The system is failing those who need it most
In a province that promises equal care to all, a study of more than half a million pregnancies has revealed that one in five expectant people in Ontario never received timely syphilis screening — a simple, inexpensive test that stands between a treatable infection and a newborn's death or lifelong disability. As syphilis rates among reproductive-age women have surged more than twentyfold over a decade, the gap in screening is not random but structural, falling heaviest on those already carrying the greatest burdens. The findings ask a quiet but urgent question of any society that calls its health care universal: who, exactly, does that word include?
- Congenital syphilis — entirely preventable with early antibiotics — has risen nearly fiftyfold in Canadian newborns over a single decade, turning a once-rare tragedy into a measurable crisis.
- Eight percent of pregnant people in Ontario received no syphilis screening at all, while another thirteen percent were tested so late that meaningful intervention became far harder to achieve.
- The screening failures are not evenly distributed: poverty, housing instability, substance use, and social isolation all predict who falls through the net, exposing the deepest fault lines in a system meant to serve everyone.
- Traditional prenatal care — scheduled appointments, stable addresses, navigable bureaucracy — is structurally ill-suited to reach the populations most at risk, leaving the model itself as part of the problem.
- Researchers are calling for opportunistic screening at any health encounter, point-of-care testing, and community-based outreach as the most promising paths to closing the gap before more newborns are harmed.
A study of more than half a million pregnancies in Ontario has exposed a quiet failure at the heart of prenatal care: one in five pregnant people did not receive timely syphilis screening, despite the fact that the test is simple, inexpensive, and capable of preventing devastating harm to newborns.
Published in the Canadian Medical Association Journal, the research examined 551,706 pregnancies between 2018 and 2023. The results were stark — eight percent of pregnant people were never screened at all, and another thirteen percent were tested only in the third trimester or at delivery, when the window for effective intervention has largely closed. International guidelines call for first-trimester screening, which only 79 percent of people received.
The stakes are high. Syphilis can cross the placenta at any stage of pregnancy, causing stillbirth, infant death, premature delivery, or severe lifelong disability — outcomes that are entirely avoidable with antibiotics if the infection is caught early. Yet over the past decade, syphilis rates among Canadian women of reproductive age have surged from 2.3 to 53.8 cases per 100,000, and congenital syphilis in newborns has climbed from 0.3 to 14.5 cases per 100,000 live births.
Led by Dr. Sahar Saeed of Queen's University, the research team found that missed or late screening tracks closely with sociodemographic vulnerability — poverty, housing instability, substance use, and social isolation. The system is failing precisely those who need it most.
The authors argue that conventional prenatal care, built around scheduled office visits and stable circumstances, cannot reach everyone. They call for a shift toward opportunistic screening at any health care encounter, community-based outreach, and point-of-care testing — approaches that meet people where they are rather than waiting for them to arrive.
A study of more than half a million pregnancies across Ontario has documented a troubling gap in one of the most basic protections available to newborns: one in five pregnant people did not receive timely screening for syphilis, a sexually transmitted infection that can devastate or kill an unborn child if left untreated.
The research, published in the Canadian Medical Association Journal, examined 551,706 pregnancies among 446,660 people between 2018 and 2023. The findings are stark. Eight percent of pregnant people received no syphilis screening whatsoever. Another 13 percent were screened too late—in the third trimester or at delivery—when intervention becomes far more difficult. Only 79 percent received screening in the first trimester, as international guidelines recommend.
The timing matters because syphilis, if present in a pregnant person's blood, can cross the placenta and infect the fetus at any stage of pregnancy. An untreated infection can result in stillbirth, infant death, premature delivery, or severe lifelong disability in the child. Yet the disease is entirely preventable with antibiotics if caught early. This is not a rare problem. Over the past decade, syphilis rates among women of reproductive age in Canada have surged from 2.3 cases per 100,000 to 53.8 cases per 100,000. In lockstep, congenital syphilis—infection in newborns—has climbed from 0.3 cases per 100,000 live births to 14.5 cases per 100,000.
Dr. Sahar Saeed, an assistant professor of public health sciences at Queen's University in Kingston, Ontario, led the research team. The authors found that late or missed screening correlates strongly with sociodemographic and behavioral risk factors—a pattern that points to a deeper problem. People who face the greatest barriers to accessing prenatal care are the same people most likely to fall through the screening net. These are often the most vulnerable populations: those experiencing poverty, housing instability, substance use, or social isolation. The system, in other words, is failing those who need it most.
The implications are sobering. In a publicly funded health care system designed to serve everyone equally, one in five pregnancies are not receiving a screening test that takes minutes and costs little. The gap is not random. It reflects structural inequities in how prenatal care is organized and delivered.
The authors argue that traditional prenatal care models—office visits scheduled in advance, requiring transportation, stable housing, and the ability to navigate bureaucracy—are simply not reaching everyone. They propose a shift toward complementary strategies: opportunistic screening at any health care encounter, community-based outreach programs, and point-of-care testing that can deliver results on the spot. These approaches have shown promise in other contexts and with other infections. The question now is whether Ontario's health system will adopt them before more newborns are born with preventable disease.
Notable Quotes
Relying solely on traditional prenatal care models may not be sufficient to reach populations who face barriers to accessing care— Dr. Sahar Saeed and coauthors, CMAJ study
The Hearth Conversation Another angle on the story
Why does timing matter so much with syphilis screening in pregnancy?
Because the infection crosses the placenta at any stage. But antibiotics work—they stop transmission cold. Screen in the first trimester, treat immediately, and the baby is safe. Screen in the third trimester and you've lost months of prevention.
So the eight percent who weren't screened at all—what happened to their babies?
The study doesn't say. But with congenital syphilis rates climbing to 14.5 per 100,000 live births, we know some of those babies were born infected. Some may have died. Others will live with permanent damage.
The researchers mention sociodemographic barriers. What does that actually mean?
It means poverty, unstable housing, addiction, isolation. People working multiple jobs who can't take time off for appointments. People without reliable transportation. People who don't trust the system. The screening gap isn't medical—it's structural.
If the test is so simple, why not just screen everyone at the hospital when they arrive in labor?
Because by then it's too late to prevent most of the damage. You need months to treat safely. And some people never make it to a hospital—they deliver at home or in crisis. The system needs to find them earlier.
What would actually work?
Meeting people where they are. Screening at any health visit, not just prenatal appointments. Mobile clinics in neighborhoods. Community health workers who know the people. Tests that give results on the spot, not days later. It requires investment and humility—admitting the current model doesn't work for everyone.