Unseen, Unheard, Unhoused: The Ethical Implications of Maternal and Fetal Healthcare for the Homeless Population

Introduction:

This paper will discuss the ethics surrounding maternal and fetal healthcare for the unhoused population in the United States. It will evaluate the current standard of care and what services are being provided now to determine whether or not that standard has to be improved. The paper will explore the question: What is the most ethical approach to providing adequate maternal and fetal healthcare to homeless women, especially considering the various unique barriers they face to receiving care? I will be performing a comparative analysis of this issue, evaluating this problem through the varying ethical lenses of responsibility, deontology, justice, and consequentialism. In terms of the scope of the argument, I will be evaluating the role of the United States government as a whole by comparing their legal and ethical duties and assessing how they inform what should be done by the government. I will then make a specific comparison between the state governments of California and Montana to evaluate how differing healthcare standards and funding yields different consequences for homeless pregnant women. I will not be delving into the condition and situation of the mother and child after the birth.

A crucial point to note is that the United States does not offer universal health coverage or healthcare. This lack of legislation pushed my thinking and forced me to consider how far the role of government currently extends and how far it should extend in providing maternal and fetal healthcare. This led me to question how that impacts society’s responsibility to supply and put more resources into increasing the accessibility of this care. When do societal organizations - which this paper defines as organizations that are part of the private or voluntary sector - such as non-profits, NGOs, charities, and religious organizations - step in? 

In this paper, I am defining “universal healthcare” based on the definition from the World Health Organization, “Universal health coverage (UHC) means that all people have access to the full range of quality health services they need, when and where they need them, without financial hardship. It covers the full continuum of essential health services, from health promotion to prevention, treatment, rehabilitation and palliative care.” (WHO) However, the services of universal healthcare vary greatly amongst countries; ultimately, no country on earth provides healthcare to all of its humans.

Consider the situation of a hypothetical homeless woman, “Nancy,” who is pregnant.  She is in California and faces challenges that will be outlined throughout this paper: She is 23 years old, 5 months pregnant, and lacks any form of health insurance. She is aware that during this time period, she should be attending one prenatal visit every two weeks (Mayo) to undergo any necessary assessments of the baby’s health and her own, including weight checks and blood tests. She finds herself trapped in her circumstances, literally and figuratively. She is unable to physically get to appointments due to a lack of transportation, unaware about which hospital or doctor to go to, and uncertain about how to pay for any care she might receive.  Initially, the financial component entirely stops her from pursuing any prenatal care.

However, Nancy recognizes that this may have negative consequences for the baby’s future - prenatal care is a crucial factor in ensuring the health of the baby. For this reason, she hesitantly decides to pursue some form of healthcare, and does so in the only way she knows how - by walking to the Emergency Department of the nearest hospital, which is 3.5 miles away. Once she arrives, she is met by a dismissive doctor who treats her with disrespect and contempt because of her situation. He does a brief and careless screening, does not explain any results, does not guide her through how to maintain her health, and quickly ushers her out the door. A few weeks later, when she returns to the shelter she stays at on occasion, she finds that she has received a bill from the hospital for that visit - a bill that she cannot afford to pay. 

This is a realistic hypothetical situation.  California’s homeless population accounts for about 25% of all unhoused people in America, with approximately 26% of those homeless adults being pregnant (of those who are able to get pregnant). Within that 26%, the rates of pregnancy are higher and pregnancy is more common in the age range of 18-24 compared to those who are 25-34 and 35-44 years old (UCSF). 

According to a study published in the Journal of Obstetric, Gynecologic & Neonatal Nursing, 75.61% of homeless pregnant women encounter severe barriers in accessing prenatal care (Bloom, et al).  Women’s abilities, accessibilities, and opportunities are influenced by their circumstances, which can cause severe stress mentally, or financially, or both, as well as severe health problems if they are unable to receive care necessary for them and their future child.  Accordingly, this paper focuses on the role that society and the government should play in working towards providing equitable healthcare and access to it, and how far that responsibility extends. By the end of this paper, I will conclude that more needs to be done to provide adequate maternal and fetal healthcare to homeless women, and it would be most effective for society and the government to collaborate when making efforts to do so.  

I will begin by introducing foundational background information, then transition into establishing and explaining the current system of healthcare in the United States, including programs that currently address the needs of these women - implemented by society and the government. Following that, I will delve into a comparative case study analysis of Montana versus California where I evaluate how differing circumstances inform the care that individuals receive in those states. From there, I segue into a nuanced discussion of ethical implications that considers responsibility, deontology, justice, and consequentialism. In my ethical analysis, I will consider the ethical nuances of a potential solution - street care. I will conclude by providing final thoughts on this complex topic and offering a few prospective strategies to address this urgent issue.

Background:

For the purpose of this paper, I adopt the definition of a “homeless” person used by the National Institutes of Health:  “an individual who lacks a fixed, regular, and adequate nighttime residence” or “an individual who has a primary nighttime residence that is a supervised or publicly operated shelter designed to provide temporary living accommodations [...] or a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings.” (NIH) 

It is crucial to emphasize that most people do not choose to be homeless. My research suggests that the majority of homeless people are forced into the situation by circumstances that are usually out of their control. (National Alliance to End Homelessness) However, many people believe that homeless individuals have more agency and control of their circumstances than they exercise, and that, at least to some extent, homelessness is “self-inflicted”. Although I grant that some individuals who become homeless may have done (or not done) something that led them to that situation, there are typically external factors that contribute to their circumstances, including their upbringing and environment. I also believe that, regardless of whether one may argue that homelessness is within or out of somebody’s control, homeless individuals should not be discriminated against based on how they came into their situation, especially when it comes to receiving necessary care. I will continue to explore this in the paper. 

Homelessness in the United States is growing rapidly, rising from 650,000 to 771,800 individuals - an 18.1% increase - from 2023 to 2024 (Thornton). When compared to the 0.57% increase in the overall population of the United States from 2023 to 2024, this highlights the significant and shocking growth in the number of homeless individuals (Worldometer). 

My research suggests that approximately 38% of the homeless population are women. First, it is important to consider that the rate of unintended pregnancy is higher among homeless women than other women. Indeed, homeless women are five times more likely to get pregnant than women with housing (Smid et al.), and the rate of unintended pregnancy in homeless women is greater than in housed women. A University of California study of homelessness in the State recently showed that, “[a]n estimated 40% of homeless women aged 18 to 24 are pregnant.” (McClure). These statistics, which reflect what is occurring across the country, demonstrate that nearly half of the women who are pregnant while homeless are very young (Clark et al.) (Galvin et al.). To add context, 7.7% of homeless people are ages 18-24, and around 30% of homeless individuals are women.  This means that approximately 17,000 homeless women are between the ages of 18 and 24. (HUD) 

Pregnancy can be a cause of homelessness as well as a consequence of it (Clark et al.). To understand the seriousness of this issue, it is important to highlight the correlation between homelessness and a lack of access to healthcare. Throughout my research, I have found that the vicious cycle of homelessness, pregnancy, and inadequate access to healthcare means that pregnancy increases the chances of becoming homeless among any group of birthing age. (NHCHC) 

In this paper, I will (only) be discussing the adverse effects of homelessness on pregnancy, maternity and access to prenatal and postpartum care. (UCSF) The first portion of my discussion addresses the importance of appropriate prenatal and postpartum care, since understanding how imperative that care is for women is a predicate for the ethical analysis. 

The American College of Obstetricians and Gynecologists (ACOG) explains that receiving pregnancy, maternity, prenatal, and postpartum care is essential to maintaining the wellbeing of both mother and baby, before, during, and after pregnancy. ACOG has specific healthcare recommendations for pregnant women throughout the stages of pregnancy. The frequency of prenatal visits should increase as the pregnancy progresses, so that health care providers can assess the well-being of the mother and fetus by evaluating the woman’s blood pressure, weight, etc. ACOG also suggests that health care providers offer sufficient prenatal education, execute recommended screening and analyze the results, detect any potential issues - both mental and physical, and reassure the mother.

Recommendations for postpartum care address a range of factors that must be taken into consideration to best support the mother and baby’s health. Both immediate postpartum care (monitoring and caring for the mother and child immediately after the birth) and subsequent postpartum care are required and are equally important. ACOG recommends that mothers get adequate rest for physical recovery, receive medications to relieve pain if necessary, have support for breastfeeding, learn about nutritional guidelines, and undergo monitoring or testing for potential issues, such as endometritis or postpartum depression.

The guidelines further specify parameters that physicians should complete to benefit homeless pregnant women: “It is important for physicians to identify women within the practice who are (or are at risk of becoming) homeless by asking questions about living conditions, nutrition, substance abuse, and intimate partner violence; provide healthcare, including preventative care, for homeless women without bias; and not withhold treatment based on concerns about lack of adherence. Health care providers are advised to simplify medical regimens and address barriers, including transportation needs for follow-up health care visits.” These admonitions take into account the unique circumstances of homeless individuals and attempt to aid them accordingly. (ACOG)

A lack of prenatal care could lead to dangerous perinatal outcomes for both the mother and the baby. In comparison to infants with mothers who do receive prenatal care, babies whose mothers do not are three times more likely to have low birth weight, die in infancy, experience respiratory and gastrointestinal issues, and suffer other adverse consequences.

Furthermore, mothers who do not receive adequate prenatal care are three to four times more likely to die of pregnancy-related problems than mothers who do receive appropriate care (Novoa). In California, a study was conducted in which 672 women - 0.05% of the cohort - were experiencing homelessness at the time of childbirth.  These women and babies experienced a multitude of adverse perinatal consequences, including an increased risk of premature delivery at several gestational age cutoffs, Newborn Intensive Care Unit (NICU) admission, low birth weight, etc. (Martin et al.). The increased risk of NICU admission - which involves a long and expensive stay for the baby in the hospital - has serious financial implications:  how does a (new) mother pay for that if they do not have insurance coverage (e.g., Medicaid)? One should consider that without insurance, then the cost of that care may be absorbed by the hospital, which leads to increased prices for other patients to compensate for those expenses. In many ways this means society literally pays the price.    

Post-birth, postpartum care is vital to monitoring the physical recovery of the mother, and addressing medical complications, such as heavy bleeding or significant pain. It is vital that the mother obtain this care for her own sake as well as for her child, considering that one cannot successfully care for others, if they do not care for themselves first. (Medpark Hospital) (Bloom-OBGYN) (HCS). Just like prenatal care, postpartum care requires a series of visits to appropriately assess and manage the health of the mother after giving birth. 

Because of their already vulnerable state and higher tendency to have or develop medical issues and illnesses, homeless women are significantly more likely to experience negative perinatal outcomes, problems during the pregnancy and birth, and postpartum complications. Homeless women are considerably more likely than housed women to experience mental health issues such as depression and anxiety. (Austin et al.) The vulnerability of homeless individuals is also amplified by the risks of substance abuse and chronic health issues, which are generally comorbidities for pregnant homeless women.

(Martin et al.) It turns out that generally, in the United States, prenatal and postpartum care are relatively poor and inept in comparison to other countries, and the maternal mortality rate in the United States is much higher than in other developed countries. (Johnson) 

What logistical or personal barriers might limit a homeless pregnant woman’s access to prenatal or postpartum care? One might be a lack of transportation. Even if homeless pregnant women had financial access to the prenatal care they need, could they make and get to appointments? Homeless women often lack the means to communicate or keep in touch with helpful doctors or supportive social service programs, and traveling to them is also challenging. 

Even if they do not face logistical barriers, some homeless pregnant women still may not seek out prenatal care. Historically, the healthcare system has acted in ways that have caused certain individuals or groups of people to develop mistrust and fear stigmatization or discrimination. Homeless people have had encounters with physicians where they were treated differently because of their circumstances - often including poor mental and physical health, and severe substance abuse. In one study, some homeless individuals reported being over prescribed medication while others felt their physicians viewed them as “drug seekers.”  This illustrates potential bias in doctors that can lead to discriminatory care.

(Gilmer and Buccieri) Although these adverse experience reports do not directly address pregnancy or perinatal care, the overarching concept is still applicable. A medical professional’s preconceived notions or biases about a homeless pregnant woman's situation may influence how they are treated, the quality of the care they receive, and the degree of empathy that is demonstrated. 

Many expectant homeless women also may be afraid to seek out care for fear that they will draw the unwanted attention of government agencies.  Some may fear contact with Child Protective Services, which could perceive their situation and lack of resources as indicators of ‘neglect’ or ‘inability to parent,’ and, if so, that could potentially lead to the removal of their child from their custody after it is born. It is also important to consider that people who are homeless and undocumented may be reluctant to seek medical care due to concerns about being detected by immigrant authorities. (Abdullahi et al.) 

Housing is one of the many social determinants of health that profoundly affect health outcomes. (OASH) These ‘determinants’ include an individual’s access to quality education, social and community context, economic stability, neighborhood and environmental conditions, and healthcare access and quality. Many of these are directly intertwined with one of the overarching and most influential factors - housing. 

Current Healthcare System and Resources/Programs:

Homeless pregnant women without health insurance, like “Nancy” from the hypothetical case study, may seek care from the emergency departments of hospitals, which they often find is the only way to be seen by a medical professional. Under the federal Emergency Medical Treatment and Labor Act (EMTALA), public hospitals are required to treat or stabilize those with an emergency or who are in active labor, regardless of their ability to pay. Otherwise, hospitals are not legally required to provide non-emergent care, like routine prenatal and postpartum care. Some do provide prenatal care to uninsured women; however, there is still no guarantee that the quality of the care will be adequate and actually beneficial to the women. (HRSA) 

There are a variety of programs, agencies, and laws that have been implemented by federal and state governments with the goal of helping vulnerable populations, including homeless pregnant women. Medicaid (known as Medi-Cal in California), is a joint federal and state program that offers health coverage to low-income, disabled, and qualified pregnant women and children, among others. The federal branch of it is overseen by CMS (Centers for Medicare and Medicaid Services) which is within the purview of the US Department of Health and Human Services that is responsible for maintaining and enhancing the health and well-being of all US citizens.. Medicaid is thought to provide health care coverage for about 72% of homeless individuals.  One facet of the Affordable Care Act (ACA), which was signed into law in 2010, makes Medicaid expansion which was implemented by many states including California and Montana  - the two states which I will explore in more detail later in the paper (Silvers) (DHCS) (HHS) While Medicaid and Medicaid expansion under the ACA are great programs, many potentially eligible people do not know if they qualify or how to qualify for them. Some do not even know that they should try to find out if they qualify. It is sad but true that some individuals may not qualify for Medicaid despite being in a dire, low-income financial situation.  As many as 20% of homeless people do not have health insurance despite living in dire circumstances.  

In addition to federal and state Medicaid programs that may pay for healthcare, there are other programs that seek to deliver care. The federal Department of Health and Human Services (HHS) runs the Healthcare for the Homeless program, which is part of a larger community health center initiative that provides no or low-cost healthcare to underserved populations like people who are homeless. It reaches slightly less than a million people out of the 3-4 million that need care. (HHS) HHS also manages the Maternity Group Homes for Pregnant and Parenting Youth, which provide education in parenting; mental, physical, and reproductive healthcare, prenatal care, as well as some other forms of aid. Individuals have to be between the ages of 16 and 22 to qualify, which narrows the scope and reach of the program.  To put this in perspective, in our hypothetical case study, “Nancy” was 23, which means she would not qualify for this program. Is it ethical to put an age limit on eligibility for the maternity groups HHS program? Should age ever be a limiting factor for people to receive necessary care (except when the issue to be addressed is one that is directly correlated with age)? (ACF) 

Having touched on some government offerings in terms of funding and programs, we can consider the role, responsibilities, and programs of the other major stakeholder - Society.  Potentially supportive organizations that are part of the private or voluntary sector (e.g., non-profits, NGOs, charities, and religious organizations) include the Homeless Prenatal Program, Good Counsel, Several Sources Foundation, Sheltering Grace, and Covenant House. While services offered by these ‘societal organizations’ vary, they tend to provide shelter in addition to more holistic care (including care that addresses prenatal needs) and they seek to give women the tools and education they need to be capable of mothering a child and working towards building a more stable life. These programs are laudable, but regrettably limited. In about 40 years of operation, the Several Sources Foundation has helped 34,000 women (Several Sources Foundation). Good Counsel Homes has only been able to help around 8,000 pregnant mothers among the hundreds of thousands who need help (Good Counsel Homes). While Government and Society programs offer significant benefits and assistance to some, are they sufficiently and effectively meeting the needs of women in need? Are they truly accessible for those who require them? The answer to both questions seems to be “no.” The goal of these programs -  to provide aid to the vulnerable homeless population - is wonderful. Unfortunately, they clearly have been unable to adequately address the pressing needs of millions of individuals.  I believe that this reflects lack of attention to the needs of people who are homeless, who often go unseen and unheard. 

It is difficult to precisely assess the size of the gap between the need for additional services and support and what is currently available. It is challenging to collect reliable comprehensive data because many homeless people are reluctant to participate in surveys or studies.  Homeless people are often reclusive, which makes it hard to locate or contact them to help connect them to programs or services (National Coalition for the Homeless). However, it may be appropriate to draw inferences from available information. A study conducted by Sheltering Grace Ministry found that approximately 1 in 5 homeless women in the United States are pregnant (Sheltering Grace). This would suggest that about 20% of the 459,598 women experiencing homelessness in 2024 may have been pregnant (US Department of Housing and Urban Development). Once again, while finding precise data measurements is challenging, the concept that studies - including one which demonstrates that around 75.61% of homeless pregnant women in northeastern Florida faced intense obstacles to accessing prenatal care - prove that millions of women struggle to access the care they need, suggesting that the programs currently in place are not doing an adequate job (Bloom et al.). In an ideal world - one that I hope we can work towards - 75.61% would be the percentage of homeless pregnant women currently accessing effective care, and we would be making great strides to increasing that figure to 100%. 

From the information presented above, we can see how the government and society attempt to offer different forms of aid to address the lack of access to adequate maternal and fetal healthcare for pregnant homeless women. Federal and state Medicaid programs provide funding and financial aid.  Some government programs provide limited care to some pregnant women.  Society has developed several programs that actively try to provide physical and mental support to women who are pregnant and homeless - helping in a way that is often more holistic and beneficial in the long-term for them.  Nevertheless, we still see numerous shortcomings and a lack of impactful reach when it comes to getting this care to all those who need it. What degree of responsibility do governments have to mend these voids of care? What responsibility does society possess? How may they differ, if at all? 

California and Montana - A Comparison

It is fascinating to analyze the differences in support for pregnant people who are homeless in different states.  Considering the large size and diversity of the United States in terms of qualities such as type of land and population size, I chose to compare California and Montana to explore the severity of homelessness in primarily rural and urban areas. This comparison will show how these factors influence the type and amount of care needed and that is necessary to help these women, and it will also be compared to what care is currently available.  

Suppose that the person in our hypothetical case study, “Nancy,” was born in Montana and resided there up until around seven months ago. She went to California with the father of the baby, who suddenly left her when they discovered that she was pregnant. Her seven-month stay in California means she has met the six month residency requirement to qualify for state healthcare programs. As Nancy struggles to find a substantial support system that meets her needs in California, she thinks about how her circumstances might have been different if she had stayed in Montana. (Kendall)

As mentioned previously, California’s homeless population accounts for about 25% of all unhoused people in America.  Nearly two-thirds of people who are homeless in California sleep outside. California’s population of homeless people increased 3% from 2023 to 2024. (Cal Matters) Other states saw more dramatic increases in their homeless populations, including Montana. Montana has many fewer people who are considered homeless - only 2,178 people as of February 2024 (NBC Montana) compared to 187,000 homeless individuals in California as of January 2024 (Cal Matters). However, Montana is currently ranked the top state in terms of the rate of increase in homelessness, with an overwhelming 45% increase from 2022 to 2023. (The Montana Coalition to Solve Homelessness) By population, California is the most populous state in the United States.  Montana is the seventh least populated state.  (Britannica) (Kendall)

Comparing California and Montana also allows us to evaluate the difference between a rural versus urban population. The majority - 95% - of California’s population lives in urban areas, which suggests that most people in California who are homeless, would be living in urban areas - typically large cities like Los Angeles, San Francisco, and San Diego (California Open Data Portal). Montana, on the other hand, is the 5th most rural state (World Population Review). Notably, rural areas are typically characterized by limited access to healthcare, including limited availability of providers, issues with transportation, and distance to healthcare facilities. (HRSA) 

It stands to reason that someone's location can influence their ability to receive care. This raises ethical concerns about whether a person’s location, specifically the state they live in or their region within a state, means they can receive more (or less) aid and attention from the government. This prompts questions about whether state or federal governments are better able to establish standards and provide funding that meets the specific needs and circumstances of the population in each location. These questions suggest consideration of equity versus equality:  Should someone be provided more support - financially, medically, and mentally - due to where they are located?  Should state governments work to address those disparities? As discussed before, healthcare services or programs may not make a difference if the people who need them cannot access them. Should there be a greater focus on localized efforts and organizations, or more attention on a national scale to programs such as Medicaid?  

These questions lead to more questions about equity versus equality. Should someone’s care and ability to access and receive care from the government or society be adjusted based on their individual circumstances - including location? Does going to greater practical lengths to help one person more than another, because of their location promote justice by giving disadvantaged people what they need to have an equal opportunity to be healthy? Or does giving some more health resources than others diminish justice? Does the federal government have a responsibility - grounded in the ethical principle of justice - for ensuring that all states have measures in place to adequately provide access to quality healthcare for homeless women? Ultimately, what exactly is the responsibility of the government and society to help these women? Should this be achieved on a person-by-person basis? Is this practical or even feasible?

With the benefit of background information about California and Montana, let’s consider how each state seeks to meet the needs of pregnant homeless women. California has several initiatives to enhance prenatal care, and access to it, for homeless women - specifically attempting to address the unique challenges and barriers they face. One service is a street medicine program. Street medicine teams are composed of doctors, nurses, psychologists, and more, who bring care to homeless people where they are. People like Dr. Kyle Patton offer prenatal services, such as portable ultrasounds and prenatal vitamins, to support the health of mother and child and the mother’s desire to maintain custody of her child after it is born. (EMS1) (Hart) Another program is the Presumptive Eligibility for Pregnant Women Program (PE4PW) which enables qualified providers to immediately grant temporary Medi-Cal coverage for prenatal care to low-income pregnant patients, including women who are homeless, while their applications are being processed. This helps these women get timely access to necessary prenatal services. (HCS) Two extensions of California’s Medi-Cal program, the Enhanced Care Management Initiative and Community Supports, aim to provide comprehensive care and support for homeless pregnant women by offering services to help them find affordable housing and strengthen access to food. (CHCS)

Montana is also trying to elevate the prenatal care available to pregnant women, including those who are homeless. One program is the Meadowlark Initiative, a joint effort between the Montana Healthcare Foundation and the Montana Department of Public Health and Human Services. This program attempts to take a more holistic approach by offering behavioral health and substance abuse services along with prenatal and postpartum care to improve the overall well-being of both the mother and child, and reduce the chances for family separation. Overall, this initiative focuses on barriers to prenatal and postpartum care that women who are homeless face, and highlights the importance of accessible care. In October 2023, the initiative expanded to all 31 Montana hospitals that deliver babies through the Meadowlark Initiative (DPHHS) (Montana Healthcare Foundation). According to a 2022 study, the percentage of women seen by Meadowlark and receiving adequate prenatal care increased from 68% to 85%  (Silvers).

Could “Nancy” take advantage of the programs in California and Montana?  In theory, one might say “Nancy” could access programs in California and Montana, but what does “access” really mean? No age limits or general qualifying factors might prevent her from being able to participate, but there might be logistical constraints. For example, if “Nancy” was living a reclusive, isolated life in California, or in a city without a street care team (and most do not yet have street care teams), the existence of street care would be irrelevant to her.  If “Nancy” was living in Montana but unaware of the Meadowlark Initiative, she might continue to avoid seeking care for fear of being financially burdened.  If she knew about the Meadowlark Initiative but had transportation problems, the Initiative would not be able to help her.  Overall, while these programs, as well as others, exist and can provide beneficial resources, there are still obstacles that may prevent someone like “Nancy” from actually benefiting from them. 

Ethical Evaluation and Analysis

Responsibility 

The ethical discussion of maternal and fetal healthcare for women who are homeless tends to focus on questions of responsibility. What is the federal and/or state government’s responsibility to provide healthcare to “Nancy” and other homeless pregnant women? What are the responsibilities and roles of society? How may these two differ and intersect? 

Citizens of the United States do not have a legal right to universal healthcare, nor does the government possess an explicit legal responsibility to provide it. (Mollmann) However, the United States government does claim to be responsible for protecting the well-being of its citizens. (HHS) Despite there being no explicit right to health or healthcare in the United States, the United States government has made efforts to address the lack of healthcare coverage, particularly for vulnerable populations, based on an ethically-driven motivation. These efforts include the implementation of programs such as Medicaid and the Affordable Care Act - both of which have not been nearly as successful nor effective as they should be in reaching the people who need this care and support. 

Being cognizant of the government’s (limited) legal responsibilities, it is vital to delve into ethical obligations to homeless pregnant women. I firmly believe all individuals should have the opportunity to be healthy and therefore, should have access to resources that enable them to achieve health. I do acknowledge that health is dependent not only on access to medical care, but on other social determinants of health. However, for the purpose of this section, I will focus on how access to medical care influences an individual’s ability to be healthy. 

It is also appropriate to ask what else, along with access to adequate prenatal and postpartum care, does the government have a responsibility to provide to ensure the successful implementation and usage of these prenatal and postpartum programs and services? As discussed previously, if individuals cannot actually access the care they need, then the availability of care becomes effectively meaningless. Does this therefore mean that the government must also provide free transportation or phone services or technology? This, once again, prompts the question of how far the responsibility of the government extends. We must then evaluate how the government’s responsibility impacts the extent of society’s responsibility to supply and put more resources into increasing the accessibility of this care. When do these societal organizations, which I have previously defined, step in?

One important ethical question explored in this paper is whether the responsibility of the government and society differ and if so, how they differ, and how their differing responsibilities are informed by legal versus ethical imperatives.   As established in this portion of the analysis, neither the government nor society carry a legal obligation to provide healthcare and aid to these women. However, the ethical implications of their roles tend to argue that they should do so. Currently, both the government and society have implemented programs that aim to support vulnerable populations, including pregnant homeless women. Yet, they come with different abilities and limitations in terms of reaching this population, with the federal and state governments typically having a broader reach. Societal programs are often more local, with a more direct and close connection to people in communities. Due to these varying conditions and capabilities, the efforts made by both of those stakeholders often have positive and negative effects. While the federal and state governments may have a larger range, their efforts may be less accessible to homeless individuals in comparison to those of societal organizations, which may make more direct efforts to reach out and actively look to help people. 

As we examine the responsibilities of the government and society, it is important to ponder the responsibility of the homeless person themself: how much responsibility does the individual hold in terms of improving their situation? Do we reduce our efforts or refuse to offer care if they are not putting in (equal) effort to overcome their struggles? If the government decides to implement a policy where the care homeless people receive depends on their own efforts to improve their situation - which could be implemented in many different ways with varying sets of rules and regulations - that would have many consequences. Many people in the homeless community face comorbid conditions and issues that are significant obstacles to overcoming their situation and being fully involved in their care. These problems often include substance abuse, depression, anxiety, PTSD and other mental illnesses.

Considering the value of responsibility is vital to evaluating how the goal of providing an adequate level of care to these women can be achieved and ultimately, who holds the ultimate responsibility for doing so. While legally, neither the government nor society is “responsible” for ensuring care for these women, there is an ethical obligation to put best efforts into helping these women access care that is at least adequate to address their health needs. I do recognize that “best efforts” may reflect different capacities considering the varying and unique limitations both the government and society may face when making these attempts.

Deontology

As stated previously, currently, in the United States, there is no universal legal right to healthcare. What are the ethical implications in terms of deontology - a framework closely linked with the value of responsibility, which evaluates the ethicality of an action based on its fulfillment of certain duties or principles?  Does an ethical duty to promote the well-being of citizens require the government to provide access to services that people need to support their health? Are federal programs like Medicaid and laws like EMTALA sufficient to fulfill the federal government's ethical obligations?

It is especially meaningful to consider the ethical duty the government has to take care of vulnerable populations who may need more care. What is the extent of this duty? In other words, would deontology say the government has a greater duty to provide homeless pregnant women with care because their circumstances usually yield poorer perinatal outcomes?  In this regard, I consider that the United States’ Constitution states that it is the government’s role to “promote the general Welfare”. This has been interpreted to mean that the government should take actions to improve the well-being, health, and safety of its citizens - a role that has been heavily assumed by the US Department of Health and Human Services as previously explained (National Archives).

Having considered the ethical duty of government, I consider the ethical duties of Society. Society does not have a legal obligation to pregnant women who are homeless.  However, I believe society has an ethical duty, including an ethical duty to protect vulnerable populations. 

Lastly, when considering the duty of the involved stakeholders, it is also valuable to consider the implications of the duty the mother has to her child. How does the considerations about a mother’s duty to her child inform her responsibilities to try and improve her situation - not only for herself, but now for her offspring.

Ultimately, while some may argue that the lack of legal obligations of the government to provide these individuals with care makes any efforts praiseworthy, others might contend that the government has an ethical duty to supply these women with adequate care and help them access it and is not adequately fulfilling that duty. I personally believe the ethical duty is more compelling than the presence or absence of legal obligation, and both the government and society must play a role in giving these women and their future children the opportunity to be healthy.  I infer this ethical duty from the language of responsibility for promoting the general welfare expressed in the US Constitution.

Justice

When considering the value of justice, we must recognize the tension between equity and equality.  Should homeless women receive the same resources as everyone else or receive more support due to their circumstances?  These women are in a vulnerable and unique position.  The care or support that the general population receives is simply not enough to give them the same opportunities for health and success. From that, we must also evaluate: how much more should the government and society be responsible for providing? How much more is owed to these women, or are governments and society already doing enough - so that it is essentially up to the woman to find ways to access them? This raises fascinating ethical considerations regarding the extent to which governments and society should provide care in order to ensure morally preferred outcomes. 

I believe that both society and the government should supply the aid and support necessary to ensure that all people have the opportunity to be healthy. Some may assert their efforts should not exceed the point at which the autonomy of the homeless individual is infringed; others may believe there are situations where it is necessary that the government insist on a treatment if the mother’s or child’s health is at risk. I personally believe intrusions on autonomy should be evaluated on a case-by-case basis and the opinion of the state or doctors must be weighed against the autonomy of the mother. 

There is a notion that homelessness is often self-inflicted, and that this supposedly renders people who are homeless undeserving of assistance.  The premise is that ‘they put themselves in that position, so they should be the ones to get themselves out of it.’ However, one must acknowledge that being homeless is almost never a choice. Countless external factors may contribute to homelessness - the detrimental and corrosive nature of substance abuse, skyrocketing housing prices, devastating health conditions, job losses, etc. (Polner). We cannot say that people are unworthy of healthcare because of their situation. That would violate the bioethical principle of justice, which asserts that those with similar conditions must be offered similar care.  

On the other hand, one might ask whether every single homeless person should receive the same type of care, medical benefits, etc regardless of their various backgrounds and behavior. Should everyone’s unique circumstances and backgrounds influence the type of care they receive? And do the causes of or contributors to those unique circumstances matter?  Previously, we considered the potential impact of location on the care that people receive, and using the consideration of equity versus equality, justified different approaches for different circumstances.  Some aspects of people’s situations may be natural consequences of their own actions - not external circumstances.  Overall, it is crucial and interesting to consider if, when and/or how a homeless person’s behavior, choices and circumstances does or should affect the way they are perceived and treated by society.

Care should be adjusted according to the specific needs, barriers, and disparities of certain populations. In essence, the availability of government funds becomes irrelevant if the practical realities of peoples’ situations are not taken into consideration and addressed. Despite the existence of funds or programs, which are still lacking in quality and resources, women who are pregnant and homeless face challenges that keep them from accessing them. In the argument of equity versus equality, there is no substantial positive effect on these women if programs and funds simply exist; they must be accessible and usable.

There is no perfect healthcare system, however, there are certainly aspects of other structures - like universal healthcare - that, despite shortcomings, have many benefits and may contribute to upholding justice. The goal of implementing universal health care would be to give these women a greater chance of receiving consistent and adequate prenatal care and ensure that the fear of financial burden does not keep them from seeking out care they need (WHO) (Evans et al.). One must acknowledge that universal health care would not necessarily address logistical problems for homeless pregnant women seeking to access health care, including transportation and communication issues. There are also several contingencies to consider when evaluating universal healthcare because it is not as simple as saying that everyone has free healthcare for everything. There are limits to what universal healthcare can cover, a significant chance of lower-quality care, and dilemmas concerning how that system would be funded. Furthermore, while there are several benefits to universal health care, there are also several drawbacks such as lower quality care and significantly long wait times (Darrudi et al.).

The concept of justice evaluates the ethical reasoning for why these women need care that addresses their specific needs and accounts for their unique circumstances. While some may argue that their situation is self-inflicted and they are therefore unworthy of help, the principle of justice supports the idea that regardless of how these women got into the situations they are in, they should receive appropriate medical care.

Consequentialism

Consequentialism is a framework that evaluates the ethicality of an action based on its consequences.  This paper will explore various consequences of failure to address the need that homeless pregnant women have for appropriate maternal and fetal healthcare.  

Firstly, it is crucial to consider how failing to offer or improve prenatal, perinatal and postnatal care can lead to a plethora of detrimental outcomes for the mother and the baby - the implications of which prompt the following question. Should the government be financially or otherwise responsible for health problems that stem from lack of pregnancy-related care? When contemplating this slippery slope concerning the future well-being of the mother and child, it becomes unequivocal that the government must first address the present condition of both stakeholders during which the pregnancy is taking place. If the source of the issue - a lack of adequate pregnancy care - is resolved at the outset, then the resultant issues likely will not manifest at all. If those needs are not met, however, then it remains the government’s responsibility to contend with the subsequent health issues as the blame for their existence partially rests on the government’s lack of ability to take action when it was needed. Ultimately, the mother and the fetus/infant would both be benefited by receiving necessary care that assesses and protects their health during the pregnancy and afterwards. 

Furthermore, it is helpful to consider the potential positive consequences of a continuum of care. By providing adequate and accessible prenatal and postpartum care to a homeless woman, her chances of being able to successfully and safely mother her child increase. Inadequate care and/or failure to address related social determinants of health may lead to complications for the mother, which in turn could increase the chances of the baby being involuntarily taken away from the mother by Child Protective Services if she is deemed unable to properly and safely provide for and raise her baby. While this might be presumed to be a benefit or positive result, it may be appropriate to consider whether or not it would (always) be in the best interest of a baby to remain in the care of its mother who lacks housing. Might a baby benefit more from an alternative option, such as being placed in the adoption or foster care systems?  

A consequentialist might also question the ethicality of providing increased amounts of aid and healthcare for homeless pregnant women on the grounds that if the programs are too appealing, they might unintentionally discourage the women from taking steps to improve their situations or attain greater financial independence. Instead, the argument goes, appealing programs will encourage homeless women to try to remain eligible for them (e.g., by conceiving and bearing additional children). It would be interesting to see if the experience with other government programs demonstrates a rational basis for this concern.

Do people stop earning money - or trying to earn money - in order to remain eligible for Medicaid? Would people really prefer to stay poor and unemployed or under-employed in order to rely on Medicaid to provide them with more stable healthcare? While it may seem implausible, some may be concerned that certain forms of public support will discourage homeless women from trying to build a better life and escape their unhoused situation, therefore enabling and perpetuating homelessness. (Watts)

The framework of consequentialism is used to assess the potential outcomes of action(s) or inaction(s). I determined that failing to meet needs for adequate and appropriate health care would be detrimental to mothers and babies, and that providing care would benefit them immediately and in the long run. Unintended consequences might arise, such as some potential perpetuation of homelessness and encouragement of dependency on programs. Another potential consequence of offering and supplying an adequate level of accessible prenatal and postnatal care could be helping women maintain custody of their infants if that is what they desire. On balance, I have concluded that there is a net benefit - the value of positive consequences outweighs potential negative impacts. The ultimate goal is to help these homeless pregnant women in order to ensure their opportunity to maintain their health and the health of their babies. As long as we manage and minimize the unfavorable unintended consequences, these women should receive the support and healthcare which they need. 

Street Care as a Solution

The implementation of street medicine teams is another forward-thinking strategy that could successfully tackle the root issue. In the past two years, the number of street medicine teams in California has doubled to around 50. These teams are funded by health insurers, hospitals, and community clinics to serve homeless people who have trouble showing up to appointments for various reasons - they may lack transportation, be too sick, or unwilling to leave where they are staying. A crucial aspect of this is that street medicine enables people to build trust with the healthcare providers, and it is important that these relationships are fostered. (Hart) 

Dr. Kyle Patton, a family physician, leads the street medicine team for the Shasta Community Health Center in Redding, California. Despite not initially expecting pregnancy care to be such a significant part of the street medicine care he provides, with the 20 pregnancies he has managed since 2022, he recognizes now that maternal and prenatal care are extremely important in what he does. He provides birth control implants, does diagnostic testing for HIV, prescribes antibiotics, and provides other services for people like Melissa Crespo, who is a homeless woman who struggles with severe drug addiction and blames the death of her most recent newborn on her addiction. Generally, street medicine teams, like the one Crespo is seeing, also provide addiction, mental illness, chronic disease, and pregnancy care. One quote that truly captured the essence of how Dr. Patton views his work is, “My job isn’t to determine if a patient is deserving of health care. If a patient is sick or has a disease, I have the skills to help, so I’m going to do it.” His personal goals and beliefs, as iterated in this quote, demonstrate the opinion that there is no question of deservedness when it comes to providing these homeless individuals with healthcare.  They need healthcare, so they should be able to receive it. (Hart)   

California Governor Gavin Newsom is directing billions of dollars to “[...] health and social services for homeless people.” It appears that the State is primarily “...redirecting Medicaid funds that would have paid for services in brick-and-mortar facilities.” (Hart)  I reflected on the idea that funds from Medi-Cal are being allocated towards more consistently and adequately paying the medical providers who administer street care. How should we weigh the importance of these different areas and determine the appropriate allocation of these Medicaid funds? Is it fair that resources that would otherwise be used in a hospital or clinic setting are being put towards street care? Is doing so decreasing the quality of care in hospitals and clinics in order to improve the quality of care for those on the street? Which group(s) of patients in need should we prioritize and how do we judge that - based on likelihood of success, effectiveness or farther reach? Would patients be better off receiving care in a hospital setting and should these efforts be focused on getting them there rather than bringing the care to their unstable living conditions? Someone like “Nancy,” the fictional homeless woman described earlier, would greatly benefit from street care considering that she needs prenatal care, yet faces many challenges in receiving it including a lack of transportation access, support system, and financial certainty. 

It is necessary to understand that street pregnancy care is merely a subset of street care as a whole. As a result, we must be mindful of the allocation of resources for this limited practice, prompting us to question how to weigh the significance of pregnancy care within the broader context of street care.

This prompts the question of where does homelessness rank in the eyes of the government and society? Likewise, where does prenatal care fall in a scale of priority for the homeless woman themself, especially if they are not aware of its importance? Some homeless people may focus on addressing their more immediate needs such as food and shelter rather than attempt to seek out prenatal care.

When it comes to street care, it is especially poignant to consider the vitality of offering a holistic approach to these peoples’ dire situations. As Patton says, “we have to be all things to our patients - like, we have to provide the health care, social support, case management, even find the housing.” (Patton) How far does their responsibility extend to address the root cause of homelessness and provide long-term solutions? If the mother ends up keeping the child, how much support and for how long after the birth should the mother receive supplemental care or shelter? One may assert that providing pregnancy care for homeless women is simply not enough because once these women give birth, they are ultimately still homeless. They have no choice but to return to the streets, now with a newborn child in arms to provide for. Thus, they may assert that actors in street care must also allocate funds and resources towards addressing the root problem of homelessness, which includes aiding housing instability and offering mental health care opportunities. They may claim that not addressing these other systemic needs is just perpetuating generational homelessness by not providing more support and guidance in regards to resolving homelessness as the root cause. Within this discussion, however, we must reevaluate whether these responsibilities should befall upon street care providers rather than the United States’ government.

Because this complex topic has so many facets, there were some aspects of this ethical dilemma that I could not address in this paper. If I had more time, I would further investigate the post-birth custody of the baby, evaluate the possible outcomes for the child after being born to a homeless mother, and the consequences for each of the stakeholders to try to determine what the most beneficial approach would be. Since being homeless in and of itself does not directly allow child protection services to take away the newborn at birth because they are not in imminent harm (OCFS) (Moore) (NPIC), the following are some questions that I would probe. Should the mother have the right to keep her baby or should the government intervene? How can we determine what outcome is in the best interests of the child, and who would be the arbiter of that decision? If the mother ends up keeping the child, how much support and for how long after the birth should the mother receive supplemental care or shelter? Does the government have a greater responsibility to respect the autonomy of the mother or protect the well-being of the child? Do the two have to be mutually exclusive? 

Conclusion

When exploring government and societal contributions to maternal and fetal healthcare for homeless pregnant women, this paper primarily considers responsibility, deontology, justice, and consequentialism. In terms of responsibility, I questioned what the responsibility of the government and society should be when addressing this issue, how they differ, and the legal and ethical implications for both. I considered a deontological approach, and weighed legal versus ethical duties of society and the government to determine what would be considered ethical action.  The ethical principle of justice influenced various questions that informed this discussion:  should we focus on equity or equality?  Is homelessness self-inflicted, and if so, what implications does that have for the provision of appropriate care? 

Should we take a nuanced approach to assessing “deservedness?”  How do we ensure that resources are both accessible and usable? Lastly, I utilized consequentialism to identify four potential outcomes, including the complicated health impacts if these women do not receive this care, potentially perpetuating dependency on government and social programs, analyzing the benefits of obtaining care, and addressing potential consequences for the infants of unhoused women.  

After engaging in this discussion of the need for more and better maternal and fetal healthcare for homeless pregnant women, it is imperative to consider possible solutions to this persistent problem. Governments and private (societal) systems and organizations should collaborate to develop effective, sustainable solutions. It will not be simple to figure out how these two sectors could work together. One could assert that they could share responsibilities and both put in the same efforts to try to evoke a stronger effect. Others may claim that, since governments and society have differing abilities and scopes of reach, it would be more effective and beneficial if they work in tandem, essentially splitting the responsibilities to achieve more success and have a broader reach. For example, if more resources are created, such as more nonprofit healthcare clinics or mobile prenatal care units, they can be run by the private sector while simultaneously receiving some funding by the government. 

Another potential solution is exemplified by the Bridge Project, an initiative funded by both the government and private sector, that provides assistance to homeless people, specifically homeless mothers and children. It offers several benefits including providing “low-income mothers with cash on a biweekly basis during pregnancy, birth, and the earliest days of their babies’ lives to support healthy development, avoid adverse childhood experiences, and break intergenerational cycles of poverty.” (The Bridge Project) This is a prime example of what a collaborative effort to tackle this prevailing issue would look like. 

While the ideal solution would be to eradicate homelessness or establish a universal right to healthcare, the most realistic solution to this problem would be to work towards helping those currently in the situation while simultaneously working to prevent it in the future. It is imperative that both the government and society work together to do so in an ethically balanced way that respects the autonomy of the homeless individual while supporting their well-being and that of their child.  Our country has put itself in a position where we need to react. We must work toward a future where this issue is not one of immense discussion because it is no longer one of immense distress; where we do not need papers offering solutions because it is no longer a problem; where we can prevent it well enough that we no longer need to react.

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