Risk of delivery complications among pregnant people experiencing housing insecurity.
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 because of structural racism and discrimination. The introduction of the International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes related to social determinants of health represent a new opportunity to identify patients with housing insecurity nationally.
This study aimed to evaluate the prevalence of and delivery outcomes for pregnant people experiencing housing insecurity, both nationally and by race and ethnicity.
This was a retrospective cohort study using data from the 2016 to 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 1 delivery for a patient with housing insecurity, logistic regression models were used to assess the odds of severe maternal morbidity associated with housing insecurity, adjusting for clinical risk and pregnancy characteristics.
Of 539,950 delivery hospitalizations, 1820 hospitalizations (0.3%) were for patients with housing insecurity. Compared to deliveries for patients with housing security, deliveries for patients with housing insecurity were more likely for patients who identified as Black (34.8% vs 18.1%; P<.001) and who had Medicaid insurance (83.5% vs 46.2%; P<.001). People with housing insecurity were more likely to have comorbidities and higher-risk pregnancies, including higher rates of substance use disorders (54.0% vs 6.9%), major mental health disorders (37.5% vs 8.7%), preeclampsia with severe features (7.4% vs 4.3%), and preterm birth <37 weeks gestation (23.7% vs 11.6%) (all P<.001). In regression analyses, patients with housing insecurity had more than twice the odds of severe maternal morbidity than patients with housing security during the delivery hospitalization (odds ratio, 2.17; 95% confidence interval, 1.75-2.68). After adjusting for clinical risk and pregnancy characteristics, the differences were attenuated overall (adjusted odds ratio, 1.17; 95% confidence interval, 0.94-1.47) and among racial and ethnic groups (White patients: adjusted odds ratio, 1.39; 95% confidence interval, 0.95-2.03; Black patients: adjusted odds ratio, 1.05; 95% confidence interval, 0.73-1.52; Hispanic patients: adjusted odds ratio, 1.04; 95% confidence interval, 0.59-1.84; Asian or Pacific Islander or Native American or other race patients: adjusted odds ratio, 1.08; 95% confidence interval, 0.45-2.58).
Pregnant individuals experiencing housing insecurity were more likely to be from groups that have been marginalized historically, had higher rates of comorbidities, and worse delivery outcomes. After risk adjustment, differences in the 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.
Huang K
，Waken RJ
，Luke AA
，Carter EB
，Lindley KJ
，Joynt Maddox KE
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The interaction between maternal race/ethnicity and chronic hypertension on preterm birth.
In both the biomedical and public health literature, the risk for preterm birth has been linked to maternal racial/ethnic background, in particular African-American heritage. Despite this well-documented health disparity, the relationship of comorbid conditions, such as chronic hypertension, to maternal race/ethnicity and preterm birth has received relatively limited attention in the literature.
The objective of the study was to evaluate the interaction between chronic hypertension and maternal racial/ethnic background on preterm birth.
This is a retrospective cohort study of singleton pregnancies among women who delivered between 2002 and 2015 at the University of California, San Francisco. The associations of chronic hypertension with both spontaneous and medically indicated preterm birth were examined by univariate and multivariate logistical regression, adjusting for confounders including for maternal age, history of preterm birth, maternal body mass index, insurance type (public vs private), smoking, substance abuse, history of pregestational diabetes mellitus, and use of assisted reproductive technologies. The interaction effect of chronic hypertension and racial/ethnicity was also evaluated. All values are reported as odds ratios, with 95% confidence intervals and significance set at P = .05.
In this cohort of 23,425 singleton pregnancies, 8.8% had preterm deliveries (3% were medically indicated preterm birth, whereas 5.5% were spontaneous preterm births), and 3.8% of women carried the diagnosis of chronic hypertension. Chronic hypertension was significantly associated with preterm birth in general (adjusted odds ratio, 2.74, P < .001) and medically indicated preterm birth specifically (adjusted odds ratio, 5.25, P < .001). When evaluating the effect of chronic hypertension within racial/ethnic groups, there was an increased odds of a preterm birth among hypertensive, African-American women (adjusted odds ratio, 3.91, P < .001) and hypertensive, Asian-American/Pacific Islander women (adjusted odds ratio, 3.51, P < .001) when compared with their nonhypertensive counterparts within the same racial/ethnic group. These significant effects were also noted with regard to medically indicated preterm birth for hypertensive African-American women (adjusted odds ratio, 6.85, P < .001) and Asian-American/Pacific Islander women (adjusted odds ratio, 9.87, P < .001). There was no significant association of chronic hypertension with spontaneous preterm birth (adjusted odds ratio, 0.87, P = .4).
The effect of chronic hypertension on overall preterm birth and medically indicated preterm birth differs by racial/ethnic group. The larger effect of chronic hypertension among African-American and Asian/Pacific Islander women on medically indicated and total preterm birth rates raises the possibility of an independent variable that is not captured in the data analysis, although data regarding the indication for medically indicated preterm delivery was limited in this data set. Further investigation into both social-structural and biological predispositions to preterm birth should accompany research focusing on the effect of chronic hypertension on birth outcomes.
Premkumar A
，Henry DE
，Moghadassi M
，Nakagawa S
，Norton ME
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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.
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.
Pantell MS
，Baer RJ
，Torres JM
，Felder JN
，Gomez AM
，Chambers BD
，Dunn J
，Parikh NI
，Pacheco-Werner T
，Rogers EE
，Feuer SK
，Ryckman KK
，Novak NL
，Tabb KM
，Fuchs J
，Rand L
，Jelliffe-Pawlowski LL
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