Adverse perinatal outcomes associated with homelessness and substance use in pregnancy

Challenges to immunization: the experiences of homeless youth

BACKGROUND

Homelessness is a critical social issue, both a product of, and contributing to, poor mental and physical health. Over 150,000 young Canadians live on the streets. Homeless youth experience a high incidence of infectious diseases, many of which are vaccine preventable. Early departure from school and limited access to public health services makes them a particularly vulnerable high-risk group. This study explores challenges to obtaining essential vaccines experienced by homeless youth.

METHODS

A qualitative research study to explore knowledge, attitudes, beliefs, and experiences surrounding immunization of hard-to-reach homeless youth was designed. Participants were recruited for focus groups from Phoenix House and Shelter, a non-profit, community-based organization assisting homeless youth in Halifax, Nova Scotia, Canada. An experienced facilitator guided the recorded discussions. Transcripts of audiotapes were analyzed using a constant comparative method until data revealed a set of exemplars and themes that best captured participants' knowledge, attitudes, beliefs and experiences surrounding immunization and infectious diseases.

RESULTS

Important themes emerged from our analysis. Considerable variability in knowledge about immunization and vaccine preventable diseases was found. The homeless youth in the study had limited awareness of meningitis in contrast to a greater knowledge about sexually transmitted infections and influenza, gained during the H1N1/09 public health campaign. They recognized their poverty as a risk for contracting infectious diseases, along with their inability to always employ known strategies to prevent infectious diseases, due to circumstances. They showed considerable insight into the detrimental effects of poor hygiene, sleeping locations and risk behaviour. Interviewed homeless youth regarded themselves as good compliers of health professional advice and offered valuable suggestions to improve immunization in their population.

CONCLUSIONS

To provide effective public health interventions, it is necessary to consider the knowledge, attitudes, beliefs, and experiences of hard to reach, high risk groups. Our study shows that homeless youth are interested and capable in discussing immunization. Active targeting of homeless youth for public health immunization programs is needed. Working collaboratively with non-profit organizations that assist homeless youth provides an opportunity to increase their knowledge of infectious risks and to improve immunization strategies in this vulnerable group.

IMPLICATIONS OF HOMELESSNESS FOR PARENTING YOUNG CHILDREN: A PRELIMINARY REVIEW FROM A DEVELOPMENTAL ATTACHMENT PERSPECTIVE

Although it has been well-documented that parents and children who experience homelessness often have compromised health and well-being, few studies have examined the potential implications of homelessness on the process of parenting young children. In this review, we consider how parents of young children might function under the circumstances of homelessness. We begin with a brief overview of the psychological, social, and medical characteristics of homeless mothers and their young children. Using a developmental attachment perspective, we next briefly review the central tasks of parenting during the first 5 years of life, including emotion regulation and fostering of child autonomy, with an eye toward how homelessness may compromise a mother's ability to complete these tasks. Finally, we provide suggestions for further research that incorporate a developmental attachment perspective and other relevant viewpoints. Because of the paucity of research in this area, our review seeks to provide a heuristic framework for future research, intervention development, and policy.

Health behaviors and infant health outcomes in homeless pregnant women in the United States

OBJECTIVE

To describe selected demographics; maternal health behaviors before, during, and after pregnancy; and infant health outcomes among homeless women in the United States.

PATIENTS AND METHODS

Analyses are based on Pregnancy Risk Assessment Monitoring System data from 31 participating states from 2000 to 2007 that were linked to birth certificate data, which contain demographic and medical information collected through the state's vital records system. Responses were then weighted to be representative of all women who gave birth in each state during that year. Assessment of these data takes into account the complex sampling designs employed by the states.

RESULTS

Four percent of women reported homelessness within 12 months before pregnancy, with the highest percentage in Illinois, followed by Oregon and Washington. Homeless women were younger, unmarried, uninsured, less educated, less likely to initiate and sustain breastfeeding, and had less prenatal care and well-visits. They were also more likely to be black, Hispanic, smoke cigarettes, be underweight or have class III obesity, and not take preconception multivitamins. Infants had lower birth weights, a longer hospital stay, and were more likely to receive neonatal intensive care.

CONCLUSIONS

In this study we provide additional insight into homelessness in the perinatal period and provide information on ways to direct interventions aimed at improving the health of homeless mothers and infants. Additional research is needed to determine factors that influence pregnancy weight gain and infant feeding practices among homeless women and how this affects infant health.

Response to Homeless Childbearing Women’s Health Care Learning Needs

The study findings showed that homeless childbearing women are at greatest risk for cancer, violence, poor nutrition, sexually transmitted infections, unplanned pregnancy, and adverse pregnancy outcomes. Collaborating with personnel at a women’s shelter, the authors studied homeless childbearing women’s knowledge, attitudes, and beliefs about general health promotion, healthy pregnancy promotion, and preterm labor prevention. Guided by the Integrative Model of Behavioral Prediction and Change, 45 homeless women participated in focus groups. They were 28.7 years old (range 18-44 years), and approximately 87% of these women had custody of their children. Three themes identified included things you do to stay healthy during pregnancy, where you learned about staying healthy, and women’s knowledge about preterm labor and general health promotion. These findings informed an 8-week educational session (1 hr/week). During the past year, four 8-week sessions were conducted with attendance between 8 and 14 participants. Each week a different health topic was discussed incorporating the associated unique challenges of homelessness.

Pregnancy and mental health of young homeless women

Pregnancy rates among young women who are homeless are significantly higher than rates among housed young women in the United States (J. M. Greene & C. L. Ringwalt, 1998). Yet, little research has addressed mental health or risk and resilience among young mothers who are homeless. Based on a sample from the Midwest Longitudinal Study of Homeless Adolescents, this study explores pregnancy and motherhood in unaccompanied homeless young women over a period of 3 years. The data are supplemented by in-depth interviews with a subset of young women. Results show that almost half (46.4%) of sexually active young women who are homeless (n=222, M age = 17.2) had been pregnant at baseline. Among those who stated they had children between Waves 2 and 13 (n=90), only half reported caring for their children consistently over time, and one fifth reported never seeing their children. Of the participants with children in their care at the last interview (Wave 13), almost one third met criteria for lifetime major depressive episode, lifetime posttraumatic stress disorder, and lifetime drug abuse, and half met criteria for lifetime antisocial personality disorder. Twelve-month diagnoses are also reported. The impacts of homelessness on maternal and child outcomes are discussed.

Assessing maternal risk for fetal-infant mortality: a population-based study to prioritize risk reduction in a healthy start community

Study goals were to distinguish between maternal risk factors for fetal versus infant mortality, and to identify which maternal characteristics contributed the greatest risk of mortality overall. This case-control retrospective study abstracted data on more than forty maternal characteristics from 261 prenatal and delivery records: all 26 fetal deaths, all 40 infant deaths and 195 randomly selected surviving births in a high-mortality Healthy Start community. Bivariate and multivariate analyses were conducted. The fetal-mortality population was significantly more likely than the infant-mortality population to have no insurance (P = .047), inadequate prenatal care (P = .039) and previous fetal death (P = .021). Comparing the combined mortality population with the surviving sample, two tiers of risk emerged: Rare-but-lethal risks, including no prenatal care (P < .001) and Child-Protective-Service involvement (P = .001), and common-and-dangerous risks, including inadequate maternal weight gain (OR = 13.55), drug or alcohol abuse (OR = 8.67), obesity (OR = 2.77) and anemia (OR = 3.61). Both fetal and infant mortality groups must be considered when identifying maternal risks. Inadequate prenatal weight gain, obesity and anemia contribute as much to feto-infant mortality as substance abuse. Public health efforts to improve maternal nutrition and healthy weight should be redoubled.

A population-based assessment of the health of homeless families in New York City, 2001-2003

OBJECTIVES

We compared estimated population-based health outcomes for New York City (NYC) homeless families with NYC residents overall and in low-income neighborhoods.

METHODS

We matched a NYC family shelter user registry to mortality, tuberculosis, HIV/AIDS, and blood lead test registries maintained by the NYC Department of Health and Mental Hygiene (2001-2003).

RESULTS

Overall adult age-adjusted death rates were similar among the 3 populations. HIV/AIDS and substance-use deaths were 3 and 5 times higher for homeless adults than for the general population; only substance-use deaths were higher than for low-income adults. Children who experienced homelessness appeared to be at an elevated risk of mortality (41.3 vs 22.5 per 100,000; P < .05). Seven in 10 adult and child deaths occurred outside shelter. Adult HIV/AIDS diagnosis rates were more than twice citywide rates but comparable with low-income rates, whereas tuberculosis rates were 3 times higher than in both populations. Homeless children had lower blood lead testing rates and a higher proportion of lead levels over 10 micrograms per deciliter than did both comparison populations.

CONCLUSIONS

Morbidity and mortality levels were comparable between homeless and low-income adults; homeless children's slightly higher risk on some measures possibly reflects the impact of poverty and poor-quality, unstable housing.

The effectiveness of antenatal care programmes to reduce infant mortality and preterm birth in socially disadvantaged and vulnerable women in high-income countries: a systematic review

BACKGROUND

Infant mortality has shown a steady decline in recent years but a marked socioeconomic gradient persists. Antenatal care is generally thought to be an effective method of improving pregnancy outcomes, but the effectiveness of specific antenatal care programmes as a means of reducing infant mortality in socioeconomically disadvantaged and vulnerable groups of women has not been rigorously evaluated.

METHODS

We conducted a systematic review, focusing on evidence from high income countries, to evaluate the effectiveness of alternative models of organising or delivering antenatal care to disadvantaged and vulnerable groups of women vs. standard antenatal care. We searched Medline, Embase, Cinahl, PsychINFO, HMIC, CENTRAL, DARE, MIDIRS and a number of online resources to identify relevant randomised and observational studies. We assessed effects on infant mortality and its major medical causes (preterm birth, congenital anomalies and sudden infant death syndrome (SIDS)) RESULTS: We identified 36 distinct eligible studies covering a wide range of interventions, including group antenatal care, clinic-based augmented care, teenage clinics, prenatal substance abuse programmes, home visiting programmes, maternal care coordination and nutritional programmes. Fifteen studies had adequate internal validity: of these, only one was considered to demonstrate a beneficial effect on an outcome of interest. Six interventions were considered 'promising'.

CONCLUSIONS

There was insufficient evidence of adequate quality to recommend routine implementation of any of the programmes as a means of reducing infant mortality in disadvantaged/vulnerable women. Several interventions merit further more rigorous evaluation.

Maternal health behaviors and infant health outcomes among homeless mothers: U.S. Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) 2000-2007

OBJECTIVE

To determine whether participation in the Women, Infants, and Children Program is associated with improved maternal and infant health outcomes among homeless women in the Pregnancy Risk Assessment Monitoring System.

METHOD

Analyses were based on Pregnancy Risk Assessment Monitoring System participants from 31 states/cities in the United States, 2000-2007 (n=272,859). Overall, 4% of women completing the Pregnancy Risk Assessment Monitoring System survey were homeless, with 76% participating in the Women, Infants, and Children Program, a federally-funded supplemental nutrition program for low-income women and children less than 5 years old.

RESULTS

Among women in the Pregnancy Risk Assessment Monitoring System survey who reported using the Women, Infants, and Children Program, those experiencing homelessness were older, less educated, less likely to have private health insurance, and more likely to receive government assistance. Homeless women in the Women, Infants, and Children Program compared with those not in the program were significantly more likely to have a higher body mass index, to initiate breastfeeding after delivery, have prenatal care visits, have a longer gestational age, and have a greater infant birth weight.

CONCLUSION

Characteristics of homeless pregnant women choosing to participate in the Women, Infants, and Children Program are consistent with the requirements for program participation for women in general. Homeless women accessing the Women, Infants, and Children Program had better maternal and infant health outcomes.

Residential mobility in the UK during pregnancy and infancy: are pregnant women, new mothers and infants 'unhealthy migrants'?

People that move home within developed countries report, on average, better health than non-movers. Pregnant women, new mothers and infants are particularly mobile, but the limited evidence regarding the relationship between their mobility and health suggests they may not conform to the 'healthy migrant' effect. This paper examines the relationship between mobility and health among these groups in the UK, using logistic regression to analyse cross-sectional data for 18,197 families in the Millennium Cohort Study wave one. It compares health status variables among mobile and non-mobile families; describes mobile families' socio-demographic characteristics; explores associations between health outcomes, reasons for residential moves, and experiences of homelessness; and assesses the association between mobility and health care utilisation, social support and residential satisfaction. The paper concludes that mobile pregnant women, new mothers and infants do have poor health outcomes in comparison to non-movers, but this is primarily explained by their socio-demographic characteristics and the negative circumstances associated with a minority of their moves. Families that moved during pregnancy and infancy had worse self-rated health and depression among mothers, and lower birth weight and higher risk of accidents among infants, than non-movers. Mothers in mobile families were younger and had lower levels of education and owner-occupation than non-movers. After adjustment for socio-demographic characteristics mobility was weakly and non-significantly associated with most health variables with the exception of self-rated health and depression among mothers who moved for negative reasons (such as relationship breakdown or problems with neighbours), or had been homeless since birth. After adjustment mobile families had lower levels of most measures of health care utilisation compared to non-movers, but mothers did not report less frequent social contacts, and those that moved during infancy for positive reasons (such as wanting a better home or neighbourhood) had greater satisfaction with home and area.

Drug problems among homeless individuals in Toronto, Canada: prevalence, drugs of choice, and relation to health status

BACKGROUND

Drug use is believed to be an important factor contributing to the poor health and increased mortality risk that has been widely observed among homeless individuals. The objective of this study was to determine the prevalence and characteristics of drug use among a representative sample of homeless individuals and to examine the association between drug problems and physical and mental health status.

METHODS

Recruitment of 603 single men, 304 single women, and 284 adults with dependent children occurred at homeless shelters and meal programs in Toronto, Canada. Information was collected on demographic characteristics and patterns of drug use. The Addiction Severity Index was used to assess whether participants suffered from drug problems. Associations of drug problems with physical and mental health status (measured by the SF-12 scale) were examined using regression analyses.

RESULTS

Forty percent of the study sample had drug problems in the last 30 days. These individuals were more likely to be single men and less educated than those without drug problems. They were also more likely to have become homeless at a younger age (mean 24.8 vs. 30.9 years) and for a longer duration (mean 4.8 vs. 2.9 years). Marijuana and cocaine were the most frequently used drugs in the past two years (40% and 27%, respectively). Drug problems within the last 30 days were associated with significantly poorer mental health status (-4.9 points, 95% CI -6.5 to -3.2) but not with poorer physical health status (-0.03 points, 95% CI -1.3 to 1.3)).

CONCLUSIONS

Drug use is common among homeless individuals in Toronto. Current drug problems are associated with poorer mental health status but not with poorer physical health status.

Rates of rubella immunity among immigrant and non-immigrant pregnant women

OBJECTIVE

Elimination of congenital rubella syndrome depends not only on effective childhood immunization but also on the identification and immunization of susceptible women of childbearing age. Since many countries do not immunize against rubella, it is possible that some immigrant women may not be immune. Moreover, contemporary estimates of rubella immunity among Canadian-born mothers are lacking. Accordingly, we sought to compare the immunity status in pregnancy of a large number of immigrant and Canadian-born women in Toronto.

METHODS

We examined data among 5783 consecutive pregnant women who gave birth at an inner city hospital in downtown Toronto between 2002 and 2007. Antenatal maternal rubella immunity status was recorded at the time of delivery, and assessed according to the mother's birthplace. Odds ratios (OR) for rubella immunity were adjusted for maternal age, gravidity and duration of residency in Canada.

RESULTS

Relative to a rate of 93.2% among Canadian-born mothers, the adjusted risk of being rubella immune was lowest among women from Northern Africa and the Middle East (OR 0.54, 95% CI 0.31-0.94) and China and the South Pacific (OR 0.78, 95% CI 0.59-1.03).

CONCLUSION

Rates of rubella immunity are lower than desired among Canadian-born and, especially, new immigrant pregnant women. Under-immunized populations might be identified at the time of the immigration medical examination, while consideration should be given to screening for rubella immunity among all young Canadian women before puberty.

Health status and birth outcomes among pregnant women in substance abuse treatment

PURPOSE

We sought to examine the physical and mental health status and low birthweight and preterm birth among low-income pregnant women in substance abuse treatment.

METHODS

A prospective correlational design was used with 84 pregnant women enrolled in a university-affiliated, comprehensive, hospital-based substance abuse treatment program. The majority of the sample reported heroin as their primary substance of abuse.

RESULTS

Approximately 39% of the infants were born preterm and 27.5% were low birthweight. Poorer perception of current health, cocaine as the primary substance of abuse, and number of prior substance abuse treatment admissions were independently associated with preterm birth. Being African American and a poorer perception of current health were independently associated with low birthweight.

CONCLUSION

Asking about perceptions of their current health is a useful addition to comprehensive assessment for pregnant women with substance abuse problems in any setting. Further knowledge of women's physical and mental health status will improve identification of those who are at even greater risk in a group at high risk overall.

Pregnancy and sexual health among homeless young injection drug users

Research on pregnancy and sexual health among homeless youth is limited. In this study, qualitative interviews were conducted with 41 homeless young injection drug users (IDUs) in Los Angeles with a history of pregnancy. The relationship between recent pregnancy outcomes, contraception practices, housing status, substance use, utilization of prenatal care, and histories of sexual victimization are described. A total of 81 lifetime pregnancies and 26 children were reported. Infrequent and ineffective use of contraception was common. While pregnancy motivated some homeless youth to establish housing, miscarriages and terminations were more frequent among youth who reported being housed. Widespread access to prenatal and medical services was reported during pregnancy, but utilization varied. Many women continued to use substances throughout pregnancy. Several youth reported childhood sexual abuse and sexual victimization while homeless. Pregnancy presents a unique opportunity to encourage positive health behaviors in a high-risk population seldom seen in a clinical setting.