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Risk of Delivery Complications among Pregnant People Experiencing Housing Insecurity

Published:November 24, 2022DOI:https://doi.org/10.1016/j.ajogmf.2022.100819

      AJOG at a Glance

      • Why was this study conducted?
        • To evaluate the prevalence and delivery outcomes for pregnant people experiencing housing insecurity, both nationally and by race/ethnicity.
      • Key findings
        • Pregnant individuals experiencing housing insecurity were more likely to be from groups that have been historically marginalized, had higher rates of comorbidities and worse delivery outcomes. Housing-insecure patients had greater odds of severe maternal morbidity than housing-secure patients, although this relationship was attenuated after controlling for obstetric risk factors.
      • What does this study add to what is already known?
        • Housing status is an important social determinant of health to screen for during prenatal visits. It is possible that early identification and intervention could help reduce adverse outcomes for housing-insecure pregnant patients.

      Abstract

      Background

      Housing-insecurity is increasingly being recognized as an important social determinant of health. Pregnant individuals experiencing housing insecurity may represent a particularly vulnerable subset of this population, but few studies have examined this population nationally. In particular, racial and ethnic minority individuals may be at risk for poor outcomes within this group due to structural racism and discrimination. The introduction of International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes related to social determinants of health represent a new opportunity to identify housing-insecure patients nationally.

      Objective

      To evaluate the prevalence and delivery outcomes for pregnant people experiencing housing insecurity, both nationally and by race/ethnicity.

      Study Design

      Retrospective cohort study using data from the 2016-2018 National Inpatient Sample. Delivery hospitalizations for people experiencing housing insecurity were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code Z59. Among hospitals that coded at least one delivery for a housing-insecure patient, logistic regression models were used to assess odds of severe maternal morbidity associated with housing insecurity, adjusting for clinical risk and pregnancy characteristics.

      Results

      Out of 539,950 delivery hospitalizations, 1,820 hospitalizations (0.3%) were for patients with housing insecurity. Compared to housing-secure deliveries, housing-insecure deliveries were more likely for patients who identified as Black (34.8% vs. 18.1%, p<0.001) and had Medicaid insurance (83.5% vs. 46.2%, p<0.001). Housing-insecure people were more likely to have comorbidities and higher-risk pregnancies, including higher rates of substance use disorder (54.0% vs. 6.9%), major mental health disorder (37.5% vs. 8.7%), pre-eclampsia with severe features (7.4% vs 4.3%), and preterm birth < 37 weeks (23.7% vs. 11.6%) (all p<0.001). In regression analyses, housing-insecure patients had more than twice the odds of severe maternal morbidity than housing-secure patients during the delivery hospitalization (odds ratio (OR) 2.17, [1.75-2.68]). Adjusting for clinical risk and pregnancy characteristics, differences were attenuated, overall (aOR: 1.17, [0.94-1.47]) and among racial and ethnic groups (White patients, aOR 1.39 [0.95-2.03]; Black patients, aOR 1.05 [0.73-1.52]; Hispanic patients, aOR 1.04 [0.59-1.84]; Asian/Pacific Islander/Native American/Other race patients, aOR 1.08 [0.45-2.58]).

      Conclusion

      Pregnant individuals experiencing housing insecurity were more likely to be from groups that have been historically marginalized, had higher rates of comorbidities and worse delivery outcomes. After risk adjustment, differences in odds of severe maternal mortality were attenuated. Screening for housing insecurity may identify these patients earlier and connect them to services that could improve disparities in outcomes.

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