Preventing eviction during pregnancy: a cost-effectiveness analysis of a theoretical safety-net program

Abstract

Eviction in pregnancy has been shown to be associated with adverse birth outcomes. A safety net program focused on covering the costs of rent during pregnancy may aid in preventing adverse complications. To evaluate the cost-effectiveness of a program covering the cost of rent to prevent eviction during pregnancy. A cost-effectiveness model using TreeAge software was designed to evaluate the cost, effectiveness, and incremental cost-effectiveness ratio (ICER) associated with eviction compared to no eviction in pregnancy. The cost of eviction from a societal perspective was compared to the annual cost of housing in the no eviction group, which was estimated by the median contract rent in the US from 2021 national census data. Birth outcomes included pre-term birth, neonatal death, and major neurodevelopmental delay. Probabilities and costs were derived from the literature. The cost-effectiveness threshold was set at $100,000/QALY. We performed univariable and multivariable sensitivity analyses to assess the robustness of the results. In our theoretical cohort of 30,000 pregnant individuals aged 15-44 facing eviction annually, the no eviction during pregnancy strategy was associated with 1,427 fewer pre-term births, 47 fewer neonatal deaths, and 44 fewer cases of neurodevelopmental delay compared to eviction. At the median cost of rent in the US, the no eviction strategy was associated increased QALYs and decreased costs. Therefore, the no eviction strategy was the dominant strategy. In univariate sensitivity analysis varying the cost of housing, no eviction remained the cost-effective strategy and was cost-saving when rent was below $1,016 per month. The no eviction strategy is cost-effective and reduces cases of preterm birth, neonatal death, and neurodevelopmental delay. When rent is below the median of $1,016 per month, no eviction is the cost-saving strategy. These findings suggest that policies supporting social programmatic implementation for rent coverage for pregnant people at risk of eviction have the potential to be highly beneficial in reducing costs and disparities in perinatal outcomes.