Eviction during pregnancy is associated with adverse birth outcomes, including prematurity and low birth weight, according to a study published in JAMA Pediatrics in March. Adverse birth outcomes are known to have lifelong and even multigenerational health and economic consequences, and the authors conclude that policies to protect tenants from eviction and assist pregnant women at risk for eviction may improve infant health.
In an accompanying editorial, Michael Silverstein, MD, MPH; Erika (Gaby) Cordova Ramos, MD; and Robert Koenig, MBA, discuss how the study’s findings shed light on the disproportionate toll eviction takes on low-income women of color, especially Black women, and their babies. The writers emphasize the importance of addressing the upstream factors that lead to health inequities and eviction.
HealthCity spoke with Cordova Ramos, a Boston Medical Center (BMC) clinical neonatologist, health services researcher, and assistant professor of pediatrics at Boston University School of Medicine, and Koenig, BMC’s senior director of strategy and operations, about the study, the inequities that lead to disparate eviction rates, and what health systems and policymakers can do to help.
HealthCity: What makes this study on housing evictions during pregnancy important or groundbreaking?
Gaby Cordova Ramos, MD: The study is very methodologically rigorous. When we look at something like eviction, there are so many unobserved confounders between mothers who have never been evicted and mothers who have experienced eviction. I think it is just tremendous work, how this study linked the data to generate the most informative comparison: mothers who experienced eviction during pregnancy compared to mothers who experienced eviction at any other time. It really gets at the question, what is the impact of in utero exposure to eviction on birth outcomes?
It is great also to see work that points out a very actionable target for interventions—eviction—to try to offset that disparity early on in life. A study that identifies tractable intervention targets strongly linked to adverse birth outcomes is highly consequential, because of the lifelong downstream effects of what happens at birth.
Robert Koenig, MBA: Findings like these are really important in how they reinforce the need for us to stretch beyond the traditional clinical setting in order to care for our patients. At Boston Medical Center, where people experiencing homelessness are approximately 10% of our inpatient stays, we see firsthand the link between housing status and health—but studies like this are critically important for quantifying impact and pointing us to remedies. It’s a clear imperative for us to continue to tailor our operations to support patients experiencing housing instability and homelessness.
HC: It seems intuitive that eviction would be a highly stressful event during pregnancy and would have a negative impact on a baby’s early life. Is this the first time a study has shown specific medical outcomes for newborns after eviction?
GCR: This is the first to do it so rigorously. There have been some ecological studies that have looked at rates of eviction in certain counties and rates of adverse birth outcomes and other studies linking other types of housing instability and adverse birth outcomes. This is the first study to do a comparison within families, comparing a child where the mom experienced eviction during the pregnancy and a sibling of the same mother that didn't. It also is the first study that examined the effects of eviction in the three trimesters of pregnancy, which further supports the potential causality in this association.
HC: What does this study reveal about disparate outcomes for Black and brown mothers?
GCR: It confirms that eviction disproportionately affects women of color. This study in particular also shows that the size effect—how much lower the birth weights were—was much greater for Black mothers. So, not only were pregnant women of color more likely to be exposed to eviction, but they were also more likely to experience more severe effects.
Our intent in this piece was to make it exceedingly clear that low-income women of color are being more affected and to underline the importance of structural racism in all sorts of health outcomes—in this case, a very important one: birth outcomes.
HC: Your editorial refers to “stacking inequities” for Black families. Can you talk about that?
GCR: Hardships don't often come alone, and low-income families of color experience the burden of multiple hardships. Discrimination and structural racism lead to socioeconomic disadvantage, and that leads to other disparities that affect health. For example, families that are at risk for eviction are often also at risk of not having the means to afford nutritious food.
It’s often so hard to find an effect at all linking a hardship to actual health outcomes in a study, because you're looking at myriad overlapping hardships. So, in this study, the sole fact that there was a significant result seen in prematurity and low birth weight is, by itself, pretty remarkable.
HC: Your editorial makes it clear that we need not only to prevent evictions of pregnant women, but to also look upstream at the social determinants that lead to eviction. What are some examples?
GCR: Black mothers are disproportionally affected by eviction actions, and this stems from much larger problems. There are upstream issues that lead to being in eviction court in the first place, which is having low wages, having insecure jobs, not having access to resources to weather unexpected circumstances—and these are not distributed equally in the population.
RK: To underscore that, myriad interconnected social factors can lead patients to face the risk of eviction, and we need to think about them in a coordinated manner—employment, nutrition, child care, among others—individually or together can affect health outcomes. We need to acknowledge the role of race and structural racism in all of these upstream factors and their relationship to health outcomes.
HC: What can health providers and policymakers do to help?
GCR: At the clinician level, just awareness of the magnitude of the problem is something. Next is getting physicians to know that patients can benefit from interventions like medical-legal partnerships and connection to community resources, either to offset being behind on rent or to connect them to safe and affordable housing.
RK: Health systems can make investments in tools like BMC's THRIVE screening and referral tool, where we screen patients for housing instability and homelessness when they come into BMC and can connect patients to services or supports that they request help accessing.
From a policy standpoint, rent assistance programs to help people behind on rent, counsel to assist people facing eviction, and, a step above that, access to affordable housing in the first place are some of the important tools. Affordability is an especially acute challenge in Boston, where we face such high housing costs in the first place.
GCR: Also at the policy level, we need regulations around what landlords can and can't do. Besides housing instability, there's substandard housing that affects the health of the mother, which affects the health of the newborn and of the children as they grow. And after we wrote this piece, I came across another paper explaining that the disparities are not only in eviction filings, but in repeated filings. These families are just caught in a constant stream of these hardships, and there needs to be more regulation around it.
HC: You also note the need for further research. What would that look like?
GCR: Any time a disparity is identified, there is a need to understand the mechanisms behind it in order to actually design interventions to close the gap. And so showing that low-income women of color are disproportionally evicted is tremendously important, but then we also need to understand the specific drivers of what is happening. That’s what will really inform policy changes.
RK: Measuring and observing a disparity is an important and constructive starting point, but at the end of the day, in terms of health system operations, we need to identify and successfully implement mechanisms that close racial inequities, not just observe them. More work to help go beyond measurement and understand how programs actually move the needle would help health systems and policymakers alike.
This interview has been edited and condensed.