Nursing Practice Strategies for Prenatal Care of Homeless Pregnant Women

Reproductive Interconception Care Among Women Recently Pregnant and Homeless: A Qualitative Analysis

Reproductive interconception care provided at maternal postpartum visits may help reduce unintended pregnancies and elongate birth intervals for women experiencing homelessness. To improve interconception care uptake, this qualitative study aimed to identify barriers and facilitators to reproductive interconception care from the perspectives of women who were recently pregnant and homeless. A semi-structured interview guide and demographic survey were developed based on epidemiological findings, Information-Motivation-Behavioral Skill framework components, and a review by community health workers for content validity. After conducting 12 interviews with women recently pregnant and homeless in a local continuum of care in 2022, audio-recorded interviews were transcribed, iteratively coded using a priori and emerging codes, and thematically analyzed. Key themes were identified to determine implications and next steps to improving reproductive interconception care uptake. Interrelated themes focused on information (e.g., knowledge and misconceptions about pregnancy, birth intervals, contraception), motivation (e.g., attitudes about interconception care experiences, perinatal social influences), behavioral skills (e.g., objective ability to obtain interconception care and perceived self-efficacy related to attending maternal postpartum visits and increasing birth intervals), and macro-level factors (e.g., obtaining housing, contextualizing socioeconomic factors, navigating COVID-19). The findings suggest the need for flexible, streamlined, and personalized interconception care delivery that acknowledges pressing housing and relationship considerations and supports women's autonomy. Improvements to reproductive interconception care may reduce future unintended pregnancies, increase birth intervals, and improve birth outcomes among women experiencing homelessness.

Improving Reproductive Health Communication Between Providers and Women Affected by Homelessness and Substance Use in San Francisco: Results from a Community-Informed Workshop

OBJECTIVES

Many cisgender women affected by homelessness and substance use desire pregnancy and parenthood. Provider discomfort with patient-centered counseling about reproductive choices and supporting reproductive decisions of these women poses barriers to reproductive healthcare access.

METHODS

We used participatory research methods to develop a half-day workshop for San Francisco-based medical and social service providers to improve reproductive counseling of women experiencing homelessness and/or who use substances. Guided by a stakeholder group comprising cisgender women with lived experience and providers, goals of the workshop included increasing provider empathy, advancing patient-centered reproductive health communication, and eliminating extraneous questions in care settings that perpetuate stigma. We used pre/post surveys to evaluate acceptability and effects of the workshop on participants' attitudes and confidence in providing reproductive health counseling. We repeated surveys one month post-event to investigate lasting effects.

RESULTS

Forty-two San Francisco-based medical and social service providers participated in the workshop. Compared to pre-test, post-test scores indicated reduced biases about: childbearing among unhoused women (p < 0.01), parenting intentions of pregnant women using substances (p = 0.03), and women not using contraception while using substances (p < 0.01). Participants also expressed increased confidence in how and when to discuss reproductive aspirations (p < 0.01) with clients. At one month, 90% of respondents reported the workshop was somewhat or very beneficial to their work, and 65% reported increased awareness of personal biases when working with this patient population.

CONCLUSIONS FOR PRACTICE

A half-day workshop increased provider empathy and improved provider confidence in reproductive health counseling of women affected by homelessness and substance use.

Homelessness in the Perinatal Period and Associations With Reproductive Interconception Care: 2016-2019 Pregnancy Risk Assessment Monitoring System

OBJECTIVES

Women experiencing homelessness have higher rates of unintended pregnancy than stably housed women and may benefit from reproductive interconception care. How reproductive interconception care differs between women who did and did not experience perinatal homelessness is not known. We estimated prevalence ratios of reproductive interconception behaviors among US women experiencing homelessness during the perinatal period.

METHODS

We used data from the 2016-2019 Pregnancy Risk Assessment Monitoring System to calculate the prevalence of 5 reproductive interconception care outcomes: attending a maternal postpartum checkup, participating in a conversation with a health care provider about birth intervals, receiving family planning counseling, obtaining a prescription for short-acting contraception, and having a long-acting reversible contraceptive inserted. We used complex survey weights, stratified by perinatal homelessness, and converted adjusted logistic regression odds ratios between housing status and outcome variables to adjusted prevalence ratios (aPRs) and 95% CIs.

RESULTS

Among participants, approximately 2.4% (weighted percentage; unweighted 2953 of 100 706) experienced homelessness sometime in the 12 months before their children were born; the majority were non-Hispanic (83.2%) and White (69.4%), were not married (82.2%), and had public health insurance (56.8%). Perinatal homelessness was significantly associated with a lower prevalence of attending a postpartum maternal visit (aPR = 0.90; 95% CI, 0.87-0.94) and a higher prevalence of having a conversation about birth intervals with their health care providers (aPR = 1.13; 95% CI, 1.03-1.21).

CONCLUSIONS

Findings suggest that improving attendance at postpartum visits and evaluating birth interval conversations may strengthen interconception care practices while contextualizing social determinants such as housing stability. Improving uptake of postpartum visits may reduce unintended pregnancy, short birth intervals, and adverse birth outcomes in future pregnancies among women experiencing homelessness.

A socioecological perspective to contraceptive access for women experiencing homelessness in the United States

OBJECTIVE

Although persons who are pregnancy-capable and experiencing homelessness may have a strong desire to avoid pregnancy, they face unique barriers to contraception. This multimethod qualitative study aimed to identify preferences for, barriers to, and facilitators of contraceptive access and use among women experiencing homelessness in the United States using a systems perspective.

STUDY DESIGN

We conducted semistructured interviews with women experiencing homelessness (n = 19), healthcare providers (n = 6), and social service providers (n = 6). We recruited participants from community-based, housing, and medical organizations in North Texas in the United States. Two coders conducted thematic analysis and reached consensus for codes.

RESULTS

Women participants were in emergency shelter, unsheltered, or transitional/rapid rehousing. We stratified themes using the Socioecological Framework to illustrate factors affecting contraception access at individual, interpersonal, organizational and community, and societal levels. Notable results include women's preferences for long-acting reversible contraception, difficulties healthcare providers face in initiating contraceptive counseling, and the underutilized role of social service providers in reproductive healthcare. Insurance policies, connections between health clinics and community organizations, and organizational priorities both facilitated and hindered women experiencing homelessness's access to women's healthcare services.

CONCLUSION

This study identified opportunities throughout the healthcare and social service systems to support contraceptive access for women experiencing homelessness. Future interventions should strengthen and leverage these connections to promote access among this vulnerable population with the goal of supporting reproductive autonomy.

IMPLICATIONS

This study explored the reproductive health needs of women experiencing homelessness. Multilevel interventions, such as interdisciplinary care, patient-centered approaches, and an emphasis on health literacy, are needed to adequately provide the preferred methods of contraception for women experiencing homelessness, thus enabling reproductive autonomy for this population.

Social Determinant of Housing Instability and Adverse Pregnancy Outcomes: A Scoping Review

BACKGROUND

We conducted a scoping review to examine the literature regarding pregnancy-related morbidities among birthing individuals and infants experiencing housing instability (HI).

METHODS

Articles were identified through electronic database searches, using numerous search terms related to pregnancy and housing. US studies published in English between 1991 and 2019 were included. Peer-reviewed qualitative and quantitative articles were synthesized and critically appraised by 2 reviewers using quality appraisal tools from the Joanna Briggs Institute.

RESULTS

Inconsistent definitions for HI weakened the rigor of aggregate findings, and birthing individual outcomes were underreported compared with infant outcomes (n = 9 095 499 women, 11 articles). Many studies reported mental health-related outcomes among birthing individuals with HI.

DISCUSSION

Study sampling approaches and lack of a standard definition of HI limit review findings, but examining this relationship is critical to understanding the effect of social determinants on birthing individual health. Future research should address the nescience regarding birthing individual outcomes in this population. Policy-level advocacy addressing social determinants must also refine policy impacting community-based prenatal programs and services for the birthing individual with HI.

VULNERABILIDADE DE GESTANTES USUÁRIAS DE ÁLCOOL E OUTRAS DROGAS EM PRÉ-NATAL DE BAIXO RISCO

RESUMO Objetivo: verificar os contextos que potencializam as dimensões de vulnerabilidade individual, social e programática associadas ao uso de álcool e outras drogas durante a gravidez. Método: estudo qualitativo, descritivo e exploratório, com corte transversal. Participaram 38 gestantes usuárias álcool e outras drogas, em nível moderado e grave, em atendimento pré-natal de baixo risco na Atenção Primária à Saúde de dois municípios da Região Metropolitana de Maringá - Paraná. Os dados foram coletados de dezembro de 2019 a março de 2020. O referencial analítico da Vulnerabilidade pautou a discussão. Resultados: no plano individual, os contextos de vulnerabilidade eram questões de gênero, raça/cor parda e preta, baixa escolaridade, período reprodutivo e alta paridade. No plano social, a ausência de inserção no mercado de trabalho, renda familiar na linha da pobreza, relações intrafamiliares abusivas, comportamento aditivo na família e violência na comunidade de convivência. No plano programático encontraram-se baixa procura a serviços de saúde, ausência de acolhimento para o tratamento do uso de drogas, rastreio para o uso de drogas deficitário, baixo vínculo com as equipes da saúde da família, ausência de atendimento odontológico, psicológico e do serviço social, inserção no nível de assistência pré-natal inadequado, risco habitual, enquanto deveriam ter sido classificadas como alto risco, e média de consultas pré-natal abaixo do preconizado. Conclusão: o estudo permitiu avançar nos contextos de vulnerabilidade dessas gestantes. O (re)conhecimento destes contextos possibilita a formulação de estratégias de redução de danos e de agravos à saúde materno fetal relacionados ao uso de drogas durante a gravidez, conduzindo a um desfecho gestacional favorável.

VULNERABILITY OF PREGNANT WOMEN USING ALCOHOL AND OTHER DRUGS IN LOW-RISK PRENATAL CARE

ABSTRACT Objective: to verify the contexts that enhance the dimensions of individual, social, and programmatic vulnerability associated with the use of alcohol and other drugs during pregnancy. Method: qualitative, descriptive, and exploratory, cross-sectional study. Participants were 38 pregnant women who used alcohol and other drugs, at a moderate and severe level, in low-risk prenatal care in the Primary Health Care of two cities in the Metropolitan Region of Maringá - Paraná. Data was collected from, December 2019 to March 2020. The Vulnerability analytical framework guided the discussion. Results: at the individual level, the vulnerability contexts were issues of gender, brown and black ethnicity/color, low education, reproductive period, and high parity. At the social level, the lack of insertion in the job market, family income below the poverty line, abusive intra-family relationships, addictive behavior in the family, and violence in the living community. In the programmatic plan, there was a low demand for health services, lack of welcoming for the treatment of drug use, screening for deficient drug use, low bond with family health teams, absence of dental, psychological, and social services, insertion in the inadequate level of prenatal care, usual risk, while they should have been classified as high risk, and mean prenatal consultations below recommended. Conclusion: the study made it possible to advance in the contexts of the vulnerability of these pregnant women. Recognizing these contexts makes it possible to formulate strategies to reduce harm and damages to maternal and fetal health related to drug use during pregnancy, leading to a favorable gestational outcome.

The development and implementation of an advanced practice registered nurse-led prenatal education program for housing insecure women

ABSTRACT

Housing insecurity has been shown to have an impact on the health care system due to negative maternal and neonatal outcomes. Housing insecurity is associated with the social determinants of health under the umbrella of economic stability and neighborhood/physical environments. Research shows that educational programs and support resources can help alleviate this strain for women who are pregnant. This article discusses the development and implementation of an advanced practice registered nurse (APRN)-led, prenatal education group for women facing housing insecurity who are pregnant and high risk. The curriculum was revised and based on a March of Dimes Becoming a Mom with alignment to Maslow's Hierarchy of Needs. The 10-week prenatal education program was created and implemented by a group of APRNs and registered nurses to aid pregnant women facing housing insecurity with coping strategies and education regarding their pregnancy.