Development and Validation of the Attitude towards Surrogacy Scale in a Polish Sample

Abstract

Background: Surrogacy is one of the options in reproductive medicine that raises a lot of ethical, legal and psychological controversy. Surveying attitudes toward surrogacy plays an important role in building awareness of this phenomenon in the society, which may help eliminate its stigma. In this study authors aimed to develop and validate a scale to examine the attitudes towards surrogacy in a polish population.

Methods: In this study cross-sectional design was implemented. Development process of the Attitude towards Surrogacy Scale (ATSS) included items development based on literature reviews, other existing questionnaires, confirmatory factor analysis (CFA), and reliability analysis using internal consistence coefficients. A pilot study using convenience sampling was conducted after consultation with the Expert Advisory Panel Board. The final survey, which was used in this study, consisted of 24 items, which were organized into the four subscales: general opinion on surrogacy and its social context (7 items), financing and legalizing surrogacy (8 items), the acceptance of surrogacy (4 items), and attitudes towards the intended parents and children born through surrogacy (5 items). 442 individuals participated in this study.

Results: The final version of Attitude towards Surrogacy Scale (ATSS) consists of 15 items, grouped in three subscales: opinion on surrogacy ethical context, financing and legalizing surrogacy, and an acceptance of surrogacy.

Conclusion: This is the first scale in Poland for the assessment of general attitudes towards surrogacy. 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.

Plain Summary

Surrogacy - is one of the most controversial methods of infertility treatment. This concept is associated with difficult ethical, psychological and social issues, in which each aspect may lead to different trends in attitudes. The study of attitudes in society plays an important role in the analysis of various aspects of a given phenomenon, helps to fill legal gaps and ambiguities, and to transform controversial dimensions into normative concepts. Thus, this study aimed to develop and validate a scale to assess the attitudes towards surrogacy in a polish population. 

The final survey used in this study, consisted of 24 questions, which were organized into the four subscales: general opinion on surrogacy and its social context (7 items), financing and legalizing surrogacy (8 items), the acceptance of surrogacy (4 items), and attitudes towards the intended parents and children born through surrogacy (5 items). 442 individuals participated in this study. The final version of Attitude towards Surrogacy Scale consists of 15 questions, grouped in three subscales: opinion on surrogacy ethical context, financing and legalizing surrogacy, and an acceptance of surrogacy. 

This is the first scale in Poland for the assessment of general attitudes towards surrogacy. 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.

Introduction

Background

Surrogacy is a known phenomenon which dates to biblical times (1,2) (Constantinidis & Cook, 2012; Gunnarsson Payne et al., 2020). Together with reproductive innovations and the introduction of the In vitro fertilization (IVF) method, where artificial insemination (the fertilization of an egg) can take place in a laboratory, surrogacy is one of the options in reproductive medicine to overcome infertility problems. It began to flourish in the USA in the 1980s, and today has grown worldwide into a global trend (2). 

Surrogacy as a form of assisted reproduction (3), is an arrangement that involves using a third party, a ‘surrogate mother’ or ‘surrogate’. A surrogate mother carries and delivers a child on behalf of a couple, who will become the child's parents after birth. Nevertheless, it must be mentioned that definitions of the terms related to surrogacy are still not fully clear, especially from a legal perspective. In most countries, the legal mother of the child is a woman, who delivers the baby, even though she is not genetically related to the baby. In Europe, a first attempt to specify what surrogate motherhood is at the supranational level, was made by the Ad Hoc Committee of Experts on Bioethics (CAHBI), dated January 10, 1989.  According to their definition ‘a surrogate mother’ or ‘a surrogate’ is a person who carries a child for another person and who, prior to becoming pregnant, consented to the transfer of the child to that other person after birth (4). In the literature on the subject a person/couple who concludes a contract with a surrogate mother acting only as a gestational mother or also as an egg donor is called the ‘commissioning party’ (4). There are two kinds of surrogacy. The first is ‘traditional surrogacy’, ‘straight surrogacy’ or ‘partial surrogacy’, where the surrogate mother uses her own egg and is artificially inseminated using sperm from the intended father or a donor (5).  The second is ‘gestational surrogacy’ or ‘full surrogacy”, where the surrogate mother receives an embryo formed in vitro fertilization (IVF) from the gametes of the ‘intended parents’ or ‘commissioning couple’ so she is not genetically related with the baby she delivers (6).

According to the World Health Organization 15% of couples in their reproductive age and 186 million individuals face infertility problems globally (7). Over the last years, there have been many advances and improvements in infertility treatments offered to people who desire to have a child. Surrogate motherhood is considered as one of the most controversial methods of infertility treatment associated with difficult ethical, psychological and social issues (8–10).

The literature has shown that individuals’ choices related to surrogacy are grounded by their societal principles including moral, religious and philosophical values and traditions, which often are entwined with ethical and social implications (11). Hence, all of the different aspects of surrogacy can lead to different trends in attitudes (9). What is more, globally the legal framework for surrogacy does not exist, thus there are different legal regulations of surrogacy across countries. Countries such as Russia and Ukraine allow commercial and altruistic surrogacy, whereas The United Kingdom, Australia, and Canada legally allow only altruistic surrogacies. In contrast, Germany, France and Italy are among countries, which ban all forms of surrogacy.

Current state of knowledge

Scientific studies across countries examining general opinions about surrogacy have shown conflicting results. An Australian study showed that 75% of respondents presented a positive general attitude towards surrogacy, which was a high increase in comparison to previous research in Australia (1). A Swedish study among physicians working within obstetrics also indicated that 63% of the sample showed support or were neutral about the concept of surrogacy surrogacy (12). However, they also were concerned about surrogate mothers’ health and the risk of coercion surrogacy (12). A review prepared by Rodriguez-Jaume et al. (2021) has shown that a high level of acceptance of surrogacy occurs in countries such as Canada, Japan, the United Kingdom, and Iran. However, in Germany the degree of acceptance of surrogacy is lower. What is interesting, social acceptance of surrogacy was not higher among people with infertility. Six of the eight studies, including infertile groups, showed acceptance rates below the average overall value (13). Research among the Spanish population has shown that 60.1% of respondents claimed that surrogacy is a “good way to help infertile or homosexual couples to have a child” (13). In addition, some researchers draw attention that the general opinion about surrogacy can also be influenced by a prevailing negative case portrayal in the media (14).

Some research studies examined attitudes about the controversial aspects of surrogacy. In terms of preference for a genetic bond in surrogacy, the Greek population showed 51.3% of acceptance for traditional surrogacy and 82.1% for gestational surrogacy. The question “If a surrogate mother should receive monetary compensation” also brings controversy. For example, in France commercial surrogacy was considered less problematic than altruistic surrogacy (15). While altruistic surrogacy is legal in some countries, it is still not clear what is the more favorable practice. In an Australian study 53% of the study group supported altruistic surrogacy (16), where in Canada 24.4% of the population stated approval for commercial surrogacy (17). The nature of the relationship between a surrogatemother and the commissioning couple can also be complicated. In countries such as the United Kingdom, Turkey and Iran, there is an opinion that surrogate mothers should be a relative of the intended parents, whereases in Greece and Japan the preference is that the surrogate mother should be a stranger (13).

As described above, attitudes towards surrogacy vary from country to country and can be related with socio-demographical factors such as gender (18) age, and socioeconomic status (19). What is more, positive or negative portrayals of surrogacy in the media (14) and cultural beliefs about parenthood likely shape the opinions of the general population (20). Nevertheless, the available research results are limited. Despite the discourse about the different aspects of surrogacy in some countries, few researchers answer the question about what the general public attitude on surrogacy is and what exactly determines peoples’ attitudes towards surrogacy (6,21)  It is very difficult to draw a conclusion from the available scientific studies about attitudes towards surrogacy, as only careful descriptions of some trends are possible. What is more, the diversity of interest in different aspects of surrogacy limits the discussion, as researchers concentrate on different elements of surrogacy. In the literature mostly public opinions and the debate about surrogacy is reviewed in the context of infertility problems, where surrogacy can be an alternative for a biological impossibility. In addition, there is a need to expand the context to different family forms, other than just traditional families. Researching the attitude towards surrogacy should include non-heterosexual and non-heteronormative groups, so they are included in the social debate about surrogacy and in the construction of surrogacy as a social issue regulated by law (13).

Existing validated scales measuring the attitude towards surrogacy

The survey in this paper was developed based on the literature and other existing questionaries (9,10,12,22). Some of the questions were translated and adapted from the previous questionnaires or scales, which are going to be described more in details. 

Firstly,The Attitude Toward Surrogacy Questionnaire isa German questionnaire, which was developed by Mohnke et al., (2019) (10). The questionnaire consists of 13 items, enables the examination of public opinion about surrogacy and whether participants could imagine using surrogacy for themselves and others. In the questionnaire there are three factors: general attitude towards surrogacy (9 items), attitude towards monetary compensation (2 items) and attitude towards surrogate mother (2 items). The questionnaire enables an assessment of positive or negative public attitudes towards these three aspects of surrogacy (10). Second scale, The Attitude Towards Gestational Surrogacy Scale (GSAS) was developed by Rahimi Kian et al., (2016) (9). It is a comprehensive 30-item tool, which enables the measurement of surrogacy attitudes among infertile couples. GSAS consist of the following 5 subscales: ‘acceptance of surrogacy’, ‘surrogacy and public attitudes’, ‘child born through surrogacy’, ‘surrogate mother’, and ‘intentional attitude’ and ‘surrogacy future attempt’. This scale covers major issues related to gestational surrogacy. The higher the score the more positive the attitude toward surrogacy, and the lower the score the more negative the attitude toward surrogacy. Development of GSAS was tested on 200 infertile couples (9). Third questionnaire, developed by Swedish scientists was created on the basis of clinical experience and earlier research.The attitude towards surrogacy questionnaire (12)a validated tool, consisted of 38 items, which aimed to assess the opinions and attitudes about surrogacy among physicians. The measure consisted of 3 domains: attitudes towards surrogacy, assessments of prospective surrogate mothers and antenatal and obstetric care for surrogate mothers. In the Attitudes towards surrogacy domain, questions about the legalization of surrogacy and its financial context were asked. In the second domain Assessments of prospective surrogate mothers, the questions were related to whether surrogate mothers should be assessed and if medical conditions or earlier pregnancy complications should be considered among potential surrogate mothers. In the third domain, antenatal and obstetric care for surrogate mothers, the participants were asked to assess whether participants agree with statements related to certain circumstances surrounding pregnancy, delivery and the time after delivery (12). Finally, in the study conducted by Rahmani, et al., (2014) viewpoints of fertile women on gestational surrogacy were examined. The scale consisted of 22 items, which were divided into five aspects of gestational surrogacy including legal and religious issues (7 items), conditions for the use of surrogacy (4 items), children born through surrogacy (5 items), the surrogate mother (2 items) and tendency to use surrogacy (4 items) (22).

To sum up, the presented studies aimed to survey opinions about surrogacy. All of the measurements are self-designed, with reliability and validation described above. More detailed comparison between above tools, including comparison to the scale developed in this paper will be presented in the discussion section.

The objective of the study

To the best of our knowledge, this is the first study, which primarily aims to develop a validated scale to determine the attitudes toward surrogacy in Poland. Secondary aim of the study is to analyze socio-demographical factors that may be related with the positive or negative attitude to surrogacy parenthood. The opinion of the Polish population about surrogacy has not been yet explored. Thus, constructing a scale with psychometric properties that allows for an in-depth study of public opinion on surrogacy is needed. Assisted reproduction, including surrogacy it’s a controversial topic, as it represents a multi-dimensional dilemma that includes moral, religious, legal, and social-political elements. In Poland surrogacy is not regulated by law, thus, it would be important to examine the opinion of Polish society to predict the trends and behaviours in terms of surrogate motherhood. Researching the attitudes, opinions and societal knowledge about a controversial topic such as surrogacy helps to find out more about potential future behaviours and possible legal solutions in the process of converting controversial topics into normative ones (24). Open discussion about surrogacy is needed, not only for future regulations, but also helping people make more informed choices about their future by increasing adequate education, awareness and knowledge related to the topic.

Materials And Methods

Measure

The development process of the Attitudes towards Surrogacy Scale (ATSS) was conducted based on a cross-sectional study design and consisted of a few stages. Firstly, a review of the literature was performed, and the main aspects of surrogacy were selected. Then the relevant item pool was appointed based on the literature and existing scales or questionnaires on attitudes towards surrogacy available in the English language (9,10,12,22). In the current study, a pilot study was conducted after consultation with the Expert Advisory Panel Board, who first commented and judged the items retrieved from the literature and other existing questionnaires. Also, additional items were added so the scale is appropriate to the Polish cultural context.

 The Expert Advisory Panel Board consisted of experienced health care professionals working in the field of obstetrics and reproductive medicine. Based on the Expert Advisory Panel Board’s comments, modifications were implemented, and the pilot study (N=25) was conducted. The comments from the pilot sample were also included in the prepared survey. The final survey, which was used in this study, consisted of 24 items, which were organized into the four subscales: 

• general opinion on surrogacy and its social context (7 items), 
• financing and legalizing surrogacy (8 items),
• the acceptance of surrogacy (4 items), 
• attitudes towards the intended parents and children born through surrogacy (5 items).

The survey used in this study is provided as a supplementary file. The respondents’ opinion was indicated by using a seven-point Likert-type scale (1= strongly disagree, 7= strongly agree). For most items a higher score indicates a more positive attitude towards surrogacy. To prevent an acquiescence response bias, 10 items were reversed. Total score was obtained by summing the items, ranging from 15 (minimum negative attitude) to 105 (maximum positive attitude). Prior to the Attitudes Towards Surrogacy survey, socio-demographic data was collected. Socio-demographic questions included: gender, age, place of living, educational background, work background, income, relationship status, sexual orientation, having children, and religion. 

Ethical Approval

The study had a cross sectional design and was approved by the Research Ethics Board at the University of Gdansk, Poland (number 46/2020) and abided by the standards of the Declaration of Helsinki.

Procedure 

 An online survey was constructed using the Forms website and took approximately 15 minutes to fill out. The invitations to participate in this study were distributed through various online institutional websites (clinics, hospitals, universities etc.) and other websites such as social platforms (Research Gate; Facebook, infertility groups and forums, parental groups etc.). Participation in the project was voluntary and could be discontinued at any time. Participants were guaranteed that all data was anonymized in its collection, storage, and in the publication of research material. Written informed consent to participate in the study has been obtained from all the participants. Prior to filling out the survey, participants were introduced to the definition of surrogacy. All items required a response throughout the whole study – i.e., participants could not complete the questionnaire without leaving an answer to each question.

Participants

The participants in this study had to meet the following inclusion criteria: (1) no restriction to gender, (2) age ≥ 18, (3) able to complete and understand the questionnaire in Polish, (4) signed informed consent, and (5) permanent residence in Poland. If at least one of the inclusion criteria was not met, the participants were excluded from the study. There was no reward for taking part in this study. The final sample included 442 individuals (344 female and 78 male) aged from 17 to 72 years old (M = 32.58, SD = 12.96). For a sample composition regarding more specific demographic characteristics see Table 1.

Table 1. Sample composition

Notes. N = 442, ^aN = 329.

Statistical Analysis 

The statistical analysis consisted of several steps. First, the data obtained was reviewed to evaluate item averages and variance by using descriptive statistics, such as means and standard deviations. Response distribution properties were also inspected using measures of skewness and kurtosis. Then, a series of confirmatory factor analyses (CFAs) was performed. As a result of testing subsequent models (starting with a three-factor model with the original assignment of 24 items), items with factor loadings less than 0.4 were removed (25). The maximum likelihood with robust standard errors estimator (MLM) was used to evaluate the structure of the scale. In the final model-fit evaluation we relied on the comparative fit index (CFI > 0.90) and root mean square error of approximation (RMSEA < 0.08) (26). Next, Cronbach’s alpha (27) and McDonald’s omega (28) were used for evaluating the reliability of the finale version of the Attitudes Towards Surrogacy Scale. In internal consistence, a score equal to 0.7 or higher was considered as the acceptable reliability reliability (29). Finally, multiple linear regression analyses were performed in order to show differences in attitudes towards surrogacy regarding various socio-demografic variables. Statistical analysis was performed using R environment environment (30) along with the appropriate packages: psych (31) and lavaan (32).

Results

The final version of the ATSS consists of 15 items making up three subscales: (1) Surrogacy Ethical Context, 4 items; (2) Acceptance of Surrogacy, 4 items; (3) Financing and Legalizing Surrogacy, 7 items. For the sake of clarity, in the following subsections the presentation of results has been limited to the data on the final version of the scale, including item analysis.

Item Analysis

To assess the responses to individual scale items, the mean, standard deviation, skewness and kurtosis were calculated for each of them (see Table 2). The inspection of means values showed that individual items were assessed differently by the respondents on average. The opinions regarding the availability of surrogacy for heterosexual couples (M = 5.28) and the recognition that surrogacy is a good alternative for people who have already exhausted other possibilities of having a child (M = 5.31) were the most widely accepted. Relatively high support was also given to the statement that surrogacy in Poland should be legalized (M = 5.08). On the other hand, the lowest rated item by respondents is the decision to surrogate yourself in case of problems with having a baby (M = 3.55). A significant proportion of the respondents also admitted that surrogacy raises ethical (M = 3.76, reverse coded) and religious (M = 3.88, reverse coded) controversies in society. Examination of standard deviations shows that the dispersion of respondents’ scores on items are comparable. A review of skewness and kurtosis did not reveal substantial deviations of the response distributions from the normal distribution.

Table 2. Descriptive statistics for the ATSS items.

Note. N = 442

Factor Structure and Reliability

The confirmatory factor analysis (CFA) results for the ATSS showed that the three-factor model indicated an acceptable model fit: Chi-square = 320.46, p < 0.01, df = 87, CFI = 0.94, TLI = 0.92, RMSEA = 0.078 (90% C.I.: 0.070–0.086), SRMR = 0.040 (for CFA standardized loading coefficients and covariances between factors see Figure 1). The omega coefficient for the Surrogacy Ethical Context subscale was 0.74, for the Acceptance of Surrogacy subscale was 0.88, for the Financing and Legalizing Surrogacy subscale was 0.92, and for the General Attitude towards Surrogacy score was 0.94. The alpha coefficients for the three subscales and overall ATSS score were respectively: 0.73, 0.88, 0.91, and 0.94.

Attitude towards surrogacy and sociodemographic variables

To model the linear relationship between selected sociodemographic variables and attitudes towards surrogacy, multiple linear regression analyses were used. The following variables were considered as hypothetical predictors of attitudes towards surrogacy: age, gender, education, study, link with the medical profession, type of relationship, having a child and being a religious believer. The analysis included variables for which complete data was collected. Some categorical variables have been aggregated to ensure the appropriate size in each category (minimum 20% of the sample). Thus, the education categories included: vocational or secondary versus undergraduate or graduate education; type of relationship categories included: being married versus being in an informal relationship versus being single, divorced or in separation; religion categories included: being a religious believer versus being atheist. To assess simultaneously the effect of several predictors on various facets of attitude towards surrogacy the analysis was conducted with adjustment for all sociodemographic factors. Table 3 shows the results of multiple regression for the three facets of attitude towards surrogacy as well as for the overall score.

As can be seen in Table 3, age, gender, continuing to study, nor being single were not significant predictors of any aspect of attitude towards surrogacy. It was found that the most significant predictor of all three aspects of the attitude towards surrogacy, as well as the general attitude towards it, was being a believer (Catholic or a follower of another religion). Believers, compared to atheists, declared much more 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. Surprisingly, a link with the medical profession, being married (versus in an informal relationship) or having a child was negatively related to some aspects of the attitude towards surrogacy. Respondents linking with the medical profession declared stronger ethical concerns and were more skeptical about the funding and legalization of this method. Married people, as well as those with children, had less acceptance of a surrogacy arrangement for those around them who, for various reasons, struggle with reproductive problems.

Table 3. Results of a multiple linear regression analyses (unstandardized coefficients) for demographic variables predicting attitudes towards surrogacy

Notes. N = 442, * p < 0.05, ** p < 0.01, *** p < 0.001.

Discussion

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. 

Limitations

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.

Clinical implications 

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.

Future research

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). 

Conclusion

In Poland, surrogacy is not regulated by law, which creates legal ambiguities. Most likely surrogacy will not be legal in Poland any time soon. However, it is a present phenomenon in Poland, which needs an open discussion, not only restricted to international incidents of surrogacy presented in media or talking judgmentally about people who travel to other countries to have a child where surrogacy is legal. Research on controversial topics such as surrogacy can contribute to expanding public knowledge about surrogacy, including the different aspects of surrogate parenthood. The research findings related to surrogacy suggest that opinions towards surrogacy are often related with a lack of information and adequate education about different forms of assisted reproduction and the need for governmental regulation (22). What is more, personal beliefs are also related with negative opinions towards modern techniques. Similarly, the mass media have influenced people’s decisions, in that often they give descriptions of extreme rather than normal cases (43). Surrogacy as a topic has not been researched in Poland - creating an opportunity to open a public debate about surrogacy. Therefore, in the future Poland will also be able to join the international discourse about a sensitive topic such as surrogacy.

Abbreviations

ATSS: Attitude towards Surrogacy Scale; CFA: Confirmatory Factor Analysis; IVF: In vitro fertilization, CAHBI: Ad Hoc Committee of Experts on Bioethics; GSAS: The Attitude Towards Gestational Surrogacy Scale.

Declarations

Ethics approval and consent to participate: The study protocol was approved by the Research Ethics Board at the University of Gdansk, Poland (number 46/2020) and abided by the standards of the Declaration of Helsinki. Written informed consent to participate in the study has been obtained from all the participants after the purpose of the study was described.

Consent for publication: Informed consent for publication has been obtained from all the participants.

Availability of data and materials: The datasets used during the current study are available from the corresponding author on reasonable request.

Competing Interest: The authors declare that they have no competing interests.

Funding: This study was conducted with the financial support of the University of Gdansk, Poland (Grant number: 1220/148/2021). The founding body did not have any role in data analysis and interpretation of the study results.

Author’s contribution: The conception and study design, Ł.B., M.B., K.L; Execution, Ł.B., M.B., K.L; Formal analysis, P.J.; Writing - original draft preparation, K.L., P.J. All authors critically revised the article for publication and approved the final version.

Author’s information: ¹ Institute of Psychology, University of Gdansk, 80-309 Gdansk, Poland; [email protected] (K.L.); [email protected] (Ł.B.); [email protected] (M.B.); [email protected] (P.J.). ²           GAMUT-The Grieg Academy Music Therapy Research Centre, NORCE Norwegian Research Centre, Bergen, Norway; [email protected]

Acknowledgments: We are grateful to all participating who took part in this study.

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