The British Columbia Healthy Connections Project: findings on socioeconomic disadvantage in early pregnancy

Socioeconomic disadvantage poses challenges to the wellbeing of both mothers and children [1‐3]. In particular, adolescent mothers (aged 19 years or younger) are more likely to experience interrupted education, lower workforce participation, lower income, unstable housing, and associated physical and mental health and cognitive problems [4, 5]. Children born to adolescent mothers, in turn, are at greater risk for preterm birth, childhood injuries and subsequent developmental and mental health problems [6‐8]. Similarly, children born to young mothers (aged 20–24 years) who are experiencing socioeconomic disadvantage (such as having low income, having limited education or having limited social supports) are also at greater risk for injuries and subsequent developmental and mental health problems [2, 9‐12]. Other health and social adversities associated with maternal socioeconomic disadvantage in general include depression, prenatal substance use and exposure to intimate partner violence (IPV), which also adversely influence the developing child [11, 13‐15].

Yet the socioeconomic disadvantage that underlies many childhood mental and physical health problems is socially produced and therefore may be amenable to intervention [16‐18]. Providing children with a better start in life, beginning before or during pregnancy and continuing in the early years, promotes healthy development and results in greater societal benefits compared to later remediation of health and social problems [18‐22]. It is therefore crucial to identify opportunities for intervening “upstream” — well before avoidable adversities occur and subsequent health and social problems begin.

One approach is to identify disadvantaged populations in early pregnancy and examine how avoidable adversities may be offset or muted by specific prevention interventions aimed at improving the life course trajectories for both children and mothers [18‐22]. Reducing socioeconomic disadvantage and improving parenting — through providing better supports for pregnant girls and young women and new mothers — is a powerful mechanism for supporting healthy development throughout the lifespan [1, 23]. Yet data describing populations of disadvantaged young mothers-to-be in Canada have been limited, in turn, limiting the data available to inform the development and provision of effective maternal and child services that are proportionate to the level of disadvantage or need [18]. As well, disadvantaged groups have often been characterized as “hard-to-reach” rather than “need-to-reach,” further hampering intervention efforts [24]. To inform intervention planning, this research therefore aimed to describe the health and social adversities experienced by a cohort of 739 pregnant girls (14–19 years) and young women (20–24 years) in British Columbia (BC), Canada.

Data are provided on the total cohort as well as on the two age groups in Tables 2, 3, 4, 5 and 6. Missing data were minimal at less than 2% for all variables, except for unstable housing (3% missing) and English as a first language (7% missing). Central descriptives on the total cohort and statistically significant age group differences are summarized below.

How does this cohort compare to other British Columbians and Canadians? Beyond the eligibility criteria, while directly comparable data were not available for all variables, our cohort nevertheless reported much higher rates of associated health and social adversities including: homelessness and unstable housing, mental health problems including prenatal substance use, and serious physical health problems [43‐50]. Rates of child maltreatment and IPV exposure were also twice those found for other Canadians [51, 52]. These comparisons confirm that we recruited a cohort who was experiencing marked disadvantage, the population NFP is most intended to benefit. See Table 7.

What have our data added? We have shown for the first time that high levels of disadvantage exist for some young Canadians — despite this country’s high-income status and its longstanding commitment to equity in access to universal healthcare and related social services [54]. As well, despite provincial/territorial variations in the delivery of health and social programs [53], our data nevertheless have national implications. In Canada, approximately 8000 children are born to adolescent mothers each year [43], while approximately 42,000 are born to young mothers (aged 20–24 years), with many of the latter experiencing low income (13%) and/or single parenthood (7%) [43, 46]. Reaching these populations and addressing avoidable adversities during early pregnancy — thereby also increasing children’s life chances — is a societal imperative [16, 18, 20]. Our data also suggest that public policy remedies must extend beyond public health and healthcare — encompassing social services, such as ensuring adequate housing and incomes, and preventing child maltreatment and IPV as early as possible in the lifespan. We believe that our study therefore provides new data underscoring an urgent call to action across public sectors not only in BC, but also in Canada.

Our data also have implications for children’s rights. We found less than a third of participants had recently received social service entitlements such as income assistance, while approximately half reported recent unstable housing and lifetime homelessness as well as exposure to child maltreatment and IPV. Addressing these serious avoidable adversities is a priority, especially for pregnant youth [1, 4, 7, 11, 54]. According to international child rights’ conventions, BC and other provinces/territories also have obligations to ensure that the basic needs of all minors are met, including protecting young people from harm and ensuring adequate housing, income and parental/caregiver supports [55, 56]. Our data suggest that these fundamental obligations may not be being fulfilled in BC.

Regarding age differences, we found that in this cohort, young women were facing adversities that were comparable to girls. The statistically significant differences that we did observe between the two groups may be explained by developmental stage (differences in cognitive functioning), eligibility criteria (being single was only a criteria for young women), or developmental context (lower reported income and education may be expected for the pregnant girls who may still be in school and less likely to be employed). The higher proportion of girls accessing primary healthcare and prenatal classes may be a result of better provision of services for these pregnant adolescents compared with young women, although further data are needed. Yet overall, our data suggest that the well-established risks facing children born to adolescents may also extend to children of young women who are experiencing socioeconomic disadvantage in BC.

The BCHCP RCT is embedded within BC’s health system, with NFP being delivered as an enhanced public health service — an example of delivering services proportionate to need [18]. Participants will be followed throughout pregnancy and until their children reach age 2 years (the duration of the NFP program). Additional outcome findings will be available in 2020–2022. The embedded nature of this RCT ensures that findings are shared quickly and efficiently with policy and practice partners to inform ongoing strategies to better reach populations in need.

Our data suggest that unacceptably high levels of socioeconomic disadvantage exist for some young British Columbians — despite existing health and social services in a high-income province in a high-income country. Concentrated disadvantage for mothers also places children at risk for a range of adversities and for long-term developmental and mental health problems. Therefore, greater health and social supports and services are warranted for this population — to help them and to help their children.