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