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ImportanceUnhoused status is a substantial problem in the US. Pregnancy characteristics and maternal outcomes of individuals experiencing homelessness are currently under active investigation to optimize health outcomes for this population.ObjectiveTo assess the trends, characteristics, and maternal outcomes associated with unhoused status in pregnancy.Design, Setting, and ParticipantsThis cross-sectional study analyzed data from the Healthcare Cost and Utilization Project National (Nationwide) Inpatient Sample. The study population included hospitalizations for vaginal and cesarean deliveries from January 1, 2016, to December 31, 2020. Unhoused status of these patients was identified from use of International Statistical Classification of Diseases, Tenth Revision, Clinical Modification code Z59.0. Statistical analysis was conducted from December 2022 to June 2023.Main Outcomes and MeasuresPrimary outcomes were (1) temporal trends; (2) patient and pregnancy characteristics associated with unhoused status, which were assessed with a multivariable logistic regression model; (3) delivery outcomes, including severe maternal morbidity (SMM) and mortality at delivery, which used the Centers for Disease Control and Prevention definition for SMM indicators and were assessed with a propensity score–adjusted model; and (4) choice of long-acting reversible contraception method and surgical sterilization at delivery.ResultsA total of 18 076 440 hospital deliveries were included, of which 18 970 involved pregnant patients who were experiencing homelessness at the time of delivery, for a prevalence rate of 104.9 per 100 000 hospital deliveries. These patients had a median (IQR) age of 29 (25-33) years. The prevalence of unhoused patients increased by 72.1% over a 5-year period from 76.1 in 2016 to 131.0 in 2020 per 100 000 deliveries (P for trend < .001). This association remained independent in multivariable analysis. In addition, (1) substance use disorder (tobacco, illicit drugs, and alcohol use disorder), (2) mental health conditions (schizophrenia, bipolar, depressive, and anxiety disorders, including suicidal ideation and past suicide attempt), (3) infectious diseases (hepatitis, gonorrhea, syphilis, herpes, and COVID-19), (4) patient characteristics (Black and Native American race and ethnicity, younger and older age, low or unknown household income, obesity, pregestational hypertension, pregestational diabetes, and asthma), and (5) pregnancy characteristics (prior uterine scar, excess weight gain during pregnancy, and preeclampsia) were associated with unhoused status in pregnancy. Unhoused status was associated with extreme preterm delivery (<28-week gestation: 34.3 vs 10.8 per 1000 deliveries; adjusted odds ratio [AOR], 2.76 [95% CI, 2.55-2.99]); SMM at in-hospital delivery (any morbidity: 53.8 vs 17.7 per 1000 deliveries; AOR, 2.30 [95% CI, 2.15-2.45]); and in-hospital mortality (0.8 vs <0.1 per 1000 deliveries; AOR, 10.17 [95% CI, 6.10-16.94]), including case fatality risk after SMM (1.5% vs 0.3%; AOR, 4.46 [95% CI, 2.67-7.45]). Individual morbidity indicators associated with unhoused status included cardiac arrest (AOR, 12.43; 95% CI, 8.66-17.85), cardiac rhythm conversion (AOR, 6.62; 95% CI, 3.98-11.01), ventilation (AOR, 6.24; 95% CI, 5.03-7.74), and sepsis (AOR, 5.37; 95% CI, 4.53-6.36).Conclusions and RelevanceResults of this national cross-sectional study suggest that unhoused status in pregnancy gradually increased in the US during the 5-year study period and that pregnant patients with unhoused status were a high-risk pregnancy group.

INTRODUCTION:This case-control study reviews complications and contraceptive outcomes following incidental, immediate post-placental intrauterine device (IUD) placement in the setting of chorioamnionitis (CDC contraindication category 4), versus waiting to receive an interval IUD per standard guidelines.METHODS:We conducted an institutional review board (IRB)-compliant retrospective chart review of individuals delivering an infant and desiring an IUD for postpartum contraception in the setting of chorioamnionitis (2015-2020). We collected demographics, histopathologic confirmation of chorioamnionitis, timing of IUD placement, duration of use, short term outcomes/complications (e.g., worsening infection), and long-term outcomes/complications (e.g., IUD retention, IUD expulsion, pelvic inflammatory disease). Data were compared between individuals receiving post-placental IUDs and those waiting to receive outpatient, interval IUDs. We conducted phone interviews to validate and follow-up on medical record data.RESULTS:Fifty-five individuals with chorioamnionitis desired an IUD for postpartum contraception (mean age: 27 years, gestational age at delivery: 39 weeks); 25% provided phone interviews. Nearly half (45%) of clinician-diagnosed chorioamnionitis was confirmed on histopathology. Among IUD recipients (22 post-placental, 10 interval), four re-presented with five complaints (one vaginal discharge, three pelvic pain, one IUD malposition). Incidence of re-presentation did not differ by timing (P=.77) or presence (P=.91) of IUD. Individuals who received a post-placental IUD were significantly more likely (P<.01) to have their IUD in place at 12 months than those intending to receive a post-partum interval IUD.CONCLUSION:No severe complications occurred among individuals receiving a post-placental IUD in the setting of chorioamnionitis. Recipients of immediate versus interval IUDs were more likely to have an IUD at 1 year follow-up.