Renting wombs

Reshma (name changed), age 35, gives me a dazzling smile. As she settles into the interview, re-adjusting the dupatta on her head, she says, 'I have not done anything wrong, have I?' It is a statement, not a question. Reshma worked briefly as a sweeper at a small private clinic in Jalandhar, Punjab, before she decided to become a surrogate for a Punjabi NRI (non-resident Indian) couple.

Surrogacy, the practice of gestating a child for another couple or individual, involves the use of Assisted Reproductive Technologies (ARTs) – a group of technologies that assist in conception or the carrying of pregnancy to term. These include intra-uterine or artificial insemination, and in-vitro fertilisation (IVF), popularly known as 'test-tube baby' technology. ART provision in India has expanded in recent years into a veritable fertility industry. As the country's medical market and medical-tourism industry grows, ARTs have been added to the long list of cheap services that high-tech India is selling to the world. Within this, commercial surrogacy is often portrayed as a win-win situation, seen to give 'desperate and infertile' parents the child they want, and poor surrogate women the money they need.

As Reshma talks, it becomes clear that she opted for surrogacy out of economic necessity. This is important because, while context compels choices, all too often talk about 'choice' obscures the structural forces that influence a decision apparently made freely. Reshma has four children – three daughters and a son. Her husband works as a cook and makes 5000 rupees a month. She wants to get her eldest daughter married and says that she was willing to work anywhere to earn enough to fund the wedding. Apart from hospital expenses that were borne by the commissioning couple, Reshma made INR 150,000 (USD 3266) from the surrogacy.

The lure of big money has been attracting many like Reshma. Jaswinder, 32, wants to be a surrogate. Waiting for a screening at an IVF clinic, she says, 'They have to see if everything is okay with me, only after that will we know if I am right for the job.' Jaswinder has two young sons. Like Reshma, she says she is doing this for her children so that they can have a better life, an education and a home of their own. Her husband and mother-in-law support her decision. Would she not rather look for other work? 'We can't find any work. There is no work in the village,' she says. 'That's why we have taken this decision.'

Glory of motherhood

Surrogacy, as US journalist Ellen Goodman writes, lies at the 'peculiar intersection of a high reproductive technology and a low-tech work force.' Globalisation has led to greater commercialisation of women's labour and their bodies, where they find themselves increasingly pushed into the informal job market. India's economic policy has shifted away from centralised industries and manufacturing units towards small, private industries that operate with minimum regulation. With cuts in spending on agriculture and increased urbanisation, the unorganised sector is growing, and more temporary, contractual jobs for under-skilled labour are on the rise. In this context, women who are involved in money-making activities such as surrogacy and sex work, perhaps even domestic work or garment work, can be thought to be engaging in commercial forms of sexual and reproductive labour – an extension of their 'care work', which was traditionally not considered economically productive and was only considered dignified if domesticated. These jobs are usually inattentive to women's rights and health, but are often some of the only options available.

Surrogacy presents an opportunity for women such as Reshma and Jaswinder to use their bodies as a resource with which to enhance their financial autonomy. It even pushes pregnancy from the private domain of 'care' to the public one of remunerated 'work'. Yet surrogacy is essentially a survival tool. It is the conspicuous lack of choice that pushes both the surrogate and the commissioning mother – who, especially if she is from the Subcontinent, is likely to be under significant social stress due to her childlessness.

Commercial surrogacy also remains highly stigmatised. While hopeful of becoming a surrogate, Jaswinder is sure she will keep the arrangement a secret from friends and neighbours. After three months of pregnancy, she plans to move out of her village and live at her mother-in-law's house in the neighbouring town of Kapurthala. 'We will say that the madam whose place I am working at is from somewhere outside, and I have gone there for six months. In the village, people really talk. If they know I am pregnant, they will ask where the child is, whom I have given it to and why,' she says.

In light of such stigma, some have suggested that altruistic surrogacy – as opposed to a commercial arrangement – could be a more socially acceptable option. But this is not without its own problems, not the least of which is that such an arrangement could render women more vulnerable than commercial arrangements that carry the same health risks but at least provide compensation. Nonetheless, altruism is an important theme in my conversations with Reshma and Jaswinder. 'It is a very good deed to give a child to someone who doesn't have one,' says the former. Jaswinder echoes this sentiment, 'It is always the women who suffer. With surrogacy, a woman's problem is being solved. So we like that. We think these women are like us. We feel bad for the problems women have to face.'

This pro-women impulse could be a post-facto rationalisation of sorts for the women, but it is a conscious marketing strategy for the industry. A look at ART clinics' websites reveals slogans that glorify motherhood:

They say women make the world go round. How true! It is because they are mothers…

The moment a child is born, the mother is also born. She never existed before…

In this way, the ART industry can be seen as lying at the intersection of patriarchy and market, relying on the pressure that society puts on women to be mothers.

An arduous autonomy

In India, the ART industry is completely unregulated. Though the Indian Council of Medical Research has set some guidelines, these are non-binding. New legislation is being proposed, but it remains in draft form. Critics of the industry warn against a race to the bottom – today, first-world, upper-class women are using the wombs of their Third World and lower-class counterparts to breed babies; tomorrow, the surrogacy industry could shift to destinations cheaper than India. Compensation will be lowered and health risks for women could remain unaddressed. But a ban on surrogacy is neither desirable nor effective, as bans have all too often resulted in the creation of black markets and even more exploitation. A ban could also force surrogate women into deeper poverty and vulnerability.

Many also have begun to suggest that the option for infertile or gay individuals and couples to have biologically related children through surrogacy should be seen as a reproductive right. While gay couples from the Global North today come to India for surrogacy arrangements, India's legal position on homosexuality is still being contested. Proposed legislation for regulation of India's ART industry is ambiguous about whether gay couples, especially Indian gay couples, can even access ARTs.

Meanwhile, 18 months later, after the delivery of her surrogate child, Reshma tells me that though she managed to get her daughter married, she ended up spending INR 300,000 on the wedding, double the amount she earned through surrogacy, and is now in debt. Will she be a surrogate again? 'Let's see,' she says. 'It is very clear that my health is finished. But even if there is no life in me, I can do a lot for my children.' Even within a limited paradigm, surrogate women like Reshma are indeed exerting agency. Commercial surrogacy might thus be best understood, as sociologist Amrita Pande points out, as labour of a new kind – one that is gendered, exploitative and stigmatised, but labour nonetheless.

When Reshma is asked whether she would like for any part of her surrogacy arrangement to be done differently, she responds, 'I did feel like the couple should have met me. It wasn't necessary for them to pay me only what was agreed in the contract. I did so much. I gave them a boy.' Commissioning couples commonly seek 'fair' (which often translates as upper caste) surrogates to gestate their babies, and want male embryos to be selected for implantation. In a free-market situation, is anything acceptable?

Surrogacy raises larger questions of reproductive autonomy and justice. According to a study by Betsy Hartmann, a women's-health activist, surrogate women in Anand, Gujarat, are 'literally producing citizens of other countries, while they remain second- or third-class citizens in their own, subject to a state-imposed two-child norm when it comes to their own offspring.' Perhaps then, rather than a moral debate around the acceptability of surrogacy, we need to focus on the terms of surrogacy, the context and implications of its operation.

The possible creation of three mothers (commissioning mother, the gestational mother, and in case of use of donor eggs, the genetic mother) has medical, ethical and legal implications. No credible, long-term studies on the health implications of the procedures and drugs in ARTs have been done, for both mother and child; the custody and citizenship of the child might be contested, such as in transnational surrogacy arrangements. In the absence of regulation, the surrogate's bodily integrity, health and rights can be compromised; and in more extreme instances, women can be sold or trafficked to be surrogates. This was the case in an orphanage in Haryana that sold a girl twice in three years to bear children for childless couples.

Jaswinder's concerns about the surrogacy arrangement she might enter into are all health-related. She is clear that she will not want to keep the child; she says she has two of her own she can barely look after. But she wants her health to be protected. Although Jaswinder does not know it yet, her concerns are not unfounded. A doctor at one of Mumbai's top IVF clinics says that she knows of cases in which the surrogate has died. A doctor at another clinic shares, with some disdain, the story of a surrogate, commissioned for a Saudi Arabian couple, who never returned to the clinic after a 'weak positive' was confirmed for the pregnancy. The couple was given another surrogate and business went on as usual. But the woman turned up after four months, pregnant with three babies. 'I told her we cannot do anything now. You should have come earlier,' the doctor recalled. 'She went away and I don't know what happened after that.'

~ Vrinda Marwah works with Sama, a Delhi-based resource group on gender and health.