A Systematic Review of Surrogacy in Policy and Practice: Fragmented Commissioning, Global Inequities, and the Case for Evidence-Based Reform (KATHERINE Project)
Bibliographic record
Abstract
Introduction: Surrogacy is a rapidly evolving area of reproductive health that spans ethical, legal, clinical, and societal dimensions. Policies governing surrogacy vary widely across countries, shaping access to services, safeguarding measures, and the protection of women and children. While some nations permit regulated altruistic or commercial surrogacy, others impose outright bans, creating global disparities and driving reproductive travel. This review examined publicly available surrogacy policies and guidance, with a focus on commissioning decisions, operational processes, and international cross-border complexities. Methods: Following PRISMA guidelines, a systematic search publicly accessible English-language surrogacy policies and guidance documents were identified through a comprehensive search of health service commissioning bodies, government agencies, and professional organisations. Thematic analysis was conducted to explore policy scope, legal frameworks, safeguarding procedures, and international variation. Policies were then compared to assess areas of convergence and divergence across global settings. Results: Globally, surrogacy regulation is highly fragmented. In Europe, most countries prohibit commercial surrogacy and, in some cases, altruistic arrangements, while nations such as the UK, Ireland, and Greece allow tightly controlled altruistic surrogacy. North America shows a patchwork approach, with some US states and Canada permitting altruistic or compensated arrangements under varying levels of regulation. In Asia, historical hubs such as India and Thailand have shifted from permissive commercial surrogacy to restrictive altruistic-only models following concerns over exploitation. Africa remains largely unregulated, except for South Africa’s comprehensive legal framework. Across settings, recurrent themes included safeguarding concerns, ethical debates over exploitation versus autonomy, and challenges in determining legal parentage and nationality. Cross-border arrangements amplify these complexities, often leaving children stateless or without clear legal protections. Conclusion: The absence of harmonised frameworks perpetuates inequities in women’s health and cross-border surrogacy, often exposing individuals to financial, legal, and health risks. These challenges underscore the urgent need for evidence-based policies and fairer, more equitable approaches to surrogacy.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.081 | 0.255 |
| Meta-epidemiology (narrow) | 0.001 | 0.002 |
| Meta-epidemiology (broad) | 0.008 | 0.007 |
| Bibliometrics | 0.023 | 0.027 |
| Science and technology studies | 0.002 | 0.004 |
| Scholarly communication | 0.008 | 0.008 |
| Open science | 0.003 | 0.005 |
| Research integrity | 0.004 | 0.003 |
| Insufficient payload (model declined to judge) | 0.006 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".