Introduction

Surrogacy involves a woman, referred to as a surrogate, who agrees before pregnancy to carry and deliver a child for an individual or couple, referred to as the intended parent(s). This method of family building is becoming increasingly prevalent, allowing individuals or couples to attain parenthood under circumstances where carrying a child is biologically impossible or medically contraindicated [1]. However, despite its advantages, surrogacy involves a range of legal, medical, cultural, and ethical considerations, including legal parenthood, kinship, reproductive rights and justice, social responsibility, reproductive politics, and economics [2–6]. The legal landscape of surrogacy is complex and dynamic, with countries either restricting or opening their markets. The existence of disparate legislative frameworks has led some couples to seek surrogacy services abroad, referred to as transnational surrogacy [5,7,8].

The use of transnational surrogacy, and particularly the fluctuation of markets, has heightened the risks faced by intended parents, surrogates, and children born through these arrangements [9–13]. From the perspective of surrogates, especially in lower-income countries, issues such as isolation, stigmatisation and exploitation have been explored [14–18]. Nonetheless, this vulnerability is not one-dimensional; it can also be interpreted through the empowerment framework enabling women to, e.g., support their families [4,6].

In contrast, research on surrogates in Canada, the United States (US), and the United Kingdom (UK) suggests that these women experience greater societal acceptance and openness regarding their roles [19,20]. This positive environment often fosters closer relationships between surrogates and intended parents, particularly when they share the same national origin [19]. Contributing factors include the absence of language barriers, shared cultural understandings, and shorter physical distances [9,19,21,22]. Contributing factors include the absence of language barriers, shared cultural understandings, and shorter physical distances. As a result, several countries are revising their legislation to promote domestic surrogacy and reduce the need for international services [23,24]. However, there is a scholarly gap in the literature concerning the successful implementation of surrogacy, particularly in understanding the contextual factors involved. Therefore, our study aims to analyse these issues collectively to develop a comprehensive understanding of the complexities involved in implementing surrogacy. To explore the contextual factors affecting implementation, we chose to use the Context and Implementation of Complex Interventions (CICI), which is based on concept analysis and provides broad coverage of contextual issues [25]. The CICI framework describes seven contextual domains: geographical, epidemiological, socio-cultural, socio-economic, ethical, political and legal [26]. Furthermore, it offers a framework for evaluating the setting, context and implementation of complex interventions embedded, all within a broad public health perspective [26].

Understanding the terminology of surrogacy is crucial for practical implementation analysis as the categories provide insights into the logistical, ethical and legal complexities involved in the implementation process. Surrogacy can be categorised by fertility method, relationship, economics and geography. Medically, surrogacy is divided into traditional and gestational methods. Traditional surrogacy involves home insemination or assisted insemination using the intended father’s sperm, making the surrogate both the genetic and the birthing mother. Gestational surrogacy employs in vitro fertilisation (IVF) at a fertility clinic, allowing the use of the intended mother’s oocytes (eggs) and the intended father’s sperm to create an embryo, which is then implanted in the surrogate. If the intended mother cannot provide oocytes, or in cases involving same-sex male couples or single men, an oocyte donor is also needed. Surrogacy can be known or unknown. In known surrogacy, the surrogate is a family member or close friend. Unknown surrogacy involves a surrogate who is initially a stranger to the intended parents, typically facilitated through an agency or online groups.

Economically, surrogacy is considered altruistic when no payment beyond expenses and minor compensation is made. Altruistic gestational surrogacy is legal in the Netherlands, the UK, Canada and Australia. Conversely, a few countries, including some states in the US, Ukraine, Georgia and Colombia, permit compensation beyond mere expenses [22,27–30]. In general, the service of gestational surrogacy is limited to the country’s national or legal residents, while few countries including Canada, states in the US, Colombia, Mexico, Ukraine and Georgia extends availability to all [31].

The group utilising surrogacy is small but diverse, including women without a uterus due to congenital absence or removal for medical reasons, women with non-functional uteri, women for whom pregnancy is life-threatening, same-sex male couples and single men [32].

Interesting, representing a partially publicly reimbursed altruistic gestational surrogacy model, the Dutch setting has received little attention. In the Netherlands, fertility services in general are highly used [33], yet domestic gestational surrogacy remains rare. Between 1997 and 2017, only 95 couples underwent IVF surrogacy, resulting in 50 births, despite over 500 applications [34,35]. However, it is estimated that 150 Dutch couples seek surrogacy services abroad on an annual basis [36]. Conversely, in the UK, domestic altruistic surrogacy is relatively common. Of the more than 500 children born annually through surrogacy in the UK, half are born via domestic arrangements [9,37]. Infertile individuals from the UK seeking surrogacy abroad primarily opt for the US, India and Ukraine [9]. Between 2014 and 2020, 21,649 children were born through gestational surrogacy in the US [38], where economic compensation to the surrogate is permissible. In 2013, 18.5% of these births involved non-US residents [39]. Surrogate cycles thus constituted 4% of all fertility cycles in the US, comparable to Canada’s rate of 2.3% in 2022 [40], yet markedly contrasting with the Netherlands’ rate, which is below 0.05% (own calculation) [33,35].

Countries such as Canada, Ireland, Belgium, New Zealand and the UK are comparable to the Netherlands in their use of altruistic gestational surrogacy. While Canada, New Zealand and the UK have established legal frameworks regulating surrogacy practices, Ireland, Belgium and the Netherlands have laws that do not explicitly prohibit altruistic gestational surrogacy [5,19,41]. Notably, all these countries except Canada are currently revising their legislation to provide a comprehensive legal framework for surrogacy to make domestic surrogacy more accessible and encourage intended parents to opt for domestic solutions, thereby reducing the need for transnational surrogacy [5,24,41]. In contrast, Canada is experiencing an increasing rate of domestic surrogacy, which may be attributed to a robust legal framework that permits the use of agencies, allows advertising to find a surrogate, and promotes non-discriminatory practices for accessing IVF services [19]. Furthermore, countries such as Denmark, Iceland and Finland, which do not currently offer gestational surrogacy, have recently reevaluated whether to introduce it. However, they have been reluctant to do so due to ethical, legal and organisational considerations [42–45].

No publications have examined facilitators and barriers to implementing domestic altruistic gestational surrogacy. This study aims to identify key elements currently in place to support the implementation process of domestic surrogacy in the Netherlands, along with those necessary for its successful continuation, through an in-depth analysis of interviews and documents, using the CICI framework. Two research questions guided this study.

1. 1). How do key stakeholders within the clinic, including doctors and psychologists, as well as those in the organisation, such as counsellors, lawyers, and officials, experience the surrogacy process?
2. 2). What are the barriers preventing the expansion of domestic surrogacy, and which factors have shaped its development to its current state?

The Netherlands as a case study

In 1985, gynaecologist Sylvia Dermout was diagnosed with gynaecological cancer, leading her to become the chairperson of the Dutch gynaecological cancer organisation Olijf [46]. In this role, she championed the cause of post-cancer women seeking to have genetically linked children through surrogacy. She sought to exert influence through political, medical and psychological channels. In 1994, the Dutch Minister of Health, Dr. Els Borst, amended the law to allow non-commercial IVF surrogacy under strict conditions set by the Dutch Society of Obstetrics and Gynaecology (NVOG). This led to the establishment of the Dutch Centre for Non-commercial IVF Surrogacy in Zaandam, led by Dr. Dermout, where a study from 1997 to 2004 resulted in the birth of 16 children through altruistic gestational surrogacy [34]. The Netherlands was one of the first countries worldwide to introduce altruistic gestational surrogacy in public facilities; until then, gestational surrogacy was known only from private fertility services, since 1985 in the US and the UK [47,48].

A consultation board, comprising six gynaecologists, a professor of psychology, a professor of ethics and a lawyer, reviewed all surrogacy cases to ensure that clinical indications were met. After the pilot study, existing fertility centres were hesitant to assume clinical responsibility for surrogacy. In 2006, with state funding, the Free University Hospital (VUmc) continued the programme, though without Dr. Dermout. It took years to reach similar case numbers as in Zaandam [35]. In 2018, the NVOG revised its guidelines, changing the requirement from the child needing to be fully genetically related to the intended parents to requiring at least one genetically related intended parent. This amendment facilitated the use of gestational surrogacy by same-sex couples [49]. In 2019, the specialised fertility clinic Nij Geertgen began offering surrogacy, becoming the second facility in the Netherlands to do so. Known for treating many same-sex female couples, they aimed to make surrogacy available for same-sex male couples as well [50]. A pending law proposal seeks to establish a legal framework for surrogacy, aiming to shift from discouraging to promoting domestic surrogacy and reducing the number of individuals pursuing surrogacy abroad. The initiative began in 2012 when the Parliament, in response to numerous legal changes in family law, requested an expert panel to prepare a report on family law focused on the child’s best interests. This culminated in the so-called 2016 report, which forms the foundation of the current law proposal. The organisational and political events are illustrated in Fig 1.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 1. Chronology of the intervention.

Key historical events leading to the introduction of gestational surrogacy in the Netherlands. VUmc: the Free University Hospital; NVOG: the Dutch Society of Obstetrics and Gynaecology; AMC: Amsterdam Medical Centre.

https://doi.org/10.1371/journal.pone.0328469.g001

The Dutch healthcare system rests on a universal social health insurance model combining public oversight with private insurance. All residents are required to obtain statutory health insurance, which is provided by private insurers obliged to offer coverage to all. The system is financed primarily through public funds derived from premiums, taxes and government contributions. Regarding reproductive health, the system provides varying degrees of coverage for family planning and infertility treatments. Basic health insurance covers certain services, including IVF, in the event of medical necessity. Reimbursement for gestational surrogacy is partial, covering solely the cost of embryo creation as the transfer of the embryo to a fertile woman is not covered. The system provides coverage for medically indicated cases only and excludes reimbursement of IVF expenses for same-sex male couples. All fertility services are conducted in public fertility departments and clinics [51, chapter 2 pp 65–67].

Methods

Key informant interviews

The material includes interviews with 14 purposively selected experts who were central to understanding the organisation and development of surrogacy in the Netherlands. The selection targeted individuals who were directly involved in or had an informed perspective on handling surrogacy, including healthcare professionals, healthcare system leaders, policymakers, non-governmental organisations (NGOs), academics, lawyers and counsellors (Table 1). Half of the interviewed stakeholders were, besides their professional career with surrogacy, also in an NGO with an interest in surrogacy. Twelve of the 14 interviewed had influenced the formation of previous and current law proposals, either as advisers in the Ministry of Justice and the Ministry of Health or in writing the 2016 report. The stakeholders had nine years of experience with surrogacy on average. Given the small number of people involved in surrogacy, and to ensure that confidentiality is maintained, the information provided on the profile of key informants is purposefully limited. Where possible and available, the research team asked key informants for documentary evidence to support claims made during the interview.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Key informant interviews by profession and experience with surrogacy.

https://doi.org/10.1371/journal.pone.0328469.t001

Document analysis

A document analysis was conducted. We focused solely on Dutch policy documents and official statements pertaining to surrogacy. This included the initial description of a national policy on surrogacy from 1990, as well as the latest updated national law proposal on domestic and transnational surrogacy from 2024. It is important to note that we did not include analyses or comments on the law itself, nor on any associated legal interpretations. Additionally, relevant academic literature was examined to contextualise the findings within the broader discourse surrounding surrogacy. For an overview of included documents, see Table 2.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Analysed documents influencing the field of surrogacy in the Netherlands.

https://doi.org/10.1371/journal.pone.0328469.t002

Data analysis

The analytical procedure unfolded over two phases, adopting a combined inductive-deductive methodology. During the initial phase, we employed a tailored version of Malterud’s systematic text condensation as an empirical method for coding the interviews and documents [53]. This phase was instrumental in generating codes that laid the groundwork for the subsequent phase. The initial phase encompassed: (i) reading the entire material to gain an overall impression and identify preliminary themes, (ii) identifying codes related to the preliminary themes, (iii) condensation of the codes to meaning and (iv) forming descriptions and concepts. The second phase was steered by the CICI framework [26] with a particular focus on the contextual factors influencing the use of domestic surrogacy. Codes were systematically categorised under the analytic domains: geographical, epidemiological, socio-cultural, socio-economic, ethical, legal and political (see Fig 2). This framework provided a methodological and targeted analytical lens.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 2. CICI Framework: Illustration of the context, implementation and setting involved in domestic surrogacy in the Netherlands.

UTx: Uterus transplantation.

https://doi.org/10.1371/journal.pone.0328469.g002

The methodological triangulation of key informant interviews and document analysis, coupled with the diligent application of the CICI framework, produced comprehensive insights into the facilitators and barriers of using surrogacy within the Dutch setting amidst possible legislative changes. The following section presents the findings of this study.

Results

The interview data predominantly aligned with four out of the seven domains of the CICI framework: 1) legal, 2) political, 3) sociocultural and 4) ethical. Within these categories, distinct themes emerged during the interviews. These themes, referred to hereafter as the context’s sub-domains [26], are characterised by a distinction between elements already present and those identified by the interviewees as necessary. Moreover, the interviewees were able to identify the key elements currently in place to support the implementation process of domestic surrogacy, along with those essential for the successful continuation of this process. For a comprehensive overview of the domains, sub-domains and key elements, please refer to Table 3.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 3. Existing and required elements within each subdomain of legal, political, ethical and socio-cultural domains.

https://doi.org/10.1371/journal.pone.0328469.t003

Discussion

Through an in-depth analysis of interviews and documents using the CICI framework, we have identified facilitators and barriers affecting the implementation of domestic gestational surrogacy in the Netherlands. This analysis explores the legal, political, ethical and socio-cultural contexts to elucidate the existence of specific barriers and facilitators. Key barriers include the absence of a legal framework securing legal parenthood and political reluctance to enact the proposed legislation. Additionally, there are limited fertility clinics willing to offer surrogacy services, as it is complex task with no economic incentives. Furthermore, the shortage of surrogate candidates is exacerbated by restrictions that prohibit advertisements and the involvement of agencies. Conversely, significant facilitators encompass extensive, well-organised collaboration between professionals and NGOs invited by the political system to share expert knowledge and support comprehensive legislation.

Our findings underscore the complexity of implementing surrogacy in a global north setting, even over a 27-year period due to the interplay of various contextual determinants. While these determinants have been described individually in multiple research studies [5,9,54], to our knowledge, no study has specifically aimed to analyse them collectively to understand the full complexity of implementing surrogacy.

The legal domain represents a crucial prerequisite for further implementation, as evidenced by all interviewees’ responses: the introduction of a comprehensive legal framework is essential. This is in line with the notable shift in legislative objectives, which initially discouraged surrogacy but made it accessible to a limited population and is now focused on promoting domestic surrogacy to reduce the number of individuals seeking surrogacy abroad. The framework should address the legal aspects of parenthood, guarantee the intended parents’ and the surrogate’s rights, facilitate the advertising process to enable parties to find each other and provide financial compensation for the surrogate. The necessity of such a legal framework is not exclusive to the Netherlands; comparable developments are occurring in the UK, Ireland and Australia, of which none of these have yet been enacted [5,41,54].

Legal factors are closely tied to political dynamics. The recent shift from a left-wing to a right-wing government has cast uncertainty on the enactment of the proposed law. The vulnerability to political dynamics is also seen in Spain [55] and Finland, where a political election halted the introduction of new surrogacy legislation [56]. The driving force behind the law proposal has been the incorporation of medical, legal, psychological and patient-oriented perspectives over several years. Interviewees felt that being heard at the ministerial level was significant during the development of the Committee Report (2016) and the subsequent law proposal. This involvement may have prevented a scenario similar to that in Iceland, where the law proposal faced overwhelming criticism from various interest groups, including medical and social worker associations and human rights organisations, ultimately leading to no changes in the legal situation in Iceland [42]. However, as noted within the legal domain, new legislation is essential for the broader adoption of domestic surrogacy in place of transnational surrogacy.

The CICI analysis also highlighted the role of gatekeepers in the organisation of surrogacy. Current gatekeepers set criteria for gestational surrogacy, with healthcare professionals screening intended parents and surrogates. However, declined intended parents or surrogates or those never seeking consultations can still pursue transnational gestational or domestic traditional surrogacy. Legal parentage and stepchild adoption are decided by the court and the Council of Child Protection, but these institutions’ decisions occur after the child is born, limiting their impact on surrogacy practices.

A national gatekeeper in the form of preconception counselling of all types of surrogacy is suggested as a required element to enhance domestic surrogacy. Instituting a gatekeeper function may increase the number of intended parents choosing domestic surrogacy by highlighting its advantages over international options. If implemented, avoiding long waiting times and reducing travel distances are crucial. Besides providing valuable information to intended parents and surrogates, it is proposed that intended parents and surrogates approved during the consultation process achieve legal parenthood from the child’s birth. This would represent a significant improvement compared to the current prolonged uncertainty surrounding the establishment of legal parenthood. Conversely, individuals who opt out of preconception consultations would still face the existing lengthy adoption procedures, involving years of legal procedures. A similar regulatory body is included in the new Irish surrogacy law proposal, which will preapprove surrogacy arrangements and introduce medical and capacity checks [5]. The effectiveness of centralised counselling services in improving and encouraging domestic surrogacy remains to be seen.

Furthermore, existing Dutch gatekeepers have requested a clear legal framework to make more clinics comfortable and safe in offering surrogacy as a fertility treatment. The NVOG recommends limiting surrogacy to one to two clinics nationally due to its complexity [49]. However, interviewees believe that only two clinics are insufficient to meet infertile couples’ needs and vulnerable to changes in case of critical personal circumstances of professionals or shifting management in the clinics.

Additionally, the study shows the importance of intersectional collaboration for the feasibility and safety of intended parents and surrogates. Unlike commercial surrogacy in countries like Ukraine, the US and Colombia, the Netherlands does not offer a “full surrogacy package” with integrated services from lawyers, clinicians, agents, counsellors and psychologists. Instead, each profession operates independently, potentially creating abrupt and insecure processes. However, the cohesiveness of the processes has been strengthened by informal collaborations built over the years, particularly since the 2016 report, and the launch of a government-supported information homepage. This collaboration influences the ethical domain, particularly the sub-theme of “choosing the ethical option”. Interviewees expressed strong opinions on ethical options and aimed to guide the choices of intended parents and surrogates in the direction of domestic solutions.

A recent survey reveals generally positive perceptions of surrogacy within the Dutch population, particularly for heterosexual couples utilising a Dutch surrogate who is a friend or family member [57]. Supportive attitudes, previous studies show, are more likely in countries where surrogacy is legal, and they affect both the surrogate and the intended parents [10,14,19,44,58,59]. Despite the positive attitude in the Netherlands, the shortage of oocyte donors and surrogates remains a significant limiting factor. Key elements identified to address this issue include the ability to advertise for potential surrogates, the establishment of a “surrogate bank” akin to sperm and oocyte banks, and the implementation of a comprehensive legal framework for surrogacy. The Canadian experience with altruistic gestational surrogacy indicates that permitting advertising for surrogates could significantly increase the pool of candidates; hence, a Canadian survey showed that 93% of surrogates met the intended parents through the Internet or an agency [19]. Moreover, the issue of economic compensation for surrogates was highlighted by interviewees and also mentioned in the 2016 report. While this compensation is not akin to that found in commercial surrogacy, it is more of a symbolic payment comparable to altruistic oocyte and sperm donation, recognising the surrogate’s contribution. The suggested compensation would be €500 per month; however, there remains uncertainty about which expenses can be covered, as this is not clearly defined in the current Dutch framework. The Canadian model allows for reimbursement of all expenses, including clothing, food, medical costs, childcare, travel expenses, and lost wages. This ensures that surrogates do not experience any financial losses during their pregnancies, a situation that contrasts sharply with the current practices in the Netherlands.

Contrary to our initial assumption that countries permitting gestational surrogacy would not utilise traditional models, our findings suggest otherwise. Our research reveals a notable, albeit unquantifiable, use of traditional surrogacy in the Netherlands, previously unknown outside the country. In nations where gestational surrogacy is prevalent, traditional surrogacy typically remains rare [60,61] as the American Society of Reproductive Medicine (ASRM) advocates for gestational surrogacy [62], and some countries even prohibit traditional surrogacy [63,64]. The preference for medicalisation to uphold professionalism and prevent strong bonds between the surrogate and the genetically linked child leads intended parents to use different oocyte donors from the surrogate if they cannot provide the oocytes themselves [65]. However, within the Dutch context, professionals reported no significant differences between traditional and gestational surrogacy in terms of conflicts or complications, provided thorough counselling and alignment of expectations were in place before conception. This finding aligns with studies conducted in the US and the UK [66,67]. Traditional surrogacy, with its lower cost, reduced medical risks and fewer individuals involved in the child’s origin story, warrants further research to explore its potential as an alternative to gestational surrogacy. The relatively high utilisation of traditional surrogacy in the Dutch setting, coupled with the increase in cases observed in clinics over recent years, indicates that the implementation of surrogacy is evolving. Even so, it is not yet fully established. Hence, interviewees estimate that more than half of the intended parents still seek surrogacy services abroad.

Strengths and limitations

This study offers a comprehensive examination of the implementation process of domestic surrogacy through the lens of the CICI framework. It involved a diverse range of professionals engaged in surrogacy practices within the Netherlands, including clinicians, private counsellors, and lawyers. This comprehensive approach allows for an investigation into domestic traditional surrogacy experiences, which have been inadequately addressed in Dutch publications due to the absence of such cases in the clinical setting..

However, some methodological considerations must be taken into account when interpreting the findings. The interviews were limited to healthcare and legal professionals actively involved in surrogacy, many of whom have been part of the development of previous or current surrogacy law proposals, which introduces the potential for confirmation bias. However, the proposed legislation has not yet been enacted due to the current political climate, leading experts to critically discuss the implications of the existing system and the limitations that may persist even if the proposed law is eventually passed. To further mitigate the risk of confirmation bias, including professionals who have opted not to handle surrogacy cases would have been beneficial. However, meaningful insights from such individuals would require them to deliberately choose not to engage in surrogacy work, as those who have not participated may lack comprehensive knowledge of the field. It is important to note that the factors identified are based on the interviewees’ perceptions, which may be shaped by their contexts. However, these insights provide a deep understanding of the dynamics present in the Netherlands. Many of these factors have also been identified in studies from other countries, suggesting that they could potentially be generalised to other national contexts.

Additionally, a significant limitation is the absence of surrogates and intended parents as interviewees. Including their perspectives could have highlighted facilitators and barriers to the organisation of surrogacy from the user viewpoint. However, a Dutch research group is concurrently conducting interviews with Dutch intended parents and surrogates, making it ethically redundant to replicate this study. Insights from their research are expected to contribute valuable knowledge to this field.

Conclusion

The CICI framework has been instrumental in identifying existing elements and areas requiring further development to enhance the implementation of surrogacy in the Netherlands, aiming to favour domestic surrogacy over transnational alternatives. Despite progress, domestic surrogacy remains largely inaccessible and is still in the process of being fully adopted.

A crucial step towards further implementation is establishing a comprehensive legal framework, which hinges on governmental engagement and prioritisation. Such a framework would provide greater legal security for intended parents and encourage more women to become surrogates by ensuring their rights and safety. Without these legal changes, surrogacy in the Netherlands will likely remain unchanged, like in other countries with pending legal reforms.

Our findings offer valuable insights for healthcare system policymakers, decision-makers and professionals involved in domestic surrogacy, both within the Netherlands and in countries undergoing similar processes.

Supporting information

Acknowledgments

We would like to thank all the healthcare professionals, lawyers, policy-makers, academics and counsellors who took the time to participate in the interviews. Furthermore, we would like to thank Mia Fredens and Stine Bollerup at the Institute of Public Health, Defactum, at Aarhus University, for providing valuable feedback on earlier versions of this manuscript.