Abstract
Background
Canada is facing a primary healthcare crisis with physician shortages and long wait times. Across Canada, 8.1% of children lack a regular healthcare provider. However, little is understood about primary care access among newborns. The objective of this study was to determine the prevalence of newborns without primary care, and to evaluate the association between lack of primary care and sociodemographic factors at a large Canadian urban hospital.
Methods
This was a cross-sectional survey of caregivers of newborns who delivered within one week on the post-partum ward at a large urban hospital in Toronto, Ontario, Canada. To determine the association between lack of a primary care provider (PCP) among newborns and caregivers’ sociodemographic characteristics, a logistic regression model estimated unadjusted and adjusted odds ratios (OR)s and 95% confidence intervals (CI).
Results
There were 656 caregivers and 659 newborns. Of these, 202 did not have access to a PCP with a prevalence of 30.6% (95% CI 27.2% − 34.3%). In the unadjusted analyses, not having a PCP for newborns was associated with caregivers not having a PCP for themselves (OR 7.59, 95% CI 5.06–11.39), not owning a home (OR 2.86, 95% CI 1.88–4.35), being born outside of Canada (OR 2.62, 95% CI 1.74–3.96), income <$75,000 (OR 2.30, 95% CI 1.47–3.61), and first language not English (OR 1.66, 95% CI 1.18–2.32). Similarly, in the adjusted analyses, not having a PCP for newborns was associated with caregivers not having a PCP for themselves (adjusted OR 6.18, 95% CI 4.04–9.46), not owning a home (adjusted OR 1.68, 95% CI 1.04–2.71), and being born outside of Canada (adjusted OR 1.69 95% CI 1.05–2.71).
Conclusio
This study found that 30.6% of newborns at a large urban Canadian hospital did not have primary care. Given the primary care crisis in Canada, it is essential to understand the lack of access to primary care among newborns. Next steps will be to link survey data to provincial datasets to determine the association between lack of primary care and emergency department visits and hospital admissions within the first year of life.
Keywords: Survey study, Primary care access, Sociodemographic characteristics, Canada, Newborns
Background
Canada is currently facing a primary healthcare crisis. Challenges such as physician shortages and long wait times contribute to the lack of primary care among Canadian children [1, 2]. These issues are especially important for young children who require a primary care provider (PCP) to monitor growth, address physical and mental health needs, and to provide preventative healthcare, including immunizations.
The 2023 Canadian Health Survey on Children and Youth reported on 69,522 children and youth and found that 8.1% did not have a regular healthcare provider [2]. This number varied by province with a range between 4.1% in Ontario and 22.3% in Prince Edward Island [2]. The COVID-19 pandemic placed additional burdens on an already taxed primary healthcare system with one in five family physicians planning to close their practices within the next five years [3]. Research has shown that Canadian children who live in areas with fewer primary care providers were more likely to have emergency department visits [1]. Young children aged 2–9 years were the age group most likely to use the emergency department for minor medical conditions when they experienced barriers to primary care [4–6]. Accessible primary care has also been shown to associate with fewer emergency department visits and hospitalizations among children in the US [7].
Additionally, research has shown that socioeconomic status is an important predictor of healthcare access among children [8]. A report from Manitoba’s Centre for Health Policy and Evaluation demonstrated that children from low-income neighbourhoods had lower rates of continuity of provider care and immunizations compared to those from high-income neighbourhoods, suggesting barriers to primary care [9].
Newborns are a vulnerable population who require medical visits within the first days of life to monitor weight, assess for hyperbilirubinemia, and screen for congenital problems. Newborns also require regular visits to ensure adequate physical and cognitive development. The Canadian Paediatric Society and the American Academy of Pediatrics recommend that newborn discharge plans should include identification of a PCP and assessment within 72 h after discharge [10, 11]. Newborns who had their first medical visit within 72 h from hospital discharge (which is typically the case for newborns with primary care) had a 15% reduction in hospital readmission rates compared to those without early primary care visits [12]. US studies have shown that almost half of neonates presenting to urban tertiary care emergency departments were for non-acute problems, which could have been managed in a primary care setting [13, 14]. There is limited literature on primary care access for Canadian children, and even less is known about the prevalence of primary care access for newborns in Canada.
Given the primary care crisis affecting Canadian children and the lack of data on primary care access among newborns we sought to estimate the prevalence of newborns without primary care, and the association between lack of primary care and sociodemographic factors at a large Canadian urban hospital.
Methods
Setting
We conducted a cross-sectional study from June 2023 to May 2024, at a large urban academic hospital in Toronto, Ontario, affiliated with the University of Toronto, with a birth rate of 2,557 births per year [15]. The hospital has a Level 2 academic neonatal intensive care unit and a large outpatient pediatric program serving a diverse urban population with high social risk factors including families experiencing homelessness, substance use disorders, and newcomers [16–18]. This study received approval from the Unity Health Toronto Research Ethics Board (Reference No. 25–053).
Participants
Caregivers of newborns (defined as parents or guardians) were approached by a research assistant on the post-partum ward and given the Primary Care Access for Newborns Survey after obtaining informed consent. Inclusion criteria were parents of newborns up to one week of age, who had delivered by either vaginal delivery or Cesarean section. We excluded caregivers of newborns who self-identified as tourists or visitors, and those of newborns who were admitted to the neonatal intensive care unit for > 48 h, as hospital admission may delay the arrangement of primary care after discharge.
Survey
The Primary Care Access for Newborns survey was comprised of 15 open- and closed-ended questions and was administered by a trained research assistant in person on the postpartum ward using a paper copy of the survey. The survey asked whether or not caregivers had a PCP arranged for their newborn, type of PCP (including family physicians, pediatricians, or midwifery), as well as caregivers’ sociodemographic characteristics. The survey was not validated or pilot-tested before use in the study. However, questions relating to sociodemographic characteristics were adapted from the REACH School Network sociodemographic data collection tool, which has been published and used in similar study populations by our institution [19–21]. Questions pertaining to race or ethnicity were based on standardized closed-ended geographically derived categories that have shown good agreement with widely used open-ended ethnicity questions [22]. Among caregivers who reported that they did not have a PCP for their newborns, we collected data on the reasons for not having primary care access.
Data collection and analysis
All survey data was transcribed by the research assistant from paper to Qualtrics [24]. For caregivers who did not feel comfortable reading and responding in English, the research assistant read the survey questions to the hospital’s virtual interpretation service, Voyce [23], and participant answers were interpreted by Voyce and transcribed by the research assistant. Mothers’ and neonates’ Ontario Health Insurance Plan numbers were also collected from medical records for future data linkage with administrative databases at the Institute for Clinical Evaluative Sciences (ICES). ICES is an independent research institute whose legal status under Ontario’s Personal Health Information Protection Act permits it to collect and analyze healthcare and sociodemographic data for health system evaluation and development without individual patient consent [25]. Because of twins in the sample, the prevalence of newborns without a PCP with 95% confidence interval (CI) was estimated using generalized estimating with a logit link. For determining the association between lack of a PCP among newborns and caregivers’ sociodemographic characteristics, we considered only one child per caregiver. A logistic regression model estimated unadjusted and adjusted odds ratios (OR)s and 95% confidence intervals (CI). All analyses were conducted in SAS 9.4 (SAS Institute Inc., Cary, NC, USA) and statistical significance was defined if p-values were < 0.05.
Results
We approached a total of 836 caregivers and 657 (78.6% response rate) provided consent and completed the survey. However, one participant was excluded because they were missing data on whether or not they had primary care for their newborn, resulting in a final sample size of 656 caregivers. Because of three pairs of twin births, the total number of newborns was 659. Of these, 202 did not have access to a PCP, resulting in a prevalence of 30.6% (95% CI 27.2% − 34.3%).
Among the 201 caregivers asked about the reason for not having primary care for their newborns (one had twins), 116 (57.7%) indicated they could not find a PCP, the PCP contacted was not accepting new patients, or they were on a waitlist. Other reasons included: caregivers not yet attempting to find a PCP (28 or 13.9%), actively searching for a PCP (16 or 8.0%), being told to wait to find a PCP (16 or 8.0%), other reasons (15 or 7.5%), having a caregiver or sibling with a PCP, who had not yet confirmed whether they would accept the newborn (8 or 4%), or the PCP having retired or closed their practice (2 or 1.0%). Among 455 caregivers who reported having primary care for their newborns, 268 (58.9%) identified a family physician, 125 (27.5%) a pediatrician, 34 (7.5%) a midwife, 19 (4.2%) identified more than one provider, 6 (1.3%) indicated a nurse or another type of provider, and 3 (0.7%) did not provide information. Table 1 describes caregivers’ characteristics overall and by PCP access for their newborn.
Table 1.
Caregiver characteristics by newborn access to a primary care provider (PCP)
| Characteristic | Total (N = 656) |
No PCP for newborn (N = 201) |
PCP for newborn (N = 455) |
|---|---|---|---|
| Age, n (%) | |||
| 17–30 | 163 (24.9) | 69 (34.3) | 94 (20.7) |
| 31–40 | 438 (66.8) | 120 (59.7) | 318 (69.9) |
| 41–50 | 47 (7.2) | 11 (5.5) | 36 (7.9) |
| >50 | 5 (0.8) | 0 (0.0) | 5 (1.1) |
| Prefer not to answer/missing | 3 (0.5) | 1 (0.5) | 2 (0.4) |
| Immigration status, n (%) | |||
| Canadian citizen, Canada born | 196 (29.9) | 35 (17.4) | 161 (35.4) |
| Canadian citizen, immigrant | 158 (24.1) | 43 (21.4) | 115 (25.3) |
| *Landed immigrant | 173 (26.4) | 54 (26.9) | 119 (26.2) |
| Work permit/work visa | 52 (7.9) | 23 (11.4) | 29 (6.4) |
| Student visa | 14 (2.1) | 9 (4.5) | 5 (1.1) |
| Refugee/temporary residence visa | 33 (5.0) | 23 (11.4) | 10 (2.2) |
| Tourist/visitor | 18 (2.7) | 10 (5.0) | 8 (1.8) |
| No status | 2 (0.3) | 1 (0.5) | 1 (0.2) |
| Immigrant unknown status/missing data | 10 (1.5) | 3 (1.5) | 7 (1.5) |
| Length of time in Canada for immigrants | |||
| ≤ 10 years | 321 (70.2) | 133 (80.1) | 188 (64.6) |
| > 10 years | 122 (26.7) | 27 (16.3) | 95 (32.7) |
| Prefer not to answer/missing data | 14 (3.1) | 6 (3.6) | 8 (2.7) |
| Marital status, n (%) | |||
| Never legally married | 50 (7.6) | 21 (10.4) | 29 (6.4) |
| Legally married | 503 (76.7) | 154 (76.6) | 349 (76.7) |
| Common law/domestic partnership | 87 (13.3) | 20 (10.0) | 67 (14.7) |
| Separated/divorced/widowed | 8 (1.2) | 4 (2.0) | 4 (0.9) |
| Prefer not to answer/missing data | 8 (1.2) | 2 (1.0) | 6 (1.3) |
| English as a first language, n (%) | |||
| Yes | 323 (49.2) | 82 (40.8) | 241 (53.0) |
| No | 330 (50.3) | 119 (59.2) | 211 (46.4) |
| Prefer not to answer/missing data | 3 (0.5) | 0 (0.0) | 3 (0.7) |
| **Race or Ethnicity, n (%) | |||
| European | 112 (17.1) | 19 (9.5) | 93 (20.4) |
| East Asian | 48 (7.3) | 13 (6.5) | 35 (7.7) |
| South Asian | 167 (25.5) | 59 (29.4) | 108 (23.7) |
| Southeast Asian | 47 (7.2) | 18 (9.0) | 29 (6.4) |
| Middle Eastern | 27 (4.1) | 11 (5.5) | 16 (3.5) |
| African | 85 (13.0) | 35 (17.4) | 50 (11.0) |
| Latin American | 58 (8.8) | 19 (9.5) | 39 (8.6) |
| Caribbean | 24 (3.7) | 8 (4.0) | 16 (3.5) |
| Indigenous | 1 (0.1) | 0 (0.0) | 1 (0.2) |
| Mixed race | 27 (4.1) | 7 (3.5) | 20 (4.4) |
| Black | 2 (0.3) | 0 (0.0) | 2 (0.4) |
| White | 35 (5.3) | 8 (4.0) | 27 (5.9) |
| North American | 9 (1.4) | 0 (0.0) | 9 (2.0) |
| Other | 7 (1.1) | 0 (0.0) | 7 (1.5) |
| Prefer not to answer/missing | 7 (1.1) | 4 (2.0) | 3 (0.7) |
| Income, n (%) | |||
| <$30,000 | 26 (4.0) | 8 (4.0) | 18 (4.0) |
| $30,000 - $49,000 | 35 (5.3) | 15 (7.5) | 20 (4.4) |
| $50,000-$74,999 | 53 (8.1) | 21 (10.5) | 32 (7.0) |
| $75,000-$99,999 | 55 (8.4) | 15 (7.5) | 40 (8.8) |
| ≥$100,000 | 318 (48.5) | 65 (32.3) | 253 (55.6) |
| Prefer not to answer/missing data | 169 (25.8) | 77 (38.3) | 92 (20.2) |
| Housing status, n (%) | |||
| Owning | 198 (30.2) | 33 (16.4) | 165 (36.3) |
| Renting | 388 (59.2) | 133 (66.2) | 255 (56.0) |
| Living with parents or relatives | 33 (5.0) | 18 (9.0) | 15 (3.3) |
| Government housing/co-operative housing/shelter/living with a friend | 27 (4.1) | 13 (6.4) | 14 (3.1) |
| Prefer not to answer/missing data | 10 (1.5) | 4 (2.0) | 6 (1.3) |
| Educational attainment, n (%) | |||
| High school or less | 73 (11.1) | 26 (12.9) | 47 (10.3) |
| College/university | 361 (55.0) | 110 (54.7) | 251 (55.2) |
| Post-graduate | 219 (33.4) | 65 (32.4) | 154 (33.8) |
| Prefer not to answer/missing data | 3 (0.5) | 0 (0.0) | 3 (0.7) |
| Has a PCP, n (%) | |||
| Yes | 507 (77.3) | 104 (51.7) | 403 (88.6) |
| No | 145 (22.1) | 96 (47.8) | 49 (10.8) |
| Prefer not to answer | 4 (0.6) | 1 (0.5) | 3 (0.7) |
| Reported a medical problem in the newborn, n (%) | |||
| Yes | 44 (6.7) | 13 (6.5) | 31 (6.8) |
| No | 604 (92.1) | 184 (91.5) | 420 (92.3) |
| Prefer not to answer/missing | 8 (1.2) | 4 (2.0) | 4 (0.9) |
Participants could select one ethnicity/race
PCP Primary care provider
*Landed immigrant denotes permanent resident status
**Categories were derived from standardized closed-ended geographically based ethnicity questions [22]
In the unadjusted analyses, not having a PCP for newborns was associated with caregivers not having a PCP for themselves (OR 7.59, 95% CI 5.06–11.39), not owning a home (OR 2.86, 95% CI 1.88–4.35), being born outside of Canada (OR 2.62, 95% CI 1.74–3.96), income <$75,000 (OR 2.30, 95% CI 1.47–3.61), and first language not English (OR 1.66, 95% CI 1.18–2.32). Similarly, in the adjusted analyses, not having a PCP for newborns was associated with caregivers not having a PCP for themselves (adjusted OR 6.18, 95% CI 4.04–9.46), not owning a home (adjusted OR 1.68, 95% CI 1.04–2.71), and being born outside of Canada (adjusted OR 1.69 95% CI 1.05–2.71). Table 2 reports the unadjusted and adjusted ORs and 95% CIs for the associations between not having a PCP for newborns and sociodemographic characteristics. Adjusted analyses excluded income because of the high missing data rate, and first language because it was highly correlated with immigrant status.
Table 2.
Unadjusted and adjusted odds ratios and 95% confidence intervals for the association between caregiver/newborn characteristics and lack of a PCP for newborns
| Characteristic | OR (95% CI) | P | Adjusted OR (95% CI) | P |
|---|---|---|---|---|
| Caregiver PCP | ||||
| Has a PCP | reference | reference | ||
| Does not have a PCP | 7.59 (5.06–11.39) | < 0.0001 | 6.18 (4.04–9.46) | < 0.0001 |
| Housing status | ||||
| Owning | reference | reference | ||
| Not owning | 2.86 (1.88–4.35) | < 0.0001 | 1.68 (1.04–2.71) | 0.0341 |
| Immigrant status | ||||
| Canadian born | reference | reference | ||
| Immigrant | 2.62 (1.74–3.96) | < 0.0001 | 1.69 (1.05–2.71) | 0.0296 |
| Among immigrants, length of time in Canada | ||||
| Established (> 10 years) | reference | |||
| Recent (≤ 10 years) | 2.49 (1.54–4.03) | 0.0002 | ||
| Income | ||||
| ≥ $75,000 | reference | |||
| < $75,000 | 2.30 (1.47–3.61) | 0.0003 | ||
| First language | ||||
| English | reference | |||
| Not English | 1.66 (1.18–2.32) | 0.0033 | ||
| Educational attainment | ||||
| College/university or more | reference | reference | ||
| Less than college/university | 1.28 (0.77–2.13) | 0.3431 | 0.76 (0.40–1.45) | 0.3980 |
| Marital status | ||||
| Married/common-law | reference | reference | ||
| Not married | 1.81 (1.05–3.14) | 0.0339 | 1.67 (0.86–3.24) | 0.1283 |
PCP Primary care provider, OR Odds ratio, CI Confidence interval
Discussion
This survey of 656 caregivers identified 30.6% newborns without a PCP before hospital discharge. The majority of families reported either that they could not find a PCP, the PCP was not accepting new patients, or they were on a waitlist. Sociodemographic factors of caregivers, including not having a PCP for themselves, not owning a home, and being born outside of Canada, were associated with lack of access to primary care for newborns.
The proportion of newborns without primary care in our study was greater than that reported for children residing in Ontario and for all of Canada, according to the 2023 Canadian Health Survey on Children and Youth [2, 26]. Reasons for not having a regular healthcare provider on the Canadian-wide survey were simliar to the reasons reported among our cohort, including not being able to find a PCP, and being on a waitlist, indicating that PCP supply and availability are important factors contributing to lack of access [2]. Ontario data has also shown that newborns residing in counties with the lowest supply of PCPs had a higher proportion of newborns without a follow-up primary care visit after discharge from birth, compared to those residing in areas with a high supply of PCPs [1]. A systematic literature review from Australia examining barriers to primary care access for newborns of migrant families, demonstrated that an appropriate physician supply was among the most significant barriers [27]. Similarly, low provider supply contributed to limited access to effective primary care among adults in Canada and the US [28, 29].
Caregivers who lacked a PCP for themselves were more likley to have newborns without a PCP. Given the primary care crisis among Canadian adults [26], it is not surprising that those without primary care for themselves would also face barriers securing primary care for their newborns. Similar to our findings, the 2023 Canadian Health Survey on Children and Youth reported that a higher proportion of children living in lower income households (10.7%) lacked a regular healthcare provider compared to those living in higher income households (6.4%) [2]. However, in contrast to our finding that parental educational attainment was not associated with lack of primary care, the 2023 Canadian Health Survey on Children and Youth reported that a higher proportion of parents with lower educational attainment (high school diploma or equivalent or lower) had children without a regular healthcare provider (12.4%) compared to parents with higher educational attainment (Bachelor’s degree or higher) (7.6%) [2]. The high percentage of non-Canadian-born caregivers in our sample may help explain why parental educational attainment was not associated with lack of primary care among newborns. Our findings showed that 68.5% of caregivers identified as being born outside of Canada, and 70.2% of these caregivers reported being in the country ≤ 10 years. Immigrants to Canada often arrive with high educational attainment due to the self-selection process for immigration [30, 31]. However, educational attainment outside of Canada among immigrants does not necessarily translate to better healthcare access, due to persistent barriers including language and cultural differences, and socioeconomic challenges [32]. Similar to the 2015-16 Canadian Community Health Survey, and the 2023 Canadian Health Survey on Children and Youth which found that new immigrants were less likely to have regular healthcare compared to established immigrants [2, 33], we found that the odds of not having a PCP for newborns was 2.4 times higher for recent immigrants (≤ 10 years) compared to established immigrants (> 10 years) (Table 2). Recent immigrants may lack language proficiency and socioeonomic stability compared to established imimgrants, rendering them less likely to find a PCP for their newborn.
This study had some limitations. First, our study was conducted at a single urban centre and may not be generalizable to other regions with differing socio-economic contexts. For example, the proportion of children without a regular healthcare provider varies across provinces and neighbourhoods [2]. Second, data was obtained through caregiver report and is therefore subject to recall and social desirabiltiy bias [34]. Third, we had missing data. For example 26% of paritipants were missing household-income data which may be related to social desireabiltiy bias and may therefore limit the generalizability of our findings [34]. Additionally, the survey was not pilot-tested and portions of it were not validated.
Conclusion
This study found that nearly one third of newborns at a large Canadian urban centre did not have a PCP. Sociodemographic circumstances of caregivers were associated with lack of access to primary care. Given the primary care crisis in Canada, it is essential to understand the lack of access to primary care among newborns; an understudied yet vulnerable population. Our next steps will be to link survey data to administrative provincial datasets at ICES to evaluate the association between lack of access to primary care and emergency department visits and hospital admissions within the first year of life.
Acknowledgements
The authors acknowledge Tasnim Anwar-Siraj for her help with data collection and data entry.
Abbreviations
- PCP
Primary care provider
- CI
Confidence interval
- OR
Odds ratio
Authors’ contributions
SF conceived the idea for the study, SF, RN, TJ, MS designed the study, KQ performed data collection, RN performed data analysis, SF, RN, TJ, and MS interpreted the data. SF wrote the first draft of the manuscript. All authors read and approved the final manuscript.
Funding
This study was funded by The Physician Services Inc (PSI) (Grant #: 24 − 15).
Data availability
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
Ethics approval was obtained by the Unity Health Toronto Research Ethics Board. Consent was obtained from all participants.
Informed consent to participate was obtained from the parents or legal guardians of any participant under the age of 16.
This study was performed in compliance with the Helsinki Declaration.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.