Perceptions of Surrogacy Within the Socio-Cultural Context of Nigeria

Study design

This research is qualitative, and its strategy of inquiry is explorative. In utilising this exploratory approach, the researcher, through painstaking interviews, accessed the perceptions of gynaecologists, traditional birth attendants (TBA) and legal professionals on the practice of surrogacy in Nigeria. Exploratory qualitative research allows the researcher to collect data from persons who possess relevant knowledge about a phenomenon and assists in developing a composite description of the essence of their experience for all individuals¹⁷ .

Ethical considerations

This study was approved by the University of KwaZulu-Natal ethical clearance Committee (Protocol number: HSS/0705/017M) after due consultation and the gatekeepers' consent letters were provided by Ekiti State Teaching Hospital, Ado-Ekiti, Ekiti- State and Oyedeji Ayodele and Co, Abuja Nigeria.

Participants

The study population consisted of three categories of participants. These included ten gynaecologists, five TBAs and five legal professionals. This study was conducted in two cities in Nigeria: the gynaecologists and TBAs were recruited and interviewed at Ekiti State Teaching Hospital, Ado-Ekiti, Ekiti State Nigeria; and the legal professionals were recruited and interviewed at Oyedeji Ayodele and Co, Abuja, Nigeria.

Considering that surrogacy is not a popular practice in Nigeria, purposive sampling was used to select participants. Both institutions served as a welcoming host to the researcher and provided access to participants and premises. The Ekiti State Teaching Hospital in Ado-Ekiti is one of the foremost fertility clinics in the South-western part of the country and thus a suitable location for the study; while, Oyedeji Ayodele legal chamber is one that has handled many legal disputes regarding children, paternity and reproductive contracts over the years. Both locations had the criteria to provide the required information this study needed.

Informed consent was gained by detailing the purpose of the study and the strategies to ensure the participants’ anonymity and confidentiality were explained to them before the study began, where after they voluntarily signed the consent forms. The informed consent included that the participants could withdraw from the study at any point if they no longer feel comfortable.

Sampling

Purposive sampling was adopted to recruit participants in the study. The institutions that served as a host for the researcher provided access to legal professionals, gynaecologist and TBA’s. Upon receiving ethical clearance from the University of KwaZulu-Natal, the gynaecological centre of Ado Ekiti Teaching Hospital was visited, and appointments were made to interview gynaecologists at their convenience. The department also served as a link to the association of TBAs in Ekiti State. Oyedeji Ayodele and Co. was also visited in Abuja where interested legal professionals within the chamber were approached and interviewed.

Data collection

Face-to-face in-depth interviews were conducted with each participant using a semi-structured interview schedule that contained three sets of questions. An audio recorder and field notes were used to collect the data. The participants had consented to the recording of the interview with an audio recorder on their informed consent form. The first set of questions examined surrogacy within a cultural perspective, the second questioned medical opinions on surrogacy arrangements as it pertains to Nigeria, and the third examined the legal trepidations in the practice of surrogacy. The interview schedule was translated into Yoruba, the most commonly spoken language in Ekiti State, for the benefit of the TBAs who might not be English speakers. Interviews lasted on average of 30–70 minutes.

Not all the participants approached participated in the study. Considering the nature of the medical and legal profession, the timing was a major constraint; several of the legal practitioners and gynaecologists cancelled appointments more than twice, and some were finally not interviewed. However, data saturation was a major guide during the process of the fieldwork. The narratives from participants were constantly assessed to identify when new information was derived, and when there were very frequent repetitions data saturation was reached and the fieldwork came to an end.

Audiotapes were transcribed by the researcher and interview transcripts and summaries were checked with participants to ensure that their narratives were captured correctly and not distorted in any way.

Data analysis

Thematic content analysis was adopted to analyse the field notes and transcripts. Thematic content analysis is an approach to the analysis of documents and texts (which may be printed or visual) that seeks to quantify content in terms of predetermined categories (in this research emerging categories from participants’ narratives) in a systematic and replicable manner¹⁸. Transcripts from the interviews were organised into a logically readable format, after which recurrent patterns and conceptual issues were identified and developed into themes that formed the basis for the analysis. Participant numbers and characteristics (age, gender, and job) (see Table 1) were used in reporting the findings of this study to ensure the anonymity of participants as noted in the informed consent.

Social perception of surrogacy in Nigeria

The participants provided varying thoughts on the popularity of surrogacy in Nigeria. Some of these seemed to be influenced by personal beliefs, religious and cultural sentiments, as well as knowledge about the practice. A careful examination of the responses revealed complex narratives that further strengthens the debates in literatures that surrogacy brings to the fore various legal, socio-cultural, and ethical concerns. Most of the gynaecologists and legal professionals expressed support for the practice of surrogacy even though they noted that it is a complex terrain to navigate, while TBAs believe it is a practice that negates normative reproductive processes and a concept that could commercialise babies and the woman’s body. Most TBAs strongly drew on religious and cultural beliefs in their discussion of surrogacy as a reproductive process. One of the gynaecologists mentioned that:

All the gynaecologists interviewed believe that surrogacy will gain prominence with time and as the country continues to transform; however, they also believe that it is still in its infancy and essentially still unpopular. They also emphasised that the popularity of the process is hampered by socio-cultural beliefs and values regulating reproduction. Notwithstanding, they noted that surrogacy is becoming a thriving venture in major urban settlements like Abuja, Lagos, and Port-Harcourt, even though the legal terrain in which it operates remains unregulated.

The legal professionals interviewed believed surrogacy is a controversial, non-existent and with a very low patronage in Nigeria.

The opinions shared by TBAs elaborated on the religious and socio-cultural factors influencing the popularity of surrogacy in Nigeria discussed in the previous section:

All the TBAs shared the same opinion that surrogacy is becoming a social discussion in Nigeria; however, they hoped it would not thrive within the country because it goes against cultural and religious norms for reproduction. The reservations they have for the practice include the fact that the surrogacy process will destroy the entire process of normal reproduction- which spans through the period of pregnancy, bonding, as well as the premium placed on children. The terrain of surrogacy is indeed very complex and currently does not constitute an important aspect of public discussion^19,20. What surrogacy means and the social reception it enjoys differ across cultural and social boundaries. It is quite evident from participants’ narratives that the discussion of surrogacy brings to the fore several concerns that are often influenced by the social, cultural and religious beliefs of the community²¹.

Surrogacy and its practice is borne out of a desire to have a child²², and contemporary practice thereof is often hinged on a desire to have a child with a biological connection^23,24. Moreover, the process as discussed is complex and could potentially lead to the exploitation and abuse of fundamental human rights, hence it remains a highly debatable topic. For instance, perceptions of surrogacy may also be grounded in descriptions that suggest commercialisation and exploitation of women^25,26. Commercialising a woman’s body by renting her womb and putting a price tag on the children that is a product of this process is highly dehumanising and disregards a fundamental human right.

TBAs in this research described surrogacy as an act that distorts the cultural normative process for reproduction and disregards the role of women. Surrogacy in Yoruba language is translated as “agbabi odi omo eni”, meaning ‘contracted pregnancy does not become yours’. The meaning and definition of the process in this local language suggests a difference between the surrogate and child, as well as between the commissioning parent and the child, and that in itself is reinforcing the stigma placed on infertility. Hence, surrogacy is perceived as a way of expressing how one woman was unsuccessful in conceiving a child; this role, however, has been taken up by another woman who has the physiological capability to conceive and carry a child to term, without paying attention to the possible feelings that might be involved as the surrogate mother carries the child to term. The process also fragments parenthood and raises serious paternity issues according to these traditional birth attendants. These narratives by TBAs describe surrogacy as a deviating act and even in cases of altruism, the altruism of the surrogate is regarded as ranging beyond normative boundaries²⁷. The perceptions of surrogacy among this study’s participants highlights the complexities and multiple contestations that characterises the entire process. Some of the socio-cultural, religious and ethical trepidations mentioned in this sections will be discussed further.

Fragmenting womanhood: socio-cultural intricacies in the process of surrogacy and the understanding of a ‘woman’

Across most African societies, there is a great deal of significance placed upon a woman . They play a significant role in the continuity of the community and the operation of social life and are considered the fabricators of life and the mothers of humankind. As a major player in the personal rituals associated with birth, puberty, and death, the symbolism of these rituals demonstrates the important cultural meanings of womanhood²⁸. There is a connection between fertility, culture, and religion across most African cultures²⁹. While the ability to conceive and carry a child to term is regarded as a gift and partly the workings of a supernatural being, the cultural definition of a woman is her ability to perform the gestational role of carrying a child to term. Across most of African cultures, high fertility is not only a divine reward but evidence of the right behaviour. Among the Chaga of Tanzania, the wife in complying with the divine order has been described in these words: “she corporates with her husband, the ancestors, even God, in creating the child”³⁰. Hence, it can be inferred that fertility is a product of complete obedience to God and the ancestors, and exuding what is considered conforming behaviours. Children are highly desired, and women are accorded a lot of regard for being fertile, usually adjudged on their ability to conceive, carry to term and nurture a child. The birth of a child is celebrated and seen as a sign of divine approval by both living and dead/ancestors. However, infertility is regarded most times as a woman’s problem and evidence of sin and disapproval by both God and the ancestors³⁰. These are extraordinarily strong gendered assumptions that continue to domesticate women, sexualise their bodies, and produces female oppression within the study’s location.

The perceptions shared by the participants are diverse but entrenches the notion that fertility and children are important parts of the African community. A woman’s ability to conceive and carry a child to term defines her and serves as a rite of passage to womanhood. In addition, religion is fundamental to the conception of fertility, while infertility is an aberration that probably results from sin. Notwithstanding, surrogacy is not seen as a solution to infertility but rather as a further disregard for religion and culture. TBAs believe that an infertile couple must continue to pray and seek alternatives that will not be unnatural. When most of the participants were asked about how they think the practice of surrogacy will influence the conceptualisation of womanhood, various issues emerged, including:

The notion that surrogacy is a reproductive process that encroaches on the pertinent understanding of reproduction and womanhood was shared by all TBAs and in fact they believe that it is not a practice any of the parties involved will be proud to identify with. In addition, surrogacy was seen as a negation of the acceptable religious process for reproduction:

Gendering infertility: women’s infertility as a consequence of promiscuity and recklessness

The perception that infertility is regarded as evidence of sin or recklessness was discussed by participants. For example, it was noted that infertility may be the result of the reckless lifestyle the woman may have lived as a youth:

The perception that infertility is a punishment for a perceived sin or recklessness usually associated with women was quite resounding. The gendered nature of infertility is actually an idea that some participants noted to have shaped the perception of fertility in Nigeria:

The gendered nature of infertility from the response above is quite popular in Nigeria and cuts across class. Equating a woman’s ability to birth a child to her attainment of womanhood is also a common narrative that further stigmatises women. One of the participants noted that:

These narratives suggest that without gestating and carrying a foetus to term, it is culturally believed that the woman is incomplete and has failed in her role, and as such transferred this responsibility to another. ‘Renting’ a womb for surrogacy, as discussed in the literature^31,32, is seen in this context as a cultural anomaly and misnomer. A process that fragments womanhood and commercialises reproduction:

The participant above noted that the failure of a woman to fulfil her cultural role as a woman has essentially created a gap that another women will fill, either for altruistic reasons, e.g. helping the woman fulfil her social expectations of becoming a mother, or for financial gain inherent in the practice of commercial surrogacy. This legal professional is of the opinion that surrogacy as it is practiced is new to Nigeria but might start to become entrenched basically because of the premium placed on having children. One participant stated that while the practice negates the normative ways of procreation, it also fulfils a cultural goal of helping other infertile couples build a family:

Another participant believes that surrogacy provides a positive view for arguments that parenthood is not just biological but could be social or by assuming the responsibility of raising another person’s child. One of the participants noted that:

Further reiterating this line of thought, another participant noted that:

This participants discussed surrogacy from a very positive point of view by focussing on the fact that it helps individuals fulfil the normative social expectations of raising a family where children are regarded as a premium, but it has failed to bring into context the exploitation, complexities in parentage and other ethical issues inherent in the practice. The conflict between agency and protecting the rights of the child that will be a product of this process, as well as some of the women who are often caught in a complex web of unequal power relations, makes the terrain very complicated to navigate. It also reemphasises the need for a comprehensive reproductive legislation in Nigeria that will protect women and children from all forms of exploitation and abuse.

Underlying data

Figshare: Surrogacy Transcript. figshare. Dataset. https://doi.org/10.6084/m9.figshare.11120891.v1³³.

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Extended data

Figshare: Interview schedule, https://doi.org/10.6084/m9.figshare.10264904.v1³⁴.

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).