Implications of Race Among Pregnant People Experiencing Housing Instability


The relationship between housing instability and poor health outcomes has been extensively documented (Cutts, Coleman, Black, Chilton, Cook, de et al., 2015a; Levinson, Group et al., 2004). People undergoing housing instability experience increased morbidity related to chronic health conditions, mental illness, substance use, and risky health behaviors compared to housed peers. They also experience increased all-cause mortality. The lack of affordable housing and current housing policies in the United States (US) is linked to the increase in housing instability among Black people. In 2019, the number of US Black people in poverty was 1.8 times greater than the general population. Black people represented 13.2% of the total population in the US, but made up 23.8% of the poverty population (Creamer, 2020). Black people are more likely than white people (or any other race/ethnicity) to be extremely low-income renters, falling at or below the poverty line for household income. Twenty percent of Black households are extremely low-income renters with household incomes at or below the poverty line or 30% of the area median income (AMI), whichever is greater (Aurand, A., Emmanuel, D., et al., 2020).

Adverse outcomes from the COVID-19 pandemic, including loss of employment, have only worsened this problem, further increasing housing instability. Other issues disproportionately experienced by Black people that increase vulnerability to housing instability include exposure to community and family violence, substance misuse disorders, and mental and physical disabilities, all of which have increased during this global crisis. Decreased access to needed resources and services further compounds housing instability.

Greater degrees of housing instability, including homelessness among pregnant people, have been associated with poor physical health and mental health and with an increased need for health services (Allen et al., 2014). Research using Pregnancy Risk Assessment Monitoring System (PRAMS) data reports pregnant people who are experiencing homelessness are more likely to smoke, receive inadequate PNC, be underweight or obese, take prenatal vitamins, and less likely to breastfeed, all leading to possible adverse pregnancy outcomes such as low birth weight and preterm birth (Richards R., Merrill R.M., & L. Baksh, 2011). Using predictive structural equation modeling, Stein et al (2000) found that after adjusting for the use of prenatal care, greater homelessness severity more strongly predicted preterm birth and low birth weight than any other factor studied, including smoking, substance abuse, and prior mental health hospitalization (Stein, J.A. Dixon, E.L. Nyamathi, A.M., 2008).

The racial disparity heightens the severity of the negative impact of the intersection of housing instability, and pregnancy makes understanding these outcomes even more relevant. Also missing from this conversation is the elevation of the voices of those who are experiencing these challenges. The Centers for Disease Control and Prevention (CDC) launched the HEAR HER campaign last summer with the goal of empowering birthing parents to speak up about their concerns and encourage providers to be responsive. With the continued and persistent disparity in the Black maternal mortality rate, actively listening to those we care for and serve is essential.

What do we know?

  • Housing instability is increasing among families with children.
  • Housing instability leads to worse pregnancy outcomes.
  • People of color disproportionately have a higher likelihood of experiencing both housing instability and pregnancy-related morbidity.

Where is the knowledge gap?

  • How does the intersection of housing instability and pregnancy-related morbidity impact outcomes for the birthing parent?
  • What are important considerations going forward for midwives and other health professionals caring for people in this population?

We encourage you to join the ACNM 66th Annual Meeting, held virtually May 23 – 25, 2021, where you can share in a discussion aimed at increasing understanding of the impact of housing instability on pregnant people and examining the additive effect of race, ethnicity, and housing instability on perinatal health outcomes.


Allen, D., Feinberg, E., & Mitchell, H. (2014). Bringing Life Course Home: A Pilot to Reduce Pregnancy Risk Through Housing Access and Family Support. Maternal and Child Health Journal, 18(2), 405-412.

Aurand, A., Emmanuel, D., Threet, D., Ikra, R., & Yentel, D. (2020). THE GAP: The Affordable Housing Gap Analysis 2016. (). Washington, DC: The National Low Income Housing Coalition.

Creamer, J. (2020).  Poverty Rates for Blacks and Hispanics Reached Historic Lows in 2019: Inequalities Persist Despite Decline in Poverty For All Major Race and Hispanic Origin Groups. census.gove.

Cutts, D., Coleman, S., Black, M., Chilton, M., Cook, J., de, C. S. E., Heeren, T., Meyers, A., Sandel, M., Casey, P., & Frank, D. (2015). Homelessness during pregnancy: a unique, time-dependent risk factor of birth outcomes. Maternal and Child Health Journal, 19(6), 1276-83.

Levinson, D., Group, G., & Publications, S. (2004). Encyclopedia of Homelessness. SAGE Publications.

Richards R., Merrill R.M., & L. Baksh. (2011). Health Behaviors and Infant Outcomes in Homeless Pregnant Women in the United States. . Pediatrics, 128, 438.

Stein, J.A. Dixon, E.L. Nyamathi, A.M. (2008).  Effects of psychosocial and situational variables on substance abuse among homeless adults. , . Psychology of Addictive Behaviors, 22(3), 410.


Doctoral candidate Kelley Robinson, CNM received a Master of Science in nursing from the Yale School of Nursing and has served as a full-time certified nurse midwife for over 15 years. Her clinical practice included full-scope midwifery care in a variety of settings, and she has extensive experience in maternal/newborn care under both normal and high-risk conditions. Kelley continues her advocacy for the childbearing parent through her doctoral research and is committed to promoting equal access to quality midwifery care from birth to senescence. She currently has limited practice at Baltimore Medical Systems in Baltimore, Maryland, caring for underserved people and voluntarily provides GYN services monthly on the Baltimore City Department’s Reproductive Health Mobile Van in downtown Baltimore in the nighttime entertainment district.

Phyllis W. Sharps, PhD, RN, FAAN, Professor, Elsie M. Lawler Endowed Chair and Associate Dean for Community Programs and Initiatives, at the Johns Hopkins University School of Nursing. Dr. Sharps is the director for the Center for Community Innovation and Scholarship (CCIAS), and the East Baltimore Community Nurse Centers (EBCNC), three community-based nurse led initiatives of the School of Nursing. She has been the principal investigator for NIH grants totaling $8M. These grants “Domestic Violence Enhanced Home Visitation – DOVE”, are among the few nurse-led home visit programs to reduce partner violence against pregnant women. She is Fellow of the American Academy of Nursing and a 2013 inductee into the International Nurse Researcher Hall of Fame, Sigma Theta Tau International Nursing Honor Society. In 2015, she was honored by the University Of Maryland School Of Nursing Alumni Associations as a Visionary Pioneer. The Friends of the National Institute of Nursing Research awarded her the President’s Award in recognition of her long-term commitment to leading interdisciplinary research teams. She teaches graduate and doctoral nursing students. She is frequently a mentor for international visiting scholars and doctoral students. She received her BSN and PhD from the University of Maryland School Of Nursing, and a master’s in maternal/child health from University of Delaware School of Nursing. She completed a fellowship in adolescent health at the University of Maryland School of Medicine. Dr. Sharps has joint faculty appointments in the Johns Hopkins School of Medicine and the Johns Hopkins Bloomberg School of Public Health. Dr. Sharps retired as a Colonel from the US Army Nurse Corps after 30 years of combined active and reserve duty.

Noelene K. Jeffers (she/her), CNM, PhD, IBCLC is a midwife with almost ten years of experience providing sexual, reproductive, and midwifery care in the Washington, DC region. Currently, Dr. Jeffers is a postdoctoral fellow in maternal-child health at the Johns Hopkins Bloomberg School of Public Health. She maintains a clinical practice at Unity Health Care, a FQHC in Washington, DC.

Ashley Gresh, CNM, MSN, MA is currently a third year doctoral candidate at Johns Hopkins University School of Nursing (JHUSON). Ashley is a Certified Nurse-Midwife and holds an advanced practice nursing degree from JHUSON in Public Health Nursing (MSN). Ashley holds previous degrees in International Development Studies from McGill University (BA) and the University of KwaZulu-Natal (MA). Ashley has worked as a community health nurse in Baltimore, MD, and has engaged in nursing research globally. Her current research interests include global women’s health, specifically postpartum care.