Renting out their wombs may ease financial problems for poor women in India, but new research suggests surrogate mothers there are unaware of the risks and often left out of key medical decisions about their pregnancy. 

“Of the 14 surrogate mothers I interviewed, not a single one could explain the risks from having multiple embryos placed in their uterus, or having a fetal reduction or a Cesarean section,” said Dr. Malene Tanderup from Aarhus University in Denmark.

“Pregnancy is the most dangerous time in a woman’s life,” she told Reuters Health. “They have to know what they are agreeing to.”

Most countries ban commercial surrogacy, but India remains a popular destination for “rent-a-womb” tourism, which brings in an estimated $500 million to $2.3 billion annually.

The women in India who become surrogate mothers are mostly poor and uneducated. The $3,000 to $7,000 they typically earn can mean a vastly improved living situation, education for their children or the chance to start a small business.

Yet large payments to fertility clinics and lack of regulation raise worries that surrogate mothers are being exploited.

New findings reported in Acta Obstetricia et Gynecologica Scandinavica fuel those concerns.

“This article shows the ground reality in a very stark manner,” said Dr. Amar Jesani, editor of the Indian Journal of Medical Ethics, who was not involved in the study.

He said lack of truly informed consent to medical procedures is a widespread problem in India. “I’m not surprised at all by the findings,” Jesani told Reuters Health.

In Tanderup’s study, none of the surrogate mothers knew how many embryos had been transferred, or the complications of multifetal pregnancy or fetal reduction.

That’s a problem, Tanderup says, because the 18 clinics she visited typically transferred several embryos at a time - in one case as many as seven.

With each additional fetus, risks to mothers and babies climb. Babies from multiple pregnancies are more likely to be premature or have cerebral palsy or learning disabilities, and mothers have higher risks of high blood pressure, diabetes or postpartum bleeding.

When Tanderup asked doctors if they told surrogate mothers how many embryos they transfer, one answered: “No, we never ask them and they are not even informed how many are going to be transferred. They are illiterate, uneducated girls.”

Two-thirds of clinics decided how many embryos to transfer without consulting the commissioning parents or the surrogates. Four said they asked the commissioning parents, and only one included the surrogate mothers.

Clinics typically reduce the number of fetuses according to commissioning parents’ wishes. A lethal solution is injected into unwanted fetuses around week 10 of pregnancy.

Fetal reduction is generally considered safe, but it carries a small risk of infection and loss of the remaining fetuses. Because surrogate mothers are paid monthly during pregnancy, they get less money if they miscarry.

Only three clinics involved surrogates in decisions about reduction.

In one case, when a woman carrying twins wanted a reduction, the agent and doctor refused. Instead, they offered an additional 50,000 rupees ($809) plus a C-section, which she accepted. As one doctor explained, if the commissioning parents get twins, “it is two in one shot, they don’t have to spend that money again.”

But whether the extra payment “makes up for the extra risks is unclear,” Tanderup said.

A twin pregnancy in India almost invariably leads to a C-section, she explained. Afterward, mothers shouldn’t lift heavy things for a while and might not be able to return to daily duties right away. And should they get pregnant again, they’ll typically need another C-section.

The contract says nothing about who pays for that procedure or for infections or other complications after delivery, Tanderup added.

An earlier study from India found that surrogacy contracts rarely addressed the health and wellbeing of the surrogate mother.

Jesani, from the Indian Journal of Medical Ethics, said the findings cast both commissioning parents and doctors in an unflattering light.

“The doctors seem to be more loyal to the commissioning parents than to the surrogates,” said Jesani, also at the Centre for Studies in Ethics and Rights in Mumbai.

He added, “A large number of commissioning parents are Indian, I’m not saying this is only foreigners.”

Legislation to regulate the Indian surrogacy market - the Assisted Reproductive Technology Bill - has been pending for years, with activists arguing it’s too soft and industry taking the opposite view.

In the meantime, business may pick up. Last month Thailand outlawed surrogacy services for foreigners following several scandals, including an Australian couple that allegedly abandoned a baby with Down syndrome with his Thai mother but took his healthy twin home with them.