Tanderup Malene, Schmidt Lone, Pande Amrita, Nielsen Birgitte Bruun, Kroløkke Charlotte, Humaidan Peter
Department of Clinical Medicine, Aarhus University, Denmark.
The Fertility Clinic Skive, Skive Regional Hospital, Denmark.
PLoS One. 2025 Jul 29;20(7):e0328469. doi: 10.1371/journal.pone.0328469. eCollection 2025.
Surrogacy involves a woman who consents, before conception, to carry and deliver a child for individuals or couples unable to do so due to biological or medical limitations. This complex process encompasses medical, ethical, legal and financial considerations, resulting in varied legislation worldwide, with countries either prohibiting, restricting or legalising it. Recently, several nations have revised their legislation to encourage domestic surrogacy over international options, driven by ethical considerations and legal concerns. However, these revisions are still pending enactment. Despite the extensive literature addressing the legal, ethical, societal and medical challenges and benefits of surrogacy, no study has comprehensively analysed these factors together to fully capture the complexity of surrogacy implementation. This study aims to identify the key elements that currently facilitate the implementation of domestic surrogacy in the Netherlands and those essential elements needed for its successful continuation.
A qualitative case study was conducted, employing both interviews and document analysis. The selection targeted individuals who were directly involved in or had an informed perspective on handling surrogacy in the Netherlands, including healthcare professionals, healthcare system leaders, policymakers, non-governmental organisations (NGOs), academics, lawyers and counsellors and 14 experts were purposively selected. The data were analysed both inductively and deductively, using the Context and Implementation of Complex Interventions (CICI) framework to assess the contextual factors influencing the implementation of domestic surrogacy.
Four CICI domains were identified as most influential on the implementation of surrogacy: legal (allowance of altruistic gestational surrogacy but missing legal framework on legal parentage, advertisement and payment), political (political shifts and experts' influence, gatekeepers, intersectional collaborations), ethical (professionals' influence on patient's choice) and socio-cultural (donation culture and public opinion). The absence of a legal framework that secures legal parenthood, the limited availability of fertility services and the shortage of surrogate candidates represent key barriers to the implementation of domestic surrogacy in the Netherlands. Conversely, significant facilitators include extensive, well-organised collaboration between professionals and non-governmental organisations (NGOs), invited by the political system to share expert knowledge and support comprehensive legislation.
In conclusion, despite the progress achieved, domestic surrogacy remains largely inaccessible to most infertile individuals and is yet to be fully adopted. Without legal reforms, the situation of surrogacy in the Netherlands is likely to remain unchanged, mirroring the experiences of other countries with pending surrogacy legislation.
代孕是指一名女性在受孕前同意为因生理或医学限制而无法生育的个人或夫妇孕育并分娩孩子。这一复杂过程涉及医学、伦理、法律和财务等多方面考量，导致全球各地的立法各不相同，有的国家禁止代孕，有的国家限制代孕，还有的国家则使其合法化。最近，一些国家出于伦理考量和法律担忧，修订了相关立法，鼓励国内代孕而非国际代孕。然而，这些修订仍有待颁布实施。尽管有大量文献探讨了代孕在法律、伦理、社会和医学方面的挑战与益处，但尚无研究综合分析这些因素，以全面把握代孕实施的复杂性。本研究旨在确定当前促进荷兰国内代孕实施的关键要素以及代孕成功持续所需的基本要素。
开展了一项定性案例研究，采用访谈和文献分析相结合的方法。研究对象为直接参与荷兰代孕事务或对其有深入见解的个人，包括医疗保健专业人员、医疗保健系统领导者、政策制定者、非政府组织（NGO）、学者、律师、顾问等，共选取了14位专家。使用复杂干预的背景与实施（CICI）框架对数据进行归纳和演绎分析，以评估影响国内代孕实施的背景因素。
确定了四个对代孕实施影响最大的CICI领域：法律（允许利他性妊娠代孕，但缺乏关于合法亲子关系、广告宣传和报酬的法律框架）、政治（政治变革和专家影响力、把关人、交叉合作）、伦理（专业人员对患者选择的影响）和社会文化（捐赠文化和公众舆论）。缺乏确保合法亲子关系的法律框架、生育服务的可及性有限以及代孕候选人短缺是荷兰国内代孕实施的主要障碍。相反，重要的促进因素包括专业人员与非政府组织（NGO）之间广泛且组织良好的合作，这种合作是应政治体系邀请，分享专业知识并支持全面立法。
总之，尽管取得了一些进展，但大多数不孕不育者在很大程度上仍无法获得国内代孕服务，代孕也尚未得到充分应用。若不进行法律改革，荷兰的代孕情况可能仍将维持不变，这与其他代孕立法悬而未决的国家的情况类似。
