Unhoused status associated with high-risk pregnancy

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According to a recent study published in JAMA Network Open, rates of unhoused status have increased over time in the United States, and unhoused pregnant patients are in a high-risk pregnancy group.

Many individuals in the United States are impacted by unhoused status, which is defined as not having a proper and consistent place to reside at night. In pregnant individuals, unhoused status is associated with worsened maternal and neonatal outcomes, with decreased odds of receiving recommended prenatal and postnatal care.

Unhoused status during pregnancy has been associated with increased risks of emergency care use, hospitalization, preterm birth, low birth weight, and neonatal intensive care unit admission. An increase of severe maternal morbidity (SMM), defined as an unplanned, serious medical conditions during pregnancy, has also been observed in the United States.

There is limited data on the association between unhoused status in pregnancy and SMM. To determine trends and maternal outcomes associated with unhoused status in pregnancy, investigators conducted a cross-sectional study.

Data was obtained from the National (Nationwide) Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project. About 20% of hospitalized patients in the United States are recorded in the NIS annually. Up to 40 diagnoses and 25 procedures are recorded in each encounter.

Participants included patients aged 12 to 55 years with hospital deliveries from January 1, 2016, to December 31, 2020. International Statistical Classification of Diseases, Tenth Revision Clinical Modification codes were used to determine unhoused status.

The primary outcomes of the study included temporal trends, patient and pregnancy outcomes, delivery outcomes, and patient choice of long-acting reversible contraception (LARC) method. SMM was included in delivery outcomes, determined based on CDC indicators. 

Other delivery outcomes included delivery route and gestational age at delivery. Mortality events were also captured by the NIS. Guidelines from the American College of Obstetricians and Gynecologists were used to determine LARC method.

Covariates included 22 pregnancy characteristics, 11 patient characteristics, 6 mental health conditions, 6 infectious diseases, 3 substance use disorders, and 3 hospital parameters. Patient characteristics included patient demographics, medical comorbidities, and gynecological factors.

Mental health conditions included bipolar disorder, depressive disorder, anxiety disorder, schizophrenia disorder, adjustment disorder, and suicidal ideation. Hospital parameters included hospital location and teaching status, region, and relative bed capacity. Substance use disorders included illicit drug use disorder, tobacco use disorder, and alcohol use disorder. 

There were 18,076,440 hospital deliveries included, with patients aged a median 29 years. Full-term gestation was seen in 88.6% of patients, vaginal birth in 67.7%, and occurrence at an urban teaching center in 69.9%. The rate of unhoused status was 104.9 per 100,000 deliveries, or 1 in 952 hospital deliveries.

A 72.1% increase in unhoused status was observed from 76.1 per 100,000 deliveries in 2016 to 131 per 100,000 deliveries in 2020. This rise was greatest in patients aged 25 to 29 years at 86.3%. Compared to 2016, the adjusted odds ratios of unhoused status at delivery were 1.09 for 2017, 1.32 for 2018, 1.33 for 2019, and 1.44 for 2020.

Factors associated with unhoused status in pregnancy included schizophrenia, bipolar, depressive, and anxiety disorders, tobacco, illicit drugs, and alcohol disorders, hepatitis virus, gonorrhea, syphilis, anogenital herpes, COVID-19, younger and older age, Black and Native American race and ethnicity, low or unknown household income, obesity, pregestational hypertension, pregestational diabetes, and asthma.

Pregnancy characteristics were also associated with unhoused status in pregnancy. These includedprior uterine scar, gestational hypertension, excess weight gain during pregnancy, and preeclampsia.

The rates of SMM in unhoused and housed patients were 53.8 per 1000 deliveries and 17.7 per 1000 deliveries, respectively. Other outcome rates in unhoused and housed patients included mortality at 0.8 vs less than 0.1 per 1000 deliveries respectively and case fatality after SMM at 1.5% vs 0.3% respectively.

Preterm delivery was seen in 34.3 per 1000 deliveries in unhoused patients and 10.8 per 1000 deliveries in housed patients, while postpartum hemorrhage was in 64.0 vs 40.0 per 1000 deliveries and prolonged hospital stay in 80.7 vs 15.5.

LARC use was more common in unhoused patients than in housed patients, at 32.1 vs 3.5 per 1000 deliveries for subdermal contraceptive implant and 30.9 vs 5.6 per 1000 deliveries for intrauterine device.

Overall, increased rates of unhoused status at delivery were observed, along with increased rates of adverse events in this population. Investigators recommended further studies to validate these results and determine the causes of SMM in unhoused patients.

Reference

Green JM, Fabricant SP, Duval CJ, et al. Trends, characteristics, and maternal morbidity associated with unhoused status in pregnancy. JAMA Netw Open. 2023;6(7):e2326352. doi:10.1001/jamanetworkopen.2023.26352