Impact of Homelessness and Housing Services on Maternal and Infant Health

Improving maternal, infant and child health and wellbeing (MCH) is an urgent public health priority. Birthing people are experiencing increases in severe maternal morbidity (SMM) and other pregnancy-related health conditions, while infant mortality in the first year of life remains greater in the U.S. than any other higher- income country. There are substantial racial and ethnic inequities and disparities in MCH, which are strongly influenced by social determinants. Thus, successfully advancing MCH in the U.S. requires interventions that address underlying factors that affect health among disinvested communities, such as housing. Homelessness is a growing phenomenon in the U.S. More than 1.2 million people experience homelessness each year, and the number of people experiencing homelessness on a single night has been rising each year since 2016. Women and girls are one of the fastest growing demographic groups among people experiencing homelessness (PEH), and 4% of all birthing people experience homelessness in the year prior to delivery. Health outcomes and behaviors associated with homelessness, such as lacking access to a regular source of medical care, are known risk factors for pregnancy-related morbidity and adverse birth outcomes. Members of racial and ethnic minoritized groups, who are more likely to face health-limiting systemic disadvantages, are overrepresented among PEH, further exacerbating inequities in MCH. However, critical gaps in our understanding of how homelessness affects MCH, and how evidence-based housing services affect MCH, limit our ability to implement effective interventions. Our overall objective is to assess how and when the experience of homelessness affects maternal and infant health and racial and ethnic health inequities, and whether Permanent Supportive Housing (PSH) and Rapid Rehousing (RRH) interventions have a positive impact on these outcomes. 

Our multidisciplinary team will apply quasi-experimental methods to linked administrative data that include homeless and housing service information, Medicaid claims, all-payer hospital records, and birth records. In Aim 1, we estimate effects of homelessness on maternal health conditions, health behaviors and healthcare utilization during pregnancy. In Aim 2, we estimate effects of homelessness on postpartum maternal and infant health and healthcare utilization. Our longitudinal dataset allows us to explore the timing of exposure, account for preconception health and compare outcomes across different pregnancies for the same person. In Aim 3, we estimate effects of PSH and RRH in this population. We use a difference-in-differences framework to provide the first quantitative estimates of the impact of these interventions on maternal and infant health and racial and ethnic health inequities. Guided by our advisory board members’ lived experience and clinical training, findings will be used to develop intervention studies and inform policy to improve prenatal and postpartum care for birthing people and infants who have experienced homelessness.