Childbirth at the Global Crossroads

The auto-rickshaw driver honks his way through the dusty chaos of Anand, Gujarat, India, swerving around motorbikes, grunting trucks, and ancient large-wheeled bullock-carts packed with bags of fodder. Both sides of the street are lined with plastic trash and small piles of garbage on which untethered cows feed. The driver turns off the pavement onto a narrow, pitted dirt road, slows to circumvent a pair of black and white spotted goats, and stops outside a dusty courtyard. To one side stands a modest white building with a sign that reads, in English and Gujarati, "Akanksha Clinic."

Two dozen dainty Indian women's sandals, toes pointed forward, are lined along the front porch. For it is with bare feet that one enters a clinic housing what may be the world's largest group of gestational surrogates -- women who rent their wombs to incubate the fertilized eggs from clients from around the globe. Since India declared commercial surrogacy legal in 2002, some 350 assisted reproductive technology (ART) clinics have opened their doors. Surrogacy is now a burgeoning part of India's medical tourism industry, which is slated to add $2 billion to the nation's gross domestic product by 2012. Advertisements describe India as a "global doctor" offering First World skill at Third World prices, short waits, privacy, and -- important in the case of surrogacy -- absence of red tape. To encourage this lucrative trend, the Indian government gives tax breaks to private hospitals treating overseas patients and lowers import duties on medical supplies.

In his 2007 book, Supercapitalism, Robert B. Reich argues that while industrial and clerical jobs could be outsourced to cheaper labor pools abroad, service jobs would stay in America. But Reich didn't count on First World clients flying to the global South to find low-cost retirement care or reproductive services. The Akanksha clinic is just one point on an ever-widening two-lane global highway that connects poor nations in the Southern Hemisphere to rich nations in the Northern Hemisphere, and poorer countries of Eastern Europe to richer ones in the West. A Filipina nanny heads north to care for an American child. A Sri Lankan maid cleans a house in Singapore. A Ukrainian nurse's aide carries lunch trays in a Swedish hospital. Marx's iconic male, stationary industrial worker has been replaced by a new icon: the female, mobile service worker.

We have grown used to the idea of a migrant worker caring for our children and even to the idea of hopping an overseas flight for surgery. As global service work grows increasingly personal, surrogacy is the latest expression of this trend. Nowadays, a wealthy person can purchase it all -- the egg, the sperm, and time in the womb. "A childless couple gains a child. A poor woman earns money. What could be the problem?" asks Dr. Nayna Patel, Akanksha's founder and director.

But despite Patel's view of commercial surrogacy as a straightforward equation, it's far more complicated for both the surrogates and the genetic parents. Like nannies or nurses, surrogates perform "emotional labor" to suppress feelings that could interfere with doing their job. Parents must decide how close they are willing (or able) to get to the woman who will give birth to their child.

As science and global capitalism gallop forward, they kick up difficult questions about emotional attachment. What, if anything, is too sacred to sell?

***

I follow a kindly embryologist, Harsha Bhadarka, to an upstairs office of the clinic to talk with two surrogates whom I will call Geeta and Saroj. (Aditya Ghosh, a journalist with the Hindustan Times, has kindly offered to join me.) The room is small, and the two surrogate mothers enter the room nodding shyly. Both live on the second floor of the clinic, but most of its 24 residents live in one of two hostels for the duration of their pregnancy. The women are brought nutritious food on tin trays, injected with iron (a common deficiency), and supervised away from prying in-laws, curious older children, and lonely husbands with whom they are allowed no visits home or sex.

Geeta, a 22-year-old, light-skinned, green-eyed beauty, is the mother of three daughters, one of whom is sitting quietly and wide-eyed on her lap. To be accepted as a surrogate, Akanksha requires a woman to be a healthy, married mother. As one doctor explains, "If she has children of her own, she'll be less tempted to attach herself to the baby."

"How did you decide to become a surrogate?" I ask.

"It was my husband's idea," Geeta replies. "He makes pav bhaji [a vegetable dish] during the day and serves food in the evening [at a street-side fast-food shop]. He heard about surrogacy from a customer at his shop, a Muslim like us. The man told my husband, 'It's a good thing to do,' and then I came to madam [Dr. Patel] and offered to try. We can't live on my husband's earnings, and we had no hope of educating our daughters."

Geeta says she has only briefly met the parents whose genes her baby carries. "They're from far away. I don't know where," she says. "They're Caucasian, so the baby will come out white." The money she has been promised, including a monthly stipend to cover vitamins and medications, is wired to a bank account that Patel has opened in Geeta's name. "I keep myself from getting too attached," she says. "Whenever I start to think about the baby inside me, I turn my attention to my own daughter. Here she is." She bounces the child on her lap. "That way, I manage."

Seated next to Geeta is Saroj, a heavy-set, dark woman with intense, curious eyes, and, after a while, an easy smile. Like other Hindu surrogates at Akanksha, she wears sindoor (a red powder applied to the part in her hair) and mangalsutra (a necklace with a gold pendant), both symbols of marriage. She is, she tells us, the mother of three children and the wife of a vegetable street vendor. She gave birth to a surrogate child a year and three months ago and is waiting to see if a second implantation has taken. The genetic parents are from Bangalore, India. (It is estimated that half the clients seeking surrogacy from Indian ART clinics are Indian and the other half, foreign. Of the foreign clients, roughly half are American.) Saroj, too, knows almost nothing about her clients. "They came, saw me, and left," she says.

Given her husband's wages, 1,260 rupees (or $25) a month, Saroj turned to surrogacy so she could move to a rain-proof house and feed her family well. Yet she faced the dilemma of all rural surrogates: being suspected of adultery -- a cause for shunning or worse. I ask the women whether the money they earn has improved their social standing. For the first time the two women laugh out loud and talk to each other excitedly. "My father-in-law is dead, and my mother-in-law lives separately from us, and at first I hid it from her," Saroj says. "But when she found out, she said she felt blessed to have a daughter-in-law like me because I've given more money to the family than her son could. But some friends ask me why I am putting myself through all this. I tell them, 'It's my own choice.'"

Since Dr. Patel began offering surrogacy services in 2004, 232 surrogates have given birth at Akanksha. A 2007 study of 42 Akanksha surrogates found that nearly half described themselves as housewives and the rest were a mix of domestic, service, and manual laborers. Hindu, Muslim, and Christian, most had seventh- to 12th-grade educations, six were illiterate, and one -- who turned to surrogacy to pay for a small son's heart surgery -- had a bachelor's degree. Each surrogate negotiates a different sum: One surrogate carrying twins for an Indian couple discovered she was being paid less (about $3,600) than a surrogate in the next bed who was carrying one baby for an American couple for about $5,600.

Observers fear that a lack of regulation could spark a price war for surrogacy -- Thailand underselling India, Cambodia underselling Thailand, and so on -- with countries slowly undercutting fees and legal protections for surrogates along the way. It could happen. Right now international surrogacy is a highly complex legal patchwork. Surrogacy is banned in China and much of Europe. It is legal but regulated in New Zealand and Great Britain. Only 17 of the United States have laws on the books; it is legal in Florida and banned in New York.

In India, commercial surrogacy is legal but unregulated, although a 135-page regulatory law, long in the works, will be sent to Parliament later this year. Even if the law is passed, however, some argue it would do little to improve life for women such as Geeta and Saroj. For example, it specifies that the doctor, not the surrogate, has the right to decide on any "fetal reduction" (an abortion). Moreover, most Indian federal laws are considered "advisory" to powerful state governments, and courts -- where a failure to enforce such laws might be challenged -- are backlogged for years, often decades. Dr. B.N. Chakravarty, the Calcutta-based chair of the surrogacy law drafting committee, says that the growth of the industry is "inevitable," but it needs regulating. Even if the law were written to protect surrogates and then actually enforced, it would do nothing to address the crushing poverty that often presses Indian women to "choose" surrogacy in the first place.

For N.B. Sarojini, director of the Delhi-based Sama Resource Group for Women and Health, a nonprofit feminist research institute, the problem is one of distorted priorities. "The ART clinics are posing themselves as the answer to an illusory 'crisis' of infertility," she says. "Two decades back, a couple might consider themselves 'infertile' after trying for five years to conceive. Then it moved to four years. Now couples rush to ARTs after one or two. Why not put the cultural spotlight on alternatives? Why not urge childless women to adopt orphans? And what, after all, is wrong with remaining childless?"

But Dr. Patel, a striking woman in an emerald green sari and with black hair flowing down her back, sees for-profit surrogacy as a "win-win" for the clinic, the surrogate, and the genetic parents. She also sees no problem with running the clinic like a business, seeking to increase inventory, safeguard quality, and improve efficiency. That means producing more babies, monitoring surrogates' diet and sexual contact, and assuring a smooth, emotion-free exchange of baby for money. (For every dollar that goes to the surrogates, observers estimate, three go to the clinic.) In Akanksha's hostel, women sleep on cots, nine to a room, for nine months. Their young children sleep with them; older children do not stay in the hostel. The women exercise inside the hostel, rarely leaving it and then only with permission. Patel also advises surrogates to limit contact with clients. Staying detached from the genetic parents, she says, helps surrogate mothers give up their babies and get on with their lives -- and maybe with the next surrogacy. This ideal of the de-personalized pregnancy is eerily reminiscent of Aldous Huxley's 1932 dystopian novel Brave New World, in which babies are emotionlessly mass-produced in the Central London Hatchery.

Patel's business may seem coldly efficient, but it also has a touch of Mother Teresa. Akanksha residents are offered daily English classes and weekly lessons in computer use. Patel arranges for film screenings and gives out school backpacks and pencil boxes to surrogates' children. She hopes to attract donations from grateful clients to help pay children's school fees as well. "For me this is a mission," Patel says.

In light of appalling government neglect of a population totally untouched by India's recent economic boom, this charity sounds wonderful. But is it wonderful enough to cancel out concerns about the factory?

***

After leaving Anand, I head to Dr. Nandita Palshetkar's office in Mumbai. With Alifiya Khan, another journalist from the Hindustan Times, I meet with Leela, a lively 28-year-old who gave birth to a baby for Indian clients about six months ago. Like Geeta and Saroj, Leela had been desperate for money, but her experience of pregnancy was utterly different. On the day I meet her, she is dressed in a pink sari, hair drawn back from her olive-skinned face into a long black braid. She leans forward, smiling broadly, eager to talk about her baby, his genetic parents, and her feelings about being a surrogate mother.

At age 20, Leela married a fellow worker at a Mumbai-based company canteen. "I didn't know he was alcoholic until after we married," she says. "My husband ran up a $7,000 debt with the moneylender who sent agents to pressure him to repay it. ... We couldn't stop the moneylender from hounding us. I decided to act. I heard from my sister-in-law that I could get money for donating my eggs, and I did that twice. When I came back to do it a third time, madam [Dr. Palshetkar] told me I could earn more as a surrogate."

Was she able to pay off the debt? Leela lowers her head: "Half of it."

She ate better food during her paid pregnancy than during her other pregnancies and delivered the baby in a better hospital than the one where she delivered her own children. Unlike others I spoke with, Leela openly bonded with her baby. "I am the baby's real mother," she says. "I carried him. I felt him kick. I prayed for him. At seven months I held a celebration for him. I saw his legs and hands on the sonogram. I suffered the pain of birth."

The baby's genetic parents, Indians from a nearby affluent suburb, kindly reached out to Leela. The genetic mother "sees me as her little sister, and I see her as my big sister," Leela says. "They check in with me every month, even now, and call me the baby's 'auntie.' They asked if I wanted to see the baby. I said 'yes' and they brought him to my house, but I was disappointed to see he was long and fair, not like me. Still, to this day, I feel I have three children." A friendship of sorts arose between the two mothers, although Leela's doctor, like Patel, discouraged it. "I deleted their phone number from my list because madam told me it's not a good thing to keep contact for long," she says.

In a November 2008 New York Times Magazine article titled "Her Body, My Baby," American journalist Alex Kuczynski describes searching through profiles of available surrogates. "None were living in poverty," she writes. Cathy, the woman she eventually chose to carry her son, was a college-educated substitute teacher, a gifted pianist, and fellow fan of Barack Obama. They shared a land, a language, a level of education, a political bent -- coming together to create a baby didn't seem like such a giant leap. But when the surrogate and genetic mother come from different corners of the globe -- when one is an Indian woman who bails monsoon rains from her mud-floor hut and the other is an American woman who drives an SUV and vacations at ski resorts -- the gap is more like a chasm. And as one childless American friend (rendered infertile through a defective Dalkon Shield intrauterine device) told me, "If I had hired a surrogate, I'm not sure how close I'd want to be to her. How open can you keep your heart when it's broken? Sometimes it's better not to touch unhealed wounds." A code of detachment seems almost necessary to circumvent the divide.

But detachment isn't so easy in practice. Even if you can separate the genetic parents from the surrogate, you cannot separate the surrogate from her womb. One surrogate mother told the sociologist Amrita Pande, "It's my blood, even if it's their genes." Psychologists tell us that a baby in utero recognizes the sound of its mother's voice. Surrogates I spoke with seemed to be struggling to detach. One said, "I try to think of my womb as a carrier." Another said, "I try not to think about it." Is the bond between mother and child fixed by nature or is it a culturally inspired fantasy we yearn to be true?

I asked Dr. Chakravarty if he thought that some children born of surrogacy would one day fly to India in search of their "womb mothers." (The proposed regulation requires parents to reveal to an inquiring child the fact of surrogacy, though not the identity of the surrogate.) "Yes," he said. But chances are such an 18-year-old would not find her womb mother. Instead, she might come to realize she had been made a whole person by uniting parts drawn from tragically unequal worlds.

In a larger sense, so are we all. Person to person, family to family, the First World is linked to the Third World through the food we eat, the clothes we wear, and the care we receive. That Filipina nanny who cares for an American child leaves her own children in the care of her mother and another nanny. In turn, that nanny leaves her younger children in the care of an eldest daughter. First World genetic parents pay a Third World woman to carry their embryo. The surrogate's husband cares for their older children. The worlds of rich and poor are invisibly bound through chains of care.

Before we leave the Akanksha clinic in Anand, the gentle embryologist, Bhadarka, remains across the table from Aditya and me after Geeta and Saroj have left the room. I ask Bhadarka if the clinic offers psychological counseling to the surrogates. "We explain the scientific process," she answers, "and they already know what they're getting into." Then she moves her hands across the table and adds softly, "In the end, a mother is a mother, isn't that true? In the birthing room there is the surrogate, the doctor, the nurse, the nurse's aide, and often the genetic mother. Sometimes we all cry."

***

Special thanks to Aditya Ghosh and Alifiya Khan.

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