Birth Tourism: Ethical?
As medical students at a large urban public safety net hospital, “Benjamin Beneficence” and “Astrid Autonomy” (not their real names) participated in a practice known as “birth tourism.” Was this ethical?
The Case: Birth Tourism in the Newborn Nursery
“Benjamin” writes: I was a medical student on my pediatrics clerkship, presenting on morning rounds to a crusty-eyed group of residents, students, and one weary attending. “The patient is a 1-day-old female, full term, normal vaginal delivery. Vital signs stable. She’s breastfeeding appropriately, and making a good number of wet diapers. When should I schedule her first follow-up appointment after discharge?” I asked the medical team.
My attending did not call me on failing to give the morning bilirubin level or quiz me on the range of acceptable number of wet diapers. Instead she asked, “It depends — when does the patient plan on leaving the country?”
One of the residents interjected snidely, “As soon as she gets the birth certificate.”
This sparked a discussion among the medical providers in which several individuals expressed perceptions of unfairness. “These patients use tax dollars without contributing,” one resident said.
The Ethical Dilemma: Who Pays for Birth Tourism?
Like many patients admitted to our hospital, the new mother described above was born outside the U.S. What distinguished her was the fact that she came to this country late in pregnancy with the intention of delivering here, obtaining a U.S. birth certificate for her child, and then returning to her home country.
This phenomenon, known as “birth tourism,” exists because of birthright citizenship (jus soli), which guarantees that anyone born on U.S. soil is automatically a U.S. citizen regardless of parentage. Birth tourism is completely legal so long as expectant mothers do not lie on any immigration or insurance paperwork. Pregnant women can enter the country at any stage, but most airlines restrict travel to before 36 weeks gestation. Following delivery, mothers usually return to their home country after receiving the birth certificate; processing time varies by state, but typically takes several weeks.
No official data on birth tourism exists, but it appears to be a rare phenomenon. In 2012, 7,955 women gave a foreign address when filling out birth certificate paperwork, according to the CDC, which would make up less than 1% of the roughly four million births that take place in the U.S. yearly. The Center for Immigration Studies, a conservative think tank that wants more restrictive immigration policies, notes that birth tourists sometimes provide a local address on paperwork and estimates that there are closer to 36,000 babies born in the U.S. to foreign nationals a year. However, this estimate, reported in numerous mainstream articles on birth tourism, is a dubious inference based on a bizarre and inappropriate comparison of two independently collected data sets.
Importantly, birth tourism is distinct from a controversial concept referred to as “anchor babies.” That term refers to children born to undocumented immigrants who plan on remaining in the U.S. to live and work, with the idea that their U.S. citizen child will “anchor” them in the U.S. (i.e., defer deportation). Birth tourists, conversely, are typically motivated by a desire to receive high-quality American healthcare or to secure future educational or employment opportunities for their child and do not want to move their family en masse to the U.S.
Birth tourism elicits strong emotional reactions and a deep sense of unfairness for some people. The majority of Republicans — most notably President Trump — want to abolish jus soli, thereby ending birth tourism. Trump offered his opinion on jus soli on “Meet the Press” in Oct. 2015, a few months after announcing his candidacy, saying, “You have to get rid of it. They’re having a baby and all of a sudden — nobody knows — the baby is here. You have no choice.” (As an aside, it is decidedly odd that a father of five children thinks that childbirth can be summarized as simply as, “all of a sudden — nobody knows — the baby is here.”
Several members of the pediatrics team that morning shared Mr. Trump’s feelings of unfairness — though fortunately not his misconceptions of parturition. These feelings largely stemmed from a presumption that these patients either could not or would not pay for their medical care. We are required to treat women in labor, regardless of citizenship, country of origin, insurance, or ability to pay. This is a legal imperative laid out by the Emergency Medical Treatment and Labor Act (EMTALA). When patients cannot pay or are unavailable (e.g., have left the country), medical costs fall upon the hospital or the taxpayer. One potential source of funds is Emergency Medicaid, which reimburses hospitals for labor and delivery of undocumented immigrants and temporary non-immigrants, such as birth tourists.
However, the assumption that birth tourists do not pay is not uniformly true. There is no comprehensive data on whether birth tourists pay their medical bills, but Jackson Health System in Miami has noted that 72% of international maternity patients pay with insurance or a pre-arranged package. While immigrants are generally poorer than native-born Americans, birth tourists must by definition have adequate economic means to cover travel costs and may, in fact, be well off.
Wealthy women from China and Russia are known to flock to Southern California and Southern Florida, respectively, to give birth. An entire industry has evolved to cater to these high rollers. Maternity agencies, such as Miami Mami, help women find apartments, sometimes called “maternity hotels,” as well as find doctors and obtain visas. Packages can cost tens of thousands of dollars. Ironically, Trump properties in Miami reportedly serve as some of the most popular maternity hotels.
Furthermore, a 2007 study out of North Carolina demonstrated that while the vast majority of Emergency Medicaid spending in that state was for pregnancy, childbirth, and complications, only 0.8% of all Emergency Medicaid patients (including expectant mothers and patients with other medical needs) were documented immigrants. This study did not specifically examine birth tourism, but given that most birth tourists have B-2 tourist visas and would therefore be considered documented, the paper seems to provide little evidence that there were a significant number of birth tourists relying on tax-funded healthcare.
While birth tourists tend to foot the bill in routine cases, this trend may be reversed when things go wrong. One study out of Orange County, Calif., found that children of birth tourists admitted to a NICU had longer hospital stays, more surgical procedures, and larger hospital bills than children of non-birth tourists. Children of birth tourists are eligible for public health insurance programs such as Medicaid (one-third of the children in the study were enrolled in such a program). U.S. taxpayers may, therefore, end up paying for care in some of these complicated cases. (Of note, this study was small — 50 patients — and homogeneous — most in the study were Chinese — limiting the generalizability of these findings.
The Bottom Line: Well-being of Birth Tourists and Their Children Outweighs the Financial Risks
The ethical principle of justice demands that scarce healthcare resources be distributed fairly. In cases where birth tourists do not pay for medical expenses out of pocket or through private insurance, taxpayers assume these costs, which can be substantial. This must be weighed against the economic influx brought by birth tourists outside of medicine (e.g., flights, lodging, food, etc.), which serves to increase the tax pool. Overall, it is unclear whether birth tourism is a net draw on the funding of the U.S. healthcare system, in which case it could potentially decrease resources accessible to others.
While ambiguous regarding justice, birth tourism unquestionably fulfills the ethical principle of beneficence, which requires that physicians promote the well-being of their patients. American physicians have a great potential to improve the health of birth tourists and their children, as those from developing countries might otherwise receive substandard care. We must, therefore, conclude that birth tourism is ethically valid. Furthermore, as Americans, we believe birth tourism is in line with our cultural embrace of equal opportunity.
Physicians, such as the resident on the pediatrics team, should drop the bias and judgment and continue providing birth tourists with the highest quality care.
“Benjamin Beneficence” is a fourth-year medical student. He received his PhD as part of a combined MD/PhD program, studying pancreatic cancer pathogenesis. He will be entering an internal medicine residency program this summer with plans to subsequently pursue a fellowship in hematology/oncology.
“Astrid Autonomy” is a fourth-year medical student going into neurology. As a student and researcher, she is committed to advocating for common-sense health policy that respects all people.