The United States is facing a crucial moment, one in which more pregnant women are at risk of becoming housing insecure than at any other time in recent history. This leaves an unprecedented number of mothers and babies vulnerable to the associated adverse health risks.  Housing instability – which includes challenges ranging from struggles paying rent to chronic homelessness – harms maternal and neonatal health as much as smoking during pregnancy. The economic effects of COVID-19 threaten to exacerbate the adverse health outcomes associated with homelessness.

Although this pregnancy risk factor may be less well-known, it affects a significant portion of the American population. In 2019, more than half a million Americans experienced homelessness every night. Of these, 30 percent were families with children. In addition, 4 percent of women in the United States reported experiencing homelessness in the 12 months before pregnancy. Even these figures do not capture the full picture. They do not account for the large number of Americans facing other forms of housing instability, including those spending a majority of household income on housing, experiencing overcrowding, or living in low-quality housing. These issues have become more prominent during the COVID-19 pandemic, placing even more mothers and babies at risk.

Housing Instability and Maternal and Infant Health

A growing body of research indicates that housing instability during pregnancy is associated with a wide range of adverse maternal and infant health outcomes, including low-birth weight and pre-term birth. These associations are significant. One study found that unstably-housed women had 20 percent higher chances of experiencing preterm birth than their stably housed peers. Prenatal housing instability has also been linked to increased risk for maternal hypertension, anemia, and hemorrhage during pregnancy.

Housing instability during the prenatal period is also linked to higher levels of health care utilization. In one analysis, unstably housed women were 60 percent more likely to have a long hospitalization stay after delivery and 170 percent more likely to visit the emergency room within three months of giving birth. Another analysis found that this group of women visited the emergency room at rates 17 percent higher than their stably housed peers.

These adverse health outcomes have steep economic costs. In fact, the costs of these adverse health outcomes far outweigh the cost of addressing housing instability during pregnancy. The average cost for one day of inpatient care is $2,424, and the average cost of hospitalization for a premature or low birthweight infant is a staggering $55,393. In contrast, the average cost of housing is $1,375 per month.

Pathways Connecting Housing and Health

These negative outcomes are the result of a variety of factors that place housing-unstable mothers at heightened risk. Some of these effects are directly due to living on the street, with greater exposure to violence and increased levels of stress. Others are associated with difficulties accessing prenatal care. Although pregnant women in the United States are eligible to receive health insurance through Medicaid, many women struggle to receive routine care. For example, lack of transportation to appointments and frequent or sudden relocation may disrupt continuity of care. Additionally, women are guaranteed Medicaid eligibility for only 60 days post-partum. Meanwhile, at least one-third of maternal deaths occur in the year after birth.

Finally, housing unstable women are more likely to be affected by other socioeconomic factors that negatively impact health. They are more likely to be low-income, to be food insecure, and to have fewer social supports. In addition, in the United States, rates of homelessness are significantly higher among communities of color. This means that women experiencing housing instability are more likely to face barriers to health care access related to structural racism. They are also more likely to experience direct negative health effects of racism through “weathering,” whereby the persistently high stress levels associated with socioeconomic disadvantages lead to adverse physiological effects and worse health outcomes among marginalized groups.

Nevertheless, the above pathways do not fully explain the relationship between housing and health. Disparities in health outcomes and health care utilization remain even when potential mediating factors (such as access to prenatal care, income level, and mental health or substance use disorders) are taken into account. Prenatal homelessness, it seems, is not merely a marker of other socioeconomic characteristics that negatively impact maternal and infant health. Prenatal homelessness is itself a “unique” risk factor. Attempts to improve maternal health that do not take housing instability into account will thus be incomplete.

The Impact of COVID-19

The economic effects of the pandemic, including increased unemployment rates, are forcing more Americans to face housing instability, as many struggle to make their rent and mortgage payments. Some 13.4 million adults—nearly 1 in 5 renters in the United States—were not caught up on rent payments as of November 2020. Renters of color and renters with children, have been particularly hard hit. This has resulted in an eviction crisis, leaving an unprecedented 30-40 million Americans at risk of eviction.

In addition to increasing the number of individuals affected by unstable housing, the pandemic is also increasing the health dangers associated with housing insecurity. Housing-insecure individuals now also face the risk of contracting COVID-19, which spreads more easily in crowded settings. This impacts individuals utilizing formal emergency shelters as well as those couch-surfing or “doubling up.” Although these more informal instances of residential crowding may seem insignificant, they can have serious consequences for the spread of COVID-19. Adding just two members to a household has been shown to double the risk of other illness for occupants. During the 1918 influenza epidemic, a decrease of just 33 square feet of living space per person was associated with a tenfold increase in the rate of illness.

Considering that pregnant women face a high risk for serious COVID-19 complications, the housing crisis created by the pandemic presents an even greater threat to the health of mother and child. Furthermore, as demand for housing assistance and danger of housing insecurity are increasing, traditional resources are being stretched thin. For example, many emergency shelters have been forced to reduce their capacity to enable social distancing.

Implications for Public Health Policy Strategy

Due to the connections between housing and health, addressing housing instability is an essential part of any effective public health strategy. The COVID-19 relief bill passed by Congress in December allays immediate concerns. However, the $25 billion in rental assistance it provides is not nearly enough to cover the estimated $34 billion owed in back rent, and as many as 20 million Americans may be at risk of eviction when the moratorium expires in January 2021.  Experts are calling on policymakers to further extend the federal eviction moratorium and to craft more comprehensive legislation addressing the full scope of American’s financial and housing needs.

We must also extend our view beyond COVID-19, incorporating housing concerns into long-term public health plans. For example, the Black Maternal Health Momnibus Act of 2020 (Momnibus), sponsored by Representative Lauren Underwood (D-IL), calls for the creation of a “Housing for Moms” taskforce to ensure that women in the perinatal and postpartum period have access to “safe, stable, affordable, and adequate housing.”

Maternal health is more than a mere amalgamation of biological causes, symptoms, and interventions. It is intimately connected to a pregnant person’s broader societal context, which affects their health and ability to be healthy. Acknowledging housing’s role in this broader context and tailoring our maternal health policies accordingly is crucial to securing the well-being of mothers and infants across the United States, saving dollars and lives for generations to come.