Prenatal Healthcare Compared: U.S., Canada, and Switzerland

Introduction

Healthcare systems in Western societies do not automatically assume that a woman requires health information; however, it has become well recognized that good information is essential for pregnant women, and that understanding the stages of pregnancy, labor, and delivery is important to quality perinatal care (Crook, 1995). This paper compares the healthcare options available to pregnant women according to their income and insurance resources in the United States, Canada, and Switzerland. A comparison of the respective healthcare systems for these three nations is provided in the summary, and a critique of the United States healthcare system is offered in the conclusion.

Healthcare Options in the United States

The U.S. spends a larger percentage of its GDP on healthcare than any other nation in the world, and it spends more on a per-person basis as well. Furthermore, not only are expenditures high, but for many years these allocations have increased faster than GDP. Yet quality healthcare remains out of reach for many pregnant women in the United States (McGarry, 2002).

Discussions of medical care for the poor frequently invoke the phrase two-tier medicine. While this approach may appear fundamentally inequitable, some advocates have maintained that an explicit two-tier system would serve the U.S. poor better than the present patchwork of services that range from no care (e.g., prenatal) to the most sophisticated (e.g., neonatal intensive care) (Ginzberg & Rogers, 1993). A frequent conclusion of health policy discussions in the United States is that everyone should have access to "basic" medical care. As Ginzberg and Rogers (1993) note, "The basic care package will constantly have to change to include 'whatever the custom of the country renders it indecent for creditable people, even of the lowest order, to be without'" (p. 18).

The question of efficiently providing care to low-income pregnant women is further complicated by the fact that there may be gross inefficiencies in the quality of medical care provided even to the affluent who enjoy robust insurance plans — including overtesting, inappropriate surgeries, and similar problems (Collins & Williams, 1995). For more on how U.S. health policy shapes access to care, scholars have explored the structural factors that drive these disparities.

Healthcare Options in Canada

According to Mhatre and Derber (1992), the 1984 Canada Health Act stated that: "The primary objective of Canadian health care policy is to protect, promote and restore the physical and mental well-being of residents of Canada, and facilitate reasonable access to health services without financial or other barriers" (p. 645). While the principle of accessibility promotes universal health care coverage in Canada, equitable access to health services is not always the case in practice (Morton & Loos, 1995).

In the second-largest country in the world, geographic proximity to tertiary healthcare facilities is one of the most important factors in the provision of quality healthcare services (Benoit, Carroll, & Millar, 2002). Although universal healthcare is provided for all Canadian citizens and the ability to pay is not supposed to be a factor, there is still prejudice against poverty. As Crook (1995) observes, "The poor receive less instruction and have fewer options than the rich, and even with 'universal' health care the insurance will not pay for 'elective' medical care — that is, the medical care that the medical industry does not think is necessary."

Today, many Canadian women are seeking ways to give birth that are more comfortable, more self-directed, and less medicalized than the typical hospital experience. Although the Canadian healthcare system maintains a number of youth clinics, particularly for birth control and abortion information, the quality at these centers varies considerably. At such centers, adolescent females receive information, counseling, and practical assistance concerning birth control and pregnancy. In some remote areas of Canada, Red Cross Outpost Stations provide these services for the teenage population. Crook (1995) notes that quality varies dramatically: "In one-nurse stations, health education is limited by the knowledge and attitudes of that one nurse. If she is competent, she gives information, pamphlets, books, and phone numbers to the teen. If she is not, she gives cursory and sometimes incorrect advice" (p. 35).

Recent changes in some provinces to again allow midwives to practice are encouraging. Nurse midwives are legally licensed to practice in all Canadian provinces, and there are nurse midwifery schools in 17 U.S. states as well as certification programs in others. British Columbia and Ontario have passed legislation making midwifery legal. There are also non-medical home births and birthing centers in some areas, where only emergency or high-risk mothers are referred for hospital care. Finally, active organizations are working to transfer greater responsibility for neonatal care from the medical establishment to Canadian mothers themselves (Crook, 1995).

Conclusion and Critique

The health of the mother during pregnancy, delivery, and the postpartum period has been directly linked with the health of her newborn, reinforcing the need to integrate maternal and neonatal healthcare strategies (Darmstadt, Lawn, & Costello, 2003). According to Ginzberg and Rogers (1993), in order to make rational allocations of resources to alleviate the health problems of the poor, it is necessary to understand the relative importance of those problems.

The research shows that the population of expectant mothers in the United States is younger and probably less mature, less experienced, and less financially stable than in the comparison countries. The United States also has higher fertility rates and a higher overall percentage of pregnancies terminated by abortion. Adolescent-specific rates — including pregnancy rates, abortion rates, and the percentage of delivering mothers younger than 20 years old — were also notably higher in the United States (Thompson, Goodman, & Little, 2002). These findings point to a systemic failure to reach low-income and young pregnant women with adequate preventive and prenatal care, a gap that public health agencies continue to identify as a national priority.

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Table 1. Comparison of GDP Share, Per Capita Expenditure, and Life Expectancy for the U.S., Canada, and Switzerland [Source: Stewart, 1995].

United States: Share of GDP (1991) — 13.4%; Per Capita (1991) — $2,867; Life Expectancy (1993) — 75.8 years.

Canada: Share of GDP (1991) — 10.0%; Per Capita (1991) — $1,915; Life Expectancy (1993) — 78.0 years.

Switzerland: Share of GDP (1991) — 7.9%; Per Capita (1991) — $1,713; Life Expectancy (1993) — 78.0 years.

Figure 1. GDP Per Capita Expenditures on Healthcare [Source: Stewart, 1995].

Table 2. Infant Mortality Rates for the U.S., Canada, and Switzerland [Source: World Factbook, 2004].

United States: 6.63 per 1,000 births (2004 est.)

Canada: 4.82 per 1,000 births (2004 est.)

Switzerland: 4.43 per 1,000 births (2004 est.)

Figure 2. Infant Mortality Rates for the U.S., Canada, and Switzerland (2004 est.) [Source: World Factbook, 2004].