Epidemiology Research InternationalVolume 2011 (2011), Article ID 467265, 10 pagesdoi:10.1155/2011/467265

Research Article

Prenatal Maternal Stress and Physical Abuse among Homeless Women and Infant Health Outcomes in the United States

Ray M. Merrill,¹ Rickelle Richards,² and Arielle Sloan¹

¹Department of Health Science, College of Life Sciences, Brigham Young University, 229-A RB, Provo, UT 84602, USA²Department of Nutrition, Dietetics, & Food Science, College of Life Sciences, Brigham Young University, S-233 ESC, Provo, UT 84602, USA

Received 27 November 2010; Accepted 26 February 2011

Academic Editor: Kenji Wakai

Copyright © 2011 Ray M. Merrill et al. Ray M. Merrill et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract.

Background. This study examines whether the relationship between maternal stress or abuse situations and infant birth weight differs between homeless and non-homeless women. Methods. Analyses are based on data from the Pregnancy Risk Assessment Monitoring System (PRAMS), 2002–2007. Results. Homeless women were significantly more likely to experience stressful life events, abusive situations, and poor maternal health than non-homeless women during pregnancy. Birth weight among infants of homeless women was, on average, 17.4 grams lighter than for infants of non-homeless women, after adjusting for maternal age, race, ethnicity, region, education, and marital status. The impact of maternal health, stress, and abuse variables on pregnancy and infant birth weight significantly interacted with homeless status. For example, vaginal bleeding, nausea, kidney/bladder infection, and failure to receive early prenatal care had significantly larger negative impacts on birth weight among homeless women than non-homeless women. Infant birth weight was consistently lower among homeless women, more so when maternal stress and abuse were involved, across all classifications of their prepregnancy weight. Conclusion. Stress and abusive situations among pregnant women have a negative influence on pregnancy-related conditions and infant birth weight. However, this negative influence is even more pronounced among homeless women.

1. Introduction

The scientific literature shows a consistent association between homelessness and stressful life events, especially among women [1–4]. The lower socioeconomic status experienced by many homeless women has been shown to be a major determinant of stressful life events [5]. Research has also shown that pregnant homeless women are exposed to more violence and abuse than their low-income, non-homeless counterparts [6]. Results from one case-control study in Worcester, Massachusetts showed that homeless mothers were more likely to experience severe sexual and physical assault than low-income housed mothers [7]. The same study also showed that homeless mothers had smaller social networks and experienced increased residential instability [7]. In a New Hampshire case-control study comparing homeless mothers with low-income housed mothers, homeless mothers were significantly more likely to report higher levels of stress and depression [8]. Stress and abuse are therefore associated with homelessness in women.

Prenatal maternal stress and physical abuse have been shown to negatively influence pregnancy outcomes [9–13]. Researchers from the University of California found that women with higher self-reported levels of stress and anxiety were significantly more likely to deliver low birth weight and preterm children [10]. A similar prospective study from London found that self-reported depression or “high nerves” in pregnant mothers was associated with low birth weight [11]. Physical violence from an intimate partner has also been linked to antepartum hemorrhage, intrauterine growth restriction, and perinatal death in the fetus [12]. Partner abuse during pregnancy increases the risk of stress and is associated with a host of risk behaviors like smoking or using drugs, which further increase the chance of preterm or low birth weight infants [13]. In addition, women experiencing partner abuse are less likely to obtain prenatal care [13]. Hence, such pregnancy-related outcomes are linked to stress and abuse experienced by the mother.

Research has shown adverse birth outcomes related to homelessness, including low birth weight and premature infants, which are strong risk factors for infant mortality and developmental disabilities [14–16]. However, to our knowledge, no study has considered the modifying effect of homelessness on the relationship between maternal psychological stress and physical abuse and infant birth weight. In the current study, we examine whether the relationship between maternal stress/abuse and infant birth weight differs between homeless and non-homeless women.

2. Methods

Analyses were based on data from 31 areas in the United States participating in the Pregnancy Risk Assessment Monitoring System (PRAMS), 2000–2007. Of 272,859 women who completed the PRAMS survey during these years, approximately 1% did not have information on homeless status. These women were dropped from the current study, leaving 268,876 for assessment.

2.1. PRAMS Weighting Process

Because PRAMS areas typically oversample low weight births and stratify by the mother’s race and ethnicity, the three weighting variables provided in the PRAMS data file (sampling weight, non-response weight, and non-coverage weight) were used. These weights are described in detail elsewhere [17]. The product of the three components of the weights produces the analysis weight, which is interpreted as the number of women like themselves in the population that each respondent represents. Weighted estimates were calculated to obtain a representation of all women who gave birth in each state during the specified years. Statistical evaluation of the PRAMS data involved statistical software that takes into account the complex sampling design (i.e., complex survey modules of SAS).

2.2. Study Variables

Homeless status was based on responses to the following: “This question is about things that may have happened during the 12 months before your new baby was bornI was homeless.” Demographic variables considered in this study were maternal age, race, ethnicity, US geographical region, maternal education, and marital status. Pregnancy- and morbidity-related variables include tobacco smoking and alcohol use, previous live birth, previous low birth weight, previous premature birth, prenatal care, preterm labor, vaginal bleeding, nausea, and kidney/bladder infection. Body Mass Index (BMI) is derived from self-reported height and weight questions: “Just before you got pregnant, how much did you weigh?” and “How tall are you without shoes?” BMI was classified as underweight (<18.5), normal weight (18.5–24.9), overweight (25–29.9), class I & II obesity (30–39.9), and class III obesity (≥40). Several psychological stress and physical abuse variables obtained in the originally requested data set were considered. Psychological stress variables included the following stressors: a family member’s illness, being divorced or separated, moving to a new address, having a partner lose their job, the survey respondent losing their job, arguing with their partner more than usual, the respondent’s partner not wanting the pregnancy, being unable to pay bills, the survey respondent being in a physical fight, the survey respondent or their partner going to jail, having someone close to the respondent with drug or alcohol problems, and having someone close to them die. Four physical abuse variables were considered: abuse before pregnancy from a partner, abuse before pregnancy from someone other than a partner, abuse during pregnancy from a partner, and abuse during pregnancy from someone other than a partner. Physical abuse was defined on the PRAMS survey as being pushed, hit, slapped, kicked, choked or physically hurt in any other way by their partner.

2.3. Statistical Techniques

Bivariate analyses were performed between homeless status and selected demographic, pregnancy and morbidity, BMI, stress, and abuse variables. Relationships were assessed for significance using the Rao-Scott chi-square test. Average infant birth weight was compared between homeless and non-homeless women using analysis of variance, adjusted for maternal age, race, ethnicity, marital status, education, area, stress, and abuse variables. Logistic regression models were calculated, regressing homeless status on the demographic, pregnancy and morbidity, BMI, stress, and abuse variables. Odds ratios obtained from logistic regression were adjusted for maternal age, race, ethnicity, marital status, education, and geographical region. Poststratification weights, described above, were applied to obtain representative population-based estimates of all homeless women giving birth in the PRAMS geographic areas. Ninety-five percent confidence intervals were calculated, and two-sided tests of significance were used, based on the 0.05 level. Statistical analyses were derived using complex survey modules in Statistical Analysis System (SAS) software, version 9.2 (SAS Institute Inc., Cary, NC, USA, 2007).

3. Results

The estimated number of births in the PRAMS areas for the specified years is presented in Table 1. The percentage of homeless women giving birth varied from 2 to 7. Overall, 4% of women who completed the PRAMS survey were homeless.

Table 1: Estimated number of births among women in each PRAMS city/state by US geographic area.

PRAMS Participants
Homeless*

PRAMS Area
Years
No.
No.†
No.†
%†

East

    Maine
2000–2007
8,075
91,889
2,799
3

    Maryland
2000–2007
9,102
374,184
14,328
4

    New Jersey
2002–2007
9,487
472,135
21,285
5

    New York
2000–2007
7,742
775,927
25,667
3

    New York City
2004–2007
3,228
250,392
11,073
4

    Rhode Island
2002–2007
7,100
59,338
2,488
4

    Vermont‡
2000–2006
7,038
39,451
1,214
3

    West Virginia
2000–2007
10,473
117,916
2,441
2

    Total

62,245
2,181,232
81,295
4

Midwest

    Illinois
2000–2006
11,069
1,029,850
69,918
7

    Michigan
2001–2006
6,531
560,904
12,784
2

    Minnesota
2002–2007
7,576
313,618
10,648
3

    Montana
2002
1,032
10,614
392
4

    Nebraska
2000–2006
11,696
148,774
5,774
4

    North Dakota
2002
903
7,298
121
2

    Ohio
2000–2007
8,881
862,379
21,057
2

    Oklahoma
2000–2007
13,271
338,138
15,108
4

    Total

60,959
3,271,575
135,802
4

South

    Alabama
2000–2004
6,147
228,313
5,595
2

    Arkansas
2000–2007
13,961
247,649
11,041
4

    Florida
2000–2006
12,086
1,226,157
60,965
5

    Georgia
2004–2006
3,333
256,221
10,387
4

    Louisiana
2000–2005
9,559
314,628
7,522
2

    Mississippi
2003–2007
3,800
105,416
2,612
2

    North Carolina
2000–2006
8,922
641,136
28,474
4

    South Carolina
2000–2007
9,925
335,517
7,036
2

    Total

67,733
3,355,037
133,632
4

West

    Alaska
2000–2007
10,298
68,816
2,737
4

    Colorado
2000–2007
14,681
461,811
23,877
5

    Hawaii
2000–2007
14,032
121,419
2,500
2

    New Mexico
2000–2006
8,662
147,033
7,367
5

    Oregon
2003–2007
7,144
176,142
11,277
6

    Utah
2000–2007
12,539
339,454
11,227
3

    Washington
2000–2007
10,583
548,739
31,814
6

    Total

77,939
1,977,272
90,799
5

Total

268,876
10,671,258
441,528
4

PRAMS: Pregnancy Risk Assessment Monitoring System. *Homeless within past 12 months. †Estimates were weighted to be representative of all women who gave birth in each state during the specified years. ‡Only data from October through December was available for 2000 in Vermont.

Homeless status is presented for selected pregnancy and morbidity variables in Table 2. Homeless women were significantly more likely to have previously given birth, to have a previous low birth weight child or to have a premature birth, to experience preterm labor, to have vaginal bleeding, nausea, and kidney/bladder infection, and to not receive prenatal care as early as wanted.

Table 2: Homeless status according to selected pregnancy and morbidity variables among women completing the PRAMS survey in 31 participating cities/states, 2000–2007.

Homeless
Non-homeless

Homeless versus Non-homeless

No.*
%*
No.*
%*
P value†
Odds Ratio‡
95% CI‡

Previous live birth

    Yes
271,724
64
5,882,289
58
<.001
1.00

    No
156,161
36
4,253,935
42

0.69
0.64–0.74

Previous low birth weightδ

    Yes
53,707
21
591,493
10
<.001
1.00

    No
203,297
79
5,047,475
90

0.59
0.52–0.65

Previous premature birthδ

    Yes
41,539
16
4,976,926
12
<.001
1.00

    No
221,018
84
668,761
88

0.80
0.71–0.90

Prenatal care early as wanted

    Yes
298,052
69
8,371,517
82
<.001
1.00

    No
131,279
30
1,731,623
17

1.76
1.63–1.90

    Did not want
4,715
1
45,170
1

2.53
1.82–3.52

Preterm labor

    Yes
132,731
31
2,545,315
25
<.001
1.00

    No
300,730
69
7,615,461
75

0.73
0.68–0.79

Vaginal bleeding

    Yes
72,666
17
1,588,901
16
.033
1.00

    No
357,266
83
8,558,210
84

0.86
0.78–0.83

Nausea

    Yes
163,993
38
2,809,289
28
<.001
1.00

    No
268,307
62
7,352,693
72

0.70
0.66–0.75

Kidney/bladder infection

    Yes
122,303
28
1,813,790
18
<.001
1.00

    No
310,854
72
8,336,483
82

0.63
0.58–0.68

Note: Of the 31 Pregnancy Risk Assessment Monitoring System (PRAMS) cities/states Montana and Vermont did not collect information on ethnicity. *Estimates were weighted to represent all homeless women who gave birth. †Based on the Rao-Scott chi-square. ‡Based on weighted data, with the estimated odds ratios and 95% confidence intervals adjusted for maternal age, race, ethnicity, marital status, and region. δLimited to those with a previous live birth.

Homeless status is presented according to selected stressful life events in Table 3. Each stressful event was significantly greater among homeless women. Homeless women were significantly more likely to have an ill family member, to experience divorce or separation, to move to a new address, to lose their job or to have a partner who lost a job, to argue more than usual with a partner, to have a partner who did not want the pregnancy, to be unable to pay bills, to have been in a physical fight, to go to jail or to have a partner who went to jail, to have someone else close to them with drug or alcohol problems, and to have someone close to them that had died.

Table 3: Homeless status according to selected stress variables among women completing the PRAMS survey in 31-participating cities/states, 2000–2007.

Homeless
Non-homeless

Homeless versus Non-homeless

Stress because
No.*
%*
No.*
%*
P value†
Odds ratio‡
95% CI‡

Family member ill

    Yes
109,608
25
2,614,848
26
.492
1.00

    No
326,797
75
7,591,618
74

0.82
0.76–0.89

Divorce

    Yes
128,954
30
899,462
9
<.001
1.00

    No
307,120
70
9,313,874
91

0.29
0.27–0.32

Moved

    Yes
277,698
64
3,559,225
35
<.001
1.00

    No
159,223
36
6,659,451
65

0.31
0.29–0.33

Partner lost job

    Yes
133,001
31
1,259,603
12
<.001
1.00

    No
296,101
69
8,931,838
88

0.35
0.33–0.38

Lost job

    Yes
144,256
34
1,023,845
10
<.001
1.00

    No
281,662
66
9,170,578
90

0.30
0.28–0.32

Argument with partner

    Yes
186,504
43
2,762,782
27
<.001
1.00

    No
249,447
57
7,436,843
73

0.54
0.50–0.58

Partner did not want pregnancy

    Yes
95,989
22
889,597
9
<.001
1.00

    No
338,051
78
9,315,897
91

0.40
0.37–0.44

Bills you could not pay

    Yes
207,260
47
2,459,949
24
<.001
1.00

    No
229,239
53
7,740,287
76

0.40
0.37–0.42

In fight

    Yes
80,257
18
404,808
4
<.001
1.00

    No
355,058
82
9,792,609
96

0.20
0.18–0.22

Partner went to jail

    Yes
74,502
17
433,255
4
<.001
1.00

    No
362,923
83
9,775,152
96

0.23
0.20–0.25

Drugs

    Yes
116,998
27
1,248,539
12
<.001
1.00

    No
320,583
73
8,966,179
88

0.35
0.33–0.38

Someone close died

    Yes
106,017
24
1,859,160
18
<.001
1.00

    No
331,592
76
8,348,188
82

0.68
0.62–0.73

Note: Of the 31 Pregnancy Risk Assessment Monitoring System (PRAMS) cities/states Montana and Vermont did not collect information on ethnicity. *Estimates were weighted to represent all homeless women who gave birth. †Based on the Rao-Scott chi-square. ‡Based on weighted data, with the estimated odds ratios and 95% confidence intervals adjusted for maternal age, race, ethnicity, marital status, and region.

Homeless status is presented according to selected abuse variables in Table 4. Homeless women were significantly more likely to experience physical abuse. Abuse from a partner or anyone else before or during pregnancy was about 4 to 6 times greater among homeless women.

Table 4: Homeless status according to selected physical abuse variables among women completing the PRAMS survey in 31-participating cities/states, 2000–2007.

Homeless
Non-homeless

Homeless versus Non-homeless

No.*
%*
No.*
%*
P value†
Odds ratio‡
95% CI‡

Physical abuse before pregnancy—Husband

    Yes
65,648
15
378,206
4
<.001
1.00

    No
368,886
85
9,773,874
96

0.25
0.23–0.28

Physical abuse before pregnancy—Anyone else

    Yes
26,871
9
122,456
2
<.001
1.00

    No
261,745
91
6,054,159
98

0.22
0.19–0.26

Physical abuse during pregnancy—Husbandδ

    Yes
53,196
12
291,961
3
<.001
1.00

    No
380,775
88
9,855,224
97

0.26
0.23–0.30

Physical abuse during pregnancy—Anyone elseδ

    Yes
18,313
6
82,855
1
<.001
1.00

    No
269,532
94
6,089,211
99

0.24
0.23–0.30

Note: Of the 31 Pregnancy Risk Assessment Monitoring System (PRAMS) cities/states Montana and Vermont did not collect information on ethnicity. *Estimates were weighted to represent all homeless women who gave birth. †Based on the Rao-Scott chi-square. ‡Based on weighted data, with the estimated odds ratios and 95% confidence intervals adjusted for maternal age, race, ethnicity, marital status, and region. δOf the 31 PRAMS cities/states, Oregon and New York City did not collect information on these variables.

Birth weight is presented by homeless status in Table 5. Birth weight among infants to homeless women was an average of 17.4 grams lighter than for infants of non-homeless women, after adjusting for maternal age, race, ethnicity, region, education, and marital status. Birth weight according to pregnancy and health variables and stress and abuse variables tend to significantly interact with homeless status (Table 6). For example, infant birth weight was greater among women with a previous live birth, but significantly more so among non-homeless women. A similar result is observed for previous low birth weight, previous premature birth, and preterm labor. Vaginal bleeding, nausea, kidney/bladder infection, and failure to receive early prenatal care had significantly larger negative impacts on birth weight among homeless women compared with non-homeless women. Infant birth weight was consistently lower among homeless women across all classifications of their pre-pregnancy weight. Finally, experiencing stress or abuse among homeless women compared with non-homeless women tended to have a much more negative impact on infant birth weight.

Table 5: Birth weight (grams) according to homeless status and other selected demographic variables among women completing the PRAMS survey in 31 participating cities/states, 2000–2007.

Weight (Grams)
P value†

Estimate*
SE*

Homeless

    Yes
0.00

    No
17.37
1.01
<.001

Demographics

Maternal Age, years

    <19
0.00

    19–25
32.04
0.91
<.001

    26–29
60.77
0.97
<.001

    ≥30
64.51
0.94
<.001

Race

    Caucasian
0.00

    African American
−201.11
0.43
<.001

    Other
−74.01
0.82
<.001

Ethnicity

    non-hispanic
0.00

    Hispanic
−4.71
0.49
<.001

    Missing
−12.95
0.47
<.001

Region

    East
0.00

    Midwest
−1.86
0.52
<.001

    South
−31.13
0.07
<.001

    West
−20.23
0.09
<.001

Maternal education, years

    <12
0.00

    12
38.05
0.61
<.001

    >12
72.47
0.62
<.001

    Missing
−2.97
1.35
.028

Marital status

    Yes
0.00

    No
−68.82
6.31
<.001

    Missing
−19.46
0.47
.002

PRAMS: Pregnancy Risk Assessment Monitoring System. *Estimates were weighted to represent all homeless women who gave birth, and each variable estimate was adjusted for the other variables in the table. †Based on the F statistic.

Table 6: Birth weight (grams) according to homeless status, pregnancy and health variables, and stress and abuse variables among women completing the PRAMS survey in 31 participating cities/states, 2000–2007.

Homeless

Non-homeless

Interaction

Estimate*
SE*
P value†
Estimate*
SE*
P value†
P value

Pregnancy and health

Previous live birth

    Yes
0.00

0.00

<.001

    No
−42.14
2.24
<.001
−95.87
−0.37
<.001

Previous low birth weight

    Yes
0.00

0.00

<.001

    No
279.61
2.52
<.001
359.66
0.72
<.001

Previous premature birth

    Yes
0.00

0.00

.004

    No
313.95
2.90
<.001
321.59
0.78
<.001

Prenatal care early

    Yes
0.00

0.00

<.001

    No
−44.82
2.50
<.001
−20.08
0.52
<.001

    Did not want
−212.37
2.75
<.001
−85.61
2.60
<.001

Preterm labor

    Yes
1.00

1.00

.114

    No
234.10
2.40
<.001
240.93
0.43
<.001

Vaginal bleeding

    Yes
0.00

0.00

<.001

    No
189.46
2.97
<.001
166.72
0.50
<.001

Nausea

    Yes
0.00

0.00

<.001

    No
70.81
2.07
<.001
55.95
0.41
<.001

Kidney/bladder infection

    Yes
0.00

0.00

<.001

    No
55.66
2.43
<.001
37.32
0.52
<.001

Pre-pregnancy BMI (kg/m²)

    Underweight
0.00

0.00

<.001

    Normal weight
59.32
4.82
<.001
141.74
0.84
<.001

    Overweight
147.42
5.03
<.001
215.65
0.89
<.001

    Class I & II obesity
176.82
5.39
<.001
233.36
0.94
<.001

    Class III obesity
192.42
6.44
<.001
259.52
1.33
<.001

    Missing
90.16
5.04
<.001
192.53
1.12
<.001

Stress

Family member ill

    Yes
0.00

0.00

<.001

    No
27.23
2.55
<.001
8.79
0.41
<.001

Divorce

    Yes
0.00

0.00

<.001

    No
6.97
2.50
.005
30.11
0.75
<.001

Moved

    Yes
0.00

0.00

<.001

    No
2.95
1.90
0.120
6.74
0.39
<.001

Partner lost job

    Yes
0.00

0.00

<.001

    No
17.94
2.43
<.001
8.99
0.57
<.001

Lost job

    Yes
0.00

0.00

.090

    No
17.83
2.19
<.001
26.23
0.60
<.001

Argument with partner

    Yes
0.00

0.00

<.001

    No
33.65
2.33
<.001
13.92
0.42
<.001

Partner did not want pregnancy

    Yes
0.00

0.00

<.001

    No
25.02
2.62
<.001
8.82
0.67
<.001

Bills you could not pay

    Yes
0.00

0.00

<.001

    No
16.25
2.00
<.001
22.19
0.44
<.001

In fight

    Yes
0.00

0.00

<.001

    No
55.67
3.48
<.001
43.34
1.03
<.001

Partner went to jail

    Yes
0.00

0.00

<.001

    No
58.06
3.45
<.001
27.28
1.03
<.001

Drugs

    Yes
0.00

0.00

<.001

    No
75.80
2.89
<.001
18.13
0.60
<.001

Someone close died

    Yes
0.00

0.00

<.001

    No
−4.22
2.37
.075
24.78
0.47
<.001

Abuse

Abuse before pregnancy—Husband

    Yes
0.00

0.00

    No
41.83
3.92
<.001
30.33
1.08
<.001
.065

Abuse before pregnancy—Anyone else

    Yes
0.00

0.00

<.001

    No
6.84
0.44
<.001
29.77
0.10
<.001

PRAMS: Pregnancy Risk Assessment Monitoring System. *Estimates were weighted to represent all homeless women who gave birth and each variable estimate was adjusted for maternal age, race, ethnicity, region, maternal education, and marital status. †Based on the F statistic.

4. Discussion

The current study showed the regional variation in homelessness and confirms other studies in showing that homelessness is related to poorer pregnancy and health outcomes, stressful life events, and abusive conditions [7, 8]. In addition, as in other studies, lower birth weight was associated with homelessness [9].

This study goes beyond previous studies by evaluating how stress and abuse are related to pregnancy and health outcomes based on homeless status. In this study, homelessness modified the effect of maternal pregnancy practices and outcomes, as well as stressful and abusive life events on infant birth weight. The overall lower infant birth weight and preterm birth among homeless women as compared with non-homeless women was also reported in a Canadian prospective cohort study by Little et al. [16]. The modifying impact of homelessness on adverse maternal health and infant birth weight in our study may have been due to the severity of adverse health circumstances reported by homeless women, such as vaginal bleeding, kidney disease, and nausea. Studies have found that homeless women engage more frequently in risky health behaviors, such as smoking, and experience more barriers to prenatal care, including cost and location; such correlations may contribute to the modifying effect of homelessness on poor maternal health and child outcomes [7, 8, 18].

Likewise, the degree of abuse and stress experienced by homeless women may have contributed to findings that homeless women who reported such symptoms were more likely to have low birth weight children than housed women. Studies have shown that homeless women are more likely to experience stress and violence than housed women [6, 8]. Sexual violence or prostitution in particular could have played a role in unwanted pregnancies and poor maternal health behaviors, such as increased smoking or drinking, which in turn could lead to lower birth weight children. In addition, a study by Stein et al. shows that adverse child health outcomes are seen more frequently in mothers whose homeless situation is more prolonged or severe during pregnancy [14]. Due to the effect of homelessness on stress and abuse, it is not surprising that homeless women in our study who reported these factors were more likely to have more serious health problems than housed women who reported similar circumstances.

This research presents new insight into the prevalence of maternal pregnancy and health conditions, stress, and abuse among homeless women in the United States by identifying the modifying effect of homelessness. The results provide public health professionals with pertinent information about this high-risk population and what measures can be undertaken to improve conditions for pregnant homeless women. It can also serve as an impetus for policy-level recommendations regarding public health programs and practices for pregnant women experiencing homelessness within the United States.

The researchers recognize some limitations related to this study. Based on the homelessness question presented on the PRAMS survey, the duration (e.g., number of weeks, months) of homelessness and whether the mother was still experiencing homelessness at the time of survey administration cannot be determined. In addition, the questions related to stress and to abuse failed to measure the duration of experiencing these factors. Some additional limitations include the self-reported and retrospective nature of the PRAMS data and that there was not information on whether homeless women resided in shelters, with family or friends, or on the street.

5. Conclusion

Homeless women are more likely to previously have experienced a low birth weight child, preterm labor, vaginal bleeding, nausea, and kidney/bladder infection, and less likely to have received early prenatal care. In addition, stressful life events and abusive relationships are more common in homeless women. Infant birth weight among homeless women is, on average, 17.4 grams lighter than in non-homeless women. The negative impact of selected pregnancy and morbidity variables (previous low birth weight, premature birth and preterm labor, receipt of early prenatal care, vaginal bleeding, nausea, kidney/bladder infection) and stress or abuse variables on infant birth weight tended to be significantly greater among homeless women.

Declaration of Interest

The authors have nothing to report.

Acknowledgments

PRAMS Working Group: Alabama—Albert Woolbright, PhD; Alaska—Kathy Perham-Hester, MS, MPH; Arkansas—Mary McGehee, PhD; Colorado—Alyson Shupe, PhD; Delaware—George Yocher, MS; Florida—Marie Bailey, MA, MSW, MPH; Georgia—Carol Hoban, Ph.D, MS, MPH; Hawaii—Mark Eshima, MA; Illinois—Theresa Sandidge, MA; Louisiana—Joan Wightkin; Maine—Tom Patenaude; Maryland—Diana Cheng, MD; Massachusetts—Hafsatou Diop, MD, MPH; Michigan—Violanda Grigorescu, MD, MSPH; Minnesota—Judy Punyko, PhD, MPH; Mississippi—Marilyn Jones, M.Ed; Missouri—Venkata Garikapaty, MSc, MS, PhD, MPH; Montana—JoAnn Dotson; Nebraska—Brenda Coufal; New Jersey—Lakota Kruse, MD; New Mexico—Eirian Coronado, MPH; New York State—Anne Radigan-Garcia; New York City—Candace Mulready-Ward, MPH; North Carolina—Paul Buescher, PhD; North Dakota—Sandra Anseth; Ohio—Connie Geidenberger; Oklahoma—Alicia Lincoln, MSW, MSPH; Oregon—Kenneth Rosenberg, MD; Pennsylvania—Tony Norwood; Rhode Island—Sam Viner-Brown, PhD; South Carolina—Mike Smith; South Dakota Tribal—Christine Rinki, MPH; Texas—Kate Sullivan, PhD; Tennessee—David Law, PhD; Utah—Laurie Baksh; Vermont—Peggy Brozicevic; Virginia—Marilyn Wenner; Washington—Linda Lohdefinck; West Virginia—Melissa Baker, MA; Wisconsin—Katherine Kvale, PhD; Wyoming—Angi Crotsenberg; CDC PRAMS Team, Applied Sciences Branch, Division of Reproductive Health.

References

S. P. Thrasher and C. T. Mowbray, “A strengths perspective: an ethnographic study of homeless women with children,” Health & social work, vol. 20, no. 2, pp. 93–101, 1995.

L. Goodman, L. Saxe, and M. Harvey, “Homelessness as psychological trauma: broadening perspectives,” American Psychologist, vol. 46, no. 11, pp. 1219–1225, 1991.

K. M. Taylor and L. Sharpe, “Trauma and post-traumatic stress disorder among homeless adults in Sydney,” Australian and New Zealand Journal of Psychiatry, vol. 42, no. 3, pp. 206–213, 2008.

M. V. Gwadz, D. Nish, N. R. Leonard, and S. M. Strauss, “Gender differences in traumatic events and rates of post-traumatic stress disorder among homeless youth,” Jounral of Adolescence, vol. 30, no. 1, pp. 117–129, 1991.

N. S. Whitehead, D. J. Brogan, C. Blackmore-Prince, and H. A. Hill, “Correlates of experiencing life events just before or during pregnancy,” Journal of Psychosomatic Obstetrics and Gynecology, vol. 24, no. 2, pp. 77–86, 2003.

L. C. Robrecht and D. G. Anderson, “Interpersonal violence and the pregnant homeless woman,” Journal of Obstetric, Gynecologic, and Neonatal Nursing, vol. 27, no. 6, pp. 684–691, 1998.

E. L. Bassuk, L. F. Weinreb, J. C. Buckner, A. Browne, A. Salomon, and S. S. Bassuk, “The characteristics and needs of sheltered homeless and low-income housed mothers,” Journal of the American Medical Association, vol. 276, no. 8, pp. 640–646, 1996.

V. L. Banyard and S. A. Graham-Bermann, “Surviving poverty: stress and coping in the lives of housed and homeless mothers,” American Journal of Orthopsychiatry, vol. 68, no. 3, pp. 479–489, 1998.

J. R. Ashdown-Lambert, “A review of low birth weight: predictors, precursors and morbidity outcomes,” Journal of The Royal Society for the Promotion of Health, vol. 125, no. 2, pp. 76–83, 2005.

P. D. Wadhwa, C. A. Sandman, M. Porto, C. Dunkel-Schetter, and T. J. Garite, “The association between prenatal stress and infant birth weight and gestational age at birth: a prospective investigation,” American Journal of Obstetrics and Gynecology, vol. 169, no. 4, pp. 858–865, 1993.

J. L. Peacock, J. M. Bland, and H. R. Anderson, “Preterm delivery: effects of socioeconomic factors, psychological stress, smoking, alcohol, and caffeine,” British Medical Journal, vol. 311, no. 7004, pp. 531–536, 1995.

P. A. Janssen, V. L. Holt, N. K. Sugg, I. Emanuel, C. M. Critchlow, and A. D. Henderson, “Intimate partner violence and adverse pregnancy outcomes: a population-based study,” American Journal of Obstetrics and Gynecology, vol. 188, no. 5, pp. 1341–1347, 2003.

L. R. Chambliss, “Intimate partner violence and its implication for pregnancy,” Clinical Obstetrics and Gynecology, vol. 51, no. 2, pp. 385–397, 2008.

J. A. Stein, M. C. Lu, and L. Gelberg, “Severity of homelessness and adverse birth outcomes,” Health Psychology, vol. 19, no. 6, pp. 524–534, 2000.

E. L. Bassuk and L. Weinreb, “Homeless pregnant women: two generations at risk,” American Journal of Orthopsychiatry, vol. 63, no. 3, pp. 348–357, 1993.

M. Little, R. Shah, M. J. Vermeulen, A. Gorman, D. Dzendoletas, and J. G. Ray, “Adverse perinatal outcomes associated with homelessness and substance use in pregnancy,” Canadian Medical Association Journal, vol. 173, no. 6, pp. 615–618, 2005.

Centers for Disease Control and Prevention, “Detailed PRAMS Methodology,” July 2009, http://www.cdc.gov/PRAMS/methodology.htm.

K. C. Bloom, M. S. Bednarzyk, D. L. Devitt, R. A. Renault, V. Teaman, and D. M. Van Loock, “Barriers to prenatal care for homeless pregnant women,” Journal of Obstetric, Gynecologic, and Neonatal Nursing, vol. 33, no. 4, pp. 428–435, 2004.