Rajiv Gandhi University of Health Sciences s58

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

SUBMITTED BY:

MRS. BEENA ALFONSA, 1st yr. M. Sc. (Nursing) OBSTETRICS AND GYNAECOLOGICAL NURSING, 2012-2013BATCH, ORIENTAL COLLEGE OF NURSING. RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE.

1 PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. NAME OF THE CANDIDATE AND MRS.BEENA ALFONSA ADDRESS IST YEAR MSC NURSING ORIENTAL COLLAGE OF NURSING. NO.43/52,2ND MAIN INDUSTRIAL TOWN, WEST OF CHORD ROAD, BANGALORE-560010. 2. NAME OF THE INSTITUTION Oriental College of Nursing, Bangalore. 3. COURSE OF THE STUDY AND SUBJECT IST year M.Sc.Nursing. Obstetrics and gynecological Nursing. 4. DATE OF ADMISSION OF COURSE 5. TITLE OF THE TOPIC “A Study to Assess The Knowledge And Attitude Towards Surrogacy Among the Surrogate Mothers of Selected Institutions in Bangalore With A View To Develop An Information Booklet”

6. BRIEF RESUME OF THE INTENDED WORK 6.0 Introduction Enclosed 6.1 Need for the study Enclosed 6.1.1 Statement of the problem Enclosed 6.2 Review of related literature Enclosed 6.3 Objectives of the study Enclosed 6.3.1 Operational definitions Enclosed 6.3.2 Assumptions Enclosed 6.3.3 Hypothesis Enclosed 6.3.4 Sampling Criteria Enclosed (Inclusion and Exclusion criteria) 6.3.5 Delimitations Enclosed 7. MATERIALS AND METHODS 7.1. Sources of data: The data will be collected from the surrogate mothers from the selected institutions at Bangalore. 7.2. Method of data collection: Descriptive survey approach. 7.3 Does the study require any investigation or intervention to be conducted on the patients or human beings or animals? – No- 7.4. Has ethical clearance being obtained from your institution? – Yes-

8 LIST OF REFERENCES Enclosed

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

2 KARNATAKA, BANGALORE.

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. NAME OF THE CANDIDATE AND MRS. BEENA ALFONSA

ADDRESS IST YEAR MSC NURSING

ORIENTAL COLLEGE OF NURSING.

NO.43/52,2ND MAIN INDUSTRIAL TOWN,

WEST OF CHORD ROAD, BANGALORE-

560010. 2. NAME OF THE INSTITUTION Oriental College of Nursing, Bangalore. 3. COURSE OF THE STUDY AND Ist year M.Sc.Nursing

SUBJECT OBSTETRICS AND GYNAECOLOGICAL

NURSING 4. DATE OF ADMISSION OF COURSE 28-06-2012 5. TITLE OF THE TOPIC “ A Study to Assess The Knowledge And

Attitude Towards Surrogacy Among the

Surrogate Mothers of Selected Institutions in

Bangalore With A View To Develop An

Information Booklet”

6. BRIEF RESUME ON INTENDED WORK

6.0 INTRODUCTION

3 “Surrogacy is the practice of a woman carrying the biological child of another person or couple with whom the baby will be placed for adoption after the birth”.

“A surrogate mother is a woman who carries a child for someone else, usually an infertile couple. There are two different types of surrogacy. They are traditional surrogacy and gestational surrogacy. Explanations for both types can be found below”. Jenn Z

To be the part of creation- the most beautiful and cherishing experience that a person ever has. Nature has bestowed this productive capacity only in the lives of the women and every woman cherishes this experience of motherhood. To become a mother is like a flowering process which is considered as the moments of the fulfilment of life. Though it is counted as the most dignified moments and experience in life, many women remain in the great depression and sorrow for not being able to be a mother. Unfortunately, due to the physiological defects many women remain helpless to give birth to their own off-spring. In order to survive this tragic situation, they may opt for the available solutions. The desire for motherhood leads them to search for the possible alternative solutions and surrogacy itself presents as the most viable and reliable alternative.1

Surrogate mother is defined by the Collins English dictionary as, “a woman who bears a child on behalf of a couple unable to have a child, either by artificial insemination from the man or implantation of an embryo from the woman”. The Oxford dictionary defines surrogate mother as, “a woman who bears a child on behalf of another woman, either from her own egg fertilized by the other woman's partner or from the implantation in her womb of a fertilized egg from the other woman.” 2 The ART Regulation Bill, 2010 defines the surrogate mother as, “a woman who is a citizen of India and is resident in India, who agrees to have an embryo generated from the sperm of a man who is not her husband and the oocyte of another woman, implanted in her to carry the pregnancy to viability and deliver the child to the couple/individual that had asked for surrogacy” .3

4 Surrogacy is a method of reproduction whereby a woman agrees to become pregnant and deliver a child for a contracted party. The word surrogate means “substitute”. Surrogacy arrangements do not only take place within the family, but also within the community, the state, the country and presently even the world. Advances in assisted reproductive techniques such as donor insemination and, embryo transfer methods, have revolutionized the reproductive environment, resulting in surrogacy, as the most desirable option. The system of surrogacy has given hope to many infertile couples, who long to have a child of their own. Taking advantage of the advanced medical facilities, they seek alternative solutions like Artificial Reproductive Technology (ART), In-Vitro Fertilization (IVF) and, Intra-Uterine Injections (IUI), in the hope of having a child of their own.4

Currently, two types of surrogacy can be observed; “traditional” and “gestational”. “Traditional surrogacy is done via artificial insemination, with the surrogate using her own egg and another man's sperm. Gestational surrogacy is done via In Vitro Fertilization (IVF), where fertilized eggs from another woman are implanted into the surrogate's uterus. Choosing which route to take is one of the most important and earliest decisions a surrogate and the intended parents will have to make”.5

Mainly these kinds of situations are occurring due to the lack of proper understanding about the duties and responsibilities of a surrogate mother. In this context it is necessary to calculate the understanding level of the people about the laws, pre-requisites etc of a surrogate mother. Therefore here I’m trying to throw light upon the knowledge about the antenatal care and attitude towards surrogacy among the surrogate mothers, mainly in Bangalore.6

6.1 NEED FOR THE STUDY

To be a mother is the dream and an ambition of every married woman. Infertility is the situation in which the married couples are stucked with and in many cases leading towards the problems like separation of spouses. What are the obstacles and difficulties that are emerging out of infertility; how can it be overcome? These 5 kinds of substantial questions were always within me. Also I had an experience which also happened to lead me to take this topic as the focal point of my assignment. One of my cousins had no children even after 11 years of their marriage. They were consulting different types of doctors, taking varieties of medicines, going for the counselling to come out of their familial problems and even going behind so much of treatment with the hope that they fill find the positive result; spent a large amount of money, praying and awaiting for a child. Being kept in the mind this bitter experience, I had decided to step towards this major problem which the married couples are facing, find out its multifarious aspects and help the people in the possible ways.7

Many health issues arise for the surrogate mother. A major issue is how much control a physician can exercise over a surrogate mother. For example, is she obligated to change her current living style? How often does she need to have vaginal ultra-sounds or amniocentesis? An important question to consider is if and when she should be allowed to terminate a pregnancy. In general, this decision would be free of the complicating factors of STDs, as physician will ensure that the pre-embryo is free of viruses such as human immune-deficiency virus (HIV), cytomegalovirus (CMV), and hepatitis B&C viruses (HBC and HCV). These viruses could compromise the health of the surrogate mother and that of the newborn.8

Among the different ways available, the best alternative is the surrogacy; irrespective of whether it is traditional-where the genetic mother is involved or gestational- where there is no involvement of a genetic mother. The surrogacy had been taken place between the friends and relatives earlier with the pure genetic purpose- being relieved from the pain of infertility. It was considered with a noble intension. But a shift in attitude has been taken place in the understanding of being a surrogate mother. A kind of commercialization had been occurred and it is the result of the growing economic stigma in the lives of the poor and the middle class people. The women who engage in the surrogacy are poor, normally. They accept to conceive on the basis and only for the money. A vast majority of the surrogates consider it as the easiest way to get a good amount of money. 9

It is also equally important to have a proper antenatal care during the pregnancy. But in many cases the illiterate surrogates are not aware about the different steps of antenatal care which may result in the deficiencies of the child. If

6 money is the only motivating force behind the surrogacy, then that also will be leading to several severe other problems. A proper antenatal care is possible only with a proper attitude. The commercialization will be deteriorating the attitude of the surrogate mothers. All these can lead to a different culture. In this scenario I think it is important and necessary to make study to assess the knowledge regarding the antenatal care and the attitude towards the surrogacy among the surrogate mothers.10

A study related to infertility reveals that infertility is perceived as a problem across virtually all cultures and societies and affects an estimated 10%-15% of couples of reproductive age. In recent years, the number of couples seeking treatment for infertility has dramatically increased due to factors such as postponement of childbearing in women, development of newer and more successful techniques for infertility treatment, and increasing awareness of available services. This increasing participation in fertility treatment has raised awareness and inspired investigation into the psychological ramifications of infertility. Consideration has been given to the association between psychiatric illness and infertility. Researchers have also looked into the psychological impact of infertility per se and of the prolonged exposure to intrusive infertility treatments on mood and well being. There is less information about effective psychiatric treatments for this population; however, there is some data to support the use of psychotherapeutic interventions.11

Infertility is defined as 12 months of appropriately timed intercourse that does not result in conception. Approximately 16% of couples in the United States will have difficulty having a child. This appears in part because of the trend for some women to delay childbirth until the mid- to late 30s and the associated decrease in fertility after the age of 35. Although there is the perception that infertility is on the rise, it is actually an artefact of the large number of women currently in the childbearing years because of the baby boom of the 1950s and early 1960s. The base rate of infertility among women has remained the same but the absolute number of women in the reproductive years has increased. Approximately 40% of infertile couples have female factor infertility, 40% male factor, and 20% a combination of both or infertility of unknown etiology.12

7 Before the advances in reproductive technology clinicians believed that infertility, particularly of unknown etiology, was caused by psychological distress. Investigators tried to identify unconscious or other psychological variables that caused infertility. In the mid-1980s clinicians and researchers began questioning the hypothesis that psychological distress caused infertility. Instead, they found that psychological distress was a consequence of infertility. With this understanding, mental health professionals have become increasingly involved in the provision of care to infertile patients. .13

A study on the infertility treatment gives amble light to solve the problem of infertility. The importance of infertility treatment in the larger field of obstetrics and gynaecology is related to the almost universal desire for a child among women. The desire for a child has had different meanings throughout the history of humankind. Before the Industrial Revolution, children were valued for their economic usefulness. After child labour laws were enacted and children were displaced from the workforce, they came to be valued for relational reasons, such as companionship and familial continuity. As Griel suggested, children became economically worthless but emotionally priceless. The shift in the value of children persists today as children are viewed as a source of fulfilment and happiness. Therefore, children have become something that couples work hard to obtain and feel they have a right to. From this vantage point, the seeking of infertility treatment for years and undergoing expensive, psychologically draining treatments can be understood as a result of the 21st century view of the value of the child.14

While many couples presenting for infertility treatment have high levels of psychological distress associated with infertility, the process of assisted reproduction itself is also associated with increased levels of anxiety, depression and stress . A growing number of research studies have examined the impact of infertility treatment at different stages, with most focusing on the impact of failed IVF trials. Hynes and colleagues assessed women at presentation for IVF and then following failure of IVF. They found that women presenting for IVF were more depressed, had lower self- esteem and were less confident than a control group of fertile women and, after a failed IVF cycle, experienced a further lowering of self-esteem and an increase in depression relative to pre-treatment levels (Hynes 1992). 15

8 The outcome of infertility treatment may also be influenced by psychological factors. A number of studies have examined stress and mood state as predictors of outcome in assisted reproduction. The majority of these studies support the theory that distress is associated with lower pregnancy rates among women pursuing infertility treatment (Boivin 1995, Thiering 1993, Demytenaere 1998, Smeenk 2001, Sanders 1999). The infertility treatment can be included certain psychological therapies like, counselling, psychotherapy, relaxation technique, medications etc.16

The study about the antenatal care can be summarized as follows:

 To ensure that the pregnant woman and her fetus are in the best possible health.

 To detect early and treat properly complications

 Offering education for parenthood

 To prepare the woman for labor, lactation and care of her infant

ANC also provides women and their families with appropriate information and advice for a healthy pregnancy, safe childbirth, and postnatal recovery, including care of the newborn, promotion of early, exclusive breastfeeding, and assistance with deciding on future pregnancies in order to improve pregnancy outcomes. An effective ANC package depends on competent health care providers in a functioning health system with referral services and adequate supplies and laboratory support.

ANC improves the survival and health of babies directly by reducing stillbirths and neonatal deaths and indirectly by providing an entry point for health contacts with the woman at a key point in the continuum of care. 17 ANC indirectly saves the lives of mothers and babies by promoting and establishing good health before childbirth and the early postnatal period – the time periods of highest risk. ANC often presents the first contact opportunity for a woman to connect with health services, thus offering an entry point for integrated care, promoting healthy home practices, influencing care seeking behaviours, and linking women with pregnancy complications to a referral system. Women are more likely to give birth with a skilled attendant if they have had at least one ANC visit.18

9 The study on the statistics explains the following data. Some agencies are reporting that the statistics on children born through Surrogacy is reaching 35,000 in total as of 2011. This is largely due to increased societal acceptance.

Surrogacy is the practice of a woman carrying the biological child of another person or couple with whom the baby will be placed for adoption after the birth. In traditional cases, the child will be related to the surrogate. In gestational surrogacy, the woman is carrying the couple's fertilized egg, or embryo. Just over 5,000 children were thought to be born and adopted through surrogacy between 2004 and 2008.19

Based on a report from the Council for Responsible Genetics, as of 2008, there are no surrogacy statistics that are available to the public. Yet, while it is known that the use of a surrogate has become quite popular over the years, it is not known exactly how many children have been carried in such a manner. However, between the years 2004 and 2008, it is approximated that the number of children is over 5,000. Another estimate is that there is an average of nine children that are born to surrogates in each state every year.20

It is also known that there have been differing rates of success for the various types of surrogacy procedures. For instance, when using in vitro fertilization with mothers who are under the age of 35, success can be as high as 60 percent or more. The success rate tends to decrease, though, as the surrogate and/or the biological mother.increase .21

The study on the advantages of surrogacy can be summarized as follows: This may be the only way to achieve parenthood for couples or persons suffering from infertility or other medical conditions that render them incapable of having a child on their own. For gay men and single men who aspire to be fathers (without getting involved in a relationship with a woman), surrogacy is the only way to have genetically-linked children. Children born through surrogacy may be completely connected to the intending parents (gestational surrogacy with own eggs) or only partly (gestational surrogacy with egg donor or traditional surrogacy).22

The act of becoming a mother (surrogate mother), is not only a self-sacrificing but truly a brave decision. The act of giving life, a reason to live, making dreams

10 possible for childless couples, is more than a benefit for you. Only the mothers understand the feeling of what it takes to carry a baby for nine months. At the end of nine months, you feel, its “YOU”, who can gave happiness & smiles to the other couple. 23

Surrogacy offer hope for various infertile couples and gives a chance for enjoying cherishing feeling of parenthood to several couples who are unable to conceive naturally and seeks another woman who carries pregnancy to its full term.

On the other hand, it gives financial security to those women who are coming forward to become a surrogate mother. Comparing with the foreign countries, though India is having very limited expenses within the existing legal framework, it is an income generating source to those poor and illiterate women.24

6.2 REVIEW OF LITERATURE

A literature review discusses published information in a particular subject area, and sometimes information in a particular subject area within a certain time period. Literature reviews provide you with a handy guide to a particular topic. Literature reviews can give you an overview or act as a stepping stone. Literature is a broad, comprehensive in depth, systematic and critical review of scholarly publications, unpublished scholarly print material, audio-visual materials and personal communications. The major goal of literature review is to develop a strong knowledge base to carry out research. Thus, literature review in many ways, starting from the selection and formulation of problems, providing conceptual framework for the study, assess feasibility, providing methodology, for comparison and replication, avoiding obstacles and making generalization.25

Review of literature was collected on the following aspects:

1. Review related to knowledge of surrogate mothers towards surrogacy

2. Review related to attitude of surrogate mothers towards surrogacy

3. Review related to antenatal care among the surrogate mothers

Review related to knowledge of surrogate mothers towards surrogacy

11 Surrogacy is the process to become a delegated mother for someone else. To become a surrogate mother is not simply a biological process but something superior which demands a high personal commitment. It’s something above a commercial contract. Due to the increasing stressful lifestyle, number of people is coming under the psychological tensions which can lead to the infertility. The surrogacy is said to be the best alternative to those infertile couples. India is considered to be the best hub of surrogacy due to the many reasons.26

Commercial surrogacy is legal in India, as recognized by the Supreme Court of India in 2002. India has emerged as a leader in international surrogacy and a destination in surrogacy-related fertility tourism. Indian surrogates have been increasingly popular with fertile couples and singles from Canada, USA, Australia, Ireland, France and UK.27

To address issues and to regulate surrogacy arrangements, the Government of India has taken certain steps including the introduction and implementation of National Guidelines for Accreditation, Supervision, and Regulation of Assisted Reproductive Technology (ART) Clinics in 2006, and guidelines have been issued by the Indian Council of Medical Research (ICMR) under the Ministry of Health and Family Welfare, Government of India.28

However, till now there is no legal provision dealing directly with surrogacy laws to protect the rights and interests of the surrogate mother, the child, or the commissioning parents. The Union health ministry of India has finalized the Assisted Reproductive Technologies (ART) Regulation Bill 2010. Here’s a quick look at some of the revolutionary stipulations

 If a surrogate mother is married, the consent of her spouse is mandatory.  No ART bank or clinic can send an Indian citizen for surrogacy abroad.  The donor’s identity cannot be revealed and both parties will have to sign legally-binding surrogacy agreements.  It allows surrogacy for individuals as well as couples. A couple is defined under the Indian law as two people living together and having a sexual relationship that is legal in the country.29

12 Even though it may take some time before the surrogacy laws are actually put into practice, surrogacy clinics in India continue to attract thousands of visitors to the country every year who visit the country in the hope of achieving parenthood. If you too are keen to start your India surrogacy journey, please fill out the quote request form on the right (www.surrogacyclinics.com/india-surrogacy-journey/30

Review related to attitude of surrogate mothers towards surrogacy

In the modern time one can observe the inculcation of commercialization in the field of surrogacy. Due to this increasing commercialization, there has been a shift in the attitude towards the surrogacy even in the surrogate mothers.

Commercial surrogacy is a form of surrogacy in which a gestational carrier is paid to carry a child in her womb and is usually resorted to by higher income infertile couples who can afford the cost involved or people who save and borrow in order to complete their dream of being parents. This procedure is done in a large scale in several countries including India due to the high international demand and ready availability of poor surrogates it is reaching industry proportions.

Commercial surrogacy is sometimes referred to by the emotionally charged and potentially offensive terms “wombs for rent”, “outsourced pregnancies”, or “baby farms”. India is foremost in surrogacy because of the low cost treatment and ready availability of women opting to be surrogate for childless foreigners. By some estimates surrogacy in India is already $ 445 million business. In India surrogacy costs about $ 12,000 compared to US where it is $ 70,000. Moreover laws in US and UK do not allow the surrogate women to charge the childless couple; whereas in India there are no laws preventing surrogate women in accepting compensation for renting her womb.

All these show the attitude of the surrogate mothers towards the surrogacy. And it is also to be accepted that this change in attitude is mainly because of the poor economic situation and the increasing demand of life.

Review related to antenatal care among the surrogate mothers

Antenatal care can be said as comprehensive health supervision of a pregnant woman before delivery or it is a planned examination, observation and guidance given

13 to the pregnant woman from conception till the time of labour. Antenatal care during the pregnancy is an important step because the health of both mother and inside baby is mutually related. The health of the mother decides the health of the child. The goals of the antenatal care are said to be to reduce maternal and perinatal mortality and morbidity rates and to improve the physical and mental health of women and children.31

Antenatal care increases awareness of maternal and newborn health needs and self care during pregnancy and the postnatal period, including the need for social support during and after pregnancy. It also promotes healthy behaviors in the home, including healthy lifestyles and diet, safety and injury prevention, and support and care in the home, such as advice and adherence support for preventive interventions like iron supplementation, condom use, and use of ITN Support care seeking behavior, including recognition of danger signs for the woman and the newborn as well as transport and funding plans in case of emergencies. Antenatal care helps the pregnant woman and her partner prepare emotionally and physically for birth and care of their baby, particularly preparing for early and exclusive breastfeeding and essential newborn care and considering the role of a supportive companion at birth.32

For antenatal care to work properly, you will be required to give in your family history, your own medical history and that of your partner and also all record of previous pregnancies, complications during pregnancy and also any cases of abortion or miscarriage. Be open with your doctor and make your list exhaustive. Include even the minute details so that your doctor understands your case thoroughly. Provide all the necessary details regarding your partner and his medical history. You can also discuss any issues that you have regarding labour and delivery so as to avoid any stress and depression. Stress can lead to preterm labour and delivery.

Antenatal care is so essential for a pregnant woman for getting a healthy child. It is having a special place in surrogacy. Since the surrogate mother conceives for a commissioning parent, there can be some laxities in the antenatal care which can lead to birth-defected problems in the child. In many cases these carelessness is occurred due to the ignorance of the surrogate mother as they are very poor and illiterate. So, it

14 is essential to increase the understanding level of the surrogate mothers regarding the antenatal care.33

6.2.1 STATEMENT OF THE PROBLEM

“A study to assess the knowledge and attitude towards surrogacy among the surrogate mothers of selected institutions in Bangalore with a view to develop an information booklet”.

6.3 OBJECTIVES OF THE STUDY

The following are the objectives: 1. To assess the level of knowledge regarding antenatal care among the surrogate mothers. 2. To assess the attitude towards the surrogacy among the surrogate mothers. 3. To the association between the level of knowledge and selected demographic variables. 4. To find out the knowledge and attitude regarding the antenatal care among the surrogate mothers. 5. To develop an information booklet regarding antenatal care among the surrogate mothers.

6.3.1 OPERATIONAL DEFINITIONS

Knowledge: It is the awareness of surrogate mothers regarding surrogacy as measured by their response to the structured knowledge questionnaire.

Attitude: It is the opinion of surrogate mothers towards surrogacy as measured by attitude scale.

15 Surrogacy: Surrogacy is an arrangement in which a woman agrees to a pregnancy, achieved through assisted reproductive technology, in which neither of the gametes belong to her or her husband, with the intention of carrying it to term and handing over the child to the person or persons for whom she is acting as surrogate.

Infertility: Female Infertility may be defined as the inability to conceive a child on the part of the woman even after a year’s time period, of having sex without any contraceptives. Interestingly, medical definition of infertility also encapsulates the inability to carry through a pregnancy to its natural conclusion resulting in miscarriages.

Information booklet: Educational materials which contains all information regarding surrogacy,antenatal,intranatal,and postnatal care.

6.3.2 ASSUMPTION

1. Surrogate mothers may have some knowledge regarding surrogacy and antenatal care.

2. Surrogate mothers may have varying knowledge towards surrogacy and antenatal care

6.3.3 HYPOTHESIS

H1: there is significant relationship between knowledge and attitude of surrogate mothers towards surrogacy.

H2: There is a significant association between level of knowledge and collected socio- demographic variables.

H3: There is a significant association between attitude and selected socio- demographic variables.

6.3.4 SAMPLING CRITERIA

INCLUSION CRITERIA

16 Surrogate mothers who are,

i. Willing to participate ii. Read and understand Kannada and English

EXCLUSION CRITERIA

Surrogate mothers who are health professionals.

6.3.5 DELIMITATIONS

Studies delimited to

 Four weeks of data collection period  Studies are conducted only with female patients who are above 35 years in selected hospitals  Data based on written responses of 100 surrogated mothers

7. MATERIALS & METHODS

7.1 SOURCE OF DATA:-

The data will be collected from the surrogate mothers from the selected institutions at Bangalore.

7.2 METHODS OF DATA COLLECTION:-

(A). Research Approach - Descriptive survey approach.

(B).Research Design -Non-experimental descriptive design

(C). Setting -Selected institutions at Bangalore.

(D). Population -Selected institutions at Bangalore.

(E).Sample -Surrogate mothers who meet inclusion criteria

(F).Sample size -100 surrogate mothers

17 (G). Sampling technique -Purposive sampling technique

(H). Method of Data collection -Self administered structures knowledge questionnaire and attitude rating scale

(I). Tool of Data collection:

 Structured knowledge questionnaire to assess the knowledge on surrogacy

 Attitude rating scale to assess the attitude towards surrogacy

(J). Method of analysis -The researcher will use appropriate statistical techniques for data analysis and present in the form of tables and diagrams.

Data will be analysed using g descriptive and inferential statistics

Descriptive statistics: Frequency and percentage distribution to describe the socio- demographic variables

Inferential statistics: Mean, mean percentage and standard deviation to assess the level of knowledge and quality of attitude – co-relation, co-efficient to find the relationship between the knowledge and attitude – chi-squire test to find association between findings and the selected demographic variables.

(K). Duration of study - 4 weeks.

(L). Research Variables -knowledge regarding surrogacy

Attitude towards surrogacy

(i). Demographic Variables - Age, place of residence, dietary pattern, infertility, infertility treatment, education status, occupation, income, area of residence, previous source of information.

(M). Projected outcome -The study will be successful in improving the knowledge and attitude of the surrogate mothers regarding surrogacy. 18 7.3 Does the study require any investigation or intervention to be conducted on the patients or human beings or animals?

No investigation or invention will be done on human beings or animals.

7.4 Has ethical clearance being obtained from your institution?

Yes, ethical clearance has been enclosed

8. LIST OF REFERENCES

1. Surrogacy in India(www.surrogacy clinics.com/India surrogacy journey.

2. Surrogate mother | Define Surrogate mother at Dictionary.com http://dictionary.reference.com/browse/surrogate+mothe

3. Art regulation bill 2010http://www.scribd.com/doc/33533932/Art-Regulation- Draft-Bill1-India?

19 4. http://dictionary.reverso.net/english-definition/surrogate%20family

5. http://childbirthsolutions.com/articles/traditional-versus-gestational-surrogacy/

6. http://ivftreatmentindia.wordpress.com/

7. http://www.mentalhelp.net/poc/view_doc.php?id=3732&type=book&cn=5

8. http://www.unicef.org/about/history/files/Child-First-CH-03-p063-090-unravel- nutrition-com...

9. http://www.reproductive-heal

10. http://www.unicef.org/about/history/files/Child-First-CH-03-p063-090-unravel- nutrition-com...

11. http://www.bjmp.org/content/psychological-aspects-infertility th- journal.com/content/5/1/9

12. FEMALE INFERTILITY: Implications and Treatments - Surrogacy India http://www.kiranivfgenetic.com/article-15.html

13. http://www.glowm.com/?p=glowm.cml/section_view&articleid=412

14. http://www.glowm.com/?p=glowm.cml/section_view&articleid=412

15. http://www.bjmp.org/content/psychological-aspects-infertility

16. http://www.womensmentalhealth.org/resource/patient-support- services/infertility-assisted-r...

17. Antenatal Care - World Health Organization http://www.who.int/pmnch/media/publications/aonsectionIII_2.pdf

18. http://www.who.int/pmnch/media/publications/aonsectionIII_2.pdf

20 19. FertilityAuthority http://www.fertilityauthority.com/treatment/surrogacy

20. Statistics on Surrogacy | Modern Family Surrogacy http://www.modernfamilysurrogacy.com/page/surrogacy_statistics

21. http://www.modernfamilysurrogacy.com/page/surrogacy_statistics

22. http://www.euro.who.int/document/e79235.pdf

23. http://www.womenleadership.in/csr/surrogacyreport/pdf

24. http://www.iwannaget pregnant.com/surrogacy.asp

25.http://www. surrogacy clinics.com/ India-surrogacy-journey

26. http://www.encyclopedia.com/topic/Motherhood.aspx

9. SIGNATURE OF THE CANDIDATE :

10. REMARKS OF THE GUIDE :

11. NAME & DESIGNATION IN

21 BLOCK LETTERS :

11.1 GUIDE :

11.2 SIGNATURE :

11.3 HEAD OF THE DEPARTMENT :

11.4 SIGNATURE :

12.1 REMARKS OF CHAIRMAN /

PRINCIPAL :

12.2 SIGNATURE :