1. SOMs and Surrogacy Presentation by South Eastern Trust SOMs:
Betty Cameron and Lorna Lawther

2. Structure
Introduction to surrogacy: legal and professional aspects of midwifery practice
Antenatal and intrapartum care: the role of the SOM
Postnatal and community care: the role of the SOM
Reflection and conclusion
There is a reproductive technological revolution happening. Midwives are practising at the point where reproductive technologies are evidenced: in the birth of a baby.
Practically our work has not changed – babies are still born the same way. However, the pathway of conception is no longer same – IVF, ICSI, assisted artificial insemination, natural artificial insemination, same sex parenthood, non-biological parenthood. All of these words conjure up a wealth of reproductive scenarios that can be encountered in contemporary midwifery practice.
As midwives we need to be cognisant of our professional responsibilities and as SOM we need to be abreast of what is occurring in order to support midwives. Hence, this presentation will use a scenario that we have encountered as midwives and SOMs to enable us today to consider our role.

3. Surrogacy: UK Law
Say something about global and local aspects of surrogacy and need for SOM to keep abreast of advances in reproductive technology

4. Surrogacy Arrangement Act (1985)
" Surrogate mother " – a woman who carries a child on behalf of another person or other persons
The agreement is made before conception
The agreement is made with the intention of handing the child and all parental rights to another person or other persons.
No person shall on a commercial basis
- advertise as a surrogate or act as an agent for a surrogacy arrangement or provide literature or compile any information with a view to its use in making, or negotiating the making of surrogacy arrangement
A surrogate is the term for the woman who is carrying the baby
She is legally defined as the mother, even if the child has not biologically or genetically related to her
Different types of surrogacy

5. HFEA Act (2008)
Clarifies parental orders and payments for surrogacy Parental order: enables intended parents to have parental rights without applying for adoption Payments for surrogacy: non profit organisations can charge a fee to advertise and match surrogates with commissioning parents (Both parties sign a surrogacy agreement which is lawful but legally unenforceable)
surrogacy arrangements in the UK are based on relationships between the surrogate and the intended parents in a trusting relationship and where legal responsibility is transferred following the birth of the baby: this differs from international surrogacy where a commercial contract can be present.
Complexities of international surrogacy: e.g. India women can be paid to be a surrogate twice; e.g. Australia baby born to Thai surrogate who had downs (see paper on surrogacy in modern obstetric practice Burrell and Edozien, 2014)
Parental orders: can be obtained between 6 weeks and 6 months following the birth.
Payments for surrogacy: non profit organisations can charge a fee for advertising; both parties sign a surrogacy agreement which is lawful but legally enforceable

6. Definitions related to surrogacy
Traditional/ partial / straight: biological mothers egg; donated sperm either from intended father or other sperm donor; surrogate mother has a genetic link with the child
Gestational/full/ host: donor egg (can be from intended mother); donor sperm (can be from intended father); involves IVF; surrogate mother has no genetic link with child
Intended parent (commissioning parent): the person who will have parental responsibility
Traditional: always a genetic link with the surrogate mother
Gestational: surrogate acts as an ‘incubator’ for a donated sperm and donated egg
Intended parent completes parental order: until this occurs, the birth mother has parental responsibility)
Different reproductive relationships leading to different gestational scenarios: (see table from Burrell and Edozien paper)

7. Provenance of Surrogate Pregnancy
Paternal Genes
Maternal Genes
Conception
Intending Father
Surrogate mother
Artificial Insemination
Sexual Intercourse
Donor
Intending Mother
IVF & Embryo Transfer
Note re language used: discourse of surrogacy leans towards surrogacy as a transaction; an arrangement
-contract
-commissioning
-agreement
-arrangement
-provenance
This is one of the elements that makes this aspect of midwifery care difficult for midwives who hold a philosophy of emotional work, trust, building of relationships and being with women…regardless of the provenance of the fetus

8. Midwifery supervision aims to:
Offer support and guidance to every midwife practising in the united kingdom. Protect women and babies by actively promoting a safe standard of midwifery practice. Support midwives to practise with confidence, therefore preventing poor practice. Promote childbirth as a normal physiological event and to work in partnership with women; Ensure that women influence the development of maternity services and also ensure that midwifery care is responsive to local needs. Provide a role in advising and supporting women who use midwifery services; advocating for the right of all women to make informed choices and providing additional advice to women who are experiencing difficulty in achieving care choices. Local supervision in action (2009)

9. Karen is a para 2 . Her friend Tanya cannot have any more children due to cancer treatment following the birth of her first child. Karen knows how much her friend would like to have another baby and offers to carry a child for her.
Karen becomes pregnant with Tanya’s husband’s donated sperm and attends her GP with Karen to make arrangements for antenatal care. The friends have both had antenatal care in this locality before and the GP is supportive of them.
The women have midwifery care with the members of team who previously cared for them in their respective pregnancies.

10. Antenatal care: SOM perspective
Mothers
establish and maintain contact with surrogate mother re plan of care
Clarify arrangements with intended parents
Explain the SOM role and the professional responsibilities of midwives
Advocate for the woman
Ensure confidentiality maintained
Midwives
Establish contact with midwives involved
Support and guide the midwife to provide optimum care
Assist with plan of care: antenatal, intrapartum, postnatal
Maintain contact with midwives throughout
Ensure confidentiality is maintained
Confidentiality when making plans. Keep managers in the loop, in all areas. Knowledge of maternity leave for intended parents, may have Social worker involved. Preparation for lactation.

11. The pregnancy progresses without problems and Karen presents at T+9 to the MLU in labour. The handover to the midwife is that ‘Karen is in labour, and she is giving her baby to Tanya’. The attending midwife has no prior knowledge of this woman or her circumstances but provides care according to Karen’s wishes.
Following the birth a 6 hour discharge is organised and Karen goes home with her husband and the baby goes home with Tanya and her husband (the baby’s father). Postnatal care is provided by the members of the midwifery team that the women know.

12. Intrapartum care: the role of the SOM
Midwives
Be a source of advice guidance and support
Act as a role model
Ensure high standard of clinical and professional practice
Ensure that the professional responsibility of the midwife is clear
Maintain confidentiality
Mothers
Ensure that the wishes of the mother are prioritised
Maintain contact until after the birth
Enable the plan of care to be fulfilled within the wishes of the mother
Where deviation from the plan is required support the midwife to achieve this
Maintain confidentiality
Clear documentation on the intentions of surrogate mother at and after birth. i.e. she may want time with baby may or may not want to have intended parents present.
What happens in the event of emergency at time of birth who is informed? who gives permission? The surrogate mother makes decision re treatment of baby.

13. The intended parents were delighted but apprehensive.
Both couples were present, not in the same room, when discharge observations and information of mother and baby was being completed.
The surrogate mother and her husband and the intended mother and her husband and baby, went home with information that the community midwife had their addresses and telephone numbers and also informed that the community midwife would be calling to their houses for routine postnatal care visit, starting the following day. The visits would continue until both c/m and families felt a suitable time for it to end, up to 28days
The intended parents were delighted but apprehensive.
Duplication of documentation, surrogate mother got her letters and the her regional notes. Intended mother got letter for baby and notes,
Which C/M put back together on completion of care.
Anxiety re: lactation

14. Postnatal care: role of SOM
Enable midwives to support the families with unconditional respect
Ensure that midwives are able to provide the information required for care should any complications arise and provide appropriate literature.
Support the midwives involved in their care who may have professional or personal issues in this situation.
The midwifery manager was supportive and available to discuss any issues that the C/M may have had
As the ladies and families were known to the team on previous occasions , the C/M offered to give the care to both women
Emphasising confidentiality she was not taking information from one house to the other. This was respected and maintained.

15. The women were friends and were open and gave information freely.
The community team took over the care of these families and we acknowledge the input from the community team leader and community midwives involved.
The families were known to the community midwives, health visitor and GP teams. They were allocated to specific members of these teams to minimise and avoid duplication of information. Both women had previously been cared for individually by the teams during previous pregnancies.
The women were friends and were open and gave information freely.
They intend to make the child fully aware of the circumstances of conception and birth.
They were in touch with their Legal advisor, who had been previously involved with surrogacy and had knowledge of different aspects of surrogacy.
Important that a legal arrangement is organised as this can be referred to if difficulties arise
However the surrogate mother is responsible for the care of the baby until parental order is granted
To the intended parents,

16. Post natal and community care: the role of the SOM
Support for community midwives to carry out the post natal care for both women in their own homes in a professional manner
ensure confidentiality maintained for each woman
Recognising that mother may require additional emotional support during the post natal period and facilitating the provision of this
Be a source of information and support to midwife and mother regarding legal issues e.g registration of the birth, requirements of parental order.
Ensure the multidisciplinary team work together to meet the needs of the surrogate mother, her family and the intended parents
Ensure a high standard of documentation of care for mother and baby (separate notes)
Pre conception counselling necessary and then on going after birth. Time to be given for both parents to reflect on the experience.
May need Birthafterthoughts specialist midwife input.

17. In conclusion: the role of the SOM
Make parents aware that there is 24/7 availability of the services of a supervisor of midwives via hospital switchboard
Protect mothers and baby.
Continuity of care: giving right care to right person at the right time
Community midwife able to assess capability of parenting and offer help as required.
Provide emotional support for midwives both personal and professional.
Provide education for staff on surrogacy.
Ensure local policies are in place and assist in their development
See reference list for reading material and web sites which are only a small sample
Surrogacy is becoming an alternative to persons who are experiencing infertility problems
As supervisors of midwives we have to embrace it and be as informed as we can when a couple requires information from us

18. On Reflection
Every situation within surrogacy is different and challenging
The role of the supervisor is to be responsive to the needs of women and support women, families and midwives within the law of the land, Trust policy and within NMC Rules and Standards.
The surrogate mother is responsible for consent for all treatment of the baby until parental order is granted (can be between 6 weeks and 6 months)
Need national guidelines for midwives on caring for parents undergoing surrogacy.
Refer to lady who spoke at MOMS Conference 23/01/2015 at the Ulster.
Health professionals must always act in the best interest of the surrogate
As midwives we may feel we are not well informed with policy or guidelines on surrogacy so lies the challenge of updating !!!

19. Thank You

20. Reference list:
Burrell, C. Edozien, L.C review - Surrogacy in modern obstetric practice: Seminar in foetal and neonatal medicine 2014
Burrell,C. O`Connor, H Surrogate pregnancy : ethical and medico legal issues in modern obstetrics. pp Royal College Obstetrics and Gynaecology.
Imrie, S. Jadva, V. 2013
Children of surrogate mothers: Psychological well-being, family relationships and experiences of surrogacy -
Human reproduction vol. 29, No1 pp
Imrie, S. Jadva, V
The long term experiences of surrogates: Relationships and contact with surrogacy families in genetic and gestational surrogacy arrangements
Reproductive Biomedicine Online pp
Nursing and Midwifery ; Rules and Standards NMC 2012
Local Supervising Authority
Local Supervising Authority Midwifery Officers’ Forum, United Kingdom Strategic Direction

21. Useful Links BioTexCo - http://biotexcom.com/-
Relevant video on this website – Successful surrogacy case
Surrogate finder website