Health Risks to Surrogate Mothers

 

“First, do no harm.”

Medical ethics, expressed in the principle “First, do no harm,” prohibit the exposure of healthy women to engage in entirely elective, medically risky procedures that not only fail to benefit their health in any way, but inflict upon them grave risks of harm, sometimes leading to their death. Governor Cuomo’s proposed legislation to legalize commercial surrogacy (the “Cuomo Proposal”) explicitly legalizes commercial surrogacy contracts that pose well-known and especially grave health risks to both surrogate women and children. 

Multiple deaths of American women resulting from complications directly related to their surrogacy pregnancies have made it into the public domain in recent years. Although we know that tens of thousands of American women are now serving as surrogates in high-risk pregnancies, we have no means of knowing the total number of them who have died or will die, in large part because the commercial surrogacy industry has ensured that such information never sees the light of day. Nothing in the Cuomo Proposal—or in any other laws or agency regulation-- requires these deaths to be reported, making it impossible for potential and actual surrogates to understand even the direst of risks that they face. The very fact that the Cuomo Proposal expressly provides that a surrogate “has the right to be provided with a life insurance policy or contractual performance indemnity or accidental death insurance policy for the duration of the policy and eight weeks post-pregnancy or termination,” to be paid for by the intended parent, reveals a recognition of the magnitude of harm risked by a surrogate. 

The frequency of the many known harms associated with surrogacy will never be ascertainable because there is no requirement that health complications experienced by surrogates—or even their deaths—be tracked and reported. The Cuomo Proposal contemplates the “establishment of a voluntary central tracking registry” to gather and maintain data, but there is no reason to believe that the surrogacy industry will ever be inclined to voluntarily share such information.

Notwithstanding the dramatically increased health risks involved, 85% of surrogacy pregnancies in the USA involve the transfer of multiple embryos to the surrogate for her to carry.

The dramatic increase in multi-birth rates in the United States resulting from the increase in surrogacy pregnancies was recognized as a “cause for concern” in a recent report entitled “Gestational Surrogacy: A Call for Safer Practice” appearing in the Fertility Sterility Journal (VOL. 106 NO. 2 / AUGUST 2016).  It explains that single-embryo transfers are performed in only 15% of all surrogacy transfers, and that two-embryo transfers are much more common in surrogacy arrangements, “leading directly to the multiple gestation and preterm risks documented in [the] report.”  The report reveals that where multiple embryos were transferred in surrogacy arrangements, “the risk of premature delivery was many times higher for multiples than for singletons,” and concludes that “it is a well-documented fact that multiple-gestation pregnancies are associated with a significantly higher risk of hyperemesis, gestational hypertension, gestational diabetes, anemia, preterm labor, hemorrhage, cesarean delivery, and cesarean hysterectomy than singleton pregnancies.”   

Sounding the alarm that “[A] significant number of [surrogates] and the resulting children are being exposed to the increased risks associated with multiple-gestation pregnancies,”  the obstetric gynecologists authoring the report explained that such multiple-gestation pregnancies result in over 30% of the deliveries being preterm and with 42%  being twins, triplets, or more children. The report urged fertility doctors “to do our utmost to ensure the medical safety of “surrogates and resulting children,” and emphasized that “one of the most effective means for achieving this goal is to minimize the number of multiple gestation pregnancies by maximizing the use of elective single-embryo transfer.” The report pointed to a major reason for such risky multiple pregnancies: limiting the number of embryos transferred increases the out-of-pocket expenses for those who desire more than one child.  Since a single surrogacy transaction can be costly, a ‘‘two for the price of one’’ arrangement “may be appealing to intended parents.”

There is woefully inadequate screening--physical, mental, and psychological--of surrogate 

For a woman to be eligible to serve as a surrogate, the Cuomo Proposal imposes only three requirements: that she must have “completed a medical evaluation with a health care practitioner,” that she be either a US citizen, a lawful permanent resident, or “other habitual resident,” and that she be “at least 21 years old.”

These eligibility requirements are woefully inadequate to ensure that women who agree to take on the risks of surrogacy are even minimally fit to do so. 

Although she must have “completed a medical evaluation,” nothing in the Cuomo Proposal requires that a would-be surrogate be disqualified, even if that medical evaluation demonstrates that she is physically, mentally, or psychologically unfit to assume the risks of surrogacy. Because this “medical evaluation” need only be administered by a non-specific “health care practitioner,” there is no requirement that she be evaluated by a doctor instead of a nurse, or by any health care practitioner possessing any expertise in fertility medicine, or psychological evaluations, or assessments of mental aptitude. 

As a result, nothing in the Cuomo Proposal prevents a woman from becoming a surrogate who has significant educational, mental, or intellectual deficits (including an inability to read, write, or understand English, or comprehend in any meaningful way the risks of surrogacy or the import of the provisions of a surrogacy contract).

Nothing prevents a woman from becoming a surrogate, even if she has physical conditions that put her at heightened medical risk (e.g., advanced age, obesity, diabetes, thyroid or autoimmune disease, high blood pressure). 

Nothing prevents a woman from becoming a surrogate, even if she has major psychological issues that would impede her ability to understand what a surrogacy pregnancy and its aftermath might entail, or who suffers from extreme stress. Surrogacy agencies favor women with a recent track record of successful complication-free past pregnancies. By definition, this means young women with young children. This also typically means young mothers with small children to care for who are often under extreme financial stress. Overwhelmingly, surrogates have limited education—typically no more than a high school education—if that—and struggle to find employment that pays the bills. Often, in practice, surrogates are single parents, struggling to provide for their children on their own. 

But nothing in the Cuomo Proposal would preclude a woman from serving as a surrogate, even if she were under extreme duress and profoundly vulnerable to coercion. She might be a young mother who is homeless, or on the brink of homelessness. She might be a woman who depends on welfare—or begging in the street—to get by. She might be an undocumented woman who is unable to find employment of any kind, and who speaks little or no English, and who is terrified that she and her children could be deported at any time. She might be an older woman—in her fifties or sixties—who has no other means of securing money to live on. She might be a woman under the control of an abusive intimate partner or a pimp or a surrogacy trafficker. Nothing in the Cuomo Proposal would protect women in such circumstances from entering into surrogacy arrangements, even when they are compelled to enter into them as a matter of survival, and have no ability to insist on the terms of the surrogacy contract being fair or reasonable.

Surrogacy death is a real possibility but an unknowable probability.

Multiple deaths of American women resulting from pregnancy-related complications have made it into the public sphere in recent years. Although we know that tens of thousands of American women are now serving as surrogates in high-risk pregnancies, we have no means of knowing the total number who have died, or will die, in large part because the commercial surrogacy industry prevents the collection and publication of such information. Non-disclosure and confidentiality provisions are common in surrogacy contracts, as are provisions mandating private arbitration proceedings to resolve disputes, in lieu of open court proceedings.  Like the surrogacy agencies, fertility clinics—for whom surrogacy procedures represent their most lucrative practice --have every incentive to prevent this information from being disclosed, and to prevent any research dollars being spent on collecting and evaluating surrogacy death rates. Nothing in the Cuomo Proposal—or any other laws or regulations-- require these deaths to be reported, making it impossible for surrogates to understand the direst of risks that they face. 

Although the Cuomo Proposal provides that a surrogate is entitled to a life insurance policy or contractual performance indemnity or accidental death insurance policy, paid for by the intended parents, “for the duration of the policy and eight weeks post-pregnancy or termination,” the Cuomo Proposal goes on to state that this time period can be shortened if the surrogacy agreement “specifies a sooner term.” Obviously, would-be surrogates in financial duress lack the bargaining power to prevent even a dramatic shortening of such life insurance protection in their surrogacy contract. Not only does a surrogate risk her own life when she signs a surrogacy contract--she risks her children being both motherless and penniless.

The Cuomo Proposal requires that surrogacy pregnancies use donor-eggs, even though the medical literature conclusively demonstrates that egg-donor pregnancies pose dramatically greater health risks to women than the risks posed by traditional pregnancies and standard IVF pregnancies.

Although the health risks of pregnancy would be dramatically reduced for both surrogates and surrogate offspring if a surrogate were allowed to use her own egg(s) in a surrogacy pregnancy, this is expressly forbidden in the Cuomo Proposal. By requiring the use of donor eggs in surrogate pregnancies, surrogate women and surrogate offspring face much greater risk of harm.  In a report entitled “Clinical and immunologic aspects of egg donation pregnancies:  a systematic review,” for example, based on 79 research papers and authored by a team of scholars from leading medical institutions from around the world, the following conclusions were reached:  

• Egg-donor pregnancies, as compared to both traditional pregnancies and standard IVF pregnancies, are at higher risk of bleeding complications in the first trimester; preterm labor; preeclampsia; protracted labor requiring Caesarean section delivery; and post-partum, hemorrhaging.
• There is a 3-fold increased incidence of hypertension complications in egg donor pregnancies compared with standard IVF pregnancies. 
• The literature conclusively demonstrates an increased risk of significant health complications in pregnancies involving the use of donor eggs.

In a report entitled, “Fertilization and Self-Oocyte In vitro Fertilization:  A Retrospective Cohort Study, Department of Obstetrics and Gynecology” AIIMS, New Delhi, India, the following conclusion was reached:

Egg donation should be treated as an independent risk factor for hypertensive disorder in pregnancy.  Women should be informed of the risks, and egg-donor pregnancies should be managed in high‐risk obstetric clinics.

In a report published in the American Journal of Obstetrics and Gynecology entitled “Risk of Severe Maternal Morbidity by Maternal Fertility Status:  a U.S. Study in Eight States”, based on a sample size of 1,477,522 pregnancies and births, the following conclusions were reached:

• Women with IVF pregnancies that used donors’ eggs had the highest rates of hypertension/high blood pressure for the whole duration of the pregnancy (both pre-gestational and gestational hypertension).
• Women with IVF pregnancies that used donors’ eggs were more likely to require an unplanned hysterectomy.
• Women with IVF pregnancies that used donors’ eggs had the highest rates of admission to the hospital’s general intensive care unit, and children conceived by IVF from donors’ eggs had the highest rates of admission to the newborn intensive care unit.

A study in the prestigious journal Fertility and Sterility, comparing the experiences had by the same woman between her traditional pregnancy and her surrogate pregnancy, reached the following conclusions:

• Neonates conceived using donor eggs and carried by surrogates have increased adverse perinatal outcomes—including preterm birth, low birth weight, maternal gestational diabetes, hypertension, and placenta previa—than those conceived by the same women using her own eggs in traditional pregnancies.
• Donor-egg conceived  pregnancies are more likely to end in cesarean section deliveries than the same women’s traditional pregnancies.

 

Surrogacy pregnancies often involve multiple fetuses, which always result in high-risk pregnancies.

Even when a surrogate mother is carrying just one child— a singleton—she as well as all other IVF-assisted pregnant women face an increased risk of severe maternal morbidity compared with naturally-conceived pregnancies, as well as an increased risk of preterm delivery, stillbirth, spontaneous abortion, preeclampsia, placenta previa, and having to deliver by c-section.  Single children born via IVF also have more health risks than do single children who have been naturally conceived, including premature birth, low birth weight, and birth defects.  “The majority of problems we see with assisted reproductive technology are multiple births, but even singletons have higher risk of complications,” said NICHD medical officer Uma M. Reddy, MD, MPH, the lead author reporting the findings of an expert panel convened in 2005 by the U.S. National Institute of Child Health and Human Development.

When surrogate mothers and IVF-assisted mothers carry more than one child, however, the risks to both them and the children dramatically increase still further, and to a far greater extent than those faced by mothers who naturally conceived and are carrying multiple children. 

Notwithstanding the much greater risks a surrogate will inevitably face, 85% of all surrogacy pregnancies in the USA involve multiple embryos being transferred to a surrogate mother for her to carry, in order to increase the likelihood of a successful outcome, including being able to procure additional children for the price of one.

Even if only a single embryo is transferred to a surrogate, however, she is still more likely to end up carrying multiple fetuses than is a woman in a traditional pregnancy, as it is well known that IVF pregnancies are more likely to result in identical multiples resulting from a fertilized egg splitting after transfer.

Health care experts have estimated that medical costs for delivery and newborn care can be as much as four times greater for twins than for single babies, and the amount increases to twelve times higher for triplets.

 

Even traditional pregnancies with no special risk factors can result in life-threatening complications to both the mother and her offspring.

Even in traditional pregnancies where conception takes place naturally without any use of artificial reproductive technology and where the woman is fit and healthy by every known metric, it is not uncommon for complications to arise.  Unlike organ donors, for example, who might part with one of their two kidneys or part of their liver to support the life of another, a woman while pregnant gives over the full use of all of her organs and bodily systems to support the life of another, and for a much more extended period of time.  Given this profound bodily invasion, it is not surprising that pregnancy can sometimes overwhelm even the sturdiest female body.

Some of the more common complications arising during even a traditional pregnancy include anemia, gestational diabetes, high blood pressure, preeclampsia, placental abruption, hyperemesis gravidarum, urinary tract and other infections, miscarriage, and preterm labor.  Because we know that these risks greatly increase in surrogacy pregnancies, however, it is very important to understand what each risk entails.

 

Gestational high blood pressure/hypertension/Preeclampsia:  Surrogates are much more likely to develop life-threatening preeclampsia, as a result of donor eggs being used in their pregnancies and because they are more likely to be carrying multiple fetuses.

In many cases, high blood pressure that can develop during a woman’s pregnancy does not harm the woman or child, and dissipates several months after childbirth.  But it does raise the woman’s risk of high blood pressure in the future, and if severe, can also result in low birth weight or preterm birth of the child.  Some women with more severe gestational hypertension, however, go on to develop preeclampsia. Preeclampsia is one of the leading causes of maternal morbidity and mortality worldwide.

Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys.  Preeclampsia usually begins after 20 weeks of pregnancy in women whose blood pressure had been normal, but can also present as late as four to six weeks after the birth of the child.  Preeclampsia can lead to serious—even fatal—complications for the woman.  Symptoms can include severe headaches, temporary loss of vision, blurred vision or light sensitivity, abdominal pain, nausea and vomiting, impaired liver and kidney function, shortness of breath caused by fluid in the lungs, and sudden weight gain and swelling.  Preeclampsia can also result in damage to the kidneys, liver, lung, heart, eyes, and may cause a stroke or other brain injury.  Having preeclampsia also increases the risk of future heart and blood vessel (cardiovascular) disease, especially where the woman has had preeclampsia more than once or had a preterm delivery.

Preeclamsia can also result in placenta abruption resulting in life-threatening heavy bleeding, and HELLP ( which stands for hemolysis—the destruction of red blood cells, elevated liver enzymes and low platelet count) syndrome— a still more severe form of preeclampsia that can rapidly become life-threatening to woman and child.

Because preeclampsia affects the arteries carrying blood to the placenta, the unborn child is at risk of receiving inadequate blood and oxygen, as well as fewer nutrients.  These deficits can restrict fetal growth and result in low birth weights and preterm births.

Women with severe preeclampsia often must undergo immediate deliveries to save their lives, regardless of the baby’s prematurity.

Studies show that women pregnant with donor eggs, which is true of all surrogates, have a more than three-fold risk of developing pregnancy induced hypertension and preeclampsia.  A recent study found that surrogate pregnancies, per se, also posed an independent increased risk of preeclampsia and gestational hypertension when compared with pregnancies of other IVF-assisted mothers and naturally conceived mothers.  For reasons not yet studied or understood, women such as surrogate mothers who become pregnant at any time with a new partner are at still at greater risk of preeclampsia.  Having babies less than two years or more than 10 years apart—as is the case with many  surrogate mothers—also leads to a still higher risk of preeclampsia.

Although preeclampsia usually starts after 20 weeks of pregnancy or after childbirth, it tends to occur earlier and is also more severe in multiple pregnancies.  Women carrying twins or more—also very common in surrogacy pregnancies—are more than twice as likely to develop preeclampsia as single pregnancies, and half of all triplet pregnancies develop preeclampsia.

Women with multiple fetuses are more than twice as likely to develop high blood pressure during pregnancy.  This health problem often develops earlier and is worse than in pregnancy with one baby.  It also raises the chance of early detachment of the placenta.  As many as 37 percent of twin pregnancies involve gestational high blood pressure/ hypertension, which is three to four times the rate in singleton pregnancies.  Left untreated, it can lead to premature labor or a stillborn baby.  Egg-donor pregnancies are also independently associated with increased pregnancy-induced hypertension, ranging from 16% to 40% of cases.

Studies have shown that women who had preeclampsia during pregnancy that ended in preterm delivery had an eight fold higher risk of death from cardiovascular disease compared with women who did not have preeclampsia and delivered at term. There is also a significant risk to these women of preeclampsia recurrence in future pregnancies, and there is an increased lifetime risk of chronic hypertension and stroke in women who experienced preeclampsia during pregnancy. 

 

Placental Abruption:  Surrogates are much more likely to develop life-threatening placental abruption because they are more likely to be carrying multiple fetuses.

Surrogates are much more likely to develop life-threatening placental abruption because they are more likely to be carrying multiple fetuses.  Placental abruption is a serious condition in which the placenta separates from the wall of the uterus before birth. It can separate partially or completely. If this happens, the baby may not get enough oxygen and nutrients in the womb, and the woman may have serious bleeding. Placental abruption is three times more likely to occur in a multiples pregnancy.

Placental abruption was also found to be a significant risk factor for long-term cardiovascular mortality.

 

Gestational Diabetes:  Surrogates are much more likely to develop life-threatening gestational diabetes as a result of donor eggs being used in their pregnancies and because they are more likely to be carrying multiple fetuses.

Gestational diabetes occurs in about 5 percent of singleton pregnancies, but women pregnant with twins are twice as likely to experience it.  The use of donor-eggs in a pregnancy had also been found to be an independent factor in increasing the risk of gestational diabetes.  If untreated, gestational diabetes can cause serious health problems for the pregnant woman and any offspring.

During pregnancy, the placenta, which connects the fetus to the woman’s blood supply, produces high levels of various hormones, almost all of which impair the action of insulin in her cells and raise her blood sugar level.  In gestational diabetes, the placental hormones provoke a rise in blood sugar to a level that threatens the growth and wellbeing of the fetus, and typically afflicts the woman with nausea, blurred vision, fatigue, frequent vaginal, bladder, and skin infections, and loss of bladder control.

Gestational diabetes also increases a woman’s risk of high blood pressure, as well as preeclampsia—a serious complication of pregnancy discussed above that can threaten the lives of both mother and baby.  A woman who develops gestational diabetes is more likely to get it again during any future pregnancy, and she is also more likely to develop type 2 diabetes as she gets older.

The health risks that gestational diabetes poses to an unborn child are still graver, including pre-term birth and respiratory distress syndrome.  Because babies of mothers with gestational diabetes also tend to experience excessive weight, they are more likely to require early delivery or c-section delivery in order to reduce the risk of becoming wedged in the birth canal or sustaining birth injuries, as well as to protect the mother.  Untreated gestational diabetes can result in a baby’s death, either before or shortly after birth.  Sometimes babies of mothers with gestational diabetes also develop low blood sugar (hypoglycemia) shortly after birth as a result of their own insulin production being abnormally high, which can result in seizures.  

Babies of mothers who have gestational diabetes also have a higher risk of developing obesity and type 2 diabetes later in life. The report found that women who experienced gestational diabetes in a pregnancy have a 36–70% risk of developing type 2 DM later in life, depending on risk factors and length of follow-up.  The report stressed that “It is important for women who had gestational diabetes to have appropriate follow up since, over time, often before patients are diagnosed, DM causes damage to various organs--heart, blood vessels, kidneys, eyes, nerves, etc. Women previously diagnosed with gestational diabetes are also at increased risk of future metabolic syndrome, a combination of metabolic abnormalities that include hypertension, DM, dyslipidemia, and obesity, all of which increase the risk of cardiovascular disease. Gestational diabetes is also associated with an increased risk of future renal morbidity. 

 

Hyperemesis gravidarum:  Surrogates are much more likely to develop life-threatening hyperemesis gravidarum because they are more likely to be carrying multiple fetuses.

Most pregnant women—70% to 80%—experience some type of morning sickness.  Severe morning sickness, better known as hyperemesis gravidarum,—resulting in severe nausea, vomiting, weight loss of 5% or more of pre-pregnancy weight, headaches, confusion, fainting, jaundice, extreme fatigue, low blood pressure, rapid heart rate—affects about 1 percent of pregnant women.  Studies, however, have demonstrated a high correlation between hyperemesis gravidarum and multiple-fetus pregnancies, which are common for surrogate women.  One study, for example, showed an incidence rate of  25.9 per thousand for twins compared to 5.1 per thousand for singletons.

Women with prolonged hyperemesis gravidarum have a greater risk of preterm labor and preeclampsia, and often require hospitalization.  There is no known cure for this affliction.

 

Anemia:  Surrogates are much more likely to develop life-threatening anemia because they are more likely to be carrying multiple fetuses.

When pregnant, the volume of blood in a woman’s body increases by as much as 50 percent to support both her and the growing unborn child, with the needs of the fetus always met first.  Iron deficiencies to the woman herself often result, causing anemia, which typically leaves the woman tired, weak, dizzy, unable to concentrate, and often causing shortness of breath, headaches, rapid or irregular heartbeat, and greater difficulty combatting infections.

Severe anemia poses graver health risks.  Pregnant women with severe anemia are twice as likely as those without it to die during or shortly after pregnancy.  In addition to greatly worsening the symptoms described above, severe anemia greatly increases the risk of other serious complications, including poor fetal growth, preterm birth and low birth weight.  Severe anemia also increases the likelihood that blood transfusions will be needed during delivery.

All pregnant women are at risk of becoming anemic, and 15% to 25% of all pregnancies experience iron deficiency.  Anemia is more than twice as common in multiple pregnancies as in a single birth, however, which means there is a greater than 50% chance that surrogate mothers carrying multiple fetuses will experience anemia during their pregnancy.

 

Miscarriage:  Surrogates are much more likely to miscarry as a result of donor eggs being used in their pregnancies and because they are more likely to be carrying multiple fetuses.

A phenomenon called the vanishing twin syndrome is more likely in multiple pregnancies and often happens in the first trimester, often accompanied with bleeding.  The risk of pregnancy loss is higher in later trimesters as well.

 

Still births:  Surrogate’ pregnancies are much more likely to result in still birth pregnancies.

A 2014 study from the Journal of Perinatology found a 4-5 fold increase in stillbirths from pregnancies that were achieved  through assisted reproductive technologies.

 

Surrogates are much more likely to have to undergo cesarean-section deliveries as a result of donor eggs being used in their pregnancies and because they are more likely to be carrying multiple fetuses.

For pregnant women, a C-section carries a higher risk of severe complications than a vaginal delivery, particularly after age 35.  Recent research shows that cesarean deliveries appear to cause an overall 80% increased risk of severe maternal complications when compared with vaginal delivery.  A woman’s likelihood of having to deliver twins by means of c -section is 50-50.  One study that was corrected for multiple gestation concluded that women who conceived using donor eggs remained at high risk for requiring c-section delivery.  The rate of c-section deliveries in egg donor pregnancies, when compared with traditionally-conceived pregnancies, showed an increase that ranged from 40% to 76% of cases.

 

Postpartum hemorrhaging and first trimester vaginal bleeding:  Surrogates are much more likely to develop life-threatening postpartum hemorrhaging and first trimester vaginal bleeding as a result of donor eggs being used in their pregnancies.

The incidence of first trimester vaginal bleeding is increased in egg-donor pregnancies, ranging from 12 % to 53% of first trimester cases.  The incidence of first trimester bleeding is substantially higher if compared with standard IVF pregnancies.

 

A common additional risk faced by surrogates:  selective reduction of fetuses.

When a surrogate finds herself carrying multiple fetuses, physicians will often recommend—and intended parents may often request—that she undergo a selective reduction to reduce the number of fetuses to just one or two in order to increase the chances of a successful, full-term pregnancy and the delivery of a healthy baby.

The reduction procedure is generally carried out during the first or second trimester of pregnancy and often takes two days.  The fetuses are evaluated, first by ultrasound, then often by testing the amniotic fluid and chorionic villus sampling; to help determine which fetuses are accessible for the procedure, and whether any fetuses are unhealthy.  Once the specific fetuses to be reduced are identified, potassium chloride is injected into the heart of each selected fetus under the guidance of ultrasound imaging; the heart stops and the fetus dies as a result.  If the fetal material is not reabsorbed into the woman’s body; it may require abortion to remove, or it may stay in the woman’s womb until the remaining children are born.

Needless to say, selective reduction raises many complex and weighty ethical issues, and the pressure put on a surrogate to make a decision favored by both intended parents and attending physicians—each of whom are likely to have a very strong point of view—can be extremely intense.

 

Surrogates are at great risk of grave life-long health risks that require multiple medical interventions in order for there to be hope that they can be reduced.

Many pregnancy-related medical complications appear to resolve at delivery or shortly thereafter. Common examples are preterm labor, placental abruption, preeclampsia, and gestational diabetes. But women who develop such complications are known to be at increased risk of developing similar complications in future pregnancies, and are also known to have increased risks of long term medical complications whether or not they become pregnant again. 

An extensively-researched report entitled “Long-Term Effects of Pregnancy Complications on Maternal Health: A Review,” published in the Journal of Clinical Medicine in August 2017 documented a “clear association between various obstetric complications and long-term effects on maternal health….Women with a history of adverse pregnancy outcomes are at increased risk of cardiovascular and metabolic diseases later in life. Data increasingly links maternal vascular, metabolic, and inflammatory complications of pregnancy with an increased risk of vascular disease in later life.”

The report found that women who delivered prematurely are at increased risk of recurrent preterm labor in all future pregnancies. The report found that those who had preeclampsia have an increased risk of preeclampsia in subsequent pregnancies, and that women who developed gestational diabetes are also likely to develop it again. The same is true for a women who experienced placental abruption and fetal growth impairment.

The report documented recent research that shows that these pregnancy-specific complications continue to affect maternal health long after the index pregnancy, and even if the woman has no further pregnancies. The report found, for example, that “It has become apparent that women with a history of adverse pregnancy outcome are at increased risk of cardiovascular and metabolic diseases later in life. Data increasingly links maternal vascular, metabolic, and inflammatory complications of pregnancy with an increased risk of vascular disease in later life.” 

The report found that there is a significant risk of preeclampsia recurrence in future pregnancies, and there is an increased lifetime risk of chronic hypertension, cardiovascular disease, and stroke in women who experienced preeclampsia during pregnancy. It was found that the risk is related to the severity of the hypertensive disorder during pregnancy and the gestational age at the time of onset.

Women who gave birth to very low birth-weight babies or experienced combined complications had a several-fold increased risk of mortality from cardiovascular causes.

The report found that women who experienced gestational diabetes in a pregnancy have a 36–70% risk of developing type 2 DM later in life, depending on risk factors and length of follow-up.  The report stressed that “It is important for women who had gestational diabetes to have appropriate follow up since, over time, often before patients are diagnosed, DM causes damage to various organs--heart, blood vessels, kidneys, eyes, nerves, etc. Women previously diagnosed with gestational diabetes are also at increased risk of future metabolic syndrome, a combination of metabolic abnormalities that include hypertension, DM, dyslipidemia, and obesity, all of which increase the risk of cardiovascular disease. Gestational diabetes is also associated with an increased risk of future renal morbidity. 

In summary, gestational diabetes is an independent risk factor for future type 2 diabetes mellitus, metabolic syndrome, cardiovascular morbidity, vascular endothelial dysfunction, renal and ophthalmic disease. The risk of these conditions may be decreased with proper prevention and interventions. However, the majority of women diagnosed with gestational diabetes do not undergo evaluation after pregnancy. According to one study, only 19% women who had gestational diabetes underwent testing to rule out type 2 DM within six months following pregnancy.

Studies have shown that women who had preeclampsia during pregnancy that ended in preterm delivery had an eight fold higher risk of death from cardiovascular disease compared with women who did not have preeclampsia and delivered at term. The report concluded that “in order to decrease the risks of long-term effects on the health of women with history of preeclampsia, women with history of preeclampsia and the medical staff caring for them during the following years need to be familiar with these risks and act to modify them.”

Women who delivered prematurely are also at increased risk of long-term cardiovascular disease and additional morbidities. A history of preterm delivery identifies women who should be targeted for disease compared with women who did not have preeclampsia and del screening and preventative therapies. Placental abruption was also found to be a significant risk factor for long-term cardiovascular mortality. Maternal obesity during pregnancy is also associated with an increased risk of various long-term maternal morbidity, and has been found to be an independent risk factor for long-term ophthalmic complications, and specifically diabetic retinopathy.

The report concluded that “it is clear that many obstetric complications are associated with increased risk of long-term maternal morbidity, “ and that “to improve women’s health and decrease such risks, both women themselves and the medical team caring for them need to be aware of these risks,” and “multiple interventions” over time may be required to help decrease these risks. 

 

The maternal mortality rate in the USA, already the worst among developed countries, is rising, and black women in the USA are three to four times more likely to die in childbirth than white women.

The maternal mortality rate in the USA has been steadily rising—the only developed country where this is true.  The USA maternal mortality rate more than doubled from 1991 to 2014, and American women have the greatest risk of dying from pregnancy complications among 11 high-income countries.  Over 700 women die of complications related to pregnancy each year in the USA, even though two-thirds of those deaths are preventable.  An additional 50,000 American women suffer from life-threatening complications of pregnancy.  Black women in the USA are three to four times more likely to die in childbirth than white women.  According to the World Health Organization, black mothers in the U.S. die at the same rate as pregnant women in Mexico or Uzbekistan.

 

Surrogacy births are increasing rapidly in the USA at a growth rate far exceeding the growth in the number of IVF babies.

The American Society for Reproductive Medicine reported a 30% increase in surrogate births in the USA between 2004 and 2006, for a total of 1,059 live births in 2006.Though few statistics are available, commercial surrogacy is increasingly prevalent in the United States, with the number of babies born to gestational surrogates growing 89% percent from 2004 to 2008.  Industry experts estimate that the actual numbers are much higher since many surrogate births go unreported. In a 2016 report published in the “Fertility and Sterility” journal, the author states that in the past 15 years, the number of gestational cycles increased by more than 470%, and a large majority of clinics—69.4%--now offer this treatment. Another trend is an increase in cross-border reproductive care, or ‘‘medical tourism,’’ involving gestational surrogacy, with 18.5% of GC cycles performed for non-U.S.- resident intended parent(s).

The growth rate in the number of surrogacy offspring now far exceeds that of IVF pregnancies.

 

Because of a dire paucity of research, the health risks to surrogates—although clearly heightened—remain unknown.

We know that the health risks faced by surrogate women are greater than those involved in traditional pregnancies and standard IVF pregnancies, by virtue of the fact that the medical literature conclusively demonstrates increased health risks in egg-donor pregnancies as well as pregnancies involving multiple fetuses, both of which typify surrogate pregnancies.  But there are still no studies that address any long-term health risks to women who experienced an egg-donor pregnancy, and there are still virtually no studies that address either the short-term or long-term health risks of surrogates, per se.

 

The fact that a surrogate had prior trouble-free traditional pregnancies should provide no assurance that she will be free of major complications in a surrogacy pregnancy

Surrogacy and fertility clinics and young women considering surrogacy often assume that a woman who has already experienced a traditional pregnancy free of complications, she is less likely to suffer complications in a surrogacy pregnancy. 

However, we know that the health risks faced by surrogate women are greater than those involved in traditional pregnancies and standard IVF pregnancies, by virtue of the fact that the medical literature conclusively demonstrates increased health risks in egg-donor pregnancies as well as pregnancies involving multiple fetuses, both of which typify surrogate pregnancies.  But there are still no studies that address any long-term health risks to women who experienced an egg-donor pregnancy, and there are still virtually no studies that address either the short-term or long-term health risks of surrogates.  

 

The health insurance provisions mandated in the Cuomo Proposal are inadequate to protect surrogate women 

The Cuomo Proposal provides that “the surrogacy agreement must include information disclosing how the intended parent will cover the medical expenses of the person acting as surrogate and the child. If health care coverage is used to cover medical expenses, the disclosure shall include a review of the health care policy pro visions related to coverage for the foe the person acting as surrogate’s pregnancy….”

The Cuomo Proposal also provides that a surrogate “has the right to a health insurance policy that covers major medical treatments and hospitalization as well as a surrogate pregnancy,” and that the policy shall be paid for, “whether directly or through reimbursement or other means” by the intended parents, “if such policy comes as an additional cost” to the surrogate.  

The Cuomo Proposal also requires intended parents to “pay for or reimburse” the surrogate “for all co-payments, deductibles and any other out-of-pocket medical costs associated with pregnancy, medical evaluation, psychological screening, or embryo transfers that accrue through 12 weeks after the birth or termination of the pregnancy,” except that this responsibility will be extended for six additional months in the event that “a medical complication related to the pregnancy is diagnosed within 12 weeks after the birth of the child or termination of the pregnancy.”

Although the Cuomo Proposal contemplates that the required health insurance covering the surrogate, as well as premiums and deductibles and out-of-pocket expenses related to the pregnancy, are to be paid for by the intended parents, the intended parents are left with the option of paying all of these expenses through reimbursement rather than directly or in advance. But what if something goes awry and an intended parent chooses not to--or is no longer able to--honor the terms of the contract? As a practical matter, a very pregnant surrogate with small children at home who may reside thousands of miles away may not be in a position to get to the New York State Supreme Court to contest any breach of contract in a timely manner—if at all—and thus may face having to pay these expenses herself, or forego critical medical care if she cannot pay. 

Although the surrogacy agreement is required to include information disclosing how the intended parent will cover the medical expenses of a surrogate and surrogate children, the Cuomo Proposal doesn’t require that an adequate dollar amount be set aside to cover these expenses, or that reliable mechanics be put in place that guarantee prompt, adequate payment or reimbursement, or even a showing that the intended parents have the financial means to pay for all of the expenses that might arise in addition to the cost of the health insurance policy itself. 

As discussed in great detail earlier, complications—even very serious complications-- resulting from a surrogate’s pregnancy are not always detected and do not always surface within the first 12 weeks following her pregnancy. But if they remain undetected within that 12 week period, or fail to arise until after that time period has passed, the Cuomo Proposal leaves the surrogate entirely on her own to bear all medical costs---or suffer the complications because she cannot afford to pay for the medical care she needs. 

 

When breaches of the surrogate contract can’t realistically be enforced, and promised reimbursement for essential medical care isn’t forthcoming, health risks follow

Although the surrogacy agreement must include information disclosing how the intended parent will cover the medical expenses of a  surrogate and surrogate children, the Bill doesn’t require that reliable mechanics be put in place that guarantee prompt, adequate payment or reimbursement, or a showing that the intended parent(s) have the financial means to pay for all of the expenses that might arise in addition to the cost of the health insurance policy itself.