The Life Factory In India, Surrogacy Has Become a Global Business

They come from Europe, Asia and America. Couples unable to have their own children are finding a booming market for surrogate motherhood in India. But what happens when a baby is born that suddenly belongs to no one?

Manji has six mothers. She's a healthy baby girl, weighing in at three kilograms (6 lbs. 10 oz.), with dark, downy hair on her head. She was brought into the world by Caesarean section at 2:41 p.m. on July 25, 2008. She is a pretty baby, with a perfectly round face and slightly protruding ears.

Manji's first mother is a Japanese woman. Last fall, she and her husband traveled to India to make the arrangements for Manji at Kaival Hospital in Anand, a city in the state of Gujarat. Mothers two and three were waiting at the clinic, which specializes in the treatment of infertility. Manji's second mother donated her egg cell, the father gave his sperm and her third mother provided the use of her womb. On Nov. 22, 2007, Manji, now an embryo, was transferred into the body of an Indian woman, where she began to grow. But just one month before her birth, the people who had planned her procreation got divorced. Suddenly Manji was motherless.

In July, her father, a Japanese doctor named Ikufumi Yamada, returned to India, bringing along his own mother, Manji's grandmother. Yamada had little time before he had to return to work in Japan. His ex-wife was no longer interested in "Project Baby," and the Indian surrogate mother had already delivered and handed over the infant, as stipulated in the contract. Manji, screaming and crying, met mother number four, who was in fact her grandmother. She fed Manji and carried her around, but what she failed to consider was that India is a hot place with a lot of germs and bacteria floating around. She did things the way she felt they ought to be done, keeping the windows shut in Manji's room, changing her diapers only once every six hours and only sterilizing her bottle once. Manji would likely have never become infected if she had been fed at her mother's breast and not from a non-sterile bottle. Instead, on the tenth day of her life, she was admitted to a hospital and diagnosed with severe diarrhea and blood poisoning.

There she is, lying in the infant ward at Arya Hospital in the Indian city of Jaipur. Her spot is at the back of the room, near the window, next to the drawn, sky-blue curtains imprinted with a pattern of brightly colored little ships, birds and Mickey Mouse. She hears the irregular beeping noises coming from various medical equipment. There are seven babies in the room -- each in an open glass box under a heat lamp, their tiny feet attached to clamps, which in turn are attached to cables. Their naked bodies lie on beds of real estate ads torn out of newspapers, one of them advertising a two-room apartment with bath, garden and luxury furniture. Diapers are expensive, and instead the hospital sterilizes old newspaper so that the parents can afford to keep their children alive.

But Manji is already a VIP baby, with the press touting her as "India's first surrogate-mother orphan." Since the day of her birth, her father has been fighting to be allowed to take his daughter back to Japan. Manji's treatment is free of charge -- she is given Pampers and has been assigned a personal nurse, mother number five, who is responsible solely for her care. When the journalists begin descending on the clinic, Manji is moved to a "Super Deluxe 1" single room furnished with a gray metal bed, a television set and a refrigerator with a small crocheted blanket on top. A clock hangs crooked on the wall and there's also a picture, of a European woman with a European child. The caption reads: "There is a mother behind every great child." By this time, Manji has already been introduced to mother number six, an Indian woman who has just given birth and is now Manji's wet nurse.

On the 17th day of her life, Manji is taken, in a mobile incubator, to see the elephant-headed, pot-bellied, bright orange god Ganesha, enthroned in his temple. A piece of paper with the ancient Indian symbol of good luck, a swastika, is taped to the incubator. In Japan the symbol is called manji. The father had wanted his daughter's name to mean something in both countries, Japan and India. On the 19th day of her life, CNN posts the grandmother's desperate wish on its Web site: "From deep inside my heart I want to return immediately to my own country with my grandchild." On the 22nd day of her life, the Japanese justice minister promises to do something so that Manji can travel to Japan.

But Manji has no travel documents -- she doesn't even have a nationality yet. On her birth certificate, the words "not recorded" are printed where the mother's name should be. Also on the document is the following handwritten statement: "The egg was used from anonymous egg donor … and donor's name should not be declared."

Manji's case, in addition to being complicated, has become very public. This child without a country is the reason India is now asking itself whether it truly wants to be known as a place for outsourced pregnancies.

The country is home to more than 100 hospitals and clinics that treat infertility, with many located in major cities like Mumbai, Delhi and Calcutta. But childless couples from around the world have already discovered infertility clinics in second-tier cities like Bhopal, Indore and Ahmedabad. India is the land of unlimited opportunity for people unable to have their own children. The doctors are good, they speak English, they are willing to help gay Israelis or Irish lesbians become parents -- and India is cheap. The cost of surrogate motherhood can run anywhere from $50,000 (€34,000) to $80,000 or more in the United States. In India, couples pay about $10,000 for the privilege of having a stranger carry their child.

One of these clinics, which provides a full range of services at low prices, is on a side street in Hyderabad. "Dr. Rama's Institute for Fertility" is written in red lettering on the front of the building. A rivulet of rainwater from a recent monsoon shower has formed in front of the entrance. A truck drives up. Two men are standing in its bed, sorting garbage with their bare hands. Upstairs, on the third floor of the clinic, embryologists are putting on their white lab coats and sterile masks. Six hundred times a year, including today, the staff at Dr. Rama's laboratory attempts to create life in a Petri dish.

'Come as Couple ... Leave as Family'

Dr. Papolu Rama Devi wears her shoulder-length black hair down, and heavy gold earrings. She's proud of her clinic. The microscopes are from Japan, the incubators for the fertilized egg cells from Germany, the artificial culture medium from Denmark, the Petri dishes and test tubes from the United States and the pipettes and needles from Australia. Only the surrogate mothers come from India.

"Almost all of our equipment for in vitro fertilization is imported," says Dr. Rama Devi, who received her training in Singapore and at the University of Göttingen in Germany among other places. "In return, we can offer our service to other people." Every country, she says, has its specialty.

The clinic and its four branches currently have 20 running cases of surrogate motherhood, with "running" being defined as the period following the embryo transfer. Seven of the customers are foreign couples and the rest are Indians, some of them living abroad. Since Dr. Rama Devi set up her English-language Web site three years ago (her slogan is: "Come as Couple ... Leave as Family!"), inquiries from abroad have been piling up.

The American couple's surrogate mother is in her second month of pregnancy, the Bangladeshis' in her third, the Chinese are still waiting for the results and the Turkish couple's surrogate mother lost the baby -- but a second attempt is scheduled to begin soon. A British couple also wants to try again. A Canadian couple took home a baby last December, and when another pair from the United States came to Dr. Rama Devi's clinic recently to sign their contract, they brought along their first child, also from a surrogate mother, in the hope of getting a little brother or sister for him.

Dr. Rama Devi offers the option of surrogacy to women who have had uterine cancer, who were born without a uterus or needed to have their uterus removed during surgery, or for whom pregnancy poses a substantial health risk. She also helps women who have already tried in-vitro fertilization several times before, but without results. "Whenever the woman says that she can no longer stand the stress, surrogacy is okay," she says.

Dr. Rama Devi offers the kind of attention to detail one would expect from global service providers. She sends the couples a photo of the surrogate mother they will be using, and she takes special requests into account. Hindu couples often ask for Hindu surrogate mothers, a couple from Dubai once insisted on a Muslim egg, an Indian couple living overseas requested a vegetarian as their surrogate mother, and for Westerners it is important that the women do not smoke or drink. And because no one knows whether the pregnancy will take the first time, the clinic also offers a special service for men. To ensure that the busy husband must only travel to India once, his sperm is frozen and kept, together with about 250 other sperm samples, in a white container at -196 degrees Celsius (-320 degrees Fahrenheit). Grateful parents have sent the clinic stacks of pictures of their children and invitations to family gatherings, and some have even named their babies after Dr. Rama Devi. The boys are simply called Rama Krishna.

Dr. Rama Devi opened her small hospital in Hyderabad in 1991, and she has been working with surrogate mothers for the past six years. The first surrogate mother was the friend of one of her receptionists. Then the daughter of a cleaning woman who worked in the clinic provided an egg cell. Today, Dr. Rama Devi recruits almost all of her surrogate mothers from among the families and acquaintances of her employees.

Dr. Rama Devi selects the surrogate mothers herself. Once a candidate has passed all medical examinations, the choice is made with a personality test. It goes like this: Dr. Rama Devi simply talks to the woman, her husband and her children. She has never found a candidate to be mentally unsuitable. "Usually there aren't that many psychological problems in India," she says.

Nagadurga Pasalapudi doesn't know whether she is carrying a boy or a girl in her womb. The doctors are not allowed to tell her, because of the high incidence of abortion of female fetuses in India. What she does know is that the baby has already kicked inside her five times today. Nagadurga doesn't know who the parents will be, neither their age nor profession. All she knows is that they are from Pakistan and that they are both Muslims. She herself is a Hindu. Nagadurga knows that she is seven months' pregnant, and she knows why she is here, in room 215: because of debts.

She moved to a village with her husband, away from her family, because he had been given a job as a supervisor on a chicken farm and had been paid his first wages in advance. He used the money to pay off some of the debts he had accrued running a store that sold eggs, lentils and salt. But it wasn't enough. When he saw a newspaper ad reading, Wanted: Surrogate Mothers, Nagadurga said "no." Then his father called, the creditors were at his front door, and Nagadurga said "yes."

Meanwhile, the Pakistanis had received a list from the clinic titled: "Criteria for Selection of Surrogate." The same handout is sent to all customers, so that they know that their planned children are in good wombs.

According to these criteria, the surrogate mother should be no smaller than 1.60 meters (5'3") and should weigh between 50 and 60 kilograms (110 and 132 pounds). She should be married, have her own children and a regular period, be free of sexually transmitted and hereditary diseases, be tested for ovarian problems, be given a hormonal and a chromosomal analyses, be emotionally stable and not have grandparents or parents who died young (not including accidental death). The skin color should not be too dark, and the appearance should be "pleasant."

Nagadurga has long hair and full lips. She is wearing a flowered dress in pink, yellow and light blue, bracelets, earrings and toe rings. She is 24. All surrogate mothers in Dr. Rama's clinic are between 22 and 30. She attended school for seven years and had her first child at 18. According to the contract she signed, she obtained her husband's consent before agreeing to be a surrogate mother. The contract also stipulates that the genetic parents have been tested negative for HIV and hepatitis. By signing the contract she also indicated that "I have however been also informed that there is a small risk of the mother or/and the father becoming seropositive for HIV during the window period." Under the terms of the contract, Nagadurga agrees to hand over the child, that she is not entitled to terminate the pregnancy "at my will," and that, if she does, she will be required to "refund all certified and documented expenses."

She certified "a) I have not had any drug intravenously administered into me through a shared syringe, b) I have not undergone blood transfusion and c) I and my husband have had no extramarital relationship in the last six months." She also agreed to avoid sexual intercourse during the pregnancy. Finally, by signing the document, she agreed that she would not wish to see the child after delivery.

"I want to see the baby," says Nagadurga. She rubs her fingers. "After all, I look at other newborns."

"I keep telling her that she should not develop any relationship with the child," says her husband. "I want to hold the baby in my arms," says Nagadurga.

Whether she will be allowed to nurse the baby that she carried and nourished for nine months will depend on the Pakistani couple. Some parents do not want the surrogate mother to be close to the baby, while others are adamant about the baby drinking the first rich, healthy mother's milk.

"They will not give me the child," says Nagadurga.

"It is better for her if she doesn't nurse the baby," says her husband.

A Challenge in Court

Nagadurga was three months' pregnant when her brother-in-law suddenly showed up at the clinic. Your husband, he said, has been in an accident. He was hit by a Jeep and was lying, unconscious and bleeding, on the street, and now he is in the hospital. The brother-in-law had come to get money for her husband's operation, and Nagadurga gave him everything she had: 30,000 rupees, her first payment, which she received after confirmation of the pregnancy. It was 20 percent of the total payment, payable after the critical ultrasound examination -- money in return for a heartbeat. Nagadurga wept and wept, and she stopped eating, until Dr. Rama Devi informed her that she was endangering the baby's life. She was told that it was her obligation to deliver the baby. She spoke with her husband by telephone every day, from her hospital bed to his, and when his condition improved he came to her.

At first the couple stayed in a patient room, at a cost of 300 rupees a day, or about €5 ($7). It was one of the clinic's cheaper rooms, but it was still too expensive for the Pakistanis, and so Nagadurga and her husband moved to a 200-rupee room off the staircase. They are now staying in a room wedged between the first and second floor, but at least they have a window. The surrogate mother on the fourth floor, who is carrying a child for a Chinese couple, is living in a windowless room with fluorescent lighting. Drinking water is available on the fourth floor and hot water on the second.

Nagadurga has never paid as much attention to a baby as to this one, which she will have to give away. "In the past, in my other two pregnancies," she says, "It was like this: God gave us the child, and God kept watch over the child. But this time the baby is made on earth, and so we have to pay special attention to it."

When her own children were growing in her womb, she ate the same food as everyone else in the house -- mostly rice. Now the Pakistani parents pay her a monthly stipend for food, and Nagadurga is on a special diet that includes more milk, more eggs and more fruit. In addition, she takes vitamin tablets three times a day and gets a lot of rest. It has been two months since she last left the clinic, when she went to the temple to pray for a natural birth.

An astrologist once predicted that she would give birth to five sons. What the astrologist did not say was that her second son would die. Before his death, Nagadurga had the "family planning operation," and her fallopian tubes are now blocked. She can no longer have children naturally, but she can work as a surrogate mother. All she needs is a functioning uterus, which she has.

Nagadurga is looking forward to the birth, because it will mean that she can finally return home to her own son, who is now staying with his grandmother. He's fortunate though. Other surrogate mothers have to put their children into a home while they carry another couple's child. Nagadurga speaks with her son by telephone every day. He's a good boy, healthy and understanding. Once, when he asked for a remote-controlled toy car, Nagadurga and her husband told him that they didn't have enough money to buy it for him. He never asked again. When the family came to the clinic the first time for a consultation, the son picked up a few sentences and told his grandmother that mommy and daddy had gone to the doctor to get a baby. Later he asked his parents: "Will I have a brother or a sister?" The father replied: "The baby is not for us. Stop asking questions!" The son, the good boy, fell silent again.

Out of shame, Nagadurga has told the other patients that she is carrying a child for an infertile aunt. She fears others will think she is tainted by the blemish of impurity, by the immorality of the fact that something created by the sperm of a stranger is growing inside her body. And yet it was not sperm but an embryo that was transferred into her.

Nagadurga and her husband have never met the Pakistani couple. Another Indian woman was originally supposed to carry the child, but she had two miscarriages and Nagadurga jumped in as a backup surrogate mother. If things had gone the way they normally do, at least the couple and Nagadurga would have had coffee together in Dr. Rama Devi's consultation room. Sometimes small gifts are given during these meetings. An American man once brought along a bag filled with used children's clothing and his wife's old shoes. He had originally intended to donate the items to an orphanage or to flood victims, but then he decided to give them to the surrogate mother. He flew back home and did not return until the child was born. He was given e-mailed updates in the interim. This is usually the way it works in Dr. Rama Devi's clinic.

But Nagadurga will hand over the baby to two strangers at the end of November. The Pakistanis will arrive 15 days before the due date. "How will I be able to speak to them?" she asks. "They don't even understand my language."

When the Pakistani couple heard that everything was going smoothly, they sent Dr. Rama Devi an e-mail. "Thanks very much for this good news," they wrote in English. "Our respect and our good wishes to all doctors and staff who have dedicated themselves to this noble cause in the service of mankind." In the next paragraph, the couple wrote: "I shall transfer the said amount as soon as possible." Nagadurga's husband says: "We are giving them such a valuable gift. They must want to know how the child is doing, and whether Nagadurga is taking her medications, but why have they not visited us once throughout the nine months?"

Nagadurga spreads her hand across her groin, her legs bent.

"I am supposed to be earning the money for the family," he says. "She is doing it for me, and so I help her."

The amount that the clinic recommends as "compensation" for the surrogate mothers is 300,000 rupees (€4,450). But the price varies. Some surrogate mothers are better negotiators than others. Some have no choice in the matter. Nagadurga's husband says that they will receive 150,000 rupees. His monthly salary at the chicken farm is 3,000 rupees.

The husband plans to use the money his wife is earning to buy her a real wedding necklace, one made of authentic gold. The pendant she now wears on a gold string is made of tin. But he also has new debts to repay: 15,000 rupees to his mother and 15,000 to the mother-in-law; all of them contributed money for his operation. "What the Pakistanis are giving us will soon be used up. But what we are giving them -- they'll have it for a lifetime."

If any of the money is left over, Nagadurga will take it to the bank and invest it for her son, her only child. She wants him to become a computer specialist. "No," she says, she will not work as a surrogate mother again. "No," says her husband, "never again."

Dr. Rama Devi, for her part, plans to expand. She wants to have clinics throughout India and abroad. Not in Europe, with its many laws, she says, but someplace in the Caribbean. Then the Americans will no longer have to make the long trip to India. Or perhaps the future lies on another continent, where artificial insemination has hardly been available until now. Perhaps Dr. Rama Devi will export her knowledge to Africa.

But for now she is just expecting her next customer, a 45-year-old British woman, who arrives this month. The woman has ordered egg cells and a surrogate mother, and her husband will supply the sperm. To improve the chances of success and speed things up, the woman has opted for two parallel pregnancies. Two or three embryos will be transferred into her own womb -- and just as many into the womb of a surrogate mother. If both pregnancies are successful, she says, she will be pleased with two children. And if both attempts fail, she will still be entitled to a third attempt, because she purchased a package that includes up to three cycles of in vitro fertilization. Or perhaps both she and the surrogate mother will give birth to twins, in which case the British woman will suddenly find herself with four children made in India. She will also sign an additional clause in the contract. The new clause is meant to stipulate who takes care of the baby in the event of a divorce, so that there cannot be another Manji, a child who ends up with six mothers.

On the 27th day of her life, Manji's case is referred to India's highest court. Her 69-year-old grandmother, with her gray curls, gold-rimmed glasses and tennis shoes, has come to New Delhi to hear the court's decision. The court building is an impressive red stone structure with a white dome. Manji's grandmother, who is wearing her best green blouse and a necklace, presses herself against the wall, trying to avoid the journalists, including those from Japan -- the only ones she could actually talk to. She speaks no English and had never been abroad before. She greets her attorney by pressing her palms together, the Indian form of greeting she has learned. She swings her arms back and forth, perhaps because it is humid, or because she is agitated. "Bag," a security guard says to her, miming the shape with his hands, and she quickly hands it over, together with the pills she is carrying in the pocket of her trousers. She is anxious to do everything right, hoping that the nightmare will soon come to an end.

In the courtroom, a small room with paneled walls and oil paintings in gold frames, she sits motionlessly in her seat, sometimes dropping her head to her chest and sometimes staring at the back of the seat in front of her, as the case takes its course.

A non-governmental organization has gotten involved, voicing its concerns about what it calls child trafficking and an abandoned child. Manji's attorney is a famous human rights lawyer, who has offered her services pro bono. The judge asks, his voice trembling: "Which law forbids surrogacy?" The NGO attorney replies, his voice firm: "Which law permits surrogacy?" The problem is that there is no law, merely guidelines issued by the Ministry of Health and Family Welfare, which legalize surrogacy.

In the end, the court rules that Manji may remain in the care of her grandmother, for the time being, and the case is adjourned until mid-September. It appears that Manji is stuck in India, the country that was only meant to produce her.

Translated from the German by Christopher Sultan

Editor's Note: This article was originally published in the Sept. 15, 2008 issue of DER SPIEGEL.

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