Birthing mothers with mother partners experience disparities in birth-related outcomes
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Birthing mothers with mother partners were more likely to experience several adverse obstetrical and birth outcomes compared with birthing mothers with father partners, according to study data.
“New data show that at least 7% of the U.S. population identifies as being sexual and/or gender minority (SGM) individuals or people who are more commonly referred to as LGBTQ+,” Stephanie A. Leonard, PhD, an instructor in the division of maternal-fetal medicine and obstetrics at Stanford University, told Healio. “Many of these individuals have children or want to have children, and some will do it through pregnancy and birth.”
“Evidence on obstetrical and birth outcomes among SGM individuals is sparse and is largely focused on cis-gender sexual minorities,” Leonard and colleagues wrote in American Journal of Obstetrics & Gynecology. “Research in large, population-based cohorts is critically needed to help identify and address the obstetrical needs of SGM individuals.”
Leonard and colleagues analyzed 1,488,578 live birth hospitalizations between 2016 to 2019 in California to compare obstetrical and birth outcomes between parents who were likely SGM with those who likely were not SGM. Since 2016, California has included gender neutral fields on its birth certificates for parents who were both giving birth and not giving birth to identify as “mother,” “father” or “parent.” Those who were likely SGM were defined as birthing patients who were either in mother-mother partnerships or identified as a father in any partnership, and those who were likely not SGM were defined as mother-identified birthing patients in mother-father partnerships.
Of those included in the study, 1,483,119 were birthing mothers in mother-father partnerships, 2,572 were birthing mothers in mother-mother partnerships and 498 were birthing fathers in any partnership.
Birthing patients in mother-mother partnerships experienced significantly higher rates of multifetal gestation (adjusted RR = 3.9; 95% CI, 3.4-4.4), labor induction (aRR = 1.2; 95% CI, 1.1-1.3), postpartum hemorrhage (aRR = 1.4; 95% CI, 1.3-1.6), severe morbidity (aRR = 1.4; 95% CI, 1.2-1.8) and nontransfusion severe morbidity (aRR = 1.4; 95% CI, 1.1-1.9) compared with those in mother-father partnerships. According to the researchers, nontransfusion severe morbidity “excluded cases in which a blood product transfusion was the only indicator of a severe event, as these cases may represent less severe complications and account for approximately half of all severe morbidity cases.”
“I was surprised at the magnitude of disparities in severe birth complications,” Leonard said. “These also persisted after we accounted for differences in factors such as age, chronic health conditions and twin pregnancies. 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.”
Gestational diabetes, hypertensive disorders of pregnancy, cesarean delivery, preterm birth, low birth weight and low 5-minute Apgar score did not significantly differ between mother-mother partnerships and mother-father partnerships in the multivariable analyses.
Outcomes between birthing fathers in any partnership and birthing mothers in mother-father partnerships were also not found to differ significantly.
“For clinicians, recognize that not all births happen to mother-father couples and become aware of the unique health care needs of SGM patients,” Leonard said. “Next, 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. Specific recommendations are available and apply to obstetric patients but also patients who may become or have been pregnant.”
Perspective
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Most studies that have looked at pregnancy outcomes among people with diverse sexual and gender identities have been small and retrospective or qualitative surveys. Large administrative databases have historically excluded people with diverse sexual and gender identities. Only recently have changes to birth certificates in some states, including California and Massachusetts, given new population level insight into obstetrical and birth outcomes among people who identity as SGM.
In their recent article, Leonard and colleagues performed a population based retrospective cohort study of all live births in California from 2016 to 2019. The study employed birth certificate data (including the new “parent giving birth” field), which were linked with discharge data for all live births during the study period. The cohort included more than 1.4 million people who gave birth, including 2,572 birthing mothers with mother partners and 498 birthing fathers with any partners — who represented the likely SGM group — and 1,483,119 birthing mothers with father partners — who represented the likely non-SGM group. Compared with the non-SGM group, the authors found that birthing mothers with mother partners had higher risks of postpartum hemorrhage, severe morbidity and non-transfusion severe morbidity, whereas birthing fathers with any partners did not experience higher risks of adverse obstetrical and birth complications.
Although the study has some limitations — including potential misclassification and lack of a validated “parent giving birth” field — it is an important contribution. The study raises questions about why birthing mothers with mother partners are at higher risk for complications. Although risks may be driven by multiple gestations, a surrogate for assisted reproduction, further study is needed. The study also found that birthing fathers, who are presumed to be men of transgender experience, are not at increased risk for adverse outcomes compared with non-SGM partnerships. While a reassuring finding, this study underscores the need for further population-based research that contains more granular data about gender identity.
Finally, the study is an excellent example of research that uses language that includes all study participants, including many who have been historically excluded from research. In some situations, the authors used gendered terms, such as “mother” and “father,” but they avoided using gendered language when its use would be inaccurate. For example, Leonard and colleagues refer to “severe morbidity” rather than “severe maternal morbidity.” The intentional use of accurate and inclusive language in this study ensures that all participants are accounted for. The use of inclusive language in this study should be emulated by researchers in obstetrics and gynecology and beyond.
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