Homelessness, housing instability, and abortion outcomes at an urban US abortion clinic.

BACKGROUND

Adverse reproductive health outcomes are well-documented among people experiencing homelessness and housing instability. Little is known about abortion outcomes among this population.

OBJECTIVE

To investigate the relationship between housing status and abortion outcomes, and whether gestational age mediates this relationship.

STUDY DESIGN

Our sample comprised 1903 individuals who had abortions at an urban clinic in San Francisco, California from 2015 to 2017. We defined homelessness and housing instability as a binary exposure, which included staying outside; with friends/family; in a tent, vehicle, shelter, transitional program, or hotel. We evaluated gestational duration at or above 20 weeks as a mediator variable. Our primary outcome was any abortion complication. Logistic regression models were adjusted for age, race, substance use, mental health diagnoses, and prior vaginal and cesarean births.

RESULTS

Nineteen percent (N=356) of abortions were among people experiencing homelessness and housing instability. Compared to those with stable housing, people experiencing homelessness and housing instability presented later in pregnancy (mean gestational duration 13.3 vs. 9.5 weeks, p0.001) and had more frequent complications (6.5% vs. 2.8%, p0.001; OR=2.2, 95% CI 1.2-3.9). Adjusting for race, substance use, mental health diagnoses, and prior cesarean births, individuals experiencing homelessness and housing instability were more likely to have abortion complications (OR 2.3, 95% CI 1.3-4.0). However, the relationship was attenuated after adjusting for gestational duration (OR 1.4, 95% CI 0.7-2.6), suggesting that gestational duration mediates the relationship between housing status and abortion complications.

CONCLUSIONS

Patients experiencing homelessness and housing instability presented later in gestation, which appears to contribute to the increased frequency of abortion complications.