Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles.
Division of Obstetrics, Gynecology and Gynecologic Subspecialties, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles.
JAMA Netw Open. 2023 Jul 3;6(7):e2326352. doi: 10.1001/jamanetworkopen.2023.26352.
Unhoused status is a substantial problem in the US. Pregnancy characteristics and maternal outcomes of individuals experiencing homelessness are currently under active investigation to optimize health outcomes for this population.
To assess the trends, characteristics, and maternal outcomes associated with unhoused status in pregnancy.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study analyzed data from the Healthcare Cost and Utilization Project National (Nationwide) Inpatient Sample. The study population included hospitalizations for vaginal and cesarean deliveries from January 1, 2016, to December 31, 2020. Unhoused status of these patients was identified from use of International Statistical Classification of Diseases, Tenth Revision, Clinical Modification code Z59.0. Statistical analysis was conducted from December 2022 to June 2023.
Primary outcomes were (1) temporal trends; (2) patient and pregnancy characteristics associated with unhoused status, which were assessed with a multivariable logistic regression model; (3) delivery outcomes, including severe maternal morbidity (SMM) and mortality at delivery, which used the Centers for Disease Control and Prevention definition for SMM indicators and were assessed with a propensity score-adjusted model; and (4) choice of long-acting reversible contraception method and surgical sterilization at delivery.
A total of 18 076 440 hospital deliveries were included, of which 18 970 involved pregnant patients who were experiencing homelessness at the time of delivery, for a prevalence rate of 104.9 per 100 000 hospital deliveries. These patients had a median (IQR) age of 29 (25-33) years. The prevalence of unhoused patients increased by 72.1% over a 5-year period from 76.1 in 2016 to 131.0 in 2020 per 100 000 deliveries (P for trend < .001). This association remained independent in multivariable analysis. In addition, (1) substance use disorder (tobacco, illicit drugs, and alcohol use disorder), (2) mental health conditions (schizophrenia, bipolar, depressive, and anxiety disorders, including suicidal ideation and past suicide attempt), (3) infectious diseases (hepatitis, gonorrhea, syphilis, herpes, and COVID-19), (4) patient characteristics (Black and Native American race and ethnicity, younger and older age, low or unknown household income, obesity, pregestational hypertension, pregestational diabetes, and asthma), and (5) pregnancy characteristics (prior uterine scar, excess weight gain during pregnancy, and preeclampsia) were associated with unhoused status in pregnancy. Unhoused status was associated with extreme preterm delivery (<28-week gestation: 34.3 vs 10.8 per 1000 deliveries; adjusted odds ratio [AOR], 2.76 [95% CI, 2.55-2.99]); SMM at in-hospital delivery (any morbidity: 53.8 vs 17.7 per 1000 deliveries; AOR, 2.30 [95% CI, 2.15-2.45]); and in-hospital mortality (0.8 vs <0.1 per 1000 deliveries; AOR, 10.17 [95% CI, 6.10-16.94]), including case fatality risk after SMM (1.5% vs 0.3%; AOR, 4.46 [95% CI, 2.67-7.45]). Individual morbidity indicators associated with unhoused status included cardiac arrest (AOR, 12.43; 95% CI, 8.66-17.85), cardiac rhythm conversion (AOR, 6.62; 95% CI, 3.98-11.01), ventilation (AOR, 6.24; 95% CI, 5.03-7.74), and sepsis (AOR, 5.37; 95% CI, 4.53-6.36).
Results of this national cross-sectional study suggest that unhoused status in pregnancy gradually increased in the US during the 5-year study period and that pregnant patients with unhoused status were a high-risk pregnancy group.
在美国，无家可归的状况是一个严重的问题。目前正在积极研究无家可归者的妊娠特征和母婴结局，以优化这一人群的健康结局。
评估与妊娠时无家可归状态相关的趋势、特征和母婴结局。
设计、地点和参与者：这是一项横断面研究，分析了医疗保健成本和利用项目国家（全国）住院患者样本的数据。研究人群包括 2016 年 1 月 1 日至 2020 年 12 月 31 日阴道分娩和剖宫产的住院患者。这些患者的无家可归状态是通过使用国际疾病分类第十次修订临床修正版 Z59.0 代码来确定的。统计分析于 2022 年 12 月至 2023 年 6 月进行。
主要结局是（1）时间趋势；（2）与无家可归状态相关的患者和妊娠特征，使用多变量逻辑回归模型评估；（3）分娩结局，包括严重孕产妇发病率（SMM）和分娩时的死亡率，使用疾病控制和预防中心对 SMM 指标的定义，并使用倾向评分调整模型评估；（4）分娩时长效可逆避孕方法和手术绝育的选择。
共纳入 18076440 例分娩，其中 18970 例孕妇在分娩时无家可归，患病率为每 100000 例分娩 104.9 例。这些患者的中位（IQR）年龄为 29（25-33）岁。无家可归患者的患病率在 5 年内增加了 72.1%，从 2016 年的每 100000 例分娩 76.1 例增加到 2020 年的每 100000 例分娩 131.0 例（趋势 P <.001）。这种关联在多变量分析中仍然独立存在。此外，（1）物质使用障碍（烟草、非法药物和酒精使用障碍），（2）心理健康状况（精神分裂症、双相、抑郁和焦虑障碍，包括自杀意念和过去的自杀企图），（3）传染病（肝炎、淋病、梅毒、疱疹和 COVID-19），（4）患者特征（黑人、美国原住民种族和民族、年轻和年长、低或未知的家庭收入、肥胖、孕前高血压、孕前糖尿病和哮喘），（5）妊娠特征（既往子宫瘢痕、妊娠期间体重过度增加和子痫前期）与妊娠时无家可归状态相关。无家可归状态与极早产（<28 周妊娠：每 1000 例分娩 34.3 例与 10.8 例；调整后的优势比 [OR]，2.76 [95%CI，2.55-2.99]）、分娩时 SMM（任何发病率：每 1000 例分娩 53.8 例与 17.7 例；OR，2.30 [95%CI，2.15-2.45]）和分娩时死亡率（每 1000 例分娩 0.8 例与<0.1 例；OR，10.17 [95%CI，6.10-16.94]）相关，包括 SMM 后死亡率（0.8%与 0.1%；OR，4.46 [95%CI，2.67-7.45]）。与无家可归状态相关的个体发病率指标包括心脏骤停（OR，12.43；95%CI，8.66-17.85）、心脏节律转换（OR，6.62；95%CI，3.98-11.01）、通气（OR，6.24；95%CI，5.03-7.74）和败血症（OR，5.37；95%CI，4.53-6.36）。
这项全国性横断面研究的结果表明，在美国，妊娠时无家可归的状况在 5 年研究期间逐渐增加，无家可归的孕妇是高危妊娠人群。
