Late last month, Perla Estrada arrived at Royal Alexandra Hospital in Edmonton in need of emergency care. Estrada was in the third trimester of a pregnancy at the time and showing signs of dangerously low amniotic-fluid levels. She needed an immediate C-section but was denied: as an undocumented immigrant without health insurance, she was asked to pay for the procedure beforehand — a $5,000 fee she could not afford in full upfront. After a scramble to connect with friends who had been supporting her throughout the pregnancy, she was eventually taken to Misericordia Community Hospital nearby and admitted immediately. Her daughter was born a few hours later.
In reporting from CBC News, advocates for health care and migrant rights agreed that Estrada should not have been denied admittance the first time and should have been billed afterward, as is usually the case with non-insured people seeking any kind of emergency health care in a similar circumstance. But perinatal care, specifically, tends to raise hackles when it comes to uninsured and undocumented patients. It’s worth trying to figure out why.
The number of non-resident births in Canada grew steadily since 2008, to a peak of 5,700 in 2019. COVID travel restrictions drastically reduced that number, but it has since rebounded to 3,575 in 2022. Detractors, many of whom invoke the concept of so-called birth tourism, argue that allowing uninsured people use of our health care for pregnancies stresses an already overtaxed system — displacing citizens in need of it — and allows non-residents a pathway to citizenship through Canada’s jus solis laws.
Reports and op-eds on this issue often focus on these facts while excluding or minimizing other important context. Even at their peak, non-resident births in Canada accounted for just 1.6 per cent of total live births in the country. This number also includes international students, some of whom are covered by provincial health insurance; temporary foreign workers; and non-residents with Canadian citizenship. Significantly, not all the births that don’t fall under those categories are the result of people travelling here exclusively to give birth. Estrada herself came to Canada on the promise of a work permit that did not materialize; she had been here for more than a year, forming relationships with people and trying to find work, before her pregnancy.
In a Journal of Obstetrics and Gynaecology Canada op-ed last summer, McMaster University professor Jon Barrett wrote that Canadian hospitals should have a “zero tolerance” policy, suggesting that they “unite in a firm stand against birth tourism by refusing to accept the non-urgent planned and deliberate birth tourists in our hospitals.” The problem with absolutes like these is that they encourage attitudes that result in discriminatory incidents of the kind experienced by Estrada in March.
If the issue is that citizens who need care in Ontario might not get it, how does it make sense to focus on a national number that basically amounts to a rounding error in terms of live births, rather than on the problem of longstanding health-care underinvestment? Our health-care systems have been sorely neglected for years: if we want to ensure overall access to obstetric and gynecological care, it seems like bad faith to focus on a statistically small group of women.
Politicians have expressed concerns about citizenship “line jumping” and birth tourism for years. But those concerns are largely presumptive and, frankly, reactionary, given that we don’t have data on how many people born to non-residents through tourist visas actually go on to stay in Canada or end up qualifying to sponsor family members 18 years later. It’s also worth pointing out that children born to refugee and asylum claimants remain vulnerable regardless of their citizenship status: if their parents are deported, their choices basically amount to family separation or leaving the country as well. A 2015 study from McGill University found that up to half of children of detained parents seeking asylum or with failed refugee claims opted to accompany their parents in detention.
Concerns about systemic stresses should be focused on where health-care systems are, in fact, experiencing problems. We do have data on specific hospitals that need support, whether as the result of unpaid birth billings or concentrated planned non-resident births. Some hospitals in Calgary also have developed proactive pre-payment policies for non-residents actively planning to give birth here — deterrents that don’t involve a widespread denial of care. Policy-makers and medical professionals should focus their energy there, instead of on contributing to the pernicious trope of pregnant women as a national liability or resource drain.
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