Pregnant and Homeless: How Unstable Housing Affects Maternal Health Outcomes

Pregnant and Homeless: How Unstable Housing Affects Maternal Health Outcomes
Robin E. Clark, Linda Weinreb, Julie M. Flahive, Robert W. Seifert
Health Affairs
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Research shows that pregnancy can increase a woman’s1 risk of homelessness, and pregnant women face greater health risks while unstably housed. Although pregnant women experiencing homelessness2 are covered under Medicaid, their unique health needs and patterns of health care use are not well understood. To help fill this knowledge gap, this study analyzed differences in the mental and physical health conditions and use of health care among women who entered emergency shelters during or shortly after pregnancy, compared with a similar group who did not enter the shelter system.

Linking family shelter enrollment data and Medicaid claims data from Massachusetts, researchers identified 9,124 pregnant women who used emergency shelters between 2008 and 2015. In Massachusetts, right to shelter laws require the state to provide shelter for all homeless families, including pregnant women. As such, this sample includes almost all pregnant women experiencing homelessness in the state during this period. The researchers matched these women with 8,757 pregnant women in the same age category, health care eligibility group, and with similar risk scores3 but who did not use emergency shelters during their pregnancy.

Among the study sample, 48 percent (4,379) of the women experiencing homelessness were pregnant while in shelter, and 52 percent (4,745) had been pregnant in the year before shelter entry. Twenty-four percent of the women using shelter had two or more homeless episodes during the study period. Although direct matching helped limit bias in the sample, women in the shelter group were slightly younger, more likely to identify themselves as black, and more likely to live in the Boston area than their counterparts. To conduct the analysis, researchers adjusted for these demographic differences and compared the frequency and likelihood of maternal health outcomes between the two groups.

Key findings

  • Women who entered shelter during or shortly after pregnancy had higher rates of alcohol, opioid, and nonopioid drug use disorders; adjustment, anxiety, and depressive disorders; injuries due to external causes; and complications during pregnancy and birth compared with pregnant women who did not use shelter.
  • Women experiencing homelessness were more than twice as likely to experience a complication that affected their health during birth and almost twice as likely to have an early or threatened labor or a hemorrhage during pregnancy than the comparison group. Health risks associated with homelessness did not change significantly after adjusting for the presence of mental health or substance use disorders.
  • Women experiencing homelessness had fewer ambulatory care visits during pregnancy than the comparison group did, despite having more complications.
  • Emergency department use was more widespread among women experiencing homelessness (76 percent) than in the comparison group (59 percent).
  • Women experiencing homelessness had more months during which they received no reimbursable health care than the comparison group (61 percent versus 18 percent).
  • Induced abortion rates were lower among pregnant women experiencing homelessness (8 percent) than in the comparison group (17 percent).
  • Among pregnant women experiencing homelessness, living in shelter was associated with higher rates of hemorrhaging and maternal birth complications compared with their health outcomes before entering shelter.

Policy implications

  • These findings suggest that homelessness or the unique social factors associated with homelessness place pregnant women at greater risk. As such, treating behavioral health disorders alone might not be sufficient to reduce risk if women continue to be unstably housed.
  • Shelter-based interventions providing prenatal care would likely improve the health outcomes of pregnant women experiencing homelessness, but they might receive the interventions too late to reduce their risk to the same level as women with greater housing stability.
  • Many conditions treated in emergency departments might have been avoided with more consistent preventive care.

1 In alignment with the original article, we use the term “pregnant women” throughout. The How Housing Matters editorial team recognizes that this term is not inclusive of the full spectrum of gender identities and expressions who experience pregnancy. We remain committed to using inclusive language whenever possible and will always attempt to explain the editorial rationale behind the labeling of certain groups.

2 For the purposes of this abstract, “experiencing homelessness” is defined as a person who used a family emergency shelter during or shortly after pregnancy. The How Housing Matters editorial team recognizes that this definition does not account for people experiencing unsheltered homelessness or other more discreet forms of housing instability.

3Risk scores are used by health insurers to predict future costs. A score of less than 1 indicates that a member’s annual expenditures were lower than the average for all members, a score of 1 means that expenditures were equal to the average, and a score of 2 means that expenditures were twice the average.

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