Pregnancy Care among Black-African and Black-Caribbean Medically Uninsured People Attending A Toronto Walk-in Clinic: A 10-Year Retrospective Chart Review

Abstract

Manavi Handa and Shani Robertson

Background: Medically uninsured pregnant people may encounter delayed or fragmented prenatal care because of cost, administrative exclusion, precarious immigration status, lack of a regular primary care provider, housing instability, and fear of healthcare or immigration systems. Canadian evidence about Black medically uninsured pregnant people is limited, and aggregation may obscure important differences among Black populations. This study described Black- African and Black-Caribbean participants attending a low-barrier Toronto pregnancy clinic, examined heterogeneity between these subgroups, and compared selected service-relevant characteristics with other medically uninsured clinic participants.

Methods: We conducted secondary analysis of a retrospective chart review of pregnancy presentations assessed by a midwife at community health centre-based walk-in clinic for medically uninsured people from July 1, 2013, to June 30, 2023. The setting was a clinic intended particularly for uninsured and undocumented Toronto residents without a primary care provider. People holding a current valid visitor, student, or temporary work visa were not eligible for services (“Non-Insured Walk-in Clinic,” n.d.). The original cohort comprised 1,170 pregnancy presentations. The three-group analysis included 1,158 presentations: Black-African (n = 114), Black-Caribbean (n = 119), and all- other medically uninsured participants (n = 925). Twelve Black participants from other regions were excluded from subgroup comparison because data cells were too small for meaningful interpretation. Analyses used variable-specific denominators, 95% confidence intervals, and overall three-group p values.

Results: Mean gestational age at first presentation was 22.12 weeks among Black-African participants, 17.61 weeks among Black-Caribbean participants, and 14.71 weeks among all-other participants. Third-trimester presentation occurred in 45.5%, 22.7%, and 17.8%, respectively. Black-African participants were more likely to report previous prenatal care overseas (44.2% vs. 12.4% Black-Caribbean and 14.3% all-other), yet 57.8% of those with prior care lacked records, compared with 34.3% and 35.6% respectively. Anemia was documented in 13.2% of Black-African, 15.1% of Black-Caribbean, and 4.8% of all-other participants. Risk classification and referral destination did not differ significantly across groups.

Conclusions: Black-African and Black-Caribbean participants were not interchangeable populations. The most pronounced inequities occurred before entry to the clinic. Black-African participants presented latest and had the highest observed proportion of absent records among participants with previous prenatal care. Both Black subgroups had more documented anemia than all-other participants. Similar risk classification and referral destinations after assessment do not establish an effect of midwifery care, but the largest observed group differences occurred before participants reached the clinic. Findings support earlier outreach, patient navigation, proactive provision of patient-held prenatal records, rapid anemia assessment and treatment, and accessible pathways into ongoing care.

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