COVID-19 continues to provide the perfect natural experiment to assess the extent of “birth tourism” – when women visit Canada for the purpose of giving birth here and thus obtaining Canadian citizenship for their child. Two years in, the data shows a decrease of almost eight per cent, compared to 2020-21 and almost 52 per cent compared to the pre-pandemic 2016-20 average, in the number of “non-resident self-pay” births in Canada.
As Figure 1 indicates, there was a steady increase of non-resident births prior to the pandemic. But after COVID-related travel restrictions were implemented in 2020, there was a sharp drop, with no recovery in 2021. This provides a very good indication of the extent of birth tourism in Canada. Now that the restrictions are loosening and travel is once again opening up, it’s time for the federal government to revisit its policy on non-resident births and Canadian citizenship.
The decline to 2,245 in 2021 from 2,433 in 2020 occurred in all provinces save Quebec, which remained relatively stable (Table 1). The decline was particularly notable in British Columbia, where most birth tourists pre-pandemic were from China – a country most affected by travel restrictions. The drop is in stark contrast to steady increases over the previous five-year period.
A similar decline in visitor visas and birth tourists has been noted in the United States.
The percentage of non-resident births in Canada fell from slightly less than two per cent of total births in 2019 to 0.7 per cent in 2020 and has remained at that level. Given increased immigration, the percentage of non-resident births also fell during the same period.
As noted in previous articles, the non-resident self-pay code that is the basis for the analysis is broader than that of women who arrive on visitor visas. It includes international students, about half of whom are covered by provincial health plans, and other temporary residents. Visitor visas recovered to only 57 per cent of pre-pandemic levels in 2021-22 while visas for temporary workers have more than recovered from pre-pandemic levels. Visitor visas for Chinese nationals, one of the major groups, have recovered to only 21 per cent of former levels compared to 57 per cent of previous levels for all visitor visas. Chinese government travel-related restrictions are likely a significant factor in the reduced number.
Table 2 provides a hospital-level view of the impact of COVID, contrasting pre- and post-pandemic years in terms of non-resident and total births for the 10 hospitals with the largest percentage of non-resident births. Non-resident births continued to decline in most hospitals. British Columbia’s Richmond Hospital – the epicentre of birth tourism with its supportive “cottage industry” of “birth hotels” – has been the hardest hit. There was a decrease of 95.6 per cent compared to pre-pandemic levels.
This suggests that my initial estimate from 2018 that about 50 per cent of non-resident births were due to birth tourism was conservative, and that the percentage of “tourism births” is about one per cent of all births (or about 0.4 per cent of current immigration levels).
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Three federal immigration ministers later, the government has not have followed up on its 2018 commitment to “better understand the extent of this practice as well as its impacts” following the first release of the Canadian Institute for Health Information numbers and related media attention. The 2021-22 decline understandably reduces political interest and pressure in addressing the issue, particularly at a time of government and stakeholder support of increased immigration, as the proportion on “non-resident” self-pay is only about 0.5 per cent of permanent resident admissions, having fallen from 1.7 per cent pre-pandemic.
Given the current focus on increased immigration, it is highly unlikely that the government will take action. The numbers are very small compared to the planned level of 500,000 immigrants to Canada in 2025 and Immigration, Refugees and Citizenship Canada’s current policy and operational challenges. However, given that visitor visas have largely reverted to pre-pandemic levels in 2022, growth in birth tourism can be expected in future years.
The government should address the policy deficit in this area. There appears to be public support for some action. A 2019 Angus Reid survey indicated that the vast majority of Canadians would support removing birthright citizenship for children born to women on visitor visas.
The use of CIHI data to quantify the extent of birth tourism, albeit approximately, highlights the potential in greater linkages between immigration and health data. With respect to birth tourism, the ability to distinguish between non-resident births for visitors, international students and temporary workers would provide greater precision on the extent of the practice.
It would also allow for more informed analysis and understanding of the health outcomes of immigrants and would identify opportunities for improvement.
The policy and operational questions remain as to whether the extent of birth tourism warrants an amendment to the Citizenship Act, visa restrictions on women intending to give birth in Canada, or other administrative and regulatory measures to curtail the practice. Because visa restrictions would be difficult to administer, and because regional administrative and regulatory measures may well encourage hospital and jurisdiction “shopping,” the “cleanest” approach would be an amendment to the Citizenship Act that would make Canadian citizenship dependent on one parent being a citizen or permanent resident, comparable to the situation in Australia.
A note on methodology
The data is from the CIHI’s Discharge Abstract Database, more specifically the responsible for funding program (RRFP) “non-resident self-pay” category, as well as totals for hospital deliveries. The RRFP data include temporary residents on visitor visas, international students, foreign workers and visiting Canadian citizens, and permanent residents. While Quebec has a slightly different coding system, CIHI ensures its data is comparable.
Health coverage for international students varies by provinces, but most are covered by provincial health plans. This is not the case in Manitoba and Ontario, and for some students in Quebec whose country of origin does not have a social security agreement with Quebec. The pre-pandemic baseline is the five-year average 2016-20.
Mackenzie Health’s Woman and Child program moved from Mackenzie Richmond Hill Hospital to Cortellucci Vaughan Hospital when it opened to the community in June 2021.