Homelessness in the Perinatal Period and Associations With Reproductive Interconception Care: 2016-2019 Pregnancy Risk Assessment Monitoring System

Abstract

Objectives:

Women experiencing homelessness have higher rates of unintended pregnancy than stably housed women and may benefit from reproductive interconception care. How reproductive interconception care differs between women who did and did not experience perinatal homelessness is not known. We estimated prevalence ratios of reproductive interconception behaviors among US women experiencing homelessness during the perinatal period.

Methods:

We used data from the 2016-2019 Pregnancy Risk Assessment Monitoring System to calculate the prevalence of 5 reproductive interconception care outcomes: attending a maternal postpartum checkup, participating in a conversation with a health care provider about birth intervals, receiving family planning counseling, obtaining a prescription for short-acting contraception, and having a long-acting reversible contraceptive inserted. We used complex survey weights, stratified by perinatal homelessness, and converted adjusted logistic regression odds ratios between housing status and outcome variables to adjusted prevalence ratios (aPRs) and 95% CIs.

Results:

Among participants, approximately 2.4% (weighted percentage; unweighted 2953 of 100 706) experienced homelessness sometime in the 12 months before their children were born; the majority were non-Hispanic (83.2%) and White (69.4%), were not married (82.2%), and had public health insurance (56.8%). Perinatal homelessness was significantly associated with a lower prevalence of attending a postpartum maternal visit (aPR = 0.90; 95% CI, 0.87-0.94) and a higher prevalence of having a conversation about birth intervals with their health care providers (aPR = 1.13; 95% CI, 1.03-1.21).

Conclusions:

Findings suggest that improving attendance at postpartum visits and evaluating birth interval conversations may strengthen interconception care practices while contextualizing social determinants such as housing stability. Improving uptake of postpartum visits may reduce unintended pregnancy, short birth intervals, and adverse birth outcomes in future pregnancies among women experiencing homelessness.

Keywords

PRAMS interconception care women experiencing homelessness birth intervals contraception

Homelessness is a critical public health issue. The US Department of Housing and Urban Development defines homelessness as having a shelter or place not suitable for residency as a primary nighttime residence.¹ The 2020 US Point-in-Time count, which includes sheltered and unsheltered homelessness, estimated that 580 000 people experienced sheltered homelessness and, of them, 223 578 (39%) were women.¹

In a longitudinal study of homelessness comparing women and men, women were younger and had more children, and they were more likely to be unemployed, less educated, less empowered, more psychologically stressed, and more victimized.² Moreover, women experiencing homelessness have several health disparities as compared with women who are stably housed, potentially resulting in a greater financial burden and sustained homelessness, which may explain an increase in homelessness rates from previous years.³ When compared with women in the general population, women experiencing homelessness have an increased risk for sexual and reproductive health problems, such as sexually transmitted infections, sexual coercion, exchange sex, and lack of preventive screenings (eg, sexually transmitted infection screenings, mammograms, prenatal care, and Papanicolaou tests).^4,5 Additionally, women experiencing homelessness have twice the rate of unintended pregnancy (10%) than women who are stably housed (5%).⁶

Unintended pregnancy (ie, mistimed or unwanted) may be especially problematic for women experiencing homelessness, exacerbating financial constraints and potential intergenerational homelessness.^7,8 The American College of Obstetricians and Gynecologists recommends assessment of maternal well-being in a postpartum visit, typically around 6 weeks and no later than 12 weeks,⁹ given the associations of such visits with improved screening and treatment for key maternal mortality-related concerns, such as hemorrhage, endometritis, thromboembolic disease, hypertensive disorders, gestational diabetes, thyroid disorders, depression, and intimate partner violence.¹⁰ The interconception period (ie, the interval between pregnancies) can also be an opportune time to reduce the potential for unintended pregnancies and promote healthy ones.

Interconception care (ie, care between pregnancies) includes conversations and screenings for several health conditions affecting maternal and child health, such as maternal depression, folic acid intake, smoking, and family planning.¹¹ Reproductive interconception care (ie, care related directly to reproductive family planning) is associated with reduced rates of prematurity, low birthweight, and congenital anomalies, conditions that are frequently associated with short birth intervals (<24 months).^12
-14 For women experiencing homelessness, interconception care that either reduces the potential for unintended pregnancy and short birth intervals (eg, use of contraception) or promotes healthy pregnancies before subsequent pregnancies (eg, family planning discussions with a health care provider) may reduce the potential for cyclical homelessness and improve quality of life.^15,16 Knowing the prevalence of reproductive interconception care for women (including all pregnant people, regardless of gender) who are experiencing homelessness can establish whether certain social determinants of health (eg, housing) can create a unique obstacle to the uptake of interconception care, which then can help to determine what to prioritize when developing health promotion interventions for populations vulnerable to poor reproductive health outcomes.

Establishing the prevalence of reproductive interconception care behaviors among women experiencing homelessness is necessary to determine whether additional or improved reproductive care during the interconception period is warranted for these women and their children. This study aimed to establish the prevalence of reproductive interconception care behaviors among women experiencing homelessness and determine whether the prevalence of this care differs significantly by housing status. We hypothesized that the prevalence of reproductive interconception care behaviors among women experiencing homelessness would be significantly lower than among women who are stably housed, when adjusting for demographic and perinatal covariates.

Methods

Study Population

The data source was 2016-2019 Phase 8 data from the Pregnancy Risk Assessment Monitoring System (PRAMS).¹⁷ PRAMS is a population-based, site-specific surveillance system partnership between the Centers for Disease Control and Prevention and local, state, and regional health departments to identify women and infants at risk of poor health outcomes and to track progress toward improving mother and infant health.¹⁸ PRAMS uses birth certificate files to randomly sample women with a live birth 2 to 6 months postpartum.¹⁸ Women respond to the survey by submitting a mailed PRAMS questionnaire or participating in a telephone interview (if they do not respond to the mailing), both of which could be completed up to 9 months after delivery.¹⁸

Eligibility criteria for this study were (1) participation in PRAMS and (2) a response of yes or no to whether homelessness was experienced 12 months before delivery, a standard (state-optional) question asked in 34 sites. In addition, we set a response rate threshold for PRAMS sites (55% in 2016-2017 or 50% in 2018-2019). Thirty jurisdictions had a ≥50% response rate in 2018-2019 or ≥55% response rate in 2016-2017: Alabama, Alaska, Colorado, Connecticut, Delaware, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Nebraska, New York City, New York State, North Carolina, North Dakota, Oregon, Pennsylvania, South Dakota, Utah, Wisconsin, and Wyoming. Because this study used deidentified data, it was deemed non–human subjects research by the North Texas Regional Institutional Review Board; thus, full review was waived.

Measures

All variables came from responses to the PRAMS survey. Our primary independent variable was housing status based on whether the participant was homeless or had to sleep outside, in a car, or in a shelter during the 12 months before her newborn was born (yes/no). Five primary outcomes assessed reproductive interconception care behaviors. The first outcome assessed whether participants attended a maternal postpartum checkup at 4 to 6 weeks (yes/no). If the answer was yes, we assessed 4 additional dichotomous outcomes (yes/no), including whether the postpartum care provider (1) talked about how long to wait before getting pregnant again, (2) discussed birth control methods to use postpartum, (3) prescribed a short-acting contraceptive method (eg, pill, patch, shot, ring), and (4) inserted a long-acting reversible contraceptive (LARC; eg, intrauterine device or implant).

We identified potential confounding covariates on the basis of a literature review and the availability of survey questions with at least 70% of valid responses among the study’s eligible sample.^19
-23 Preconception covariates were whether the respondent, at a health care visit 12 months before becoming pregnant, had a conversation with a health care provider about the desire to have children or not (yes/no) or the use of birth control to prevent pregnancy (yes/no). The question about pregnancy desire asked participants how they felt about the idea of becoming pregnant just before they became pregnant with their most recent infant. Response options were as follows: (1) “I wanted to be pregnant later,” (2) “I wanted to be pregnant sooner,” (3) “I wanted to be pregnant then,” (4) “I didn’t want to be pregnant then or any time in the future,” and (5) “I wasn’t sure what I wanted.” The survey determines the timing of the participant’s first prenatal care visit, which is initially assessed by the number of weeks pregnant at the first visit and is then categorized by trimester (first, second, or third) with a fourth category (none) for participants with no prenatal care visit. The survey also assessed whether contraception and family planning were discussed during the prenatal period (yes/no).

Demographic covariates were as follows:

Maternal age: <18, 18-24, 25-29, 30-34, ≥35 years

Health insurance: private (any employer provided, nongovernmental), public (Medicaid, Children’s Health Insurance Program [CHIP or state CHIP], or other government-offered insurance with no private insurance), other (another insurance type that is not private or public), no insurance

Maternal education: <9th grade, 9th-12th grade (no degree), high school degree or GED (General Educational Development), some college/2-year degree, ≥4-year degree

For maternal race and ethnicity, demographic descriptive data included Hispanic or Latinx for ethnicity (yes/no) and the following race categories: American Indian/Alaska Native, Asian/Pacific Islander, Black or African American, White, other race (for any race not previously listed), and mixed race (reporting ≥2 races). In adjusted analysis, to account for small cell sizes, we operationalized race and ethnicity into 4 categories: Hispanic (any race), non-Hispanic Black, non-Hispanic White, and non-Hispanic other race (for any race not White or Black) or mixed race.

Data Analysis

We used SAS version 9.4 (SAS Institute Inc) to estimate the prevalence of the 5 reproductive interconception care outcomes among women experiencing homelessness and women who were stably housed. All statistical calculations incorporated complex survey analysis including standardized weights and strata. To account for missing data, we used the SAS option NOMCAR, which instructs SAS to perform a domain analysis of missing and nonmissing values.²⁴ We used the Taylor series variance estimation method for survey analysis.²⁴ Bivariate Rao–Scott χ² tests determined whether each reproductive interconception care outcome was significantly associated with homelessness; we considered P < .05 to be significant.²⁵

Five adjusted logistic regression models estimated the odds ratios (ORs) with covariate-adjusted associations between housing status and each of the 5 reproductive interconception care outcomes, using complex survey analysis including standardized weights and strata. We selected all covariates on the basis of past associations with homelessness and birth outcomes^19
-23 and entered these covariates into models for model selection. We systematically assessed each covariate for inclusion in the final model on the basis of confounding (using direct acyclic graphs to examine potential confounding relationships between exposure and outcomes), biological plausibility, extent of missingness, and overall model fit. Model fit comparisons using direct acyclic graphs and change in estimation criterion ensured that final models had the best fit without overcorrection. We then converted adjusted ORs (aORs) into prevalence ratios by using the following formula: prevalence ratio = OR/[(1 – P₀) + (OR × P₀)], where P₀ is the risk of the outcome (eg, attending maternal postpartum visits) in the unexposed population (ie, unexposed to homelessness).²⁶ We calculated 95% CIs accordingly. All descriptions of the sample are reported as unweighted sample sizes and weighted percentages.

Results

The study sample consisted of 100 706 participants, with 2953 (2.4%) experiencing homelessness (Table 1). Most were aged 25-29 years (29.2%) or 30-34 years (29.6%). Most (83.2%) reported non-Hispanic/Latinx ethnicity, and the majority (69.4%) self-identified as White, as compared with 15.6% Black, 5.3% Asian/Pacific Islander, 0.9% American Indian/Alaska Native, 5.9% other race, and 2.8% mixed race. The proportion that reported having any private health insurance was 59.4%. By education level, the largest proportion (37.0%) had ≥4-year degree, followed by some college/2-year degree (27.3%), high school degree or GED (24.1%), and less than a high school degree (11.6%). All demographic characteristics except Hispanic ethnicity were significantly different (P < .05) between women experiencing homelessness and women who were stably housed.

Table 1.

Prevalence of women experiencing homelessness during the perinatal period and characteristics of participants (n = 100 706) in 30 sites in the Pregnancy Risk Assessment Monitoring System, United States, 2016-2019^a

	Experienced homelessness in the 12 mo before giving birth
	Yes (n = 2953)		No (n = 97 753)
Characteristic	Unweighted no.	Weighted % (95% CI)	Unweighted no.	Weighted % (95% CI)	P value^b
Maternal age, y (unweighted n = 100 706)					<.001
<17	49	1.2 (0.7-1.8)	1092	1.1 (1.0-1.2)
18-24	1075	38.5 (35.6-41.5)	20 560	21.1 (20.7-21.5)
25-29	889	30.4 (27.6-33.2)	28 580	29.2 (28.8-29.6)
30-34	616	19.1 (16.8-21.3)	29 024	29.8 (29.4-30.3)
≥35	324	10.8 (9.0-12.6)	18 497	18.8 (18.4-19.1)
Maternal race^c (unweighted n = 99 891)					<.001
American Indian/Alaska Native	201	1.5 (1.0-1.9)	2500	0.5 (0.5-0.6)
Asian/Pacific Islander	42	1.0 (0.5-1.5)	7171	5.1 (4.9-5.3)
Black/African American	1256	37.9 (35.0-40.7)	19 941	14.7 (14.4-14.9)
White	1047	49.0 (46.0-52.0)	57 192	71.6 (71.3-72.0)
Other race	104	5.7 (4.0-7.4)	5092	5.4 (5.1-5.6)
Mixed race	280	5.0 (3.8-6.2)	5065	2.7 (2.6-2.9)
Maternal ethnicity (unweighted n = 99 900)					.44
Hispanic or Latinx	425	16.6 (14.2-18.9)	16 048	15.7 (15.3-16.0)
Not Hispanic or Latinx	2495	83.4 (81.1-85.8)	80 932	84.3 (84.0-84.7)
Maternal education level (unweighted n = 99 854)					<.001
<9th grade	76	2.3 (1.3-3.2)	2923	2.9 (2.8-3.1)
9th-12th grade (no degree)	673	24.7 (22.0-27.5)	8541	8.4 (8.1-8.6)
High school degree or GED	1122	38.7 (35.8-41.6)	23 072	23.7 (23.3-24.1)
Some college/2-y degree	892	28.9 (26.2-31.6)	28 093	27.3 (26.9-27.7)
≥4-y degree	154	5.4 (4.1-6.7)	34 308	37.8 (37.3-38.2)
Health insurance^d (unweighted n = 100 706)					<.001
Private	557	19.8 (17.4-22.3)	56 466	60.4 (60.0-60.9)
Public	1732	56.8 (53.8-59.8)	25 608	23.4 (23.1-23.8)
Other	84	3.1 (1.9-4.3)	2382	2.6 (2.4-2.8)
None	580	20.2 (17.8-22.7)	13 297	13.5 (13.2-13.9)
Married (unweighted n = 100 631)					<.001
Yes	543	17.8 (15.6-19.9)	60 059	63.0 (62.6-63.5)
No	2398	82.2 (80.1-84.4)	37 631	37.0 (36.5-37.4)

Abbreviation: GED, General Educational Development.

Data source: Centers for Disease Control and Prevention.¹⁷ Results are from 30 US jurisdictions with ≥50% response rate for 2018-2019 or ≥55% response rate for 2016-2017: Alabama, Alaska, Colorado, Connecticut, Delaware, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Nebraska, New York City, New York State, North Carolina, North Dakota, Oregon, Pennsylvania, South Dakota, Utah, Wisconsin, and Wyoming.

Calculated by Rao–Scott χ² test; significant at P < .05.

“Other race” consists of people who reported being another race not listed in the table. “Mixed race” consists of people who identified as ≥2 races.

Private: having any employer-provided nongovernmental insurance. Public: Medicaid, Children’s Health Insurance Program (CHIP/state CHIP), or other government-offered insurance with no private insurance. Other: having another insurance type that is not private or public.

Bivariate Analysis

There were 3 significant reproductive interconception care outcomes: (1) having attended a maternal postpartum visit, (2) having a postpartum conversation about pregnancy intervals, and (3) having a postpartum LARC inserted (Table 2). A significantly larger proportion of women who were stably housed reported attending a maternal postpartum visit as compared with women who experienced homelessness (91.2% vs 73.7%; P < .001). Conversely, the proportion of women receiving counseling on birth intervals and insertion of LARC was larger among women experiencing homeless than among women who were stably housed (58.3% vs 49.7% [P < .001] and 25.2% vs 20.2% [P < .001], respectively).

Table 2.

Prevalence of reproductive interconception care outcomes among women, by experience of homelessness during the perinatal period, in 30 sites in the Pregnancy Risk Assessment Monitoring System, United States, 2016-2019^a

	Experienced homelessness in the 12 mo before giving birth
	Yes (n = 2953)		No (n = 97 753)
Outcome	Unweighted no.	Weighted % (95% CI)	Unweighted no.	Weighted % (95% CI)	P value^b
Since your new baby was born, have you had a postpartum checkup for yourself? (unweighted n = 99 486)					<.001
Yes	2147	73.7 (71.0-76.4)	87 555	91.2 (91.0-91.5)
No	756	26.3 (23.6-29.0)	9028	8.8 (8.5-9.0)
If respondent had a postpartum checkup: During your postpartum checkup, did a doctor, nurse, or other health care worker do any of the following things?
• Talk to me about how long to wait before getting pregnant again (unweighted n = 88 983)					<.001
Yes	1223	58.3 (54.7-62.7)	44 876	49.7 (49.2-50.2)
No	906	41.7 (37.3-45.3)	41 978	50.3 (49.8-50.8)
• Talk to me about birth control methods I can use after giving birth (unweighted n = 89 309)					.15
Yes	1881	87.7 (85.4-89.9)	77 592	89.2 (88.9-89.6)
No	255	12.3 (10.1-14.6)	9581	10.8 (10.4-11.1)
• Give or prescribe me a contraceptive method such as the pill, patch, shot (Depo-Provera), NuvaRing, or condoms (unweighted n = 88 917)					.10
Yes	1009	47.6 (44.1-51.1)	39 158	44.6 (44.1-45.1)
No	1121	52.4 (48.9-55.9)	47 629	55.4 (54.9-55.9)
• Insert a long-acting reversible contraceptive device: an intrauterine device (Mirena, ParaGard, or Skyla) or a contraceptive implant (Nexplanon or Implanon) (unweighted n = 88 542)					<.001
Yes	593	25.2 (22.1-28.2)	19 564	20.2 (19.8-20.6)
No	1526	74.8 (71.8-77.9)	66 859	79.8 (79.4-80.2)

Calculated by Rao–Scott χ² test; significant at P < .05.

Adjusted Models

Like the bivariate results, the adjusted models showed that attending a maternal postpartum visit and having a postpartum conversation about pregnancy intervals were significantly associated with experiencing perinatal homelessness (Table 3). When compared with women who were stably housed, women experiencing homelessness had a lower prevalence of attending a maternal postpartum visit (aPR = 0.90; 95% CI, 0.87-0.94). Among those who attended a maternal postpartum visit, women experiencing perinatal homelessness had a higher prevalence of having a conversation about birth intervals with their health care providers than women who were stably housed (aPR = 1.13; 95% CI, 1.03-1.21). Having a postpartum LARC inserted was no longer significantly associated with experiencing perinatal homelessness after adjusting for covariates (aPR = 0.98; 95% CI, 0.76-1.08). Similarly, postpartum contraception or family planning counseling (aPR = 0.97; 95% CI, 0.93-1.01) and prescription of short-acting contraception (aPR = 0.97; 95% CI, 0.87-1.08) were significantly associated with experiencing perinatal homelessness.

Table 3.

Association between experiencing homelessness during the perinatal period and 5 reproductive interconception outcomes, in 30 sites in the Pregnancy Risk Assessment Monitoring System, United States, 2016-2019^a

	Outcome, aPR (95% CI)^b,c
Housing status	Attended a maternal visit	Conversation about elongating birth intervals^d	Conversation about birth control and family planning^d	Prescription for short-acting birth control^d	Insertion of long-acting reversible contraception^d
Unweighted no. of respondents	66 134	60 913	61 031	60 818	60 622
During the 12 mo before my new baby was born: I was homeless or had to sleep outside, in a car, or in a shelter
Yes	0.90 (0.87-0.94)^e	1.13 (1.03-1.21)^e	0.97 (0.93-1.01)	0.97 (0.87-1.08)	0.91 (0.76-1.01)
No	1 [Reference]	1 [Reference]	1 [Reference]	1 [Reference]	1 [Reference]

Abbreviation: aPR, adjusted prevalence ratio.

Covariates adjusted for in all 5 models: preconception conversation about desiring kids, preconception conversation about birth control, prenatal conversation about postpartum birth control, timing of first prenatal visit, pregnancy desire, health insurance status, maternal age, maternal race and ethnicity, and maternal education level.

Each model was assessed with survey-weighted logistic regression (PROC SURVEYLOGISTIC) with the NOMCAR option (not missing completely at random), which computes variance estimates by analyzing the nonmissing values as a domain (subpopulation), where the entire population includes nonmissing and missing domains. Adjusted odds ratios (ORs) were then converted into prevalence ratios by using the following formula: prevalence ratio = OR/[(1 – P₀) + (OR × P₀)], where P₀ is the risk of the outcome (eg, attending maternal postpartum visits) in the unexposed population (ie, unexposed to homelessness).

Among those who attended a maternal postpartum visit.

Calculated by logistic regression likelihood ratio test; significant at P < .05.

Discussion

Using 2016-2019 PRAMS data, this study compared estimates of reproductive interconception care behaviors between women experiencing homelessness and women who were stably housed during the perinatal period. Approximately 2.4% of PRAMS participants experienced homelessness in the 12 months before their infants were born. Attending a postpartum maternal visit was less prevalent among participants who were experiencing homelessness than among those who were stably housed, while having a conversation about birth intervals with a health care provider was more prevalent among participants experiencing homelessness.

In samples of postpartum women participating in other large national cross-sectional surveys, the prevalence of postpartum visit attendance was approximately 89%.^27,28 In our study, approximately 73.7% of participants experiencing homelessness and 91.2% who were stably housed attended a maternal postpartum visit. Our findings may suggest difficulty among women experiencing homelessness with making health care appointments, consistent with previous research on women and other people experiencing homelessness.^29
-32 The unique experiences of unstable housing may affect maternal postpartum visit attendance; further research is needed to assess whether the interconception period may be an opportune time to facilitate improvements in maternal outcomes for this population. Future studies should integrate our quantitative findings with qualitative data to provide a perspective directly from women experiencing homelessness and pregnancy and to identify barriers and facilitators to reproductive interconception care. This information is especially important for women experiencing homelessness, who are more transient than stably housed women and who may delay or skip postpartum visits and other perinatal and contraceptive services because of competing priorities or lack of streamlined services.^33,34

The American College of Obstetricians and Gynecologists recommends that all postpartum health care providers discuss the avoidance of a birth interval <6 months and the risks and benefits of repeat pregnancy earlier than 18 months.⁹ In our study, conversations about birth intervals during maternal postpartum visits occurred more frequently among women experiencing homelessness than among women who were stably housed. Among the subset of PRAMS-participating women who did attend their postpartum maternal visits, women experiencing homelessness had a 1.13-times higher prevalence of receiving birth interval counseling than women who were stably housed. This finding may highlight how women who are pregnant and experiencing homelessness may benefit from attending maternal postpartum visits, where they may get birth interval counseling. Alternatively, this finding may demonstrate the perceived need for birth interval conversations in health care for all pregnancy-capable people. Future research should determine how to increase the provision of just reproductive health care for women experiencing homelessness. Health care providers may have a bias against women experiencing homelessness or assume that they do not want children or should be on a form of contraception. Future studies should also consider health care provider bias toward pregnancy during homelessness, given that conversations about birth intervals occurred more frequently among women experiencing homelessness than among women who were stably housed. It is critical for health care providers to facilitate autonomous and informed decision making.

Postpartum conversations about contraception and family planning counseling occurred among 89.2% of women who attended their postpartum visits and did not differ significantly by housing status. These findings are comparable to those in previous studies that reported postpartum interconception conversations about contraceptives and family planning at roughly 89.0%,³⁵ with a smaller percentage of women (86%) using short-acting birth control or LARC postpartum.²³ In our study, the provision of postpartum short-acting birth control was not significantly associated with homelessness. Although unadjusted estimates revealed significant associations between postpartum LARC insertion and homelessness, this relationship was no longer significant in the adjusted model. This finding may suggest that associations between LARC insertion and perinatal homelessness are better explained by other covariates that the model adjusted for (eg, health insurance status) rather than homelessness alone. In addition to access-related barriers, other barriers to contraception uptake are either shelter-related (storage and privacy, timing restrictions) or based on personal beliefs and misinformation about contraception (fear of side effects, effects on fertility, normative beliefs).^36,37 Our study provides additional support for the need to identify barriers and facilitators to postpartum contraception for the population experiencing homelessness. Future research should examine contextualized needs from women who are recently pregnant and homeless with recent lived experiences. For organizations with sufficient funding and infrastructure, provision of reproductive interconception care through telehealth may help reach women experiencing homelessness who have internet access, but future studies should identify additional novel cost-saving ways to connect with postpartum women experiencing homelessness.

Limitations

Our study had several limitations. First, it had a cross-sectional design. PRAMS is a single point-in-time snapshot; thus, causality and temporality cannot be inferred. Second, responses were self-reported, with the possibility of recall and social desirability bias. Third, because of the way in which homelessness is assessed in PRAMS, we could not determine whether participants were pregnant before, during, or after experiencing homelessness. Fourth, the question uses a narrow definition of homelessness from the US Department of Housing and Urban Development, which does not include people who are unstably housed in doubled-up situations or staying in hotels or motels because of an inability to afford housing.¹ Fifth, although we used survey weighting to increase response generalizability, the births in the 50 jurisdictions that participate in PRAMS surveillance represent approximately 81% of all live US births,¹⁸ so our findings cannot be generalized to the entirety of the United States. Sixth, homelessness was assessed in only 34 jurisdictions, with just 30 having at least a 50% response rate, excluding other states with notably higher rates of homelessness (eg, California). These findings may underestimate the prevalence of reproductive interconception care for people who are recently pregnant and homeless. Lastly, we excluded 2020 and 2021 PRAMS data because of the potential effect of the COVID-19 pandemic on access to reproductive care and homelessness.

Conclusion

Health care clinicians, community partners, and policy makers can seek to reduce barriers to the attendance of maternal postpartum visits and improve supportive reproductive health outcomes. Certain strategies in promoting follow-up include health care and community organization partnerships, multisystem care coordination, and community advocacy.^33,34 Systems of care in partnership with women experiencing homelessness can build support of policies that promote access to postpartum and interconception health care coupled with economic support for pregnant and postpartum women. Reducing the additional burdens and various priorities of recently pregnant women experiencing homelessness may help to empower these populations to engage in preventive care and promote health for themselves and their children.

With the narrow definition of homelessness used in our study, estimates may understate the actual picture of homelessness in the United States, especially among women and children. A study published in 2021 used American Community Survey public-use microdata to show that 3.7 million people in the United States were doubled up in 2019 (ie, living with others because of economic hardship or housing loss).³⁸ Identifying ways to access postpartum people who are doubled up or living in hotels or motels and who may not receive shelter services is another critical next step in facilitating postpartum and interconception care for recently pregnant women experiencing homelessness. Community organizations and health care providers who serve postpartum people who were recently pregnant and homeless can also benefit from incorporating comprehensive and streamlined screening instruments that assess homelessness or risk for homelessness. Several housing screening tools exist³⁹ that can further explore types of homelessness beyond sheltered and unsheltered homelessness. Other social determinants of health can be screened in conjunction with housing to ensure that holistic social care is provided to improve health outcomes.^39,40

Our findings lay the groundwork for understanding how homelessness may affect attendance at maternal postpartum visits and whether the interconception period may be used to facilitate improvements in maternal outcomes for the population experiencing homelessness. Findings may strengthen current interconception practices and augment reductions in unintended pregnancy, short birth intervals, or adverse birth outcomes in future pregnancies among women experiencing homelessness.

Footnotes

Acknowledgements

The authors acknowledge the PRAMS Working Group and the Centers for Disease Control and Prevention. Thank you to the PRAMS Team of the Centers for Disease Control and Prevention (Applied Sciences Branch, Division of Reproductive Health) and the representatives of the PRAMS Working Group: Danita Crear, DrPH (Alabama), Kathy Perham-Hester, MS, MPH (Alaska), Mary McGehee, PhD (Arkansas), Alyson Shupe, PhD (Colorado), Jennifer Morin, MPH (Connecticut), George Yocher, MS (Delaware), Pamela Oandasan, MPH (District of Columbia), Jerri Foreman, MPH (Florida), Jenna Self, MPH (Georgia), Emily Roberson, MPH (Hawaii), Theresa Sandidge, MA (Illinois), Jenny Durica, MPH (Indiana), Sarah Mauch, MPH (Iowa), Jane Herwehe, MPH (Louisiana), Tom Patendaude, MPH (Maine), Diana Cheng, MD (Maryland), Emily Lu, MPH (Massachusetts), Cristin Larder, MS (Michigan), Judy Punyko, PhD, MPH (Minnesota), Brenda Hughes, MPPA (Mississippi), Venkata Garikapaty, PhD, MPH, MSc, MS (Missouri), JoAnn Dotson, PhD, MSN (Montana), Brenda Coufal (Nebraska), Paulette Valliere, MPH (New Hampshire), Lakota Kruse, MD (New Jersey), Eirian Coronado, MPH (New Mexico), Candace Mulready-Ward, MPH (New York City), Anne Radigan-Garcia (New York State), Kathleen Jones-Vessey, MS (North Carolina), Sandra Anseth (North Dakota), Connie Geidenberger, PhD (Ohio), Alicia Lincoln, MSW, MSPH (Oklahoma), Kenneth Rosenberg, MD, MPH (Oregon), Tony Norwood (Pennsylvania), Sam Viner-Brown, PhD (Rhode Island), Mike Smith, MSPH (South Carolina), Angela Miller, PhD, MSPH (Tennessee), Rochelle Kingsley, MPH (Texas), Lynsey Gammon, MPH (Utah), Peggy Brozicevic, MA (Vermont), Marilyn Wenner (Virginia), Linda Lohdefinck, BS (Washington), Melissa Baker, MA (West Virginia), Mireille Perzan, MPH (Wisconsin), and Amy Spieker, MPH (Wyoming).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Annalynn M. Galvin, PhD, RN

Erika L. Thompson, PhD

References

Henry

de Sousa

Roddey

Gayen

Bednar

; Abt Associates. The 2020 Annual Homeless Assessment Report (AHAR) to Congress, Part 1: Point-in-Time Estimates of Homelessness. US Department of Housing and Urban Development; 2021. Accessed January 15, 2022. https://www.huduser.gov/portal/sites/default/files/pdf/2020-AHAR-Part-1.pdf

de Vet

Beijersbergen

Lako

DAM

van Hemert

Herman

Wolf

JRLM.

Differences between homeless women and men before and after the transition from shelter to community living: a longitudinal analysis. Health Soc Care Community. 2019;27(5):1193-1203. doi:10.1111/hsc.12752

Henry

Watt

Mahathey

Ouellette

Sitler

; Abt Associates. The 2019 Annual Homeless Assessment Report (AHAR) to Congress, Part 1: Point-in-Time Estimates of Homelessness. US Department of Housing and Urban Development; 2020. Accessed January 15, 2022. https://www.huduser.gov/portal/sites/default/files/pdf/2019-AHAR-Part-1.pdf

Chau

Chin

Chang

, et al Cancer risk behaviors and screening rates among homeless adults in Los Angeles County. Cancer Epidemiol Biomarkers Prev. 2002;11(5):431-438.

Teruya

Longshore

Andersen

, et al Health and health care disparities among homeless women. Women Health. 2010;50(8):719-736. doi:10.1080/03630242.2010.532754

Health Care for the Homeless Clinicians’ Network. Decreasing unintended pregnancy among women experiencing homelessness. Heal Hands. 2012;16(4):1-8.

Hall

Beauregard

Rentmeester

Livingston

Harris

KM.

Adverse life experiences and risk of unintended pregnancy in adolescence and early adulthood: implications for toxic stress and reproductive health. SSM Popul Health. 2018;7:100344. doi:10.1016/j.ssmph.2018.100344

Walford

Trinh

Wiencrot

. What is the role of prenatal care in reducing racial and ethnic disparities in pregnancy outcomes? In: Handler

Kennelly

Peacock

eds. Reducing Racial/Ethnic Disparities in Reproductive and Perinatal Outcomes. Springer; 2011:151-179. doi:10.1007/978-1-4419-1499-6_8

McKinney

Keyser

Clinton

Pagliano

ACOG Committee opinion no. 736: optimizing postpartum care. Obstet Gynecol. 2018;132(3):784-785. doi:10.1097/AOG.0000000000002849

10.

Paladine

Blenning

Strangas

Postpartum care: an approach to the fourth trimester. Am Fam Physician. 2019;100(8):485-491.

11.

Johnson

Posner

Biermann

, et al Recommendations to improve preconception health and health care—United States: report of the CDC/ATSDR Preconception Care Work Group and the select panel on preconception care. MMWR Recomm Rep. 2006;55(RR-6):1-23.

12.

Cox

Zhang

Zotti

Graham

Prenatal care utilization in Mississippi: racial disparities and implications for unfavorable birth outcomes. Matern Child Health J. 2011;15(7):931-942. doi:10.1007/s10995-009-0542-6

13.

Goyal

Folger

Hall

Greenberg

Van Ginkel

Ammerman

RT.

Home visiting for first-time mothers and subsequent pregnancy spacing. J Perinatol. 2017;37(2):144-149. doi:10.1038/jp.2016.192

14.

Shannon

Alberg

Nacul

Pashayan

Preconception healthcare delivery at a population level: construction of public health models of preconception care. Matern Child Health J. 2014;18(6):1512-1531. doi:10.1007/s10995-013-1393-8

15.

Entringer

Buss

Wadhwa

PD.

Prenatal stress, development, health and disease risk: a psychobiological perspective. Psychoneuroendocrinology. 2015;62:366-375. doi:10.1016/j.psyneuen.2015.08.019

16.

Monk

Spicer

Champagne

FA.

Linking prenatal maternal adversity to developmental outcomes in infants: the role of epigenetic pathways. Dev Psychopathol. 2012;24(4):1361-1376. doi:10.1017/S0954579412000764

17.

Centers for Disease Control and Prevention. Are PRAMS data available to researchers? Updated April 22, 2022. Accessed July 20, 2021. https://www.cdc.gov/prams/prams-data/researchers.htm

18.

Shulman

D’Angelo

Harrison

Smith

Warner

The Pregnancy Risk Assessment Monitoring System (PRAMS): overview of design and methodology. Am J Public Health. 2018;108(10):1305-1313. doi:10.2105/AJPH.2018.304563

19.

Bellanca

Hunter

MS.

One key question: preventive reproductive health is part of high quality primary care. Contraception. 2013;88(1):3-6. doi:10.1016/j.contraception.2013.05.003

20.

Frayne

DJ.

A paradigm shift in preconception and interconception care: using every encounter to improve birth outcomes. Zero Three. 2017;37(4):4-12.

21.

Kost

Landry

Darroch

JE.

Predicting maternal behaviors during pregnancy: does intention status matter?

Fam Plann Perspect. 1998;30(2):79-88. doi:10.1363/3007998

22.

Makins

Cameron

Post pregnancy contraception. Best Pract Res Clin Obstet Gynaecol. 2020;66:41-54. doi:10.1016/j.bpobgyn.2020.01.004

23.

Richards

Merrill

Baksh

McGarry

Maternal health behaviors and infant health outcomes among homeless mothers: US Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) 2000-2007. Prev Med. 2011;52(1):87-94. doi:10.1016/j.ypmed.2010.10.010

24.

Gorrell

Survey analysis: options for missing data. NorthEast SAS Users Group, Inc. Updated 2009. Accessed January 1, 2020. https://www.lexjansen.com/nesug/nesug09/sa/SA03.pdf

25.

Rao

Scott

AJ.

The analysis of categorical data from complex sample surveys: chi-squared tests for goodness of fit and independence in two-way tables. J Am Stat Assoc. 1981;76(374):221-230. doi:10.1080/01621459.1981.10477633

26.

Zhang

KF.

What’s the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. JAMA. 1998;280(19):1690-1691. doi:10.1001/jama.280.19.1690

27.

Danilack

Brousseau

Paulo

Matteson

Clark

MA.

Characteristics of women without a postpartum checkup among PRAMS participants, 2009-2011. Matern Child Health J. 2019;23(7):903-909. doi:10.1007/s10995-018-02716-x

28.

Prentice

The postpartum visit: risk factors for nonuse and association with breast-feeding. Am J Obstet Gynecol. 2002;187(5):1329-1336. doi:10.1067/mob.2002.126848

29.

Aparicio

Kachingwe

Phillips

, et al Holistic, trauma-informed adolescent pregnancy prevention and sexual health promotion for female youth experiencing homelessness: initial outcomes of Wahine Talk. Child Youth Serv Rev. 2019;107:104509. doi:10.1016/j.childyouth.2019.104509

30.

Clark

Player

Gillam

Hanson

Steel

Evaluating a specialist primary care service for patients experiencing homelessness: a qualitative study. BJGP Open. 2020;4(3):bjgpopen20X101049. doi:10.3399/bjgpopen20X101049

31.

Kitson

Haines

O’Byrne

Understanding the perspectives of women who use intravenous drugs and are experiencing homelessness in an urban centre in Canada: an analysis of ethnographic data. Glob Qual Nurs Res. 2022;9:23333936221080935. doi:10.1177/23333936221080935

32.

Weinreb

Goldberg

Perloff

Health characteristics and medical service use patterns of sheltered homeless and low-income housed mothers. J Gen Intern Med. 1998;13(6):389-397. doi:10.1046/j.1525-1497.1998.00119.x

33.

Azarmehr

Lowry

Sherman

Smith

Zuñiga

JA.

Nursing practice strategies for prenatal care of homeless pregnant women. Nurs Womens Health. 2018;22(6):489-498. doi:10.1016/j.nwh.2018.09.005

34.

Ovrebo

Ryan

Jackson

Hutchinson

The homeless prenatal program: a model for empowering homeless pregnant women. Health Educ Q. 1994;21(2):187-198. doi:10.1177/109019819402100205

35.

D’Angelo

Williams

Morrow

, et al Preconception and interconception health status of women who recently gave birth to a live-born infant—Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 26 reporting areas, 2004. MMWR Surveill Summ. 2007;56(SS10):1-35.

36.

Galvin

Garg

Griner

Diener

Thompson

EL.

“The chances are zero”: a qualitative study on perceived susceptibility to pregnancy among women experiencing homelessness. Sex Health. 2022;19(3):164-171. doi:10.1071/SH21241

37.

Thompson

Galvin

Rohr

Klocek

Lowe

Spence

EE.

Navigating the system for families experiencing homelessness: a community-driven exploration of barriers encountered. J Child Poverty. 2020;26(2):253-267. doi:10.1080/10796126.2020.1835131

38.

Richard

Dworkin

Rule

Farooqui

Glendening

Carlson

Quantifying doubled-up homelessness: presenting a new measure using US Census microdata. Hous Policy Debate. Published online January 17, 2022. doi:10.1080/10511482.2021.1981976

39.

Anderst

Hunter

Andersen

, et al Screening and social prescribing in healthcare and social services to address housing issues among children and families: a systematic review. BMJ Open. 2022;12(4):e054338. doi:10.1136/bmjopen-2021-054338

40.

Centers for Medicare & Medicaid Services. The accountable health communities health-related social needs screening tool. 2019. Accessed April 21, 2023. https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf