Discounted Life

The Price of Global Surrogacy in India

Sharmila Rudrappa

• Publisher: NYU Press
• Year: 2015
• ISBN:
  9781479879489
• Topic: Social Sciences
• Subtopic: Gender Studies
• Index: Social Sciences

Winner, American Sociological Association Asia and Asian America Section Best Book on Asia/Transnational Asia Finalist, 2015 C. Wright Mills Award from the Society for the Study of Social Problems India is the top provider of surrogacy services in the world, with a multi-million dollar surrogacy industry that continues to grow exponentially, as increasing numbers of couples from developed nations look for wombs in which to grow their babies. Some scholars have exulted transnational surrogacy for the possibilities it opens for infertile couples, while others have offered bioethical cautionary tales, rebuked exploitative intended parents, or lamented the exploitation of surrogate mothers—but very little is known about the experience of and transaction between surrogate mothers and intended parents outside the lens of the many agencies that control surrogacy in India. Drawing from rich interviews with surrogate mothers and egg donors in Bangalore, as well as twenty straight and gay couples in the U.S. and Australia, Discounted Life focuses on the processes of social and market exchange in transnational surrogacy. Sharmila Rudrappa interrogates the creation and maintenance of reproductive labor markets, the function of agencies and surrogacy brokers, and how women become surrogate mothers. Is surrogacy solely a labor contract for which the surrogate mother receives wages, or do its meanings and import exceed the confines of the market? Rudrappa argues that this reproductive industry is organized to control and disempower women workers and yet her interviews reveal that, by and large, the surrogate mothers in Bangalore found the experience life affirming. Rudrappa explores this tension, and the lived realities of many surrogate mothers whose deepening bodily commodification is paradoxically experienced as a revitalizing life development. A detailed and moving study, Discounted Life delineates how local labor markets intertwine with global reproduction industries, how Bangalore’s surrogate mothers make sense of their participation in reproductive assembly lines, and the remarkable ways in which they negotiate positions of power for themselves in progressively untenable socio-economic conditions.

Part I

The Labor Market for Surrogate Mothers

1

Reproductive Interventions

In one of our many conversations I asked the late Dr. Sulochana Gunasheela, my mentor in Bangalore, foremost infertility specialist in the city, and feminist par excellence, why she provided infertility assistance. She replied that over the 1980s she had participated very actively in population control programs. Trained in laparoscopic sterilization at Johns Hopkins in Baltimore, she began performing sterilization surgeries on women from 1978 onward in her private ob-gyn practice and in government-sponsored “family planning” camps organized in rural areas all over the southern Indian states of Karnataka and Tamil Nadu. She said women would often ask her,“You know how to stop us from having children. But what about helping us have children?” That is when she began to understand what it meant for women to remain childless in a pro-natalist society such as India. As a feminist, she said, she was obligated to intervene.

With that early conversation I should have realized that the history of fertility control and fertility assistance were connected. Because of the sheer number of years of gynecological intervention and the vast number of women patients they examine, many Indian doctors such as Dr. Gunasheela have an intimate familiarity with the nuances, particularities, and idiosyncrasies of women’s bodies. Their knowledge becomes intuitive because of the countless hours of work they have expended in performing pelvic examinations, assisting in birthing, conducting caesarians, and finally, sterilizing thousands of women. Dr. Gunasheela held two skill sets; one that hindered, and the other that facilitated women’s fertility. These two skills, however, were meant for two different kinds of bodies.

Technologies of fertility desistance, propagated by various agencies including the Population Council and World Bank in tandem with various Third World governments, were directed at women of color, specifically at working-class women’s bodies. Massive effort and funds went into population control programs in Third World countries. Yet even as the forced sterilization of the poor was taking place in India, a horrendous offshoot of population control policies was coming to a head, different sorts of developments were occurring in a laboratory at the University of Cambridge in England. In 1978, working with Dr. Steptoe at Oldham General Hospital, Dr. Edwards helped create the world’s first test tube baby. If Third World poor women were having too many babies, First World infertile women were not having any babies at all. What we witness, then, are the twin development of policies directed at desisting fertility in poor women in the Third World and medicotechnical developments at assisting the fertility of privileged, mostly white women, in the First World. The technologies of desisting and assisting fertility were implemented on different bodies for very different purposes. But with transnational surrogacy both kinds of interventions are performed on the very same body. Indian working-class women’s bodies are targeted for population control because they are the cause of India’s “demographic deluge.”1 Yet they are simultaneously recruited as surrogate mothers and subjected to new medical technologies that contribute to the reproduction of upper-middle-class families in India and around the world.

In this chapter I map out the popularization of sterilization as birth control for working-class women in India, and then trace the development of commercial infertility assistance. My purpose here is to show that markets in life are shaped by longue durée technological interventions that make some women’s bodies available for the reproductive gains of privileged others. To use anthropologist Lawrence Cohen’s succinct term, these women are made bioavailable.2 By locating surrogacy in the history of medical interventions I reveal the long-term patterns of control over working-class women’s bodies that form the backdrop to India’s emergence as a key reproductive hub.

Managing the “Demographic Deluge”: Population Control in India

I took my digital camera with me every time I conducted interviews with surrogate mothers in Bangalore. Playing with my digital camera, they’d come upon photographs of my then seven-month-old son, and invariably ask two questions. First, was he was really my child? Given that they were active participants in the infertility industry, this question did not surprise me—after all, I was dark-skinned and gray-haired with a very young, light-skinned baby. He could very well be the result of “donated” eggs and surrogacy. But the second question surprised me; upon hearing that my second born was a boy my interview subjects would ask me if I had had “the operation.”

Listening to my interviews all over again, I was struck by the constant references to “the operation,” the English word used in Kannada to refer to female sterilization whereby women’s fallopian tubes are snipped, blocked, or tied. That most of the surrogate mothers have been permanently sterilized is not remarkable, given that 37 percent of married women in India had opted for tubal ligation in 2005–06. Female sterilization is far more common in India than in any other country, including China. And it is far more common in South India than in the north.3 While there is no exact data on how birth control choice is influenced by class, better educated and wealthier women are more likely to use the pill, IUDs, or condoms than their less privileged counterparts. In Karnataka, in 2005–06 female sterilization accounted for 90 percent of “contraception” among married women, being higher among rural women and those with lower levels of education. The median age at sterilization is 24 years. And because working-class women have fewer resources and tend to utilize state-subsidized facilities, it comes as no surprise that 87 percent of the sterilized women had their tubal ligation performed in a government facility; 49 percent of the IUD users also used a government facility.4

The question then is why is sterilization the most common form of birth control in India in general, and especially for southern states such as Karnataka where population levels have reached replacement rates? The answer lies in the history of population control programs. The very first state-sponsored birth control clinics were established in Karnataka, previously known as the princely state of Mysore. The erstwhile Wodeyar royal family that ruled the region of Mysore perceived fertility control as a crucial step toward modernization. Along with having an efficient irrigation system that led to the expansion of commercial sugar cane farming, rural areas around the cities of Mysore, Bangalore, and Mandya were the first regions on the Indian subcontinent to be electrified in the early 1900s.5 And by 1930 Mysore, Bangalore, and Mandya each had a birth control clinic.6

However, the concerted push for intervention in reproduction came later, with Indian independence in 1947.7 Building on anxieties regarding population size that plagued British colonial officers, India was among the first nations to emphasize population control, initiating in 1952 what was to become over the 1960s the largest state-sponsored family planning program in the world.8 Initial family planning efforts in India were rife with conflict because various state actors held diametrically opposite views. Then Prime Minister Jawaharlal Nehru firmly believed in family planning, but Mahatma Gandhi spoke out against contraception on moral grounds because contraception relied on technological interventions that he believed harmed women. For the first decade after independence Gandhian philosophies shaped the Indian Ministry of Health’s policies on birth control. However, this was soon to change; international funding agencies and foreign governments, notably the United States, worried about India’s population growth. The New York-based Population Council, through the efforts of John D. Rockefeller III, with demographers, scientists, and population activists in attendance, supported Indian officials keen on population control by coordinating the efforts of various international agencies.9 Under this international pressure Indian administrators acquiesced to population control programs, leading over the 1950s and 1960s to “increasingly coercive policies with grievous health consequences” for women.10

By the early 1960s various international expert committees through the Population Council, the Ford Foundation, and the World Bank began promoting intrauterine devices (IUDs) around the world, including India. Under the guidance of Dr. Guttmacher, the Population Council had popularized a spiral IUD, which could be inserted without cervical dilation and local anesthesia.11 This spiral IUD still needed the expertise of trained physicians for insertion, and was to be inserted only after determining that the woman acceptor had no history of pelvic inflammatory disease, gynecological bleeding disorders, or congenital uterine abnormalities. Gottmacher, however, wanted minimal restrictions on the “cure for birth” because the need to control population growth was so great. J. Robert Wilson, chair of Obstetrics and Gynecology at Temple University in attendance at a conference where IUDs were discussed, agreed with Guttmacher, saying, “We must stop functioning like doctors . . . thinking about the one patient with pelvic inflammatory disease; or the one patient who might develop this, that, or some other complication.”12 Population control in Third World countries was imperative.

Indian Health Ministry administrators were reluctant to implement IUD usage without studying its effects; but Alan Guttmacher, in his varied roles as chief of obstetrics in Mt. Sinai Hospital, head of the Population Council’s medical committee, and newly appointed president of Planned Parenthood–World Population, persuaded then Indian health minister, Dr. Sushila Nayar, to overrule their objections. The concerted international campaign in 1965–67 to induce 29 million women to accept IUDs had disastrous results. In some regions of India nearly half of the women with IUDs complained of prolonged bleeding, and there were documented cases of severe infections. In Bihar, for example, clinics tasked with fitting women with IUDs lacked even soap to clean their hands and sterilize instruments. Peace Corps volunteers posted there recalled that “workers would wipe bloody inserters on their saris or with a cloth after each procedure, then reuse the inserter on other patients.”13 The number of IUD acceptors fell drastically.14 This might have seemed like a setback for population control, but by January 1966 Indira Gandhi became prime minister and the young woman leader intensified efforts toward stymieing population growth.15

Sripati Chandrashekar, a renowned demographer, took over as minister of Health and Family Planning. Declaring that “the greatest obstacle in the path of overall economic development is the alarming rate of population growth,” Chandrashekar aimed to reduce birth rates from the prevailing rates of 41 to as low as 20–25 per 1,000 by the mid-1970s. Lyndon B. Johnson pledged $435 million in loans and credits in order to support India’s ambitious population control plans.16 In 1966 vasectomies and tubal ligations were introduced into state-sponsored birth control programs. Health workers had to achieve sterilization targets established by administrative fiat rather than ground-driven realities and regional specificities.17 To encourage acceptors, patients were offered cash benefits to offset wage loss, transportation costs, and other incidental expenses incurred by undergoing sterilization.18 And finally, abortions were legalized in 1971 through the Medical Termination of Pregnancy Act in a partial gesture toward population control. Yet none of this explains why female sterilization became the most common form of “birth control” in India.

Why female sterilization? A cursory examination of “family planning” in India shows that female sterilization was not necessarily the mainstay of population control programs. Rhythm methods were supplemented with condoms, but experts worried that men did not want to use condoms during sex.19 And women could not be trusted to take fixed hormonal doses, the pill, on a regular basis. The popular notion was that these products were “birth control for the individual, not birth control for a nation.”20 If India wanted to limit its population, birth control decision making had to be removed from the hands of targeted individuals.

So why not vasectomies for men, which is a reversible procedure and is less invasive than tubal ligations performed on women? Given the ease with which vasectomies could be performed, taking a competent surgeon just ten to fifteen minutes under local anesthesia, male sterilization was initially held up as ideal because it was an easy, minimally invasive surgery that cost the state little money. Indeed, vasectomies had been popular; in 1962 more than 70 percent of the sterilizations were of men. The central state of Maharashtra, for example, conducted a five-week intensive family planning campaign in 1960 where more than 10,000 men underwent vasectomies in a camplike, carnival-like atmosphere in order to maximize group pressure.21 The southern state of Kerala, however, pioneered mass vasectomy camps where men were given incentives of Rs.100 to opt for sterilization.22 The first vasectomy camp set up in 1970 had 40 operating booths where 15,005 men were sterilized, which was an all-India record for the era. The second camp held in July 1971 had 50 operating booths with 100 doctors performing surgeries, which resulted in 62,913 vasectomies on men and 505 tubectomies on women.23

The Kerala model was quickly adopted in other parts of India, and by the early 1970s vasectomy camps, temporary mobile field hospitals in rural areas, were set up in order to maximize the number of men who could be sterilized. These camps were preceded by intensive publicity and propaganda efforts. Health officers, district development officers, elected members of village councils, local revenue officers, and teachers were urged to exert their influence on rural couples. Over 3 million vasectomies were conducted in 1970–71 alone.24

But vasectomies fell out of favor. In 1963, 67.3 percent of Indian couples who chose sterilization opted for vasectomies. Yet in 1980–81 that dropped to 21.4 percent, and in 1990–91 it fell to 6.2 percent.25 By 2005–06 that figure hovered around 3 percent.26 The low rates of vasectomies are observable in Karnataka too, where 1.2 million women underwent tubal ligations and only 14,000 men underwent vasectomies between 2006 and 2010.27

A large contributing factor to why vasectomies became highly unpopular was because of sterilization abuse of poor communities in India during the Emergency period between June 1975 and July 1977.28 Faced with seemingly insurmountable economic problems, including the highest rates of inflation since independence and political problems that included charges of violating India’s election laws, then Prime Minister Indira Gandhi suspended a wide range of civil rights and declared a national emergency. Opposition leaders were arrested, the press censored, and crucially for our story here, men from impoverished communities were rounded up and coercively sterilized. Spearheaded by her younger son, Sanjay Gandhi, who believed that a “demographic deluge . . . threatening to throw all socio-economic efforts off balance” was imminent, sterilization became a national priority.29 There are a number of anecdotal accounts of villagers leaving their homes or hiding in the fields for days on end in order to escape being caught and sent to the camps. The sterilization campaign resulted in a number of deaths and the government offered compensation of up to U.S.$575 (five years’ income for an unskilled agricultural laborer) for those who had died within ten days of sterilization.30 Indira Gandhi’s defeat in the March 1977 national elections is attributed to the sterilization campaigns because she lost overwhelmingly in the northern states where sterilization was pursued most aggressively.

In 1975, the year the Emergency was declared, 2.67 million people were sterilized. The following year the number reached 8.26 million individuals; 6.5 million of them between July and December 1976 alone.31 Though women too were sterilized, over 75 percent of the targets were men.3...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Acknowledgments
• Introduction: Markets in Life
• Part I. The Labor Market for Surrogate Mothers
• Part II. Incorporating Pregnancy and Childbirth into the Market Economy
• Notes
• Index
• About the Author