Dispatch

The World's Baby Factory

It's already the world's second-most populous country. So why is India turning grandmothers into mothers?

KOLHAPUR, India — Four years ago, when she was expecting her first baby, Kisabai Biranje wanted desperately to be invisible. She tried for as long as she could to keep her pregnancy hidden behind the crumpled pleats of her floral printed cotton saris. But as the months passed, it became impossible to keep her bulging belly a secret. 

Becoming a mother was Kisabai's greatest joy. But pregnancy in the sixth decade of her life was also her greatest shame.

As her stomach began to show, it set off a trail of tarnishing gossip and innuendo in this agrarian town in India's western sugar belt: How did she get pregnant in her post-menopausal years? Was the egg her own? Was the sperm her husband's? Why would she want to become a mother at the age of a grandmother?

But her unremitting quest for motherhood, however risky -- or risqué -- at her age, kept her going. "We had nearly given up after more than two decades of marriage," explains Kisabai, who does not have a birth certificate, but says she was born just after British colonial rule in India ended in 1947. "We went to doctors, shamans, god men -- nothing worked."

"Then we discovered a clinic that made childbearing at our age a reality," chimes in her husband Mahadev Biranje, a 68-year-old sugarcane farmer. "When we told the doctor we were thinking about adoption, he said, ‘Why do you want to raise someone else's child when you can have your own?' We looked at him incredulously and said, ‘Can we really do that at our age?'"

The Biranjes discovered that in vitro fertilization (IVF) -- a procreation technique that involves harvesting a woman's egg from the ovary and fertilizing it artificially with a healthy sperm -- could circumvent, if not undo, the deleterious influences of aging on female fecundity, making pregnancy possible even at an advanced reproductive age. For Mahadev, the procedure was akin to being plopped on a biological time machine that miraculously rolled back the years.

In recent years, thousands of fertility clinics have cropped up around India, spawning a new industry of "fertility tourism" for reproductively challenged couples from around the world. They are the medical equivalent of dollar stores, offering IVF treatment at a fraction of the cost in developed economies, and often without the strict regulations and waiting periods that elsewhere make the procedure a logistical nightmare. IVF -- along with other reproductive specialties like surrogacy (the world-famous "womb-for-rent" business), hormone therapy, and gamete (egg or sperm) donation -- are part of India's flourishing fertility treatment business, on track to blossom into a $2.3 billion enterprise in 2012 according to the lobby group Confederation of Indian Industry. The sector, described as a "pot of gold" in a report by the Indian Law Commission, has earned India the dubious reputation of being the world's baby factory.

Fertility clinics aren't just serving the international market, they're increasingly serving the domestic market as well. And regulation has not kept pace with the proliferation of clinics as India emerges as the Wild West of fertility. In recent years, facilities have been accused of a litany of shocking abuses -- from exploiting impoverished women who became surrogate mothers to prescribing unapproved fertility drugs to delivering "stateless babies" who are refused citizenship by both their mother's country and their Indian birthplace.

The Indian government is gearing up to pass a new law to regulate the fertility business, prepared by a 12-member committee of the Indian Council of Medical Research and expected to be tabled in parliament in the coming months. It mandates that all fertility clinics be registered with the government; spells out specific guidelines for the sourcing, purchase and storage of gametes; and also explicitly enumerates the health and legal rights of surrogate mothers and babies delivered by them.

But one pressing issue has remained beyond the purview of regulation: How old is too old to get pregnant?

In 2008, Rajo Devi Lohan, an Indian woman from a tiny village in the northern state of Haryana, became the world's oldest mother at the age of 70.  About a year and a half later, Bhateri Devi, a 66-year-old from the same state, became the world's oldest woman to give birth to triplets.

In India, as in many other countries, medically assisted procreation techniques have long been the preserve of the upper-class elite. But in recent years, with proliferating clinics hawking cheap treatment, it is fast becoming the trend du jour among middle- and working-middle class couples, including the elderly. Bearing children at an old age is considered anathema to cultural norms in India, as the Biranjes have learned, but it often does not overshadow the social pressure to reproduce.

After about five decades of a childless marriage, both of the Haryana women were impregnated by fertilized eggs implanted to their post-menopausal uteruses by Dr. Anurag Bishnoi, who runs a private fertility clinic in the city of Hisar. Lohan's health rapidly deteriorated after her caesarean delivery and she suffered internal bleeding. In various media interviews, she said she is still surviving on pain killers and wasn't forewarned by Bishnoi about the dangers of giving birth at her age.

Critics say Lohan's predicament is not an isolated case. Fertility clinics generally don't offer patients reliable information about IVF's low rate of success and high probability of health complications and fetal abnormalities. Women over the age of 50 who undergo IVF are known to be prone to a high incidence of gestational diabetes and pregnancy-associated hypertension. With an older uterus being less capable of effecting normal labor and vaginal delivery, the chances of cesarean delivery in women of this age group are significantly higher after IVF than with natural conception. There is also a high probability of twins or triplets -- which increase the chances of maternal and neonatal morbidity.

Bishnoi, the doctor in Haryana, has publicly denied that Lohan's ill health was linked to her delivery and appears to glorify women who take the plunge despite the risks involved in such pregnancies. "Becoming pregnant at advanced age has its own hazards," he acknowledges on his website. But "procreation is considered a basic civil right of man. We salute those women who endanger their lives when opting for IVF for becoming mother and getting rid of the stigma of infertility."

The website lists a number of cases of advanced-age pregnancies, including Lohan's case, under a separate header titled "our achievements." Leading the list is a 75-year-old man who got married twice, apparently in the quest of a baby, but to "no avail". Then in 2007, he brought one of the wives, a 60-year-old woman, to Bishnoi and was "blessed with a son and a daughter" in the same year. The reason for the woman's infertility is unknown, the website says, but her case highlights that "if a lady has uterus," nothing -- not even age -- can stop her from becoming a mother.

India's draft fertility law will mandate that a surrogate mother should not be over 35 and cannot produce more than five children, including her own. But it defines no upper age limit for other women looking to get pregnant through fertility treatments. In the United States, as in India, there are no restrictions on advanced-age pregnancies. Britain's Human Fertilization and Embryology Authority officially lifted age restrictions on pregnancies in 2005. France is one of the world's few countries that has sought to outlaw artificial insemination of post-menopausal women, arguing that the practice is "immoral" and "dangerous to the health of mother and child."

In India, where fertility treatment is significantly cheaper, regulation weaker, and childlessness is considered a curse, the recent high profile cases have highlighted how women -- even across small towns and villages where health facilities are scarce -- are taking extraordinary risks to conceive babies.

"Medically it is now possible to impregnate a 60-year-old. But medically, it is also possible to impregnate a pre-pubescent girl. Does that mean we should allow it?" says Imrana Qadeer, a retired professor from the Centre of Social Medicine and Community Health at New Delhi's Jawaharlal Nehru University. "The misguided emphasis on genetics -- ‘It has to be my baby, my blood' -- has overshadowed safer and more progressive options such as adoption."

But Dr. Pushpa Bhargava, one of the chief architects of the Assisted Reproductive Technology Bill, says deciding whether an upper age limit should be fixed is a "non-question."

"Procreation is a basic right, and we cannot deny it to anyone," he says, adding that the draft law includes a provision to "discourage" medically unfit women from seeking fertility treatment by requiring  clinics to provide professional counseling about its health implications, the low rate of success, the costs involved, and also advice on the possibility of adoption. Bhargava says a fertility counselor's role would be analogous to that of a marriage counselor. "The counselor will offer advice, but in the end, to do or not to do is entirely your decision."

But given the intense social pressure that surrounds childbirth in many parts of India, prospective mothers often don't see it as a choice. Infertility is rarely countenanced as just another random happenstance of birth. A victim of nature's caprice you may well be, but childlessness in many corners around India epitomizes a grave sexual defect, eliciting guilt and shame. "‘No baby? Is something wrong? Is it you or your husband?'" Kisabai Biranje describes it. "That's the general thinking. A married couple must reproduce to be venerable in society."

Before their marriage, Mr. Biranje was wedded to Kisabai's elder sister, Akatai, but he left her after she was diagnosed with a uterine fibroid -- a non-cancerous tumor lining the muscles of her uterus -- which challenged her ability to conceive. The current legal status of their marriage is unclear. The two women and Mr. Biranje live together in the same house. IVF was tried on Akatai once, but it failed. Kisabai has undergone numerous IVF cycles in the past half-decade -- each more physically daunting and emotionally nerve wracking than the other. "After every failed cycle, you cry and cry for days," she says. "Then you wipe off your tears and get yourself ready for more needle pricks." Mr. Biranje says the medical bills have cost him more than 200,000 rupees ($4,000). He is not comfortable sharing where the egg or sperm came from, but the source was vetted from their own caste. The Biranjes say they were warned by their doctor of the low success rate, but they still revere him as "god" for holding out hope that they "won't die barren."

Hope does eclipse realism at Dr. Satish Patki's clinic, spread over three floors in a boxy building that stands out in a sedate neighborhood in Kolhapur's leafy suburbia only because of the crowds it attracts. On a typical weekday, the clinic's slender corridors are packed with patients, clutching scans and medical reports, many from faraway places -- a nurse from Pune city -- 145 miles away -- whose husband has threatened to dump her if she did not produce an heir; a municipal employee from Hubli in neighboring Karnataka state whose wife has been declared "normal" by gynecologists and is troubled by whispers among relatives that he maybe impotent; a Moscow-based Indian businessman visiting with photographs of his teenage daughter delivered in Patki's clinic in 1997 after his Russian wife underwent 19 failed IVF attempts elsewhere.

Patki, a diminutive man with an amiable boy-like charm and receding hairline, has delivered more than 1,000 IVF babies in over two decades. His private chamber is festooned with a rack full of awards and trophies and photographs of him hobnobbing with influential politicians. But he spends much of his time inside his laboratory, a compact cleanroom accessed through a hygiene sluice with an air shower system. Inside, Patki, dressed in surgical scrubs and squinting into a microscope, makes babies in a petri dish. Outside, white-clad nurses explain the technique to bewildered couples watching the magnified image on a large plasma television. On one afternoon, a waiting middle-aged couple gazed with amazement at shoals of sperm bobbing around like jumpy tadpoles as they were plucked and pierced into egg cells. Minutes later, Patki emerged from the lab, wearing a triumphant smile as he took off his scrubs and reassured the wonderstruck couple that the embryos would soon be ripe for implantation.

Young and middle-aged couples form the bulk of his patients, he said later, sinking into the overstuffed swivel chair in his office. His clients comprise poor peasants -- who are lured to his small-town clinic, which is significantly cheaper than fertility clinics in cities -- as well as wealthy tycoons who are assured fully discreet personal service if they so wish. With some patients, he often feels compelled to explain that medically it is not possible to manipulate the gender of babies -- at least not yet -- a stark indicator of the cultural preference for male children in India, which has dangerously distorted the country's sex ratio. He says he does not carry out requests for sex-determination tests either. "Disclosure of sex of fetus is prohibited under law," reads a placard tacked on his cabin wall.

Unlike the controversial Bishnoi, he does not advertise advanced-age pregnancies as a specialty, but he does not discourage them either. "The uterus is the only organ that can be rejuvenated" post menopause, he beams, as if declaring a prophecy.

Patki says he has had only a "handful" of such cases, the most memorable of which was that of a 50-plus woman from a nearby village who became a surrogate for her own daughter in 2006. The daughter suffered from Rockitansky syndrome -- a rare congenital disorder which causes the uterus to be absent. Too ashamed to publicly reveal that she was pregnant with her grandchild, the woman was given a private room in the clinic after her abdomen started to bulge.

The local press had a field day with the sensational story. "Granny delivers grandson," read a headline in the best-selling Times of India -- the clipping is part of Patki's glossy clinic literature. But she had no desire to be celebrated. Just hours after her caesarian delivery, she sidled out of the clinic with the baby, becoming the only patient who, Patki regretfully says, lost all contact with him.

The Biranjes had no desire to be celebrated either. For them, undergoing IVF was like taking a blind leap, knowing fully well there may be no redemption in the end. But many failed cycles -- and a million tears -- later, a miracle happened. "Parenthood, however late in life, makes you feel complete," Mr. Biranje says, as Madhura, his tiny and underweight daughter, lolls on the floor near his feet. The wives, coy and reserved, nod in agreement. As he lifts her in his arms, Kisabai speaks, almost as an afterthought: "Yes, but we might not be around when she grows up."

Her eyes brim, but don't well over. After she had Madhura, Kisabai got lucky a second time in 2010, but suffered a miscarriage in the third month. The Biranjes recently sent Patki a stack of freshly peeled sugarcane from their farm through a messenger, requesting another appointment. They are hoping he will give them a boy.

ROBERTO SCHMIDT/AFP/Getty Images

Dispatch

Sex for Sale in Beirut

Lebanon's "super nightclubs" straddle the line between brothel and strip club.

BEIRUT — Jad sits on a couch in the lobby of a hotel in Maameltein, Lebanon. The air is thick with stale cigarette smoke, and the mirror-lined walls are smeared and cracked. A gold crucifix gleams on his chest. There's a large notebook on the chair beside him. Every so often, an attractive, young, Slavic-looking woman walks over, and he opens the notebook so she can sign her name.

"I have to make sure they sign out before leaving the hotel," says Jad, whose name has been changed. "Otherwise, Immigrations will make me pay a penalty."

Jad owns a "super nightclub," one of approximately 130 in Lebanon, most of which are located in the town of Maameltein -- just 20 minutes away from the glitzy clubs and high-end boutiques of Beirut. Not quite strip clubs, not quite brothels, super nightclubs represent the seedy underside of Lebanon's famous night life. Owners import women, usually from Eastern Europe or Morocco, to work in their clubs under an "artist" visa. It's understood, however, that "artist" is really just a euphemism for "prostitute."

Lebanese law stipulates that these women can enter the country only after signing an employment contract, which has to be approved by the Directorate of General Security. Although the women come voluntarily, it's not clear how many of them understand what their job will actually entail. According to Jad, most know what they're getting into. Once in Lebanon, however, the women's passports are usually confiscated until their contract is over.

There is no precise data on the super nightclub industry's revenues, but Jad estimates that he makes a maximum profit of $30,000 a month. In a 2009 article, Executive magazine reported that super nightclubs haul in at least $23 million a year through legitimate channels. That might be only the tip of the iceberg, however, as the industry also generates under-the-table income through prostitution. Although prostitution is technically legal in Lebanon under a 1931 law, it's only permitted in licensed brothels -- and the Lebanese government stopped issuing the licenses in 1975. Therefore, any prostitution that occurs in super nightclubs is nominally illegal.

As a result, a complicated ritual takes place in these establishments in order to stay on the right side of the law. Customers pay about $80 for a bottle of champagne (the government collects a 10 percent sales tax on each bottle) and an hour with one of the women at the club that night. The women are always fully dressed, and while kissing is allowed, further sexual contact is strictly prohibited. However, a bottle also buys you a "date" with the woman sometime during the next week. Although there are clubs that will allow customers to take a woman on the same night for an extra fee, Jad says, this is rare since the penalties for such offenses are severe.

"One mistake, and Immigrations can ruin your business," he says. "It's not worth it to break the rules, even if it makes you money, because if you get caught, it can cost you a lot more."

At first, Jad is evasive when asked whether the "dates" purchased by customers usually include sex.

"We don't sell girls," he maintains. "We're not bordellos. We sell time with the girls. I only make money from the transactions at the club. But I don't have GPS on every girl. If they want to do that, it's their business. Nobody's forcing them."

As the conversation continues, though, Jad concedes that most of the time, it's expected that the "date" will end in a room at one of Maameltein's many cheap hotels. He insists, however, that the women have the option of saying no, and he's adamant that the industry gets a bad rep.

"Everybody thinks that people who work at cabarets are the worst people in Maameltein," he says. "But we're really the cleanest people.… I'm not trying to say that we're saints, but we have rules."

Although Lebanon is widely considered to be one of the more sexually permissive countries in the Middle East, large portions of the country remain culturally conservative. According to Jad, most of his customers are wealthy, middle-aged Lebanese men, usually Muslim, who are looking to bypass the restrictions of Lebanese society.

"Lebanese girls don't like to go out and have fun because they're afraid people will say they're whores," he says. "Lebanese men like Russian girls because they like to have fun. If a guy wants to kiss a Lebanese girl, she'll probably start talking marriage and then he'll have to deal with her family."

When I ask whether it would be possible to speak with one of the women, Jad is initially reluctant, but he seems to relax as the interview continues. At one point, he is interrupted by his cell phone and, after a brief conversation in Russian, indicates that one of the women will be coming downstairs to answer a few questions, though he insists on being present. Shortly after, a tall woman with white-blond hair enters the lobby dressed in pajamas. She rubs her eyes sleepily and sits down next to him. Her name is Lina, and she's from Ukraine. Although she seems wary at first, it's soon clear that she has quite a different perspective on the industry. Surprisingly, Jad lets her talk.

"Coming here was the biggest mistake of my life," she says immediately. "In my country, I have my home, my family. But it's hard to make money. I worked with my brother in his business, but because of the economy, the business failed."

Lina lights a cigarette and sighs. "I've worked many jobs in my life, but I hate the system in Lebanon," she says. "I thought I was coming here to work in a disco, but when I came here and found out everything, I was shocked. Girls had told me what it would be like, but they only told me half the truth. I imagined that I would only have to go with people I liked.… I'm just waiting for my contract to finish so I can go home."

Her eyes fill with tears and she looks away. "I hate when someone chooses me," she says quietly. "I feel like I'm a product in a market and anyone can just point at me and say, 'I want that.'"

Jad interrupts her. "You're not happy you came to Lebanon?"

She looks him in the eye and smiles sadly. "I'm happy for one reason. You know why."

After she leaves, Jad leans back in his chair and is silent for a moment.

"I'm in love with her," he says after a while. "But I can't marry her, because if I do, I'd have to get out of this business, and I can't do that right now. This business isn't for her, and I respect her for that."

Not everyone involved with the industry is as forthcoming as Jad. It takes some time for Toros Siranossian, who represents super nightclubs to the Syndicate of Owners of Restaurants, Cafes, Night-Clubs and Pastries in Lebanon, which serves as a lobbying body between investors and owners and the government, to admit that he's involved with the industry at all.

Siranossian is a grandfatherly man with sharp black eyes, who looks to be in his late 60s. Every time he's asked a direct question, his perfect English suddenly fails him. When he reluctantly agrees to discuss the super nightclub industry, he insists it's a system that actually benefits Lebanese society.

"Lebanon is a tourist country, and because of that, we can't invite people to come see churches and mosques," he says. "We must have everything. It's better to have super nightclubs so people can go out with foreign girls instead of Lebanese girls. They'd have to pay a fortune to go out with Lebanese girls, and a lot of Lebanese girls would become prostitutes."

According to Siranossian, the industry has fallen on hard times in recent years.

"Girls cost more to bring over now," he says. "After paying money to the Ministry of Tourism and paying off the police, that's a lot of expenses.… Now, unless [super nightclubs] do dirty business, like forcing the girls to sleep with customers, they won't make enough."

Recent difficulties aside, the super nightclubs still have a loyal clientele among many Lebanese. Tony, a confident, muscular man in his early 40s dressed in jeans and a crew-neck sweater, is a frequent customer of the clubs. Although technically Christian, Tony, whose name has been changed, doesn't consider himself religious. He says that the industry is completely unique to Lebanon.

"These clubs would not be able to operate for one day in any other country," he says.

"They're in a category by themselves. I mean, the whole thing is such a procedure -- you can't even get a girl on the same night. But it works here, maybe because of the culture, which is open in a lot of ways but still very conservative in others."

According to Tony, the super nightclub industry has its redeeming qualities.

"There are benefits to the system," he says. "The girls have to get tested, and they're usually pretty well protected. But there are downsides too. Those girls basically live in a prison. They're locked in their hotels for most of the time, and they don't leave unless they have a customer. All the girls I meet at clubs are completely depressed. It's not exactly a turn-on."

Tony said that the government tolerates the industry because they can tax its revenues and because officials consider it better to contain and regulate prostitution than have it spread throughout the country. "They've turned Maameltein into Lebanon's red-light district," he says.

The complex nature of the super nightclub industry is typical of Lebanon, a country with more than its fair share of contradictions. As one drives past the neon signs of Maameltein's cheap hotels and seedy clubs, it's almost impossible not to compare it to the glitz and glamour of Beirut night life. Every Saturday night, while sleek Dior-clad women sip cocktails at luxurious rooftop clubs, super nightclub women just 20 minutes away don halter tops and micro-minis and prepare for work.

"It's like Jesus and Judas," Jad says of the industry, touching his crucifix. "God put Judas on Earth to kill Jesus. The super nightclubs are just fulfilling their purpose. Lebanon needs us, but it still judges us."

JOSEPH EID/AFP/Getty Images