Childbirth appears to be more dangerous for lesbian couples than opposite-sex partners, a new study has found.
Women in mother-mother partnerships had significantly higher rates of severe adverse outcomes, such as post-delivery bleeding, than women with a male partner, according to an analysis of more than 1 million women in California.
“New data show that at least 7% of the US population identifies as being sexual and/or gender-minority individuals, or people who are more commonly referred to as LGBTQ+,” study leader Stephanie A. Leonard, PhD, of Stanford University, told Medscape Medical News. “Many of these individuals have children or want to have children, and some will do it through pregnancy and birth. It’s critical that we better understand and meet their unique healthcare needs to support their families.”
In a study published in the American Journal of Obstetrics and Gynecology, Leonard and her colleagues reviewed hospital data from live births between 2016 and 2019. They were able to conduct the study because the state changed its reporting rules in 2016 to allow birth certificates to reflect the genders of both the birthing and the nonbirthing parent. “This change allowed us to look at health outcomes among couples in which there was a mother with a mother partner and in which there was a father who gave birth,” Leonard said.
The final study population included 1,483,119 mothers with father partners, 2572 mothers with mother partners, and 498 fathers with any partner.
Overall, birthing patients in mother-mother pairs were significantly more likely than those in mother-father pairs to experience postpartum hemorrhage (8.6% vs 4.4%) and severe morbidity (3.5% vs 1.7%), according to the researchers.
Compared with birthing patients in mother-father partnerships, birthing patients in mother-mother partnerships experienced higher rates of multifetal gestation (adjusted risk ratio [aRR], 3.9) and labor induction (aRR, 1.2), as well as severe morbidity that did not require a blood transfusion (aRR, 1.4).
After excluding multifetal gestations, the differences in risk for mother-mother pairings persisted. Birthing patients who identified as fathers in any partnerships were not at a significantly elevated risk of any adverse obstetric or birth outcome considered in the study.
Potential drivers of the disparities in outcomes include policies that affect how sexual and/or gender minority (SGM) people who are pregnant access healthcare, as well as negative experiences in traditional healthcare settings, according to the researchers. Data suggest that chronic stress associated with discrimination and stigma can have deleterious effects on physical and mental health, they write.
In addition, “assisted reproductive technology use, which is more common among women in same-sex partnerships, has also been consistently associated with an increased risk of obstetrical and birth complications,” they report. “Together, these mechanisms may explain the increased risk of adverse outcomes among mothers with mother partners that were observed in this study.”
“We were not able to measure stress in this study, and it’s an important area of further research to understand the contributing causes of disparities in mother-mother partnerships,” Leonard told Medscape. “Multiple studies have shown that sexual and/or gender-minority individuals experience chronic stress, and chronic stress has a negative impact on the body.”
The study findings were limited by several factors, including the use of listed parental roles to infer SGM status and the consequent potential for misclassification, the researchers note. Other limitations include the possible incorrect reporting of births because of variations in the language used for recording births to gestational carriers at different hospitals, and potential undercount of SGM pairs because of individuals’ reluctance to disclose their status, they say.
However, the results were strengthened by the large and diverse sample size and the use of recently modified birth certificates, as well as the inclusion of birthing parents who identified as a father, the researchers write.
Call for Attention
Leonard said she was surprised by the magnitude of disparities in severe birth complications. “These also persisted after we accounted for differences in factors such as age, chronic health conditions, and twin pregnancies,” she said. “I think such large and persistent disparities point to quality of medical care as a potential driving factor and is something that we intend to explore further,” she added.
The take-home message for clinicians is “to recognize that not all births happen to mother-father couples and become aware of the unique healthcare needs of sexual and/or gender-minority patients,” Leonard said. “Critically assess what your practice could do differently to provide inclusive and high-quality care for LGBTQ+ people as they build their families through pregnancy and birth.”
More Research Needed to Improve Patient Care
“Sexual and/or gender minorities are building families, and there is an increased need to understand potential obstetric risks,” Iris Krishna, MD, assistant professor in the Department of Maternal-Fetal Medicine at Emory University, Atlanta, said in an interview.
Krishna said she, too, was surprised by the increased risk of postpartum hemorrhage and severe morbidity even after adjusting for confounders in comparison with mother-father pairs. Also of interest was the fact that birthing patients who identified as fathers ― and who likely were transmasculine ― seemed to have better outcomes than mother-mother pairs, she noted. The reason for the difference remains unclear, although mother-mother pairs had higher rates of having twins and other multiple gestations.
Physicians can help reduce disparities by creating a welcoming environment for all prospective parents, including SGM couples, Krishna said. She suggested using gender-affirming and inclusive language in educational materials and intake paperwork, as well as in the exam room. She also recommended training for staff, if appropriate, to increase awareness and improve the experiences of SGM couples.
“Overall, it appears that most SGM partnerships did not experience adverse outcomes,” Krishna said. However, more research is needed to explore the reasons for disparity for mother-mother pairs, she said.
“Mother-mother pairs have higher usage of assisted reproductive technology [ART] and higher rates of multifetal gestation, and research is also needed in the use of ART in this population,” she said. “Understanding these and other risks will lead to improved care of SGM partnerships.”
The study was supported by the Stanford Maternal and Child Health Research Institute. Leonard and Krishna reported no relevant financial relationships.
Am J Obstet Gynecol. Published online March 27, 2022. Abstract
Heidi Splete is a freelance medical journalist with 20 years of experience.