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

Published:March 27, 2022DOI:https://doi.org/10.1016/j.ajog.2022.02.041

      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.

      Key words

      Why was this study conducted?

      We hypothesized that patients giving birth in sexual and/or gender minority partnerships are at an elevated risk of adverse outcomes.

      Key findings

      Birthing patients in mother-mother partnerships experienced significantly higher rates of several adverse outcomes than birthing patients in mother-father partnerships, including postpartum hemorrhage (8.6% vs 4.4%) and severe morbidity (3.5% vs 1.7%).
      Outcomes in birthing patients who identified as fathers in any partnership did not significantly differ from birthing patients in mother-father partnerships (P≥.05).

      What does this add to what is known?

      Mothers with mother partners experienced disparities in obstetrical and birth outcomes; they were independent of sociodemographic factors and comorbidities. Data collection improvements are needed to further research in the understudied area of sexual and/or gender minority perinatal health.

      Introduction

      Many people who are sexual and/or gender minorities (SGM), which include but are not limited to lesbian, gay, bisexual, and/or transgender people, build families through pregnancy and childbirth.
      • Goldberg A.E.
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      • Nazem T.G.
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      Understanding the reproductive experience and pregnancy outcomes of lesbian women undergoing donor intrauterine insemination.
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      Pregnancy intentions and outcomes among transgender, nonbinary, and gender-expansive people assigned female or intersex at birth in the United States: results from a national, quantitative survey.
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      Transgender men and pregnancy.
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      • Mann E.S.
      Experiences with achieving pregnancy and giving birth among transgender men: a narrative literature review.
      Advancements in marriage and parenting rights for SGM individuals and availability of assisted reproductive technologies have possibly led to enhanced family building among SGM people.
      • Downing J.M.
      Pathways to pregnancy for sexual minority women in same-sex marriages.
      • Besse M.
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      • Waddill C.B.
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      Care during pregnancy, childbirth, postpartum, and human milk feeding for individuals who identify as LGBTQ.
      However, SGM individuals face barriers to equitable healthcare, including discrimination and stigma in medical settings and clinicians who are not trained to meet their needs.
      Institute of Medicine
      The health of lesbian, gay, bisexual, and transgender people: building a Foundation for Better Understanding.
      These barriers are exacerbated in obstetrical care, as pregnancy and childbirth are widely assumed to be experiences of heterosexual cisgender women and care is generally offered in heteronormative, cisnormative settings.
      • Moseson H.
      • Fix L.
      • Hastings J.
      • et al.
      Pregnancy intentions and outcomes among transgender, nonbinary, and gender-expansive people assigned female or intersex at birth in the United States: results from a national, quantitative survey.
      ,
      • Obedin-Maliver J.
      • Makadon H.J.
      Transgender men and pregnancy.
      ,
      • Besse M.
      • Lampe N.M.
      • Mann E.S.
      Experiences with achieving pregnancy and giving birth among transgender men: a narrative literature review.
      • Griggs K.M.
      • Waddill C.B.
      • Bice A.
      • Ward N.
      Care during pregnancy, childbirth, postpartum, and human milk feeding for individuals who identify as LGBTQ.
      Institute of Medicine
      The health of lesbian, gay, bisexual, and transgender people: building a Foundation for Better Understanding.
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      • Borneskog C.
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      Mothers in same-sex relationships describe the process of forming a family as a stressful journey in a heteronormative world: a Swedish grounded theory study.
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      • Sevelius J.
      From erasure to opportunity: a qualitative study of the experiences of transgender men around pregnancy and recommendations for providers.
      SGM individuals also experience increased discrimination and stigma over their life course, which manifests as chronic “minority stress” that likely contributes to elevated rates of chronic conditions.
      Institute of Medicine
      The health of lesbian, gay, bisexual, and transgender people: building a Foundation for Better Understanding.
      ,
      • Hatzenbuehler M.L.
      How does sexual minority stigma “get under the skin”? A psychological mediation framework.
      It is highly plausible that this chronic overexposure to stress accelerates physiological deterioration so that the experience of pregnancy exacerbates existing or new health conditions, contributing to worse perinatal health outcomes.
      • Geronimus A.T.
      The weathering hypothesis and the health of African-American women and infants: evidence and speculations.
      Further, higher use of assisted reproductive technologies among SGM individuals could also confer an increased risk of complications.
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      • Wu Y.W.
      • Croughan M.S.
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      • Downing J.
      • Everett B.
      • Snowden J.M.
      Differences in perinatal outcomes of birthing people in same-sex and different-sex marriages.
      Together, these factors may put SGM individuals at an elevated risk of adverse outcomes during pregnancy and childbirth.
      Evidence on obstetrical and birth outcomes among SGM individuals is sparse and is largely focused on cisgender sexual minorities.
      • Moseson H.
      • Fix L.
      • Hastings J.
      • et al.
      Pregnancy intentions and outcomes among transgender, nonbinary, and gender-expansive people assigned female or intersex at birth in the United States: results from a national, quantitative survey.
      ,
      • Besse M.
      • Lampe N.M.
      • Mann E.S.
      Experiences with achieving pregnancy and giving birth among transgender men: a narrative literature review.
      ,
      • Downing J.
      • Everett B.
      • Snowden J.M.
      Differences in perinatal outcomes of birthing people in same-sex and different-sex marriages.
      • Everett B.G.
      • Kominiarek M.A.
      • Mollborn S.
      • Adkins D.E.
      • Hughes T.L.
      Sexual orientation disparities in pregnancy and infant outcomes.
      • Everett B.G.
      • Limburg A.
      • Charlton B.M.
      • Downing J.M.
      • Matthews P.A.
      Sexual identity and birth outcomes: a focus on the moderating role of race-ethnicity.
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      • Goldberg A.E.
      • Flanders C.E.
      • Yudin M.H.
      • Ross L.E.
      Reproductive and pregnancy experiences of diverse sexual minority women: a descriptive exploratory study.
      Research in large, population-based cohorts is critically needed to help identify and address the obstetrical needs of SGM individuals. In this study, we utilized newly modified birth certificate fields for self-identified parenting roles in California to compare the obstetrical and birth outcomes between birthing mothers with father partners (likely non-SGM), birthing mothers with mother partners, and birthing fathers with any partner (likely SGM).

      Materials and Methods

      This population-based cohort study drew from all live births in California from 2016 to 2019. California modified its birth certificate in 2016 to include the fields “parent giving birth” (henceforth “birthing parent”) and “parent not giving birth,” (henceforth “non-birthing parent”) with options for each role to specify “mother,” “father,” or “parent.” The California Maternal Quality Care Collaborative linked the state’s live birth certificate data to birth hospitalization discharge data for birthing parents and newborns through 2019 (with a successful linkage rate of 98.2%).
      • Herrchen B.
      • Gould J.B.
      • Nesbitt T.S.
      Vital statistics linked birth/infant death and hospital discharge record linkage for epidemiological studies.
      The California Committee for the Protection of Human Subjects and the Stanford University Research Compliance Office provided human subjects research approval.
      We focused this study on the comparison of birthing parents in likely SGM partnerships with birthing parents in likely non-SGM partnerships. We therefore excluded births in which either or both the parental roles were missing (Figure 1). Unlinked birth records and those with missing or implausible data were also excluded.
      Centers for Disease Control and Prevention
      User guide to the 2019 natality public use file. 2020.
      ,
      • Barradas D.T.
      • Dietz P.M.
      • Pearl M.
      • England L.J.
      • Callaghan W.M.
      • Kharrazi M.
      Validation of obstetric estimate using early ultrasound: 2007 California birth certificates.
      For analyses of birthing parent characteristics and outcomes, we selected the first record in the case of multifetal gestations to avoid duplicates (ie, 1 parent record for a twin birth). We classified birthing mothers with father partners as likely non-SGM and birthing mothers with mother partners and birthing fathers with any partner (ie, the nonbirthing parent selected parent, father, or mother) as likely SGM. We did not classify other parental structures.
      Figure thumbnail gr1
      Figure 1Sample selection from the full study population
      Leonard et al. Sexual and/or gender minority birth disparities. Am J Obstet Gynecol 2022.
      We evaluated several obstetrical and birth outcomes. From the birth certificate, these included multifetal gestation, cesarean delivery, preterm birth (<37 weeks’ gestation), low birthweight (<2500 g), and low Apgar score (<7 at 5 minutes). From the hospitalization discharge data, the outcomes included gestational diabetes mellitus, hypertensive disorders of pregnancy (and separately: preeclampsia with severe features or eclampsia and gestational hypertension or preeclampsia without severe features), labor induction, postpartum hemorrhage, severe morbidity, and nontransfusion severe morbidity. We identified severe morbidity following an established index.
      Centers for Disease Control and Prevention
      Severe maternal morbidity in the United States.
      ,
      Alliance for Innovation on Maternal Health
      AIM SMM codes list.
      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 they account for approximately half of all severe morbidity cases.
      Centers for Disease Control and Prevention
      Severe maternal morbidity in the United States.
      ,
      • Main E.K.
      • Abreo A.
      • McNulty J.
      • et al.
      Measuring severe maternal morbidity: validation of potential measures.
      We used causal diagrams to select the covariates for model adjustment on the basis of previous evidence and available variables (Supplemental Figure).
      • Downing J.
      • Everett B.
      • Snowden J.M.
      Differences in perinatal outcomes of birthing people in same-sex and different-sex marriages.
      ,
      • Everett B.G.
      • Kominiarek M.A.
      • Mollborn S.
      • Adkins D.E.
      • Hughes T.L.
      Sexual orientation disparities in pregnancy and infant outcomes.
      ,
      • Leonard S.A.
      • Main E.K.
      • Carmichael S.L.
      The contribution of maternal characteristics and cesarean delivery to an increasing trend of severe maternal morbidity.
      • Ratnasiri A.W.G.
      • Parry S.S.
      • Arief V.N.
      • et al.
      Recent trends, risk factors, and disparities in low birth weight in California, 2005-2014: a retrospective study.
      • Goldenberg R.L.
      • Culhane J.F.
      • Iams J.D.
      • Romero R.
      Epidemiology and causes of preterm birth.
      • Leonard S.A.
      • Kennedy C.J.
      • Carmichael S.L.
      • Lyell D.J.
      • Main E.K.
      An expanded obstetric comorbidity scoring system for predicting severe maternal morbidity.
      • Leonard S.A.
      • Main E.K.
      • Lyell D.J.
      • et al.
      Obstetric comorbidity scores and disparities in severe maternal morbidity across marginalized groups.
      We recognize that many of these covariates could be considered as confounders or mediators of associations between the SGM status and clinical outcomes. Therefore, the findings should be interpreted as how a given outcome for the likely SGM group would change if the distribution of the covariate were set to that of the likely non-SGM group.
      • VanderWeele T.J.
      • Robinson W.R.
      On the causal interpretation of race in regressions adjusting for confounding and mediating variables.
      For every outcome, the covariates included patient age, expected method of payment for the birth hospitalization, educational attainment, race-ethnicity (as a social characteristic), and parity. For obstetrical outcomes occurring during pregnancy, additional covariates included multifetal gestation, prepregnancy body mass index, and a prepregnancy comorbidity index, adapted from a validated obstetrical comorbidity index by excluding gestational comorbidities (eg, placenta previa).
      • Leonard S.A.
      • Kennedy C.J.
      • Carmichael S.L.
      • Lyell D.J.
      • Main E.K.
      An expanded obstetric comorbidity scoring system for predicting severe maternal morbidity.
      ,
      • Leonard S.A.
      • Main E.K.
      • Lyell D.J.
      • et al.
      Obstetric comorbidity scores and disparities in severe maternal morbidity across marginalized groups.
      For birth outcomes, the covariates in addition to the initial set included multifetal gestation and an obstetrical comorbidity index, which included prepregnancy and gestational comorbidities.
      • Leonard S.A.
      • Kennedy C.J.
      • Carmichael S.L.
      • Lyell D.J.
      • Main E.K.
      An expanded obstetric comorbidity scoring system for predicting severe maternal morbidity.
      ,
      • Leonard S.A.
      • Main E.K.
      • Lyell D.J.
      • et al.
      Obstetric comorbidity scores and disparities in severe maternal morbidity across marginalized groups.
      In the analysis, we first descriptively compared the characteristics and clinical outcomes between mothers giving birth with a mother partner, fathers giving birth with any partner, and mothers giving birth with a father partner. The P values were calculated using one-way analysis of variance tests for continuous variables and the Chi-square or Fisher exact test for categorical variables on the basis of the sample size. Next, we conducted a series of multivariable modified Poisson regression models to estimate the risk ratios (RRs) with 95% confidence intervals (CIs) for the associations between each likely SGM group and the outcomes described above. For gestational diabetes as an outcome, patients with preexisting diabetes mellitus were excluded from the analysis, because they cannot be at risk of developing gestational diabetes. For the neonatal outcomes of low birthweight (<2500 g) and low Apgar score (<7), we included each infant if the birth was multifetal and used robust standard errors in the models to account for correlation.
      • Zhang A.
      • Berrahou I.
      • Leonard S.A.
      • Main E.K.
      • Obedin-Maliver J.
      Birth registration policies in the United States and their relevance to sexual and/or gender minority families: identifying existing strengths and areas of improvement.
      These models in addition restricted to full-term infants (≥37 weeks’ gestational age).
      We then compared the 2 unclassified parental structures as follows: (1) parent was selected for the birthing parent role and parent, mother, or father was selected for the nonbirthing parent role and (2) mother was selected for the birthing parent role and parent selected for the nonbirthing parent role. The P values for descriptive comparisons were calculated using the Welch t test for continuous variables and the Chi-square or Fisher exact test for the categorical outcomes on the basis of the sample size. We conducted multivariable regression models as above.
      We also performed 2 ad hoc analyses to assess the robustness of our findings under different analytical decisions as follows: (1) We replicated the main regression models restricted to singleton gestations. Although multifetal gestation was included as a confounder in the multivariable regression models, the restriction was informative given the high prevalence of multifetal gestations among mother-mother partnerships. (2) We replicated the main regression models restricted to birthing parents who were born in the United States. Because the initial descriptive results showed a significantly higher proportion of foreign-born individuals in the father birthing parent group, we wanted to investigate whether foreign birthplace (a proxy for linguistic misinterpretation of the birth certificate fields) may have contributed to group classification and outcomes. The dataset was made in SAS version 9.4 (SAS Institute Inc, Cary, NC) and analyzed in R version 3.6.1 (R Core Team, Vienna, Austria).

      Results

      Study population

      The study sample included 1,488,578 parents giving birth to 1,511,323 infants over the period 2016 through 2019 (Figure 1). Of these, 1,483,119 were mothers with father partners (likely non-SGM), 2572 were mothers with mother partners, and 498 were fathers with any partner (likely SGM). In addition, 1501 were parents with any partner and 888 were mothers with parent partners, which we did not classify as likely SGM or non-SGM. In comparison with mothers with father partners, a higher proportion of mothers with mother partners had commercial health insurance, an undergraduate degree or higher, identified as White, were born in the United States, and were nulliparous (Table 1). Mothers with mother partners also had a higher age, prepregnancy body mass index, and comorbidity score. Fathers with any partner had overall similar characteristics as mothers with father partners, except that a lower proportion were Asian-Pacific Islander or nulliparous.
      Table 1Study population characteristics by likely sexual and/or gender minority parental structure, California, 2016 to 2019 (N=1,486,189)
      CharacteristicLikely SGMLikely non-SGM
      Mother giving birth with mother partner (n=2572) n (%)Father giving birth with any partner (n=498) n (%)Mother giving birth with father partner (n=1,483,119) n (%)
      Age, y (mean [SD])33.1 (5.4)30.8 (6.8)30.1 (5.8)
      Born in the United States2053 (80)289 (58)933,703 (63)
      Race-ethnicity
       Asian-Pacific Islander182 (7)62 (12)248,740 (17)
       Black114 (4)16 (3)61,176 (4)
       Hispanic-Latinx857 (33)238 (48)680,985 (46)
       White1224 (48)154 (31)417,516 (28)
       Multirace or other195 (8)28 (6)74,702 (5)
      Educational attainment
       Less than high school degree155 (6)70 (14)180,727 (12)
       High school degree or equivalent402 (16)130 (26)361,726 (24)
       Some college624 (24)132 (27)408,777 (28)
       Undergraduate degree or higher1391 (54)166 (33)531,889 (36)
      Expected method of payment for birth
       Commercial insurance1933 (75)256 (51)778,576 (52)
       Government-sponsored program596 (23)227 (46)651,096 (44)
       Self-pay or other43 (2)15 (3)53,447 (4)
      Obstetrical history
       Nulliparous1643 (64)166 (33)580,031 (39)
       Multiparous without previous cesarean647 (25)236 (47)639,534 (43)
       Multiparous with previous cesarean282 (11)96 (19)263,554 (18)
      Prepregnancy body mass index (mean [SD])28.6 (6.7)27.3 (5.6)27.6 (6.5)
      Obstetrical comorbidity score
      Weighted summary score of medical comorbidities and obstetrical comorbidities.28
      (mean [SD])
      5.8 (7.7)4.0 (6.7)4.2 (6.4)
      P value for all comparisons <.001.
      SD, standard deviation; SGM, sexual and/or gender minority.
      Leonard et al. Sexual and/or gender minority birth disparities. Am J Obstet Gynecol 2022.
      a Weighted summary score of medical comorbidities and obstetrical comorbidities.
      • Leonard S.A.
      • Kennedy C.J.
      • Carmichael S.L.
      • Lyell D.J.
      • Main E.K.
      An expanded obstetric comorbidity scoring system for predicting severe maternal morbidity.

      Outcomes by likely sexual and/or minority parental structure

      All obstetrical and birth outcomes differed by the likely SGM parental structure, except gestational diabetes (all P<.001) (Table 2). Mothers with mother partners experienced the highest rates of multifetal gestation (8.0%), hypertensive disorders of pregnancy (16.2%), labor induction (18.7%), cesarean delivery (40.4%), postpartum hemorrhage (8.6%), severe morbidity (3.5%), nontransfusion severe morbidity (1.7%), and preterm birth (11.8%). In addition, full-term infants born to mothers with mother partners experienced the highest rates of low birthweight (3.4%) and low Apgar score (1.7%). Differences in outcomes between fathers with any partner and mothers with father partners were minimal; the prevalence of multifetal gestation was higher (2.4% vs 1.5%).
      Table 2Clinical outcomes by likely sexual and/or gender parental structure, California, 2016 to 2019 (N=1,486,189)
      OutcomeLikely SGMLikely non-SGM
      Mother giving birth with mother partner (n=2572) n (%)Father giving birth with any partner (n=498) n (%)Mother giving birth with father partner (n=1,483,119) n (%)
      Multifetal gestation205 (8.0)12 (2.4)22,342 (1.5)
      Gestational diabetes mellitus
      Patients with preexisting diabetes mellitus excluded from denominator
      272 (10.7)45 (9.1)147,638 (10.1)
      Hypertensive disorder of pregnancy417 (16.2)40 (8.0)135,405 (9.1)
       Preeclampsia with severe features or eclampsia141 (5.5)<1243,739 (2.9)
       Gestational hypertension or preeclampsia without severe features286 (11.1)30 (6.0)95,224 (6.4)
      Labor induced481 (19)54 (11)189,789 (13)
      Cesarean delivery1038 (40)153 (31)461,803 (31)
      Postpartum hemorrhage220 (8.6)19 (3.8)65,810 (4.4)
      Severe morbidity
      Centers for Disease Control and Prevention index22
      90 (3.5)<1225,287 (1.7)
      Nontransfusion severe morbidity
      Centers for Disease Control and Prevention index22
      43 (1.7)<1211,483 (0.8)
      Preterm birth (<37 wk)301 (11.8)41 (8.3)112,093 (7.6)
      Low birthweight
      Restricted to full-term infants (≥37 weeks gestational age at birth).
      (<2500 g)
      80 (3.4)<1230,251 (2.2)
      Apgar score <7 at 5 min
      Restricted to full-term infants (≥37 weeks gestational age at birth).
      39 (1.7)<1212,182 (0.9)
      <12 indicates cell size too small to display per data use agreement. P values for all comparisons <.001, except for gestational diabetes mellitus (P value=.44).
      SGM, sexual and/or gender minority.
      Leonard et al. Sexual and/or gender minority birth disparities. Am J Obstet Gynecol 2022.
      a Patients with preexisting diabetes mellitus excluded from denominator
      b Centers for Disease Control and Prevention index
      Centers for Disease Control and Prevention
      Severe maternal morbidity in the United States.
      c Restricted to full-term infants (≥37 weeks gestational age at birth).
      Adjustment for covariates by multivariable regression attenuated all associations between the mother-mother parental structure and outcomes (Table 3). After adjustment, the mother-mother parental structure was associated with a higher risk of multifetal gestation (adjusted RR [aRR], 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 mother-father parental structure. No significant differences were observed in cesarean delivery or severe preeclampsia or eclampsia after covariate adjustment. No unadjusted or adjusted associations between the father birthing parental structure and outcomes were significant. Figures 2 and 3 summarize these results.
      Table 3Associations between likely sexual and/or gender minority parental structures and obstetrical and birth outcomes, California, 2016 to 2019 (N=1,486,189)
      Group

      Outcome
      Mother-mother partnerships vs mother-father partnershipsFather birthing parent partnerships vs mother-father partnerships
      Unadjusted risk ratio (95% CI)Adjusted risk ratio (95% CI)Unadjusted risk ratio (95% CI)Adjusted risk ratio (95% CI)
      Multifetal gestation
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, and parity
      ,
      Patients with preexisting diabetes mellitus excluded from denominator
      5.3 (4.6–6.0)3.9 (3.4–4.4)1.6 (0.9–2.8)1.5 (0.9–2.7)
      Gestational diabetes mellitus
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, prepregnancy body mass index, and weighted summary score of prepregnancy comorbidities28
      1.1 (0.9–1.2)0.9 (0.8–1.0)0.9 (0.9–1.2)0.9 (0.8–1.0)
      Hypertensive disorder of pregnancy
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, prepregnancy body mass index, and weighted summary score of prepregnancy comorbidities28
      1.8 (1.6–1.9)1.1 (0.9–1.2)0.9 (0.7–1.2)0.9 (0.7–1.2)
       Preeclampsia with severe features or eclampsia
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, prepregnancy body mass index, and weighted summary score of prepregnancy comorbidities28
      1.9 (1.6–2.2)1.1 (0.9–1.2)0.7 (0.4–1.3)0.7 (0.4–1.2)
       Gestational hypertension or preeclampsia without severe features
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, prepregnancy body mass index, and weighted summary score of prepregnancy comorbidities28
      1.7 (1.6–1.9)1.1 (0.9–1.2)0.9 (0.7–1.3)1.0 (0.7–1.4)
      Labor induced
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean)
      1.5 (1.3–1.6)1.2 (1.1–1.3)0.8 (0.7–1.1)0.9 (0.7–1.1)
      Cesarean birth
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean)
      1.3 (1.2–1.4)1.0 (0.9–1.1)1.0 (0.9–1.1)0.9 (0.8–1.1)
      Postpartum hemorrhage
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean)
      1.9 (1.7–2.2)1.4 (1.3–1.6)0.9 (0.6–1.3)0.9 (0.6–1.4)
      Severe morbidity
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean)
      ,
      Centers for Disease Control and Prevention index22
      2.1 (1.7–2.5)1.4 (1.2–1.8)1.1 (0.6–2.0)0.9 (0.4–1.9)
      Nontransfusion severe morbidity
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean)
      ,
      Centers for Disease Control and Prevention index22
      2.2 (1.6–2.9)1.4 (1.1–1.9)0.8 (0.3–2.4)0.5 (0.1–1.9)
      Preterm birth (<37 wk)
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean)
      1.6 (1.4–1.7)0.9 (0.9–1.1)1.1 (0.8–1.5)0.7 (0.4–1.5)
      Low birthweight (<2500 g)
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean)
      ,
      Restricted to full-term infants (≥37 weeks gestational age at birth). Each infant included if a multifetal gestation and used robust standard errors in models to account for correlation
      1.6 (1.2–1.9)0.9 (0.8–1.2)0.8 (0.4–1.6)0.8 (0.4–1.6)
      Apgar score <7 at 5 min
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean)
      ,
      Restricted to full-term infants (≥37 weeks gestational age at birth). Each infant included if a multifetal gestation and used robust standard errors in models to account for correlation
      1.9 (1.4–2.6)1.3 (0.9–1.7)
      Models were unstable because of a very small sample size.
      Models were unstable because of a very small sample size.
      CI, confidence interval.
      Leonard et al. Sexual and/or gender minority birth disparities. Am J Obstet Gynecol 2022.
      a Adjusted for patient age, education level, race-ethnicity (social factor), payment method, and parity
      b Patients with preexisting diabetes mellitus excluded from denominator
      c Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, prepregnancy body mass index, and weighted summary score of prepregnancy comorbidities
      • Leonard S.A.
      • Kennedy C.J.
      • Carmichael S.L.
      • Lyell D.J.
      • Main E.K.
      An expanded obstetric comorbidity scoring system for predicting severe maternal morbidity.
      d Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean)
      e Centers for Disease Control and Prevention index
      Centers for Disease Control and Prevention
      Severe maternal morbidity in the United States.
      f Restricted to full-term infants (≥37 weeks gestational age at birth). Each infant included if a multifetal gestation and used robust standard errors in models to account for correlation
      g Models were unstable because of a very small sample size.
      Figure thumbnail gr2
      Figure 2Mother-mother parental structure compared with mother-father parental structure
      Unadjusted (red) and adjusted (blue) risk ratios and 95% confidence intervals presented.
      Leonard et al. Sexual and/or gender minority birth disparities. Am J Obstet Gynecol 2022.
      Figure thumbnail gr3
      Figure 3Parental structure of father giving birth in any partnership compared with mother-father parental structure
      Unadjusted (red) and adjusted (blue) risk ratios and 95% confidence intervals presented.
      Leonard et al. Sexual and/or gender minority birth disparities. Am J Obstet Gynecol 2022.

      Outcomes among unclassified parental structures

      We then compared the unclassified parental structures as follows: (1) parent selected for the birthing parent role and parent, mother, or father selected for the nonbirthing parent role and (2) mother selected for the birthing parent role and parent selected for the nonbirthing parent role (Table 4). These 2 groups significantly differed in all the characteristics and outcomes (P<.01). Parents with any partner had relatively high proportions of foreign-born, Hispanic-Latinx race-ethnicity, college education, and payment method other than commercial or government-sponsored insurance. In contrast, mothers with parent partners had relatively high proportions of US-born, Black race-ethnicity, college education, commercial health insurance, and nulliparity. When compared with the mother-father parental structure, the parent birthing parental structure was associated with a higher risk of multifetal gestation (aRR, 1.7; 95% CI, 1.3–2.3) and a lower risk of gestational diabetes (aRR, 0.8; 95% CI, 0.7–0.9) (Table 5). The mother-parent parental structure was associated with a higher risk of multifetal gestation (aRR, 3.4; 95% CI, 2.6–4.3) and labor induction (aRR, 1.2; 95% CI, 1.0–1.3).
      Table 4Study population characteristics and clinical outcomes among unclassified parental structures, California, 2016 to 2019 (N=2389)
      CharacteristicsParent giving birth with any partner (n=1501) n (%)Mother giving birth with parent partner (n=888) n (%)
      Age, y (mean [SD])31.6 (5.7)32.5 (5.8)
      Born in the United States701 (47)716 (81)
      Race-ethnicity
       Asian-Pacific Islander171 (11)66 (7)
       Black54 (4)85 (10)
       Hispanic-Latinx843 (56)314 (35)
       White373 (25)349 (39)
       Other60 (4)74 (8)
      Educational attainment
       Less than high school degree106 (7)56 (6)
       High school degree or equivalent270 (18)146 (16)
       Some college295 (20)260 (29)
       Undergraduate degree or higher830 (55)426 (48)
      Expected method of payment for birth
       Commercial insurance621 (41)632 (71)
       Government-sponsored program409 (27)251 (28)
       Self-pay or other471 (31)<12
      Obstetrical history
       Nulliparous718 (48)574 (65)
       Multiparous without previous cesarean delivery537 (36)221 (25)
       Multiparous with previous cesarean delivery246 (16)93 (10)
      Prepregnancy body mass index (mean [SD])27.4 (6.3)29.2 (7.1)
      Obstetrical comorbidity score
      Weighted summary score of medical comorbidities and obstetrical comorbidities28
      (mean [SD])
      3.8 (6.6)5.8 (7.8)
      Clinical outcomes
      Multifetal gestation44 (2.9)57 (6.4)
      Gestational diabetes mellitus
      Patients with preexisting diabetes mellitus excluded from denominator
      132 (8.9)113 (12.9)
      Hypertensive disorder of pregnancy136 (9.1)149 (16.8)
       Preeclampsia with severe features or eclampsia49 (3.3)48 (5.4)
       Gestational hypertension or preeclampsia without severe features91 (6.1)103 (11.6)
      Labor induced143 (10)156 (18)
      Cesarean delivery487 (32)321 (36)
      Postpartum hemorrhage60 (4.0)61 (6.9)
      Severe morbidity
      Centers for Disease Control and Prevention index22
      32 (2.1)28 (3.2)
      Nontransfusion severe morbidity
      Centers for Disease Control and Prevention index22
      16 (1.1)14 (1.6)
      Preterm birth (<37 wk)117 (7.8)87 (10.0)
      Low birthweight (<2500 g)
      Restricted to full-term infants (≥37 weeks gestational age at birth).
      25 (1.8)31 (3.8)
      Apgar score <7 at 5 min
      Restricted to full-term infants (≥37 weeks gestational age at birth).
      <12<12
      <12 indicates that the cell size is too small to display per data use agreement. P value for all comparisons <.01.
      SD, standard deviation.
      Leonard et al. Sexual and/or gender minority birth disparities. Am J Obstet Gynecol 2022.
      a Weighted summary score of medical comorbidities and obstetrical comorbidities
      • Leonard S.A.
      • Kennedy C.J.
      • Carmichael S.L.
      • Lyell D.J.
      • Main E.K.
      An expanded obstetric comorbidity scoring system for predicting severe maternal morbidity.
      b Patients with preexisting diabetes mellitus excluded from denominator
      c Centers for Disease Control and Prevention index
      Centers for Disease Control and Prevention
      Severe maternal morbidity in the United States.
      d Restricted to full-term infants (≥37 weeks gestational age at birth).
      Table 5Associations between unclassified parental structures and obstetrical and birth outcomes, California, 2016 to 2019 (n=1,485,508)
      OutcomeParent birthing parent partnerships vs mother-father partnershipsMother-parent partnerships vs mother-father partnerships
      Unadjusted risk ratio (95% CI)Adjusted risk ratio (95% CI)Unadjusted risk ratio (95% CI)Adjusted risk ratio (95% CI)
      Multifetal gestation
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, and parity
      ,
      Patients with preexisting diabetes mellitus excluded from denominator
      2.0 (1.5–2.6)1.7 (1.3–2.3)4.3 (3.3–5.5)3.4 (2.6–4.3)
      Gestational diabetes mellitus
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, prepregnancy body mass index, and weighted summary score of prepregnancy comorbidities
      0.9 (0.8–1.1)0.8 (0.7–0.9)1.3 (1.1–1.5)0.9 (0.8–1.1)
      Hypertensive disorder of pregnancy
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, prepregnancy body mass index, and weighted summary score of prepregnancy comorbidities
      1.0 (0.8–1.2)0.9 (0.8–1.1)1.8 (1.6–2.1)1.1 (0.9–1.3)
       Preeclampsia with severe features or eclampsia
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, prepregnancy body mass index, and weighted summary score of prepregnancy comorbidities
      1.1 (0.8–1.5)1.0 (0.7–1.3)1.8 (1.4–2.4)0.9 (0.7–1.2)
       Gestational hypertension or preeclampsia without severe features
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, prepregnancy body mass index, and weighted summary score of prepregnancy comorbidities
      0.9 (0.8–1.2)0.9 (.7–1.1)1.8 (1.5–2.2)1.2 (0.9–1.4)
      Labor induced
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean delivery)
      0.7 (0.6–0.9)0.7 (0.6–0.9)1.4 (1.2–1.6)1.2 (1.0–1.3)
      Cesarean birth
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean delivery)
      1.0 (1.1–1.3)0.9 (0.9–1.1)1.2 (1.1–1.3)1.0 (0.9–1.1)
      Postpartum hemorrhage
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean delivery)
      0.9 (0.7–1.2)0.9 (0.7–1.2)1.5 (1.2–2.0)1.1 (0.9–1.4)
      Severe morbidity
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean delivery)
      ,
      Centers for Disease Control and Prevention index22
      1.3 (0.9–1.8)1.2 (0.8–1.6)1.8 (1.3–2.7)1.2 (0.8–1.8)
      Nontransfusion severe morbidity
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean delivery)
      ,
      Centers for Disease Control and Prevention index22
      1.4 (0.8–2.2)1.3 (0.8–2.0)2.0 (1.2–3.4)1.2 (0.7–2.1)
      Preterm birth (<37 wk)
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean delivery)
      1.0 (0.9–1.2)0.9 (0.8–1.1)1.3 (1.1–1.6)0.8 (0.7–1.1)
      Low birthweight (<2500 g)
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean delivery)
      ,
      Restricted to full-term infants (≥37 weeks gestational age at birth). Each infant included if a multifetal gestation and used robust standard errors in models to account for correlation
      0.8 (0.6–1.2)0.8 (0.5–1.1)1.7 (1.2–2.4)0.9 (0.7–1.3)
      Apgar score <7 at 5 min
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean delivery)
      ,
      Restricted to full-term infants (≥37 weeks gestational age at birth). Each infant included if a multifetal gestation and used robust standard errors in models to account for correlation
      0.8 (0.4–1.5)
      Models were unstable because of a very small sample size.
      1.4 (0.7–2.5)
      Models were unstable because of a very small sample size.
      CI, confidence interval.
      Leonard et al. Sexual and/or gender minority birth disparities. Am J Obstet Gynecol 2022.
      a Adjusted for patient age, education level, race-ethnicity (social factor), payment method, and parity
      b Patients with preexisting diabetes mellitus excluded from denominator
      c Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, prepregnancy body mass index, and weighted summary score of prepregnancy comorbidities
      d Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean delivery)
      e Centers for Disease Control and Prevention index
      Centers for Disease Control and Prevention
      Severe maternal morbidity in the United States.
      f Restricted to full-term infants (≥37 weeks gestational age at birth). Each infant included if a multifetal gestation and used robust standard errors in models to account for correlation
      g Models were unstable because of a very small sample size.

      Sensitivity analyses

      Comparisons restricted to singleton gestations (n=1,463,630) revealed some differences in crude associations but negligible differences in adjusted associations compared with statistical adjustment for multifetal gestation in the primary analysis (Supplemental Table 1). Restriction to only US-born birthing parents (n=936,045 parents, 950,667 infants) produced similar results as among the full study sample (Supplemental Table 2).

      Comment

      Principal findings

      Mothers with mother partners experienced higher rates of several adverse obstetrical and birth outcomes than mothers with father partners in a large, diverse state. These associations were attenuated but persisted with adjustment for sociodemographic factors and comorbidities and restriction to singleton gestations. Fathers giving birth in any partnership did not experience significant differences in obstetrical and birth outcomes from mothers with father partners.

      Results in the context of what is known

      Previous studies on obstetrical and birth outcomes among SGM individuals are limited and have focused on cisgender women.
      • Downing J.
      • Everett B.
      • Snowden J.M.
      Differences in perinatal outcomes of birthing people in same-sex and different-sex marriages.
      • Everett B.G.
      • Kominiarek M.A.
      • Mollborn S.
      • Adkins D.E.
      • Hughes T.L.
      Sexual orientation disparities in pregnancy and infant outcomes.
      • Everett B.G.
      • Limburg A.
      • Charlton B.M.
      • Downing J.M.
      • Matthews P.A.
      Sexual identity and birth outcomes: a focus on the moderating role of race-ethnicity.
      In a study of singleton live births, Everett et al
      • Everett B.G.
      • Kominiarek M.A.
      • Mollborn S.
      • Adkins D.E.
      • Hughes T.L.
      Sexual orientation disparities in pregnancy and infant outcomes.
      reported higher rates of low birthweight and preterm birth among 86 cisgender lesbian women than among 15,135 cisgender heterosexual women. We found disparities in low birthweight and preterm birth for mothers with mother partners that were lower in magnitude than those reported by Everett et al
      • Everett B.G.
      • Kominiarek M.A.
      • Mollborn S.
      • Adkins D.E.
      • Hughes T.L.
      Sexual orientation disparities in pregnancy and infant outcomes.
      and were not significant after accounting for the difference in multifetal gestations. In the United States, several states have modified options for gender and parental role on birth certificates.
      • Zhang A.
      • Berrahou I.
      • Leonard S.A.
      • Main E.K.
      • Obedin-Maliver J.
      Birth registration policies in the United States and their relevance to sexual and/or gender minority families: identifying existing strengths and areas of improvement.
      Downing et al
      • Downing J.
      • Everett B.
      • Snowden J.M.
      Differences in perinatal outcomes of birthing people in same-sex and different-sex marriages.
      utilized birth certificate data from singleton live births to married parents in Massachusetts, finding similar rates of preterm birth, small for gestational age, and low birthweight among 1112 births in same-sex marriages as among 200,761 births in different-sex marriages. Our study expands on the important work of Downing et al,
      • Downing J.
      • Everett B.
      • Snowden J.M.
      Differences in perinatal outcomes of birthing people in same-sex and different-sex marriages.
      finding similar results for neonatal outcomes and further leveraging hospitalization discharge data, which were linked to birth certificate records in a large, diverse state. This unique data resource enabled us to study obstetrical complications, which are not reliably captured on birth certificates.
      • Lydon-Rochelle M.T.
      • Holt V.L.
      • Nelson J.C.
      • et al.
      Accuracy of reporting maternal in-hospital diagnoses and intrapartum procedures in Washington State linked birth records.
      Our findings add substantial evidence on obstetrical and birth outcomes among fathers giving birth. Several researchers have led foundational work in understanding the pregnancy experiences of transmasculine individuals through smaller, often qualitative studies without comparison groups, which have featured experiential data on the basis of self-reporting.
      • Moseson H.
      • Fix L.
      • Hastings J.
      • et al.
      Pregnancy intentions and outcomes among transgender, nonbinary, and gender-expansive people assigned female or intersex at birth in the United States: results from a national, quantitative survey.
      ,
      • Obedin-Maliver J.
      • Makadon H.J.
      Transgender men and pregnancy.
      ,
      • Besse M.
      • Lampe N.M.
      • Mann E.S.
      Experiences with achieving pregnancy and giving birth among transgender men: a narrative literature review.
      ,
      • Hoffkling A.
      • Obedin-Maliver J.
      • Sevelius J.
      From erasure to opportunity: a qualitative study of the experiences of transgender men around pregnancy and recommendations for providers.
      Their work has established that transmasculine individuals in the US have children through pregnancy and childbirth but face heightened barriers to positive experiences and outcomes, including negative interactions with obstetrical healthcare professionals.
      • Moseson H.
      • Fix L.
      • Hastings J.
      • et al.
      Pregnancy intentions and outcomes among transgender, nonbinary, and gender-expansive people assigned female or intersex at birth in the United States: results from a national, quantitative survey.
      ,
      • Obedin-Maliver J.
      • Makadon H.J.
      Transgender men and pregnancy.
      ,
      • Besse M.
      • Lampe N.M.
      • Mann E.S.
      Experiences with achieving pregnancy and giving birth among transgender men: a narrative literature review.
      ,
      • Hoffkling A.
      • Obedin-Maliver J.
      • Sevelius J.
      From erasure to opportunity: a qualitative study of the experiences of transgender men around pregnancy and recommendations for providers.
      Transgender and gender-diverse individuals also experience exceptionally high rates of major mental health conditions likely stemming from chronic exposure to stigma and discrimination.
      • Valentine S.E.
      • Shipherd J.C.
      A systematic review of social stress and mental health among transgender and gender non-conforming people in the United States.
      In our study, we classified birthing parents who identified as a father on the birth certificate as likely transmasculine individuals. Our findings provide the first population-based insight into outcomes in this extremely understudied obstetrical patient population. In general, we found father birthing parents to share similar demographic and clinical characteristics and outcomes as likely non-SGM birthing parents and better outcomes compared with birthing parents in mother-mother partnerships. These preliminary data should be interpreted considering the unknown validity of the father as birthing parent option on the birth certificate (further described below).

      Clinical implications

      Interrelations between societal, community, interpersonal, and individual factors contribute to health disparities experienced by SGM people.
      National Institute on Minority Health and Health Disparities
      Sexual & gender minority health disparities research framework. 2022.
      At the societal level, there are laws and policies that affect how SGM pregnant people access and experience healthcare.
      Institute of Medicine
      The health of lesbian, gay, bisexual, and transgender people: building a Foundation for Better Understanding.
      At the community and interpersonal levels, cisnormative, heteronormative obstetrical healthcare is widely reported to have a negative impact on SGM pregnant people.
      • Obedin-Maliver J.
      • Makadon H.J.
      Transgender men and pregnancy.
      ,
      • Besse M.
      • Lampe N.M.
      • Mann E.S.
      Experiences with achieving pregnancy and giving birth among transgender men: a narrative literature review.
      ,
      • Appelgren Engström H.
      • Häggström-Nordin E.
      • Borneskog C.
      • Almqvist A.L.
      Mothers in same-sex relationships describe the process of forming a family as a stressful journey in a heteronormative world: a Swedish grounded theory study.
      ,
      • Hafford-Letchfield T.
      • Cocker C.
      • Rutter D.
      • Tinarwo M.
      • McCormack K.
      • Manning R.
      What do we know about transgender parenting?: findings from a systematic review.
      At the individual level, the minority stress model proposes that the discrimination and stigma experienced by SGM individuals creates chronic stress that has pathophysiological effects leading to increased rates of physical and mental health conditions.
      Institute of Medicine
      The health of lesbian, gay, bisexual, and transgender people: building a Foundation for Better Understanding.
      ,
      • Hatzenbuehler M.L.
      How does sexual minority stigma “get under the skin”? A psychological mediation framework.
      ,
      • Caceres B.A.
      • Streed C.G.
      • Corliss H.L.
      • et al.
      Assessing and addressing cardiovascular health in LGBTQ adults: a scientific statement From the American Heart Association.
      Assisted reproductive technology use, which is more common among women in same-sex partnerships,
      • Downing J.M.
      Pathways to pregnancy for sexual minority women in same-sex marriages.
      has also been consistently associated with an increased risk of obstetrical and birth complications.
      • Jackson R.A.
      • Gibson K.A.
      • Wu Y.W.
      • Croughan M.S.
      Perinatal outcomes in singletons following in vitro fertilization: a meta-analysis.
      ,
      • Chih H.J.
      • Elias F.T.S.
      • Gaudet L.
      • Velez M.P.
      Assisted reproductive technology and hypertensive disorders of pregnancy: systematic review and meta-analyses.
      Together, these mechanisms may explain the increased risk of adverse outcomes among mothers with mother partners that were observed in this study.
      Relatedly, previous research has identified disparities in cardiovascular risk factors and outcomes for SGM individuals, particularly cisgender lesbian and/or bisexual women and transgender women.
      • Caceres B.A.
      • Streed C.G.
      • Corliss H.L.
      • et al.
      Assessing and addressing cardiovascular health in LGBTQ adults: a scientific statement From the American Heart Association.
      Our findings suggest these health disparities in the general adult population extend into pregnancy and have implications for the health of SGM birthing patients. Although further research is needed, clinicians may be able to improve healthcare and subsequently outcomes for pregnant SGM patients through the use of inclusive practices in the clinical setting.
      • Griggs K.M.
      • Waddill C.B.
      • Bice A.
      • Ward N.
      Care during pregnancy, childbirth, postpartum, and human milk feeding for individuals who identify as LGBTQ.
      Recommendations on how to provide more inclusive obstetrical healthcare to SGM patients are available.
      • Griggs K.M.
      • Waddill C.B.
      • Bice A.
      • Ward N.
      Care during pregnancy, childbirth, postpartum, and human milk feeding for individuals who identify as LGBTQ.
      ,
      • Moseson H.
      • Zazanis N.
      • Goldberg E.
      • et al.
      The imperative for transgender and gender nonbinary inclusion: beyond women’s health.
      Our study also demonstrated a very high rate of multifetal gestation among mothers with mother partners (8%) and mothers with parent partners (6%). This finding is likely explained by higher usage of assisted reproductive technology among birthing women in same-sex partnerships.
      • Downing J.M.
      Pathways to pregnancy for sexual minority women in same-sex marriages.
      Further guidance to support SGM individuals who desire to build their family using assisted reproductive technologies while minimizing harm, is needed.

      Research implications

      This study demonstrates the need for further research to understand perinatal health and family building among SGM individuals. In particular, our study is the first to investigate and identify disparities in multiple obstetrical complications, including higher rates of postpartum hemorrhage and severe morbidity among mothers with mother partners. The designation of parental role on the birth certificate in California enabled this initial investigation, but additional research is needed to understand how parents and hospital workers are interpreting and selecting the options presented. Parents who identify as a parent rather than as a mother or father likely represent diverse sexual orientations and/or gender identities, and their reason for selecting parent is unknown. Population-based research that directly collects sexual orientation and gender identities as distinct from reproductive anatomy is needed.
      Institute of Medicine
      The health of lesbian, gay, bisexual, and transgender people: building a Foundation for Better Understanding.
      In addition, this study focused on parents giving birth in partnerships. However, research is needed on the barriers and facilitators to family building among all SGM individuals who would like to and have had children, including those who do not have partners.
      • Hafford-Letchfield T.
      • Cocker C.
      • Rutter D.
      • Tinarwo M.
      • McCormack K.
      • Manning R.
      What do we know about transgender parenting?: findings from a systematic review.
      ,
      • Chen D.
      • Matson M.
      • Macapagal K.
      • et al.
      Attitudes toward fertility and reproductive health among transgender and gender-nonconforming adolescents.

      Strengths and limitations

      This study has 3 notable strengths. First, we utilized data from recently modified birth certificates linked to data from birth hospitalizations in a large, diverse state to assess perinatal health among likely SGM birthing parents. Together, the birth certificate and hospitalization discharge data provide rich, reliable information on both sociodemographic and clinical characteristics and outcomes that has been previously unavailable for research in SGM health.
      • Lydon-Rochelle M.T.
      • Holt V.L.
      • Nelson J.C.
      • et al.
      Accuracy of reporting maternal in-hospital diagnoses and intrapartum procedures in Washington State linked birth records.
      ,
      • Vinikoor L.C.
      • Messer L.C.
      • Laraia B.A.
      • Kaufman J.S.
      Reliability of variables on the North Carolina birth certificate: a comparison with directly queried values from a cohort study.
      Second, this study assessed obstetrical and birth outcomes among birthing parents who identified as a father, expanding previous work among cisgender sexual minority people to include likely gender minority people. Third, these study characteristics combined, enabled evidence highly relevant to obstetrical healthcare and supported the internal and external validity of our findings.
      Our results must also be interpreted in the context of the following 3 study limitations. First, parental roles were used to infer likely SGM status, but misclassification undoubtedly resulted. Specific groups could be particularly vulnerable to misclassification, such as cisgender bisexual women giving birth or transgender parents in the nonbirthing role. For example, a cisgender bisexual woman partnered with a cisgender man could indicate a mother-father partnership on the birth certificate, as could a cisgender heterosexual woman partnered with a transgender man. In both the cases, these 2 parental structures would have been misclassified as likely non-SGM. This was unavoidable given the available data. Given the known and substantial health disparities among cisgender bisexual women and other SGM people,
      • Everett B.G.
      • Kominiarek M.A.
      • Mollborn S.
      • Adkins D.E.
      • Hughes T.L.
      Sexual orientation disparities in pregnancy and infant outcomes.
      ,
      Health of lesbian, gay, bisexual, and transgender populations.
      ,
      • Limburg A.
      • Everett B.G.
      • Mollborn S.
      • Kominiarek M.A.
      Sexual orientation disparities in preconception health.
      misclassification of these partnerships in the likely non-SGM group could have attenuated differences in comparisons with the other groups. Second, parents and staff who fill out the birth certificate worksheet may not understand the options presented for the parental role. Although there is a statewide standard birth certificate system, individual hospitals may provide customized birth certificate worksheets to parents, likely introducing variation in reporting. In addition, hospitals may vary in their reporting of births to gestational carriers. The federal government currently instructs that in instances of a gestational carrier, the information on the birth certificate worksheet for “the woman who gave birth to or delivered the infant” should be for the gestational carrier.
      Centers for Disease Control and Prevention
      Guide to completing the facility worksheets for the certificate of live birth and report of fetal death.
      ,
      • Perkins K.M.
      • Boulet S.L.
      • Levine A.D.
      • Jamieson D.J.
      • Kissin D.M.
      Differences in the utilization of gestational surrogacy between states in the U.S.
      However, both the birth recording practices and the usage and legality of gestational carriers vary by state.
      • Zhang A.
      • Berrahou I.
      • Leonard S.A.
      • Main E.K.
      • Obedin-Maliver J.
      Birth registration policies in the United States and their relevance to sexual and/or gender minority families: identifying existing strengths and areas of improvement.
      ,
      • Perkins K.M.
      • Boulet S.L.
      • Levine A.D.
      • Jamieson D.J.
      • Kissin D.M.
      Differences in the utilization of gestational surrogacy between states in the U.S.
      Third, parents could be apprehensive to disclose their minoritized parenting structure, leading to a possible undercount of likely SGM people and misclassification into other parental structures; this would minimize the observed differences in the outcomes.

      Conclusions

      Most parents giving birth in likely SGM partnerships did not experience adverse obstetrical or birth outcomes. However, mothers with mother partners experienced disparities in several outcomes when compared with mothers with father partners, including a higher risk of postpartum hemorrhage and severe morbidity. The perinatal health of SGM individuals is understudied, and additional research is needed to facilitate equitable healthcare and outcomes.

      Acknowledgment

      We acknowledge the California Department of Health Care Access and Information and the California Maternal Quality Care Collaborative for providing the study data.

      Supplementary Data

      • Loading ...

      Appendix

      Figure thumbnail fx1
      Supplemental FigureCausal diagrams used to plan multivariable analyses for this study from the available data
      Some arrows are bidirectional, as the sexual and/or gender minorities status could affect or be affected by the factor. A, Multifetal gestation as outcome B, Obstetrical outcome during pregnancy. In separate models, these included gestational diabetes mellitus, hypertensive disorder of pregnancy, preeclampsia with severe features or eclampsia, and gestational hypertension or preeclampsia without severe features. The prepregnancy comorbidities were included as a weighted summary score of pulmonary hypertension, chronic renal disease, bleeding disorder, cardiac condition, HIV/AIDS, moderate or severe asthma, gastrointestinal disorder, neuromuscular disorder, connective tissue or autoimmune disorder, diabetes mellitus, chronic hypertension, major mental health condition, uterine fibroids, and thyroiditis, selected from an obstetrical comorbidity scoring system.
      • Barradas D.T.
      • Dietz P.M.
      • Pearl M.
      • England L.J.
      • Callaghan W.M.
      • Kharrazi M.
      Validation of obstetric estimate using early ultrasound: 2007 California birth certificates.
      C, Birth outcome. In separate models, these included labor induction, cesarean delivery, postpartum hemorrhage, severe maternal morbidity (the Centers for Disease Control and Prevention index), preterm birth and low birthweight and low Apgar score among full-term births. For prepregnancy and gestational comorbidities, we used 1 weighted composite score.
      • Barradas D.T.
      • Dietz P.M.
      • Pearl M.
      • England L.J.
      • Callaghan W.M.
      • Kharrazi M.
      Validation of obstetric estimate using early ultrasound: 2007 California birth certificates.
      In addition to the aforementioned prepregnancy comorbidities, this score included anemia, preeclampsia with severe features, gestational hypertension or preeclampsia without severe features, delivery body mass index 40 kg/m2 or greater, placenta accrete spectrum, placenta previa, placental abruption, gestational diabetes mellitus, preterm birth, and previous cesarean delivery.
      Leonard et al. Sexual and/or gender minority birth disparities. Am J Obstet Gynecol 2022.
      Supplemental Table 1Associations between parental structure and obstetrical and birth outcomes among singleton gestations, California, 2016 to 2019
      Group

      Outcome
      Mother-mother partnerships vs mother-father partnershipsFather birthing parent partnerships vs mother-father partnerships
      Unadjusted risk ratio (95% CI)Adjusted risk ratio (95% CI)Unadjusted risk ratio (95% CI)Adjusted risk ratio (95% CI)
      Gestational diabetes mellitus
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, prepregnancy body mass index, and weighted summary score of prepregnancy comorbidities21
      ,
      Patients with preexisting diabetes mellitus excluded from denominator
      1.0 (0.9–1.2)0.9 (0.8–1.0)0.9 (0.7–1.2)0.9 (0.7–1.2)
      Hypertensive disorder of pregnancy
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, prepregnancy body mass index, and weighted summary score of prepregnancy comorbidities21
      1.6 (1.5–1.8)1.1 (0.9–1.2)0.9 (0.7–1.2)0.9 (0.7–1.3)
       Preeclampsia with severe features or eclampsia
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, prepregnancy body mass index, and weighted summary score of prepregnancy comorbidities21
      1.6 (1.3–1.9)1.0 (0.8–1.2)0.7 (0.4–1.3)0.7 (0.4–1.2)
       Gestational hypertension or preeclampsia without severe features
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, prepregnancy body mass index, and weighted summary score of prepregnancy comorbidities21
      1.6 (1.4–1.8)1.1 (0.9–1.3)1.0 (0.7–1.4)1.0 (0.7–1.5)
      Labor induced
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score21 (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean delivery)
      1.5 (1.4–1.6)1.2 (1.1–1.3)0.8 (0.7–1.1)0.9 (0.7–1.1)
      Cesarean birth
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score21 (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean delivery)
      1.2 (1.1–1.3)1.1 (1.0–1.1)1.0 (0.8–1.1)0.9 (0.8–1.1)
      Postpartum hemorrhage
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score21 (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean delivery)
      1.7 (1.5–2.0)1.4 (1.2–1.6)0.8 (0.5–1.3)0.8 (0.5–1.3)
      Severe maternal morbidity
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score21 (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean delivery)
      1.7 (1.3–2.2)1.4 (1.1–1.8)0.9 (0.4–1.8)0.7 (0.3–1.6)
      Non-transfusion severe maternal morbidity
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score21 (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean delivery)
      1.6 (1.1–2.4)1.2 (0.9–1.7)
      Model unstable because of a very small sample size
      Model unstable because of a very small sample size
      Preterm birth (<37 wk)
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score21 (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean delivery)
      1.1 (0.9–1.3)1.0 (0.8–1.1)1.0 (0.7–1.4)0.6 (0.2–1.4)
      Low birthweight (<2500 g)
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score21 (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean delivery)
      ,
      Restricted to full-term infants (≥37 weeks gestational age at birth). Each infant included if a multifetal gestation and used robust standard errors in models to account for correlation.
      1.3 (0.9–1.7)1.2 (0.9–1.5)0.8 (0.4–1.7)0.9 (0.4–1.8)
      Apgar score <7 at 5 min
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score21 (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean delivery)
      ,
      Restricted to full-term infants (≥37 weeks gestational age at birth). Each infant included if a multifetal gestation and used robust standard errors in models to account for correlation.
      1.8 (1.3–2.5)1.3 (0.9–1.7)
      Model unstable because of a very small sample size
      Model unstable because of a very small sample size
      CI, confidence interval.
      Leonard et al. Sexual and/or gender minority birth disparities. Am J Obstet Gynecol 2022.
      a Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, prepregnancy body mass index, and weighted summary score of prepregnancy comorbidities
      • Barradas D.T.
      • Dietz P.M.
      • Pearl M.
      • England L.J.
      • Callaghan W.M.
      • Kharrazi M.
      Validation of obstetric estimate using early ultrasound: 2007 California birth certificates.
      b Patients with preexisting diabetes mellitus excluded from denominator
      c Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score
      • Barradas D.T.
      • Dietz P.M.
      • Pearl M.
      • England L.J.
      • Callaghan W.M.
      • Kharrazi M.
      Validation of obstetric estimate using early ultrasound: 2007 California birth certificates.
      (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean delivery)
      d Model unstable because of a very small sample size
      e Restricted to full-term infants (≥37 weeks gestational age at birth). Each infant included if a multifetal gestation and used robust standard errors in models to account for correlation.
      Supplemental Table 2Associations between parental structure and obstetrical and birth outcomes among birthing parents born in the United States, California, 2016 to 2019
      OutcomeMother-mother partnerships vs mother-father partnershipsFather birthing parent partnerships vs mother-father partnerships
      Unadjusted risk ratio (95% CI)Adjusted risk ratio (95% CI)Unadjusted risk ratio (95% CI)Adjusted risk ratio (95% CI)
      Multifetal gestation
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, and parity
      ,
      Patients with preexisting diabetes mellitus excluded from denominator
      5.6 (4.8–6.4)4.1 (3.6–4.8)1.6 (0.8–3.3)1.5 (0.7–3.1)
      Gestational diabetes mellitus
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, prepregnancy body mass index, and weighted summary score of prepregnancy comorbidities21
      1.2 (1.1–1.4)0.9 (0.8–1.1)0.9 (0.6–1.3)0.9 (0.6–1.3)
      Hypertensive disorder of pregnancy
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, prepregnancy body mass index, and weighted summary score of prepregnancy comorbidities21
      1.7 (1.5–1.9)1.1 (0.9–1.2)0.9 (0.6–1.3)0.9 (0.6–1.3)
       Preeclampsia with severe features or eclampsia
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, prepregnancy body mass index, and weighted summary score of prepregnancy comorbidities21
      1.8 (1.5–2.2)1.0 (0.9–1.2)
      Model unstable because of a very small sample size
      Model unstable because of a very small sample size
       Gestational hypertension or preeclampsia without severe features
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, prepregnancy body mass index, and weighted summary score of prepregnancy comorbidities21
      1.6 (1.5–1.8)1.1 (0.9–1.2)1.0 (0.7–1.5)1.1 (0.7–1.6)
      Labor induced
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean delivery)
      1.4 (1.3–1.6)1.2 (1.1–1.3)0.8 (0.6–1.1)0.8 (0.6–1.2)
      Cesarean birth
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean delivery)
      1.3 (1.3–1.4)1.0 (0.9–1.1)1.0 (0.8–1.2)0.9 (0.8–1.1)
      Postpartum hemorrhage
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean delivery)
      2.1 (1.9–2.4)1.5 (1.3–1.7)0.6 (0.3–1.3)0.6 (0.3–1.3)
      Severe maternal morbidity
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean delivery)
      2.2 (1.8–2.7)1.5 (1.3–1.9)
      Model unstable because of a very small sample size
      Model unstable because of a very small sample size
      Non-transfusion severe maternal morbidity
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean delivery)
      2.3 (1.7–3.2)1.5 (1.1–2.0)
      Model unstable because of a very small sample size
      Model unstable because of a very small sample size
      Preterm birth (<37 wk)
      Model unstable because of a very small sample size
      1.6 (1.4–1.8)1.0 (0.9–1.4)1.3 (0.9–1.8)0.7 (0.3–1.8)
      Low birthweight (<2500 g)
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean delivery)
      ,
      Restricted to full-term infants (≥37 weeks gestational age at birth). Each infant included if a multifetal gestation and used robust standard errors in models to account for correlation.
      1.5 (1.2–2.0)0.9 (0.7–1.1)
      Model unstable because of a very small sample size
      Model unstable because of a very small sample size
      Apgar score <7 at 5 min
      Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean delivery)
      ,
      Restricted to full-term infants (≥37 weeks gestational age at birth). Each infant included if a multifetal gestation and used robust standard errors in models to account for correlation.
      1.8 (1.3–2.5)1.2 (0.9–1.7)
      Model unstable because of a very small sample size
      Model unstable because of a very small sample size
      CI, confidence interval.
      Leonard et al. Sexual and/or gender minority birth disparities. Am J Obstet Gynecol 2022.
      a Adjusted for patient age, education level, race-ethnicity (social factor), payment method, and parity
      b Patients with preexisting diabetes mellitus excluded from denominator
      c Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, prepregnancy body mass index, and weighted summary score of prepregnancy comorbidities
      • Barradas D.T.
      • Dietz P.M.
      • Pearl M.
      • England L.J.
      • Callaghan W.M.
      • Kharrazi M.
      Validation of obstetric estimate using early ultrasound: 2007 California birth certificates.
      d Model unstable because of a very small sample size
      e Adjusted for patient age, education level, race-ethnicity (social factor), payment method, parity, multifetal gestation, and weighted comorbidity score (including medical comorbidities, obstetrical comorbidities, delivery body mass index ≥40 kg/m2, and previous cesarean delivery)
      f Restricted to full-term infants (≥37 weeks gestational age at birth). Each infant included if a multifetal gestation and used robust standard errors in models to account for correlation.

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