Attitude towards Surrogacy Scale and comparison with other surrogacy measures
Surrogacy is not regulated by law in Poland, however, it is present in the society. Thus, the aim of the study was to develop a scale with psychometric properties, which enables the measurement of the general attitude towards surrogacy among the Polish population. The present scale has a total of 15 items that allows to capture the opinions of the Polish population towards three aspects of surrogacy: surrogacy’s ethical context, financing and legalizing surrogacy, and acceptance of surrogacy. To our knowledge this is the first scale and the first research assessing attitudes towards surrogacy in the Polish population.
Studies conducted around the world, which measured attitude towards surrogacy, mostly used self-designed measures. However, the validation process and used methods often are not fully explained. In this study, the developed scale has Cronbach’s alpha and omega coefficient were used as reliability measurements. Both measurements show satisfactory reliability of this scale, which also is comparable to studies conducted by Rahimi Kian et al., (2016); Mohnke et al., 2019; and Rahmani et al., (2014). In contrast Poote and van den Akker (2009) did not apply Cronbach’s alpha or other validity and reliability measurements (33). Similarly to other studies, this paper used the Likert Scale for scoring items (9,10,22,33). The statistical approach in this study is different than in other research. In this study for validation purpose, a series of Confirmatory Factor Analyses (CFAs) was performed on a pool of items to identify essential items and group them into factors. Where in comparison Mohnke et al., (2019) and Chliaoutakis et al., (2002) conducted a Principal Component Analysis (PCA) (10,34). Rahimi Kian, et al. (2016) applied a different approach, in which qualitative and quantitative content validity approaches were applied in the pilot study (N=30) and the data pool was enhanced by the comments provided by the members of an Expert Advisory Panel (9). In some previous research, an Expert Advisory Panel and a pilot study were not included in the process of scale development (21). While some other research includes an Expert Advisory Panel pilot study (9,12) or only just a pilot study (10,22)
The range of surrogacy factors classified in this study is comparable to other scales and questionnaires (9,10,22). For example, in the German Attitude Towards Surrogacy Questionnaire developed by Mohnke et al., (2019) attitude towards monetary compensation included only two items, related to altruistic and commercial surrogacy (10). However, in our scale the financial and legal context of surrogacy was condensed into one factor – financial and legal context. Additionally, our scale has one question regarding if surrogacy should be legalized and one question if surrogacy should be publicly founded, which were not included in the German Scale. In terms of the legal aspect of surrogacy there are 7 items in this scale, which allows the assessment of opinions about legalizing surrogacy among not only heterosexual couples, but also same-sex couples and singles. Similarly, no detailed questions like the above are included in the Scale developed by Rahmani et al., (2014) or Rahimi Kian et al., (2016). Many advances in assisted reproduction technology are facilitating the development of new types of families. Recently, researchers have shown that the concept of family is changing, and new types of families are emerging, including same-sex parenting. Thus, including items related to the attitude towards surrogacy for other groups other than heterosexual is important (35). The items related to the acceptance of surrogacy in our scale consisted of 4 items, which are similar to those in the German questionnaire (10). However, the German questionnaire consists of 9 items, and these are included in the general attitude towards surrogacy aspect. The ethical context of surrogacy in this paperconsists of 4 items, which covered religion, if surrogacy conflicts with ethical and social rules, and the negative social and ethical consequences of surrogacy. Some of the items related to the acceptance of surrogacy are like those in the scale developed by Rahmani et al., (2014) or Rahimi Kian et al., (2016).
From 24 items in the original survey used in this study, 9 items dropped out based on the conducted statistical analysis. Obtained results showed that those items in this study do not differentiate participants who have positive or negative attitudes towards surrogacy. It can be assumed that those items are more related to the general opinion about the current political and social context in Poland, which also can be related with the participants answers.
Attitude towards surrogacy in Poland
The respondents in this study declared the highest support for surrogacy as a good option for heterosexual couples (in comparison with same sex couples or singles) and those who have tried all other alternatives to have a baby. Similarly, a Romanian study also demonstrated opinion that surrogacy should be available only for heterosexual couples (36). In contrast, surrogacy as an option to have a baby for same sex couples was acceptable among Swedish physicians (12,37). Swedish physicians were also less supportive for the surrogacy among singles (12).
The lowest support in this study sample was related to the statement “If me or my partner could not conceive a child on our own, I would consider surrogacy”. Research conducted by Chliaoutakis et al., (2002) showed that the public attitude towards a willingness for using gamete donation and surrogacy or encourage a family member to do the same, is divided, where specifically, the majority of participants had a negative attitude about using surrogacy (34). In the study conducted by (Rahmani et al., 2014) among Muslim women a significant percentage of the sample would not recommend surrogacy to women with infertility and claimed that
adoption would be a better solution than surrogacy (22). Researchers have presented that the main motivation of intended parents to use gestational surrogacy as a method to have a child is based on the desire to have a genetic connection with their baby in comparison with adoption (38) Intended parents want to be able to participate in the childs life and development process from the very beginning (35).
Obtained findings in this study, showed that a significant proportion of the respondents believed that surrogacy raises ethical and religious controversies in the society. People very often perceive new innovations or technologies through social and cultural norms, values, and traditions, which are normative in the population (21). The findings are in line with other research, where religious beliefs play an important role in shaping opinions about surrogacy and also assisted reproductive methods (22,39).
The literature on the subject has shown that individuals’ choices related to surrogacy are grounded by their societal principles including moral, religious and philosophical values and traditions, which are often entwined with ethical and social implications (40). Surrogate parenthood can be further complicated by ethical and moral dilemmas when some intended couples looking for a surrogate may offer financial compensation (41). Studies has shown that altruism is the main motivation for being involved in surrogacy (21). Thus, in some countries such as the United Kingdom, Belgium or Netherlands altruistic surrogacy is legal (21,39,42). Currently,Poland has no law regulating surrogacy, which creates legal ambiguities. Respondents in this study declared high support for surrogacy to be legalized.
Current trends towards surrogacy are different in different countries. Surrogacy is related with complex aspects, thus is considered as the most controversial method of all the reproductive options. A general positive attitude towards surrogacy does necessarily mean that a couple would pursue the surrogacy option themselves. Some aspects of surrogacy (for example commercial surrogacy) can be related with negative attitudes and lack of acceptance. Thus, it is important to research attitudes towards surrogacy including its various aspects.
Attitudes towards surrogacy in Poland and socio-demographic factors
The analysis of attitude towards surrogacy with socio-demographic variables showed that age, gender, level of education, or being single were not significant predictors of any aspect of attitude towards surrogacy. In this study the most significant predictor of the general attitude towards surrogacy, and three aspects of surrogacy was being a religious person (Catholic or a follower of another religion). Religious respondents indicated ethical and social objections to surrogacy, were less supportive of financing and legalizing surrogacy, and were more skeptical about surrogacy as one of the options in reproductive medicine. Similarly, in other conducted studies religious respondents are less willing to support and be positive about surrogacy (34). It can be claimed that religion and religious beliefs play a significant role in shaping attitudes towards surrogacy. In our study the majority of the participants (57%) declared being a Catholic or believing in another religion, while 38% declared themselves as atheist. Religions, which exist around the world present different approaches to surrogacy (39). According to the Catholic stance, the intrusion of a third person into a couple’s relations is immoral and as such they are strongly opposed to surrogacy(39). Thus, it is not surprising that in Poland, where Catholicism is still a dominant religion, surrogacy and different aspects of surrogacy are often perceived negatively.
Contrary to expectations, the medical profession, being married (versus an informal relationship) or having a child was negatively connected to some aspects of the attitude towards surrogacy. Those participants, who were related with the medical profession, had stronger ethical concerns about surrogacy and had more negative attitudes about the funding and legalization of this method. In this study 55% of participants worked in the health care profession. Swedish research, which included a sample of physicians working in an infertility clinic declared more supportive attitudes towards the legalization and public financing of surrogacy in comparison with those working within antenatal and delivery care. The risk that the commissioning couple might pay the surrogate mother “under the table” was declared by 82% of respondents (12).
Findings in this paper also show that married people, as well as those with children, presented less acceptance of a surrogacy arrangement for those who struggle with reproductive problems. It is a surprising result, since 65% of participants in this study did not have children. Other findings in a review conducted by Rodriguez-Jaume et al., (2021) suggest that social acceptance of surrogacy and positive attitude was not higher among people with infertility (13). Six of the eight studies including infertile groups showed acceptance rates below the average overall value (13). In an Australian study, where demographic variables were measured, none of those variables were predictors of attitudes towards surrogacy. Age, education level, or having one’s own children did not correlate with attitudes towards surrogacy (1). This is in line with the findings in this study.
Strength of the study
The presented scale measures attitudes towards surrogacy in Poland, which to our knowledge is novel in Poland. The major strength of this study is constructing the scale with the established validity and reliability.There are other research where surrogacy attitude surveys have been developed. However, in many of these the reliability and/or the validation process is not clearly and fully described. Secondly, in the process of scale development a pilot testing was conducted to decrease the risk of bias. Pilot assessmentsare needed for the scale feasibility, readability of included items and assessment whether they are subjectively perceived by respondents as addressing what they are designed to measure.The other strength of the developed scale is that it can be addressed to different groups and is not only limited to people with infertility.
Assessing the opinions and attitudes on a controversial topic such as surrogacy, plays an important role in disclosing various aspects of surrogacy, helps to fill in legislative gaps and ambiguities, and to convert controversial dimensions surrounding surrogacy into a normative concept that eliminates stigma (9). We hope that creating this scale will add to the growing body of the literature through the addition of a new tool in reproductive medicine.
To make appropriate interpretation and use of the study findings the limitations need to be acknowledged.The major limitation of this study is a lack of generalizability of the study sample. Adequacy of the response rate in this study is not sufficiently high. The present study was conducted only online, thus only people with internet access had the possibility to participate. In terms of representativeness of the sample the majority of the study participants were women 78% (344 female and 78 male), which demonstrates that the male perspective is underrepresented. On the other hand, a higher rate of female participation in this type of research, related to reproduction, is not surprising. Additionally, more than half of the participants were Catholic 57%, and only 38% were atheist, where also the atheist perspective is underrepresented. It is therefore possible, that much of the current sample is a more conservative cross-section of society. The obtained findings should be interpreted with caution, as the scale require further validation studies including broader sample.
This paper has important implications by raising the importance of discourse about surrogacy in Poland.To our knowledge, this is the first validated scale, which allows the assessment of attitudes towards surrogacy in Poland. This measure allows to capture the opinions towards three aspects of surrogacy: surrogacy’s ethical context, the financing and legalizing surrogacy, and acceptance of surrogacy. The scale can be addressed to various groups in the population, not only for studies related to reproductive medicine.
Further research studies are needed to determine if the developed instrument can accurately measure attitudes towards surrogacy among a broader cross section of the community and with different cultural backgrounds. What is more, variety among participants and their socio-demographic characteristic is needed. In future studies it would be important to expand the knowledge of what exactly shapes the attitude and opinion about surrogacy (factors and variables).