Volume 126, Issue 1, 1 May 2006, Pages 39-47
doi:10.1016/j.ejogrb.2005.07.030 | How to Cite or Link Cited By in Scopus Using DOI
Copyright ? 2005 Elsevier Ireland Ltd All rights reserved. (6)
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Analysis of national representative
opinion surveys concerning gestational
surrogacy in Japan
aDepartment of Obstetrics and Gynecology, School of Medicine, University
of Yamanashi, 1110 Shimokato, Tamaho, Yamanashi 409-3898, Japan
bDepartment of Health Sciences, School of Medicine, University of
Yamanashi, 1110 Shimokato, Tamaho, Yamanashi 409-3898, Japan
cDepartment of Obstetrics and Gynecology, Showa University, School of
Medicine, Shinagawa-ku, Tokyo 142-8666, Japan
Received 13 April 2005;
revised 30 May 2005;
accepted 21 July 2005.
Available online 19 September 2005.
Although gestational surrogacy offers several advantages, this procedure has given rise to some ethical and legal issues. We aimed to clarify the factors affecting the attitude of the Japanese toward gestational surrogacy.
Nationwide opinion surveys concerning assisted reproductive technologies (ART) were carried out in 1999 and 2003. Participants included 2568 and 3647 people from the general public surveyed in 1999 and 2003, respectively (1564 people received only the questionnaire, and 2083 people received a questionnaire and brochure about ART).
Multivariate-adjusted odds ratio and 95% confidence interval from logistic regression models for factors affecting the attitude toward gestational surrogacy.
In both surveys, approximately half of respondents approved of gestational surrogacy; 20–30% disapproved of the procedure. People
with high socioeconomic status clearly expressed their opinion on this issue. A liberal attitude toward gender role promoted approval of gestational surrogacy; a liberal attitude toward family had the opposite effect.
Our findings suggest that socioeconomic status affects people's expression of their opinion regarding this issue, while attitudes toward
this procedure were influenced by individual belief. Considering
socioeconomic status and diversity of individual belief is required for
further discussion on this topic.
Attitude; Surrogate mothers; Public opinion; Infertility;
2.1. Outline of the surveys in 1999 and 2003
2.3. Study method
2.3.1. Evaluation of factors that affect a person's ability to clearly
express an opinion about gestational surrogacy (Fig. 1)
18.104.22.168. Independent variables 2.3.2. Evaluation of factors that affect the general attitude toward the
pros and cons of gestational surrogacy (Fig. 2)
2.4. Statistical analyses
3.1.1. Evaluation of factors that affect the person's ability to clearly
express an opinion regarding gestational surrogacy
22.214.171.124. The 1999 survey
126.96.36.199. The 2003 survey
3.1.2. Evaluation of factors that affect the general attitude the pros
and cons of gestational surrogacy 188.8.131.52. The 1999 survey
184.108.40.206. The 2003 survey
Appendix A. Appendix
Assisted reproductive technology (ART) has enabled both partners in a
relationship to have their own genetic children through a surrogate host.
Often referred to as ‘gestational surrogacy’ or ‘in vitro
fertilization (IVF) surrogacy’, this procedure allows women with functioning ovaries but suffering from uterine infertility or a severe
medical condition that is incompatible with pregnancy to have their own
genetic offspring. Although gestational surrogacy offers several
advantages, this procedure has given rise to some ethical issues,
including the separation of sex from procreation  and exploitative
commercial surrogacy . In 1998, 2001 and 2004, the International Federation of Fertility
Societies (IFFS) reported the actual circumstances regarding the
worldwide implementation of gestational surrogacy ,  and .
The latest report in 2004 showed that gestational surrogacy is
employed in approximately half of all surveyed countries and regions, and
that some jurisdictions often have special legal requirements .
In Japan, no legal system has been established for the regulation of ART
. The Japan Society of Obstetrics and Gynecology has set guidelines
regarding ART; these guidelines approve donor insemination but not
surrogacy . Under these circumstances, nationwide opinion surveys
on ART, including gestational surrogacy, were carried out in 1999 and
2003 by a research group of the Ministry of Health, Labor and Welfare
(formerly, the Ministry of Health and Welfare). A number of opinion
surveys have been conducted among people who have experienced gestational
surrogacy; however, only a few of these have included the general
public , ,  and . Therefore, these nationwide surveys on gestational surrogacy are globally rare, and results of these surveys
will contribute to further discussion of this issue in other countries.
In this study, we analyzed nationwide opinion surveys regarding
gestational surrogacy to identify factors that affect people's
attitude toward this procedure.
We analyzed the National Survey of People's and Medical Doctors’
Attitudes Toward ART Involving Donors and Surrogate Mothers, which was conducted by a research group of the Ministry of Health and Welfare in February 1999, and the National Survey of People's Attitudes Toward ART Involving Donors and Surrogate Mothers, which was conducted by a research group of the Ministry of Health, Labor and Welfare in January 2003. These opinion surveys were cross-sectional and independent of each other. The participants in these surveys represented the general population in Japan because they were selected using stratified two-step randomization. The questionnaire was circulated among the general public by the leaving method (distributed during the first visit and collected during a revisit or by mail, depending on the subjects’ preference) with the cooperation of health centres of the selected survey points. The questionnaire was completed anonymously.
In the 2003 study, in order to estimate the effect of knowledge about ART on people's attitude toward the procedure, we established the brochure group, which included members of the general public. Participants of this group received the questionnaire along with a brochure that contained information regarding ART.
These surveys were approved by the Ethical Review Board, Yamanashi University School of Medicine on the basis of the ‘Guidelines Concerning Epidemiological Research’ (Ministry of Education, Culture, Sports, Science, and Technology and Ministry of Health, Labor and Welfare). The participants of this study included 2568 people from the general public surveyed in 1999 and 3647 people from the general public surveyed in 2003 (1564 people from the questionnaire-alone group and 2083 people from the brochure group).
We used the data of the above surveys concerning the attitude toward
gestational surrogacy. The answers to the questions of these surveys
were analyzed (see Appendix A). The questions in the 2003 survey partially
differed from those in the previous survey because the Ministry of Health
and Welfare that implemented the surveys wanted to examine people's
attitude toward gestational surrogacy under limited conditions.
When discussing the general attitude toward gestational surrogacy,
the people's ability to express their opinion is considered to be an
important issue. To identify factors that affect this ability,
multivariate analysis using multiple logistic analysis was performed with
regard to the effects of the independent variables that are described in
Appendix A. This analysis was performed using the response ‘I can decide’ (answered as either ‘should be approved’ or ‘should not be approved’)
and ‘I cannot decide’ (answered as ‘I cannot decide’) as dependent
variables (Fig. 1).
Full-size image (55K)
Fig. 1. Evaluation of factors that affect the ability of a person to
clearly express an opinion regarding gestational surrogacy.
These variables were based on some national surveys in Japan (e.g.
Comprehensive Survey of Living Conditions of the People on Health and
Welfare). The details of these variables and questionnaires are described
in Appendix A.
Gender, age class.
Marital status, children, household income, occupation, educational
The answers to the eight questions common to both the 1999 and 2003 surveys
were analyzed. These questions determined whether respondents had
conservative or liberal attitudes toward gender roles, marriage and
divorce, family, children, and development of medical technology. Factor
analysis was performed first, and the eight questions were classified into
three factors—‘gender role’, ‘view regarding the concept of a
family’, and ‘development of medical technology’. Since there was only
one question with regard to the attitude toward gender role, the analysis
was performed using a scale of 1–4, where 1 indicated a conservative
attitude and 4 indicated a liberal attitude. Additionally, since there
was only one question with regard to the attitude toward development of
medical technology, the analysis was performed using a scale of 1–4,
where 1 indicated that the person was unhappy and 4 indicated that the
person was happy. Since there were six questions concerning the peoples’
views about the family, Crombach's α coefficient was calculated.
Internal coherence was acceptable with an α coefficient of 0.85 with all
six questions combined. These questions were answered on a scale of 1–4,
where 1 indicated a conservative attitude and 4 indicated a liberal
attitude. The scores of the six answers were totalled, and this total score
was analyzed using quantile regression techniques.
In the brochure group, the participants estimated their own level of understanding of the brochure's contents, based on the five options provided in the questionnaire. Because the median of their answers was the ‘60–80% of the contents’ category, those who stated that they understood 60% or more of the brochure contents were regarded as a high-understanding group, and those who stated that they understood less than 60% of the brochure contents were regarded as a poor-understanding group. Their answers to the questionnaire were analyzed along with those of the questionnaire-alone group.
Next, if people can express their opinions regarding gestational surrogacy, these opinions could be used to draft laws and prepare guidelines pertaining to gestational surrogacy. To identify factors that have major effects on the general attitude toward gestational surrogacy, multivariate analyses were performed using ‘should be
approved’ (answered as either ‘should be approved’ or ‘should be approved on conditions’ in the 1999 survey) and ‘should not be approved’ in the 1999 and 2003 surveys as dependent variables, and the same independent variables as in the evaluation of factors that affect the person's ability to express their opinion regarding gestational surrogacy (Fig. 2).
Full-size image (49K)
Fig. 2. Evaluation of factors that affect the general attitude towards
the pros and cons of gestational surrogacy.
Statistical analyses were performed using the statistical software SAS
p < 0.05 was regarded as significant in all (SAS Institute Inc.);
In the 1999 survey, the number of participants who received the
questionnaire was 3646, and the total number of responses was 2568
In the 2003 survey, the number of participants who received the
questionnaire was 5840 (2522 people in the questionnaire-alone group and
3318 people in the brochure group); the number of responses was 1564 (62.0%)
in the questionnaire-alone group and 2083 (62.8%) people in the brochure
In the 1999 survey, 52% of the respondents believed that gestational
surrogacy should be approved, and 18% stated that they could not make
a decision in this regard (Fig. 3). In the 2003 survey, less than 50% of
the respondents approved of gestational surrogacy, and approximately,
30% stated that they could not make a decision in this regard (Fig. 4).
In both surveys, 20–30% of the respondents disapproved of gestational surrogacy, with no notable difference between the two groups (Fig. 3
and Fig. 4).
Full-size image (14K) Fig. 3. Distribution of answers to the question, ‘in general, do you
think gestational surrogacy should be approved by society’? in the 1999 survey. The figure and analysis are restricted to the subset of 2095
subjects who had answered this question.
Full-size image (24K) Fig. 4. Distribution of answers to the question ‘in general, do you think
the use of gestational surrogacy by couples in whom the condition of
the wife's womb prevents pregnancy should be approved by society’? in
the 2003 survey. The figure and analysis are restricted to the subset of
3580 subjects who had answered this question.
The factors of gender, age class and educational background were analyzed
first. With regard to gender, females could not clearly express their
opinions when compared with males (adjusted odds ratio (OR) = 0.60; 95%
confidential interval (CI) = [0.47–0.77]). With regard to age class,