Severe Housing Insecurity during Pregnancy: Association with Adverse Birth and Infant Outcomes

Abstract

Introduction: Housing insecurity is increasingly commonplace among disadvantaged women and children. We measured the individual- and population-level impact of severe housing insecurity during pregnancy on adverse birth and infant outcomes. Methods: We analyzed data from 3428 mother-infant dyads enrolled in the Fragile Families and Child Wellbeing Study, a prospective cohort study representing births in 20 large U.S. cities from 1998 to 2000. Severe housing insecurity was defined as threatened eviction or homelessness during pregnancy. Outcomes included low birth weight and/or preterm birth, admission to a neonatal intensive care unit (NICU) or stepdown facility, extended hospitalization after delivery, and infant health and temperament. We estimated exposure-outcome associations with risk ratios adjusted for pre-pregnancy maternal sociodemographic and heath factors and calculated a population attributable fraction (PAF) of outcomes attributable to severe housing insecurity. Results: We found statistically significant associations between severe housing insecurity during pregnancy and low birth weight and/or preterm birth (risk ratio (RR] 1.73, 95% confidence interval (CI) 1.28, 2.32), NICU or stepdown stay (RR 1.64, CI 1.17, 2.31), and extended hospitalization (RR 1.66, CI 1.28, 2.16). Associations between housing insecurity and infant fair or poor health (RR 2.62, CI 0.91, 7.48) and poor temperament (RR 1.52, CI 0.98, 2.34) were not statistically significant. PAF estimates ranged from 0.9-2.7%, suggesting that up to three percent of adverse birth and infant outcomes could be avoided by eliminating severe housing insecurity among low-income, pregnant women in US cities. Conclusions: Results suggest that housing insecurity during pregnancy shapes neonatal and infant health in disadvantaged urban families.

Keywords: birth weight; eviction; homeless persons; housing; infant health; neonatal intensive care units; premature birth.

Figure 1

Framework illustrating hypothesized associations between severe housing insecurity (threated eviction or homelessness) during pregnancy, birth outcomes, and infant health and potential pathways linking the exposure and outcomes.

Figure 2

Flow diagram showing specification of study populations sourced from the Fragile Families and Child Wellbeing Study, 1998–2000.

Figure 3

(A) Crude risk, (B) adjusted risk ratios, and (C) population attributable fraction of birth and infant outcomes associated with severe housing insecurity during pregnancy, the Fragile Families and Child Wellbeing Study, 1998–2000. ^a Covariates include maternal age category, race/ethnicity, poverty level, education, marital status, pre-pregnancy mental health status, preexisting conditions (hypertension, renal disease, diabetes, lung disease, heart disease, and/or anemia), and infant sex. ^b > 2 days for vaginal births, >4 days for cesarean births. ^c Scoring in topmost quintile of a scale constructed from the emotionality subscale of the Emotionality, Activity, and Sociability (EAS) Temperament Survey for Children.