The transnational nature of the commercial gestational surrogacy
arrangement has become a source of contentious academic debates. The
practice of incubating an artificially fertilised foetus in exchange of
compensation by Indian women, seeking monetary help, has been attacked
and lauded in equal measure. However, the nature of the practice and the
way it operates has got limited attention from academics working on
commercial surrogacy in India.
At a time when the case of the Thai surrogate Pattaramon Chanbua (who
allegedly kept one of the two children she gave birth to for an
Australian couple on the charge that the latter abandoned the baby
because he had Down’s Syndrome) is receiving widespread attention, it is
imperative that we engage with the Indian commercial surrogacy
“industry”. What converts this practice into an industry?
Going beyond market projections (though that plays a significant part
in its popularity), commercial surrogacy is symbolic of a growing
desire for a biological family facilitated through the use of assisted
reproductive technologies (ARTs) such as in vitro fertilisation (IVF).
Asexual reproduction – the hallmark of commercial gestational surrogacy –
has been made possible to a large measure through the use of ARTs. The
administration and availability of these technologies and allied medical
services are mapped in the book
Sourcing Surrogates: Actors, Agencies and Networks.
The book contributes to the emerging debate on surrogacy by
describing the kind of networks that operate within the commercial
surrogacy industry, especially in terms of creating a transnational
demand for the same. As part of “reproductive tourism” the book notes
that the ARTs industry caters to,
a desire to access either cheaper reproductive services or a wider
range of them; this turns citizens who would otherwise be restricted by
their nations’ policies into global reproductive health consumers –
individuals around the world who can carefully select services based on
access, geographic convenience and price (p 2).
The focus of the book is firmly embedded in tracking the ways in
which couples from India and across the world approach surrogacy in
India. This is undertaken through interviews with service providers such
as IVF specialists, surrogacy agents and others who create networks
through which the arrangement is organised.
Sourcing Surrogates is
an ethnography of the transnational commercial gestational surrogacy
industry in India that documents the practice of surrogacy across four
cities (called “sites”): Delhi, Chandigarh, Hyderabad and Mumbai. A
fifth site discussed in the book is the internet and its role in the
transnational networks of reproductive tourism.
Local-Global Networks
The book has four sites as chapters each identifying the primary
players within a city and the ways in which they operate within
commercial surrogacy. In the description and discussion of each site,
the local clinics and agents are seen to create linkages with clients in
other parts of the world.
In site 1 in the city of Chandigarh, clinics and hospitals arrange
the surrogacy arrangement for couples in India and abroad through
religious contacts of the gurudwara. Averse to the idea of advertising
infertility clinics rely on word-of-mouth publicity to attract
non-resident Indians and foreigners. One of the clinics studied was
attached to a gurudwara which had traditionally been patronised by
devotees for its healing powers in relation to curing infertility.
Within such a context, the limited or missing access to ARTs treatment
and commercial surrogacy in most of the government, public hospitals in
the city is glaring. The growth in medical services in the private
sector has been encouraged by the slow impetus to the same in the
government/public healthcare system. Infertility medicine has come to be
predominant within the private healthcare sector with the “family-owned
nursing home” being the prototype for IVF and surrogacy in the city.
Here, referrals and networks between doctors work to the advantage of
the clinic in drawing in customers.
In the city of Mumbai, site 2 in the book, networks are an essential
component of the assisted reproduction industry (ARI). Here, IVF
clinics, maternity homes, nursing homes and third party surrogacy
agencies provide surrogacy services in differing modules. The authors
discuss the emergence of the third party agency (TPA) which brings
together doctors, surrogates and couples in a way that is supposed to
make the arrangement easier to navigate and organise. The popularity of
Mumbai as a sought-after destination for foreign couples coming to India
to have babies through surrogacy is inspired by the business “model” of
outsourcing.
[A] model based completely on outsourcing, and on the principles of
‘concierge medical services’, which in the medical tourism market is
known to generate business by offering high levels of customer services
and blurring the line between hospitals and hotels… (p 42).
However, while TPAs attracted foreign clientele based on their model
of “efficient delivery systems”, domestic couples are more likely to go
to the maternity-nursing home to seek infertility treatment and
surrogacy services. The outsourcing model is also utilised by
maternity-nursing homes in Mumbai to recruit surrogates. This involves
local agents who bring in surrogates and take care of them during the
period of the pregnancy.
In New Delhi, site 3 in the study, the provision of IVF and surrogacy
services is dominant in the private sector. Corporate hospitals, trust
hospitals, multi-specialty nursing homes, single doctor clinics are some
of the varieties of establishments providing IVF services. The TPA
business model is popular in New Delhi as well. The authors present the
case study of a Delhi-based TPA that also doubles up as a rural
non-governmental organisation (NGO). Here, another form of network is
utilised, wherein rural NGOs also act as recruiters for potential
surrogate mothers. The TPA is able to effectively tap into the community
base of the rural NGO to be able to recruit surrogate mothers.
The TPA has tied up with an NGO called Ma that organises camps in
nearby rural areas. Field coordinators liaise with the NGO and create
awareness about surrogacy and educate the mothers about family planning.
They also give an identity to the woman – a voter’s identity card, and a
bank account, and teach her how to use a bank account (p 68).
These networks link the local to the global through the help of
intermediaries and other actors. However, within such cross-cutting
networks of recruitment and managing commercial surrogacy,
ethical-health considerations in the operation of IVF-surrogacy are
ignored: such as the harvesting of multiple oocytes for egg extraction,
the implantation of multiple embryos, and the practice of “embryo
sharing” (p 66).
Local networks are utilised in another way in site 4 of the book, in
Hyderabad. Here, a non-resident of India is able to resurrect
connections in his home state with local IVF doctors in order to connect
them to clients/couples overseas. Based in Chicago, the US, this
“specialist transnational agency” owner sources clients for Hyderabadi
clinics and IVF specialists. The interviews with the TPA point towards
the focus being on the overseas couples-clients who come to India – this
is the case with each of the TPAs discussed in the other sites.
Creating an easy, more navigable experience through the transnational
circuits of assisted reproduction and surrogacy is the primary aim of
TPAs. This is also evident in the ways in which citizenship papers for
the newborn are processed by them in conjunction with consulates and
embassies. The chapter on Hyderabad mentions the process of
transnational citizenship, which has proven to be very problematic for
commercial surrogacy arrangements in India as many countries do not
recognise surrogacy.
Transnational considerations mark the site of the internet as a space
for advertising and blogs for questions regarding surrogacy. Though not
recognised as a site like the other four places mentioned earlier, the
internet is an important source of accessing and creating connections
with clinics, couples and TPAs. A mapping of the websites and blogs is
undertaken to show the links between the United Kingdom (UK) and India
in relation to the reproductive tourism industry. Besides clinic and TPA
websites, the UK immigration websites also list the kind of
documentation that is required from British couples wanting to take up
surrogacy in India, especially since commercial surrogacy is outlawed in
the UK. Blogs by couples who had children through surrogacy in India
are also accessed to understand the process involved.
Reproductive Marketplace
The book succinctly identifies the aim of the reproductive marketplace:
to encourage the view of assisted reproduction as a business venture
not unlike any other form of elective medical procedure that can be
bought and sold in a world market. Such a market needs new and more
extensive networks, that bring the user and provider together (p 96).
It is these very networks through the clinics, TPAs, NGOs and
international agents and agencies that have come to dominate the ways in
which, surrogacy is being marketed. And even though across sites
surrogacy may not be the main source of clientele for IVF clinics, it
commands attention through the active intervention of TPAs.
There is a “hype” surrounding surrogacy when in reality it occupies a
very small part of their medical practice. The author notes with
reference to an IVF specialist practising in Mumbai: “[I]n his practice,
typically out of 100 IVF cycles, there are only two-three surrogate
pregnancies” (p 53). Similar findings are echoed in Chandigarh where the
family-owned nursing home has conducted only five to six surrogacy
arrangements as opposed to the overwhelming number of patients coming in
for IVF treatment. The book discusses the ways in which the demand for a
new service is created through aggressive marketing and word-of-mouth
referrals that draw in both clients and surrogates. It is here that
corporate TPAs that are active in cities like Delhi, Mumbai and
Hyderabad create a viable reproductive marketplace.
However, of importance is the connection between ARTs and surrogacy
which is often lost in discussions on surrogacy. The ARTs industry
creates the possibility of another industry that outsources expertise
and services. In that sense this book essentially provides an in-depth
look at how reproductive technology is made commercially viable. The
book effectively identifies the key stakeholders in the ART industry and
also highlights the variations in the practice of ARTs and surrogacy,
which point towards how the different sites have their own set of
cultural, social and infrastructural conditions that affect the ways the
industry works. These differences also affect the kind of
clientele/patients they bring as well as the ways in which a surrogacy
arrangement may be arranged. Chandigarh is different from the way in
which Delhi and Mumbai operate. Which is why, the identification of
clinics in a typological grid from nursing home-to-TPAs-to family-owned
clinics is a big contribution of the book in the mapping of service
providers and participants in the ARTs and surrogacy industry.
Conclusions
Sourcing Surrogates invites the reader to understand how a
complicated arrangement like surrogacy operates at a commercial level.
In a purely descriptive format the book raises questions about the ways
in which medical practices are structured by market considerations and
the demand for infertility treatment. It is in this vein that the
authors note:
The new roles for certain NGOs as recruiting sites, the naming of
recruiting agents as ‘social workers’, the provision of hostels to
protect pregnant surrogates from the disapproval of their neighbours,
the assistance in setting up a bank account for the payments, all
suggest a curious attempt at incorporation of the most extreme form of
commercial activity for the poor – the sale or hire of one’s own body –
into the language and forms of social development (p 95).
Missing discussions on some of the couples and surrogates who access
the arrangement leave a gap in the description of “actors, agencies and
networks”.
