Press release

'Flawed' Health Canada program puts money in wrong place

p. 663  Maternal nutrition, pregnancy outcome and public health policy — Michael S. Kramer, MD [full text]

Health Canada should be spending money on research into the causes of preterm births rather than on a program to provide food to pregnant women in need. The Canada Prenatal Nutrition Program (CPNP) is spending $85 million over 4 years and even though Dr. Michael Kramer writes that he can't argue against programs that give food to the poor, he says it is misguided for Health Canada to think the program will improve pregnancy outcomes. "It's superficially laudable but fundamentally flawed," he writes. The program's objective was to reduce the incidence of both low birth weight (less than 2500 g) and preterm births. But giving women more calories has never been shown to affect prematurity. Likewise, supplementation with various nonprotein nutrients does not seem to affect pregnancy outcomes.

Kramer argues that what's really needed is more research into the causes of preterm births. He calls for increased research funding and compares Canada's situation with that in the US. In 1997/98, the US spent about Cdn$66 per capita on its National Institutes of Health while Canada spent Cdn$8 per capita on its Medical Research Council. Kramer concludes that the CPNP is wasted money and a wasted opportunity.

p. 651  Psychological outcomes following maternal serum screening: a cohort study — Vivek Goel, MD, MSc; Richard Glazier, MD, MPH; Anne Summers, MD; Stephen Holzapfel, MD [full text]

Many physicians fear that maternal serum screening, used to help detect prenatal congenital anomalies, increases women's anxiety. Maternal serum screening (also referred to as the triple-marker test) is a technique for estimating the risk for fetal trisomy 18, Down's syndrome and neural tube defects. These tests have sensitivities ranging between 60% and 80%. Unfortunately, the specificity is as low as 92% for Down’s syndrome. Thus, for every fetus with Down's syndrome that is detected by the test, about 70 pregnant women will be told incorrectly that their fetus has the condition. Physicians have been justifiably concerned about creating unnecessary anxiety by performing this test, particularly for women who are apparently at low risk. These include women with no family history of these disorders.

Dr. Vivek Goel and colleagues studied about 2000 pregnant women, of whom nearly 1200 underwent the test. They found only a slight increase in anxiety among women who had a false-positive result. They also discovered, surprisingly, that at the time of follow-up for the study (at about 24 weeks' gestation), almost 8% of those who had been tested were unsure of their results. Dr. Goel concluded that better communication between patient and physician is needed.

p. 695  The return of the 100-day cough: resurgence of pertussis in the 1990s — Theresa W.S. Tam, BM, BS; Adwoa Bentsi-Enchill, MB, ChB, MSc [full text]

The number of cases of whooping cough has nearly tripled this decade. In the 1980s there were between 1000 and 3000 cases per year but during the '90s there have been between 2700 and 10 000 cases annually. Scientists Theresa Tam and Adwoa Bentsi-Enchill find that a combination of factors are likely involved. Vaccine coverage is still not optimal: the national coverage for age-appropriate immunization by the second and seventh birthdays is estimated at 83% and 75% respectively. In addition, the vaccine in use until recently may not have provided adequate protection against the disease. And vaccination only offers immunity for 12 years. There is also a muted but highly contagious form of whooping cough that adults and adolescents are catching.

We have entered the whooping cough season (September through January). In those infected with the causative agent, Bordetella pertussis, the epithelial lining of the respiratory tract is destroyed, and normal secretions cannot be cleared. Because it takes about 3 months for the epithelium to regenerate, pertussis is also known as "the 100-day cough."

p. 671  Is Canada falling behind international standards for stroke care? — Antoine M. Hakim, MD, PhD; Frank Silver, MD; Corinne Hodgson, MSc [full text]

Canada risks falling behind international standards if it doesn't implement organized stroke care. Dr. Antoine Hakim and colleagues write that the type of care a stroke patient now receives is "far too frequently a function of where he or she lives and, thus, the resources that happen to be available." They state that Canada needs organized stroke care so it can enter the new era in stroke prevention, treatment and recovery.

Organized stroke care involves many professions collaborating to provide high quality, standardized, cost-effective and evidence-based patient care. It covers the entire spectrum from stroke prevention to rehabilitation to secondary prevention.

About 50 000 Canadians suffer a stroke each year, and as the population ages that number is expected to increase. The annual national cost is about $2.7 billion. There is also the human cost to patients and caregivers. Half of all caregivers, for example, develop an emotional illness within a year. The authors argue that "brain attack" should become as urgent a matter for our health care system as heart attack.

See also the special supplement on stroke from the Heart and Stroke Foundation of Ontario in this issue of CMAJ.