Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (Ms Huang and Drs Waken, Lindley, and Joynt Maddox).
Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA (Ms Luke).
Am J Obstet Gynecol MFM. 2023 Feb;5(2):100819. doi: 10.1016/j.ajogmf.2022.100819. Epub 2022 Nov 25.
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.
住房无保障日益被视为健康的一个重要社会决定因素。住房无保障的孕妇可能代表这一人群中一个特别脆弱的亚组，但很少有研究在全国范围内研究这一人群。特别是，由于结构性种族主义和歧视，少数族裔个人可能面临该群体中不良结局的风险。与社会决定因素相关的国际疾病分类第十版临床修正诊断代码的引入，代表了在全国范围内识别住房无保障患者的新机会。
本研究旨在评估全国范围内以及按种族和族裔划分的住房无保障孕妇的患病率和分娩结局。
这是一项回顾性队列研究，使用了 2016 年至 2018 年全国住院患者样本的数据。使用国际疾病分类第十版临床修正诊断代码 Z59 识别住房无保障患者的分娩住院情况。在对至少有 1 例住房无保障患者进行编码的医院中，使用逻辑回归模型评估与住房无保障相关的严重产妇发病率的比值比，同时调整临床风险和妊娠特征。
在 539950 例分娩住院中，有 1820 例（0.3%）为住房无保障患者。与住房有保障的患者相比，住房无保障的患者更有可能是黑人（34.8% vs 18.1%；P<.001）和拥有医疗补助保险（83.5% vs 46.2%；P<.001）。住房无保障的患者更有可能患有合并症和高危妊娠，包括更高的物质使用障碍率（54.0% vs 6.9%）、主要心理健康障碍率（37.5% vs 8.7%）、有严重特征的子痫前期率（7.4% vs 4.3%）和早产<37 周妊娠率（23.7% vs 11.6%）（均 P<.001）。在回归分析中，与住房有保障的患者相比，住房无保障的患者在分娩住院期间发生严重产妇发病率的比值比超过两倍（比值比，2.17；95%置信区间，1.75-2.68）。在调整临床风险和妊娠特征后，总体差异减弱（调整比值比，1.17；95%置信区间，0.94-1.47），且在种族和族裔群体中差异减弱（白人患者：调整比值比，1.39；95%置信区间，0.95-2.03；黑人患者：调整比值比，1.05；95%置信区间，0.73-1.52；西班牙裔患者：调整比值比，1.04；95%置信区间，0.59-1.84；亚洲或太平洋岛民或美洲原住民或其他种族患者：调整比值比，1.08；95%置信区间，0.45-2.58）。
住房无保障的孕妇更有可能来自历史上被边缘化的群体，合并症发生率更高，分娩结局更差。在风险调整后，严重产妇死亡率的比值比差异减弱。住房无保障筛查可能会更早地发现这些患者，并将他们与可以改善结局差异的服务联系起来。
