Sexual Identity and Birth Outcomes: A Focus on the Moderating Role of Race-ethnicity

An examination of the independent and intersectional effects of racial and heterosexist medical mistrust on timing of sexual/reproductive health care visits among Black sexual minority women in the USA

Experiences of racism and heterosexism in medical settings are social and systemic barriers to 'on-time' receipt of sexual and reproductive health services among women with both racial and sexual minority identities. Medical mistrust based on experiences related to these dual identities is associated with avoidance and delays in care. However, investigators are just beginning to apply an intersectional lens to quantitatively understanding such barriers. The purpose of this study was to examine the independent and interaction effects of racial and heterosexist medical mistrust on timing of sexual/reproductive health care among Black sexual minority women who have sex with women and men. A total of 320 women participated in an online study of factors affecting sexual health in this population. Ordinal logistic regression was used to assess the independent and interaction effects of racial and heterosexist medical mistrust on self-reported time since last sexual/reproductive health visit. Results indicated an interaction between the two types of medical mistrust. Research on Black women who have sex with women and men's experiences of racism and heterosexism in the US healthcare system can lead to the development of the comprehensive training programmes needed to alleviate medical mistrust among women with racial and sexual minority identities.

Sexual Orientation-Specific Policies Are Associated With Prenatal Care Use in the First Trimester Among Sexual Minority Women: Results From a Prospective Cohort Study

BACKGROUND

Previous research has shown sexual minority women (SMW) are more likely to report multiple maternal and infant health outcomes compared to heterosexual women and that these outcomes are moderated by the policy environment. Little is known, however, about prenatal care use disparities or the social determinants of prenatal care use for SMW.

PURPOSE

To examine the relationship between sexual orientation-specific policies that confer legal protections (e.g., hate crime protections, housing discrimination, same-sex marriage) and prenatal care use among women using a prospective, population-based data set.

METHODS

Using the National Longitudinal Study of Adolescent to Adult Health and logistic regression, we link measures of state policies to the use of prenatal care in the first trimester among women who had live births. The use of prospective data allows us to adjust for covariates associated with preconception care use prior to pregnancy (n = 586 singleton births to SMW; n = 4,539 singleton births to heterosexual women).

RESULTS

Sexual orientation-specific policies that conferred protections were associated with increased use of prenatal care among pregnancies reported by SMW (OR = 1.86, 95% CI 1.16, 2.96). In fact, in states with zero protections, we found no differences in prenatal care use by sexual minority status; however, in states with two or more protective policies, SMW were more likely to access prenatal care in the first trimester than heterosexual women. There was no relationship between sexual orientation-specific policy environments and prenatal care use among pregnancies reported by heterosexual women.

CONCLUSIONS

Recent research has documented that SMW are more likely to have adverse perinatal and obstetrical outcomes than their heterosexual peers. These findings suggest that Lesbian/Gay/Bisexual-specific policy protections may facilitate the use of prenatal care among SMW, a potentially important pathway to improve reproductive health among this population.

Sexual orientation disparities in gestational diabetes and hypertensive disorders of pregnancy

BACKGROUND

Sexual minority (SM) individuals (e.g., those with same-sex attractions/partners or who identify as lesbian/gay/bisexual) experience a host of physical and mental health disparities. However, little is known about sexual orientation-related disparities in gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP; gestational hypertension [gHTN] and preeclampsia).

OBJECTIVE

To estimate disparities in GDM, gHTN and preeclampsia by sexual orientation.

METHODS

We used data from the Nurses' Health Study II-a cohort of nurses across the US enrolled in 1989 at 25-42 years of age-restricted to those with pregnancies ≥20 weeks gestation and non-missing sexual orientation data (63,518 participants; 146,079 pregnancies). Our primary outcomes were GDM, gHTN and preeclampsia, which participants reported for each of their pregnancies. Participants also reported their sexual orientation identity and same-sex attractions/partners. We compared the risk of each outcome in pregnancies among heterosexual participants with no same-sex experience (reference) to those among SM participants overall and within subgroups: (1) heterosexual with same-sex experience, (2) mostly heterosexual, (3) bisexual and (4) lesbian/gay participants. We used modified Poisson models to estimate risk ratios (RR) and 95% confidence intervals (CI), fit via weighted generalised estimating equations, to account for multiple pregnancies per person over time and informative cluster sizes.

RESULTS

The overall prevalence of each outcome was ≤5%. Mostly heterosexual participants had a 31% higher risk of gHTN (RR 1.31, 95% CI 1.03, 1.66), and heterosexual participants with same-sex experience had a 31% higher risk of GDM (RR 1.31, 95% CI 1.13, 1.50), compared to heterosexual participants with no same-sex experience. The magnitudes of the risk ratios were high among bisexual participants for gHTN and preeclampsia and among lesbian/gay participants for gHTN.

CONCLUSIONS

Some SM groups may be disparately burdened by GDM and HDP. Elucidating modifiable mechanisms (e.g., structural barriers, discrimination) for reducing adverse pregnancy outcomes among SM populations is critical.

Differences in medically assisted reproduction use by sexual identity and partnership: a prospective cohort of cisgender women

STUDY QUESTION

Does medically assisted reproduction (MAR) use among cisgender women differ among those with same-sex partners or lesbian/bisexual identities compared to peers with different-sex partners or heterosexual identities?

SUMMARY ANSWER

Women with same-sex partners or lesbian/bisexual identities are more likely to utilize any MAR but are no more likely to use ART (i.e. IVF, reciprocal IVF, embryo transfer, unspecified ART, ICSI, and gamete or zygote intrafallopian transfer) compared to non-ART MAR (i.e. IUI, ovulation induction, and intravaginal or intracervical insemination) than their different-sex partnered and completely heterosexual peers.

WHAT IS KNOWN ALREADY

Sexual minority women (SMW) form families in myriad ways, including through fostering, adoption, genetic, and/or biological routes. Emerging evidence suggests this population increasingly wants to form genetic and/or biological families, yet little is known about their family formation processes and conception needs.

STUDY DESIGN, SIZE, DURATION

The Growing Up Today Study is a US-based prospective cohort (n = 27 805). Participants were 9-17 years of age at enrollment (1996 and 2004). Biennial follow-up is ongoing, with data collected through 2021.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Cisgender women who met the following criteria were included in this sample: endorsed ever being pregnant; attempted a pregnancy in 2019 or 2021; and endorsed either a male- or female-sex partner OR responded to questions regarding their sexual identity during their conception window. The main outcome was any MAR use including ART (i.e. procedures involving micromanipulation of gametes) and non-ART MAR (i.e. nonmanipulation of gametes). Secondary outcomes included specific MAR procedures, time to conception, and trends across time. We assessed differences in any MAR use using weighted modified Poisson generalized estimating equations.

MAIN RESULTS AND THE ROLE OF CHANCE

Among 3519 participants, there were 6935 pregnancies/pregnancy attempts and 19.4% involved MAR. A total of 47 pregnancies or pregnancy attempts were among the same-sex partnered participants, while 91 were among bisexual participants and 37 among lesbian participants. Participants with same-sex, compared to different-sex partners were almost five times as likely to use MAR (risk ratio [95% CI]: 4.78 [4.06, 5.61]). Compared to completely heterosexual participants, there was greater MAR use among lesbian (4.00 [3.10, 5.16]) and bisexual (2.22 [1.60, 3.07]) participants compared to no MAR use; mostly heterosexual participants were also more likely to use ART (1.42 [1.11, 1.82]) compared to non-ART MAR. Among first pregnancies conceived using MAR, conception pathways differed by partnership and sexual identity groups; differences were largest for IUI, intravaginal insemination, and timed intercourse with ovulation induction. From 2002 to 2021, MAR use increased proportionally to total pregnancies/pregnancy attempts; ART use was increasingly common in later years among same-sex partnered and lesbian participants.

LIMITATIONS, REASONS FOR CAUTION

Our results are limited by the small number of SMW, the homogenous sample of mostly White, educated participants, the potential misclassification of MAR use when creating conception pathways unique to SMW, and the questionnaire's skip logic, which excluded certain participants from receiving MAR questions.

WIDER IMPLICATIONS OF THE FINDINGS

Previous studies on SMW family formation have primarily focused on clinical outcomes from ART procedures and perinatal outcomes by conception method, and have been almost exclusively limited to European, clinical samples that relied on partnership data only. Despite the small sample of SMW within a nonrepresentative study, this is the first study to our knowledge to use a nonclinical sample of cisgender women from across the USA to elucidate family formation pathways by partnership as well as sexual identity, including pathways that may be unique to SMW. This was made possible by our innovative approach to MAR categorization within a large, prospective dataset that collected detailed sexual orientation data. Specifically, lesbian, bisexual, and same-sex partnered participants used both ART and non-ART MAR at similar frequencies compared to heterosexual and different-sex partnered participants. This may signal differential access to conception pathways owing to structural barriers, emerging conception trends as family formation among SMW has increased, and a need for conception support beyond specialized providers and fertility clinics.

STUDY FUNDING/COMPETING INTEREST(S)

The research reported in this publication was supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health (NIH), under award number R01MD015256. Additionally, KRSS is supported by NCI grant T32CA009001, AKH by the NCI T32CA057711, PC by the NHLBI T32HL098048, BM by the Stanford Maternal Child Health Research Institute Clinical Trainee Support Grant and the Diversity Fellowship from the American Society for Reproductive Medicine Research Institute, BGE by NICHD R01HD091405, and SM by the Thomas O. Pyle Fellowship through the Harvard Pilgrim Health Care Foundation and Harvard University, NHLBI T32HL098048, NIMH R01MH112384, and the William T. Grant Foundation grant number 187958. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The first author recently had a leadership role in the not-for-profit program, The Lesbian Health Fund, a research fund focused on improving the health and wellbeing of LGBTQ+ women and girls. The fund did not have any role in this study and the author's relationship with the fund did not bias the findings of this manuscript.

TRIAL REGISTRATION NUMBER

N/A.

A multilevel developmental psychopathology model of childbirth and the perinatal transition

Despite recent applications of a developmental psychopathology perspective to the perinatal period, these conceptualizations have largely ignored the role that childbirth plays in the perinatal transition. Thus, we present a conceptual model of childbirth as a bridge between prenatal and postnatal health. We argue that biopsychosocial factors during pregnancy influence postnatal health trajectories both directly and indirectly through childbirth experiences, and we focus our review on those indirect effects. In order to frame our model within a developmental psychopathology lens, we first describe "typical" biopsychosocial aspects of pregnancy and childbirth. Then, we explore ways in which these processes may deviate from the norm to result in adverse or traumatic childbirth experiences. We briefly describe early postnatal health trajectories that may follow from these birth experiences, including those which are adaptive despite traumatic childbirth, and we conclude with implications for research and clinical practice. We intend for our model to illuminate the importance of including childbirth in multilevel perinatal research. This advancement is critical for reducing perinatal health disparities and promoting health and well-being among birthing parents and their children.

Black Queer Being/Knowing/Feeling: Storytelling of Barriers to Reproductive Healthcare

Anti-Blackness and heteronormativity are the driving forces that determine access to reproductive healthcare and services in the United States, and the rate of Black birthing-related deaths continue to skyrocket. Still, there is a dearth of literature that includes the reproductive experiences of Black birthing people and their interactions with the healthcare system. This current study builds power with 10 Black Queer birthing people (or Partners) by centering on their gestation-based storytelling within discourse about reproduction. By blending these Partners' self-examination of their lived experiences with gestation with health research, Black feminism, and researcher interpretation of their stories, this study reveals the unparalleled truths of Black Queer reproduction. Six thematic areas within the healthcare system as experienced by Partners are explored. Additionally, through this disruptive approach, this study identifies the lived and material needs that necessitate reproductive justice for all.

Family building and pregnancy experiences of cisgender sexual minority women

BACKGROUND

Although 10% to 20% of cisgender women aged 18 to 40 years have a sexual minority identity (eg, bisexual, lesbian, and queer), there is limited research on the family building and pregnancy experiences of sexual minority cisgender women. Improving our understanding of the family building and pregnancy experiences of cisgender sexual minority women is critical for improving the perinatal health of this population.

OBJECTIVE

This study aimed to compare the mode of family building, past pregnancy experiences, and future pregnancy intentions among cisgender sexual minority women by sexual orientation.

STUDY DESIGN

This is an observational study which was conducted using cross-sectional data collected in 2019 from a national sample of 1369 cisgender sexual minority women aged 18 to 45 years.

RESULTS

Most participants (n=794, 58%) endorsed multiple sexual orientations, most commonly queer (n=641, 47%), lesbian (n=640, 47%), and/or bisexual (n=583, 43%). There were 243 (18%) cisgender sexual minority women who were parents. Pregnancy was used by 74% (181/243) of women to build their families. Among participants who used pregnancy, 60% (108/181) became pregnant through sexual activity with another parent of the child, whereas 27% (64/243) of women used donor sperm. An additional 10% (n=24) became parents through second-parent adoption, 10% (n=25) through adoption, and 14% (n=35) through step-parenting. Bisexual women more often used sexual activity to become parents (61/100, 61%) compared with queer (40/89, 45%) and lesbian women (40/130, 31%). In contrast, lesbian (50/130, 39%) and queer (25/89, 27%) women more often used donor sperm to become parents compared with bisexual women (11/100, 11%). Among the 266 (19%) cisgender sexual minority women who had ever been pregnant, there were 545 pregnancies (mean, 2.05 pregnancies per woman). Among those pregnancies, 59% (n=327) resulted in live birth, 23% (n=126) resulted in miscarriage, 15% (n=83) resulted in abortion, and 2% (n=9) resulted in ectopic pregnancy. A quarter of women had future pregnancy intentions, with no differences by sexual orientation. Overall, few participants (16%) reported that all of their healthcare providers were aware of their sexual orientation.

CONCLUSION

Cisgender sexual minority women primarily built their families through pregnancy and a quarter have future pregnancy desires. In addition, there were important differences in family building methods used by sexual orientation. Providers should be aware of the pregnancy and family-building patterns, plans, and needs of cisgender sexual minority women.

Mapping the scientific literature on obstetrical and perinatal health among sexual and gender minoritised (SGM) childbearing people and their infants: a scoping review protocol

INTRODUCTION

Sexual and gender minoritised (SGM) populations are disproportionately impacted by multilevel risk factors for obstetrical and perinatal outcomes, including structural (eg, stigma, discrimination, access to care) and individual risk factors (eg, partner violence, poor mental health, substance use). Emerging evidence shows SGM childbearing people have worse obstetrical outcomes and their infants have worse perinatal outcomes, when compared with their cisgender and heterosexual counterparts; this emerging evidence necessitates a comprehensive examination of existing literature on obstetrical and perinatal health among SGM people. The goal of this scoping review is to comprehensively map the extent, range and nature of scientific literature on obstetrical and perinatal physical health outcomes among SGM populations and their infants. We aim to summarise findings from existing literature, potentially informing clinical guidelines on perinatal care, as well as highlighting knowledge gaps and providing directions for future research.

METHODS AND ANALYSIS

We will follow the Joanna Briggs Institute (JBI) scoping review framework and report findings according to the PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines. We will conduct a broad systematic search in Medline/PubMed, Embase, CINAHL and Web of Science Core Collection. Eligible studies will include peer-reviewed, empirical, English-language publications pertaining to obstetrical and perinatal physical health outcomes of SGM people or their infants. No temporal or geographical limitations will be applied to the search. Studies conducted in all settings will be considered. Records will be managed, screened and extracted by two independent reviewers. Study characteristics, key findings and research gaps will be presented in tables and summarised narratively.

ETHICS AND DISSEMINATION

Ethical approval is not required as primary data will not be collected. The findings of this scoping review will be disseminated through a peer-reviewed journal and conference presentations.

PROTOCOL REGISTRATION

Open Science Framework https://osf.io/6fg4a/.

Sexual Orientation-Related Nondiscrimination Laws and Maternal Hypertension Among Black and White U.S. Women

Background: Black women and sexual minority women are more likely to report adverse maternal health. Little research has investigated maternal health disparities at the intersection of race/ethnicity and sexual orientation or the mechanisms that contribute to these disparities. Materials and Methods: We analyzed data from the National Longitudinal Study of Adolescent to Adult Health. Our sample was restricted to Black and White women who had at least one live birth and were followed-up in Wave V of the data (n = 3,396). We used multivariable logistic regression to analyze the associations between race, sexual orientation identity, and a four-item state-level index of sexual orientation-related nondiscrimination laws. Results: We found that higher numbers of state-level sexual orientation-related nondiscrimination laws were associated with lower risk of maternal hypertension among U.S. women overall (odds ratio [OR] = 0.82, 95% confidence interval [CI] 0.73-0.93), and Black women had a higher risk of maternal hypertension relative to White women (OR = 1.32, 95% CI 1.00-1.79). Interactions between race, sexual orientation identity, and sexual orientation-related policies show that, regardless of sexual orientation identity, sexual orientation-related nondiscrimination laws were associated with a lower risk of maternal hypertension among White mothers (OR = 0.80, 95% CI 0.70-0.92). However, among Black women, these laws were associated with a lower risk of maternal hypertension among lesbian and bisexual women (OR = 0.18, 95% CI 0.05-0.68) only. Conclusions: Laws that prevent discrimination related to sexual orientation in various societal domains may play an important role in improving maternal health outcomes among White women in general and Black lesbian and bisexual women in particular.

Adverse pregnancy and birth outcomes in sexual minority women from the National Survey of Family Growth

BACKGROUND

Few studies have examined how multiple marginalized identities are associated with adverse pregnancy and birth outcomes, especially for Black and Hispanic sexual minority women. Sexual minorities are people who identify as lesbian, gay, bisexual or transgender (LGBT). The purpose of this study was to examine differences in adverse pregnancy (i.e., miscarriage) and birth outcomes (i.e., preterm birth, low birthweight, and stillbirth) in a national sample of women by race and ethnicity, and sexual minority status (LGBT identification and same-sex sexual behavior).

METHODS

We conducted a cross-sectional analysis of the National Survey of Family Growth (NSFG). The unit of analysis was pregnancy, not participants. In this study, we examined pregnancies to participants who identified as heterosexual, lesbian, and bisexual, by race and Hispanic ethnicity. We also studied sexual behaviors to categorize participants as women who have sex with women (WSW) and women who have sex with men (WSM). Outcomes included preterm birth, low birthweight, miscarriage, and stillbirth. We employed logistic and linear regression analyses for analyses using STATA.

RESULTS

We studied 53,751 pregnancies, and 9% of these occurred in people who identified as heterosexual, but had engaged in sexual activity with a female partner (heterosexual-WSW), 7% in those identifying as bisexual, and 1% to women who identified as lesbian. Pregnancies ended in preterm birth (10.7%) and low birthweight (9.0%), stillbirths (2-4%), and miscarriages (17-21%) in sexual minority women. We observed that pregnancies reported by Hispanic lesbian women had a higher birthweight (β = 10.71, SE = 4.1, p-value = 0.01) compared to infants born to Hispanic heterosexual-WSM. Pregnancies to lesbian women were significantly more likely to end in stillbirth (aRR = 3.58, 95% CI 1.30,9.79) compared to heterosexual-WSM. No significant differences were noted in risk of adverse birth outcomes by sexual orientation for NH Black or Hispanic women.

CONCLUSION

In this sample, preterm births were less likely to occur among heterosexual-WSW than in heterosexual-WSM. Pregnancies to lesbians and bisexual women were more likely to end in miscarriage or stillbirth than heterosexual WSM. Lesbian Hispanic women reported higher birthweights compared to heterosexual-WSM Hispanic women. More research should be done to further understand these findings.

Mothers' Sexual Identity and Children's Health

Sexual minority women face a plethora of structural, socioeconomic, and interpersonal disadvantages and stressors. Research has established negative associations between women's sexual minority identities and both their own health and their infants' birth outcomes. Yet a separate body of scholarship has documented similarities in the development and well-being of children living with same-sex couples relative to those living with similarly situated different-sex couples. This study sought to reconcile these literatures by examining the association between maternal sexual identity and child health at ages 5-18 using a US sample from the full population of children of sexual minority women, including those who identify as mostly heterosexual, bisexual, or lesbian, regardless of partner sex or gender. Analyses using data from the National Longitudinal Study of Adolescent to Adult Health (N=8,978) followed women longitudinally and examined several measures of their children's health, including general health and specific developmental and physical health conditions. Analyses found that children of mostly heterosexual and bisexual women experienced health disadvantages relative to children of heterosexual women, whereas the few children of lesbian women in our sample evidenced a mixture of advantages and disadvantages. These findings underscore that to understand sexual orientation disparities and the intergenerational transmission of health, it is important to incorporate broad measurement of sexual orientation that can capture variation in family forms and in sexual minority identities.

Sexual and/or gender minority disparities in obstetrical and birth outcomes

BACKGROUND

Many sexual and/or gender minority individuals build families through pregnancy and childbirth, but it is unknown whether they experience different clinical outcomes than those who are not sexual and/or gender minority individuals.

OBJECTIVE

To evaluate obstetrical and birth outcomes comparing couples who are likely sexual and/or gender minority patients compared with those who are not likely to be sexual and/or gender minority patients.

STUDY DESIGN

We performed a population-based cohort study of live birth hospitalizations during 2016 to 2019 linked to birth certificates in California. California changed its birth certificate in 2016 to include gender-neutral fields such as "parent giving birth" and "parent not giving birth," with options for each role to specify "mother," "father," or "parent." We classified birthing patients in mother-mother partnerships and those who identified as a father in any partnership as likely sexual and/or gender minority and classified birthing patients in mother-father partnerships as likely not sexual and/or gender minority. We used multivariable modified Poisson regression models to estimate the risk ratios for associations between likely sexual and/or gender minority parental structures and outcomes. The models were adjusted for sociodemographic factors, comorbidities, and multifetal gestation selected by causal diagrams. We replicated the analyses after excluding multifetal gestations.

RESULTS

In the final birthing patient sample, 1,483,119 were mothers with father partners, 2572 were mothers with mother partners, and 498 were fathers with any partner. Compared with birthing patients in mother-father partnerships, birthing patients in mother-mother partnerships experienced significantly higher rates of multifetal gestation (adjusted risk ratio, 3.9; 95% confidence interval, 3.4-4.4), labor induction (adjusted risk ratio, 1.2; 95% confidence interval, 1.1-1.3), postpartum hemorrhage (adjusted risk ratio, 1.4; 95% confidence interval, 1.3-1.6), severe morbidity (adjusted risk ratio, 1.4; 95% confidence interval, 1.2-1.8), and nontransfusion severe morbidity (adjusted risk ratio, 1.4; 95% confidence interval, 1.1-1.9). Severe morbidity was identified following the Centers for Disease Control and Prevention "severe maternal morbidity" index. Gestational diabetes mellitus, hypertensive disorders of pregnancy, cesarean delivery, preterm birth (<37 weeks' gestation), low birthweight (<2500 g), and low Apgar score (<7 at 5 minutes) did not significantly differ in the multivariable analyses. No outcomes significantly differed between father birthing patients in any partnership and birthing patients in mother-father partnerships in either crude or multivariable analyses, though the risk of multifetal gestation was nonsignificantly higher (adjusted risk ratio, 1.5; 95% confidence interval, 0.9-2.7). The adjusted risk ratios for the outcomes were similar after restriction to singleton gestations.

CONCLUSION

Birthing mothers with mother partners experienced disparities in several obstetrical and birth outcomes independent of sociodemographic factors, comorbidities, and multifetal gestation. Birthing fathers in any partnership were not at a significantly elevated risk of any adverse obstetrical or birth outcome considered in this study.

The unequal consequences of family structures for infant health

Rapid changes in American families have reshaped inequalities in child well-being. This paper examines the unequal consequences of family structures for infant health, focusing on birthweight. Existing studies mainly address the average association between marriage (versus singlehood) and birthweight. I extend the literature by 1) explicitly considering cohabitation and 2) exploring the heterogeneous associations based on mother's likelihood of union formation at conception. Pooling nationally representative data from the National Survey of Family Growth 2011-17, I analyze a sample of recent births (N = 4,376) born to mothers aged between 20 and 49 years. Propensity score methods are used to address selections. Results show that 1) compared to single mothers, married mothers reap birthweight benefits, while cohabiting mothers do not; 2) married mothers with a higher likelihood to marry at conception (i.e., more advantaged) reap even larger birthweight benefits than their low-likelihood counterparts (i.e., less advantaged). Overall, the findings reveal important and nuanced roles of family structure in the reproduction of intergenerational inequality through infant health.