OBJECTIVES: This study aimed to estimate the prevalence of homelessness shortly before or during pregnancy and describe differences in maternal characteristics and adverse birth outcomes between people reporting homelessness and not reporting homelessness. METHODS: We used 2016-2020 Pregnancy Risk Assessment Monitoring System (PRAMS) data from 31 sites to estimate the prevalence of self-reported homelessness during the 12 months before giving birth. We used logistic regression models to evaluate the association between homelessness and adverse birth outcomes, specifically small for gestational age (SGA), low birth weight (LBW), and preterm birth (PTB). RESULTS: Of 138,603 respondents, 4,045 reported homelessness, representing 2.4% of weighted respondents. Respondents reporting homelessness differed from respondents who did not report homelessness in maternal demographic characteristics, health conditions, behavioral and environmental risk factors, and adequacy of prenatal care. In unadjusted models, homelessness was associated with higher prevalences of SGA, LBW, and PTB (PR 1.38, 95% CI 1.21-1.57; PR 1.73, 95% CI 1.56-1.91; PR 1.42, 95% CI 1.25-1.61; respectively). After adjusting for maternal age, race and ethnicity, education, BMI, and cigarette smoking, prevalence ratios were attenuated and no longer significant. CONCLUSIONS FOR PRACTICE: Although homelessness was not independently associated with adverse birth outcomes in adjusted models, people reporting homelessness before or during pregnancy represent a group at increased risk of inadequate health care utilization and adverse birth outcomes due to other underlying demographic and social factors. Health care providers can play a critical role in identifying if patients may be experiencing homelessness and facilitating connections to social support.

Screening for sexually transmitted infections (STIs) during pregnancy is vital for maternal and neonatal health, and adverse birth outcomes can occur if diagnosis and treatment are delayed. Sexually transmitted infections, such as chlamydia, trichomoniasis, and bacterial vaginosis, have been implicated in preterm birth.1 Herpes simplex virus can be transmitted during a vaginal delivery, requiring a cesarean section during active or recent infection.2 Infants who do acquire neonatal herpes simplex virus infections may suffer from a range of outcomes, from localized skin infections to meningitis or encephalitis to disseminated infections involving multiple organs, or even death.3 Similarly, infants born to mothers infected by chlamydia or gonorrhea are at increased risk of acquiring neonatal ophthalmia or other complications.4,5 Syphilitic infections during pregnancy can result in spontaneous abortion, stillbirth, preterm delivery, neonatal death, and live infants born with congenital syphilis,6,7 the latter of which has been increasing throughout the United States. During 2015 to 2019, the rate of congenital syphilis in the United States increased by 291.1% (12.4–48.5 per 100,000 live births), making the importance of STI prevention in pregnancy all the more urgent.8 Given its impact on the health care system, the extent to which the SARS-CoV-2 (COVID-19) pandemic may have impacted STI care for pregnant women is not yet clear.

Congenital syphilis (CS) is on the rise in the United States and is a growing public health concern. CS is an infection with Treponema pallidum in an infant or fetus, acquired via transplacental transmission when a pregnant woman has untreated or inadequately treated syphilis. Pregnant women with untreated syphilis are more likely to experience pregnancies complicated by stillbirth, prematurity, low birth weight, and early infant death, while their children can develop clinical manifestations of CS such as hepatosplenomegaly, bone abnormalities, developmental delays, and hearing loss. One of the ways CS can be prevented is by identifying and treating infected women during pregnancy with a benzathine penicillin G regimen that is both appropriate for the maternal stage of syphilis and initiated at least 30 days prior to delivery. In this article we discuss many of the challenges faced by both public health and healthcare systems with regards to this preventable infection, summarize missed opportunities for CS prevention, and provide practical solutions for future CS prevention strategies.