The doctor, clad in a bright red-and-orange sari, sits at a large desk that covers 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 office 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 dormitories. Among the claims: Akanksha is little more than a baby factory. "The world will point a finger at me," Patel responds when I ask 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 20 minutes, and then escorts me out. I had hoped to get her take on the residency units, but it's not a topic she cares to discuss.
ON A QUIET STREET about a mile 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 the site 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.
Akanksha surrogates spend their entire pregnancies within guarded residential facilities. The clinic claims they live better here than at home.
The women—all married and with at least one previous child—have traded the comforts of home to enroll as laborers in India's burgeoning medical tourism industry. Most will spend their entire pregnancies living in this building. In exchange for the inconvenience and physical discomforts, they stand to receive a sum that's quite substantial by their meager standards, but which the clinic's customers understand is a steal. The customers are mostly foreigners—three of the city's boardinghouses are constantly booked with American, British, French, Japanese, and Israeli surrogacy tourists.
After a few minutes of recon, I cross the street to the bungalow, where a friendly smile 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. The classroom-size space is dominated by a maze of iron cots that spills out into a hallway and additional rooms upstairs. It is remarkably uncluttered given the number of people living here—each surrogate has only a few personal belongings, perhaps 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 see me. 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 people I talked with 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 her two school-age children behind. She'll use the money she makes to fund their 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.
Will the surrogates have trouble handing over their newborns? "Maybe it will be easier to give up the baby," replies one, "when I see it and it doesn't look like me."
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. 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. (Kristen Jordan, a 26-year-old California housewife I met later, told me she 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.")
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 living conditions than they might have back home. For their part, the women tell me their condition would almost certainly make them the subject of village gossip.
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, far along and bulging in her pink nightgown, with a gold locket around her neck. She looks older than the rest—tired. It's her second surrogacy here, she tells me. Apart from occasional medical checkups, she hasn't left this building in nearly three months, nor had any visitors. But $5,000 is more than she would make in years of ordinary labor. Mostly she just looks forward to collecting her check and being done with it.
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. (Not a single surrogate I interviewed expected a vaginal birth, even though C-sections are considered riskier for the baby under normal circumstances and double to triple the woman's risk of death during childbirth. They are, however, far faster than vaginal labor—and some clinics charge clients extra for them.)
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."
INDIA LEGALIZED surrogacy in 2002 as part of a long-term push to promote medical tourism. Since 1991, when the country's new free-market policies took effect, private money has flowed in, fueling construction of world-class hospitals that cater to foreigners. Surrogacy tourism has grown steadily here as word gets around that babies can be incubated at a low price and without government red tape. Patel's clinic charges about $15,000 to $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 costs between $50,000 and $100,000. "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."
Surrogacy in India is all but unregulated. Forget laws, says one Gujarat health official. "There are no rules."
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 more than 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 350 other 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 Hospital, which boasts a sizable surrogacy program, trains outside fertility doctors to identify and recruit promising candidates. The Confederation of Indian Industry 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 in services, surrogacy is not officially regulated in India. There are no binding legal standards for treatment of surrogates, nor has any state or national authority been empowered to police the industry. While clinics have a financial incentive to ensure the health of the fetus, 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 Ishwarya Fertility Clinic in the city of Coimbatore. A year earlier, her husband, Murugan, had seen an ad calling for surrogates and asked her to sign up to earn the family extra money. As a second wife, 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. (The clinic did not respond to emailed questions for this story.)
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. "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 after a great deal of bureaucratic runaround. 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 topic. "Perhaps you should talk to my boss," Avasia says. Alas, the boss won't return my calls. There hasn't been any effort to regulate surrogacy contracts on the receiving end, either. 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.