Background Surrogacy is either gestational (GS) using donor egg, or traditional (TS) using surrogate’s own egg. GS rates are rising, partly from unwarranted beliefs over less difficulty in giving the baby to intended parents. Objectives To investigate obstetric outcomes in GS vs TS and vs surrogate’s own spontaneous conceptions (SC), comparing genetically unrelated embryos versus genetically related embryos. Selection criteria Studies with historical or concurrent GS to TS or to SC comparisons, reporting any obstetric outcomes. Search strategy MEDLINE, Embase, Global Health and PsycINFO databases were searched to October 2024, specialist surrogacy researchers’ publications assessed. Data Collection and Analysis Citations, data extraction and quality assessment were conducted in duplicate. Results tabulated, and meta-analysis using relative risks (RR) conducted (Cochrane Revman software version 5.4.1). Main results From 937 records, eight studies were included, four each in singleton pregnancies comparing GS to TS and TS to SC. GS to TS studies were small with unreliable results on obstetric and mental health outcomes. GS to SC studies showed worse pre-eclampsia/gestational hypertension (RR=2.39 (95%CI=1.15-4.49)), gestational diabetes (RR=4.68 (95%CI=1.53-14.25)), and pre-term birth (RR=3.18 (95%CI=1.64-6.14)). Conclusions Insufficient research compares GS to TS and to SC, but the evidence available suggests higher rates of adverse obstetric and birth outcomes in GS pregnancies. Underlying causes are likely genetic. All parties considering GS should be informed of higher maternal and neonatal complication rates. Further research should be conducted, reporting for singleton and twin pregnancies.