BY BEATRICE NAKIBUUKA
Surrogacy has become a ray of hope for many in a world where the harsh reality of infertility and the desire to become a parent can collide. In Uganda, where laws and cultural norms about reproductive rights are changing, surrogacy offers both enormous potential and formidable obstacles.
Lisa’s experience
Lisa Stark Hughes is the Chief Executive Officer and founder of Gestational Surrogate Moms Inc. (GSMoms) which she established 14 years ago in North America.
She applied to a surrogacy agency online, and after medical record reviews, interviews, psychological screening by the agency and then the IVF Clinic, she was shown a profile of a couple and after speaking with them and doing a video call they both decided to work together.
First she carried twins, and the second time a single baby. The first time, the Intended Mother struggled believing that the babies would make it to delivery.
“It is a very powerful feeling to know that I have made such a difference in someone’s life. My pregnancy was easy, and uncomplicated. I was very big at the end and that became uncomfortable, but that is not very uncommon, especially with twins. I carried the twins a couple days over 38 weeks and they were born naturally and very healthy,” Hughes recalls.
Hughes also remarks that pregnancy for the second couple was also easy except that after the water broke and the doctors realised it was breech, so she had a C-section and these children are all doing well.
At first, she struggled with understanding why the Intended Mother was worried and nervous about something going wrong with the pregnancy. “My pregnancies had always been successful and easy, but later I understood that she had had so many failures and complications in her own pregnancies that she was worried something would happen again. She was worried to get her hopes up and get disappointed again,” she recalls.
Hughes believes her surrogacy experience blessed her life and without that experience, “I would not have gone to law school, I would not have started my business, I would not be on the international ethics boards that I am on. I might not even be in Uganda.”
She explains that attachment to the baby is a common misconception about surrogacy. “People try to make surrogacy similar to carrying your own baby. Attachment is an emotional process that begins in your brain when you realize you are pregnant with YOUR baby. With surrogacy, you meet the Intended Parents prior to ever becoming pregnant. The baby is not genetically related to you. The baby is ALWAYS the Intended Parents’ baby.”
She advises that the Intended Parents should, if possible, be in the delivery room so they can experience their baby’s birth and the surrogate can see their joy in those moments.
But what is surrogacy?
When a lady cannot use her uterus to carry a baby, she can rent a womb. Surrogacy for that matter is an arrangement, often supported by a legal agreement, whereby a woman agrees to conceive and carry a baby until its birth on behalf of another person who becomes the child’s parent after birth.
Gestational surrogacy is the most common type of surrogacy where a fertilized embryo(s) consisting of the egg and sperm of the intended parents are inserted into the surrogate’s uterus using IVF technology.
According to Dr Edward Tamale-Sali, a gynaecologist and co-founder of Women’s Hospital International and Fertility Centre, surrogacy is when, for several reasons, a woman cannot use her uterus to carry a baby so she opts for renting a womb from another lady who can. The biological parents have the same DNA as the child and the surrogate does not carry any characteristics to the baby.
Depending on the agreement, some people view surrogacy as full-time employment, others part-time; while others may offer to be surrogates for their family members for free. When it comes to surrogacy, there is no set method of payment. The surrogate and biological parents sign an agreement, which the lawyer and the hospital witness.
“We try to make sure that there is no abuse or taking advantage of any party so we usually have a legal person that explains the details of the agreement to both parties,” says Dr Ssali.
After the consent agreement is signed, the surrogate goes through a series of tests for HIV, Hepatitis, and a history of mental illness, social background checks are done and support from the husband or relative who is her next of kin.
Dr Ssali says, “We do not take women who have never had their children to become surrogates. This is because surrogacy, like any other pregnancy, can compromise their fertility if they get complications. One can only be surrogate twice.”
He also notes that different from other countries, surrogates are free to live in their own homes and enjoy sexual relationships with their husbands while pregnant if they wish to.
“The mode of delivery depends on the assessment done by the hospital’s obstetrician. A surrogate mother can deliver through the vagina or by C-section. After birth, the baby is immediately given to the biological parents and the mother can start breastfeeding by putting the baby on the breast,” Dr Ssali says.
What is in the surrogacy agreement?
A surrogacy agreement is a formal contract between intending parents and a surrogate mother, outlining the terms under which the surrogate will carry and give birth to a child for the parents. This agreement details the rights, responsibilities, and expectations of all parties involved, including personal information about the surrogate, such as her name, age, marital status, and health status, confirming her capability to bear a child without unreasonable risk.
Key elements of the contract include:
•Purpose and Legal Rights: It must state that the surrogate is carrying the child for the intended parents, who will assume full legal rights upon birth.
•Medical Procedures: The agreement specifies the assisted reproductive methods (e.g., IVF) to be used, requiring informed consent from all parties regarding medical procedures.
•Obligations: The surrogate agrees to maintain prenatal care, avoid harmful activities, and follow medical advice. The intended parents are responsible for all medical costs related to the pregnancy and must accept parental responsibility for the child after birth.
•Termination Conditions: The contract outlines conditions for termination, including mutual consent or failure to conceive after specified attempts. The surrogate may not terminate the pregnancy except for medical reasons.
•Counseling and Legal Representation: The agreement ensures that the surrogate receives counselling throughout the process and mandates independent legal representation for both parties to guarantee fairness and understanding of their rights and obligations.
Ethical and Exploitation Concerns
A regulated system is crucial for safeguarding the rights of all parties involved in surrogacy and assisted reproductive technology (ART) in Uganda, which has been unregulated for nearly two decades.
Angualia emphasizes that the absence of regulation increases the risk of medical malpractice, with some physicians exploiting vulnerable patients seeking ART. The proposed Human Assisted Reproductive Technology (HART) Bill aims to restrict ART services to registered medical practitioners, ensuring that qualified individuals provide these services.
Many surrogates lack awareness of the medical and psychological challenges involved, often foregoing legal representation due to financial incentives. Angualia advocates for clear information to protect both surrogates and intended parents from exploitation. The HART Bill allows surrogacy for women aged 18 and older but raises concerns about whether younger individuals can truly provide informed consent.
Angualia suggests increasing the minimum age to 25, as this could ensure greater maturity and life experience. Additionally, he calls for fertility clinics to offer comprehensive counselling services to prepare surrogates psychologically.
The need for a robust regulatory framework is underscored by the fact that current laws inadequately address the complexities of modern surrogacy arrangements, leaving many legal and ethical issues unresolved. Learning from countries like South Africa could provide valuable insights into effective regulation in Uganda’s evolving surrogacy landscape.
Cultural and Social Stigma
In Uganda, the use of Assisted Reproductive Technologies like surrogacy, is shrouded in social stigma, particularly tied to cultural norms surrounding fertility.
According to Resty Nalwanga, a registered advocate at Angualia Busiku & Co. Advocates, BMK House, couples who have successfully conceived through ARTs often keep the information private, fearing criticism or judgment about how their children were conceived.
“Infertility itself carries a heavy burden in Ugandan society, and revealing that a child was conceived through methods such as surrogacy invites questions that challenge the child’s legitimacy, raising doubts about whether the child is normal,” she says.
Questions like “Is the child normal?” reflect deep-seated misconceptions and reinforce the stigma associated with surrogacy and other ARTs. The judgment faced by these individuals creates a paradox where, despite societal pressure to bear children, those who use alternative methods are viewed with suspicion.
Nalwanga says, “Efforts should be made to raise awareness about surrogacy and ARTs. By openly discussing the positive outcomes and addressing the social stigma head-on, there is hope that Ugandan society will begin to embrace ARTs as a legitimate and empowering option for couples facing infertility.”
Many religious groups oppose surrogacy, viewing it as interfering with the natural process of life. They argue that it raises moral and theological issues, particularly regarding the use of medical technology in reproduction.
