Transnational Reproduction

Race, Kinship, and Commercial Surrogacy in India

Daisy Deomampo

• Publisher: NYU Press
• Year: 2016
• ISBN:
  9781479890378
• Topic: Social Sciences
• Subtopic: Cultural & Social Anthropology
• Index: Social Sciences

Transnational Reproduction traces the relationships among Western aspiring parents, Indian surrogates, and egg donors from around the world. In the early 2010s India was one of the top providers of surrogacy services in the world. Drawing on interviews with commissioning parents, surrogates, and egg donors as well as doctors and family members, Daisy Deomampo argues that while the surrogacy industry in India offers a clear example of “stratified reproduction”—the ways in which political, economic, and social forces structure the conditions under which women carry out physical and social reproductive labor—it also complicates that concept as the various actors in this reproductive work struggle to understand their relationships to one another. The book shows how these actors make sense of their connections, illuminating the ways in which kinship ties are challenged, transformed, or reinforced in the context of transnational gestational surrogacy. The volume revisits the concept of stratified reproduction in ways that offer a more robust and nuanced understanding of race and power as ideas about kinship intersect with structures of inequality. It demonstrates that while reproductive actors share a common quest for conception, they make sense of family in the context of globalized assisted reproductive technologies in very different ways. In doing so, Deomampo uncovers the specific racial reproductive imaginaries that underpin the unequal relations at the heart of transnational surrogacy.

1

Public Health and Assisted Reproduction in India

I first met Karishma in Dr. Singh’s office, where she was pursuing a second attempt at becoming a gestational surrogate. She was friendly and inquisitive throughout our brief conversation, and at the end of our interview she invited me to visit her at her home in Kailash, about an hour and a half outside Mumbai. I eagerly accepted.

I would soon learn that in contrast to many of the homes I had visited (which often lacked running water and many material possessions), Karishma’s appeared perched on the edge of the middle class, belying dominant media representations of impoverished Indian women desperate to rent their wombs as surrogates. Indeed, while making plans to visit Karishma and her family, Karishma’s husband inadvertently texted a shopping list intended for the local provisions store instead of the directions we needed to travel to their home. The list included items such as brand-name household supplies and Bournvita (a chocolate malt drink mix); reflecting her surprise at the shopping list, my translator remarked, “These are items we would buy ourselves,” indicating that the family was closer to middle-class status than working class. My translator’s hunch was confirmed once we arrived at Karishma’s home; unlike some of the women I had interviewed who lived in small, one-room shanties, Karishma and her family lived in a two-room flat with running water. Various food provisions lined the pantry shelves, as well as a few children’s toys. In the background, Karishma’s two daughters were watching cartoons on a large television set, and in the center of the room Karishma set a plate of biscuits on the coffee table. After offering us snacks and refreshments, she sat down to tell us her story.

Twenty-nine-year-old Karishma was married and had two daughters, aged seven and three. She and her husband, Rajan, had both completed high school. While Rajan worked in the hospitality industry after completing a diploma in hotel management, Karishma described herself as a “housewife,” though she had also previously studied nursing and had worked as an auxiliary nurse midwife. Yet, after the birth of her children, she said, “I had to think about who would take care of them,” and she decided to stop working in order to care for her children.

Though Rajan could sometimes earn a monthly salary of up to U.S.$650, the family’s finances were unstable. Rajan was in the process of starting his own hospitality consulting business with several colleagues and did not have a steady income. Karishma wanted to help her husband support the family and suggested that she might earn money as an egg donor or surrogate, which she had learned about from Rajan’s sister, herself a former surrogate. Explaining his reaction, Rajan says, “I was against it then, but there were some financial messes. Checks were bouncing, and we were in need, so she said she wanted to contribute and help.” Karishma too initially was somewhat uncertain, saying, “I kept wondering how such things [conception through egg donation or surrogacy] could happen.” But eventually, she realized, “By doing this, we are getting some financial help. And there is no other place where such immediate financial help is available.”

While Rajan was out of town for work, Karishma decided she would sell her eggs in exchange for approximately U.S.$260. She returned to sell a second time at a different clinic, earning the same amount of money. When she wanted to sell her eggs a third time, however, her doctor, Dr. Singh, suggested that she become a surrogate. As Karishma explained, “The doctor said that donors were not needed; surrogates were needed. ‘Don’t do donation now,’ she said.” Talking it over with Rajan, they decided to move forward with surrogacy: “We thought that if we got good money, we could add to our earlier savings and buy a house.”

In the end, Karishma attempted to become pregnant as a gestational surrogate twice; embryos made from the intended father’s sperm and an anonymous donor’s eggs were transferred to Karishma’s uterus. In both attempts, the client was a Russian man named Seth, whom Karishma met once, briefly. The first attempt ended in miscarriage early in the pregnancy, and the second attempt did not result in pregnancy. She earned about U.S.$220 for undergoing embryo transfer at each attempt, and the family ended up with little savings. Rajan explained that both times the couple had to commute long distances and keep both children in day care during Karishma’s hospital stay—fifteen days following each embryo transfer. The costs of travel and childcare consumed a substantial portion of her earnings.

Karishma also described the surrogacy process, which included multiple injections of hormonal treatments over a period of weeks, as physically painful. She explained:

During the process, surrogate mothers alone face the problems. The injections, which you take for about 15–20 days[,] are very painful. We can’t sit; we can’t sleep on one side. There are a lot of cramps after the injections. . . . I took forty injections the first time, which went on for about two to three months. It failed. There was so much pain. The second time I took 15–20 injections and again there was so much pain.

Furthermore, she was disappointed and disillusioned with the treatment she received from Dr. Singh, who, as we will see, Karishma believed did not fully inform her of policy changes that would affect her payment. However, when asked if she would ever try becoming a surrogate again, she replied that she would consider surrogacy with a different doctor, telling me, “You go to other hospitals [for your research]. If you hear of a good offer, let me know.”

***

As Karishma struggled to gain access to the global surrogacy market, another family in Australia grappled with infertility and dreams of parenthood. Jan Marks was thirty-seven years old when she first met her husband, Stephen, in 2005. Two years later, Jan and Stephen were married and in the midst of expanding their home from two to five bedrooms; already a stepmother to her husband’s sons from a previous marriage, Jan treasured her family and was eager to fill their home with two more children of her own. Aware of the difficulties women of her “advanced age” face in getting pregnant, the Australian couple immediately began trying to have children. After several years of multiple miscarriages and attempts at IVF, Jan learned that she had a bicornuate uterus, commonly referred to as a “heart-shaped” uterus, and that it was very unlikely that she would ever be able to gestate and give birth to a child of her own. Moreover, she learned that if they decided to continue pursuing parenthood through surrogacy, they would have to do so with donor eggs, as her own eggs were no longer a viable option.

Jan was devastated by this news but undeterred in her desire to become a parent. She turned next to adoption, but quickly realized that domestic adoption was “completely out” for them; in their native Australia, she explained, “we don’t have adoption agencies that are private—and nobody adopts.” Given the low rate of domestic adoption, they considered international adoption, yet grew disheartened when they learned of the long waiting periods and additional barriers due to their age and marital histories:

There are very few domestic adoptions, so we looked at intercountry adoption. And because we had both been married before, our choice was narrowed down to one country. We don’t have a good intercountry adoption system here and there are so, so many people wanting to adopt overseas. In our state, there were fifty couples inquiring every six months. To even get to the first waiting list, it was going to take eighteen months to get to the first interview. If we were successful, if we were allowed to even get into the program, it would have been seven years. And because I was thirty-nine at that stage, they basically said to me, “No chance!”

At this point, they briefly considered fostering, but quickly decided that fostering was not a good “fit” for them:

One of the questions we were asked was, “Are you entering into fostering with the hope of having a child come to live with you?” And I could honestly not answer “no” to that because my intentions were that I would hope that I would have the child because I wanted to be a mother. And then we found out that a child would be taken away from us eventually and we’d be told not to have any contact with that child who had been with us—and emotionally we couldn’t do that.

In 2008, believing they had exhausted all their options for expanding their family, Jan and her husband began to consider surrogacy with egg donation. While altruistic surrogacy—in which a surrogate is paid only for expenses incurred—is legal in Australia, commercial surrogacy—in which surrogates receive financial compensation—is considered a criminal offense. Knowing that there are very few cases of altruistic surrogacy in Australia, Jan looked to the United States, as she had not yet learned about surrogacy in India. Jan and Stephen were not exceptionally wealthy, but both were educated professionals, and while the surrogacy fees in the United States were prohibitive for most parents in my study (often costing upward of U.S.$80–150,000), Jan and Stephen were financially stable and keen to begin the process. They sold everything except their house, paid off most of their mortgage, and were ready to proceed.

Then, as the economic crisis of 2008 erupted, they realized their costs had grown well beyond their surrogacy budget. With surrogacy in the United States now out of reach, Jan canceled their plans, continued to do more research, and discovered surrogacy in India. Though her initial reaction was of denial and disbelief—Jan’s first thought was, “No way in the world are we going all the way there and plucking poor Indian women out of the slums for surrogacy!”—she discovered online support forums and blogs that shared successful stories of parents returning home from India with babies born through surrogacy. Eventually, Jan and her husband thought, “If these people can do it, so can we,” and they booked their first trip to India in 2008. Over the next two years, Jan and Stephen would make three more trips to India in order to attend two different clinics in Mumbai and Delhi before finally welcoming their son, James Alok, into the world in 2010.

***

The two stories above are very different: one of a struggling middle-class Indian family that turned to surrogacy and egg donation as a temporary solution to ease financial hardship and the other of a well-off Australian couple pursuing parenthood through Indian surrogacy. On the one hand, Karishma and Rajan’s story mirrored that of many families who felt ambivalent about surrogacy or egg donation but pursued it anyway because of financial need. Though both had concerns about the process and Karishma had strong complaints about the physical toll egg donation and surrogacy took on her body, Karishma remained interested in the prospect of becoming a surrogate in the hope that she would meet a new doctor who would pay more. What motivates so many women like Karishma to become egg donors and/or surrogates?

At the same time, Jan’s story, like those of many parents I interviewed in the course of this research, illustrates the ways in which parents eventually reach the decision to pursue surrogacy in India. Indeed, couples did not reach these decisions easily, and many were initially quite resistant to the idea of surrogacy in India, as was Jan. For many parents, the decision to pursue surrogacy is a difficult one, often following long histories of infertility and financial loss, and elucidates the range of ethical, moral, financial, and physical challenges at stake. In Jan and Stephen’s case, their surrogacy journey included several IVF attempts and miscarriages, explorations into international adoption and fostering, significant financial losses from failed surrogacy plans in the United States, and finally several surrogacy attempts in two different clinics and cities in India. While the parents’ stories uncover a range of motivations and personal histories with infertility and reproductive disruptions, how did they all end up journeying to India to hire gestational surrogates?

As commissioning parents and surrogates narrate complicated reproductive and personal histories, this chapter asks how India in particular emerged as a surrogacy destination for foreign prospective parents seeking babies and Indian women seeking an income. What is the constellation of contexts that makes surrogacy in India possible for both infertile couples pursuing parenthood and women seeking to become surrogates or egg donors? When and why did India surface as a leader in reproductive tourism?

In this chapter I address these questions by tracing the history and context of global medical travel for assisted reproduction in India. Indeed, this chapter provides the historical context necessary to understand not just the current state of reproductive tourism in India, but how and why India emerged as a major destination for reproductive tourists. I treat three topics: changes in health care accessibility for Indians, the rise of reproductive tourism, and efforts to regulate assisted reproduction in India. I place in historical context the emergence of India as a global surrogacy destination within a broader discussion of public health, assisted reproduction, and medical tourism, showing how the shift in health care priorities from primary health care to high-tech solutions set the stage for the growth of reproductive tourism in India. I then analyze the political economy of medical and reproductive travel in India, examining ART laws and regulation in order to show how India emerged as a key “therapeutic landscape” (Buzinde and Yarnal 2012) for travelers seeking ARTs. By investigating the political-economic contexts of reproductive tourism, I consider the practice as a “racialized therapeutic landscape” that unveils the sociopolitical dynamics within which gestational surrogacy has flourished. I suggest that in order to understand the contemporary politics of reproduction in India, we must grapple with the structural relations of power that characterize transcultural sites of medical tourism. For example, exploring the encounters between elite consumers of ARTs and local providers of ART services reveals the foundations of a racialized politics of power in transcultural health care settings. A critical examination of the dynamics that give rise to and emerge from such settings offers invaluable insights into the negotiation of power.

My second goal in this chapter is to point to the practices and practicalities that are integral to the experience of reproductive tourism in India. As many intended parents explained to me, one of the most challenging aspects of surrogacy in India is the complex coordination of multiple reproductive actors, including doctors, surrogates, and egg donors. For intended parents, surrogates, and egg donors, the surrogacy journey includes numerous attempts, negative test results, and miscarriages. Commissioning parents also make multiple trips to India, though surrogate women too may travel long distances from their homes to reach clinics in the city or other cities in India. As intended parents, surrogates, and egg donors navigate the process of transnational baby making, what is the range of practices that Indian clinics make available to international consumers of assisted reproductive technology? How do these clinics approach their work with Indian women hoping to become surrogates? As surrogacy relationships are facilitated across transnational spaces through Skype, email, phone, and the Internet, what is the context of surrogacy “on the ground” in India?

Thus, this chapter also contextualizes the practice of surrogacy in India, describing the range of clinics and surrogacy practices that an intended parent or surrogate may encounter. While commercial gestational surrogacy has blossomed into a multimillion dollar industry in India,1 the current absence of any laws regulating surrogacy has resulted in the proliferation of surrogacy clinics throughout the country, with no governmental oversight regarding surrogacy recruitment, medical care, treatment, and costs. While I argue that reproductive tourism takes place in a transnational context, my goal in this chapter is to investigate the context of reproductive tourism in India. In doing so, I demonstrate how the construction of therapeutic landscapes perpetuates certain stereotypes about race that simultaneously locate India as a reproductive tourism destination and reinforce global stratified reproduction. While many actors involved in reproductive tourism, including doctors, policy makers, and intended parents, claim that transnational surrogacy is about creating families for infertile couples and supporting poor Indian women to help their own families, I argue that it is simultaneously about positioning India as a modern, safe space for foreigners seeking advanced medical technologies in their journeys to parenthood. Ultimately, in scaling up India’s participation in the global medical tourism industry, the patterns and practices of surrogacy reinforce the hierarchical relationships that draw medical tourists to India in the first place.

From Public Health to Privatized Health

Surrogacy and assisted reproductive technologies encompass a range of public health concerns, and scholars have called attention to the potentially adverse health outcomes for surrogates and infants born through surrogacy (Knoche 2014). Thus, in order to comprehend how medical travel for assisted reproductive technologies gained purchase in India’s private medical market, I begin with the context of public health in India, particularly with an examination of the ways that public health approaches shifted over time from the period prior to and following independence to the current, neoliberal India. Understanding such histories of public health in India are central to examinations of ARTs and transnational surrogacy, as they shed light on the dynamics that produce India as a global medical tourism destination.

Public health policy during colonial rule largely reflected an interest in maintaining the health of the Indian Army, particularly from the mid-nineteenth century, following the rebellion of 1857. While the British government in India established medical services meant for British nationals, the armed forces, and a few privileged civil servants, the majority of the Indian population was denied access to Western medicine (Roy 1985). This interest gradually led to a broader interest in the health of the general population, and then only in response to urgent health crises caused by unrest and social disruption related to colonial conflict (Amrith 2009). Though provincial health departments were established in 1919, neither health planning nor medical education was related to the health needs of the people. However, while colonial health policy was limited and focused primarily on addressing epidemics, the most substantial improvements in public health occurred in early twentieth-century British India. The establishment of panchayats (local governments) led to improvements in sanitation and decreased rates of cholera (Tinker 1954). The provision of clean drinking water at major sites of pilgrimage further contributed to the decline in cholera (Arnold 1993).

Notwithstanding these improvements, public health remained a low priority for the colonial state, which justified its sparse spending on public health by citing India’s “naturally” high death rate and threats of Malthusian catastrophe if too much was done to reduce mortality (Arnold 1993; Davis 2001). Yet while the colonial state was ambivalent with respect to questions of public health, Indian elites began to politicize health in order to hold the state accountable. By the 1920s India’s modernizing nationalists were arguing that only a representative national government could look after the health of the Indian people (Amrith 2009).

In the 1930s, then, while still under British rule, the National Planning Committee of the Indian National Congress prioritized the health of the population as part of a broader agenda of transformation from above. Subsequent initiatives, organized by the Health Survey and Development Committee in 1946, the National Health Survey and Planning Committee, and the Five Year Plans, highlighted concrete principles for public health in resource-limited settings. These principles emphasized comprehensive, holistic approaches to public health. They maintained too that public health must address the problems of the entire population and that the state must focus on issues that caused maximum mortality and morbidity. Finally, these initiatives asserted that public health solutions must account for the availability and costs of technology, and prioritized building and maintaining infrastructure for providing services (Banerji 2001). Throughout these initiatives, public health off...

Table of contents

• Cover
• Title Page
• Copyright Page
• Dedication
• Contents
• Acknowledgments
• Introduction
• 1. Public Health and Assisted Reproduction in India
• 2. Making Kinship, Othering Women
• 3. Egg Donation and Exotic Beauty
• 4. The Making of Citizens and Parents
• 5. Physician Racism and the Commodification of Intimacy
• 6. Medicalized Birth and the Construction of Risk
• 7. Constrained Agency and Power in Surrogates’ Everyday Lives
• Conclusion
• Appendix: Profile of Study Participants
• Notes
• Bibliography
• Index
• About the Author