couples, but leave the women serving as surrogates extremely vulnerable to exploitation. “While surrogacy can be seen as enhancing reproductive freedom for the commissioning mother to have a genetic child, and for a surrogate mother to utilize her reproductive capacities for altruistic or financial reasons, surrogacy arrangements are ripe with possibilities for women’s reproductive freedom to be violated,” write Rotabi and Bromfield.

“The power divide among these women, the sophisticated organizations that are developing the services, and the consumers (relatively wealthy couples and individuals) is such that human protections are an absolute imperative.”

Surrogacy can provide women in developing countries with a life changing amount of money. Rotabi and Bromfield found that surrogates in India were paid $5,000 per child on average – the equivalent of 10 years’ worth of wages for a rural woman. However, there are often few alternatives. They found many global surrogates have only more oppressive forms of work as their other choices, including sex work. In some cases, surrogates do not have a choice at all. “‘Prospecting’ is being carried out by husbands, fathers, brothers, or other family or community members (including recruiters),” write Rotabi and Bromfield, “who may entice and/or coerce the women.”

Many global surrogacy agencies require women to live in dormitory-style housing throughout the duration of the pregnancy, ostensibly to ensure access to nutritious foods, clean drinking water, and high quality antenatal care. But experts have raised concerns regarding the “total lack of autonomy” surrogates are subjected to, writes Priya Shetty in a special report for The Lancet.

Maternal Health Implications

Though detailed statistics are lacking, there are indications this trend is on the rise, and there are important maternal health implications beyond the power dynamics at play. Ninety-nine percent of maternal deaths occur in developing countries, and surrogacy only serves to exacerbate the chances of poor women encountering a life-threatening complication.

One of the most dangerous aspects of surrogacy is the increased likelihood of bearing more than one child. During IVF it is often recommended that more than one egg is implanted at a time in the hopes that at least one will “stick” and develop into a fetus. This practice leads to a greatly inflated number of multiple births as compared to non-IVF pregnancies.

A multiple gestation pregnancy poses serious risks for the surrogate and fetuses. “Even a twin pregnancy strains organs such as the liver, kidneys, and thyroid” in the mother, writes Shetty in The Lancet. There is a higher possibility of a premature birth, which increases the potential for many health problems too. “One-third or even one-half of infant mortality is due to complications of prematurity, and a large contributor to prematurity is infertility treatment,” writes M. M. Tieu in an article on the ethics of surrogacy for The Journal of Medical Ethics.

Cesarean section is also more likely with a multiple gestation pregnancy, a complex surgery associated with a variety of risks, such as wound infection, increased bleeding, and elevated risk of problems during future pregnancies. Even women who aren’t carrying multiple fetuses are more likely to face problems after a Cesarean. Rotabi and Bromfield found surrogates face a higher risk for Caesarean not only because of the possibility of a multiple gestation pregnancy but in order to make the timing convenient for commissioning parents.

Women living in crowded conditions and separated from their families are also more likely to manifest mental health issues that can have a harmful impact on the surrogate and fetus. Once the surrogates deliver, many face postpartum depression as any special treatment from their employers stop. Approximately 20 percent of women in developing countries experience post-partum depression following delivery, which can lead to severe mental problems, including suicide.

Can It Be Done Right?

The complications cropping up around the global surrogacy market are not necessarily an argument against surrogacy writ large, but for more oversight over a potentially very damaging trade. The American Society of Reproductive Medicine recommends surrogates should undergo thorough screening of their physical and mental health history and complete counseling before and throughout the duration of the pregnancy on topics such as their right to make choices about their bodies and more. They also recommend counseling continues after birth as a preventative measure against postpartum depression and other mental health issues.

This type of high quality care and monitoring is feasible when the commissioning parents are paying up to $70,000 (i.e., in the United States), but when the cost is up to five times cheaper in the developing world, there are simply fewer funds and quality services available.

India has responded by making it more difficult for foreigners to get visas to collect children and, just this August, proposing a complete ban on commercial surrogacy. A law put forth by the governing Hindu nationalist party would allow only “altruistic surrogacies” for childless Indian couples that have been married at least five years, are not capable of having children, and have a “close relative” who can be the surrogate.

An ideal solution is likely somewhere in between a complete ban and a freewheeling market. Regulation “will likely take years to develop and adopt,” writes Erica Davis in the Minnesota Journal of International Law. In the meantime she recommends countries model surrogacy laws after adoption laws. For instance, “adoptive parents are required to work with accredited adoption service[s]” and if future “accredited [surrogacy] agencies comply with an overall regulatory scheme, this type of rule would function to protect all parties from exploitation.”

Ultimately, the challenge lies in placing a quantitative value on women’s reproductive capabilities. This has the potential to be exploitative, particularly in the absence of regulation, and threatens the health and wellbeing of women whose bodies are deemed less valuable due to their race, class, socioeconomic status, or country of origin. Tieu argues that surrogacy as it currently exists “requires the subordination of the welfare of the surrogate and [the fetus] in favor of the commissioning parents desires to have a child.”

Davis quotes University of Michigan law professor Margaret Radin: “We can both know the price of something, and know that it is priceless.”