Associations between unstable housing, obstetric outcomes, and perinatal health care utilization


      While there is a growing interest in addressing social determinants of health in clinical settings, there are limited data on the relationship between unstable housing and both obstetric outcomes and health care utilization.


      The objective of the study was to investigate the relationship between unstable housing, obstetric outcomes, and health care utilization after birth.

      Study Design

      This was a retrospective cohort study. Data were drawn from a database of liveborn neonates linked to their mothers’ hospital discharge records (2007–2012) maintained by the California Office of Statewide Health Planning and Development. The analytic sample included singleton pregnancies with both maternal and infant data available, restricted to births between the gestational age of 20 and 44 weeks, who presented at a hospital that documented at least 1 woman as having unstable housing using the International Classification of Diseases, ninth edition, codes (n = 2,898,035). Infants with chromosomal abnormalities and major birth defects were excluded. Women with unstable housing (lack of housing or inadequate housing) were identified using International Classification of Diseases, ninth edition, codes from clinical records. Outcomes of interest included preterm birth (<37 weeks’ gestational age), early term birth (37–38 weeks gestational age), preterm labor, preeclampsia, chorioamnionitis, small for gestational age, long birth hospitalization length of stay after delivery (vaginal birth, >2 days; cesarean delivery, >4 days), emergency department visit within 3 months and 1 year after delivery, and readmission within 3 months and 1 year after delivery. We used exact propensity score matching without replacement to select a reference population to compare with the sample of women with unstable housing using a one-to-one ratio, matching for maternal age, race/ethnicity, parity, prior preterm birth, body mass index, tobacco use during pregnancy, drug/alcohol abuse during pregnancy, hypertension, diabetes, mental health condition during pregnancy, adequacy of prenatal care, education, and type of hospital. Odds of an adverse obstetric outcome were estimated using logistic regression.


      Of 2794 women with unstable housing identified, 83.0% (n = 2318) had an exact propensity score–matched control. Women with an unstable housing code had higher odds of preterm birth (odds ratio, 1.2, 95% confidence interval, 1.0–1.4, P < .05), preterm labor (odds ratio, 1.4, 95% confidence interval, 1.2–1.6, P < .001), long length of stay (odds ratio, 1.6, 95% confidence interval, 1.4–1.8, P < .001), emergency department visits within 3 months (odds ratio, 2.4, 95% confidence interval, 2.1–2.8, P < .001) and 1 year after birth (odds ratio, 2.7, 95% confidence interval, 2.4–3.0, P < .001), and readmission within 3 months (odds ratio, 2.7, 95% confidence interval, 2.2–3.4, P < .0014) and 1 year after birth (odds ratio, 2.6, 95% confidence interval, 2.2–3.0, P < .001).


      Unstable housing documentation is associated with adverse obstetric outcomes and high health care utilization. Housing and supplemental income for pregnant women should be explored as a potential intervention to prevent preterm birth and prevent increased health care utilization.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Obstetrics & Gynecology MFM
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Centers for Disease Control and Prevention
        Preterm birth, maternal and infant health, and reproductive health.
        Centers for Disease Control and Prevention. 2018; (Available at:)
      1. Stoll BJ, Hansen NI, Bell EF, et al; of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Neonatal outcomes of extremely preterm infants from the NICHD Neonatal Research Network. Pediatrics 20101;26:443-456.

        • Swamy G.K.
        • Ostbye T.
        • Skjaerven R.
        Association of preterm birth with long-term survival, reproduction, and next-generation preterm birth.
        JAMA. 2008; 299: 1429-1436
        • Goldenberg R.L.
        • Culhane J.F.
        • Iams J.D.
        • Romero R.
        Epidemiology and causes of preterm birth.
        Lancet (London, England). 2008; 371: 75-84
        • Yamamoto S.
        • Premji S.
        The role of body, mind, and environment in preterm birth: mind the gap.
        J Midwifery Womens Health. 2017; 62: 696-705
        • Dunkel Schetter C.
        • Tanner L.
        Anxiety, depression and stress in pregnancy: implications for mothers, children, research, and practice.
        Curr Opin Psychiatry. 2012; 25: 141-148
        • Braveman P.
        • Heck K.
        • Egerter S.
        • et al.
        Worry about racial discrimination: a missing piece of the puzzle of black-white disparities in preterm birth?.
        PLoS One. 2017; 12e0186151
        • Institute of Medicine (United States)
        Committee on Understanding Premature Birth and Assuring Healthy Outcomes.
        in: Behrman R.E. Butler A.S. Preterm birth: causes, consequences, and prevention. National Academies Press (United States), Washington (DC)2007
        • Stein J.A.
        • Lu M.C.
        • Gelberg L.
        Severity of homelessness and adverse birth outcomes.
        Health Psychol. 2000; 19: 524-534
        • Collins J.W.
        • David R.J.
        • Handler A.
        • Wall S.
        • Andes S.
        Very low birthweight in African American infants: the role of maternal exposure to interpersonal racial discrimination.
        Am J Public Health. 2004; 94: 2132-2138
        • Kushel M.
        • Gupta R.
        • Gee L.
        • Haas J.
        Housing instability and food insecurity as barriers to health care among low-income Americans.
        J Gen Intern Med. 2006; 21: 71-77
        • Frederick T.
        • Chwalek M.
        • Hughes J.
        • Karabanow J.
        • Kidd S.
        How stable is stable? Defining and measuring housing stability.
        J Community Psychol. 2014; 42: 964-979
        • Office of Disease Prevention and Health Promotion
        Housing stability. Accessed online via on 5/6/2019.
        (Available at:) (Accessed May 6, 2019)
        • Department of Housing and Urban Development Exchange
        2017. AHAR: Part 1: PIT estimates of homelessness in the United States. Department of Housing and Urban Development Exchange.
        (Available at:)
        • Richards R.
        • Merrill R.M.
        • Baksh L.
        Health behaviors and infant health outcomes in homeless pregnant women in the United States.
        Pediatrics. 2011; 128: 438-446
        • Little M.
        • Shah R.
        • Vermeulen M.J.
        • Gorman A.
        • Dzendoletas D.
        • Ray J.G.
        Adverse perinatal outcomes associated with homelessness and substance use in pregnancy.
        Can Med Assoc J. 2005; 173: 615-618
        • Cutts D.B.
        • Coleman S.
        • Black M.M.
        • et al.
        Homelessness during pregnancy: a unique, time-dependent risk factor of birth outcomes.
        Matern Child Health J. 2015; 19: 1276-1283
        • California Legislature
        California State Senate Bill No. 1152. Accessed via California Legislative Information online.
        (Available at:)
        • Centers for Medicare and Medicaid Services
        Accountable health communities model.
        (Available at:)
        Date accessed: February 11, 2019
        • Felder J.N.
        • Baer R.J.
        • Rand L.
        • Jelliffe-Pawlowski L.L.
        • Prather A.A.
        sleep disorder diagnosis during pregnancy and risk of preterm birth.
        Obstet Gynecol. 2017; 130: 573-581
        • Anderson J.
        • Baer R.
        • Partridge J.
        • et al.
        Survival and major morbidity of extremely preterm infants: a population-based study.
        Pediatrics. 2016; 138e20154434
        • Yang J.
        • Baer R.
        • Berghella V.
        • et al.
        Recurrence of preterm birth and early term birth.
        Obstet Gynecol. 2016; 128: 364-372
      2. California Offices of Statewide Health Planning and Development.
        (Available at:)
        Date accessed: May 7, 2019
        • Reddy U.
        • Bettegowda V.
        • Dias T.
        • Yamada-Kushnir T.
        • Ko C.
        • Willinger M.
        Term pregnancy: a period of heterogeneous risk for infant mortality.
        Obstet Gynecol. 2011; 117: 1279-1287
        • Bailit J.
        • Gregory K.
        • Reddy U.
        • et al.
        Maternal and neonatal outcomes by labor onset type and gestational age.
        Am J Obstet Gynecol. 2010; 202: 245.e1-245.e12
        • Institute of Medicine (United States)
        Committee on Health Care for Homeless People (1988). Health problems of homeless people. National Academies Press (United States).
        (Available at:)
        Date accessed: December 13, 2018
        • Baer R.J.
        • McLemore M.R.
        • Adler N.
        • et al.
        Pre-pregnancy or first-trimester risk scoring to identify women at high risk of preterm birth.
        Eur J Obstetr Gynecol Reprod Biol. 2018; 231: 235-240
        • Cnattingius S.
        • Villamor E.
        • Johansson S.
        • et al.
        Maternal obesity and risk of preterm delivery.
        JAMA. 2013; 309: 2362-2370
        • Jarde A.
        • Morais M.
        • Kingston D.
        • et al.
        Neonatal outcomes in women with untreated antenatal depression compared with women without depression: a systematic review and meta-analysis.
        JAMA Psychiatry. 2016; 73: 826-837
        • Baer R.J.
        • Chambers C.D.
        • Bandoli G.
        • Jelliffe-Pawlowski L.L.
        Risk of preterm birth by subtype among Medi-Cal participants with mental illness.
        Am J Obstet Gynecol. 2016; 215: 519.e1-519.e9
        • Kotelchuck M.
        An evaluation of the Kessner Adequacy of Prenatal Care Index and a proposed Adequacy of Prenatal Care Utilization Index.
        Am J Public Health. 1994; 84: 1414-1420
        • Partridge S.
        • Balayla J.
        • Holcroft C.A.
        • Abenhaim H.A.
        Inadequate prenatal care utilization and risks of infant mortality and poor birth outcome: a retrospective analysis of 28,729,765 US deliveries over 8 years.
        Am J Perinatol. 2012; 29: 787-793
        • Wadhwa P.D.
        • Entringer S.
        • Buss C.
        • Lu M.C.
        The contribution of maternal stress to preterm birth: issues and considerations.
        Clin Perinatol. 2011; 38: 351-384
        • Morrison D.S.
        Homelessness as an independent risk factor for mortality: results from a retrospective cohort study.
        Int J Epidemiol. 2009; 38: 877-883
        • March of Dimes
        Premature babies cost employers $12.7 billion annually | March of Dimes.
        (Available at:)
        • Kaiser Family Foundation
        Hospital adjusted expenses per inpatient day.
        (Available at:)
        • Bureau of Labor Statistics Reports
        Consumer expenditures in 2017. United States Department of Labor Bureau of Labor Statistics.
        (Available at:)
        • Brownell M.
        • Chartier M.
        • Nickel N.
        • et al.
        on behalf of the PATHS Equity for Children Team. Unconditional prenatal income supplement and birth outcomes.
        Pediatrics. 2016; 137e20152992
        • Patrick S.W.
        • Davis M.M.
        • Sedman A.B.
        • et al.
        Accuracy of hospital administrative data in reporting central line-associated bloodstream infections in newborns.
        Pediatrics. 2013; 131: S75-S80
        • Pisesky A.
        • Benchimol E.I.
        • Wong C.A.
        • et al.
        Incidence of hospitalization for respiratory syncytial virus infection amongst children in Ontario, Canada: a population-based study using validated health administrative data.
        PloS One. 2016; 11e0150416
        • Aronson P.L.
        • Williams D.J.
        • Thurm C.
        • et al.
        of the Febrile Young Infant Research Collaborative. Accuracy of diagnosis codes to identify febrile young infants using administrative data.
        J Hosp Med. 2015; 10: 787-793
        • Navathe A.S.
        • Zhong F.
        • Lei V.J.
        • et al.
        Hospital readmission and social risk factors identified from physician notes.
        Health Serv Res. 2018; 53: 1110-1136
        • Torres J.M.
        • Lawlor J.
        • Colvin J.D.
        • et al.
        ICD social codes: an underutilized resource for tracking social needs.
        Med Care. 2017; 55: 810-816
        • Challis J.
        • Newnham J.
        • Petraglia F.
        • Yeganegi M.
        • Bocking A.
        Fetal sex and preterm birth.
        Placenta. 2013; 34: 95-99
        • Himmelstein D.U.
        • Thorne D.
        • Warren E.
        • Woolhandler S.
        Medical bankruptcy in the United States, 2007: results of a national study.
        Am J Med. 2009; 122: 741-746