INTRODUCTION — Homelessness is defined by the United States Department of Health and Human Services (HHS) as "an individual without permanent housing who may live on the streets; stay in a shelter, mission, single room occupancy facilities, abandoned building or vehicle; or in any other unstable or nonpermanent situation" [1].
Homelessness disproportionately affects women and children: women represent approximately 80 percent of adults in families experiencing homelessness in the United States [2]. Women who are homeless are at higher risk of having chronic illnesses, infectious diseases, substance abuse problems, mental illness, and being a victim of sexual or domestic violence than women who are not homeless [3,4]. They are also less likely to have insurance, social support, income, or access to preventive health services [5].
Persons who experience homelessness may be less likely to engage in the health care system due to challenging relationships with care providers, inconvenience, cost, and a perceived lack of compassion and discrimination on the part of the providers [6]. Senior members of the health care team are particularly responsible for educating house staff and students on how to appropriately care for this vulnerable group.
This topic will discuss issues specific to the evaluation and care of pregnant women who are homeless. Homelessness in other populations is reviewed separately. (See "Health care of people experiencing homelessness in the United States".)
EPIDEMIOLOGY — According to the United States Department of Housing and Urban Development (HUD) point-in-time counts, 17 of 10,000 individuals were homeless in 2019 (ie, up to 3.5 million individuals are homeless annually) [7]. The rate of homelessness among women was 13 in 10,000. The number of individuals experiencing homelessness has increased in past years, and this trend is likely to continue due to the effects from coronavirus disease 2019 (COVID-19).
Data derived from the Pregnancy Risk Assessment Monitoring System (PRAMS) from 2000 to 2007 found that 4 percent of pregnant women reported homelessness in the 12 months prior to birth [8]. A study of data collected from 2009 to 2011 reported 9 percent of participants reported homelessness during pregnancy, though this sample was predominately low-income women [9].
Pregnant women experiencing homelessness are typically younger than nonpregnant women experiencing homelessness and frequently have a history of family disruption [10]. The teenager experiencing homelessness is often the product of domestic instability and/or poverty [11].
In a survey of women at emergency departments and primary care clinics, pregnant women who were homeless had higher rates of cigarette smoking, lower rates of employment, and lower achieved educational levels as compared with consistently housed counterparts [9].
RISK FACTORS FOR AND CAUSES OF HOMELESSNESS — Homelessness has many causes, and pregnant women who are homeless are a heterogeneous group. Domestic and sexual violence are the leading causes of homelessness in women, as 20 to 50 percent of all women and children experiencing homelessness become so as a direct result of trying to escape domestic violence [5]. Women continue to be at risk for experiencing violence when in homeless shelters or when living on the streets [12]. Some shelters do not accept pregnant women out of concern of liability if the woman experiences complications or problems while in the shelter [13].
Other risk factors and causes include joblessness; inadequate social or financial support; substance use; mental illness; previous incarceration; loss of a home (eg, fire, eviction, building condemned or sold); and discrimination in housing because of ethnicity, number of children, receipt of government assistance, or pregnancy. Pregnancy or pregnancy complications may lead to loss of employment and, in turn, loss of income to pay for housing.
For a teenager, pregnancy may be the precipitating event that leads to her voluntarily or involuntarily leaving her parents' home. Psychosocial issues are also common in this population. A three-year study of pregnancy and motherhood in unaccompanied women ages 16 to 19 years experiencing homelessness observed high rates of mental illness and substance abuse: approximately 32 percent suffered from major depressive disorder, 65 percent from a conduct disorder, and 51 percent from posttraumatic stress disorder [14]. The rates of alcohol and drug abuse were 21 and 35 percent, respectively; thus, treating a concurrent substance use disorder is critical to providing a pathway to stable housing.
PREVALENCE OF PREGNANCY IN WOMEN EXPERIENCING HOMELESSNESS — Most reports suggest pregnancy is more prevalent in women who are homeless, but accurate data are difficult to obtain.
●In one study of 764 women who were homeless in Los Angeles, 28 percent reported being pregnant in the past year and almost 75 percent of these pregnancies were unintended [15].
●In a study in London, 24 percent of women who were homeless were pregnant [16].
●In a study from Montreal, adolescents who were homeless had higher pregnancy rates compared with their counterparts living at home: 48 and 10 percent, respectively [17].
By comparison, approximately 6 percent of reproductive-age women in the United States become pregnant each year.
Unintended pregnancies are more common in women experiencing homelessness because of the many barriers to contraceptive use in this population, including lack of education about, and access to, free or low cost contraceptives, lack of storage space for contraceptives, an irregular and unpredictable lifestyle, involvement in the sex trade, victimization by sexual violence, and partners unwilling to use condoms [4,18,19].
In a study of 15 pregnant women experiencing homelessness, pregnancy was sometimes the precipitating factor that caused these women to become homeless, but the majority of women became pregnant while they were homeless [13]. From their self-reports, factors that contributed to becoming pregnant included victimization, economic survival, lack of access to contraceptives, the need for closeness and intimacy, uncertain fertility, and hope for the future. For some women, the pregnancy was their only source of joy and a catalyst for them to resolve past problems and seek a better life.
In the study of Montreal adolescents experiencing homelessness, a past history of sexual abuse and early initiation of injected drug use were both significantly associated with pregnancy among the girls in the study [17]. Others have suggested that teenagers experiencing homelessness may avoid contraception because they perceive pregnancy as an opportunity to form stable bonds and restructure their lives [11].
PREGNANCY OUTCOME — Few studies have examined pregnancy outcomes in women experiencing homelessness. The risk of adverse maternal and fetal outcomes is increased in pregnant women who are homeless due to poor access to health care, poor nutrition, lack of housing, substance abuse, exposure to violence, a high prevalence of infection, and medical comorbidities [20,21]. The most common complications are preterm birth and low birth weight, but an increased risk of other adverse pregnancy outcomes (eg, hemorrhage, hypertensive disorders of pregnancy) has been reported compared with a matched cohort [20].
A Canadian study found that pregnant women who were homeless or had inadequate housing had a threefold increase in risk of preterm birth or small for gestational age infant and a sevenfold increase in risk of birth weight <2000 grams compared with women who were not homeless, after adjustment for risk factors such as maternal age, number of previous pregnancies, and smoking [22]. Women experiencing homelessness and who have a substance use disorder were at even higher risk of these outcomes.
In another study, none of the women experiencing homelessness had consistent prenatal care, and they were not taught about, and could not differentiate between, normal and pathologic signs and symptoms related to pregnancy.
Others have reported that women experiencing homelessness and sleeping on the streets have an even greater risk of adverse pregnancy outcomes than women sleeping in shelters [23].
CHILD HEALTH OUTCOMES — The effects of homelessness extend beyond pregnancy and significantly impact health outcomes of the newborn and young child. Several studies have shown higher rates of acute and chronic health problems in children experiencing homelessness compared with low-income children with homes. There is an increase in the rates of infectious, respiratory, gastrointestinal, and dermatologic diseases, as well as otitis media, diarrhea, bronchitis, scabies, lice, dental caries, asthma, and accidents and injuries [24]. It is therefore important for pediatricians to provide comprehensive care at each visit, including immunizations and screening for at-risk conditions.
PREGNANCY CARE
General principles — Attention to the following principles is likely to improve results when providing care for people experiencing homelessness [25]:
●Outreach to engage those in need of health care services.
●Respect for each patient, regardless of circumstances.
●Cultivation of trust and rapport between the health care provider and patient.
●Flexibility in providing health care services, including location, hours of service, missed appointments, and treatment approaches.
●Attention to the basic survival needs of people experiencing homelessness. Health care may not be the patient's priority until those needs are met.
●Multidisciplinary case management to coordinate services (medical and nonmedical).
●Clinical expertise to address complex clinical problems.
●Continuing care until the patient's life situation is stabilized.
●Help with housing options, including programs combining housing with services (eg, childcare, substance abuse, mental health).
Identifying pregnancy — Ideally, shelters for people experiencing homelessness, urgent care centers, and emergency medicine departments should test women of reproductive age for pregnancy in order to allow early identification and referral to appropriate sources of prenatal care. Some women experiencing homelessness do not know that they are pregnant because their menstrual periods have stopped or have become irregular [13].
Overcoming barriers to receiving prenatal care — The major barriers to prenatal care are site-related factors, such as distance to the prenatal care site, lack of transportation, and long wait times for appointments [10]. Socioeconomic factors, such as financial constraints and lack of insurance coverage, contribute to poor compliance with visits and recommendations for drug therapy. Health care demands compete with needs for food, clothing, and shelter. Other significant limitations are lack of knowledge about where or how to acquire prenatal care and fear of how the woman experiencing homelessness will be perceived or treated by health care providers. For example, women with substance use disorder, mental illness, or undocumented resident status may fear being reported to the authorities [26], and women with children may fear that their children will be taken away [5].
In the United States, all states provide medical insurance (Medicaid) to low income pregnant women who have no medical insurance or inadequate insurance. The income threshold varies among states, but the minimum is a family income at or below 133 percent of the Federal poverty level. Women who earn too much money to qualify for Medicaid when they were not pregnant may qualify when they become pregnant and when they have a child because the income threshold is different for these groups. Pregnant women are usually given priority in determining Medicaid eligibility, and will receive qualification within two to four weeks of submitting an application.
Approach to prenatal care — Prenatal providers should identify patients who may be homeless or at risk of becoming homeless, recognizing that pregnant women may be reluctant to voluntarily reveal their homelessness [5,13].
Prenatal care of women experiencing homelessness should include referral for available resources, social support, and screening for conditions more prevalent in the population of homeless people. It is helpful to be flexible about scheduling appointments. Many women who experience homelessness do not have a reliable phone number, thus part of the prenatal intake should include discussing alternate ways of reaching the patient.
Care should be provided without bias or prejudice and with empathy and effort to establish rapport so that a trusting relationship can be developed [5]. The provider should be honest and let the patient know when tests for drugs and reportable diseases are being performed and when the provider is obligated to notify child protective services. Treatment regimens should be simplified whenever possible and more cost effective options offered, when available. Treatment should not be withheld due to assumptions about lack of adherence.
Initial assessment — A standard initial prenatal assessment should be performed (see "Prenatal care: Initial assessment", section on 'Laboratory tests'). However, for a woman experiencing homelessness, the initial prenatal care visit may be the only opportunity to provide care prior to delivery; therefore, it is important to assess what information is critical and prioritize accordingly. Information should be relevant to the patient's circumstances and living situation, and provided in small increments.
Screening for the following problems is particularly important in women who are homeless since these problems are more prevalent in this population.
●Substance use disorder (see "Substance use during pregnancy: Screening and prenatal care", section on 'Screening for substance use')
●Intimate partner violence (see "Intimate partner violence: Diagnosis and screening")
●Mental illness (see "Somatic symptom disorder: Assessment and diagnosis", section on 'Assessment')
●Food insecurity
A complete physical examination is performed, with attention to establishing gestational age. The skin should be examined carefully since skin conditions are among the most common diagnoses in clinics for people experiencing homelessness. Lice, scabies, and secondary bacterial complications are highly contagious problems that may easily be identified and treated (see "Health care of people experiencing homelessness in the United States", section on 'Skin and foot problems'). Dental health and visual acuity should be assessed as these needs may have been neglected.
Routine prenatal laboratory tests are obtained, as well as additional testing based on patient-specific risk factors (see "Prenatal care: Initial assessment", section on 'Laboratory tests'). For example, the rate of HIV infection among youth who are homeless is substantially higher than the national rate for youth; 2.3 percent versus 0.1 percent nationally [27]. In addition to routine screening for chlamydia, syphilis, hepatitis B, and HIV, we suggest screening women experiencing homelessness for:
●Gonorrhea (see "Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents", section on 'Diagnostic approach')
●Hepatitis C (see "Screening and diagnosis of chronic hepatitis C virus infection")
●Tuberculosis (see "Health care of people experiencing homelessness in the United States", section on 'Respiratory infections and disorders' and "Tuberculosis disease (active tuberculosis) in pregnancy")
●Illicit drugs (see "Substance use during pregnancy: Screening and prenatal care")
Immunization records should be obtained, if available, and missed immunizations should be provided. (See "Immunizations during pregnancy".)
Issues related to surveillance and testing strategies for COVID-19 in the population experiencing homelessness, as well as the challenges of managing COVID-19 in a setting where quarantine is not possible, are reviewed separately. (See "Health care of people experiencing homelessness in the United States", section on 'COVID-19' and "COVID-19: Overview of pregnancy issues" and "COVID-19: Intrapartum and postpartum issues".)
Ongoing prenatal care — At institutions where group prenatal care is available, this option can be offered to further develop social supports for the women and their growing families. (See "Group prenatal care".)
We encourage the use of technology to connect with patients for both medical and psychosocial needs, while recognizing that individuals experiencing homelessness may not have access to telemedicine platforms. (See "Telemedicine for adults".)
The appropriate use of the emergency department should be discussed, as women experiencing homelessness visit the emergency department more often than their housed counterparts [20].
During the course of prenatal care, women experiencing homelessness (like all pregnant women) need to be prepared for labor and delivery, postpartum issues, care of the newborn, and parenting. Continued access to social workers and ongoing assessment of basic needs (food, clothing, etc) is a vital component of continued prenatal care in this population.
Testing for sexually transmitted infections (STIs; eg, HIV, syphilis, chlamydia, gonorrhea, hepatitis [hepatitis B surface antigen, anti-hepatitis C virus antibodies]) is recommended in the third trimester (28 to 36 weeks) and at delivery in women at increased risk based on standard risk factors, such as homelessness. (See "Prenatal care: Second and third trimesters".)
Anticipatory counseling for planning postpartum housing may be offered by the prenatal provider and/or perinatal social worker.
Resources for ancillary services — Obstetric health care providers may use the patient's pregnancy and prenatal care as an opportunity to connect the patient with resources for substance use, housing, and mental health care. Health care providers should be aware of local resources for people experiencing homelessness and how to access them.
Case management or social workers should be involved in patient care so they can provide information on shelters for women and children, affordable housing, transportation to and from appointments and the hospital, mental health and substance abuse treatment programs, food banks, clothing, child care resources, legal aid, and crisis lines. For women who do not live in shelters that provide meals, obtaining, transporting, storing, and cooking nutritious food can be a major problem. Individuals with substance use disorder are prone to undernutrition and malnutrition, and women with diabetes may not have access to antihyperglycemic drugs or be able to adhere to a regular schedule of meals. Preexisting mental health issues may be exacerbated by stress and pregnancy-related mood changes. Social workers are often familiar with staff at local shelters, government agencies for housing vouchers, and other resources, which facilitates obtaining these resources for patients who need them.
Labor and delivery — As previously discussed, women who experience homelessness may have had limited prenatal care. Their first connection with a perinatal provider may be when presenting in labor. For a woman who first presents in labor during the third trimester, we suggest:
●Assessment of gestational age and medical/obstetric disorders.
●Routine laboratory tests (complete blood count, blood type and antibody screen, rubella immunity, urine culture, cervical cytology), as well as screening for STIs, tuberculosis, illicit drugs, and diabetes (random blood glucose concentration).
●Rapid HIV testing, as intrapartum antiretroviral therapy in HIV infected women can decrease perinatal transmission. (See "Prenatal evaluation of women with HIV in resource-rich settings".)
●Group B streptococcus (GBS) antibiotic prophylaxis if the culture status is unknown (culture not performed or result not available) and intrapartum fever (≥100.4°F [≥38°C]) or preterm labor (<37 weeks of gestation) or prolonged rupture of membranes (≥18 hours). (See "Prevention of early-onset group B streptococcal disease in neonates".)
Postpartum — All women should be encouraged to breastfeed, unless there are contraindications (eg, HIV infection, active tuberculosis or herpetic breast lesions). (See "Breastfeeding: Parental education and support" and "Infant benefits of breastfeeding" and "Maternal and economic benefits of breastfeeding".)
Long-acting reversible contraception should be made available prior to discharge, if possible. (See "Postpartum contraception: Counseling and methods", section on 'Progestin-only implants' and "Postpartum contraception: Counseling and methods", section on 'Intrauterine devices'.)
Discharge planning — It is the responsibility of the hospital staff to ensure the mother is prepared to care for her baby, despite the many obstacles that homelessness may create [2-4]. Discharge planning involves the various members of the interdisciplinary team. It is important to view every patient individually; each situation should be handled on a case-by-case basis [28-30].
The initial assessment should address living situation, support system, knowledge of childcare issues, resources, and issues regarding substance abuse and mental health. Many women experiencing homelessness will be reluctant to honestly share this information and worry about being judged by the hospital staff; however, many are eager and receptive to getting help. Their dignity should be respected, and their strengths and accomplishments recognized.
The decision to involve Child Protective Services (CPS) is made after evaluating whether or not the mother is making healthy choices for her child. This assessment is typically done by a social worker rather than the health care provider. Living in a shelter may show that she has made some choices to regain the stability that her child will need. A qualitative study of women in California suggested that attaining stable housing is a primary determinant in retaining custody of one's children after delivery [31]. Many shelters provide counseling, day care, and assistance with other basic needs. This shelter may be the closest thing to a home that this mother and her child will have. If this is the case, and there are no other high-risk concerns, the usual course of action would be to assist her with resources and provide encouragement. However, if a mother plans on returning to life on the streets with her newborn, or if there are additional concerns regarding the safety and well-being of the baby, a report to CPS is generally needed. When indicated, involving CPS will not only help to ensure the safety of the baby, but can also help the mother to get the help she may need.
After identifying the woman's needs, the case manager and social worker often collaborate to ensure these needs are met prior to her discharge. It is the role of the case manager to assist with home health needs, medication assistance, identification of a primary care physician for the child, and help in scheduling follow-up appointments. The social worker's role involves resource assistance, connection to community services, and advocating for the patient.
Various community case management programs are available to address these needs and to support the mother in her time of transition. These referrals are made by the social worker prior to the mother's discharge. At the time of discharge, assisting with transportation is generally required. Some shelters offer transportation for their residents; when this is not an option, the social worker will assist with transportation back to the shelter by providing a taxi voucher or utilizing transportation services through the mother's insurance [28-30]. An infant car seat is generally mandated by state law, even for a short ride from the hospital to the shelter. If the mother cannot purchase or borrow a car seat, then the social worker can help arrange for one.
Legal responsibilities — It is difficult to define a physician's legal responsibilities related to the disposition of a patient experiencing homelessness, as laws vary by state. Each case should be assessed on an individual basis with social work and case management to determine whether the patient and her infant are being discharged to a safe environment. Ideally, the involvement of a multidisciplinary team should ensure a smooth transition from the hospital. However, any concern with the child's welfare or the mother's ability to make choices that do not endanger her newborn should prompt a report to CPS. Complicated cases may require involvement of the hospital's legal office or ethics committee, depending on the specific case. Tools to help clinicians with discharge planning are available from the National Health Care for the Homeless Council's website [32].
RESOURCES — The National Health Care for the Homeless Council provides a wide range of resources to help clinicians overcome the barriers they experience in providing health care to those who are homeless.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General prenatal care" and "Society guideline links: Medical care for homeless persons".)
SUMMARY AND RECOMMENDATIONS
●Epidemiology – Homelessness disproportionately affects women and children. Domestic and sexual violence are the leading cause of homelessness in women. Pregnancy may be the precipitating event that leads a teenager to voluntarily or involuntarily leave her parents' home. (See 'Introduction' above and 'Epidemiology' above and 'Risk factors for and causes of homelessness' above.)
●Scope of prenatal care – Pregnant women experiencing homelessness should receive routine prenatal care tailored to their specific needs, with emphasis on assessment of basic needs (eg, housing, food, clothing, transportation to appointments; evaluation for domestic violence, sexual abuse, substance use, mental illness, sexually transmitted diseases, tuberculosis; and examination of the skin, teeth and gums, and vision). (See 'Approach to prenatal care' above.)
Financial, physical, and psychosocial barriers impede pregnant women experiencing homelessness from receiving prenatal care. Using telemedicine and/or group prenatal care can sometimes increase access to information and care. (See 'Overcoming barriers to receiving prenatal care' above.)
●Pregnancy outcome – The risk of adverse maternal and fetal outcomes is increased in pregnant women experiencing homelessness due to poor access to health care, poor nutrition, lack of housing, substance use, exposure to violence, a high prevalence of infection, and medical comorbidities. The most common complications are preterm birth and low birth weight. (See 'Pregnancy outcome' above.)
●Postpartum planning – Discharge planning involves the various members of the interdisciplinary team to ensure that the basic needs of the mother and baby are met. The decision to involve Child Protective Services (CPS) is made after evaluating whether or not the mother is making healthy choices for her child. (See 'Discharge planning' above.)
ACKNOWLEDGMENTS — The UpToDate editorial staff acknowledges Nicole Ruddock Hall, MD, Sheryl D Perriatt, BSN, RNC, FAACM, and Casey W Hedges, LCSW, who contributed to an earlier version of this topic review.
