"Once the Medicaid application is approved, this fee will be refunded," the e-mail said.
"Sometimes we have to hold the infant for eight to 10 days to rule out illnesses," Heywood said. Sexually transmitted disease is the most common problem.
The number of pregnant Marshallese enrolling in Medicaid prompted Hawaii state Sen. Rosalyn Baker to sponsor a bill that would force adoption agencies to pay the hospital bills.
"We don't want Hawaii to be the gateway for trafficking in women," said Baker, a Democrat. "One way to stop the practice is to force the adoption agencies to pay the bills. They should at least have to pay for it."
"It's horrible," she said. "The federal government should be doing something."
Nancy Partika, executive director of the Healthy Mothers, Healthy Babies Coalition in Hawaii, which urged Baker to introduce the bill, said she was particularly concerned that the Marshallese were arriving late in their pregnancies, with untreated health conditions.
"This situation appears to exploit, for profit, these women, their infants and families, and the Marshallese people who are losing their future generations," Partika said.
The measure was put on hold and will be reconsidered during the next legislative session.
While Lach said she pays the medical expenses of her Marshallese mothers, Heywood said Medicaid pays for most delivery and postpartum care for the women sent to Hawaii.
Adoption Choices testified against Baker's bill. Carolyn M. Golojuch, a social worker for the agency, told members of Hawaii's Senate Judiciary Committee at a February hearing that the bill was "a misguided missile" aimed at poverty-stricken Pacific Islanders.
She called it "a sign of mean-spirited misunderstanding of the benefits of adoption."
Partika testified that the adoptions of Marshallese in Hawaii appear to be profitable for the adoption agencies, and called the process "shadowy and difficult to monitor."
The bill, she said, "may discourage these agencies from exploiting and depleting one of the Marshalls' few natural resources - its children."
Rosita Hiram, 32, has six children, including one she gave up in February. Like Johnny, she was recruited, flown to Hawaii and when her daughter was born, she signed her over to adoptive parents.
Hiram, whose sister also gave up a child for adoption, is among the minority of Marshallese birth mothers who continue to have contact with the adoptive family. She receives a $50 gift certificate every month with which to buy groceries in Majuro. Recently she was given a new refrigerator.
She describes the arrangement while sitting on her steps and holding one of the five children who live with her. The family laundry dries on a line running to the house.
Her sister, Roseanna Hiram, tells a different, sadder story. She said she had resisted a recruiter's call to give up her unborn child five years ago but then her husband was approached. He pressed her to relent. She said she tried to run away and was supported by her son Jam, now 11, who said, "Don't give my brother away."
Her husband prevailed, she said.
Describing how adoption agencies go about looking for children, Roseanna said she had been promised pictures and letters from the adoptive parents but never received any. She said she did not know the name of the agency she dealt with.
She thinks her son, now 5, lives in Oregon.
"At the time I was very sad," Roseanna said. "Even to this day I miss him."
In her tin-roofed shack, Johnny keeps the legal papers that show how she signed her baby girl over to Adoption Choices.
One document she signed has an "X" marked next to a line which says that once her daughter reaches "the age of majority, I do wish to have my identity disclosed to said child." Despite the long months with no word of her daughter, Johnny said she is hopeful that the child she gave up will one day seek her out.
"They told me she would come back when she is 18."