[Editor's note: For an introduction to this series about new mothers on the margins, go here.]
Pamela will never forget the birth of her first baby. The 20-something from Mexico had moved to Vancouver less than a year before with her Canadian common-law husband. Pregnant and with no health care insurance, she was told she'd have to pay at least $10,000 out of pocket for a hospital delivery. She opted instead for a home birth, with a midwife who was willing to help her despite her lack of coverage.
Relying on homeopathic remedies to relieve her contraction pains, Pamela's labour came on fast and seemed to progress quickly at first. But 20 hours later, there was still no end in sight. Exhausted and frightened, Pamela remembers fearing the worst. (Pamela's name has been changed to protect her identity.)
"I was so scared," she said. "At one point my midwife said, 'If the tea and the remedies don't work, we're going to have to call an ambulance, and that's going to cost a lot of money.'"
Pamela's son was eventually born at home, without complications, but the experience left the new mother shaken. She fought back tears as she recounted the feeling of terror, which recurred a week later after she began to haemorrhage uncontrollably. Too frightened to call 911, she anxiously waited for the midwife to arrive.
"My midwife gave me stitches and some medicine, but I was so scared of going to the hospital because it was going to be a lot of money," she said.
Going thousands of dollars into debt to pay for medical fees or having a baby at home without professional help is the frightening dilemma facing women who live in Canada without health insurance. And if an "illegal" woman does go to the hospital, health officials are supposed to alert immigration authorities, making deportation a very real risk.
Despite many Canadians' broad sense that their medical system is superior to most, estimates of the country's uninsured -- which include refugee claimants, sponsored-class newcomers, temporary workers and visitors to Canada whose work or education permits have expired -- range from 500,000 to 800,000 in number, with approximately five to 10 per cent of those believed to be living in British Columbia.
And while President Barack Obama fights to extend health insurance in the United States, Canada's Conservative government is slowing withdrawing it: over the last two years, federal changes to health coverage for many classes of newcomers to Canada was reduced or eliminated altogether.
The predicament of uninsured mothers like Pamela also places a strain on health professionals, who must navigate a labyrinthine system to determine what care, if any, the mothers can claim under any federal health insurance. Many doctors also face difficult decisions over whether to provide free care to mothers who don't qualify for coverage and who can't otherwise afford it.
How moms become uninsured
Helping uninsured women get perinatal care in Vancouver is one of Byron Cruz's many jobs. An outreach health worker and activist, Cruz has helped newcomers, primarily from Latin America, access the health care system for almost 20 years.
With his wife Ingrid acting as labour coach, Cruz helped Pamela with her home birth earlier this spring, and wrote about the experience in an email to friends before a June rally in support of refugee health care in Canada. He describes finding Pamela at 2 a.m., scared and in active labour in her apartment just steps away from St. Paul's Hospital, where she would have delivered if she were insured.
Pamela's story was one of many shared at a weekly support group co-organized by Cruz at a Vancouver church. The gatherings bring together women from Latin American countries, including Mexico, Dominican Republic, Peru and Guatemala, to share a meal and their experiences living in Canada. All are pregnant or new mothers with children up to eight years old. All live without access to health insurance, and many fear immigration authorities.
Women in their situation might first come to Canada as students; others as visitors. Some arrive as temporary workers and are uninsured because of a change in employer or expired visas. Still others apply for refugee status living in limbo, waiting on paperwork to be processed. Others choose to remain in the country even if they're not accepted. Living ordinary lives -- studying, working, dating, falling in love -- some become pregnant by choice, others by accident.
Regardless of the circumstance, pregnancy can leave an uninsured woman with hundreds of dollars in unpayable debt. According to the report "Giving Birth in Canada" by the Canadian Institute for Health Information, a night in a Canadian hospital can cost around $1,400. For babies admitted to intensive care, costs can reach $3,000 to $5,000 or more, depending on the facility. For some, even a comparatively low pregnancy-related expense -- $385 for an emergency room visit, for example -- can be excessive.
Confusion reigns in determining coverage, doctors say
Whether an uninsured woman unable to pay for care will receive it largely depends on her connections, and whether she can find a provider who will see her ahead of her due date.
Some of these women may be referred to a community health clinic like Vancouver's Bridge Refugee Clinic, which sees refugees from countries eligible for coverage through Immigration Canada's Interim Federal Health (IFH) program, as well as low-income uninsured newcomers.
But changes to the program, wrapped up in Bill C-31 and introduced in 2012, withdrew coverage from many patients.
In an effort to cut public health care costs, the legislation reduced access to IFH coverage by limiting an individual's eligibility to apply for immigration and refugee status depending on their country of origin. The effect is a rising number of undocumented and uninsured immigrants.
Under the revised IFH program, refugee claimants can be denied medical coverage even for medical conditions that are potentially dangerous for both a pregnant mother and unborn baby if untreated.
Additionally, claimants from countries that Citizenship and Immigration Canada deemed to be "safe" such as Mexico or Caribbean nations, who were once covered, are no longer eligible for prenatal care -- or any health care at all, except in rare circumstances.
Dr. Martina Scholtens, a physician at Bridge Refugee Clinic, peered at the clinic's website as she tried to explain the differences in coverage under the IFH program for recognized refugees and claimants who are still going through the process.
"The doctors here, we're constantly poring over this and conferring with each other, because it's very confusing. [We say] 'Okay I've got a patient from this country with this coverage, can she get an X-Ray, is that covered?' It's really hard to remember."
Assessing how the new rules work is also time-consuming for the clinic's social worker, Shirley Alvarez. Clinic physicians regularly consult Alvarez about their patients' coverage, said Scholtens.
"Sometimes we have disagreements, because she will come to me with something I've given to a patient and say 'Wait, this isn't going to work because... they are this kind of claimant,' and I'll say 'No, well, it says here on the website that they have this kind of coverage," said Scholtens.
Alvarez is in regular contact with the IFH program and Citizenship and Immigration Canada. "Before there might be some confusion here and there; now it's almost every client," Alvarez said.
The changes are evident in clinics and hospitals, said Scholtens. For example, while African, Romanian and Iranian patients still frequent her clinic, far fewer patients from Latin American countries or the Czech Republic show up. "We really see the effects of [political] decisions here," she said.
While the number of IFH-claiming refugees has declined, the clinic has seen a growing population of uninsured immigrants. Until last year, patients from all over B.C. were accepted for care, but due to a lack of resources the clinic was forced to limit services to uninsured patients living within the Vancouver Coastal Health Authority's boundaries.
With reduced coverage, Scholtens said the clinic's physicians have had to find work-arounds to help uninsured patients, including negotiating favours from lab technicians for diagnostic tests and seeking out donated medications.
"I have personally not had any instances where a pregnant woman who really needed something couldn't get it," she said. "We've been able to provide [medication] for them either through stock medications or asking the manufacturer to provide it."
Cobbling together solutions
Physicians at Bridge Refugee Clinic aren't the only ones searching for creative solutions to help uninsured women access needed care.
"We've been able to cobble some things together. For example, we try to negotiate to get an ultrasound or blood work done for people who don't have insurance for those tests," said Dr. Meb Rashid of Canadian Doctors for Refugee Care who is also a physician at Toronto's Christie Refugee Welcome Centre.
"It's taken considerable effort and a lot of good will from hospitals, from some of our co-workers. I can guarantee that most pregnant women who don't come to clinics like ours would struggle."
Physicians at community health clinics like Bridge and Christie mostly provide only prenatal care. They can't help women deliver their babies. Typically, the average doctor can't help either.
"To really understand [IFH] properly, you have to understand the different types of refugees, you have to know the refugee migration process, and in some contexts you actually have to know the diagnosis before you see [a patient], because some diagnoses are covered and some are not," Rashid said.
"Most doctors don't have the time to figure out someone's insurance coverage -- what's covered, what's not. They don't have the time to contact other colleagues and ask them if they can do them a favour, they don't have time to negotiate rates with the hospitals. So unfortunately, I think a lot of people will be falling through the cracks."
Rashid knows of a number of pregnant refugee claimants denied care for lack of coverage. In one case, a claimant 37 weeks pregnant was told by her obstetrician that IFH would no longer provide insurance for her pregnancy or delivery. (After further investigation, the IFH program admitted it was a mistake and the woman would be covered.)
In another example, a refugee claimant from a war-torn nation who had received prenatal care throughout her pregnancy was told at 32 weeks that her coverage had changed, and she would be suddenly forced to pay for care.
"It's quite well known that prenatal care is very, very cost-effective," said Manavi Handa, a Toronto-based midwife and assistant professor at Ryerson University. Handa argues that government shouldering the costs of preventative health care related to prenatal care saves the system money in the long run.
"Prenatal care [results] in healthier pregnancies and healthier babies, and unhealthy babies are really expensive," she said.
The Canadian Council for Refugees reviewed government calculations of per capita health expenditures prior to the changes to the IFH, and found that IFH costs per claimant were one-tenth the Canadian per-person average.
"One day in a neonatal intensive care unit can cost thousands and thousands of dollars. Babies who are born too early or too small can spend weeks or months in a neonatal intensive care unit --- and that's if they end up being healthy. After birth, they can spend more weeks and months in the intensive care unit and still end up with lifelong disabilities," she said.
"Lots of premature children end up being disabled for the rest of their lives, and then the health care system has to deal with them."
Midwifery off the side of the desk
In B.C., the number of uninsured is increasing along with the number of temporary foreign workers coming to the province. Data from Citizenship and Immigration Canada shows the number of foreign workers in B.C. more than tripled from 22,000 in 2003 to 74,000 in 2012.
Midwifery care is often one of the last options for women like Clara, an energetic single mother from the Dominican Republic who arrived to Canada as a temporary foreign worker two years ago. (Clara's name has been changed to protect her identity.)
With her visa and BC Medical Services Plan coverage due to expire days after her due date, she wasn't sure she would be covered to give birth in the hospital and she was told hospital fees could cost anywhere between $8,000 to $12,000.
"Friends told me I should just go to the hospital and give birth and worry about the cost later, but I couldn't; that's my credit score, and I came here to get a better life. I wanted to do things the right way. I didn't want to be in debt to the government," she said.
Through friends, Clara met Byron Cruz, who connected her with Marijke de Zwager, a midwife known for providing care for uninsured women. In addition to being able to speak Spanish, de Zwager was also able to provide prenatal appointments in Clara's home that worked around Clara's 16-hour work days.
Working off the side of their desks, B.C. midwives like de Zwager negotiate a fee with uninsured clients and rely on out-of-pocket payments. For those who can't afford it, midwives often provide their services for free.
"Normally I tell people what I'm paid by the government for care," said de Zwager. "I say 'I can negotiate whatever works for you and your partner in terms of what you have available.' Some people will pay the whole amount, some won't pay anything and others will try and negotiate a middle ground."
Costs associated with ultrasounds and lab work are separate from the cost of the midwife.
"Usually women don't do everything. They'll say, 'I'm not sure what my situation is going to be with MSP, so why don't we just do the very bare bones?" explains Martha Roberts, a midwife and founder of the Strathcona Midwifery Collective.
Midwives at the year-old East Vancouver clinic focus on delivering care to vulnerable Vancouver women, including low-income, single mothers, active drug users and women who work in the sex trade, as well as those with precarious citizenship status.
"Most women want the ultrasound, but they might wait a little bit and just get the location of the placenta. But what are you going to do if you pay for your $218 ultrasound and we find a heart defect? Are you going to go see anyone? Are you going to have your baby in the hospital? Is that going to change your plan? It just depends on the situation."
'If you hear screaming, don't call the police'
Though home births are on the rise among hip urban professionals embracing holistic approaches to delivery, having a baby at home without medical assistance is a very different, and frightening, proposition for new immigrants, who are often from countries with high maternal mortality rates, without health insurance, and who face underemployment, poverty, racism, language barriers or mental health issues.
But the fear of being found out and deported by immigration authorities is just as scary as the cost of medical help, according to Byron Cruz.
"Giving birth at home is a huge challenge," he explains. "How would you communicate with your neighbours or with the managers of the building that you are giving birth at home if you're undocumented and fearful of deportation? Sometimes we talk to the [building] managers and say 'If you hear screaming, don't call the police... she's just giving birth.'"
Home births with a midwife are only an option for women with low-risk, healthy pregnancies. Undocumented women forced to transfer to a hospital for emergency care may be presented with a steep hospital bill.
According to Anna Marie D'Angelo, spokesperson for Vancouver Coastal Health, under Canada Health Act regulations, if the patient billing department discovers that an individual it billed is illegally in Canada, the health authority is legally obliged to report it to the Canadian Border Services Agency.
Midwife de Zwager remembers a client who had to go to the hospital for an emergency Caesarean section. Immediately after birth, the woman was presented with separate bills for the obstetrician, the anaesthetist and the hospital. Costs can range anywhere from $4,000 for a normal birth with no interventions, to $15,000 for a birth involving a C-section, epidural, oxcytocin, and nurse care, plus fees for the hospital stay, she said.
De Zwager's client refused further care to avoid paying more money. "She lost quite a bit of blood with that birth. She was okay, but she was pretty anaemic and she refused a blood transfusion because she didn't want to pay for it. She left the hospital earlier than we would have recommended, because she was having to pay... every minute that she was there she was having to pay more money."
De Zwager refers clients who prefer a hospital birth but can't afford the cost to the New Beginnings Maternity Clinic at B.C. Women's Hospital, a clinic run by residents. The clinic's website states that it accepts patients without insurance. In reality, only limited spots are available, de Zwager said.
"They do quite a bit of financial digging to see if the women can afford to pay for their own care -- or if they have finances they could access somewhere else -- before they accept them into the clinic," said de Zwager. "They only accept about 15 people a month."
Multiple requests to interview staff at B.C. Women's Hospital and the New Beginnings Maternity Clinic were declined.
Glimpse of the way forward
The increasing number of babies born in B.C. to mothers in precarious circumstances, unable to access health insurance or whose access is delayed by endless paperwork, suggests a systemic solution is needed. Yet resources are not forthcoming.
In contrast to B.C., Ontario midwives have been funded by the Ministry of Health and Long-Term Care for the past 20 years to provide care for both insured and uninsured residents. Though midwifery fees are covered, uninsured clients still must cover costs like ultrasounds and lab work.
Some midwifery practices, like Handa's West End Midwives in Toronto, have built relationships with community health centres where clients can receive tests free of charge. But midwife Manavi Handa argues a nation-wide solution is required.
"Midwifery can fill the gaps for low-risk women, but [it] can't fill the gaps for high-risk women -- and there's no way to guarantee that someone who starts out low-risk is going to stay low-risk," she said.
Handa notes that the U.S. system is better equipped to support uninsured women.
"The U.S. has places where people without health insurance go, because they actually acknowledge that there are people without health insurance. Canada hasn't even acknowledged how many people live within our borders who don't have health insurance," Handa said.
"We know it because as practitioners we live it in a very real way, and we know that we care for these women -- but it's time for us both federally and provincially to come up with solutions to this issue."