A population-based retrospective cohort study of 551,706 pregnancies in Ontario (CMAJ, 2026) reveals that 21% of cases lacked timely first-trimester syphilis screening, with 8% receiving none at all. This observational analysis, drawn from administrative health data without reported conflicts of interest, underscores how late or absent testing correlates with sociodemographic barriers rather than isolated lapses. The findings extend beyond the reported 10-fold rise in congenital syphilis (0.3 to 14.5 per 100,000 live births) by exposing reliance on traditional prenatal models that fail marginalized groups. Parallel U.S. CDC surveillance data show similar patterns tied to disrupted care during COVID-19 and housing instability, while a 2023 Public Health Agency of Canada report highlights missed opportunities in community outreach. These gaps reflect systemic underinvestment in reproductive healthcare equity, where point-of-care testing and non-clinical venues could interrupt transmission more effectively than clinic-centric approaches alone.