Prenatal care for people experiencing homelessness

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: females represent approximately 80 percent of adults in families experiencing homelessness in the United States [2]. Women who experience homelessness are at higher risk of having chronic illnesses, infectious diseases, substance use problems, mental illness, and being a victim of sexual or domestic violence than those 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 a history of trauma, 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 people who are homeless. We do not specifically address care of transgender or gender non-conforming people who experience homelessness. We may use the words "women" or "females" interchangeably throughout the article, recognizing that these terms may not always represent the full spectrum of gender identity of people who experience pregnancy. 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 females was 13 in 10,000. The HUD's 2022 Annual Homeless Assessment Report showed that rates of homelessness have largely been unchanged in recent years [8].

The Healthcare Cost and Utilization Project National Inpatient Sample of over 18 million hospital deliveries in the United States (2016 through 2020) found nearly 19,000 involved pregnant patients who were experiencing homelessness at the time of delivery, yielding a prevalence rate of 104.9 per 100,000 hospital deliveries [9]. In contrast to the HUD data, the rate of homeless pregnant people increased 72 percent over the five-year period.

Pregnant people experiencing homelessness are typically younger than nonpregnant females experiencing homelessness and frequently have a history of family disruption [10]. The median age of homeless pregnant people in the study described above was 29 years. [9] The teenager experiencing homelessness is often the product of domestic instability and/or poverty [11].

In a survey of females at emergency departments and primary care clinics, pregnant people who were homeless had higher rates of cigarette smoking, lower rates of employment, and lower educational attainment as compared with consistently housed counterparts [12].

RISK FACTORS FOR AND CAUSES OF HOMELESSNESS — Homelessness has many causes, and pregnant people who are homeless are a heterogeneous group. Domestic and sexual violence are the leading causes of homelessness in females, as 20 to 50 percent of all females and children experiencing homelessness become so as a direct result of trying to escape domestic violence [5]. Females continue to be at risk for experiencing violence when in homeless shelters or when living on the streets [13]. Some shelters do not accept pregnant people out of concern of liability if the individual experiences complications or problems while in the shelter [14].

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. Up to one half of people experiencing homelessness have a history of substance use [15].

For a teenager, pregnancy may be the precipitating event that leads to their voluntarily or involuntarily leaving their parents' home. Psychosocial issues are also common in this population. A three-year study of pregnancy and motherhood in unaccompanied females ages 16 to 19 years experiencing homelessness observed high rates of mental illness and substance use: approximately 32 percent suffered from major depressive disorder, 65 percent from a conduct disorder, and 51 percent from posttraumatic stress disorder [16]. 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 FEMALES EXPERIENCING HOMELESSNESS — Most reports suggest pregnancy is more prevalent in females who are homeless, but accurate data are difficult to obtain.

●In one study of 764 females who were homeless in Los Angeles, 28 percent reported being pregnant in the past year and almost 75 percent of these pregnancies were unintended [17].

●In a study in London, 24 percent of females who were homeless were pregnant [18].

●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 [19].

By comparison, approximately 6 percent of reproductive-age females in the United States become pregnant each year.

Unintended pregnancies are more common in females 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 activities providing sexual services for money; victimization by sexual violence; and partners unwilling to use condoms [4,20,21].

In a study of 15 pregnant people experiencing homelessness, pregnancy was sometimes the precipitating factor that caused them to become homeless, but the majority became pregnant while they were homeless [14]. 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, uncertainty about their fertility, and hope for the future. For some, the pregnancy was their only source of joy and a catalyst for resolving past problems and seeking 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 young females in the study [19]. 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 — A limited number of studies have examined pregnancy outcomes in people experiencing homelessness. The risk of adverse maternal, fetal, and neonatal outcomes is increased in this population 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 [22-24]. 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 [22].

●A Canadian study found that pregnant people 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 those who were not homeless, after adjustment for risk factors such as maternal age, number of previous pregnancies, and smoking [25]. Pregnant people with a substance use disorder experiencing homelessness were at even higher risk of these outcomes. A study from California noted a higher likelihood of poor neonatal outcome persisted even after accounting for prematurity [24].

●The Healthcare Cost and Utilization Project National Inpatient Sample of nearly 19,000 pregnant patients in the US who were experiencing homelessness at the time of delivery reported unhoused status was associated with an increased risk of the following adverse outcomes compared with housed patients: preterm birth <28 weeks (34.3 versus 10.8 per 1000 deliveries; adjusted OR [aOR] 2.76, 95% CI 2.55-2.99), severe maternal morbidity at in-hospital delivery (53.8 versus 17.7 per 1000 deliveries; aOR 2.30, 95% CI 2.15-2.45), and in-hospital mortality (0.8 versus <0.1 per 1000 deliveries; aOR 10.17, 95% CI 6.10-16.94) [9].

Unstable housing is associated with a higher likelihood of health care utilization in the immediate postpartum period, including emergency department visits and readmissions [26].

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 [27]. 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 [28]:

●Outreach to engage those in need of health care services.

●Respect for each individual, 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.

●Use of a trauma-informed approach to care.

●Help with housing options, including programs combining housing with services (eg, childcare, substance use, mental health).

Identifying pregnancy — Ideally, shelters for people experiencing homelessness, urgent care centers, and emergency medicine departments should test females of reproductive age for pregnancy to allow early identification and referral to appropriate sources of prenatal care or abortion services. Some individuals experiencing homelessness do not know that they are pregnant because their menstrual periods have stopped or have become irregular [14].

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 individual experiencing homelessness will be perceived or treated by health care providers. For example, individuals with substance use disorder, mental illness, or undocumented resident status may fear being reported to the authorities [29], and those 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 people 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. People 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 people are usually given priority in determining Medicaid eligibility, and will receive qualification within two to four weeks of submitting an application. An on-site social worker or patient navigator will help patients connect to local county assistance offices and thereby expedite insurance applications.

Approach to prenatal care — Prenatal providers should identify patients who may be homeless or at risk of becoming homeless, recognizing that they may be reluctant to voluntarily reveal their homelessness [5,14].

Prenatal care of people 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 people 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 patient 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 people 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 [30]. In addition to routine screening for chlamydia, syphilis, hepatitis B, and HIV, we suggest screening pregnant people 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 pregnant individual 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".)

Providing access to treatment for substance use disorder is critical given the rising numbers of pregnant people who are actively using substances and are unhoused.

The appropriate use of the emergency department should be discussed, as people experiencing homelessness visit the emergency department more often than their housed counterparts [22].

During the course of prenatal care, people experiencing homelessness (like all pregnant people) need to be prepared for labor and giving birth, 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 patients 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 females and children, affordable housing, transportation to and from appointments and the hospital, mental health and substance use treatment programs, food banks, clothing, child care resources, legal aid, and crisis lines. For people 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 those 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 or triggered by prior pregnancy-related trauma. 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, people who experience homelessness may have had limited prenatal care. Their first connection with a perinatal provider may be when presenting in labor. For an individual 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 pregnant people 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 pregnant/postpartum individuals 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 "Contraception: Postpartum counseling and methods", section on 'Progestin-only implants' and "Contraception: Postpartum 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 their newborn, 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 [31-33].

The initial assessment should address living situation, support system, knowledge of childcare issues, resources, and issues regarding substance use and mental health. Many people 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 their child. This assessment is typically done by a social worker rather than the health care provider. Living in a shelter may show that they have made some choices to regain the stability that their child will need. A qualitative study of females in California suggested that attaining stable housing is a primary determinant in retaining custody of one's children after giving birth [34]. 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 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 them with resources and provide encouragement. When indicated, involving CPS will not only help to ensure the safety of the infant, but can also help the mother receive the help they may need.

After identifying the mother's needs, the case manager and social worker often collaborate to ensure these needs are met prior to 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 during the 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 [31-33]. 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 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 the 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 [35].

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 females and children. Domestic and sexual violence are the leading cause of homelessness in females. Pregnancy may be the precipitating event that leads a teenager to voluntarily or involuntarily leave their parents' home. Unhoused people have high rates of substance use disorder (See 'Introduction' above and 'Epidemiology' above and 'Risk factors for and causes of homelessness' above.)

●Scope of prenatal care – Pregnant people 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 infections, tuberculosis; and examination of the skin, teeth and gums, and vision). (See 'Approach to prenatal care' above.)

Financial, physical, and psychosocial barriers impede pregnant people 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 people 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 newborn are met. The decision to involve Child Protective Services (CPS) is made after evaluating whether or not the mother is making healthy choices for the 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.