The booming business in international surrogacy, whereby Westerners have begun hiring poor women in developing countries to carry their babies, has been the subject of plenty of media buzzing over the past few years. Much of the coverage regards the practice as a win-win for surrogates and those who hire them; couples receive the baby they have always wanted while surrogates from impoverished areas overseas earn more in one gestation than they would in many years of ordinary work. Heartening stories recount how infertile people, as well lesbian and gay couples who want to have children (and who often suffer the brunt of discriminatory adoption policies), have formed families by finding affordable surrogates abroad. The Oprah Winfrey Show has even portrayed the practice as a glowing example of “women helping women” across borders, celebrating the arrangements as a “confirmation of how close our countries can really be.”
But make no mistake: This is first and foremost a business. And the product this business sells—third-party pregnancy—is now being offered with all sorts of customizable options, guarantees, and legal protections for clients (aka would-be parents). See for example the December 2010 Wall Street Journal article “Assembling the Global Baby,” which focused on high-profile PlanetHospital, a Los Angeles-based medical tourism company that has become one of many one-stop-shops for overseas surrogacy and that is going to great lengths to woo customers. "We take care of all aspects of the process, like a concierge service," company founder Rudy Rupak told the Journal.
The Journal article didn’t go into much detail about how surrogates’ rights might figure into this “concierge service.” But interviews with those running the operation, information that was available on PlanetHospital’s website until it was redesigned last year, and an information packet called “Results Driven Surrogacy” that the company distributes to prospective clients, begin to fill in the picture. The version of the packet that PlanetHospital sent me in July assures clients that each surrogate is “well looked after.” Surrogates spend “the entire duration of the pregnancy at the clinic or a guest house controlled by the clinic” where their habits, medications, and diets are carefully regimented and monitored. PlanetHospital promises clients that when surrogates have a history of smoking, “we make sure they do not suddenly get a craving for it during pregnancy.” Like most other surrogacy clinics and brokers, PlanetHospital accepts only surrogates who already have children of their own. While the usual reasoning for this sort of requirement is that having children proves a woman can safely carry a pregnancy to term, PlanetHospital’s literature notes that the policy also ensures that she does “not bond with your baby.”
In addition, PlanetHospital offers customers a novel means of accelerating their bid for a family: The option of having embryos implanted into two surrogates at the same time. The selling points of this package (which was previously marketed under the name “India Bundle”): Implantation in two surrogates at a time increases the chance of immediate impregnation and decreases the waiting time for a baby. As the company’s website used to explain:
PlanetHospital innovated the idea of routinely performing IVF on two surrogates simultaneously thus increasing the odds of pregnancy by more than 60%. The notion of hiring two surrogates in the US and doing IVF on both surrogates would be financially prohibitive, PlanetHospital has negotiated rates with a highly reputable clinic in India that not only provide couples with two surrogates, but also four attempts.
Of course, this approach could also leave a couple with multiple babies, possibly gestating in multiple women. Until recently, if both surrogates became pregnant—or if either surrogate became pregnant with twins—clients could opt to have the extra pregnancy aborted or twins reduced to a singleton, depending on how many babies the clients wanted or decided they could afford. As PlanetHospital’s website used to explain, “The simple answer to that is it is up to you to decide what you wish to do, you can choose to have all the children (which will cost slightly more of course…) or you can request an embryo reduction.” Founder Rudy Rupak told me via email that the company no longer allows clients to elect either reductions or abortions under the advice of its lawyers, who worry that it could open up some “nasty debates” as Indian authorities discuss the possibility of surrogacy regulation. “If a client wants both surrogates then they have to accept it if both are pregnant,” he wrote.
According to the pricing information PlanetHospital provided me, the company’s cheapest package for a single surrogate pregnancy is $28,000. To use two surrogates simultaneously, clients pay an initial $15,500, plus $19,600 for each surrogate that gets pregnant and delivers a baby. (And if one or more surrogate ends up carrying twins, clients pay a surcharge of at least $6,000 per twin.)
Of those amounts, PlanetHospital’s Indian surrogates are paid between $7,500 and $9,000. By comparison, the cost of a single surrogate pregnancy in the United States can run up to $100,000 (PDF) including medical expenses, of which about $20,000 (PDF) goes to the surrogate. Rupak emphasized the extent to which Indian surrogates stood to benefit from the arrangement. “While some people might scream exploitation,” he wrote to me in an email, “bear in mind that the per capita average income of a typical [Indian] surrogate would be $600/annum. She is thus making close to 12x her annual salary by being a surrogate.”
It is worth looking beyond economic comparisons, however, to see how such transactions may compromise surrogates’ choices. For example, if one of PlanetHospital’s Indian surrogates wants to abort her own pregnancy, she is out of luck. The company’s vice president of corporate affairs and business development, Geoff Moss, recently told me:“If they feel like terminating the pregnancy, they can’t do that; there is a legal contract.” He also suggested that surrogates would not want to take that step even if it were available to them: “They have children at home,” he said, “so they understand how important it is for these people to be parents.”
It seems unlikely that PlanetHospital’s prohibition on surrogate-elected abortions would fly in the United States. George Annas, chair of the department of Health Law, Bioethics & Human Rights at Boston University’s School of Public Health, told me via email that he believes “there is no way a competent adult woman could prospectively waive her constitutional right to terminate (or not) a pregnancy (or selectively reduce one) that would be upheld by a U.S. court.” It would appear, then, that Western surrogacy brokers benefit by looking across borders not just because it allows them to locate cheap “labor” but also because some arrangements may face less legal scrutiny than they would in the United States. Moss confirmed that legal differences between the two countries make India an attractive location for surrogacy. “In the United States, in many cases, there will be surrogates all of a sudden saying that they want to keep the baby,” he said, “In India it’s all contractual.”
The surrogates’ lack of control over the course of their pregnancies continues through delivery day. According to PlanetHospital’s information packet, “All the surrogates will deliver the child through cesarean birth.” Moss explained one reason for this policy: “Because we can time it that way for the intended parents to be there for the birth. That way if the baby is going to be born on Dec. 10, the parents can make their travel arrangements, fly to India, and be there to receive the baby when it’s born.” The information packet adds another reason: C-sections are “much safer for the child and the surrogate.” Rupak told me that while surrogates can refuse the operation and delivery naturally, PlanetHospital had been advised by independent obstetricians that routine Cesarean delivery was the safest choice. Women’s health experts and advocates would likely disagree, as many believe C-sections to be riskier to both mother and baby in the absence of other complications. The procedure also makes vaginal birth more hazardous in subsequent pregnancies and could therefore endanger the lives of low-income surrogates who may not have access to hospital care for future deliveries.
PlanetHospital’s information packet ends with a note cautioning prospective clients not to make too much of any negative reviews of the company that they might find on the Internet. "[S]urrogacy is a very emotional matter,” the packet explains. “This is not a matter of buying a car, this is a life you are asking us to help you create.” But while we can probably all agree that ordering up a child is nothing like buying a car, PlanetHospital goes on to draw an equally unlikely parallel between its business and that of a well-known purveyor of mail-order shoes. “Like Zappos,” the note concludes, “we too want to ‘deliver happiness’ and maintaining our integrity is the most important part of that mission.”
Babies aren’t like shoes any more than they’re like cars, of course, but the comparison is telling. Wombs are being rented in what amounts to an international marketplace. And with new cross-border surrogacy operations springing up recently in countries such as Panama, Guatemala, Georgia, and Greece, the number of pregnancies involving multinational players and profit interests is likely to increase. If for-profit companies are going to continue to approach baby-making like an import-export business, maybe it’s time for governments to start treating it that way, adapting oversight and protections for all parties involved. In the meantime, in the absence of meaningful regulation, the rights of surrogate mothers are being bought, sold, and signed away.