Cash on Delivery

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A fertility clinic in Anand, Gujarat, is adding a whole new dimension to the great outsourcing experiment. It offers wombs on affordable rent

From its pockmarked exterior walls and stark interior, you’d never guess that this pink three-story building a few blocks from the train station houses India’s most successful surrogate childbirth business. But when Oprah raved about the Akanksha Infertility Clinic in the fast-growing city of Anand, it became an overnight success. The clinic fertilizes eggs from donors, implants and incubates embryos in the womb of a surrogate mother, and finally delivers contract babies at a rate of nearly one a week.

Since 2006 Dr Nayna Patel, Akanksha’s founder, has been the subject of dozens of gushing articles in addition to that game-changing 2007 Oprah segment, which all but heralded Patel as a savior of childless middle-class couples and helped open the floodgates for the outsourcing of American pregnancies. Autographed photos of Ms Winfrey are displayed prominently throughout the clinic, which claims to have a waiting list hundreds deep. According to news reports, Akanksha receives at least a dozen new inquiries from potential surrogacy customers every week.

The doctor, clad in a bright red-and-orange sari, sits at a large desk that takes up about a third of the room. Heavy diamond jewelry dangles from her neck, ears, and wrists. Her wide grin projects a mixture of politeness and caution as she beckons me to sit in a rolling desk chair. I showed up here without an appointment, fearing Patel would refuse to see me if I phoned in advance: Despite all the laudatory press, in the weeks prior to my visit a spate of critical articles had appeared, focusing on the clinic’s controversial practice of cloistering its hired surrogate mothers in guarded residency units.

Among the claims is that Akanksha is little more than a baby factory. “The world will point a finger at me,” Patel responds when I ask her about the criticism. “She will point, he will point. I don’t have to keep answering people for that.”

As if to prove it, she politely evades my questions for the next twenty minutes, and then abruptly escorts me out when I ask about the residency units again. But in a town as small as Anand, I can track down where the women are without the doctor’s assistance.

On a quiet street about a mile away from the clinic, a government ration shop issues subsidized rice to an endless stream of impoverished clients. Across the road is a squat concrete bungalow enclosed by concrete walls, barbed wire, and an iron gate. Police once used it as a storehouse for bootleg liquor captured in Eliot Ness–style raids. (Like the rest of India’s Gujarat state, Anand is a dry city.) The security measures were intended to keep away bootleggers who might be tempted to reclaim the evidence.

Now the building functions as one of two residential units for Akanksha’s surrogates. They aren’t prisoners here. But they can’t just up and leave, either. The women—all married and with at least one previous child—have swapped freedom and physical comfort to enroll as laborers in India’s burgeoning medical and fertility tourism industry. They will spend their entire pregnancies under lock and key. A watchman wearing an official-

looking uniform and armed with a bamboo cane monitors everyone’s movements from the front gate. Visits by family members are limited but, in most cases, they are too poor to make the trip.

Outdoor exercise, even a walk around the block, is a no-go. To get past the guard, the women must have an appointment at the clinic or special permission from their overseers. In exchange, they stand to receive a sum that’s quite substantial by their meager standard of living, but that the clinic’s foreign customers understand is a steal.

Most of the customers come from outside of India, and three of the city’s boardinghouses are constantly booked with American, British, French, Japanese, and Israeli surrogacy tourists. Accompanied by my interpreter, I cross the street to the bungalow, where a friendly smile and a purposeful, confident walk get me past the gatekeeper. In the hostel’s main living quarters, some twenty nightgown-

clad women in various stages of pregnancy lie about, conversing in a hurried mix of Gujarati, Hindi, and a bit of English. A lazy ceiling fan stirs the stagnant air, and a TV in the corner—the only visible source of entertainment—broadcasts Gujarati soaps. A maze of iron cots dominates the classroom-sized space and spills out into the hallway and through additional rooms upstairs. It is remarkably uncluttered given the number of people living here. Each surrogate has only a few personal belongings, perhaps just enough to fill a child’s knapsack. In a well-stocked kitchen down the hall, an attendant who doubles as the house nurse prepares a midday meal of curried vegetables and flatbread.

The women are pleasantly surprised to have a visitor. It’s rare, one tells me, for a white person to show up here. The clinic discourages personal relationships between clients and surrogates, which, according to several sources, makes things easier when it comes time to hand over the baby.

Through an interpreter, I tell the women that I’m here to learn more about how they live. Diksha, a bright, enthusiastic woman in her first trimester, elects herself spokeswoman, explaining that she used to be a nurse at the clinic. She left her home in neighboring Nepal to find work in Anand, leaving behind her two school-age children. She reasons that she could earn just as much as a surrogate as she could working full-time tending to them. She’ll use the money she makes to fund her children’s education. “We miss our families, but we also realize that by being here we give a family to a woman who wants one,” Diksha says. She and her dormmates are paid $50 a month, she says, plus $500 at the end of each trimester, and the balance upon delivery.

All told, a successful Akanksha surrogate makes between $5,000 and $6,000—a bit more if she bears twins or triplets. (Two other Indian surrogacy clinics catering to foreign couples told me they paid between $6,000 and $7,000.) If a woman miscarries, she keeps what she’s been paid up to that point. But should she choose to abort—an option the contract allows—she must reimburse the clinic and the client for all expenses. No clinic I spoke with could recall a surrogate going that route.

Diksha is the only Akanksha surrogate I meet who has an education to speak of. Most of the women hail from rural areas; for some, the English tutor Patel sends to the dormitories several times a week is their first exposure to anything resembling schooling. But they’re not here to learn English. Most heard about the clinic via local newspaper ads promising straight cash for pregnancy.

Among the justifications for cloistering the surrogates—Akanksha isn’t the only clinic doing it—is the facilitating of medical monitoring and the providing of better conditions for the women than they might have back home. Kristen Jordan, a twenty-six-year-old California housewife, opted for a Delhi clinic that recruits educated surrogates and doesn’t cloister them after she learned that some clinics hire “basically very, very poor [people who are] strictly doing it for the money.” For their part, the Akanksha surrogates tell me that their swollen bellies would almost certainly make them the subject of gossip back home. Even so, those who have been on the ward longer than Diksha don’t seem terribly thrilled with the whole setup.

I sit down next to Bhavna. She’s far along and bulging in her pink nightgown and wearing a gold locket around her neck. She looks older than the rest and more tired. It’s her second surrogacy here in as many years, she tells me. Apart from occasional medical checkups, she hasn’t left this building in nearly three months, nor has she had any visitors. But $5,000 is more than she would make in ten years of ordinary labor.

I ask for her view of the overall experience. “If we have a miscarriage we don’t get paid the full amount; I don’t like that,” she says. But she’s thankful to be here and not at the clinic’s other hostel, a few towns away in Nadiad, which isn’t as nice. When I ask what happens after she hands over the baby, she replies that the cesarean section will take its toll. “I will stay here another month recovering before I am well enough to go home,” Bhavna says. No surrogate I interviewed expected a vaginal birth. Even though C-sections are considered riskier for the baby under normal circumstances and double to quadruple the woman’s risk of death during childbirth, the doctors rely on them heavily. They are, after all, far faster than vaginal labor and can be scheduled.

We’re joined by a second woman, who has dark brown eyes and wears a muumuu embroidered with pink flowers. I ask them whether they think they’ll have trouble handing over their newborns. “Maybe it will be easier to give up the baby,” says the second woman, “when I see it and it doesn’t look like me.”

The clinic isn’t that worried about the women keeping the children for themselves and tying up the handoff with legal challenges, but another reason that Akanksha may keep such a close eye on their surrogates is the worry that some of the women may go into business for themselves. In 2008 Rubina Mandal, an ex-surrogate, decided that the Anand model was a perfect platform for fraud. She began posing as one of the clinic’s representatives and duping Americans into sending her advance fees for medical checkups.

According to a warning posted on the Akanksha website “Ms Mandal is not a doctor, she is a fraud and has been known to dupe innocent couples, hence please be mindful in any dealings with her. Moreover, Ms. Mandal may be using our clinic’s name in her efforts to lure innocent couples.” Below the warning is a grainy black-and-white photo of Mandal wearing a black necklace and impeccably parted hair. The fraud is understandable, if egregious. With so much potential profit in surrogacy, some women want a bigger cut of the action. To date, Mandal has not been apprehended.

India legalized surrogacy in 2002 as part of a larger effort to promote medical tourism. Since 1991, when the country’s new procapitalist policies took effect, private money has flowed in and fueled construction of world-class hospitals that cater to foreigners. Surrogacy tourism has grown steadily here as word has gotten out that babies can be incubated at a low price and without government red tape. Patel’s clinic charges between $15,000 and $20,000 for the entire process, from in vitro fertilization to delivery, whereas in the handful of American states that allow paid surrogacy, bringing a child to term can cost between $50,000 and $100,000, and is rarely covered by insurance. “one of the nicest things about [India] is that the women don’t drink or smoke,” adds Jordan, the Delhi surrogacy customer. And while most American surrogacy contracts also forbid such activities, Jordan says, “I take people in India more for their word than probably I would in the United States.”

Dependable numbers are hard to come by, but at minimum, Indian surrogacy services now attract hundreds of Western clients each year. Since 2004 Akanksha alone has ushered at least 232 babies into the world through surrogates. By 2008 it had forty-five surrogates on the payroll, and Patel reports that at least three women approach her clinic every day hoping to become one. There are at least another 350 fertility clinics around India, although it’s difficult to say how many offer surrogacy services, since the government doesn’t track the industry. Mumbai’s Hiranandani Hospi- tal, which boasts a sizable surrogacy program of its own, trains outside fertility doctors on how to identify and recruit promising candidates. A page on its website advertises franchising opportunities to entrepreneurial fertility specialists around India who might want to set up surrogacy operations with an endorsement from Mumbai. India’s Council on Medical Research (which plays an FDA-like role—except that it has far less power to actually enforce its edicts) predicts that medical tourism, including surrogacy, could generate $2.3 billion in annual revenue by 2012. “Surrogacy is the new adoption,” says Delhi fertility doctor Anoop Gupta.

Despite the growth projections, surrogacy is not officially regulated in India. There are no binding legal standards for treatment of surrogates, nor does state or national authority have the power to police the industry. While clinics like Akan- ksha have a financial incentive to ensure the health of the fetus, there is nothing to prevent them from cutting costs by scrimping on surrogate pay and follow-up care, or to ensure they behave responsibly when something goes wrong.

In May 2009, for instance, a young surrogate named Easwari died after giving birth at the Iswarya Fertility Centre in the city of Coimbatore. A year earlier, her husband, Murugan, had seen a newspaper ad calling for surrogates and pressured her to sign up to earn the family extra money. As a second wife in a poly- gamous marriage, Easwari was hard-pressed to refuse. The pregnancy went smoothly and she gave birth to a healthy child. But Easwari began bleeding heavily afterward, and the clinic was unprepared for complications. Unable to stop Easwari’s hemorrhaging, clinic officials told Murugan to book his own ambulance to a nearby hospital. Easwari died en route.

The child was delivered to the customer according to contract, and the fertility clinic denied any wrongdoing. But in a police complaint the husband suggested that the clinic had essentially dumped responsibility for his dying wife. The official investigation was perfunctory. When I contacted the clinic through e-mail, it took almost half a year to get a response. A doctor from the center wrote that Easwari “developed a severe disseminated intravascular clotting defect,” because the child’s head was too large. The doctor, who identified himself as Arun Muthuvel, added that the team was unable to save her life despite tearing through seven bottles of blood and calling in additional surgeons. Whether Easwari could have been saved remains a question that only a thorough investigation might hope to answer. However, nobody has the authority to examine such cases, which means that in instances of malpractice patients generally have to take the hospital’s word that everything happened according to the highest medical standards. India’s Parliament, however, is in the process of crafting legislation to address some of the concerns about surrogacy. The bill could be ready for formal consideration sometime around the end of 2011, but it is not clear which agency would be charged with enforcement.

Any regulatory oversight would likely fall to the states, yet pinning someone down in the government to comment on what department might be able to examine or regulate fertility clinics now is like playing a seemingly endless game of hot potato. It took six visits to different offices in Gujarat’s bureaucratic center and phoning three different ministers to get even half an answer: “At the state level, no one looks at surrogacy,” says Sunil Avasia, Gujarat’s deputy director of medical services, in a short interview.

When it comes to ethical conduct, it might as well be the Wild West. Forget laws, he says. “There are no rules.” That’s all he has to offer on the subject. “Perhaps you should talk to my boss,” Avasia says. Alas, the boss never returned my calls. Nor has there been an effort to regulate surrogacy contracts on the receiving end. So long as a surrogate infant has an exit permit from the Indian government, the process for getting the baby an American passport is straightforward.

For their part, Patel’s customers view the residency program as an insurance policy of sorts. “When I was told by my doctor they could get someone in Stockton, [California,] I don’t know what they’re eating, what they’re doing. Their physical environment would have been a concern for me,” says Ester Cohen, a forty-year-old from Berkeley who runs a catering company with her husband and teaches Jewish ethics lessons to children on weekends. “The way they have things set up here is that the surrogate’s sole purpose is to carry a healthy baby for someone.”

I met Cohen in the hallways of the Laksh Hotel, which caters to Akanksha’s surrogacy tourists. For many, this Indian excursion represents the final stage of an expensive and emotionally fraught quest for parenthood—their last, best option after a series of failed fertility treatments. Cohen tried for years to conceive, and after extensive testing was told she never would. Adoption didn’t appeal to her. Then she read a news article about Patel and knew immediately that she wanted to come to Anand. “Money was definitely one of the reasons, but it was like my gut feeling,” she says. “This is where I needed to be.” Cohen and her husband decided to keep their undertaking secret from friends and neighbors—at least until they returned home with a baby.

In the United States, a surrogate and her client must establish a relationship before coming to a fertility clinic, but Cohen has barely met Saroj, the woman Akanksha hired to carry her child. They connected just once at the clinic a few minutes after embryos from donor eggs fertilized with her husband’s sperm were implanted in Saroj’s uterus. That was nine months ago. Cohen has been back in Anand three days now but hasn’t gone to visit Saroj. “The clinic wants to keep a separation,” Cohen says. “They want it to be clear that this is what her job is: She’s the vessel.”

But this is where the ethos of commercial surrogacy becomes confusing. Co- hen is quick to add that Saroj is giving her one of the most precious gifts one human can offer another. “The clinic won’t let someone be a surrogate more than twice, because they don’t want them to be just a vessel,” she says. “It shouldn’t be a job.”

Then how to view it? Oprah showcased Jennifer and Kendall, a childless couple who had tried everything else but couldn’t afford the American surrogacy system. With Patel’s help, Jennifer became a mom, and an Indian woman was lifted from poverty—a transaction that was part business and part sisterhood. The clinics also frame surrogacy this way, insisting that the women offer their wombs out of a sense of communal responsibility, not simply because they need a paycheck.

Like every other market in human tissue, surrogacy blends notions of altruism and humanistic donation with the bottom line of medical profitability. Expanding the market for surrogate mothers to India certainly allows more Western women to have access to a medical procedure that they would have otherwise been priced out of. However, the new market is simply passing the bill down the line.

Before India, only the American upper classes could afford a surrogate. Now it is almost within reach of the middle class. While surrogacy has always raised ethical questions, the increasing scale of the industry makes the issue far more urgent. With hundreds of new clinics poised to open, the economics of surrogate pregnancies are moving faster than our understanding of its implications.

The red market for new children spans the distance between questionable practices in adoption, egg donation, and surrogacy. All three businesses are tied together by our most basic desires for reproduction and raising a happy family.

As customers, the intended parents are often unaware of the complexities of the supply chain and can easily enter into dangerous territory unintentionally. All three markets for children are expanding at unprecedented rates, making it easier than ever to buy a child on the red market.

Eeter Cohen is childless no longer. From the day we met in Anand, it took five weeks to finalize her newborn’s status as a US citizen, complete with a shiny blue-and-silver passport and a no-objection certificate issued by the Indian government. Cohen has since traded the smog and chaos of Anand for her quiet neighborhood in North Berkeley, where the realities of motherhood have kicked in.

The small apartment she and Adam, her husband, share now feels too cramped, and the couple is looking to move. The electric piano Adam once played daily sits unused in the corner of a room dominated by a crib and assorted baby stuff. As we chat, Cohen bounces Danielle, a healthy blue-eyed girl, on one knee. “It already seems like a thousand years ago that we were in India,” she says. “But we are so grateful for what Saroj has given us.”

Although Saroj had hoped for a vaginal birth, the clinic delivered Danielle via C-section. “There was an intensity in her eyes,” Cohen recalls of the handover. “It was hard for her, and you could see how much she cared for Danielle.” In the end, though, the baby had to come home with her mother.

Excerpted with permission from The Red Market, Hachette India, 2011