Reduced rate of postpartum readmissions among homeless compared with non-homeless women in New York: a population-based study using serial, cross-sectional data

Abstract

ObjectiveTo assess differences in rates of postpartum hospitalisations among homeless women compared with non-homeless women.DesignCross-sectional secondary analysis of readmissions and emergency department (ED) utilisation among postpartum women using hierarchical regression models adjusted for age, race/ethnicity, insurance type during delivery, delivery length of stay, maternal comorbidity index score, other pregnancy complications, neonatal complications, caesarean delivery, year fixed effect and a birth hospital random effect.SettingNew York statewide inpatient and emergency department databases (2009–2014).Participants82 820 and 1 026 965 postpartum homeless and non-homeless women, respectively.Main outcome measuresPostpartum readmissions (primary outcome) and postpartum ED visits (secondary outcome) within 6 weeks after discharge date from delivery hospitalisation.ResultsHomeless women had lower rates of both postpartum readmissions (risk-adjusted rates: 1.4% vs 1.6%; adjusted OR (aOR) 0.87, 95% CI 0.75 to 1.00, p=0.048) and ED visits than non-homeless women (risk-adjusted rates: 8.1% vs 9.5%; aOR 0.83, 95% CI 0.77 to 0.90, p<0.001). A sensitivity analysis stratifying the non-homeless population by income quartile revealed significantly lower hospitalisation rates of homeless women compared with housed women in the lowest income quartile. These results were surprising due to the trend of postpartum hospitalisation rates increasing as income levels decreased.ConclusionsTwo factors likely led to lower rates of hospital readmissions among homeless women. First, barriers including lack of transportation, payment or childcare could have impeded access to postpartum inpatient and emergency care. Second, given New York State’s extensive safety net, discharge planning such as respite and sober living housing may have provided access to outpatient care and quality of life, preventing adverse health events. Additional research using outpatient data and patient perspectives is needed to recognise how the factors affect postpartum health among homeless women. These findings could aid in lowering readmissions of the housed postpartum population.

The patient experience of a postpartum readmission for hypertension: a qualitative study

“…Results of this study align well with other research, which have shown that worries about the newborn’s health issues often supersede the patient’s own health concerns, that major barriers to seeking care include a lack of understanding of the risks of preeclampsia, and that patients are often only aware of preeclampsia if they had been diagnosed in a prior pregnancy [ 15 , 16 ]. Finally, qualitative literature on the postpartum period overall suggests that patients feel that their needs are often overlooked during this time [ 17 ].…”

Why do homeless women in New York state experience fewer hospital revisits after childbirth than housed women?

“…The study by Sakai-Bizmark et al 9 also contributes to the current discussion regarding whether postpartum hospital revisits can be used to measure the quality of perinatal care at hospitals 13. Recent studies suggest that postpartum readmission rates differ by race/ethnicity and insurance status,14 15 but it has also been reported that hospital-level variation is negligible 15 16.…”

“…The study did not investigate the underlying mechanisms explaining why hospital revisit rates after delivery were lower among homeless women compared with housed women. The authors discussed two possible explanations, but with very different interpretations regarding the quality of care9: (1) limited access to necessary hospital services among homeless women, suggesting a potential problem in the quality of care; (2) the protective effect of the respite and convalescent care that homeless women in New York state receive in homeless shelters after childbirth, suggesting possible directions to improve care for women with low incomes who do not have access to the same resources. Although these two mechanisms have vastly different implications, the authors did not empirically examine the plausibility of these two hypotheses, so they could neither support nor refute the mechanisms.…”

“…In this issue of BMJ Quality and Safety , Sakai-Bizmark and colleagues9 report the results of an observational study that analysed how rates of hospital revisits (ie, readmissions and emergency department (ED) visits) differ between postpartum homeless and housed women, using an administrative database of all hospitalisations and ED visits in New York state from 2009 to 2014. New York state has one of the highest numbers of homeless people in the nation, with 92 091 homeless individuals identified on a given night in 2019, accounting for more than 16% of total homelessness in the USA.…”

Advancing equity, diversity and inclusion atBMJ Quality and Safety

“…7 Nevertheless, there have been some important papers published. These include studies that reduced disparities in breast cancer screening for Arab women in Israel, 8 decreased disparities in maternal morbidity between black and white women in the USA, 9 demonstrated that homeless women were less likely to be hospitalised or visit an emergency department after giving birth than low-income housed women, 10 explored the effect of income on medication non-adherence 11 and found that voluntary reporting systems underdetect safety events in vulnerable patients. 12 An important editorial, 3 commenting on this last paper, also presents a framework for advancing health equity, pitfalls to avoid and recommendations for the patient safety field to advance health equity.…”