A longitudinal pre-pregnancy to post-delivery comparison of genetic and gestational surrogate and intended mothers: Confidence and genealogy OLGA B. A. VAN DEN AKKER Department of Psychology, Aston University, Birmingham, UK (Received 17 August 2004; accepted 26 April 2005) Abstract For women opting to use surrogacy to overcome subfertility, a choice can be made to have a genetically related or unrelated baby. Similarly, women opting to become surrogate mothers also have to choose to gestate and relinquish a genetically related or unrelated baby. This study explored the cognitions behind the initial choices made and determined the strength of those cognitions six months post-delivery of the surrogate baby. Surrogate and Intended mothers (N ¼ 81) undergoing Artificial Insemination (AI, genetic) or Embryo Transfer (ET, gestational) were studied separately (four groups) at the start of their surrogate arrangement and those with a positive outcome (n ¼ 34) were re-interviewed at six months post- relinquishment. There were significant differences between surrogate and intended mothers in their confidence about the arrangement. Beliefs about the importance of a genetic link were predictors of ET arrangements. Responses were consistent over a one and a half-year study period. The ethical and clinical implications of the results are discussed in relation to appropriate self-selection and confidence with the surrogate process and the importance of genetic offspring. Keywords: Surrogacy, genetic, gestational, cognitive dissonance Introduction Previous studies of surrogate arrangements have been exploratory, one off accounts [1,2] or retro- spective in nature [3,4]. Research designs using such methods tend to optimize numbers of participants, but lose out on changes over time and rely entirely on recall, which may not be accurate. There was a pressing need to conduct a long term prospective study, where changes over time could be reliably recorded. Unfortunately, longitudinal research de- signs are commonly marked by high attrition rates, and in studying infertile populations, attrition, lack of cooperation and giving socially desirable responses are not uncommon [5]. The study reported here is longitudinal following surrogate and intended mothers up over a period of approximately one and a half years. It consequently suffers from considerable attrition but benefits from increased reliability of participant responses. Infertility is investigated through many different disciplines, and although it is generally interpreted as a medical condition with a likely physiological basis, involuntary childlessness has strong interrelated social- psychological connotations. You cannot ‘‘see’’ inferti- lity, but you can ‘‘see’’ childlessness. Options to overcome infertility are numerous, and many are associated with uncertainty and psychological stress [6]. For many infertile women, the infertility itself would have been experienced as a life crisis [7], a stressful life event [8], or as a stigma [9]. The subsequent treatment choice may therefore pose an additional burden on these already compromised populations. Surrogacy offers an option that, like many others, is riddled with uncertainty, financial and emotional stress [2,3]. Confidence and flexibility in maintaining a cognitively consonant state because of the lack of gestation and/or social motherhood accompanying the surrogate pregnancy are therefore important factors for psychological health following a surrogate arrangement. The surrogate, though not subject to the same prior life crisis, life-event or stigma of infertility, is likely to experience some of these factors during and following a surrogate arrangement. Having babies is seen as positive in our pronatalist society, and subsequent parenthood has been considered a ‘‘moral obligation’’ [10]. Surrogate arrangements contradict the norma- tive pattern of life events, putting surrogate mothers at an increased risk of experiencing surrogacy as a negative, stressful life event, subject to stigma [11]. Cognitive adaptation to the situation is addressed in Correspondence: Dr. Olga B.A. van den Akker, Department of Psychology, Aston University, Aston Triangle, Birmingham B4 7ET, UK. E-mail: o.vandenakker@aston.ac.uk Journal of Psychosomatic Obstetrics & Gynecology, December 2005; 26(4): 277–284 ISSN 0167-482X print/ISSN 1743-8942 online Ó 2005 Taylor & Francis DOI: 10.1080/01674820500165745