Maternal and Child Health Journal

, Volume 19, Issue 6, pp 1276–1283 | Cite as

Homelessness During Pregnancy: A Unique, Time-Dependent Risk Factor of Birth Outcomes

  • Diana B. CuttsEmail author
  • Sharon Coleman
  • Maureen M. Black
  • Mariana M. Chilton
  • John T. Cook
  • Stephanie Ettinger de Cuba
  • Timothy C. Heeren
  • Alan Meyers
  • Megan Sandel
  • Patrick H. Casey
  • Deborah A. Frank


Evaluate homelessness during pregnancy as a unique, time-dependent risk factor for adverse birth outcomes. 9,995 mothers of children <48 months old surveyed at emergency departments and primary care clinics in five US cities. Mothers were classified as either homeless during pregnancy with the index child, homeless only after the index child’s birth, or consistently housed. Outcomes included birth weight as a continuous variable, as well as categorical outcomes of low birth weight (LBW; <2,500 g) and preterm delivery (<37 weeks). Multiple logistic regression and adjusted linear regression analyses were performed, comparing prenatal and postnatal homelessness with the referent group of consistently housed mothers, controlling for maternal demographic characteristics, smoking, and child age at interview. Prenatal homelessness was associated with higher adjusted odds of LBW (AOR 1.43, 95 % CI 1.14, 1.80, p < 0.01) and preterm delivery (AOR 1.24, 95 % CI 0.98, 1.56, p = 0.08), and a 53 g lower adjusted mean birth weight (p = 0.08). Postnatal homelessness was not associated with these outcomes. Prenatal homelessness is an independent risk factor for LBW, rather than merely a marker of adverse maternal and social characteristics associated with homelessness. Targeted interventions to provide housing and health care to homeless women during pregnancy may result in improved birth outcomes.


Pregnancy Homeless Low birth weight (LBW) Preterm delivery Housing Maternal 



Low birth weight


Pregnancy Risk Assessment Monitoring System (PRAMS)


Adjusted odds ratio


Confidence interval


Special Supplemental Nutrition Program for Women, Infants and Children



The authors acknowledge Ingrid Weiss, Justin Pasquariello, and Allison Bovell for their invaluable assistance in preparation of this manuscript, as well as the Children’s HealthWatch interviewers, administrative staff, and participants. This work was supported by a grant from the Gerald D. and Katherine T. MacArthur Foundation.

Conflict of interest

The authors have no conflicts of interest to disclose.


  1. 1.
    National Coalition for the Homeless (2009). How many people experience homelessness? Washington D.C.: National Coalition for the Homeless.
  2. 2.
    Homelessness Research Institute (2012). The state of homelessness in America 2012. Washington D.C.: National Alliance to End Homelessness.
  3. 3.
    McCoy-Roth, M., Mackintosh, B. B., & Murphey, D. (2012). When the bough breaks: The effects of homelessness on young children. Early childhood highlights: Child trends. MD: Bethesda.
  4. 4.
    Bassuk, E. (1991). Homeless families. Scientific American, 265, 66–74.CrossRefPubMedGoogle Scholar
  5. 5.
    O’Leary, C. M., Nassar, N., Kurinczuk, J. J., et al. (2010). Prenatal alcohol exposure and risk of birth defects. Pediatrics, 126(4), e843–e850.CrossRefPubMedGoogle Scholar
  6. 6.
    Czeizel, A. E., Tímár, L., & Sárközi, A. (1999). Dose-dependent effect of folic acid on the prevention of orofacial clefts. Pediatrics, 104(6), 1375–1376.CrossRefGoogle Scholar
  7. 7.
    Whitehead, E., Dodds, L., Joseph, K. S., Gordon, K. E., Wood, E., & Allen, A. C. (2006). Relation of pregnancy and neonatal factors to subsequent development of childhood epilepsy: A population-based cohort study. Pediatrics, 117(4), 1298–1306.CrossRefPubMedGoogle Scholar
  8. 8.
    Harding, J. (1995). Nutrition and fetal growth. Reproduction, Fertility, and Development, 7, 539–547.CrossRefPubMedGoogle Scholar
  9. 9.
    Dietz, W. H. (1994). Critical periods in childhood for the development of obesity. American Journal of Clinical Nutrition, 59(5), 955–959.PubMedGoogle Scholar
  10. 10.
    Moore, V. M., & Davies, M. J. (2005). Diet during pregnancy, neonatal outcomes and later health. Reproduction, Fertility, and Development, 17(3), 341–348.CrossRefPubMedGoogle Scholar
  11. 11.
    Chen, X. K., Wen, S. W., Fleming, N., Demissie, K., Rhoads, G. G., & Walker, M. (2007). Teenage pregnancy and adverse birth outcomes: A large population based retrospective cohort study. International Journal of Epidemiology, 36(2), 368–373.CrossRefPubMedGoogle Scholar
  12. 12.
    Richards, R., Merril, R. M., & Baksh, L. (2011). Health behaviors and infant health outcomes in homeless pregnant women in the United States. Pediatrics, 128(3), 438–446.PubMedGoogle Scholar
  13. 13.
    Little, M., Shah, R., Vermeulen, M. J., Gorman, A., Dzendoletas, D., & Ray, J. G. (2005). Adverse perinatal outcomes associated with homelessness and substance use in pregnancy. CMAJ, 173(6), 615–618.CrossRefPubMedCentralPubMedGoogle Scholar
  14. 14.
    Merrill, R. M., Richards, R., & Sloan, A. (2011) Prenatal maternal stress and physical abuse among homeless women and infant health outcomes in the United States. Epidemiology Research International, Article ID 467265.Google Scholar
  15. 15.
    Zlotnick, C., & Zerger, S. (2009). Survey findings on characteristics and health status of clients treated by the federally funded (US) Health Care for the Homeless Program. Health and Social Care in the Community, 1, 18–26.CrossRefGoogle Scholar
  16. 16.
    Drake, M. A. (1992). The nutritional status and dietary adequacy of single homeless women and their children in shelters. Public Health Reports, 107(3), 312–319.PubMedCentralPubMedGoogle Scholar
  17. 17.
    Hwang, S. W., Wilkins, R., Tjepkema, M., O’Campo, P. J., & Dunn, J. R. (2009). Mortality among residents of shelters, rooming houses, and hotels in Canada: 11 year follow-up study. BMJ, 339, b4036.CrossRefPubMedCentralPubMedGoogle Scholar
  18. 18.
    Cheung, A. M., & Hwang, S. W. (2004). Risk of death among homeless women: A cohort study and review of the literature. CMAJ, 170(8), 1243–1247.CrossRefPubMedCentralPubMedGoogle Scholar
  19. 19.
    Cutts, D. B., Meyers, A. F., Black, M. B., Casey, P. H., Chilton, M., Cook, J. T., et al. (2011). Housing insecurity and the health of very young children. American Journal of Public Health, 101(8), 1507–1514.CrossRefGoogle Scholar
  20. 20.
    Richards, R., Merrill, R. M., Baksh, L., & McGarry, J. (2011). Maternal health behaviors and infant health outcomes among homeless mothers: U.S. Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) 2000–2007. Preventive Medicine, 52(1), 87–94.CrossRefPubMedGoogle Scholar
  21. 21.
    Jaddoe, V. W., Troe, E. J., Hofman, A., Mackenbach, J. P., Moll, H. A., Steegers, E. A., et al. (2008). Active and passive maternal smoking during pregnancy and the risks of low birthweight and preterm birth: The Generation R Study. Paediatric and Perinatal Epidemiology, 22(2), 162–171.CrossRefPubMedGoogle Scholar
  22. 22.
    Bassuk, E. L., Buckner, J. C., Weinreb, L. F., Browne, A., Bussak, S. S., Dawson, R., et al. (1997). Homelessness in female-headed families: Childhood and adult risk and protective factors. American Journal of Public Health, 87, 241–248.CrossRefPubMedCentralPubMedGoogle Scholar
  23. 23.
    US Department of Housing and Urban Development (2009). The 2008 annual homeless assessment report (AHAR) to congress. Washington D.C.: Office of Community Planning and Development.
  24. 24.
    The crisis in homelessness: Effects on children and families (1987). Testimony before the U.S. House of Representatives Select Committee on Children, Youth and Families. 100th Cong., 1st Sess.Google Scholar
  25. 25.
    US Department of Housing and Urban Development (2010). The 2010 annual homelessness assessment report to congress. Washington D.C.: Office of Community Planning and Development.
  26. 26.
    Webb, D. A., Culhane, J., Metraux, S., Robbins, J. M., & Culhane, D. (2003). Prevalence of episodic homelessness among adult childbearing women in Philadelphia, PA. American Journal of Public Health, 93(11), 1895–1896.CrossRefPubMedCentralPubMedGoogle Scholar
  27. 27.
    Underwood, M. A., Danielsen, B., & Gilbert, W. M. (2007). Cost, causes and rates of rehospitalization of preterm infants. Journal of Perinatology, 27, 614–619.CrossRefPubMedGoogle Scholar
  28. 28.
    Allen, L. H. (2000). Anemia and iron deficiency: Effects on pregnancy outcome. The American Journal of Clinical Nutrition, 71(suppl), 1280S–1284S.PubMedGoogle Scholar
  29. 29.
    Centers for disease control and prevention. Preterm birth. Washington D. C.: National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health.
  30. 30.
    Gayle, H. D., Yip, R., Frank, M. J., Neiburg, P., & Binkin, N. J. (1988). Validation of maternally reported birthweight among 46,637 Tennessee WIC program participants. Public Health Reports, 103(2), 143–147.PubMedCentralPubMedGoogle Scholar
  31. 31.
    Tomeo, C. A., Rich-Edwards, J. W., Michels, K. B., Berkey, C. S., Hunter, D. J., Frazier, A. L., et al. (1999). Reproducibility and validity of maternal recall of pregnancy-related events. Epidemiology, 10(6), 774–776.CrossRefPubMedGoogle Scholar
  32. 32.
    Adegboye, A. R. A., & Heitman, B. L. (2008). Accuracy and correlates of maternal recall and birthweight and gestational age. BJOG, 115, 886–893.CrossRefPubMedCentralPubMedGoogle Scholar
  33. 33.
    Jasinski, J. L. (2004). Pregnancy and domestic violence. Trauma, Violence, & Abuse, 5(1), 47–64.CrossRefGoogle Scholar
  34. 34.
    Bailey, B. A., McCook, J. G., Hodge, A., & McGrady, L. (2012). Infant birth outcomes among substance using women: Why quitting smoking during pregnancy is just as important as quitting illicit drug use. Maternal and Child Health Journal, 16(2), 414–422.CrossRefPubMedGoogle Scholar
  35. 35.
    Jacobson, J. L., Jacobson, S. W., Sokol, R. J., Martier, S. S., Ager, J. W., & Shankaran, S. (1994). Effects of alcohol use, smoking, and illicit drug use on fetal growth in black infants. Journal of Pediatrics, 124(5 Pt 1), 757–764.CrossRefPubMedGoogle Scholar
  36. 36.
    Slotkin, T. (1998). Fetal nicotine or cocaine exposure: Which one is worse? Journal of Pharmacology and Experimental Therapeutics, 285, 931–945.PubMedGoogle Scholar
  37. 37.
    Miranda, M. L., Maxson, P., & Sharon, E. (2009). Environmental contributions to disparities in pregnancy outcomes. Epidemiologic Reviews, 31(1), 67–83.CrossRefPubMedGoogle Scholar
  38. 38.
    Roberts, E. M. (1997). Neighborhood social environments and the distribution of low birthweight in Chicago. American Journal of Public Health, 87(4), 597–603.CrossRefPubMedCentralPubMedGoogle Scholar
  39. 39.
    Banyard, V. L., & Graham-Bermann, S. A. (1998). Surviving poverty: Stress and coping in the lives of housed and homeless mothers. American Journal of Orthopsychiatry, 68(3), 479–487.CrossRefPubMedGoogle Scholar
  40. 40.
    Ashdown-Lambert, J. R. (2005). A review of low birth weight: Predictors, precursors and morbidity outcomes. JRSH, 125(2), 76–83.CrossRefPubMedGoogle Scholar
  41. 41.
    Matthews, T. J., & MacDorman, M. F. (2010). Infant mortality statistics from the 2006 period linked birth/infant death data set. National Vital Statistics Reports, 58(17).
  42. 42.
    Callaghan, W. M., MacDorman, M. F., Rasmussen, S. A., Qin, C., & Lackritz, E. (2006). The contribution of preterm birth to infant mortality rates in the United States. Pediatrics, 118, 1566–1573.CrossRefPubMedGoogle Scholar
  43. 43.
    Kugelman, A., & Colin, A. A. (2013). Late preterm infants: Near term but still in a critical developmental time period. Pediatrics, 132(4), 741–751.CrossRefPubMedGoogle Scholar
  44. 44.
    The McKinney Vento Homeless Assistance Act, Pub. L. No. 100-77, 101 Stat. 482 (July 22, 1987).Google Scholar
  45. 45.
    United states interagency council on homelessness. Washington D.C.: United States Interagency Council on Homelessness. About USICH [about 1 screen]
  46. 46.
    U.S. Department of Housing and Urban Development (HUD). Homelessness Prevention and Rapid Re-Housing Program.
  47. 47.
    United States Interagency Council on Homelessness (2010). Opening doors: Federal strategic plan to prevent and end homelessness.
  48. 48.
    Kaufmann, G. (2013) Congress misses opportunity to reverse sequester cuts to housing. In What matters today. New York: Moyers and Company [about 1 screen].

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Diana B. Cutts
    • 1
    Email author
  • Sharon Coleman
    • 2
  • Maureen M. Black
    • 3
  • Mariana M. Chilton
    • 4
  • John T. Cook
    • 5
  • Stephanie Ettinger de Cuba
    • 2
  • Timothy C. Heeren
    • 2
  • Alan Meyers
    • 5
  • Megan Sandel
    • 5
  • Patrick H. Casey
    • 6
  • Deborah A. Frank
    • 5
  1. 1.Department of PediatricsHennepin County Medical CenterMinneapolisUSA
  2. 2.Data Coordinating CenterBoston University School of Public HealthBostonUSA
  3. 3.Department of PediatricsUniversity of Maryland School of MedicineBaltimoreUSA
  4. 4.Department of Health Management and PolicyDrexel University School of Public HealthPhiladelphiaUSA
  5. 5.Department of PediatricsBoston University School of MedicineBostonUSA
  6. 6.Department of PediatricsUniversity of Arkansas for Medical SciencesLittle RockUSA

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