Last week, Maclean's magazine published an interesting little one-interview piece featuring Simrit Brar, an OB-GYN physician at Calgary's Foothills Hospital. Author Liza Agrba had caught wind of an interesting and overlooked study, published in January 2022, on the contentious topic of "birth tourism" — i.e., pregnant foreigners who visit Canada for the purpose of having their babies be born with Canadian citizenship. Past attempts to count birth tourists required some statistical inference, but Dr. Brar led a groundbreaking local effort to enumerate them directly and learn whatever could be discovered about their health outcomes and their effects on Calgary hospital capacity.
This opportunity was provided through what the economists might call a "natural experiment." In July 2019, the Calgary health region, which was not quite sure how much birth tourism the region was actually seeing, created a "Central Triage" office designed to capture all prenatal referrals for uninsured maternity patients.
As Brar et al. describe it, this administrative creature was instituted with a number of goals. It allowed hospitals to distinguish situationally uninsured patients — refugees, persons with expired visas and undocumented residents — from intentional tourists. It established a process for getting full consent from the uninsured, who might have had a nebulous legal status otherwise, and it allowed Alberta Health Services to impose some order on chaotic physician-service pricing. And patients placed in the "birth tourist" category were given pamphlets explaining, basically, "We don't want you here, although we can't chase you away," and were required to hand over a refundable deposit of $15,000.
The study describes the traffic experienced by this unique Central Triage (CT) system. Of 227 pregnant patients sent to CT without Canadian health insurance over a period of 15½ months, 102 were labelled tourists and 125 were uninsured residents. A few of the birth tourists were lost to follow-up for various reasons (a few went home or gave birth outside Calgary, perhaps as a way of evading the cash deposit), but 83 were treated in Calgary hospitals. About a quarter of the tourists were from Nigeria, 18 per cent were from the Middle East and 11 per cent were from China.
Calgary has about 15,000 childbirths in a typical year, so those 83 patients represent an added burden on maternity services of about half a percentage point — all other things being equal. But the first thing to note is that the study period ran up to Nov. 1, 2020. About two-thirds of it thus coincided with the COVID pandemic, and doctors did observe a decline in tourism visits when world air travel basically shut down.
Moreover, Calgary was the only place in Canada where birth tourists were, and are, being discouraged by means of a deposit. (Dr. Brar told Maclean'sshe is concerned that the Central Triage system may be diverting tourism patients to suburban and rural hospitals that are even more overmatched than the city's.)
Most of the birth tourists ended up using less than the $15,000 deposit and received refunds, but the study reveals that even in a city determined to address birth tourism consciously, it might create external problems. Birth tourists often arrive in Canada late in pregnancy, when air travel is risky, and some arrive with health problems from the Third World. One tourist was diagnosed with HIV in Calgary and three needed to have cervical cerclagesremoved. Since uninsured patients are on the meter while in an Alberta hospital, they may leave against medical advice. Nine birth-tourist babies required time in the neonatal intensive care unit, including a pair of twins who were in the NICU for 50 and 63 days at the worst conceivable time.
The kicker is that collecting hospital fees from birth tourists can be tricky if the cost of their care goes over the deposit. During the 15½ months of the study, the tourists ran up about $700,000 in Alberta health bills that are still unpaid. Brar takes a surprisingly unsentimental view of the birth-tourism phenomenon in her Maclean's interview, emphasizing the "finite" nature of Canadian health care and the affluent nature of the tourists. Her team's paper suggests making the Central Triage setup province-wide, and perhaps it ought to be imitated even more widely.
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