FROM ITS POCKMARKED EXTERIOR WALLS and stark interior, you’d never guess that this pink three-storey building a few blocks from the train station houses India’s most successful surrogate childbirth business. But when Oprah Winfrey raved about the Akanksha Infertility Clinic in the fast-growing city of Anand, it became an overnight success. The clinic fertilises eggs, implants and incubates embryos in the wombs of surrogate mothers, and finally delivers contract babies at a rate of nearly one per week.
For the past three to four years, 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 saviour of childless middle-class couples, and helped open the floodgates for the outsourcing of American pregnancies. Autographed photos of 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 jewellery 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: 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 the point, she politely evades my questions for the next 20 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 kilometre and a half from the clinic, a government ration shop issues subsidised rice to an endless stream of impoverished buyers. 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 Gujarat, Anand is a prohibitionist 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 labourers 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—and, in most cases they are too poor to try to make the trip.
Outdoor exercise, even a walk around the block, is a no-go. To get past the guard, they 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 meagre standard of living, but which the clinic’s foreign customers understand is a steal. Most of the customers come from outside India and three of the city’s boarding houses are constantly booked with American, British, French, Japanese and Israeli surrogacy tourists. I cross the street to the bungalow, where a friendly smile and a purposeful confident walk accompanied by my interpreter gets me past the gatekeeper. In the hostel’s main living quarters, some 20 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-size 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 chapattis.
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 actually used to be a nurse at the clinic. She left her home in Nepal to find work in Anand, leaving behind her two school-age children. She’ll use the money she makes to fund their education. “We miss our families, but we also realise that by being here we give a family to a woman who wants one,” Diksha says. She and her dorm mates are paid 50 dollars each a month, she says, plus 500 dollars at the end of each trimester, and the balance on delivery.
All told, a successful Akanksha surrogate makes between 5,000 and 6,000 dollars per pregnancy—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 dollars.) 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 to facilitate medical monitoring and provide the women better conditions than they might have back home. Kristen Jordan, a 26-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 the very, very poor, 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 set-up.
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. Other than for occasional medical check-ups, she hasn’t left this building in nearly three months, nor has she had any visitors. But 5,000 dollars is more than she would make in ten years of ordinary labour.
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 Caesarean 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 labour 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, but another reason that Akanksha may keep such a close eye on their surrogates is because they worry that some of the women may go into business for themselves. In 2008, Rubina Mandal, an ex-surrogate in the facility, 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 check-ups. 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 with impeccably parted hair. The fraud is understandable, if egregious. With so much profit in surrogacy, some women want a bigger cut of the action. To date, Mandal has not been apprehended.
India legalised surrogacy in 2002 as part of a larger effort to promote medical tourism. Since 1991, when the country’s new pro-capitalist policies took effect, private money has flowed in and fuelled 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 dollars for the entire process, from in vitro fertilisation 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 dollars, 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 45 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 Dr LH Hiranandani hospital, which boasts a sizable surrogacy programme of its own, trains outside fertility doctors on how to identify and recruit promising candidates. A page on their website advertises franchising opportunities to entrepreneurial fertility specialists around India who might want to set up surrogacy operations with an endorsement from Mumbai. The Indian 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 dollars 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 do the state or national authorities have the power to police the industry. While clinics like Akanksha have a financial incentive to ensure the health of the foetus, there’s 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.
Last May, for instance, a young surrogate named Easwari died after giving birth at the Iswarya Fertility Clinic 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 polygamous 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 haemorrhaging, 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 the 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 over email, it took almost half a year to get a response. A doctor from the centre, Arun Muthuvel, wrote that Easwari “developed a severe disseminated intra-vascular clotting defect,” because the child’s head was too large. He added that the team was unable to save her life despite tearing through seven bottles of blood and calling in additional surgeons. Whether or not 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 cases of malpractice, patients generally have to take the hospital’s word that everything happened according to the highest medical standards. India’s parliament is in the process of crafting legislation to address some of the concerns about surrogacy. The bill could be ready for formal consideration sometime this year, but it is not clear which agency would be charged with enforcement.
In any case, any regulatory oversight would likely fall to the states. Even 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 centre and phoning three different ministers to even get half an answer. “At the state level, no one looks at surrogacy,” says Sunil Avasia, Gujarat’s deputy director of medical services, whom I finally manage to 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 programme 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 40-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 Hotel Laksh Residency, 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 that 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 neighbours—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, briefly, at the clinic a few minutes after embryos from donor eggs fertilised 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. Cohen 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. “That shouldn’t be a job.”
Then how to view it? Oprah showcased Jennifer and Kendall West, 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 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 paycheque.
Over eight dollar coffees at a swank hotel, Amit Karkhanis, one of Mumbai’s most prominent surrogacy lawyers, explains that this language of altruism gives clinics the upper hand in pay negotiations. Meanwhile, the contracts signed by clinic, client and surrogate are vague about what type of service is being provided. “Is it work? Is it charity?” Karkhanis asks rhetorically, cocking one eyebrow before offering his own opinion: “Surrogacy is a type of employment, plain and simple. Foreigners are not coming here for their love of India. They are coming here to save money.” And if surrogacy is being treated as a job, then why aren’t women getting market rates for their time in the hospital?
While both cost of living and earning potential are far lower in India than in America, it is still possible to compare the relative pay for surrogates and clinics on either side of the globe: An American surrogate typically gets half to three-quarters of the total paid by the couple, while surrogates paid Akanksha’s rates are getting one-quarter to one-third of the total. “Surrogacy is a form of labour,” lawyer Usha Smerdon, who runs a US-based adoption reform group called Ethica, told me in an email. “But it’s an exploitative one, similar to child labour and sweatshops driven by Western consumerism... I challenge the notion that within these vastly differential power dynamics that surrogates are truly volunteering their services, that hospitals are operating above board when driven by a profit motive.”
Besides India, only a handful of countries—the United States, Belgium, Canada, Israel and Georgia—allow surrogacy for pay, and most of these have imposed strict regulations. France, Greece and the Netherlands forbid even unpaid arrangements, and no country, not even India, recognises surrogacy as a legitimate form of employment. The US leaves regulation to individual states. Eight recognise and support it, and have mandated health safeguards and counselling for surrogates; six have banned it outright. The rest have either deemed surrogacy contracts unenforceable, left surrogacy for the courts to deal with through case law, or simply ignored the practice. The Indian Council on Medical Research has come up with proposed surrogacy guidelines that caution against some practices already in common use in Anand and elsewhere, such as allowing the clinics to broker surrogacy transactions. But these non-binding rules, considered a starting point for national legislation, ignore other glaring ethical issues, such as whether it’s okay to impose C-sections on a surrogate. Or whether keeping surrogates cloistered under strict medical supervision violates a fundamental principle.
Implantation is another dicey issue. For healthy young women, the American Society for Reproductive Medicine advises American doctors to implant just one—and certainly no more than two—embryos in a woman’s uterus per attempt. The Indian guidelines recommend no more than three for surrogates. But Patel’s clinic routinely uses as many as five embryos at a time. Using more embryos boosts the success rate but also results in multiple births, which are far riskier for the woman and often lead to premature delivery (by C-section) and dire health problems in the infants. Although it’s impossible to verify, Akanksha claims an implantation success rate of 44 percent (similar to other Indian clinics), compared to a US norm of 31 percent. Several of the surrogates I met in Anand were pregnant with twins. In cases where three or more embryos take, the Akanksha clinic selectively aborts specific embryos to bring the total down to more manageable levels. They do this often without asking permission of the intended parents, or the surrogate’s.
India’s surrogacy guidelines are also silent on the issue of locking down the women, a practice that lawyer Karkhanis believes to be illegal. “The Anand model is completely flawed,” he tells me. “Holding surrogates like that is unlawful confinement under the Indian Penal Code.”
While the guidelines clearly state that “the responsibility of finding a surrogate mother, through advertisement or otherwise, should rest with the couple,” Akanksha advertises far and wide for surrogates in local-language newspapers, and many hospitals have responded to the demand by hiring headhunters.
At Mumbai’s imposing Hiranandani Hospital, physician Kedar Ganla introduces me to a gaunt woman named Chaya Pagari—his direct line to the slums. The 40-year-old “medical social worker,” as Ganla calls her, sits uncomfortably in his office and meets my questions with hesitation. Given her sparse résumé, ‘recruiter’ would be a more apt title. Ganla pays Pagari 75,000 rupees (about 1,750 dollars) for each surrogate he accepts. He’s already accepted three this year, she tells me—meaning she’s making more than the women she recruits. “Between us brokers,” she adds, “there is near constant competition to find surrogates.”
Doctor Anoop Gupta does things a bit differently. He runs Delhi-IVF & Fertility Research Centre, the clinic where I met California customer Kristen Jordan, and where his waiting room is packed with chatty patients. Next to Akanksha’s spartan vibe, it is night and day, with wood-panelled walls and a brightly lit aquarium exuding a sense of security and warmth usually lacking in Indian medical facilities.
Clad in green scrubs and a blue hairnet, Gupta is always on the move and has little time for questions. Instead, he has me observe a constant stream of patients who have come to him from as far away as Ireland and California, or from as close as a few blocks away. While most are here for routine fertility treatments, Gupta has at least seven surrogates on the rolls this month. “In India the government makes it difficult to arrange an adoption, while having your own genetic child through a surrogate is legal and easy,” the doctor says as he slathers a clear gel on the paddles of an ultrasound machine. The only hurdle, as he sees it, is finding a surrogate who isn’t motivated by desperation. For this, he relies on Seema Jindal, his medical coordinator, who is a licenced social worker and registered nurse at the clinic. Her recruiting method has a twinge of evangelism: “I ask just about every woman I meet socially if she has thought about surrogacy.” She focuses on women who have completed college and are well-off enough not to have to rely on the clinic’s payments for basic needs. Otherwise, she says, “How do they know they are not being exploited?”
Several months before our interview, Jindal confides, she took a train to Gujarat to snoop on Patel’s operation firsthand, both to glean trade secrets that might make her own clinic more profitable and to scrutinise its flaws. In her view, the residency programme treats women like livestock. “They sit, they talk, and they sleep,” she says. “It’s just not right.”
One of Jindal’s recruits, a 32-year-old social worker named Sanju Rana, is here for her ultrasound. Unlike Patel’s surrogates, she is college-educated and plans to work full-time throughout her pregnancy. She’s been promised 7,500 dollars for her services, and has Gupta’s direct phone number. During the procedure, Rana, already a mother of two, is surprised to learn that she is carrying twins for an American couple. She’s worried, she tells me, but will most likely carry them to term. “They are good people, and have been childless for so long,” she says.
LIKE EVERY OTHER MARKET in human tissue, surrogacy blends notions of altruism and humanistic donation with the bottom line of corporate medicine. 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’s 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 is moving faster than our understanding of its implications.
Ester Cohen is childless no longer. From the day we met in Anand, it took five weeks to finalise her newborn’s status as a United States citizen, complete with a shiny blue and silver passport and a no-objection certificate issued by the Indian government.
But Cohen has since traded the smog and chaos of Anand for her quiet neighbourhood in North Berkeley, where the realities of motherhood have kicked in.
The small apartment she shares with her husband, Adam, 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.
[A version of this article has previously appeared in Mother Jones.]