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An economy of desire

“In our village, a childless woman is considered an ill-omen; if we see her face first thing in the morning, the whole day will be spoilt”, observed a man who had come with his wife for in vitro fertilisation (IVF) treatment at a clinic situated on the outskirts of a town in the district of Rajasthan (northwestern India). He said that though there are several children in his extended family, he needed to have his ‘own’ child at any cost. This, of course, is a matter of desire. But then, this desire is not limited to personal inclinations only, but connected to larger, more complex forces.

The impetus to have an ‘own’ (i.e. biological) child results from a conglomeration of desires: the desire of the woman to attain a projected sense of reproductive ‘fulfilment’; the desire of the husband (or male partner) to prove his ‘manhood’; the desire of the family to have an heir who would carry on the family name; the desire of society to ensure that certain ‘norms’ within the triadic institutions of family, marriage and motherhood are maintained; and the much more abstract and structuralised statist desire to generate a future workforce.

Assisted reproductive technology (ART) has fuelled this desire and made reproductive possibilities seem limitless. While in pre-ART times, infertility was considered a curse, ART has made it a choice—and a rather irresponsible one at that. ART allows the (allegedly infertile) woman—for they are almost always the ones who are blamed—to fulfil her expected role as the reproducer by enabling her to conceive, or at least by ensuring that ‘her’ child is carried to term by some other woman.

ART has spread ‘reproductive responsibility’ much wider. The infertile woman has no way out now; she has to bear a child herself or get it borne by another.  

Economising desire

The Indian government began to promote ART in the 1980s as part of a counterintuitive effort to convince people—particularly the poor who are accused of reproducing far too much—to accept family planning measures. The state quickly moved into the back seat, however, and private players stepped in to offer an entire spectrum of ART services. This, of course, led to ART becoming a niche market, highly priced and catering exclusively to affluent infertility. But the desire to have a child of one’s own is a strong one, and the need and mandate to perform the role of the reproducing woman affects the rich and poor alike.

The market began to recognise the huge potential of this population, which, despite not buying into the higher-end services straightaway, cumulatively accounts for a large quantity of low- and medium-end fertility service purchases.

Fragments from the field

My colleagues and I have undertaken a qualitative study, funded by the The Wellcome Trust, to explore the ways cultural expectations, conventional practices, and beliefs shape motivations to access ART services amongst the poor. We are also interested in the ways in which such services are marketed and delivered to these constituencies, among other topics. We have completed data collection and a preliminary round of analysis. Of the many interesting points that emerged from the semi-structured interviews, I shall briefly describe three key points that are defining contemporary (in)fertility experiences in non-urban spaces.

Low access to information

A prevalent concern among recipients is their absence of, or very limited access to, updated fertility information/knowledge. A couple from rural Rajasthan shared their experience of infertility: the wife was once pregnant, but then the doctor informed her that she had a uterine tumour. There was no choice but to excise the growth immediately, and consequently she had to terminate the pregnancy. She lost her fallopian tubes in the course of the surgery, and the doctor then suggested that she go for IVF. While we can wonder at the clinical truth of the medical indicators in this chain of events, this couple’s dependence on the advice of this one doctor exemplifies the level and quality of medical service provision in non-urban India. We are talking about a very closed context. This couple lives in a village, in which nobody from their community, family or neighbourhood could offer sound advice on where to go next. Consequently, in their quest to have a child, they had no other option but to depend on this doctor for guidance.

Childlessness is severely stigmatised in this setting, however awareness of IVF in the community is also far too low for the couple to openly discuss it. So, even as the couple sought to ‘treat’ the dubiously acquired infertility, they also felt pressured to keep the entire process under wraps. They hoped that, if the implantation was successful, they would be able to pretend that the baby was naturally conceived. Despite all these challenges, the couple’s desire to have a child remained undiminished. On the contrary, the promised possibilities of ART made them all the more determined: “However much money I have to spend [I will, but] I want my [own] child”, the husband asserted, revealing a political economy of desire, a subterranean fear of societal marginalisation, and an economic constraint camouflaged in the language of desperate determination—not to add, a surreptitious demand on the wife to ensure conception at any cost.

In another case, the wife was diagnosed with uterine tuberculosis (TB) and subsequently treated for it. However, after the TB was ‘cured’, “there was some other problem and [the doctors] did a small operation”. After the surgery, the prognosis was permanent infertility. The couple were recommended for IVF. “They [i.e. the doctors] said that they had done whatever they could possibly do and they didn’t know whether it [i.e. fertility] was in our fate”. Questions to the couple revealed that they were not aware of what the surgery had originally aimed to achieve, or what exactly had gone wrong. They accepted the acquired infertility as their fate and moved to the precincts of medical technology to help bypass it.

The dubious-yet-benevolent god

We observed many contradictions and layers of complexity during the course of our fieldwork. Many of the non-urban couples interviewed tended to accommodate the role of ‘fate’ in infertility, but with a contradictory belief that fate could be subverted with help from medical technology. To change their destiny they depended on ART clinics and providers, even as they remained deeply suspicious of the clinics and providers. The husband of the woman who was treated for TB was sure the clinics were all out to fool them, but he insisted that he would not be taken for a ride. To prove his point, he boasted that they had changed a clinic after his advance request for additional DNA testing (to ensure that the clinic would not secretly use donor sperm) was refused. This was the same man who had no clue of what had gone wrong during his wife’s treatment that had resulted in infertility. The husband of the woman who had the tumour, also opined that “doctors were not gods, but [are] like gods”—revealing the ambivalent nature of their relation with providers.  

The relation of couples with these god-but-not-yet-god providers is nuanced; this complex investment of faith, fatalism, cynicism and trust makes the experience of fertility treatment in non-urban spaces intriguing to say the least.

Veiled in secrecy

Under-regulation is a blemish that maligns much of the ART industry in India. But, as Bronwyn Parry points out in her article, both experience and empirics reveal that ART provision can, in places, be highly regulated in India. While Parry is discussing surrogacy, the same holds true for other fertility services. What our Wellcome Trust study has revealed is that the more sophisticated a clinic is, the more it abides by regulatory guidelines. Better clinics are also more likely to maintain higher internal standards of performance and service delivery. This implies, on the other side however, that clinics in non-urban settings often suffer from a lack of regulation.

One practicing fertility specialist with whom we spoke noted that, in the drive to offer fertility services to the non-affluent populace, providers tend to give in to technological gimmicks (e.g. implanting more than the recommended number of embryos) so as to achieve quick ‘success’. Such potentially dangerous games are able to go unchallenged because of the information deficit discussed above. He also talked about how these clinics, as a consequence of such unethical practices, are immensely “secretive”. He said, “They won’t tell you their data, they won’t maintain their database”. These are behaviours that clinics catering to more educated clientele in urban spaces do not dare replicate.

What emerges from this brief overview of ART in non-urban spaces in contemporary India is that the socially-economically trickling down of ART services has resulted in a redefinition of the ‘terms of access’ to such originally high-end technologies, as of the nature and quality of services.