A Systematic Review of Surrogacy in Policy and Practice: Fragmented Commissioning, Global Inequities, and the Case for Evidence-Based Reform (KATHERINE Project)

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.