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ABSTRACT Homelessness during pregnancy poses significant health risks for mothers and infants. As health care providers increase their emphasis on social determinants of health, it is important to understand how unstable housing contributes to complications during pregnancy. We linked data about emergency shelter enrollees with Massachusetts Medicaid claims for the period January 1, 2008-June 30, 2015 to compare health care use and pregnancy complications for 9,124 women who used emergency shelter with those for 8,757 similar women who did not. Rates of mental illness and substance use disorders were significantly higher among homeless women. Adjusted odds of having nine pregnancy complications were also significantly higher for homeless women and remained substantially unchanged after we adjusted for behavioral health disorders. Emergency shelter users also had fewer ambulatory care visits and more months without billable care and were more likely to visit an emergency department. Homelessness and behavioral health disorders appear to be independent factors contributing to pregnancy complications and should be addressed simultaneously.
Pregnancy can increase a woman's risk of becoming homeless, and pregnant women face significantly greater health risks while unstably housed.1-4 Homelessness and unstable housing during pregnancy are associated with low birthweight and preterm delivery.5-8 Adverse pregnancy outcomes while homeless are often attributed to behavioral health comorbidities (such as depression, anxiety, and substance use disorders, which are more prevalent during a period of homelessness) or to underuse of prenatal care.2,8 Because most studies rely on self-reports or hospital records and typically do not include comparison groups, our understanding ofhowhomelessness, as opposed to co-occurring health conditions, contributes to these outcomes-and, thus, of the potential health benefits of stable housing during pregnancy-is incomplete. Few studies accurately document comorbidities, complications, or patterns of care for pregnant homeless women compared to others with more stable housing, or weigh the relative contributions of comorbidities and housing to women's health during pregnancy. As the emphasis on addressing social determinants of health grows, it becomes more important for health care providers and policy makers to understand the unique influence of homelessness on health outcomes.
The US Department of Housing and Urban Development's 2017 Annual Homeless Assessment Report (AHAR) to Congress counted more than a half million (553,742) people who were homeless on one night in the winter of 2017, a...