It was September 2023 and I was a third-year medical student arriving for my first in-hospital placement, on the pediatrics service at Humber River Hospital in North York. I had brushed up on all the back-to-school specials—hand, foot, and mouth disease, RSV, gastro—but I never would have expected the question staff physicians were grappling with.

Would you like to pay cash or credit?

On the table in front of them was a Square reader, that tiny white piece of plastic we have all tapped our credit cards to, seemingly everywhere but the hospital.

It represented everything that I had hoped never to encounter as a physician in Canada.

The first two years of medical school in Canada are spent in classrooms and mock hospital rooms, where patient-actors humour students as we stumble through uncomfortable canned phrases and awkward moments. The hope is that by the time we are released into teaching hospitals to interact with real patients, we have stopped mindlessly using filler phrases like “OK, great” as a patient vividly describes their 10/10 hemorrhoid pain.

In the hundreds of hours I had spent with practice patients, the question of how a patient would like to pay never arose. For me, this was not an oversight, but an intentional choice. I had always wanted to study and practise medicine in Canada, under a universal health care system where a person’s ability to pay would not influence my patient interactions. The biggest benefit of working under a publicly funded health care system, I believed, was the ability to just focus on the patient and the medicine, and to forget the rest.

Despite my best efforts, there I was, and there was the Square.

It is hard to estimate how many non-resident births are for the purposes of birth tourism because there is no available administrative data from immigration agencies. One of the only studies exploring birth tourism rates used data from Calgary’s central triage database between July 2019 to November 2020, and found 227 non-resident births, of which 102 were categorized through chart review as birth tourists. That’s nearly 45 percent.

On August 6, 2023, the organization CanadaMama Consulting posted on social media that they were working directly with a number of hospitals in Toronto and Vancouver, including Humber River. Their website, which is in Russian, states that their “goal is to do everything” for aspiring “baby-tourists” including visa document preparation, housing, transport, and medical care. They have three tiers of services, ranging from $16,900 (economy) to $23,900 (comfort, for those desiring “concierge service”). The company promotes “baby tourism” as being both popular and legal, with the newborn having future benefits related to education, health care, employment, and travel. The company claims to be able to provide a selection of not only hospitals, but also health care providers. (CanadaMama Consulting did not respond to requests for comment).

None of this is true.

Weeks later, Humber River Hospital put out a notice formally stating that they “are not affiliated, associated, or in any way officially connected” with birth tourism agencies. The hospital warned that the total charge for non-OHIP patients to deliver their baby at Humber would be $10,028, to be paid ten days in advance of the delivery.

Those are just the delivery fees for the hospital. An uninsured non-resident patient having their baby in a Canadian hospital will generally encounter three specialist physicians. The baby will be delivered by an obstetrician, often with the assistance of an anesthesiologist, and then must be assessed by a pediatrician.

While the hospital collects its fees up front, these physicians must individually collect their fees directly from the patient. If there are any complications requiring additional assessments, treatments, or care, patients are hit with additional fees and the physicians must collect again.

That was the case for one patient family, who have lingered in my mind in the two years since I met them. Their baby was born at Humber, but his pre-delivery ultrasound showed hydronephrosis, a dangerous swelling of one of his kidneys. The treatment for this is a week-long admission for prophylactic intravenous antibiotics to prevent urinary tract infections, which can be potentially fatal in newborns, and surgical unblocking of the ureter if it does not open on its own.

I spoke multiple times a day with the parents, who consistently questioned the medical necessity of an admission, claiming there was no way they would be able to pay the bill. They were well-dressed, seemingly well-resourced, and medically literate. I could not shake the feeling that they were misrepresenting their means, but I avoided the conversation entirely. Claiming ignorance as a medical student is one of the few perks of being at the bottom rung of the medical hierarchy.

Turns out there’s no good time to give someone a bill for their baby.

On the fourth day of the newborn’s admission to hospital, the dynamic inexplicably shifted. There were no more daily debates over cost. Instead, we were ensuring continuity of care for when the couple returned to their home in Lagos, speaking with their family doctor, pediatrician, and obstetrician in Nigeria over video call.

I wondered if the physician had confronted the patients, or if the patients had simply grown tired of bargaining for their baby.

I recently called Jay Dahman, the pediatrician with whom I was working at the time, to ask if he remembered this family. He said he could not remember them, but that it is highly unlikely that he ever received his fees. Not being paid by non-resident patients has been a common experience in his 15 years at Humber River.

He said many patients will receive the bill, claim they will pay by wire transfer, and walk away. Once a patient leaves, there’s no way to hold them to account, and chasing down patients to bill them is neither aligned with his values nor is it often successful. Patients have gone as far as giving him fake phone numbers and addresses in the past.

I asked him if he’s gotten more comfortable asking patients to pay before they leave, or has a standard way of approaching these conversations. He says it’s still nerve-wracking, particularly when patients attempt to negotiate with him. “I have to ask them—did you haggle with Airbnb? Did you haggle with the car rental company or the company providing the SIM card for you to use your phone in Canada? It’s very uncomfortable.”