Tommy Douglas was a former professional boxer, who was also a Baptist minister, and is the father of Canadian Medicare. He was from the Canadian Prairies, has been referred to as the ‘greatest Canadian of all time’ and worked tirelessly to start a Canadian Health Care system which provides care to all, regardless of ability to pay.
Prenatal care is supplied to everyone, in every province, and leads to us having perinatal outcomes which are excellent. There are still disparities, however, and poor women have a number of outcomes which are worse than women with more resources.
Our system (actually systems, there are significant differences between the provinces, that are responsible for administering health care) is far from perfect, acute and emergency care tends to be favoured, so neonatal care, for example, is in a privileged position. Central management makes regionalization quite effective, so we have almost no avoidable deliveries of very preterm babies in non-tertiary hospitals. But central management also creates problems, with, for example, the size of medical school intakes oscillating as the government tries to decide if we have too many physicians or too few, and keeps changing its mind.
Chronic care, and domiciliary care are the big losers in our system, as it is politically easier to cut budgets when the adverse effects are slowly cumulative rather than acutely visible. Non-urgent surgery is another place where our system does poorly, so a hip replacement might be quite delayed, with consequent avoidable pain and disability. One interesting comparison with the US system was made a few years ago by John Ralston Saul. The cost of US Medicare divided by the entire US population, (even though it only covers a small part of the US population) was greater than the cost of Canadian Medicare, divided by the entire Canadian Population, but the Canadian system covers everybody.
In Manitoba (one of the Canadian Provinces, total population just over a million) they introduced a program in 2001 where any pregnant woman with an annual income under $32000 was eligible to receive an income supplement, as long as she applied for it, the income supplement was up to $81.41 a month,and was accompanied by written information about prenatal care, breastfeeding, etc.
In this new study the authors examined the outcomes of the nearly 11,000 pregnancies where the woman claimed and received the supplement, to those of eligible women who did not (nearly 4,000). After matching for propensity scores, those who got the extra cash had less low birth weight, less small for gestational age, more breast-feeding initiation, and more large for gestational age babies.
The average annual income of the mothers who received the supplement was less than $10,000, so the supplement, which doesn’t sound like much to a Canadian doctor like me, was actually a nearly 10% increase in their monthly income.
The authors of this remarkable work contrast their results with those of other countries (mostly in Latin America) who have introduced income supplements, but only for mothers who attend antenatal care, or who satisfy other conditions.
They note that when the program was introduced in Manitoba there were questions:
As a society, we tend to assume that poor people cannot be trusted to make good choices. Indeed, when HBPB (the income supplement program) was first introduced in Manitoba, concerns were expressed about introducing a program for low-income women without conditions or accountability. Although information about prenatal and infant health is included with the monthly payment, the Manitoba HBPB program trusts low-income women to make good choices regarding their pregnancies.
For a small cost, just giving poor pregnant women a small amount of money every month during their second and third trimesters, improves pregnancy outcomes. There was also a decrease in length of stay after delivery, so it probably saved money as well.